No association between HIV status and risk of non-fatal overdose among people who inject drugs in Vancouver, Canada

BACKGROUND:

The evidence to date on whether HIV infection increases the risk of accidental drug overdose among people who inject drugs (PWID) is equivocal. Thus, we sought to estimate the effect of HIV infection on risk of non-fatal overdose among two parallel cohorts of HIV-positive and -negative PWID.

METHODS:

Data were collected from a prospective cohort of PWID in Vancouver, Canada between 2006 and 2013. During biannual follow-up assessments, non-fatal overdose within the previous 6months was assessed. Bivariable and multivariable generalized mixed-effects regression models were used to determine the unadjusted and adjusted associations between HIV status, plasma HIV-1 RNA viral load, and likelihood of non-fatal overdose.

RESULTS:

A total of 1760 eligible participants (67% male, median age=42, and 42% HIV-positive at baseline) were included. Among 15,070 unique observations, 649 (4.3%) included a report of a non-fatal overdose within the previous 6months (4.4% among seropositive and 4.3% among seronegative individuals). We did not observe a difference in the likelihood of overdose by HIV serostatus in crude (odds ratio [OR]: 1.05, p=0.853) analyses or analyses adjusted for known overdose risk factors (adjusted OR [AOR]: 1.19, p=0.474). In a secondary analysis, among HIV-positive PWID, we did not observe an association between having a detectable viral load and overdose (AOR: 1.03, p=0.862).

CONCLUSIONS:

Despite the evidence that HIV infection is a risk factor for fatal overdose, we found no evidence for a relationship between HIV disease and non-fatal overdose. However, overdose remains high among PWID, indicating the need for ongoing policy addressing this problem, and research into understanding modifiable risk factors that predict non-fatal overdose.

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By:  Escudero DJ1, Marshall BD1, Kerr T2, Hayashi K2, Feng C3, Guillemi SA3, Hogg RS3, Montaner J2, Wood E2, Milloy MJ4.

• 1Department of Epidemiology, Brown University School of Public Health, 2nd Floor, 121 S. Main St., Providence, RI 02906, United States.
• 2British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Division of AIDS, Department of Medicine, University of British Columbia, 667-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.
• 3British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada.
• 4British Columbia Centre for Excellence in HIV/AIDS, 608-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada; Division of AIDS, Department of Medicine, University of British Columbia, 667-1081 Burrard Street, Vancouver, BC V6Z 1Y6, Canada. Electronic address: uhri-mjsm@cfenet.ubc.ca. 
• Addict Behav. 2016 Apr 1;60:8-12. doi: 10.1016/j.addbeh.2016.03.029. 

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Lethality of Opioid Overdose in a Community Cohort of Young Heroin Users

BACKGROUND:

The aim of the study was to estimate the lethality of opioid overdose among young heroin users.

METHODS:

A prospective community cohort study was conducted in Barcelona and Madrid, Spain. Participants included 791 heroin users aged 18-30 years who were followed up between 2001 and 2006. Fatal overdoses were identified by record linkage of the cohort with the general mortality register, while non-fatal overdoses were self-reported at baseline and follow-up interviews. The person-years (py) at risk were computed for each participant. Fatal and non-fatal overdose rates were estimated by city. Transition towards injection shortly before the overdose could not be measured. Overdose lethality (rate of fatal overdose in proportion to total overdose) and its 95% CI was estimated using Bayesian models.

RESULTS:

The adjusted rates of fatal and non-fatal opioid overdose were 0.7/100 py (95% CI: 0.4-1.1) and 15.8/100 py (95% CI: 14.3-17.6), respectively. The adjusted lethality was 4.2% (95% CI: 2.5-6.5).

CONCLUSIONS:

Four out of 100 opioid overdoses are fatal. These are preventable deaths that could be avoided before or after the overdose takes place. Resources are urgently needed to prevent fatal opioid overdose.

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By:  Espelt A1, Barrio G, Álamo-Junquera D, Bravo MJ, Sarasa-Renedo A, Vallejo F, Molist G, Brugal MT; ITINERE Project Group.

