 |
 |
||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
 |
|
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
 |
 |
 |
 |
 |
|||||
|
|
|
|
|
|
|
|
|
|
 |
|
|
|
Preventing Overdose | ||
|
|
|
|
Introduction The numbers of illicit drug users dying as a result of overdose rose steadily during the 1990s - from approximately 250 in 1991, to 600 in 1997, and higher towards the end of the decade. People who inject heroin are about 14 times more likely to die than their peers. The average age of people dying through heroin related overdose is just 30 years. While heroin related overdose deaths are relatively small in number in comparison to the number of deaths arising from alcohol or tobacco use, the potential life years lost per overdose death is greater than that associated with death resulting from alcohol or tobacco use. In Australia it has been estimated (using 1992 data) that overdose deaths represent over 20,000 years of life lost. The Commonwealth Department of Health and Aged Care ‘National Heroin Overdose Strategy’ reported that there were 958 deaths attributable to opioid overdose among those aged 15 - 44 years in 1999. Many of these deaths could have been prevented. Up to 60% of injecting heroin users report having experienced at least one overdose, while up to 70% have witnessed someone else overdosing. Research shows that around 60% of overdose deaths occur in the presence of others, and that sudden death immediately after injecting is rare, occurring in only 15% of cases. This suggests that if drug services provide appropriate information, training and support on how to respond to an overdose, it is likely that the number of overdose deaths can be reduced. We have designed this guide, and the campaign materials that accompany it, to help services working with injecting drug users to work in a concerted way to: 1. Get the key messages across to injecting drug users that:
all increase the risk of overdose. 2. Encourage people who might witness an overdose to give appropriate first aid and call an ambulance. 3. Consider implementing first aid training for:
Causes of overdose More often, death is caused by using opiates in combination with other central nervous system depressants - especially alcohol, and benzodiazepines. In the presence of other depressant drugs, a ‘normal’ or usual dose of heroin may prove fatal.
In many cases of overdose, death occurs several hours after the drug (usually heroin) is injected.
Risk factors These risks can be summarised as:
Injecting and mixing drugs Just as talking to injectors about their experience of witnessing overdose can create opportunities to improve the first aid and other responses, so talking to injectors about their past history of non-fatal overdose may help to identify, and reduce, risk factors. Using combinations of depressant drugs is a major cause of overdose. As well as the possibility of potentiating (increasing the effectiveness of) each other, it is likely that drug users often do not fully appreciate the risks of:
A history of recent heavy drinking is one of the most consistent predictors of how likely a heroin user is to overdose. This is an issue that all drug services need to tackle, in terms of assessment and advice and information giving. Contrary to popular belief, variations in drug purity only account for a small proportion of overdose deaths. Deliberate overdose Suicidal thoughts can be an important factor in overdose, and workers should make sure that clients have the opportunity to explore this area. Talking about these problems is likely to reduce the risk. People who are in methadone treatment appear to be more likely to attempt suicide than people who are opiate dependent and are not in treatment. This may be because they have more severe problems. However, as they should also have access to counselling and support, this is an area of risk that it should be possible to reduce. For those heroin injectors who feel that life has little to offer, there may be a grey area between suicidal intent and neglecting personal safety. A feeling that life is not worth protecting can hamper efforts to get injectors to act on life-saving messages. Services which improve the quality of life for their clients are probably indirectly helping to reduce the risk of overdose. Cocaine and speed overdose can cause strokes and heart problems. They can also play a role in deaths due to sedative overdose drug use by temporarily masking sedative effects and contributing to a feeling that reckless behaviour will be safe. Drug treatment and overdose Heroin injectors not in methadone treatment are around four times more likely to die than those who are in treatment. This is mainly because people in methadone treatment use much less heroin. The start of treatment is associated with a higher risk of overdose than later in treatment. It may be possible to reduce the risk of death at the start of treatment by:
Ending treatment prematurely is also associated with increased overdose risk. This may be due to a number of factors including loss of tolerance if the treatment has ended following detoxification, and increased poly drug use as the cause, or consequence, of treatment ending. Treatment services can cut the number of deaths by being attractive to drug users and by retaining them in treatment. Conversely, services with high rates of discharge put patients at risk. Detoxification programs have a strong relationship with overdose deaths. Resumption of opioid use following periods of reduced consumption or abstinence increases the risk of overdose. It is important that services offering opportunities for people to become drug free, tackle the issue of helping clients to manage the overdose risk if they return to drug/alcohol use. Responding to overdose Despite research which indicates that approximately 60% of overdose deaths occur when others are present, and that sudden death immediately after injecting occurs in only 15% of cases, it has been shown that in 79% of cases there is no intervention by bystanders before death. It may be that heroin injectors witnessing overdoses, having seen non-fatal overdoses before, are over-optimistic about the probable outcome. There is also evidence that deep snoring, associated with breathing difficulties, is sometimes thought to be someone sleeping soundly. Many drug users do not realise that there is often a long time delay (often several hours) between injecting heroin and overdose death. People who witness overdoses may wrongly assume that, following survival of the initial ‘hit’, the risk of death reduces. All potential witnesses of an overdose including:
should be aware of the signs of overdose. The signs of unconsciousness they should be able to identify include:
People who witness overdoses need to be able to identify the transition from sleep to unconsciousness so that they can give appropriate first aid. If someone is unconscious and lying on their back, their airway can become blocked by their tongue, vomit or saliva in the back of the mouth. This can stop them breathing and result in death. This type of death can be avoided if someone puts the unconscious person into the recovery position. All staff in contact with injecting drug users should be able to teach this skill. Injectors should be encouraged to practice the recovery position and to teach it to their peers. The poster, booklet and intervention pad that accompany this campaign are available as teaching aids to help workers and drug users to pass on this skill among people who take heroin. Learning how to put someone in the recovery position is something that is best learnt in practice. Where appropriate, workers should teach this skill by example. This brief intervention can make a big difference to overdose fatalities. Through concerted overdose awareness campaigns, drugs services should aim to achieve 100% awareness of how to put someone in the recovery position amongst injectors in contact with the service. Drug services should also encourage wider knowledge of this important first aid message. Expired Air Resuscitation (EAR) and Cardio-Pulmonary Resuscitation (CPR) Training in expired air resuscitation (EAR) and cardio-pulmonary resuscitation (CPR) should be done in a workshop situation with a qualified trainer. First aid training
is essential for both injecting drug users and staff who work with them. Many drug users who have witnessed overdoses would have been willing to resuscitate the victim, but couldn’t because they did not know how. Staff need quality training in first aid, both to teach the skills to drug users and also to deal with overdose situations in the workplace. Training can often be provided by the local ambulance service. This can have the added benefits of fostering understanding and trust between injecting drug users and ambulance staff. If this is not possible or practical, St. John Ambulance and the Australian Red Cross have a national network of qualified first aid trainers who may be able to tailor courses to the needs of your staff and client group. Consideration should be given to paying service users to come to first aid courses, as this can be a cost-effective way of saving lives. Calling an ambulance The ambulance service has the ability to respond to an overdose with a range of medical interventions. In the majority of overdoses, the short-acting opiate antagonist ‘naloxone’ (or ‘Narcan’) may not be required - keeping the person breathing will be the paramedic’s first priority. According to a study by the Australian Institute of Criminology, using data from the 1998 National Drug Strategy Household Survey, 22% of witnesses of heroin overdose did not call for medical assistance because “they didn’t want to get involved,” and another 39% thought they were “capable of handling the overdose.” This reluctance to call an ambulance is costing lives. As discussed, it may be that some people witnessing overdoses, having seen non-fatal overdoses before, are over-optimistic about what will happen. Other reasons for not calling an ambulance include:
However, for many drug users the main reason ambulances are not called is fear that the police will attend and possibly:
Collaboration between NSPs, drug services, police, and ambulance should result in a policy whereby the police are only called to those incidents where there has been a death, or where there is risk to the ambulance crew, children, or others. Every NSP and drug service should work with the police and ambulance service to establish good practice. Injecting drug users should be informed about the local policy, and encouraged to make sure that everyone who overdoses receives appropriate medical help. Myths The most usual of these centre around the idea that someone who is overdosing can be stimulated into regaining consciousness. Practices to do this include:
While it is important to assess the level of consciousness of someone who may have overdosed, if they cannot be roused when shaken and shouted at, they are unconscious - further stimulation will not change this. Just as it is impossible to resist the effect of an anaesthetic through willpower, so it is impossible to overcome the effects of overdose by willpower or stimulation. Putting people in a cold shower or bath is a particularly dangerous practice because:
Trying to walk people around may also make the situation worse because the increased heartbeat may increase absorption of drugs from the intestine, and the helpers may drop the person having the overdose. There is some understanding of this amongst drug users - in one study 92% of people who had witnessed overdose had tried stimulation, yet only 62% maintained that this was the right thing to do. It is likely that with better information and first aid training, the desire to help can be turned from an intervention that may increase risk, into life-saving action. Another dangerous practice which has been reported is that of injecting someone who has overdosed with salt water. There is no medical basis for this practice. One explanation for it may be that drug users have seen people in hospital having a ‘drip’ put up. This is done to make sure medical staff are able to give intravenous medication. The fluid in the ‘drip’ is usually ‘normal saline’. This has tiny quantities of salt added to prevent disrupting the chemistry and fluid balance of the blood - it does not affect the overdose at all. Injecting people with salt water is dangerous because it:
10 key strategies for reducing overdose deaths
Useful contacts St John Ambulance Australian Red Cross Bibliography and further reading The Advisory Council on the Misuse of Drugs. (2000). Reducing drug related deaths. The Stationary Office. London. Bennett G A, Higgins S. (1999) Accidental overdose among injecting drug users in Dorset UK. Addiction 94(8), 1179-1190 Caplehorn J R, Dalton M S, Haldar F et al. (1996) Methadone maintenance and addicts’ risk of fatal heroin overdose. Substance Use & Misuse, 31(2), 177-196. Commonwealth Department of Health and Aged Care. (2001). National Heroin Overdose Strategy. Canberra: Commonwealth of Australia. Darke S and Ross J, et al. (1996). ‘Overdose among heroin users in Sydney, Australia: I Prevalence and correlates of non-fatal overdose’ Addiction 91: 405-411. Darke S and Ross J, et al. (1996). ‘Overdose among heroin users in Sydney, Australia: II Responses to overdose’ Addiction 91: 413-417. Darke S and Zador D. (1996). ‘Fatal heroin ‘overdose’: a review’ Addiction 91: 1765-1772. Darke S, Zador D (1996). ‘Fatal heroin ‘overdose’: a review’ Addiction 91 (12), 1765-1772. Neale J, (2000). Suicidal Intent in non-fatal illicit drug overdose. Addiction. 95 (1), 85-93. Strang J, Best D, Man L et al. (2000). Peer-initiated overdose resuscitation: fellow drug users could be mobilised to implement resuscitation. International Journal of Drug Policy, 437-445. Strang J, Griffiths P, Powis B et al. (1999). Which drugs cause overdose among opiate misusers? Study of personal and witnessed overdoses. Drug and Alcohol Review 18, 253-261. Warner-Smith M, Lynskey M, Darke S, Hall W. (2000). ‘Heroin overdose: prevalence, correlates, consequences and interventions Monograph No. 46’ National Drug and Alcohol Research Centre, University of New South Wales. Zador D, Sunjic S, Darke S. (1996). ‘Heroin-related deaths in New South Wales, 1992: toxicological findings and circumstances’ Medical Journal of Australia 164: 204-207. Credits Published by Exchange Campaigns for Queensland Health. | ||
|
|
|
 |
||
|
|
|