Paul Dietze

Randomized controlled trial comparing the effectiveness and safety of intranasal and intramuscular naloxone for the treatment of suspected heroin overdose

AIMS Traditionally, the opiate antagonist naloxone has been administered parenterally; however, intranasal (i.n.) administration has the potential to reduce the risk of needlestick injury. This is important when working with populations known to have a high prevalence of blood-borne viruses. Preliminary research suggests that i.n. administration might be effective, but suboptimal naloxone solutions were used. This study compared the effectiveness of concentrated (2 mg/ml) i.n. naloxone to intramuscular (i.m.) naloxone for suspected opiate overdose. METHODS This randomized controlled trial included patients treated for suspected opiate overdose in the pre-hospital setting. Patients received 2 mg of either i.n. or i.m. naloxone. The primary outcome was the proportion of patients who responded within 10 minutes of naloxone treatment. Secondary outcomes included time to adequate response and requirement for supplementary naloxone. Data were analysed using multivariate statistical techniques. RESULTS A total of 172 patients were enrolled into the study. Median age was 29 years and 74% were male. Rates of response within 10 minutes were similar: i.n. naloxone (60/83, 72.3%) compared with i.m. naloxone (69/89, 77.5%) [difference: -5.2%, 95% confidence interval (CI) -18.2 to 7.7]. No difference was observed in mean response time (i.n.: 8.0, i.m.: 7.9 minutes; difference 0.1, 95% CI -1.3 to 1.5). Supplementary naloxone was administered to fewer patients who received i.m. naloxone (i.n.: 18.1%; i.m.: 4.5%) (difference: 13.6%, 95% CI 4.2-22.9). CONCLUSIONS Concentrated intranasal naloxone reversed heroin overdose successfully in 82% of patients. Time to adequate response was the same for both routes, suggesting that the i.n. route of administration is of similar effectiveness to the i.m. route as a first-line treatment for heroin overdose.

The effects of cannabis and alcohol on simulated arterial driving: Influences of driving experience and task demand

This study compared the effects of three doses of cannabis and alcohol (placebo, low and high doses), both alone and in combination, on the driving performance of young, novice drivers and more experienced drivers. Alcohol was administered as ethanol (95%) mixed with orange juice in doses of approximately 0, 0.4 and 0.6g/kg. Cannabis was administered by inhalation of smoke from pre-rolled cannabis cigarettes (supplied by the National Institute of Drug Abuse, USA). Active cigarettes contained 19 mg delta-9-THC. Using a counterbalanced design, the simulated driving performance of 25 experienced and 22 inexperienced drivers was tested under the nine different drug conditions in an arterial driving environment during which workload was varied through the drive characteristics as well as through the inclusion of a secondary task. High levels of cannabis generally induced greater impairment than lower levels, while alcohol at the doses used had few effects and did not produce synergistic effects when combined with cannabis. Both cannabis and alcohol were associated with increases in speed and lateral position variability, high dose cannabis was associated with decreased mean speed, increased mean and variability in headways, and longer reaction time, while in contrast alcohol was associated with a slight increase in mean speed. Given the limitations of the study, it is of great interest to further explore the qualitative impairments in driving performance associated with cannabis and alcohol separately and how these impairments may manifest in terms of crash characteristics.

Individual and community correlates of young people's high-risk drinking in Victoria, Australia

OBJECTIVES To examine key individual- and community-level correlates of regular very high-risk drinking (more than 20 drinks at least 12 times a year for males and more than 11 drinks at least 12 times a year for females) among young (16-24) drinkers in Victoria. METHODS CATI survey of 10,879 young Victorian drinkers. Multi-level modelling of correlates of proportion drinking at very high-risk levels at both individual (e.g. age, gender) and community levels (e.g. alcohol outlet density, remoteness). RESULTS One-fifth of the sample reported regular (at least monthly) very high-risk drinking. Significant individual-level correlates of very high-risk drinking included age, gender, cultural background, recreational spending money, life stage, living situation, family conflict and age at first drink. Significant community-level correlates included remoteness (living in a rural area) and packaged liquor outlet density. CONCLUSIONS The study highlights a range of important factors relating to regular drinking of dangerous amounts of alcohol by youth. Interventions aimed at preventing early initiation or managing recreational spending should be explored. Further, regulatory management of packaged liquor outlets and or remote rural communities in Victoria with high levels of dangerous drinking should be a priority.