Eur Addict Res. 2015;21(6):300-6. doi: 10.1159/000377626. Epub 2015 May 28.

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Years of Potential Life Lost amongst Heroin Users in the Australian Treatment Outcome Study Cohort, 2001-2015

BACKGROUND:

Heroin use carries the highest burden of disease of any drug of dependence. The study aimed to determine mortality rates of the Australian Treatment Outcome Study cohort over the period 2001-2015, and the years of potential life lost (YPLL).

METHODS:

The cohort consisted of 615 heroin users. Crude mortality rates per 1000 person years (PY) and Standardised Mortality Ratios (SMR) were calculated. YPLL were calculated using two criteria: years lost prior to age 65, and years lost prior to average life expectancy.

RESULTS:

The cohort was followed for 7,790.9 PY. At 2015, 72 (11.7%) of the cohort were deceased, with a crude mortality rate of 9.2 per 1000 PYs. Neither age nor gender associated with mortality. The SMR was 10.2 (males 7.3, females 17.2), matched for age, gender and year of death. The most common mortality cause was opioid overdose (52.8%). Using the<65 years criterion, there were 1988.3 YPLL, with a mean of 27.6 (males 27.6, females 27.7). Using the average life expectancy criterion, there were 3135.1 YPLL, with a mean of 43.5 (males 41.9, females 46.3). Accidental overdose (<65yr 63.0%, average life expectancy 63.7%) and suicide (<65yr 12.8%, average life expectancy 13.3%) accounted for three quarters of YPLL where cause of death was known.

CONCLUSIONS:

YPLL associated with heroin use was a quarter of a century, or close to half a century, depending on the criteria used. Given the prominent role of overdose and suicide, the majority of these fatalities, and the associated YPLL, appear preventable.

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By:  Darke S1, Marel C2, Mills KL2, Ross J2, Slade T2, Tessson M2.

• 1National Drug and Alcohol Research Centre, University of New South Wales, Australia. Electronic address: s.darke@unsw.edu.au.
• 2National Drug and Alcohol Research Centre, University of New South Wales, Australia; NHMRC Centre for Research Excellence in Mental Health and Substances Use, Australia 
• Drug Alcohol Depend. 2016 Mar 18. pii: S0376-8716(16)00152-6. doi: 10.1016/j.drugalcdep.2016.03.010. 

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Life Expectancy and Cause of Death in Popular Musicians: Is the Popular Musician Lifestyle the Road to Ruin?

Does a combination of lifestyle pressures and personality, as reflected in genre, lead to the early death of popular musicians? We explored overall mortality, cause of death, and changes in patterns of death over time and by music genre membership in popular musicians who died between 1950 and 2014. 

The death records of 13,195 popular musicians were coded for age and year of death, cause of death, gender, and music genre. Musician death statistics were compared with age-matched deaths in the US population using actuarial methods. Although the common perception is of a glamorous, free-wheeling lifestyle for this occupational group, the figures tell a very different story. 

Results showed that popular musicians have shortened life expectancy compared with comparable general populations. Results showed excess mortality from violent deaths (suicide, homicide, accidental death, including vehicular deaths and drug overdoses) and liver disease for each age group studied compared with population mortality patterns. These excess deaths were highest for the under-25-year age group and reduced chronologically thereafter. 

Overall mortality rates were twice as high compared with the population when averaged over the whole age range. Mortality impacts differed by music genre. In particular, excess suicides and liver-related disease were observed in country, metal, and rock musicians; excess homicides were observed in 6 of the 14 genres, in particular hip hop and rap musicians. For accidental death, actual deaths significantly exceeded expected deaths for country, folk, jazz, metal, pop, punk, and rock.

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By:  Kenny DT1, Asher A.

• 1Faculty of Arts and Social Sciences, Room 468, Bldg H04, The University of Sydney, NSW 2006, Australia. Tel 612 9114 0711, fax 612 9351 3838. dianna.kenny@sydney.edu.au. 
• Med Probl Perform Art. 2016 Mar;31(1):37-44.

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Sharing Overdose Data Across State Agencies to Inform Public Health Strategies: A Case Study

Data sharing and analysis are important components of coordinated and cost-effective public health strategies. However, legal and policy barriers have made data from different agencies difficult to share and analyze for policy development. 

