Bystander resuscitation attempts at heroin overdose: does it improve outcomes?

Study objective: To document the characteristics and effectiveness of cardiopulmonary resuscitation (CPR) at non-fatal heroin overdose events in Melbourne, Australia. Methods: A retrospective analysis of a computerised database of ambulance attendance records at non-fatal heroin overdose cases for the period 1/12/1998 to 31/7/2000 was undertaken.

Main outcome measures: The main outcome measure was the rate of patient hospitalisation. The rate of CPR administration at heroin overdose cases was also examined, along with characteristics of the attendance, such as the age and sex of the overdose case, the relationship of person providing CPR to the overdose case as well as the location, time and date of the event.

Results: CPR was administered prior to ambulance arrival in 579 heroin overdose cases (9.4% of total heroin overdose cases attended) between 1/12/98 and 31/7/2000. A greater proportion of female overdose cases were administered CPR than males and CPR administrations were evenly distributed across attendances occurring in private and public locations. Bystander administration of CPR prior to ambulance attendance resulted in a significantly lower rate of heroin user hospitalisation (14.5%) compared to cases where bystander CPR was not administered (18.8%).

Conclusions: While CPR administration prior to ambulance attendance at heroin overdose events is relatively uncommon (especially compared to out-of-hospital cardiac arrest), such administration was associated with a statistically significant improvement in clinical outcomes in cases of non-fatal heroin overdose. These findings suggest that the provision of CPR training to people likely to come into contact with heroin overdose events may be an effective strategy at minimising consequent overdose-related harm.

Patterns and Characteristics of Ambulance Attendance at Heroin Overdose at a Local-Area Level in Melbourne, Australia: Implications for Service Provision

The monitoring of heroin use and related harms is undertaken in Australia with a view to inform policy responses. Some surveillance data on heroin-related harms is well suited to inform the planning and delivery of heroin-related services, such as needle and syringe provision. This article examines local-area variation in the characteristics of nonfatal heroin overdoses attended by ambulances in Melbourne over the period June 1998 to October 2000 to inform the delivery of services to the heroin-using population in Melbourne.

Intentional overdose among heroin overdose survivors

Previous studies have reported varying rates of intentional overdose among heroin overdose survivors. This article reports on the prevalence of intentional heroin overdose among a sample of overdose survivors in Melbourne, Australia. This is part of a larger study examining the risk factors associated with nonfatal overdose. The study involved interviews, with 256 heroin overdose survivors successfully resuscitated by Melbourne Ambulance Service paramedics. A substantial minority (17%) of the sample indicated that they had ever had an intentional overdose, and 67% had one within the last 6 months (11% of the total sample). Of those who had ever intentionally overdosed, 21% did so at the overdose for which they were recruited into the study (4% of total sample). Self-reported reasons for intentional heroin overdose fell into two categories: precipitating events and emotional states prior to use. Intentional overdose appears to comprise a relatively low proportion of overall heroin overdoses. However, given the complexity of suicidal thought and behavior, it is possible that some heroin overdose survivors who report their overdose to be unintentional were in fact experiencing some degree of suicidal thinking at the time of the overdose. Future research could address the potentially ambiguous nature of some intentional heroin overdoses.

Media reports of heroin overdose spates: public health messages, moral panics or risk advertisements?

This article reports on an investigation of the public health utility of media messages concerning spates (temporal clusters) of heroin-related overdose (HOD) from the perspective of some injecting drug users (IDUs). In-depth qualitative interviews were carried out with a convenience sample of 60 IDUs, in the setting of two Needle and Syringe Programs in an Australian regional city (Geelong) between April and May 2000. Very few interviewees reported that they had personally experienced a spate of overdoses. None of the interviewees reported communicating the existence of a killer batch to other IDUs. No interviewees reported having changed either their injecting practices or the amount of heroin they used following such a media alert. Indeed, a substantial minority of the interviewees reported seeking out these stronger batches and participant narratives illustrate that, for a substantial group of interviewees, the media reporting of a hypothetical 'killer batch' of heroin may have implications for their drug-seeking and health-related behaviour. It was found that the accuracy of information available to IDUs is mixed and that the flow of information within this social network was slow. Findings demonstrate that media reporting of killer batches of heroin has little value as a public health strategy and provide an example of how some activities that are proposed as public health measures may in fact have the opposite effect.

Intranasal naloxone for the treatment of suspected heroin overdose

AIMS: This paper reviews available literature regarding the effectiveness, safety and utility of intranasal (i.n.) naloxone for the treatment of heroin overdose.

