|
Preventing
overdose
by Andrew Preston,
Neil Hunt and Jon Derricott
© Exchange
Campaigns / Department of Health. 2001.
Plain English Campaign
approved the clarity of this guide, and the campaign materials that go
with it.
Introduction
Causes
of overdose
Risk
factors
Injecting
and mixing drugs
Deliberate
overdose
Drug
treatment and overdose
Responding
to overdose
First
aid training
Calling
an ambulance
Myths
10
key strategies for reducing overdose deaths
Useful
contacts
Bibliography
and further reading
Back
x
Introduction
In the future, cigarette smoking and viral infections such as hepatitis
C and HIV will cause the death of large numbers of people who inject illicit
drugs. However, at the time of writing, overdose is the largest cause
of death amongst injectors.
The numbers of illicit
drug users dying as a result of overdose rose steeply during the 1990s
- doubling in the second half of the decade.
People who inject heroin
are about 14 times more likely to die than their peers.
The average age of people
dying through overdose in most studies is just 30. And, the number of
life years lost through overdose amongst men is the same as those lost
due to road traffic accidents.
The Advisory Council
on the Misuse of Drugs report ‘Reducing Drug Related Deaths’
reported that there
were 2300 drug related deaths in England and Wales in 1998.
Many of these deaths could have been prevented.
About a third of injecting
heroin users report having experienced an overdose (some of them many
times). And, about half have witnessed someone else overdosing and
more than three quarters knew someone who had died as a result of an overdose.
Drug users, many of them
in contact with drug services, are often present at fatal overdoses. If
drug services provide appropriate information, training and support on
how to respond to an overdose, it is likely that the number of deaths
can be reduced.
We have designed this
guide, and the campaign materials that accompany it, to help services
working with injecting drug users to work in a concerted way to:
1. Get the key messages
across to injecting drug users that:
- injecting drugs;
- mixing drugs and alcohol;
- mixing opiates and
other drugs; and
- using opiates when
tolerance is low, particularly after prison, detoxification or a break
in use
all increase the risk
of overdose.
2. Encourage people
who might witness an overdose to give appropriate first aid and call an
ambulance. These simple actions are life-saving responses.
3. Run first aid training
for:
- staff;
- injecting drug users;
and
- relatives of injecting
drug users and others who may be likely to witness an overdose.
top
x
Causes of
overdose
Only a minority of deaths that are reported as ‘heroin overdose’
or ‘methadone overdose’ are actually caused by taking just one
drug.
More often, death is
caused by using opiates in combination with other central nervous system
depressants - especially alcohol, and benzodiazepines.
In the presence of
other depressant drugs, a ‘normal’ or usual dose of heroin may
prove fatal.
Indeed the blood levels of heroin in those who die has often been found
to be:
- less than that which
would kill someone not used to taking heroin; and
- no different to those
of other people with a similar level of tolerance, who use the same
amounts and survive.
In many cases of overdose,
death occurs more than three hours after the heroin is injected.
This fact highlights some key issues in preventing death from overdose:
- people present at
an overdose often have time to save life by putting the person in the
recovery position and calling an ambulance; and
- combinations of sedatives
(especially when they include heroin and alcohol) are particularly dangerous.
top
x
Risk factors
There are a
number of risk factors and behaviours that, if identified, can predict
those drug users who are at greater risk of dying from an overdose.
Awareness of these amongst both those working with injecting drug users,
and injecting drug users themselves, may help to reduce the number of
deaths caused by overdose.
These risks can be
summarised as:
- injecting heroin;
- history of previous
non-fatal overdose;
- longer history of
injecting;
- high levels of drug
use or intoxication;
- high levels of alcohol
use;
- low tolerance;
- depression, feelings
of hopelessness and suicidal thoughts;
- a history of using
combinations of drugs including benzodiazepines or alcohol;
- higher risk injecting
behaviours, such as sharing or using used equipment; and
- not being in a methadone
or other treatment programme.
top
x
Injecting
and mixing drugs
Injecting heroin
greatly increases the risk of overdose. One study, carried out in London,
found that 31% of injectors had experienced a non-fatal overdose, compared
with just 2% of those who smoke heroin.