To address a rise in overdose deaths, Maryland used an innovative and focused approach to bring together data on overdose decedents across multiple agencies. The effort was focused on developing discrete intervention points based on information yielded on decedents' lives, such as vulnerability upon release from incarceration. 

Key aspects of this approach included gubernatorial leadership, a unified commitment to data sharing across agencies with memoranda of understanding, and designation of a data management team. Preliminary results have yielded valuable insights and have helped inform policy. 

This process of navigating legal and privacy concerns in data sharing across multiple agencies may be applied to a variety of public health problems challenging health departments across the country.

Full PDF article at:   http://goo.gl/vVlkne

By:  Cherico-Hsii S1, Bankoski A1, Singal P2, Horon I1, Beane E3, Casey M3, Rebbert-Franklin K4, Sharfstein J1.

• 1Maryland Department of Health and Mental Hygiene, Baltimore, MD.
• 2Johns Hopkins University School of Medicine, Baltimore, MD.
• 3Office of the Governor of Maryland, Annapolis, MD.
• 4Maryland Department of Health and Mental Hygiene, Behavioral Health Administration, Catonsville, MD. 
• Public Health Rep. 2016 Mar-Apr;131(2):258-63.

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Demographics & Post-Mortem Toxicology Findings in Deaths among People Arrested Multiple Times for Use of Illicit Drugs and/or Impaired Driving

BACKGROUND:

Multiple arrests for use of illicit drugs and/or impaired driving strongly suggests the existence of a personality disorder and/or a substance abuse problem.

METHODS:

This retrospective study (1993-2010) used a national forensic toxicology database (TOXBASE), and we identified 3943 individuals with two or more arrests for use of illicit drugs and/or impaired driving. These individuals had subsequently died from a fatal drug poisoning or some other cause of death, such as trauma.

RESULTS:

Of the 3943 repeat offenders 1807 (46%) died from a fatal drug overdose and 2136 (54%) died from other causes (p<0.001). The repeat offenders were predominantly male (90% vs 10%) and mean age of drug poisoning deaths was 5 y younger (mean 35 y) than other causes of death (mean 40 y). Significantly more repeat offenders (46%) died from drug overdose compared with all other forensic autopsies (14%) (p<0.001). Four or more drugs were identified in femoral blood in 44% of deaths from poisoning (drug overdose) compared with 18% of deaths by other causes (p<0.001). The manner of death was considered accidental in 54% of deaths among repeat offenders compared with 28% for other suspicious deaths (p<0.001). The psychoactive substances most commonly identified in autopsy blood from repeat offenders were ethanol, morphine (from heroin), diazepam, amphetamines, cannabis, and various opioids.

CONCLUSIONS:

This study shows that people arrested multiple times for use of illicit drugs and/or impaired driving are more likely to die by accidentally overdosing with drugs. Lives might be saved if repeat offenders were sentenced to treatment and rehabilitation for their drug abuse problem instead of conventional penalties for drug-related crimes

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By:  Ahlner J1, Holmgren A2, Jones AW3.

• 1Department of Forensic Genetics and Forensic Toxicology, Swedish National Board of Forensic Medicine, Linköping, Sweden; Department of Clinical Pharmacology, Faculty of Medicine, Linköping University, Linköping, Sweden.
• 2Department of Forensic Genetics and Forensic Toxicology, Swedish National Board of Forensic Medicine, Linköping, Sweden.
• 3Department of Forensic Genetics and Forensic Toxicology, Swedish National Board of Forensic Medicine, Linköping, Sweden; Department of Clinical Pharmacology, Faculty of Medicine, Linköping University, Linköping, Sweden. Electronic address: wayne.jones@liu.se. 
• Forensic Sci Int. 2016 Feb 3;265:138-143. doi: 10.1016/j.forsciint.2016.01.036.

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‘What Is Known About Community Pharmacy Supply of Naloxone’: A Scoping Review

Highlights

• Take-home naloxone may be expanded through community pharmacy.
• Early work indicates pharmacists are willing to supply naloxone.
• Existing models for community pharmacy of naloxone supply exist.
• Supply models have important cost implications for consumers.
• Larger implementation studies are needed to determine effectiveness.