METHODS: Scientific literature in the form of published articles during the period January 1984 to August 2007 were identified by searching several databases including Medline, Cinahl and Embase for the following terms: naloxone, narcan, intranasal, nose. The data extracted included study design, patient selection, numbers, outcomes and adverse events.

RESULTS: Reports of the pharmacological investigation and administration of i.n. naloxone for heroin overdose are included in this review. Treatment of heroin overdose by administration of i.n. naloxone has been introduced as first-line treatment in some jurisdictions in North America, and is currently under investigation in Australia.

CONCLUSION: Currently there is not enough evidence to support i.n. naloxone as first-line intervention by paramedics for treatment of heroin overdose in the pre-hospital setting. Further research is required to confirm its clinical effectiveness, safety and utility. If proved effective, the i.n. route may be useful for drug administration in community settings (including peer-based administration), as it reduces risk of needlestick injury in a population at higher risk of blood-borne viruses. Problematically, naloxone is not manufactured currently in an ideal form for i.n. administration.

Nonfatal heroin overdoses in Queensland, Australia : an analysis of ambulance data

In the past decade, the utilization of ambulance data to inform the prevalence of nonfatal heroin overdose has increased. These data can assist public health policymakers, law enforcement agencies, and health providers in planning and allocating resources. This study examined the 672 ambulance attendances at nonfatal heroin overdoses in Queensland, Australia, in 2000. Gender distribution showed a typical 70/30 male-to-female ratio. An equal number of persons with nonfatal heroin overdose were between 15 and 24 years of age and 25 and 34 years of age. Police were present in only 1 of 6 cases, and 28.1% of patients reported using drugs alone. Ambulance data are proving to be a valuable population-based resource for describing the incidence and characteristics of nonfatal heroin overdose episodes. Future studies could focus on the differences between nonfatal heroin overdose and fatal heroin overdose samples.

Treatment of illicit opioid and γ-hydroxybutyrate overdose by Helsinki emergency medical services