Just as talking to injectors
about their experience of witnessing overdose can create opportunities
to improve the first aid and other responses, so talking to injectors
about their past history of non-fatal overdose may help to identify, and
reduce, risk factors.
Using combinations
of depressant drugs is a major cause of overdose.
As well as the possibility of potentiating (increasing the effectiveness
of) each other, it is likely that drug users often do not fully appreciate
the risks of:
- mixing heroin (especially
when injected) with other sedative drugs taken some hours earlier;
- mixing heroin and
other sedatives with methadone, which is a very long-acting opiate;
and
- using combinations
of drugs and alcohol.
A history of recent heavy
drinking is one of the most consistent predictors of how likely a heroin
user is to overdose. This is an issue that all drug services need to tackle,
in terms of assessment and advice and information giving.
Contrary to popular
belief, variations in drug purity only account for a small proportion
of overdose deaths.
top
x
Deliberate
overdose
While impossible to quantify, it is thought that deliberate overdose -
with some degree of prior suicidal thought or intent - may account for
up to a third of overdose deaths.
Suicidal thoughts can
be an important factor in overdose, and workers should make sure that
clients have the opportunity to explore this area. Talking about these
problems is likely to reduce the risk.
People who are in methadone
treatment appear to be more likely to attempt suicide than people who
are opiate dependent and are not in treatment. This may be because they
have more severe problems. However, as they should also have access to
counselling and support, this is an area of risk that it should be possible
to reduce.
For those heroin injectors
who feel that life has little to offer, there may be a grey area between
suicidal intent and neglecting personal safety. A
feeling that life is not worth protecting can hamper efforts to get injectors
to act on life-saving messages. Services which improve the quality of
life for their clients are probably indirectly helping to reduce the risk
of overdose.
Cocaine and crack overdose
can cause strokes and heart problems. They can also play a role in deaths
due to sedative overdose drug use by temporarily masking sedative effects
and contributing to a feeling that reckless behaviour will be safe.
top
x
Drug treatment
and overdose
Although methadone is dangerous in overdose (particularly for people who
are not tolerant to its effects), scientific evidence shows that being
in effective methadone maintenance treatment
(that is treatment with adequate doses, high levels of supervision, support
and retention) greatly reduces the risk due to overdose in heroin injectors.
Heroin injectors not
in methadone treatment are around four times more likely to die than those
in treatment.
This is mainly because
of the increased risk of overdose.
The start of treatment
is associated with a higher risk of overdose than later in treatment.
It may be possible to reduce the risk of death at the start of treatment
by:
- careful assessment;
- limiting starting
doses to less than 50mg; and
- where necessary, supervised
consumption of initial doses.
Ending treatment prematurely
is also associated with increased overdose risk. This
may be due to a number of factors including loss of tolerance if the treatment
has ended following detoxification, and increased poly drug use as the
cause, or consequence, of treatment ending.
Treatment services can
cut the number of deaths by being attractive to drug users and by retaining
them in treatment. Conversely, services with high rates of discharge put
patients at risk.
Detoxification programmes
have a strong relationship with overdose deaths. In the period following
treatment, death rates of up to 22 times those of patients who stay in
methadone maintenance treatment have been reported.
It is important that
services offering opportunities for people to become drug free, tackle
the issue of helping clients to manage the overdose risk if they return
to drug/alcohol use.
top
x
Responding
to overdose
In the mid 1980s it became clear that drug injectors were prepared to
change their behaviour in order to reduce HIV risk. Reassuringly, current
injectors also seem open to messages about preventing overdose and first
aid.
Studies have shown that
in up to 97% of cases where an overdose was witnessed, someone did something
to try to help. And over half of all injectors say they would go to a
workshop on overdose aid.
It may be that heroin
injectors witnessing overdoses, having seen non-fatal overdoses before,
are over-optimistic about the probable outcome.
There is also evidence
that deep snoring, associated with breathing difficulties, is sometimes
thought to be someone sleeping soundly.
