Transcript MMT-Belfast

Overdose deaths from street heroin
and prescribed methadone:
analysis and prevention options
Professor John Strang
National Addiction Centre, London, UK
Issues to be covered today
Topic 1: Analysis of the overdose death problem
Topic 2: How could we respond more effectively?
Issues to be covered today
Topic 1: Analysis of the overdose death problem
Why the special attention to the opiates?
Methadone as well as heroin (in the UK)
Injecting heroin, in particular
Special time of risk – at start and after the end of treatment
Special time of risk – on release from prison
Topic 2: How could we respond more effectively?
Methadone – dose
Methadone – supervision
Take-Home Emergency Naloxone
Issues to be covered today
Topic 1: Analysis of the overdose death problem
Why the special attention to the opiates?
Methadone as well as heroin (in the UK)
Injecting heroin, in particular
Special time of risk – at start and after the end of treatment
Special time of risk – on release from prison
Topic 2: How could we respond more effectively?
Methadone – dose
Methadone – supervision
Take-Home Emergency Naloxone
Drug-related deaths in England and Wales 1997
– 2002 (ONS)
Drug
Prevalence in general
population (use in last
year, age 16-59)
No. of deaths in the
last 5 years
Cannabis
10.8%
78
Cocaine
2.4%
508
Amphetamine
1.5%
436
Ecstasy
2%
200
Opiates (inc Heroin,
morphine &
methadone)
0.2%
6,194
Drug-related deaths in England and Wales 1997
– 2002 (ONS)
Drug
Prevalence in general
population (use in last
year, age 16-59)
No. of deaths in the
last 5 years
Cannabis
10.8%
78
Cocaine
2.4%
508
Amphetamine
1.5%
436
Ecstasy
2%
200
Opiates (inc Heroin,
morphine &
methadone)
0.2%
6,194
Issues to be covered today
Topic 1: Analysis of the overdose death problem
Why the special attention to the opiates?
Methadone as well as heroin (in the UK)
Injecting heroin, in particular
Special time of risk – at start and after the end of treatment
Special time of risk – on release from prison
Topic 2: How could we respond more effectively?
Methadone – dose
Methadone – supervision
Take-Home Emergency Naloxone
Total number of drug-related deaths in
England with associated substances: 19932001 (ONS).
1993
1997
2000
2001
(% change)
Total annual -England
821
1237
1561
1524
(-2%)
Heroin and Morphine
187
445
926
889
(-4%)
Methadone
232
421
238
207
(-13%)
Cocaine
12
39
80
96
(+20%)
MDMA/Ecstasy
8
12
36
55
(+53%)
“Methadone heals, but methadone also kills.
The challenge is to achieve the former
without incurring the latter”.
1600
1400
1200
1000
800
600
400
200
0
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
prescriptions per annum (x 1000)
NHS methadone prescriptions per annum
(England 1990-2002)
35
30
25
20
15
10
5
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
0
1993
Directly age-standardised mortality
rate per million
Trends in O/D deaths – heroin and
methadone (Hickman et al, IJE, 2006)
METHADONE Male
METHADONE Female
HEROIN/MORPHINE Male
HEROIN/MORPHINE Female
35
30
25
20
15
10
5
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
0
1993
Directly age-standardised mortality
rate per million
Trends in O/D deaths – heroin and
methadone (Hickman et al, IJE, 2007)
METHADONE Male
METHADONE Female
HEROIN/MORPHINE Male
HEROIN/MORPHINE Female
Issues to be covered today
Topic 1: Analysis of the overdose death problem
Why the special attention to the opiates?
Methadone as well as heroin (in the UK)
Injecting heroin, in particular
Special time of risk – at start and after the end of treatment
Special time of risk – on release from prison
Topic 2: How could we respond more effectively?
Methadone – dose
Methadone – supervision
Take-Home Emergency Naloxone
London PAI Study #1:
438 Early Heroin Users
[48% in first 3 years; 45% SDS6]
Overdose history among 98 (22%)
Of 309 ever-injectors, 96 (31%) had overdosed
Of 125 never-injectors, 2 (2%) had overdosed
(c2=44.2, p<0.001 [data missing on 4])
(Gossop, Griffiths, Powis, Williamson and Strang, BMJ, 1996)
HOW COMMON
(among injectors)?
