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Overdose deaths from s treet heroin and prescribed methadone: analysis and prevention options

Overdose deaths from s treet heroin and prescribed methadone: analysis and prevention options. Professor John Strang National Addiction Centre, London, UK. Issues to be covered today. T opic 1: Analysis of the overdose death problem Topic 2: How could we respond more effectively?.

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Overdose deaths from s treet heroin and prescribed methadone: analysis and prevention options

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  1. Overdose deaths from street heroin and prescribed methadone:analysis and prevention options Professor John Strang National Addiction Centre, London, UK

  2. Issues to be covered today • Topic 1: Analysis of the overdose death problem • Topic 2: How could we respond more effectively?

  3. Issues to be covered today • Topic 1: Analysis of the overdose death problem • Why the special attention to the opiates? • Methadone as well as heroin (in the UK) • Injecting heroin, in particular • Special time of risk – at start and after the end of treatment • Special time of risk – on release from prison • Topic 2: How could we respond more effectively? • Methadone – dose • Methadone – supervision • Take-Home Emergency Naloxone

  4. Issues to be covered today • Topic 1: Analysis of the overdose death problem • Why the special attention to the opiates? • Methadone as well as heroin (in the UK) • Injecting heroin, in particular • Special time of risk – at start and after the end of treatment • Special time of risk – on release from prison • Topic 2: How could we respond more effectively? • Methadone – dose • Methadone – supervision • Take-Home Emergency Naloxone

  5. Drug-related deaths in England and Wales 1997 – 2002 (ONS)

  6. Drug-related deaths in England and Wales 1997 – 2002 (ONS)

  7. Issues to be covered today • Topic 1: Analysis of the overdose death problem • Why the special attention to the opiates? • Methadone as well as heroin (in the UK) • Injecting heroin, in particular • Special time of risk – at start and after the end of treatment • Special time of risk – on release from prison • Topic 2: How could we respond more effectively? • Methadone – dose • Methadone – supervision • Take-Home Emergency Naloxone

  8. Total number of drug-related deaths in England with associated substances: 1993-2001 (ONS). 1993 1997 2000 2001 (% change) Total annual -England 821 1237 1561 1524 (-2%) Heroin and Morphine 187 445 926 889 (-4%) Methadone 232 421 238 207 (-13%) Cocaine 12 39 80 96 (+20%) MDMA/Ecstasy 8 12 36 55 (+53%)

  9. “Methadone heals, but methadone also kills. The challenge is to achieve the former without incurring the latter”.

  10. Trends in O/D deaths – heroin and methadone (Hickman et al, IJE, 2006)

  11. Trends in O/D deaths – heroin and methadone (Hickman et al, IJE, 2007)

  12. Issues to be covered today • Topic 1: Analysis of the overdose death problem • Why the special attention to the opiates? • Methadone as well as heroin (in the UK) • Injecting heroin, in particular • Special time of risk – at start and after the end of treatment • Special time of risk – on release from prison • Topic 2: How could we respond more effectively? • Methadone – dose • Methadone – supervision • Take-Home Emergency Naloxone

  13. London PAI Study #1:438 Early Heroin Users [48% in first 3 years; 45% SDS£6] • Overdose history among 98 (22%) • Of 309 ever-injectors, 96 (31%) had overdosed • Of 125 never-injectors, 2 (2%) had overdosed (c2=44.2, p<0.001 [data missing on 4]) (Gossop, Griffiths, Powis, Williamson and Strang, BMJ, 1996)

  14. HOW COMMON(among injectors)?

  15. London PAI Study #2:312 injectors • Personal overdose? - 117 (38%) • Witnessed overdose? - 157 (50%) • Witnessed fatal O/D? - 46 (15%) (Strang, Griffiths, Powis, Fountain, Williamson and Gossop, Drug and Alcohol Review, 1999)

  16. Aus (Adelaide) PAI Study #2:218 heroin users (i.e. injectors) • Personal overdose? - 48% • Witnessed overdose? - 70% • (Witnessed fatal O/D? - n/a) (McGregor, Darke, Ali and Christie, Addiction, 1998)

  17. Issues to be covered today • Topic 1: Analysis of the overdose death problem • Why the special attention to the opiates? • Methadone as well as heroin (in the UK) • Injecting heroin, in particular • Special time of risk – at start and after the end of treatment • Special time of risk – on release from prison • Topic 2: How could we respond more effectively? • Methadone – dose • Methadone – supervision • Take-Home Emergency Naloxone

  18. When in particular? • During methadone early treatment • Post-detox/rehab

  19. Risk of death during and after treatment • BMJ 2010;341:c5475

  20. Issues to be covered today • Topic 1: Analysis of the overdose death problem • Why the special attention to the opiates? • Methadone as well as heroin (in the UK) • Injecting heroin, in particular • Special time of risk – at start and after the end of treatment • Special time of risk – on release from prison • Topic 2: How could we respond more effectively? • Methadone – dose • Methadone – supervision • Take-Home Emergency Naloxone

  21. When in particular? • Post-detox/rehab • During methadone early treatment • Prison release

  22. Post-release ‘carnage’ • Seaman Brettle Gore, BMJ, 1998 • Bird & Hutchinson, Addiction, 2002 • Farrell & Marsden, Addiction, 2008

  23. Prevalence of drug dependence Drug dependence prior to prison Substance Misuse in Prisoners 2002 Singleton N, Farrell M, Meltzer H ONS.