Aims: To examine the characteristics, incidence, treatment and outcome of presumed opioid, γ-hydroxybutyrate (GHB) and γ-butyrolactone (GBL) overdoses involving users of illicit drugs in Helsinki. GHB/GBL were included in this study, despite not being opioids, due to the relative ease with which they can cause potentially fatal respiratory depression. The incidence and time interval of recurrent opioid toxicity after prehospital administration of naloxone, an opioid antagonist, was studied in presumed heroin overdose patients. Naloxone has been reported to have many adverse effects and the effects of naloxone administered during an opioid overdose on the cardiovascular system and catecholamine levels in piglets were studied. Materials and methods: Patients included in these published retrospective studies were from the following time periods: Study I: 1995-2002, II: 1997-2000, III: 1995-2000, V: 2006-2007. Presumed opioid overdose patients were examined in studies I, II and III. GHB/GBL overdoses among injecting drug users was examined in study V. Recurrent opioid toxicity after prehospital naloxone administration in heroin overdose patients was examined in study III. The effects of naloxone (80 μg/kg i.v.) on the cardiovascular system and catecholamine levels administered during morphine overdose (8mg/kg i.v.) and under propofol anesthesia with spontaneous breathing were studied in eight piglets (IV). In this thesis, previously unpublished data on the incidence of opioid overdose between 2001-2007 and comparison of the characteristics of buprenorphine and heroin overdose patients encountered in 1995-2005 are also included. Results: Helsinki Emergency Medical Service (EMS) ambulances were dispatched annually to 34,153- 45,118 calls from 1995 to 2007. Of them, 7-8% were coded as intoxications or overdoses. During this time, 436 patients were treated by the EMS for presumed opioid overdose. The peak incidence of opioid overdoses was in the year 2000 (113 cases), after which they declined to 6-26 cases annually. The annual incidence of buprenorphine related overdoses increased from 4 (4% of opioid overdoses) in the year 2000 to 8 (30% of opioid overdoses) in 2007. The annual number of GHB related overdose patients treated by Helsinki EMS increased from 21 to 73 between 2004-2007. There appeared to be a peak in the incidence of both GHB/GBL and opioid related overdoses on Saturdays. Characteristics of opioid overdose patients The median age of opioid overdose patients was 28 years (22;33, 25- and 75-percentiles), and 84% were male. Buprenorphine overdose patients had more polydrug, such as alcohol and/or benzodiazepines, use in comparison with heroin overdose patients, 70% versus 33%, respectively. Severe respiratory depression was reported less often with buprenorphine overdoses compared to heroin overdoses, in 67.0% versus 85.4%, respectively. Outcome of heroin overdose patients with cardiac arrest Ninety four patients suffered cardiac arrest due to acute drug poisoning/overdose and were thus considered for resuscitation. Resuscitation was attempted in 72 cases. Cardiac arrest was caused by heroin overdose for 19 patients of which three (16%) were discharged alive. Other agents also induced cardiac arrest in 53 patients, of which six (11%) were discharged alive. The arrest was either EMS witnessed or occurring after the emergency call for all survivors of heroin induced cardiac arrest. Characteristics of GHB/GBL overdose patients The records of 100 GHB/GBL related overdose patients from 2006-2007 were retrieved. The median age of GHB/GBL overdose patients encountered on weekend nights was 24 years (22;27, 25- and 75-percentiles) and 49% were male. Polydrug use was reported in 62-80% of the cases. Thirty nine patients were encountered on Friday-Saturday or Saturday-Sunday night between 11 pm-6 am. The remaining sixty one patients were outside this time frame. There was a statistically significant difference between these two groups in history of chronic injecting drug use (33% vs. 59%, respectively, p=0.012). Recurrent heroin toxicity after prehospital naloxone administration Study III included 145 presumed heroin overdose patients. After prehospital care, 84 patients refused further care and were not transported to an Emergency Department (ED). Seventy one (85%) of them were administered naloxone by the EMS. During a 12-h follow up period, none of these patients developed severe recurrent opioid toxicity. The remaining 61 patients were transported to an ED. Prior to transportation, 52 (85%) patients were administered naloxone by the EMS. Fifteen of them were administered naloxone also in the ED and recurrent opioid toxicity was evident either on arrival at the ED or shortly thereafter. Prehospital naloxone was administered either intravenously, intramuscularly (i.m.) or subcutaneously (s.c.). There was a tendency for more frequent recurrent heroin toxicity among the patients with only intravenous administration of prehospital naloxone (13/36) compared with the patients with intramuscular or subcutaneous prehospital naloxone (2/16), p=0.106. The effects of naloxone on the cardiovascular system and catecholamine levels in piglets The administration of morphine to piglets resulted in an obvious respiratory depression, which was reversed by naloxone. Two severely hypoxemic piglets developed cardiac arrest after naloxone administration. In the other six animals, the administration of naloxone did not provoke arrhythmias, cardiac ischemia or visible evidence of pulmonary edema. There was a statistically significant (p=0.012) increase in norepinephrine levels after morphine administration and before naloxone administration: from 1.9 (1.3-2.3) ng/ml at baseline, to 31.7 (8.3-83.0) ng/ml (median, 25 and 75 percentiles parentheses) after morphine administration. After the administration of naloxone, the catecholamine levels continued to increase in only one of the animals. Conclusions: The incidence of buprenorphine related overdoses increased during the study period, but was still lower in comparison to those involving heroin. Injecting drug users have also started to use GHB/GBL. While recreational drug users use GHB/GBL during weekend nights, a GHB/GBL overdose patient encounter during weekdays has a more probable history of injecting drug use. Patients with cardiac arrest after heroin overdose have a poor prognosis. It appears to be safe to leave heroin overdose patients on scene after prehospital treatment with naloxone. Although no statistically significant difference was observed, it seems prudent to administer part of the total naloxone dose s.c. or i.m. to reduce the risk of recurrent respiratory depression. If transported to an ED, an observation period of one to two hours after the last naloxone dose seems adequate. The treating physician must be vigilant, however, due to the high prevalence of polydrug use and high morbidity after non fatal heroin overdose. Furthermore, care should be taken regarding possible chronic disorders and drug rehabilitation should be addressed. In the experimental animal study, two animals developed cardiac arrest after receiving naloxone while in hypoxemia and bradycardia. Further studies are required to assess the effect of naloxone during opioid-induced hypercapnia and hypoxemia in animals addicted to opioids.

Nonfatal heroin overdoses in Queensland, Australia: an analysis of ambulance data

In the past decade, the utilization of ambulance data to inform the prevalence of nonfatal heroin overdose has increased. These data can assist public health policymakers, law enforcement agencies, and health providers in planning and allocating resources. This study examined the 672 ambulance attendances at nonfatal heroin overdoses in Queensland, Australia, in 2000. Gender distribution showed a typical 70/30 male-to-female ratio. An equal number of persons with nonfatal heroin overdose were between 15 and 24 years of age and 25 and 34 years of age. Police were present in only 1 of 6 cases, and 28.1% of patients reported using drugs alone. Ambulance data are proving to be a valuable population-based resource for describing the incidence and characteristics of nonfatal heroin overdose episodes. Future studies could focus on the differences between nonfatal heroin overdose and fatal heroin overdose samples.

