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Biography of an epidemic: Fentanyl overdose in Chicago. Harold Pollack Greg Scott Sandra Thomas. Roadmap. Opiate overdose as a general health risk Fentanyl as a specific risk Maps of Chicago Blather Implications for harm reduction. Opiate OD.
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Biography of an epidemic:Fentanyl overdose in Chicago Harold Pollack Greg Scott Sandra Thomas
Roadmap • Opiate overdose as a general health risk • Fentanyl as a specific risk • Maps of Chicago • Blather • Implications for harm reduction
Opiate OD • OD is a leading cause of premature death among injection drug users (IDU) in industrial democracies. • Several studies report incidence of 1-2 percent/year among street IDU. • Up to 45% of reported deaths in IDU cohort studies.
Risk-factors for OD • Toxicological features of ingested drugs • Variable purity of street heroin plays a role. • Poly-substance use (alcohol, cocaine) • Additives/adulterants • Hazardous circumstances of use • Loss of tolerance
Risk-factors for fatal OD • Injecting alone • Chosen dose/mixture of substance injected • Reluctance of onlookers/shooting partners to summon help, particularly given possible police involvement. • Improper/ineffective/lame intervention by lay persons • Mechanical stimulation common • Reluctance to provide rescue breathing • Injection of ineffective/harmful substances (milk, crack)
Loss of tolerance • Known risk factor for fatal OD. • Release from hospitalization, detox, drug substance abuse treatment, or incarceration are key pathways. • Strang et al. (BMJ, 2003) followed 137 consecutive IDU admitted to inpatient detox followed by a (roughly 28-day) inpatient treatment at National Addiction Center, Maudsley Hospital, London. • 5/137 patients died during the next year, all from OD. • All 5 had successfully completed at least detox phase of intervention, • 4 of the 5 were evaluated as successfully completing the full inpatient treatment program.
OD in Chicago • Chicago area home to estimated 45,000 IDU. • Huge confidence interval on the 45,000. • Research team identifying and mapping all Chicago OD deaths, and relating locations to location of new prevention interventions. • Search of individual death certificates 1999-2007. • Current detailed microdata 1999-2003. • 2004-2007 data now entering the nonfictional genre.
OD is common among street IDU • CDC-funded Chicago survey of street IDU • 63% Shoot alone • 50% report observing at least 1 fatal OD • 41% report having attempted a rescue • 50% have suffered at least on non-fatal OD, with loss of tolerance playing a key role. • 30% of self-reported cases within 1 week of release from incarceration. • 15% of self-reported cases within 1 week of release from detoxification Slide courtesy of Greg Scott
Of the 50% Non-Fatal ODs … • The term “revived” inherently vague • 33% revived by medical professional • 44% revived by a fellow injector • 9% revived by a non-injecting peer/relative • Of the 53% revived by laypersons: • 80% by manual stimulation • 19% by administration of non-recommended substance (e.g. milk, crack) • 1% by injection of appropriate medication Slide courtesy of Greg Scott
Naloxone interventions • Beginning in 2002, Chicago Recovery Alliance (CRA), city’s largest syringe exchange, began Naloxone distribution program to address OD. • Key program ingredients • OD education/awareness • Training of IDUs and shooting partners in first responses • Distributing Naloxone (“Narcan”) • Anecdotal reports of approximately 500 OD “reversals.” • Program penetration in south and west Chicago, with weaker program penetration far from CRA syringe exchange sites.
Overall Pattern 1999-2004 • High and stable, slightly declining OD incidence across Chicago. • Some evidence of more rapid declines among white male users in CRA served areas.
Apparent explanation • Use of Fentanyl as an adulterant/ additive and by itself. • Illustrative brand names illustrate one public health challenge: • Flat line, lethal injection, DOA. • Sold as “China White” for many years • Fatal OD incidence roughly doubled, though the excess OD incidence attributable to fentanyl remains unclear. • As noted, many deaths elsewhere…
Fentanyl noted Among OD cases
Would Naloxone bring some problems? • Yup… • Let’s go to the ethnography. • Greg Scott’s field notes.
Thus the need for evaluation • Syringe exchange hard to evaluate well, given cultural politics of HIV and needle provision, broader political climate. • Naloxone/OD seem less politically visible and freighted. • Interventions at early phase, and can therefore be explicitly tracked. • Chicago, Boston, parts of New York, LA, Albuquerque, NM. • Evaluation more likely to improve implementation of complex interventions.
Policy lessons • Policy and intervention failures predated Fentanyl epidemic and still remain after Fentany problem has abated. • E.G. Methadone maintenance waiting list of 600 people throughout this story. • There is some self-limiting dimension to new threats such as Fentanyl.
More policy lessons • “You can’t easily regulate what you prohibit” • Need for law enforcement response, informed by user community. • Effective law enforcement requires informal contacts, and some degree of selective targeting or intensity of supply-side enforcement. • Users adapted to new threat—with a lag. • Necessity and limitations of harm reduction models.
Conclusion • Opiate OD is a (surprisingly) prevalent threat to life and health. • Successful OD prevention will straddle traditional boundaries between “harm reduction,” and other forms of care. • Syringe exchanges were largely implemented outside formal systems of substance abuse treatment and medical care. • Key OD risk-factors and (missed) opportunities for intervention arise in medical care/substance abuse treatment. • Finding politically feasible strategies to promote and evaluate OD prevention will bring high payoffs unrealized in syringe exchange debate.
