Research paper
Infrequent opioid overdose risk reduction behaviours among young adult heroin users in cities with wide coverage of HIV prevention programmes

https://doi.org/10.1016/j.drugpo.2010.06.003Get rights and content

Abstract

Background

Opioid overdose risk reduction behaviours include some preventive behaviours to avoid overdoses (PB) and others to avoid death after overdose, such as never using heroin while alone (NUA). Few studies have examined the prevalence and predictors of these behaviours.

Aim

To establish the prevalence and predictors of PBs and NUA among heroin users, both injectors and non-injectors, in three Spanish cities.

Methods

516 injecting and 475 non-injecting heroin users aged 18–30 were street-recruited in 2001–2003 and interviewed by face-to-face computer-assisted interview. PBs and NUA in the last 12 months were explored using open-ended and precoded questions, respectively. Specific predictors for three PB categories were investigated: control of route of drug administration, control of quantity or type of heroin used, and control of co-use of other drugs. Bivariate and logistic regression methods were used.

Results

Overall, the most prevalent PBs were: using a stable and not excessive amount of heroin (12.7%), injecting or using the whole heroin dose slowly or dividing it into smaller doses (12.4%), reducing or stopping heroin injection (8.3%), and not mixing heroin with tranquillisers (5.1%). Most PBs were significantly more prevalent among injectors than non-injectors. No one mentioned reducing the amount of heroin after an abstinence period. Some 36.2% had NUA. In multiple regression analysis, knowledge of risk factors for opioid overdose was a predictor of specific PBs, although this was not always the case. Use of syringe exchange programmes was a predictor of PB among injectors. However, attending methadone maintenance treatment (MMT) or other drug-dependence treatment was not a predictor of any opioid overdose reduction behaviour. Only ever having witnessed or experienced an overdose predicted PB in both injectors and non-injectors.

Conclusions

The proportion of heroin users with opioid overdose risk reduction behaviours is very low. Additional specific measures to prevent overdose are needed, as well as increased emphasis on reducing the risk of overdose in programmes to prevent HIV and other blood-borne infections in heroin injectors.

Introduction

Opioid overdose remains an important cause of death and emergency care among young people in many countries (Darke and Zador, 1996, EMCDDA, 2009, Green et al., 2009, Powis et al., 1999, Sporer, 2003). In Europe, an increase in overdose deaths was observed between 2003 and 2005 (Vicente, Giraudon, Matías, Hedrich, & Wiessing, 2009). In recent years Spain, England and Wales have reported the highest mortality rates from overdose in Europe (Morgan, Vicente, Griffiths, & Hickman, 2008). Studies have shown that non-fatal overdose is also very frequent among heroin users (annual prevalence 9–22%) (Brugal et al., 2002, Darke et al., 1996, Gossop et al., 1996).

In the field of opioid overdose prevention, there is solid evidence of the effectiveness of drug-dependence treatments (Darke et al., 2007) and especially methadone maintenance treatment (MMT) (Brugal et al., 2005, Darke and Hall, 2003, Langendam et al., 2001, Sporer, 2003, van Ameijden et al., 1999). Furthermore, some studies also suggest a beneficial effect of supervised injection facilities (SIFs) (Darke and Hall, 2003, Hedrich, 2004, MSIC Evaluation Committee, 2003) or resuscitation using naloxone by persons witnessing an opioid overdose (Darke and Hall, 2003, Doe-Simkins et al., 2009), and others describe how syringe exchange programmes (SEPs) have been used to implement specific programmes for overdose prevention (Doe-Simkins et al., 2009, Galea et al., 2005, Piper et al., 2008, Tobin et al., 2009).

Among the reasons that could explain the high rates of non-fatal opioid overdose are low prevalence of preventive behaviours to avoid opioid overdose (PB), which could be related with lack of knowledge of the main risk factors for opioid overdose (Dietze et al., 2006, Green et al., 2009, Neira-León et al., 2006), such as use of the injected route (Brugal et al., 2002, Darke and Hall, 2003), low tolerance after a period of abstinence (Darke and Hall, 2003, Farrell and Marsden, 2008) and concurrent consumption of other central nervous system depressors (Darke & Hall, 2003). However, the complexity of the mechanisms involved in the adoption of PBs can hinder the success of these educational interventions (Moore, 2004, Rhodes, 2009). This complexity would also help to explain some paradoxical findings, like the association found by Dietze et al. (2006) between knowledge of the dangers of mixing benzodiazepines and/or alcohol with heroin and an increased likelihood of such mixing prior to overdose.