Many drug users do not
realise that there is often a long time delay (often several hours) between
injecting heroin and overdose death. People who witness overdoses may
wrongly assume that, following survival of the initial ‘hit’,
the risk of death reduces.
All potential witnesses
of an overdose including:
- drug workers;
- injecting drug users;
and
- their family and friends;
should be aware of
the signs of overdose. The signs of unconsciousness they should be able
to identify include:
- deep snoring;
- unwakeable;
- turning blue; and
- not breathing.
People who witness overdoses
need to be able to identify the transition from sleep to unconsciousness
so that they can give appropriate first aid.
If someone is unconscious
and lying on their back, their airway can become blocked by their tongue,
vomit or saliva in the back of the mouth. This can stop them breathing
and result in death.
This type of death can
be avoided if someone puts the unconscious person into the recovery position.
All staff in contact
with injecting drug users should be able to teach this skill.
Injectors should be encouraged
to practice the recovery position and to teach it to their peers.
The poster, booklet and
intervention pad that accompany this campaign are available as teaching
aids to help workers and drug users to pass on this skill among people
who take heroin.
Learning how to put someone
in the recovery position is something that is best learnt in practice.
Where appropriate, workers should teach this skill by example.
This brief intervention
can make a big difference to overdose fatalities. At the time of writing,
less than half of all injectors know how to put someone in the recovery
position.
Through concerted overdose
awareness campaigns, drugs services should aim to achieve 100% awareness
of how to put someone in the recovery position amongst injectors in contact
with the service. Drug services should also encourage wider knowledge
of this important first aid message.
Mouth-to-mouth resuscitation
and Cardio-Pulmonary Resuscitation (CPR) When
people have stopped breathing, mouth-to-mouth resuscitation is a simple
technique which can save lives.
Training in mouth-to-mouth
resuscitation (artificial respiration) and cardiac massage or cardio-pulmonary
resuscitation (CPR) should be done in a workshop situation with a qualified
trainer.
top
x
First aid
training
First aid training
covering:
- risks and signs
of overdose;
- the recovery position;
- mouth-to-mouth
resuscitation; and
- cardio pulmonary
resuscitation (CPR)
is essential for both
injecting drug users and staff who work with them.
First aid training
should also be offered to the family and friends of injecting drug users.
Many drug users who have
witnessed overdoses would have been willing to resuscitate the victim,
but couldn’t because they did not know how.
Staff need quality training
in first aid, both to teach the skills to drug users and also to deal
with overdose situations in the workplace.
Training can often be
provided by the local ambulance service. This can have the added benefits
of fostering understanding and trust between injecting drug users and
ambulance staff.
If this is not possible
or practical, almost all acute hospital trusts have qualified Resuscitation
Training Officers. And, St. John Ambulance and the Red Cross have a national
network of qualified first aid trainers who may be able to tailor courses
to the needs of your staff and client group.
Courses for injectors
can range from a single 90-minute session through to a series of six or
seven sessions which train drug users in a range of skills and techniques
to prevent overdose.
Longer courses can also
train participants to provide overdose response training to their peers.
Consideration should
be given to paying service users to come to first aid courses, as this
can be a cost-effective way of saving lives.
top
x
Calling an
ambulance
Dialling 999 and calling an ambulance to an overdose should be an instant
response. In overdoses where opiates are involved, a simple injection
of the short-acting opiate antagonist ‘naloxone’ usually brings
the person round.
All paramedics should
carry this drug and, as long as it is given in time, it is a life-saving
intervention.
One study found that
71% of people who had witnessed an overdose thought that the emergency
services should be called but only 44% had done it.
This reluctance to call an ambulance is costing lives.
As discussed earlier,
it may be that some people witnessing overdoses, having seen non-fatal
overdoses before, are over-optimistic about what will happen.
However, in some places
the main reason ambulances are not called may be fear on the part of drug
users. This is usually fear that the police will attend and possibly:
- arrest witnesses;
- search the premises;
- execute outstanding
arrest warrants; and
- pass information to
the drug squad.
