Victoria Manning

Overdose training and take-home naloxone for opiate users : prospective cohort study of impact on knowledge and attitudes and subsequent management of overdoses

AIM To examine the impact of training in overdose management and naloxone provision on the knowledge and confidence of current opiate users; and to record subsequent management of overdoses that occur during a 3-month follow-up period. DESIGN Repeated-measures design to examine changes in knowledge and confidence immediately after overdose management training; retention of knowledge and confidence at 3 months; and prospective cohort study design to document actual interventions applied at post-training overdose situations. METHOD A total of 239 opiate users in treatment completed a pre-training questionnaire on overdose management and naloxone administration and were re-assessed immediately post-training, at which point they were provided with the take-home emergency supply of naloxone. Three months later they were re-interviewed. RESULTS Significant improvements were seen in knowledge of risks of overdose, characteristics of overdose and appropriate actions to be taken; and in confidence in the administration of naloxone. A 78% follow-up rate was achieved (186 of 239) among whom knowledge of both the risks and physical/behavioural characteristics of overdose and also of recommended management actions was well retained. Eighteen overdoses (either experienced or witnessed) had occurred during the 3 months between the training and the follow-up. Naloxone was used on 12 occasions (a trained clients own supply on 10 occasions). One death occurred in one of the six overdoses where naloxone was not used. Where naloxone was used, all 12 resulted in successful reversal. CONCLUSIONS With overdose management training, opiate users can be trained to execute appropriate actions to assist the successful reversal of potentially fatal overdose. Wider provision may reduce drug-related deaths further. Future studies should examine whether public policy of wider overdose management training and naloxone provision could reduce the extent of opiate overdose fatalities, particularly at times of recognized increased risk.

New estimates of the number of children living with substance misusing parents: results from UK national household surveys

BackgroundThe existing estimates of there being 250,000 - 350,000 children of problem drug users in the UK (ACMD, 2003) and 780,000 - 1.3 million children of adults with an alcohol problem (AHRSE, 2004) are extrapolations of treatment data alone or estimates from other countries, hence updated, local and broader estimates are needed.MethodsThe current work identifies profiles where the risk of harm to children could be increased by patterns of parental substance use and generates new estimates following secondary analysis of five UK national household surveys.ResultsThe Health Survey for England (HSfE) and General Household Survey (GHS) (both 2004) generated consistent estimates - around 30% of children under-16 years (3.3 - 3.5 million) in the UK lived with at least one binge drinking parent, 8% with at least two binge drinkers and 4% with a lone (binge drinking) parent. The National Psychiatric Morbidity Survey (NPMS) indicated that in 2000, 22% (2.6 million) lived with a hazardous drinker and 6% (705,000) with a dependent drinker. The British Crime Survey (2004) and NPMS (2000) indicated that 8% (up to 978,000) of children lived with an adult who had used illicit drugs within that year, 2% (up to 256,000) with a class A drug user and 7% (up to 873,000) with a class C drug user. Around 335,000 children lived with a drug dependent user, 72,000 with an injecting drug user, 72,000 with a drug user in treatment and 108,000 with an adult who had overdosed. Elevated or cumulative risk of harm may have existed for the 3.6% (around 430,000) children in the UK who lived with a problem drinker who also used drugs and 4% (half a million) where problem drinking co-existed with mental health problems. Stronger indicators of harm emerged from the Scottish Crime Survey (2000), according to which 1% of children (around 12,000 children) had witnessed force being used against an adult in the household by their partner whilst drinking alcohol and 0.6% (almost 6000 children) whilst using drugs.ConclusionWhilst harm from parental substance use is not inevitable, the number of children living with substance misusing parents exceeds earlier estimates. Widespread patterns of binge drinking and recreational drug use may expose children to sub-optimal care and substance-using role models. Implications for policy, practice and research are discussed.