Data on the number of patients in MMT and sterile syringe distribution by SEPs in the cities of Barcelona, Madrid and Seville in 2001–2003 suggest wide coverage of these programmes (AACM, 2004, Bravo et al., 2007, de la Fuente et al., 2006a, DGPNSD, 2006, Espelt et al., 2009, Secretaria del Plan Nacional sobre Sida, 2009). Other free drug-dependence treatment modalities were also easily accessible during that period (DGPNSD, 2006). However, even though harm reduction programmes generally included messages on overdose prevention, only Barcelona had a structured programme on naloxone distribution, albeit with limited coverage (AACM, 2002, AACM, 2003, AACM, 2004, Ilundain, 2009, Trujols, 2001). The Spanish national strategy on drugs does not explicitly mention overdose prevention as a priority (DGPNSD, 2005).

In 2009 the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) reported that 23 European Union member states addressed the prevention of infectious diseases among drug users as part of their national drug strategy, but only 12 countries included the reduction of drug-related deaths. The lack of awareness of the public health relevance of this issue could be a contributing factor to the sustained number of reported overdose deaths in Europe despite the downward trend in heroin injection and the expansion of treatment and harm reduction programmes in many countries.

Among the training needs identified by EMCDDA are the problems of reduced tolerance after abstinence periods and the consequences of taking multiple drugs (EMCDDA, 2008, EMCDDA, 2009). EMCDDA (2009) also emphasises that a large proportion of overdoses occur in the presence of witnesses, including drug users’ peers, family members, passers-by, police, or prison staff, a situation which could be used to advantage in avoiding deaths from overdose. In fact, quite a few countries have reported the existence of specific materials or interventions aimed at helping families, police officers or prison staff to recognise and manage drug overdoses (EMCDDA, 2009). To be most effective, these interventions should be promoted in conjunction with the message “Never use heroin while alone” (NUA).

Since many studies have focused on the prevalence of overdose and its predictors and very little work has been done on the preventive behaviours that could avoid overdose or death, we focused our study, first, on measuring the prevalence of PB and NUA in a sample of regular heroin users and second, on determining the factors that predict these risk reduction behaviours.

Since heroin injectors and non-injectors usually differ in overdose risk (Brugal et al., 2002, Darke and Hall, 2003, Darke et al., 1996), HIV prevalence (de la Fuente et al., 1999) or contact with health care services (Vallejo et al., 2007) all the analyses were stratified by injecting status. We hypothesised that prevalence of PB would be greater among heroin injectors and that different preventive factors would be identified for injectors and non-injectors. We especially focused on whether knowledge of the principal risk factors for opioid overdose and MMT or other drug-dependence treatment attendance are predictors of opioid overdose risk reduction behaviours among non-injectors or injectors, and whether SEP attendance is a predictor of risk reduction behaviours among drug injectors.

Section snippets

Materials and methods

We used data from the 991 subjects recruited at baseline in the Itinere cohort of young adult heroin users. The methodology used has been described in detail elsewhere (de la Fuente et al., 2005, Neira-León et al., 2006). Inclusion criteria were age 18–30 years, residence in the cities of Barcelona, Madrid or Seville, and having used heroin in the last 90 days, and on at least 12 days in the 12 months before the interview. The entire sample was recruited in 2001–2003 in outdoor settings by

General characteristics of the sample

Overall, 52.1% of heroin users had injected in the last 12 months (injectors). Injectors generally had a sociodemographic profile of greater social and health vulnerability than non-injectors, with higher prevalences, for example, of obtaining income from marginal activities, of being homeless, of opioid overdose, HIV infection or use of emergency care. Half of the participants scored 9 or more on the Severity of Dependence Scale (SDS); the percentage in the top level of dependence was higher

Discussion

Our study yielded several main findings: (1) The prevalence of opioid overdose risk reduction behaviours was low in this Spanish sample. (2) The prevalence of PBs was higher among injectors than among non-injectors, while the prevalence of NUA was similar in both groups. (3) Knowledge of the main risk factors for opioid overdose tends to be associated with the practice of the corresponding PB, although this is not always the case. (4) Having received treatment for drug dependence, including

Acknowledgements

Study design, collection and analysis of data were funded by the Foundation for AIDS Prevention and Research in Spain (Fipse 3035/99). A supplemental grant by RTA (RD06/0001/1018) made it possible to write the paper. We also thank Kathryn M. Fitch for translation and suggestions.
Conflict of interest

The authors have no conflict of interest to declare.

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