Overdose deaths following previous non‐fatal heroin overdose: Record linkage of ambulance attendance and death registry data

INTRODUCTION AND AIMS Experiencing previous non-fatal overdoses have been identified as a predictor of subsequent non-fatal overdoses; however, few studies have investigated the association between previous non-fatal overdose experiences and overdose mortality. We examined overdose mortality among injecting drug users who had previously been attended by an ambulance for a non-fatal heroin overdose. DESIGN AND METHODS Using a retrospective cohort design, we linked data on non-fatal heroin overdose cases obtained from ambulance attendance records in Melbourne, Australia over a 5-year period (2000-2005) with a national death register. RESULTS 4884 people who were attended by ambulance for a non-fatal heroin overdose were identified. One hundred and sixty-four overdose deaths occurred among this cohort, with an average overdose mortality rate of 1.20 per 100 person-years (95% CI, 1.03-1.40). Mortality rate decreased 10-fold after 2000 coinciding with widely reported declines in heroin availability. Being male, of older age (>35 years) and having been attended multiple times for previous non-fatal overdoses were associated with increased mortality risk. DISCUSSION AND CONCLUSIONS As the first to show a direct association between non-fatal overdose and subsequent overdose mortality, this study has important implications for the prevention of overdose mortality. This study also shows the profound effect of macro-level heroin market dynamics on overdose mortality.

Alcohol-related negative consequences among drinkers around the world

AIMS This paper examines (i) gender and country differences in negative consequences related to drinking; (ii) relative rates of different consequences; and (iii) country-level predictors of consequences. DESIGN SETTING AND PARTICIPANTS Multi-level analyses used survey data from the Gender, Alcohol, and Culture: An International Study (GENACIS) collaboration. MEASUREMENTS Measures included 17 negative consequences grouped into (i) high endorsement acute, (ii) personal and (iii) social. Country-level measures included average frequency and quantity of drinking, percentage who were current drinkers, gross domestic product (GDP) and Human Development Index (HDI). FINDINGS Overall, the three groupings of consequences were reported by 44%, 12% and 7% of men and by 31%, 6% and 3% of women, respectively. More men than women endorsed all consequences, but gender differences were greatest for consequences associated with chronic drinking and social consequences related to male roles. The highest prevalence of consequences was in Uganda and lowest in Uruguay. Personal and social consequences were more likely in countries with higher usual quantity, fewer current drinkers and lower scores on GDP and HDI. However, significant interactions with individual-level quantity indicated a stronger relationship between consequences and usual quantity among drinkers in countries with lower quantity, more current drinkers and higher scores on GDP and HDI. CONCLUSIONS Both gender and country need to be taken into consideration when assessing adverse drinking consequences. Individual measures of alcohol consumption and country-level variables are associated with experiencing such consequences. Additionally, country-level variables affect the strength of the relationship between usual quantity consumed by individuals and adverse consequences.

Enabling environments and the reduction of drug-related harm: re-framing Australian policy and practice.

In this paper Moore & Dietze use data from their study of street-based injecting drug users and sex workers in the Melbourne suburb of St Kilda to challenge the dominant emphasis of drug policy in Australia. They remind us that while existing harm reduction strategies that encourage individual behaviour change should be continued, these measures need to be complemented and extended by further attention to the environmental aspects of drug-related harm. This is a timely call. Responses targeting individual behaviour change are relatively easy to implement and less politically challenging. However, if we are really serious about reducing drug-related harm in the Australian community, then broader systemic and structural barriers which undermine these efforts must be addressed.Simon LentonEditor, Harm Reduction Digest.

Let's get Wasted! and Other Apps: Characteristics, Acceptability, and Use of Alcohol-Related Smartphone Applications

Background Smartphone applications (“apps”) offer a number of possibilities for health promotion activities. However, young people may also be exposed to apps with incorrect or poor quality information, since, like the Internet, apps are mostly unregulated. Little is known about the quality of alcohol-related apps or what influence they may have on young people’s behavior. Objective To critically review popular alcohol-related smartphone apps and to explore young people’s opinions of these apps, their acceptability, and use for alcohol-related health promotion. Methods First, a content analysis of 500 smartphone apps available via Apple iTunes and Android Google Play stores was conducted. Second, all available blood alcohol concentration (BAC) apps were tested against four individual case profiles of known BAC from a previous study. Third, two focus group discussions explored how young people use alcohol-related apps, particularly BAC apps. Results 384 apps were included; 50% (192) were entertainment apps, 39% (148) were BAC apps, and 11% (44) were health promotion and/or stop drinking–related apps. When testing the BAC apps, there was wide variation in results, with apps tending to overestimate BAC scores compared with recorded scores. Participants were skeptical of the accuracy of BAC apps, and there was an overall concern that these apps would be used as a form of entertainment, further encouraging young people to drink, rather than reduce their drinking and risk taking. Conclusions The majority of popular alcohol-related apps encouraged alcohol consumption. Apps estimating blood alcohol concentration were widely available but were highly unreliable. Health departments and prominent health organizations need to endorse alcohol smartphone apps that are accurate and evidence-based to give specific apps credibility in the ever-expanding market of unregulated apps.

