Deborah Zador

Heroin-related deaths in New South Wales, Australia, 1992-1996

The coronial files of all heroin-related fatalities that occurred in New South Wales (NSW) over the period 1992-1996 were inspected. There were 953 heroin-related fatalities in NSW over the study period. There was a substantial, statistically significant increase in heroin-related fatalities over the study period, from 152 deaths in 1992 to 226 during 1996. The mean age of cases was 31.0 years, 85% were male, and 85% were classified as dependent on heroin at the time of death. There was a significant increase in the age of cases over the study period and the proportion of cases that were employed. Fatalities predominantly occurred in home settings (61%). No intervention occurred in 79% of cases. Fifty deaths (5%) occurred in the month following release from prison, 16 of which occurred the first 24 hours after release. Morphine concentrations rose from 0.24 mg/l in 1992 to 0.38 mg/l in 1996. Seventy six percent of cases involved heroin in combination with other drugs: alcohol (46%), benzodiazepines (27%), antidepressants (7%) and cocaine (7%). In only 24% of cases was morphine the sole drug detected. Males were significantly more likely to have alcohol detected at autopsy (49 vs. 24%), while females were more likely to have benzodiazepines detected (41 vs. 17%). The median blood morphine concentration among cases in which alcohol was detected was significantly lower than other cases (0.27 vs. 0.39 mg/l). It is concluded that heroin-related deaths continued to rise throughout the study period, and that deaths were predominantly among older, untreated males. Despite the rise in blood morphine concentrations, polydrug use remained the predominant toxicological pattern.

The alcohol withdrawal syndrome

The alcohol withdrawal syndrome (AWS) is a set of signs and symptoms that typically develops in alcohol-dependent people within 6–24 h of their last drink. It may occur unintentionally if abstinence is enforced by illness or injury, or deliberately if the person voluntarily stops drinking because of an alcohol-related illness, or as a prelude to becoming and remaining abstinent. The signs and symptoms of the syndrome (panel) are largely, but not exclusively, those of autonomic hyperactivity, the reverse of the effects of alcohol intoxication. They represent a homoeostatic readjustment of the central nervous system (CNS) to the neuroadaptation that occurs with prolonged alcohol intoxication.1 RC Turner, PR Lichstein and JG Peden et al., Alcohol withdrawal syndromes: a review of pathophysiology, clinical presentation and treatment, J Gen Intern Med 4 (1989), pp. 432–444. Full Text via CrossRef | View Record in Scopus | Cited By in Scopus (39)1 They vary in severity from mild to severe.1

Supervised injectable heroin or injectable methadone versus optimised oral methadone as treatment for chronic heroin addicts in England after persistent failure in orthodox treatment (RIOTT): a randomised trial