The Cardiovascular Pathology of Stimulant Overdose Decedents in King County, Washington

Thesis (Master's)--University of Washington, 2016-09

Average White Band poster, ca. 2000

The Average White Band's debut album, Show your hand, was released in 1973. The "classic funk and R & B" band included members Alan Gorrie, Owen "Onnie" McIntyre, Malcolm "Mollie" Duncan, Roger Ball, Robbie McIntosh, and Mike Rosen. Rosen was quickly replaced by Hamish Stuart. The band, comprised of Scotsmen, released a second album in 1974 that featured the US number 1/UK Top 10 single "Pick up the Pieces". That same year, Robbie McIntosh died of a heroin overdose and was replaced by Steve Ferrone. The song "Cut the Cake" from their third album made the US top 10, and subsequent releases in the late 1970s and early 1980s proved successful. The members largely pursued individual projects in the years that followed, but re-formed in 1989 (with original members Gorrie, Ball and McIntyre, and new members Alex Ligertwood and Eliot Lewis) and released the album Aftershock. Over the years, the band's members have changed, and the band is currently comprised of Onnie McIntyre, Rocky Bryant, Alan Gorrie, Fred "Freddy V" Vigdor and Klyde Jones. Their most recent album, Times Squared, was released in 2009.

Moral panic : the old and the new

The theory of moral panics has been prominent in the sociology of deviance since the 1970s. This article uses this theory to trace the rise of the moral panic around the high number of heroin overdose deaths in Australian in the mid to late 1990s. It argues, however, that much of the panic was generated by groups not traditionally associated with moral panics, but by political progressives in the field of illicit drugs as well as victims, parent groups, and those who work with illicit drug users. In this way it was not a conventional right-wing moral crusade, but it was no less a moral panic.

Serious adverse events in the Australian National Evaluation of Pharmacotherapies for Opioid Dependence (NEPOD)

Aims The study estimated serious adverse event (SAE) rates among entrants to pharmacotherapies for opioid dependence, during treatment and after leaving treatment. Design A longitudinal study based on data from 12 trials included in the Australian National Evaluation of Pharmacotherapies for Opioid Dependence (NEPOD). Participants and settings A total of 1.244 heroin users and methadone patients treated in hospital, community and GP settings. Intervention Six trials included detoxification; all included treatment with methadone, buprenorphine, levo-alpha-acetyl-methadol (LAAM) or naltrexone. Findings During 394 person-years of observation, 79 SAEs of 28 types were recorded. Naltrexone participants experienced 39 overdoses per 100 person-years after leaving treatment (44% occurred within 2 weeks after stopping naltrexone). This was eight times the rate recorded among participants who left agonist treatment. Rates of all other SAEs were similar during treatment versus out of treatment, for both naltrexone-treated and agonist-treated participants. Five deaths occurred, all among participants who had left treatment, at a rate of six per 100 person-years. Total SAE rates during naltrexone and agonist treatments were similar (20, 14 per 100 person-years, respectively). Total SAE and death rates observed among participants who had left treatment were three and 19 times the corresponding rates during treatment. Conclusions Individuals who leave pharmacotherapies for opioid dependence experience higher overdose and death rates compared with those in treatment. This may be due partly to a participant self-selection effect rather than entirely to pharmacotherapy being protective. Clinicians should alert naltrexone treatment patients in particular about heroin overdose risks. Duty of care may extend beyond cessation of dosing.

The contribution of research to Australian policy responses to heroin dependence 1990-2001: a personal retrospection

Periodic public concern about heroin use has been a major driver of Australian drug policy in the four decades since heroin use was first reported. The number of heroin-dependent people in Australia has increased from several hundreds in the late 1960s to around 100000 by the end of the 1990s. In this paper I do the following: (1) describe collaborative research on heroin dependence that was undertaken between 1991 and 2001 by researchers at the National Drug and Alcohol Research Centre: (2) discuss the contribution that this research may have made to the formulation of policies towards the treatment of heroin dependence during a period when the policy debate crystallized around the issue of whether or not Australia should conduct a controlled trial of heroin prescription; and (3) reflect on the relationships between research and policy-making in the addictions field, specifically on the roles of investigator-initiated and commissioned research, the interface between researchers, funders and policymakers: and the need to be realistic about the likely impact of research on policy and practice.