  24. Issues to be covered today • Topic 1: Analysis of the overdose death problem • Why the special attention to the opiates? • Methadone as well as heroin (in the UK) • Injecting heroin, in particular • Special time of risk – at start and after the end of treatment • Special time of risk – on release from prison • Topic 2: How could we respond more effectively? • Methadone – dose • Methadone – supervision • Take-Home Emergency Naloxone

  25. Issues to be covered today • Topic 1: Analysis of the overdose death problem • Why the special attention to the opiates? • Methadone as well as heroin (in the UK) • Injecting heroin, in particular • Special time of risk – at start and after the end of treatment • Special time of risk – on release from prison • Topic 2: How could we respond more effectively? • Methadone – dose • Methadone – supervision • Take-Home Emergency Naloxone

  26. Cochrane review of dose and methadone Faggianoet al (2007) Cochrane review of significance of dose in methadone OST Retention rate - RCTs: High versus low doses at shorter follow-ups: RR=1.36 [1.13,1.63], and at longer ones: RR=1.62 [0.95,2.77]. Opioid use (self reported), times/w - RCTs: high versus low doses WMD= -2.00 [-4.77,0.77] high vs middle doses WMD= -1.89[-3.43, -0.35] Opioid abstinence, (urine based) at >3-4w-RCTs: high versus low doses: RR=1.59 [1.16,2.18] high vs middle doses RR=1.51[0.63,3.61] Cocaine abstinence (urine based) at >3-4 w - RCTs: high versus low doses RR=1.81 [1.15,2.85] Overdose mortality: high dose versus low dose at 6 years follow up: RR=0.29 [0.02-5.34] high dose vs middle dose at 6 years follow-up: 0.38 [0.02-9.34] middle dose vs low dose at 6 years follow-up: RR=0.57 [0.06-5.06]

  27. Issues to be covered today • Topic 1: Analysis of the overdose death problem • Why the special attention to the opiates? • Methadone as well as heroin (in the UK) • Injecting heroin, in particular • Special time of risk – at start and after the end of treatment • Special time of risk – on release from prison • Topic 2: How could we respond more effectively? • Methadone – dose • Methadone – supervision • Take-Home Emergency Naloxone

  28. What is the OD4 Index? OD4 = ODDDD (Overdose Deaths per Daily Dispensed Dose) Thus essentially a measure of safety of a medication, as applied

  29. Issues to be covered today • Topic 1: Analysis of the overdose death problem • Why the special attention to the opiates? • Methadone as well as heroin (in the UK) • Injecting heroin, in particular • Special time of risk – at start and after the end of treatment • Special time of risk – on release from prison • Topic 2: How could we respond more effectively? • Methadone – dose • Methadone – supervision • Take-Home Emergency Naloxone

  30. Pre-filled syringe1 mg per ml, 2 ml syringe available from: Antigen, Aurum, Mayne £6.30

  31. First investigated: • Strang J, Powis B, Best D et al (1999) Preventing opiate overdose fatalities with take-home naloxone: pre-launch study of possible impact and acceptability. Addiction, 94 (2): 199-204.

  32. Structure – 4 areas • Training elements • (a) how to recognise overdose • (b) how to manage situation – general • (c) how to give naloxone

  33. How to Recognise Opiate Overdose Person unconscious, and cannot be woken – UNROUSABLE CYANOSIS – BLUE lips or tongue Not breathing at all or breathing slowly – deep snoring. Pin point pupils

  34. Actions on Discovering Overdose A – Ambulance - CALL AMBULANCE B- Breathing - Check Airway – clear if blocked, Check breathing. C – reCovery - If breathing, place in recovery position – if not breathing, begin basic life support Administer naloxone

  35. How to inject Naloxone – intramuscular (into muscle) • Remove syringe from box and packet • Attach needle to syringe • Inject into the outer thigh, upper arm or outer part of buttock • Hold needle 90 degree above skin • Insert needle into muscle (needs pressure) • Slowly and Steadily push plunger all the way down • Put syringe back in box. Don’t cover needle

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