Abstract

Background

There is growing evidence that expanded supply of take-home naloxone to prevent opioid overdose deaths is needed. Potential routes for expansion of naloxone provision include through community pharmacies. The aim of this scoping review is to establish what is known about community pharmacy supply of naloxone, in light of unique challenges and opportunities present in pharmacy settings.

Methods

A scoping review methodology was employed using the six stage iterative process advocated by Arksey and O’ Malley (2005) and Levac et al. (2010). Searches used key words and terms such as ‘naloxone’; ‘overdose prevention/drug overdose/opiate overdose’; ‘community/retail pharmacy’; ‘pharmacist/pharmacy/community pharmacy/pharmaceutical services’; ‘professional practice/role’; ‘community care’; attitude of health personnel’; ‘training/supply/cost’). Appropriate search terms were selected for each database. After initial exploratory searches, comprehensive searches were conducted with Cochrane Database of Systematic Reviews, Medline, Medline in Process, Embase, PsycINFO and CINAHL. Eligibility criteria centered on whether studies broadly described supply of naloxone in community pharmacy or had content relating to community pharmacy supply.

Results

The search identified 95 articles, of which 16 were related to pharmacy supply of naloxone. Five themes were presented after initial review of the data and consultation with the project Expert Group, and are; ‘Pharmacists Perceptions of Naloxone: Facilitators and Barriers’, ‘Patient Populations: Identification and Recruitment’, ‘Supply Systems and Cost’, ‘Legal Issues’, and ‘Training of Pharmacists and Community Pharmacy Naloxone Recipients’.

Conclusion

The community pharmacy based route for distribution of take home naloxone provision warrants further consideration and development. Existing strengths include a range of established supply models, and training curricula, few direct concerns regarding legal liability of pharmacists in the supply of naloxone (once legal supply systems have been established) and the wide range of potential identifiable patient populations, which include pain patients that may not be in contact with existing naloxone supply programmes.

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By:  Suzanne Nielsen, Marie Claire Van Hout

Affiliations

• National Drug and Alcohol Research Centre, University of New South Wales, Australia

• Drug and Alcohol Services, South Eastern Sydney Local Health District

Correspondence

• Corresponding author.at: National Drug and Alcohol Research Centre University of New South Wales Sydney 2052, Australia.

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“There's Nothing Here”: Deindustrialization as Risk Environment for Overdose

Applying the “risk environment” approach proposed by ( Rhodes, 2002; Rhodes, 2009 ), this study considers the diverse contextual factors contributing to drug overdose in a deindustrialized region of the United States. 

The Monongahela Valley of Pennsylvania, once a global center of steel production, has suffered a mass exodus of jobs, residents, and businesses since a national manufacturing crisis erupted in the early 1980s; more recently, it has seen a dramatic uptick in accidental drug poisoning deaths. 

Where recent local and national media attention to overdose has focused on suburban areas and middle class victims, this study concentrates instead on the deteriorating mill city of McKeesport, Pennsylvania. Eighteen clients of the city's sole drug treatment facility participated in in-depth interviews concerning their direct experience with accidental overdose. Specifically, participants were asked to describe their own most recent overdose event and/or the last overdose they had personally witnessed. They were also asked to speculate upon the roots of the local overdose epidemic, while venturing possible remedies. 

In relating their overdose experiences, participants characterized a micro-level risk environment that was hidden behind closed doors, and populated by unprepared, ambivalent overdose “assistants.” Tasked with explaining a geographic concentration of overdose in and around McKeesport, interviewees referenced the hopelessness of the area and its lack of opportunity as driving the use of heroin, with many explicitly suggesting the need for jobs and community reinvestment to reduce fatalities. 

While state and county efforts to ameliorate overdose mortality have focused upon creating an open market in naloxone, this study suggests the need for interventions that address the poverty and social isolation of opiate users in the post-industrial periphery.