In some areas the control
room staff routinely call the police to overdose incidents. Some ambulance
control rooms have a list of addresses (or even streets) to which the
police are called. These are usually addresses where there has been some
history of violence or other problems.
Although this type of
list may be necessary for operational reasons, it should be reviewed regularly
with the police and used very selectively in cases of overdose.
In Nottingham the practice
of having a list of ‘problem addresses’ and of calling the police
routinely to overdoses was identified as a factor which was putting drug
users’ lives at risk.
Changing the practice
involved:
- training for control
room staff and police;
- formal and informal
liaison between the drug service and control room staff;
- preparing appropriate
policies; and
- passing on information
to drug users about the change of policy.
Inter-agency co-operation
of this kind usually needs involvement at Drug Action Team level.
The result of such collaboration
should be a policy whereby the police are only called to those incidents
where there has been a death or where there is risk to the ambulance crew
or children.
Every drug service should
work with the police and ambulance service to establish good practice.
Drug users should be
informed of the local policy and encouraged to make sure that everyone
who overdoses receives appropriate medical help.
top
x
Myths
As well as promoting
appropriate responses to overdose, it is important to counter common myths
and dangerous practices about how to respond to overdose situations.
The most usual of these
centre around the idea that someone who is overdosing can be stimulated
into regaining consciousness.
Practices to do this
include:
- putting people in
cold baths;
- walking (or dragging)
them around
- the room; and
- inflicting pain through
hitting or even burning.
While it is important
to assess the level of consciousness of someone who may have overdosed,
if they cannot be roused when rubbed by knuckles on the sternum (centre
of the rib cage), they are unconscious - further stimulation will not
change this.
Just as it is impossible
to resist the effect of an anaesthetic through willpower, so it is impossible
to overcome the effects of overdose by willpower or stimulation.
Putting people in
cold baths is a particularly dangerous practice because:
- it may take some time
to run the bath - and the person may die during this delay;
- there is a risk of
drowning; and
- there may be a risk
of hypothermia.
Trying to walk people
around may also make the situation worse because the increased heartbeat
may increase absorption of drugs from the intestine, and the helpers may
drop the casualty.
There is some understanding
of this amongst drug users - in one study 92% of people who had witnessed
overdose had tried stimulation, yet only 62% maintained that this was
the right thing to do.
It is likely that with
better information and first aid training, the desire to help can be turned
from an intervention that may increase risk, into life-saving action.
Another dangerous
practice which has been reported is that of injecting someone who has
overdosed with salt water. There
is no medical basis for this practice.
One explanation for it
may be that drug users have seen people in hospital having a ‘drip’
put up. This is done to make sure medical staff are able to give intravenous
medication. The fluid in the ‘drip’ is usually ‘normal
saline’. This has tiny quantities of salt added to prevent disrupting
the chemistry and fluid balance of the blood - it does not affect the
overdose at all.
- Injecting people with
salt water is dangerous because it:
- wastes time that should
be spent putting the person in the recovery position and calling an
ambulance; and
- may result in exposure
to viral infection if, in the haste and panic, the salt water is given
in a used syringe.
top
x
10 key strategies
for reducing overdose deaths
1. Staff at drug treatment
agencies (and other agencies working with injecting drug users) should
have first aid training so that they can pass these skills on to injecting
drug users and respond to overdose situations within the workplace.
2. All injecting drug
users in contact with services should be given written and spoken information
on overdose risk factors and how to avoid them.
3. First aid training
should be made available to all injecting drug users, their relatives
and friends who are likely to witness an overdose.
4. First aid training
must be delivered by qualified and competent staff (although they might
usefully be helped by a drug worker or peer educator). Organisations that
can provide this training include ambulance services, St. John Ambulance,
Red Cross and acute hospital trusts.
5. Every prisoner with
a history of opiate use and every opiate user leaving residential or other
detoxification facility must be given information (such as the materials
which accompany this guide) on the risks of overdose following a break
in use and loss of tolerance.