Establishing the Melbourne injecting drug user cohort study (MIX): rationale, methods, and baseline and twelve-month follow-up results

BackgroundCohort studies provide an excellent opportunity to monitor changes in behaviour and disease transmission over time. In Australia, cohort studies of people who inject drugs (PWID) have generally focused on older, in-treatment injectors, with only limited outcome measure data collected. In this study we specifically sought to recruit a sample of younger, largely out-of-treatment PWID, in order to study the trajectories of their drug use over time.MethodsRespondent driven sampling, traditional snowball sampling and street outreach methods were used to recruit heroin and amphetamine injectors from one outer-urban and two inner-urban regions of Melbourne, Australia. Information was collected on participants’ demographic and social characteristics, drug use characteristics, drug market access patterns, health and social functioning, and health service utilisation. Participants are followed-up on an annual basis.Results688 PWID were recruited into the study. At baseline, the median age of participants was 27.6 years (IQR: 24.4 years – 29.6 years) and two-thirds (67%) were male. Participants reported injecting for a median of 10.2 years (range: 1.5 months – 21.2 years), with 11% having injected for three years or less. Limited education, unemployment and previous incarceration were common. The majority of participants (82%) reported recent heroin injection, and one third reported being enrolled in Opioid Substitution Therapy (OST) at recruitment. At 12 months follow-up 458 participants (71% of eligible participants) were retained in the study. There were few differences in demographic and drug-use characteristics of those lost to follow-up compared with those retained in the study, with attrition significantly associated with recruitment at an inner-urban location, male gender, and providing incomplete contact information at baseline.ConclusionsOur efforts to recruit a sample of largely out-of-treatment PWID were limited by drug market characteristics at the time, where fluctuating heroin availability has led to large numbers of PWID accessing low-threshold OST. Nevertheless, this study of Australian injectors will provide valuable data on the natural history of drug use, along with risk and protective factors for adverse health outcomes associated with injecting drug use. Comprehensive follow-up procedures have led to good participant retention and limited attrition bias.

Post-marketing surveillance of buprenorphine-naloxone in Australia: Diversion, injection and adherence with supervised dosing

BACKGROUND These studies compared the diversion and injection of buprenorphine-naloxone (BNX), buprenorphine (BPN) and methadone (MET) in Australia. METHODS Surveys were conducted with regular injecting drug users (IDUs) (2004-2009, N=881-943), opioid substitution treatment (OST) clients (2008, N=440) and authorised OST prescribers (2007, N=291). Key outcome measures include the unsanctioned removal of supervised doses, diversion, injection, motivations, drug liking and street price. Levels of injection among IDUs were adjusted for background availability of medications. Doses not taken as directed by OST clients were adjusted by total number of daily doses dispensed. RESULTS Among regular IDUs, levels of injection were lower for BNX relative to BPN, but comparable to those for MET, adjusting for background availability. Among OST clients, fewer BNX clients (13%) reported recently injecting their medication, than BPN (28%) and MET clients (23%). Fewer MET clients (10%) reported removal of supervised doses, than BPN (35%) and BNX clients (22%). There were no differences in prevalence of recent diversion (28% of all OST clients). Adjusting for the total doses dispensed, more BPN was injected (10%), removed (12%) and diverted (5%), than MET (5%, <1% and 2% respectively) and BNX (5%, 9% and <1% respectively). In 2009, the median street price of BNX was equivalent to that for BPN. CONCLUSIONS BNX was less commonly and less frequently injected than BPN, but both sublingual medications were diverted more than liquid MET.

Ambulance attendance at heroin overdose in Melbourne: the establishment of a database of Ambulance Service records

This paper presents some of the preliminary data extracted from a database of non-fatal heroin overdoses attended by ambulances in metropolitan Melbourne. The database has been developed in order to provide interested parties with reliable, high quality and timely data on heroin-related harm. Heroin overdose victims were defined as those people who were unconscious at the time the ambulance arrived and subsequently responded positively to the administration of naloxone. There were 388 heroin overdoses attended by ambulances in Melbourne over the period 1 November 1997-31 January 1998. The majority of victims were male (74 %) with an estimated mean age of 27.1 years. The overdoses occurred most commonly during the afternoon and evening, with Thursdays and Fridays most prominent. Police attendance was low (12%) and the vast majority of victims were not transported to hospital. An analysis by postcode revealed that the overdoses tended to be concentrated around a number of locations which have identified str...