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By:  Katherine McLean

The Pennsylvania State University - Greater Allegheny, 4000 University Drive, McKeesport, PA, 15131, United States

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Correlates of Overdose Risk Perception among Illicit Opioid Users

BACKGROUND:

Opioid-related mortality continues to increase in the United States. The current study assesses demographic and behavioral predictors of perceived overdose risk among individuals who use opioids illicitly. By examining these correlates in the context of established overdose risk factors, we aim to assess whether characteristics and behaviors that have been associated with actual overdose risk translate to higher perception of risk.

METHODS:

We conducted a cross-sectional survey of 172 adult illicit opioid users in San Francisco, CA and used multivariable logistic regression to identify predictors of perception of high risk for opioid overdose.

RESULTS:

Age (aOR=0.96, 95%CI=0.93-1.00) and number of injection days per month (0.91, 0.86-0.97) were associated with a lower odds of perceived high overdose risk. There was no independent association between use of opioid analgesics, concurrent use of opioids and benzodiazepines or cocaine, or HIV status and overdose risk perception.

CONCLUSIONS:

Opioid users who injected more frequently and those who were older were less likely to perceive themselves as being at risk of overdose, notwithstanding that those who inject more are at higher risk of overdose and those who are older are at higher risk overdose mortality. In addition, despite being established overdose risk factors, there was no relationship between use of opioid analgesics, concurrent use of opioids and cocaine or benzodiazepines, or self-reported HIV status and overdose risk perception. These findings highlight key populations of opioid users and established risk factors that may merit focused attention as part of education-based overdose prevention and opioid management strategies.

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By:  Rowe C1, Santos GM2, Behar E3, Coffin PO2.

• 1San Francisco Department of Public Health, 25 Van Ness Avenue, Suite 500, San Francisco, CA 94102, USA. Electronic address: chris.rowe@sfdph.org.
• 2San Francisco Department of Public Health, 25 Van Ness Avenue, Suite 500, San Francisco, CA 94102, USA; University of California, San Francisco, 500 Parnassus Avenue, San Francisco, CA 94143, USA.
• 3San Francisco Department of Public Health, 25 Van Ness Avenue, Suite 500, San Francisco, CA 94102, USA. 
• Drug Alcohol Depend. 2015 Dec 30. pii: S0376-8716(15)01833-5. doi: 10.1016/j.drugalcdep.2015.12.018. 

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What are opioids:  http://goo.gl/ncoQ9R 

Prevention of Injury and Violence in the USA

In the first three decades of life, more individuals in the USA die from injuries and violence than from any other cause. Millions more people survive and are left with physical, emotional, and financial problems. Injuries and violence are not accidents; they are preventable. Prevention has a strong scientific foundation, yet efforts are not fully implemented or integrated into clinical and community settings. In this Series paper, we review the burden of injuries and violence in the USA, note effective interventions, and discuss methods to bring interventions into practice. Alliances between the public health community and medical care organisations, health-care providers, states, and communities can reduce injuries and violence. We encourage partnerships between medical and public health communities to consistently frame injuries and violence as preventable, identify evidence-based interventions, provide scientific information to decision makers, and strengthen the capacity of an integrated health system to prevent injuries and violence.

Below:  Top 10 leading causes of death for ages 1 to 30 years – United States, 2010

Below:  Age-adjusted suicide and homicide rates by race/ethnicity – United States, 2010

Below:  Rates of opioid overdose deaths, sales and treatment admissions – United States, 1999–2010

Full article at:   http://goo.gl/xH8Uiq

By:  Tamara M Haegerich, Linda L Dahlberg, Thomas R Simon, Grant T Baldwin, David A Sleet, and Arlene I Greenspan

National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, US Department of Health and Human Services, Atlanta, GALinda C Degutis, Independent Consultant, Atlanta, GA

Correspondence to: Dr. Tamara M Haegerich, Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA, Email: vog.cdc@hciregeaht

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Brief Overdose Education Is Sufficient for Naloxone Distribution to Opioid Users

BACKGROUND:

While drug users are frequently equipped with naloxone for lay opioid overdose reversal, the amount of education needed to ensure knowledge of indications and administration is unknown.