BACKGROUND Some heroin addicts persistently fail to benefit from conventional treatments. We aimed to compare the effectiveness of supervised injectable treatment with medicinal heroin (diamorphine or diacetylmorphine) or supervised injectable methadone versus optimised oral methadone for chronic heroin addiction. METHODS In this multisite, open-label, randomised controlled trial, we enrolled chronic heroin addicts who were receiving conventional oral treatment (>or=6 months), but continued to inject street heroin regularly (>or=50% of days in preceding 3 months). Randomisation by minimisation was used to assign patients to receive supervised injectable methadone, supervised injectable heroin, or optimised oral methadone. Treatment was provided for 26 weeks in three supervised injecting clinics in England. Primary outcome was 50% or more of negative specimens for street heroin on weekly urinalysis during weeks 14-26. Primary analysis was by intention to treat; data were adjusted for centre, regular crack use at baseline, and treatment with optimised oral methadone at baseline. Percentages were calculated with Rubins rules and were then used to estimate numbers of patients in the multiple imputed samples. This study is registered, ISRCTN01338071. FINDINGS Of 301 patients screened, 127 were enrolled and randomly allocated to receive injectable methadone (n=42 patients), injectable heroin (n=43), or oral methadone (n=42); all patients were included in the primary analysis. At 26 weeks, 80% (n=101) patients remained in assigned treatment: 81% (n=34) on injectable methadone, 88% (n=38) on injectable heroin, and 69% (n=29) on oral methadone. Patients on injectable heroin were significantly more likely to have achieved the primary outcome (72% [n=31]) than were those on oral methadone (27% [n=11], OR 7.42, 95% CI 2.69-20.46, p<0.0001; adjusted: 66% [n=28] vs 19% [n=8], 8.17, 2.88-23.16, p<0.0001), with number needed to treat of 2.17 (95% CI 1.60-3.97). For injectable methadone (39% [n=16]; adjusted: 30% [n=14]) versus oral methadone, the difference was not significant (OR 1.74, 95% CI 0.66-4.60, p=0.264; adjusted: 1.79, 0.67-4.82, p=0.249). For injectable heroin versus injectable methadone, a significant difference was recorded (4.26, 1.63-11.14, p=0.003; adjusted: 4.57, 1.71-12.19, p=0.002), but the study was not powered for this comparison. Differences were evident within the first 6 weeks of treatment. INTERPRETATION Treatment with supervised injectable heroin leads to significantly lower use of street heroin than does supervised injectable methadone or optimised oral methadone. UK Government proposals should be rolled out to support the positive response that can be achieved with heroin maintenance treatment for previously unresponsive chronic heroin addicts. FUNDING Community Fund (Big Lottery) Research section, through Action on Addiction.

A comparison of blood toxicology of heroin-related deaths and current heroin users in Sydney, Australia

Blood toxicology results for deaths attributed to heroin overdose during 1995 in the South Western Sydney (SWS) region (n = 39) were compared with those of a sample of 100 current SWS heroin users who had injected within the preceding 24 h. Heroin-related deaths had a higher median concentration of morphine than current heroin users (0.35 versus 0.09 mg/l). However, there was substantial overlap between the blood morphine concentrations of the two groups, ranging from 0.08-1.45 mg/l. This range incorporated 90% of heroin-related deaths. A third of current users had morphine concentrations over twice the toxic blood morphine concentration employed by the analytical laboratories, and 7% had morphine levels higher than the median recorded for fatal cases. Alcohol was detected in 51% of fatal cases (median = 0.10 g/100 ml) compared with 1% of current heroin user. There was a significant negative correlation among fatal cases between blood morphine and blood alcohol concentrations (r2 = -0.41). There was no significant difference between groups in the proportions of subjects positive for blood benzodiazepines. The results raise questions about the mechanisms of death in what are termed overdoses, and about the role of alcohol in these fatalities.

Methodology for the Randomised Injecting Opioid Treatment Trial (RIOTT): evaluating injectable methadone and injectable heroin treatment versus optimised oral methadone treatment in the UK.

Whilst unsupervised injectable methadone and diamorphine treatment has been part of the British treatment system for decades, the numbers receiving injectable opioid treatment (IOT) has been steadily diminishing in recent years. In contrast, there has been a recent expansion of supervised injectable diamorphine programs under trial conditions in a number of European and North American cities, although the evidence regarding the safety, efficacy and cost effectiveness of this treatment approach remains equivocal. Recent British clinical guidance indicates that IOT should be a second-line treatment for those patients in high-quality oral methadone treatment who continue to regularly inject heroin, and that treatment be initiated in newly-developed supervised injecting clinics.The Randomised Injectable Opioid Treatment Trial (RIOTT) is a multisite, prospective open-label randomised controlled trial (RCT) examining the role of treatment with injected opioids (methadone and heroin) for the management of heroin dependence in patients not responding to conventional substitution treatment. Specifically, the study examines whether efforts should be made to optimise methadone treatment for such patients (e.g. regular attendance, supervised dosing, high oral doses, access to psychosocial services), or whether such patients should be treated with injected methadone or heroin.Eligible patients (in oral substitution treatment and injecting illicit heroin on a regular basis) are randomised to one of three conditions: (1) optimized oral methadone treatment (Control group); (2) injected methadone treatment; or (3) injected heroin treatment (with access to oral methadone doses). Subjects are followed up for 6-months, with between-group comparisons on an intention-to-treat basis across a range of outcome measures. The primary outcome is the proportion of patients who discontinue regular illicit heroin use (operationalised as providing >50% urine drug screens negative for markers of illicit heroin in months 4 to 6). Secondary outcomes include measures of other drug use, injecting practices, health and psychosocial functioning, criminal activity, patient satisfaction and incremental cost effectiveness. The study aims to recruit 150 subjects, with 50 patients per group, and is to be conducted in supervised injecting clinics across England.