Cocaine Use in Europe – A Multi-Centre Study: Patterns of Use in Different Groups

Aim: The study investigates patterns of cocaine powder and crack cocaine use of different groups in nine European cities. Design, Setting, Participants: Multi-centre cross-sectional study conducted in Barcelona, Budapest, Dublin, Hamburg, London, Paris, Rome, Vienna, and Zurich. Data were collected by structured face-to-face interviews. The sample comprises 1,855 cocaine users out of three subgroups: 632 cocaine users in addiction treatment, mainly maintenance treatment; 615 socially marginalized cocaine users not in treatment, and 608 socially integrated cocaine users not in treatment. Measurements: Use of cocaine powder, crack cocaine and other substances in the last 30 days, routes of administration, and lifetime use of cocaine powder and crack cocaine. Findings: The marginalized group showed the highest intensity of cocaine use, the highest intensity of heroin use and of multiple substance use. 95% of the integrated group snorted cocaine powder, while in the two other groups, injecting was quite prevalent, but with huge differences between the cities. 96% of all participants had used at least one other substance in addition to cocaine in the last 30 days. Conclusions: The use of cocaine powder and crack cocaine varies widely between different groups and between cities. Nonetheless, multiple substance use is the predominating pattern of cocaine use, and the different routes of administration have to be taken into account.

Drinking and smoking as concurrent predictors of illicit drug use and positive drug attitudes in adolescents

The study investigates the relationship between smoking and drinking, and the use of illicit drugs in a cohort of London adolescents. A high prevalence of drug experimentation and positive attitudes to illicit drug use were characteristic of those who both drank alcohol and smoked cigarettes on a regular basis. There was then a clear hierarchy in which lower prevalence of use and more negative attitudes marked those who only smoked, then those who only drank, while non-smokers and non-drinkers (the largest group) had lowest lifetime and recent drug use prevalence and the most negative attitudes about drug use.

Cocaine Use in Europe – A Multi-Centre Study

An increase in the use of cocaine and crack in several parts of Europe has raised the question whether this trend is similar to that of the USA in the 1980s. However, research in the field of cocaine use in Europe has been only sporadic. Therefore, a European multi-centre and multi-modal project was designed to study specific aspects of cocaine and crack use in Europe, in order to develop guidelines for public health strategies. Data on prevalence rates were analysed for the general population and for specific subgroups. Despite large differences between countries in the prevalence of cocaine use in the general population, most countries show an increase in the last few years. The highest rate with a lifetime prevalence of 5.2% was found for the United Kingdom, although with a plateau effect around the year 2000. With regard to specific subgroups, three groups seem to show a higher prevalence than the general population: (1) youth, especially in the party scene; (2) socially marginalized groups, such as homeless and prostitutes or those found in open drug scenes; (3) opiate-dependent patients in maintenance treatment who additionally use cocaine. Specific strategies need to be developed to address problematic cocaine use in these subgroups.

Ethnic and gender differences in drinking and smoking among London adolescents.

Objectives. The study examines stages of drinking and smoking careers and transitions from initiation to regular use among adolescents, as a function of ethnic status and gender. Design. The data were collected using a confidential, self-completion questionnaire assessing onset and frequency of drinking and smoking. The sample consisted of 1777 adolescents, between the ages of 11 and 14, drawn from eight secondary schools in south-west London. Results. For both smoking and drinking, white children were more likely to have ever smoked tobacco and drunk alcohol, and were also more likely to progress from initiation to regular use than were either black or Asian children. Asian children reported the latest onset and the lowest prevalence rates for both drinking and smoking. Males reported experimenting with both cigarettes and alcohol at an earlier age than females, although a lower proportion of males report regular and lifetime involvement with both alcohol and tobacco. Furthermore, a significantly higher proportion of females who try smoking go on to do so regularly. Discussion. The importance of sociocultural factors in relation to race and gender in predicting onset and escalation of substance use is discussed. The fact that age of onset does not appear to be a significant determinant of transition rate from initiation to regular use is also explored.

Can we prevent drug related deaths by training opioid users to recognise and manage overdoses