METHODS:

We administered four instruments, assessing comfort and knowledge around opioid overdose and naloxone administration, to opioid users receiving naloxone for the first time (N=60) and upon returning for a refill (N=54) at community distribution programs. Participants completed the instruments prior to receiving naloxone; first-time recipients repeated the instruments immediately after the standardized 5-10min education.

RESULTS:

Comfort with recognition of, response to, and administration of naloxone for an overdose event significantly increased after brief education among first-time recipients (p<0.05). Knowledge of appropriate responses to opioid overdose was high across all assessments; 96% of participants could identify at least one acceptable action to assess and one acceptable action to care for an opioid overdose. Facility with naloxone administration was high across all assessments and significantly increased for intranasal administration after education for first-time recipients (p<0.001). First-time recipients (before and after education) and refillers demonstrated a high level of knowledge on the Brief Overdose Recognition and Response Assessment, correctly identifying a mean of 13.7 out of 16 overdose scenarios.

CONCLUSIONS:

Opioid users seeking naloxone in San Francisco have a high level of baseline knowledge around recognizing and responding to opioid overdose and those returning for refills retain that knowledge. Brief education is sufficient to improve comfort and facility in recognizing and managing overdos

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By:  Behar E1, Santos GM2, Wheeler E3, Rowe C4, Coffin PO2.

• 1San Francisco Department of Public Health, Substance Use Research Unit, San Francisco, CA, USA. Electronic address: Emily.behar@sfdph.org.
• 2San Francisco Department of Public Health, Substance Use Research Unit, San Francisco, CA, USA; University of California San Francisco, San Francisco, CA, USA.
• 3Harm Reduction Coalition, Oakland, CA, USA.
• 4San Francisco Department of Public Health, Substance Use Research Unit, San Francisco, CA, USA; University of California Berkeley, Berkeley, CA, USA.
• Drug Alcohol Depend. 2015 Mar 1;148:209-12. doi: 10.1016/j.drugalcdep.2014.12.009. Epub 2014 Dec 19. 

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Evaluation of Overdose Prevention Trainings in NYC: Knowledge and Self-Efficacy among Participants Twelve Months after Training

BACKGROUND:

Prevention of unintentional opioid overdose deaths is effective through overdose prevention trainings (OPTs), in which laypersons are taught overdose response through six actions. This longitudinal study examines trainee knowledge twelve months after OPT completion.

METHODS:

We enrolled participants following OPT at six sites. At twelve months follow-up, participants were asked to: name the drug overdoses that naloxone reverses; name overdose response actions. We created a 6-point scale comprised of number of correct overdose response actions mentioned (check breathing; administer sternum rub; call 911; give rescue breathing; administer naloxone; put victim in recovery position). We compared mean knowledge by participant sociodemographic characteristics, confidence, and site of OPT training (indoors versus outdoors).

RESULTS:

273 of 344 OPT participants were reached at twelve months. Nearly all (99%) participants identified that naloxone reverses heroin; 77% opioid analgesics; and 68% methadone overdoses. Overdose response actions most frequently mentioned were giving naloxone (86%) and calling 911 (76%). The remaining four actions were mentioned by less than 40% of participants. Overall mean knowledge score was 2.7 out of 6. Mean knowledge scores were higher for college graduates than those with less than college education (3.2 vs 2.6, p<0.001), for those who felt very confident (mean score (ms) = 2.9), compared to somewhat confident (ms = 2.4) and a little or not at all confident (ms = 1.5) in their ability to reverse an overdose (p<.001), and for indoor-training recipients (3.0 vs 2.5, p = 0.02). There were no differences in mean knowledge scores for trainees by age, race, or gender.

CONCLUSIONS:

Our findings suggest the need for several improvements in OPT curriculum, including emphasis on naloxone reversal of opioid analgesic and methadone overdoses, and all 6 rescue actions. Lower knowledge scores among outdoor-trained participants likely reflect session brevity, suggesting that outdoor trainings need to be enhanced.

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By:  Maldjian L1, Siegler A1, Kunins HV1.

• 1a Department of Health and Mental Hygiene , Bureau of Alcohol and Drug Use Prevention, Care and Treatment , Queens , NY , USA.
• Subst Abus. 2016 Jan 5:0

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