The Fine Line between Harm Reduction and Harm Production – Development of a Clinical Policy on Femoral (Groin) Injecting

Background/Aims: The femoral region (‘groin’) appears to be increasingly commonly used by injecting drug users in the UK. With the advent of Britain’s first supervised prescribed injectable opioid treatment clinic, unprecedented decisions and judgements were required about the safe supervision of this practice, or whether to permit this behaviour on site at all. This paper reports the reasons for, and outcome of, development of a clinical policy on injecting into the deep femoral vein (groin injecting). Method: A small in-depth audit of the complications of femoral injecting was undertaken in a supervised injecting clinic. Results: All femoral injectors had had either local site-related medical complications or other health problems which could potentially be worsened by ongoing injection. This finding along with the personal and professional issues raised by staff for supervision of femoral injecting led to a revised policy focussing on achieving a shift towards lower-risk peripheral venous and intramuscular sites. Conclusion: While the clinic staff’s training may be more compatible with professional duties of care by encouraging cessation of femoral injecting, this does not tell us what advice harm reduction workers in the field should offer groin injectors. More research is needed into this high-risk, controversial injecting practice.

Challenge of reducing drug-related deaths

The public-health attention given to deaths caused by illicit drug use in general, and by drug overdose in particular, should be commensurate with their contribution to premature death. For too long these deaths have been regarded as an unavoidable hazard of illicit drug use, their neglect abetted by the implicit view that the lives of illicit drug users are less deserving of being saved than those of others. In its report published this week,1 the UK Advisory Council on the Misuse of Drugs (ACMD) has rejected these implicit assumptions. Its view is that “drug-related deaths can, will and must in the near future be radically reduced in number”. It points out that the effort that society expends on preventing premature deaths “should apply no less to drug misusers than it does to other classes of people”.1

Using ambulance attendances to recruit people who have experienced non-fatal heroin overdose

AIMS To trial two novel methods of recruiting people who experience non-fatal heroin overdose through the ambulance service. SETTING Melbourne and Sydney, Australia. METHODS In Melbourne potential participants were given numbered contact cards by ambulance paramedics after revival, while in Sydney potential participants were approached after revival by a researcher who travelled with ambulance paramedics to the overdose scene. RESULTS In Melbourne 281 cards were distributed during the period 1 June 1998-31 December 1998 and a subsequent contact rate of 24% was achieved with 14% attending a subsequent interview. In Sydney there were 170 initial contacts of which 139 (82%) answered a series of questions asked at the scene (the remainder either ineligible or incapable of answering questions) with 48 (35%) also attending for follow-up interviews. CONCLUSIONS Recruitment through contact with ambulance services is a novel method of recruiting heroin users for research into non-fatal heroin overdose with advantages over other methods of sampling for research on non-fatal heroin overdose.

Drug use, health and social outcomes of hard-to-treat heroin addicts receiving supervised injectable opiate treatment: secondary outcomes from the Randomized Injectable Opioid Treatment Trial (RIOTT)

