Research paperInfrequent opioid overdose risk reduction behaviours among young adult heroin users in cities with wide coverage of HIV prevention programmes
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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2014, Gaceta SanitariaCitation Excerpt :Even though they presented lower prevalence of limited knowledge than their peers, this difference was not statistically significant, and neither was the association measure (adjusted prevalence ratio). Other studies21,29,30 have reported better scores regarding overdose prevention knowledge in those IDUs attending courses or IDU-oriented resources. We would expect finding an association between knowledge about overdose prevention and access to health care services, but in our sample, use of harm reduction resources (supervised injecting facilities and overdose prevention courses) does not seem to protect against limited knowledge.
Endogenous opiates and behavior: 2011
2012, PeptidesCitation Excerpt :Females showed greater amounts of mental distress in a heroin-assisted treatment in a German randomized controlled trial [314]. Infrequent opioid overdose risk reduction behaviors were observed among young adult heroin users in cities with wide coverage of HIV prevention programs [939]. The Andalusian trial on heroin-assisted treatment showed positive outcomes in a 2 years follow-up [982].
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The Itínere Project Group consists of the previously cited authors as well as: Albert Espelt, Yolanda Castellano, Fermín Fernández, Francisco González, Teresa C Silva, Daniel Lacasa, Noelia LLorens, Eusebio Mejías, Gemma Molist, Luis Sordo and Fernando Vallejo.