BackgroundNaloxone has been evidenced widely as a means of reducing mortality resulting from opiate overdose, yet its distribution to drug users remains limited. However, it is drug users who are most likely to be available to administer naloxone at the scene and who have been shown to be willing and motivated to deliver this intervention. The current study builds on a national training evaluation in England by assessing 6-month outcome data collected primarily in one of the participating centres.MethodsSeventy patients with opioid dependence syndrome were trained in the recognition and management of overdoses in Birmingham (n = 66) and London (n = 4), and followed up six months after receiving naloxone. After successful completion of the training, participants received a supply of 400 micrograms of naloxone (in the form of a preloaded syringe) to take home. The study focused on whether participating users still had their naloxone, whether they retained the information, whether they had witnessed an overdose and whether they had naloxone available and were still willing to use it in the event of overdose.Results & DiscussionThe results were mixed - although the majority of drug users had retained the naloxone prescribed to them, and retention of knowledge was very strong in relation to overdose recognition and intervention, most participants did not carry the naloxone with them consistently and consequently it was generally not available if they witnessed an overdose. The paper discusses the reasons for the reluctance to carry naloxone and potential opportunities for how this might be overcome. Future issues around training and support around peer dissemination are also addressed.ConclusionOur findings confirm that training of drug users constitutes a valuable resource in the management of opiate overdoses and growth of peer interventions that may not otherwise be recognised or addressed. Obstacles have been identified at individual (transportability, stigma) and at a systems level (police involvement, prescription laws). Training individuals does not seem to be sufficient for these programmes to succeed and a coherent implementation model is necessary.

Cognitive impairment in dual diagnosis inpatients with schizophrenia and alcohol use disorder

Cognitive impairment has been found independently among individuals with schizophrenia and individuals with alcohol use disorders. Less is known about the nature and severity of cognitive impairment in patients with a dual diagnosis, though the co-occurrence of these disorders may further exacerbate cognitive impairment. The study investigates the possible additive effect of alcohol use disorder and schizophrenia on cognitive impairment among patients diagnosed with schizophrenia. Participants were inpatients with schizophrenia (n=30), inpatients with a dual diagnosis of schizophrenia and alcohol use disorder (n=30), and matched controls (n=30): all completed a comprehensive neuropsychological battery. Both patient groups were significantly impaired, relative to controls, across the battery. Dual diagnosis patients were significantly more impaired than schizophrenia patients on delayed verbal memory, and executive functioning, primarily set-shifting, working memory, and planning, and had higher psychiatric morbidity scores. The findings provide support for an additive effect of the two disorders on cognitive impairment. These cognitive deficits may affect capacity to engage in treatment, increase risk of relapse, and adversely affect treatment outcomes. An understanding of the cognitive profile of people with dual diagnosis may help to tailor treatment delivery to meet their specific needs, enhance cognitive strengths, accommodate deficits and improve treatment outcomes.

Cannabis use in adolescents: the impact of risk and protective factors and social functioning

The study uses a school-based sample to test the social and familial risk and protective factors relating to cannabis use. Based on a self-completion survey of 2078 14-16-year-olds (mean age of 15 years) attending seven standard state-run secondary schools in south London, an assessment was made of rates and risk factors for cannabis use. Twenty-four per cent of the total sample had ever used cannabis, with 15% having done so in the month prior to assessment. In addition to greater likelihood of illicit drug use, lifetime cannabis users were less likely to spend time regularly with both their mothers and fathers, but more likely to spend free time with friends who smoked, drank alcohol and used illicit drugs, and with friends involved in criminal activities. Among those who had ever used cannabis, frequency of cannabis use was predicted (using linear regression) by two onset factors (earlier initiation of drinking and cannabis use were both linked to more frequent use) and two social factors (more time spent with drug-using friends and less time spent with the mother). Overall, the study showed that early onset, itself predicted by social networks, is linked to more frequent use of cannabis and that this appears to be sustained by less time spent with parents and more with drug-using peers.

Family carers and the prevention of heroin overdose deaths: Unmet training need and overlooked intervention opportunity of resuscitation training and supply of naloxone

Aim: To assess (a) carers’ experiences of witnessing overdose; (b) their training needs; and (c) their interest in receiving training in overdose management. Design: Postal questionnaire distributed through consenting participating local carer group co-ordinators in England. Sample: 147 carers attending local support groups for friends and families of drug users. Findings: Carers were usually parents (80%); 89% were currently caring for a heroin user of whom 49% had already had an overdose (93% involving opiates). One third had witnessed heroin being used, and 31 had witnessed an overdose. For eight carers, there had already been a death from drug overdose. There was poor knowledge of how to manage an overdose. Only a quarter had received advice on overdose management (26%) and only one third knew of the opiate antagonist naloxone (33%). The majority (88%) wanted training in overdose management, especially in emergency naloxone administration (88%). Interest in training did not differ according to carer type nor previous overdose experience. Conclusion: We found evidence of an extensively overlooked carer population, many of whom have already been faced with an overdose situation and yet have received minimal training. We also found high levels of interest in receiving overdose training, in particular, in emergency naloxone administration.