AIMS The Randomized Injectable Opioid Treatment Trial (RIOTT) compared supervised injectable heroin (SIH) and supervised injectable methadone (SIM) with optimized oral methadone (OOM) (ISRCTN0133807). Heroin addicts (previously unresponsive to treatment) made significant reductions in street heroin use at 6 months when treated with SIH. We now examine secondary outcomes. DESIGN Multi-site randomized controlled trial (RCT) comparing SIH versus OOM and SIM versus OOM. SETTING Three supervised injectable opiate clinics in England. PARTICIPANTS Chronic refractory heroin addicts continuing to inject street heroin virtually daily despite oral substitution treatment (n = 127), randomized to either SIH(n = 43), SIM(n = 42) or OOM(n = 42). All received high levels of medical and psychosocial support. MEASUREMENTS SECONDARY OUTCOMES wider drug use, crime, health and social functioning at 6 months. FINDINGS At 6 months, no significant differences were found between treatment groups in wider drug use (crack/cocaine, benzodiazepines, alcohol), physical and mental health (SF-36) or social functioning. Within each treatment group, significant reductions were observed in crime [SIH = odds ratio (OR) 0.05; P < 0.001; SIM = OR 0.11; P = 0.002; OOM = OR 0.11; P = 0.003] and money spent per week on illicit drugs (SIH = mean change £-289.43; P < 0.001; SIM = mean change £-183.41; P < 0.001; OOM = mean change £-162.80; P < 0.001), with SIH significantly more likely to have reduced money spent on illicit drugs versus OOM (mean difference £-92.04; P < 0.001). Significant improvements were seen in physical health for SIH and SIM (SIH = mean change 3.97; P = 0.008; SIM = mean change 4.73; P = 0.002) and mental health for OOM (mean change 6.04; P = 0.013). CONCLUSIONS Supervised injectable heroin treatment and supervised injectable methadone treatment showed no clearly identified benefit over optimized oral methadone in terms of wider drug use, crime, physical and mental health within a 6-month period, despite reducing street heroin use to a greater extent. However, all interventions were associated with improvements in these outcomes.

Differences between injectors and non-injectors, and a high prevalence of benzodiazepines among drug related deaths in Scotland 2003

Drug related deaths (DRDs) have been increasing in Scotland over at least the past decade. This study aimed to describe the characteristics (gender, age, ICD10 cause of death), toxicology and circumstances of all Scotlands DRDs in 2003 to help inform a national overdose prevention strategy. Coronial files for 300/317 (95%) DRDs registered with the General Register Office for Scotland (GROS) in 2003 were examined retrospectively (in 2004). Characteristics: 241/300 (80%) were male. Mean age at death was 32.8 years (SE 0.63, range 16–82). Route of administration was injecting for 137/268 (51%) who were classifiable. Classified injectors were more likely to be male (91%: 124/137) and younger (mean age of 32 years) than those whose death was by a non-injecting route (male: 87/131 (66%) and mean age of 35 years). Twenty-five to forty-four year olds made up 108/137 DRDs by injecting (79%), but only 62/131 (47%) by non-injecting routes. Cases of intentional self-poisoning (injectors 1; non-injecting 34) and undetermined intent (injectors 14; non-injecting 26) were infrequent among injectors. Of those who died by the injecting route, 108/137 were known intravenous drug users, but so too were 29/131 DRDs by non-injecting routes. Toxicology: overall 38/300 cases of DRD (13%) were negative for opioid drugs–only 2/137 DRDs by injecting (1%) were negative for opioids compared with 33/131 (25%) by non-injecting route. Methadone was present for 15/137 DRDs by injecting route (11%) and for 57/131 DRDs by non-injecting routes (44%, p < 0.001). Presence of dihydrocodeine, and anti-depressants was about three times and six times respectively, more likely in DRDs by non-injecting routes. Irrespective of route, two-thirds of DRDs tested positive for benzodiazepines (202/300 DRDs). Circumstances: time between overdose and death was within the hour for 61/137 DRDs (45%) by injecting, but rarely by non-injecting routes (3%: 4/131). Three out of four DRDs occurred in a house or flat: 98/137 DRDs (72%) by the injecting route and 101/131 (77%) by non-injecting routes. Interpretation: A relatively high proportion of cases died by non-injecting routes. National mortality databases should separate out cases of injecting-related DRD from non-injecting cases, and public health strategies to reduce DRDs should distinguish between these groups. Widespread availability in Scotland of prescribed and illicit benzodiazepines needs attention.