London PAI Study #2:
312 injectors
Personal overdose? - 117 (38%)
Witnessed overdose? - 157 (50%)
Witnessed fatal O/D? - 46 (15%)
(Strang, Griffiths, Powis, Fountain, Williamson and Gossop, Drug and
Alcohol Review, 1999)
Aus (Adelaide) PAI Study #2:
218 heroin users (i.e. injectors)
Personal overdose? - 48%
Witnessed overdose? - 70%
(Witnessed fatal O/D? - n/a)
(McGregor, Darke, Ali and Christie, Addiction, 1998)
Issues to be covered today
Topic 1: Analysis of the overdose death problem
Why the special attention to the opiates?
Methadone as well as heroin (in the UK)
Injecting heroin, in particular
Special time of risk – at start and after the
end of treatment
Special time of risk – on release from prison
Topic 2: How could we respond more effectively?
Methadone – dose
Methadone – supervision
Take-Home Emergency Naloxone
When in particular?
During methadone early treatment
Post-detox/rehab
Risk of death during and after
treatment
BMJ 2010;341:c5475
Issues to be covered today
Topic 1: Analysis of the overdose death problem
Why the special attention to the opiates?
Methadone as well as heroin (in the UK)
Injecting heroin, in particular
Special time of risk – at start and after the end of treatment
Special time of risk – on release from prison
Topic 2: How could we respond more effectively?
Methadone – dose
Methadone – supervision
Take-Home Emergency Naloxone
When in particular?
Post-detox/rehab
During methadone early treatment
Prison release
Post-release ‘carnage’
Seaman Brettle Gore, BMJ, 1998
Bird & Hutchinson, Addiction, 2002
Farrell & Marsden, Addiction, 2008
Prevalence of drug dependence
Drug dependence prior to prison
Substance Misuse in Prisoners 2002 Singleton N, Farrell M, Meltzer H ONS.
Excess mortality ratio
Excess mortality ratio for different time periods post-release by
cause of death (Singleton, Farrell, Marsden et al 2003)
45
40
35
30
25
20
15
10
5
0
U
Drug-related deaths
o1
t
p
3
6
2
1
2
5
o2
o4
o8
t
t
t
o
o
o
t
t
t
p
p
p
p
up
up
1u
2u
4u
8u
3
6
1
2
Time since release (w eeks)
Not drug-related
2
5
>=
l
a
t
To
Issues to be covered today
Topic 1: Analysis of the overdose death problem
Why the special attention to the opiates?
Methadone as well as heroin (in the UK)
Injecting heroin, in particular
Special time of risk – at start and after the end of treatment
Special time of risk – on release from prison
Topic 2: How could we respond more effectively?
Methadone – dose
Methadone – supervision
Take-Home Emergency Naloxone
Issues to be covered today
Topic 1: Analysis of the overdose death problem
Why the special attention to the opiates?
Methadone as well as heroin (in the UK)
Injecting heroin, in particular
Special time of risk – at start and after the end of treatment
Special time of risk – on release from prison
Topic 2: How could we respond more effectively?
Methadone – dose
Methadone – supervision
Take-Home Emergency Naloxone
Cochrane review of dose and methadone
Faggiano et al (2007) Cochrane review of
significance of dose in methadone OST
Retention rate - RCTs: High versus low doses at shorter
follow-ups: RR=1.36 [1.13,1.63], and at longer ones:
RR=1.62 [0.95,2.77].
Opioid use (self reported), times/w - RCTs: high versus
low doses WMD= -2.00 [-4.77,0.77] high vs middle
doses WMD= -1.89[-3.43, -0.35]
Opioid abstinence, (urine based) at >3-4w-RCTs: high
versus low doses: RR=1.59 [1.16,2.18] high vs middle
doses RR=1.51[0.63,3.61]
Cocaine abstinence (urine based) at >3-4 w - RCTs: high
versus low doses RR=1.81 [1.15,2.85]
Overdose mortality: high dose versus low dose at 6 years
follow up: RR=0.29 [0.02-5.34] high dose vs middle
dose at 6 years follow-up: 0.38 [0.02-9.34] middle dose
vs low dose at 6 years follow-up: RR=0.57 [0.06-5.06]
Issues to be covered today
Topic 1: Analysis of the overdose death problem
Why the special attention to the opiates?