6. High-quality, accessible
methadone treatment that keeps patients in treatment, reduces injecting,
prioritises overdose risk and improves quality of life, should be available
in all areas.
7. Every accident and
emergency department should give written and spoken information to every
opiate user they see, about preventing and managing overdose.
8. Drug Action Teams
should make sure that local procedures covering police involvement in
emergency calls for overdoses have preventing death as the first priority.
Police should not be called to the scene of an overdose unless it is essential.
9. Services should communicate
local policies regarding the involvement of the police in overdose emergency
callsto drug users.
10. All ambulance crews
should carry the opiate antagonist naloxone and be trained in how to use
it.
top
x
Useful contacts
Both St. John Ambulance and the Red Cross have national networks of qualified
first aid trainers. You can get details of local branches from their head
offices.
St. John Ambulance, National
Headquarters, 27 St. John’s Lane, London EC1M 4BU. 020 7324 4000
Red Cross, 9 Grosvenor
Crescent, London SW1 7EJ.020 7235 5454
Acorn drug service have
experience of running a successful six-session training course for injecting
drug users. This allows those taking part to give overdose prevention
and first-aid information to their peers. You can contact them at: 49
Farnham Road, Guildford, Surrey GU2 4JN. 01483 450256
For information on drawing-up
and implementing an emergency response to overdose which does not routinely
involve the police, contact: Kate Davies North Nottinghamshire Drug Action
Team c/o Ransom Hall, Southwell Road West, Rainworth, Mansfield, Notts
NG21 0ER. 01623 414114
top
x
Bibliography
and further reading
Best D, Man L, Zador D, et. al. (2000) Appreciating the extent and understanding
the causes of opiate overdose: A thematic review. Findings, 1 (4), 1-4.
The Advisory Council
on the Misuse of Drugs. (2000). Reducing drug related deaths. The Stationary
Office. London.
Bennett G A, Higgins
S. (1999) Accidental overdose among injecting drug users in Dorset UK.
Addiction 94(8), 1179-1190
Caplehorn J R, Dalton
M S, Haldar F et al. (1996) Methadone maintenance and addicts’ risk
of fatal heroin overdose. Substance Use & Misuse, 31(2), 177-196.
Darke S, Zador D (1996)
Fatal heroin ‘overdose’: a review. Addiction 91(12), 1765-1772.
Neale J, (2000). Suicidal
Intent in non-fatal illicit drug overdose. Addiction. 95 (1), 85-93.
Strang J, Best D, Man
L et al. (2000)
Peer-initiated overdose
resuscitation: fellow drug users could be mobilised to implement resuscitation.
International Journal of Drug Policy, 437-445.
Strang J, Griffiths P,
Powis B et al. (1999) Which drugs cause overdose among opiate misusers?
Study of personal and witnessed overdoses. Drug and Alcohol Review 18,
253-261.
We would like to thank
all those who have helped us produce the overdose prevention campaign
materials including:
Mike Ashton - Editor
Findings magazine;
Sarah Bates - Acorn Drug
Service;
Rupert Baillie - Community
Drug Education Project;
Gerald Bennett - East
Dorset Addiction Service;
Jill Britton - DrugScope;
Kate Davies - Co-ordinator
North Nottinghamshire Drug Action Team;
Richard Eccles - St.
John Ambulance;
Jaye Foster, the service
users and the rest of the team - HOT, London;
Mary Glover - CADAS,
Dorchester;
Lorraine Hewitt - Stockwell
Project, London;
Aamer Iqbal - Media and
Public Relations Officer, Nottinghamshire Police;
Mari Ottridge - East
Surrey Pharmacy Needle Exchange Co-ordinator;
John Perry - Red
Cross;
Rachael Pizzey - Turning
Point, Yeovil;
Frances Potter - Release;
June Richards - Acorn
Drug Service;
Kay Roberts - Greater
Glasgow Health Board.
Published by Exchange
Campaigns for DrugScope as part of the Department of Health ‘Making
Harm Reduction Work’ initiative.
The authors are responsible
for any errors or omissions.
top
Back
|