Methadone as well as heroin (in the UK)
Injecting heroin, in particular
Special time of risk – at start and after the end of treatment
Special time of risk – on release from prison
Topic 2: How could we respond more effectively?
Methadone – dose
Methadone – supervision
Take-Home Emergency Naloxone
What is the OD4 Index?
OD4 = ODDDD (Overdose Deaths per
Daily Dispensed Dose)
Thus essentially a measure of safety of a
medication, as applied
Issues to be covered today
Topic 1: Analysis of the overdose death problem
Why the special attention to the opiates?
Methadone as well as heroin (in the UK)
Injecting heroin, in particular
Special time of risk – at start and after the end of treatment
Special time of risk – on release from prison
Topic 2: How could we respond more effectively?
Methadone – dose
Methadone – supervision
Take-Home Emergency Naloxone
Pre-filled syringe
1 mg per ml, 2 ml syringe
available from: Antigen, Aurum, Mayne £6.30
First investigated:
Strang J, Powis B, Best D et al (1999)
Preventing opiate overdose fatalities with
take-home naloxone: pre-launch study of
possible impact and acceptability. Addiction,
94 (2): 199-204.
Structure – 4 areas
Training elements
(a) how to recognise overdose
(b) how to manage situation – general
(c) how to give naloxone
Person unconscious, and cannot be
woken – UNROUSABLE
CYANOSIS – BLUE lips or tongue
Not breathing at all or breathing slowly –
deep snoring.
Pin point pupils
A – Ambulance - CALL AMBULANCE
B- Breathing - Check Airway – clear if
blocked, Check breathing.
C – reCovery - If breathing, place in recovery
position – if not breathing, begin
basic life support
Administer naloxone
How to inject Naloxone – intramuscular
(into muscle)
Remove syringe from box and packet
Attach needle to syringe
Inject into the outer thigh, upper arm or outer part of buttock
Hold needle 90 degree above skin
Insert needle into muscle (needs pressure)
Slowly and Steadily push plunger all the way down
Put syringe back in box. Don’t cover needle
Changes in knowledge after training
***All significant at p<0.001
10
9
Before training
8
After training
7
6
5
4
3
2
1
0
risks (7)
signs (8)
Clinicians
actions (11)
risks (7)
signs (8)
Clients
actions (11)
Carers – the overlooked intervention
workforce
102 carers attending 4 organisations
•
•
•
•
•
•
•
80% parents, 20% other relative/partner
96% of opiate users, 87% IDU, 57% in Tx,
1/3 used in presence of carer, 47% had past OD
20% of carers had witnessed an OD
5 had lost user to fatal OD (3 children 2 partners)
16% would ‘panic’ or ‘not know what to do’
83% expressed an interest OD management & N training
Evidence of potential to extend naloxone…
Strang, Manning, Mayet et al, (2008) Family carers
and prevention of heroin overdose deaths: ……
Drugs: Education, Prevention & Policy, 15: 211-218.
Does the naloxone ever get used?
Initial experience ……
Berlin/Jersey – about 10% used within a year
New Mexico, USA – 2/100 within few months
Chicago, USA – 52/550
Dettmer, Saunders and Strang, BMJ, 2001
Baca et al, BMJ, 2001
Bigg, BMJ, 2002
N-ALIVE trial – pilot & main phase
N-ALIVE research trial proposal to
test/prove reduced deaths post-release
Pilot – n=5600
Main study – n=56000 (28k + 28k)
Conclusiona
Topic 1: Analysis of the overdose death problem
Why the special attention to the opiates?
Methadone as well as heroin (in the UK)
Injecting heroin, in particular
Special time of risk – at start and after the end of treatment
Special time of risk – on release from prison
Topic 2: How could we respond more effectively?
Methadone – dose
Methadone – supervision
Take-Home Emergency Naloxone
Thank you