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DrugInfo seminar: Heroin and other opioids - patterns of use and harm and Australian responses

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Presentation to the DrugInfo seminar: Heroin and other opioids, 27 September 2011, in Melbourne, Australia.

Presentation to the DrugInfo seminar: Heroin and other opioids, 27 September 2011, in Melbourne, Australia.

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  • 1. Heroin and other opioids – patterns of use and harm and Australian responses Paul Dietze, Trevor King, Louisa Degenhardt, Stuart Kinner, Margaret Hellard
  • 2. Heroin and other opioids – Paper outline Trends Patterns of use and harms Consequences Overdose Policy responses Prescription and regulation Treatments Substitution therapy Abstinence based therapy Additional supports Special needs groups Prisoners and ex-prisoners Harm reduction Overdose response
  • 3. Heroin and other opioids – NDS survey results 2010 Males Females total Heroin 0.2 Prescription painkillers 3 3 3 Other opiates 0.4 Methadone/buprenorphine 0.2
  • 4. Heroin and other opioids – NSP survey results Taken from: Iverson, J. Topp, L. & Maher, L. (2011) AUSTRALIAN NSP SURVEY NATIONAL DATA REPORT 1995 ‐ 2010 Sydney, Kirby Institute, UNSW. Drug last injected % 2000 2002 2004 2006 2008 2010 Heroin 56 36 36 26 34 34 Methadone 3 7 7 9 8 7 Buprenorphine 1 2 5 5 4 Pharm opioids 4 7 8 12 15 16 Methamphetamine 22 33 33 38 28 26
  • 5. Heroin and other opioids – mortality (2007) Taken from: Roxburgh A. and Burns L. (2011) Drug-induced deaths in Australia, 2007 Edition. Sydney, National Drug and Alcohol Research Centre, UNSW.
  • 6. Heroin and other opioids – trends in heroin overdose (2008-10) Taken from: Lloyd B. (2011). Trends in alcohol and drug related ambulance attendances in Melbourne: 2009/10. Fitzroy, Victoria: Turning Point Alcohol and Drug Centre
  • 7. Heroin and other opioids – trends in ‘other’ heroin attendances (2008-10) Taken from: Lloyd B. (2011). Trends in alcohol and drug related ambulance attendances in Melbourne: 2009/10. Fitzroy, Victoria: Turning Point Alcohol and Drug Centre
  • 8. Heroin and other opioids – trends in opioid analgesic attendances Taken from: Lloyd B. (2011). Trends in alcohol and drug related ambulance attendances in Melbourne: 2009/10. Fitzroy, Victoria: Turning Point Alcohol and Drug Centre
  • 9. Policy responses Primary prevention Prevent or delay onset of use Secondary prevention Treating problems in early stages of development Tertiary prevention Arresting or retarding existing condition National Drug Strategy Harm minimisation (supply reduction, demand reduction, harm reduction) National Pharmaceutical Drug Misuse Strategy Currently being finalised
  • 10. Treatment responses Opioid Substitution Therapy Methadone, buprenorphine, buprenorphine-naloxone, ?Other opioids, esp heroin Withdrawal Not treatment on its own, agonist assisted Psycho-social rehabilitation Therapeutic Communities Residential and non-residential options Self-help Narcotics Anonymous Antagonists Not recommended for routine treatment
  • 11. Issues for OST system Treatment costs Non-PBS medications, dispensing fees Jurisdictional variation Access varies according to location Stigma Quality Dosing issues, facilities OST misuse Misuse and injection
  • 12. Opioid overdose (e.g. heroin)
    • Heroin binds to receptor sites in the central nervous system
    • One of the sites is in the respiratory control centre
    • Blocks the body’s ability to detect carbon dioxide levels
  • 13. Respiratory Arrest
    • Raised CO 2 levels and low O 2 levels
    • Systemic acidosis affecting the brain, heart, lungs and kidneys
    • Lowered blood pressure
    • Low GCS
    • Lowered or loss of gag and cough reflex which increases the aspiration risk
  • 14. Signs of heroin overdose
    • Altered consciousness (eg low GCS)
    • Depressed respiration (‘snoring’)
    • Cyanosis
    • Weak or absent pulse
  • 15. People who use heroin overdose on heroin but they die from respiratory arrest and its consequences
  • 16. Overdose Risks Reduced tolerance Prison, abstinence-based treatment Mixing drugs CNS depressants, e.g. alcohol, benzodiazepines Too much heroin (possibly related to tolerance) Public injecting Shifting locations Route of administration Injection increased risk compared to inhalation
  • 17. Reducing overdose risks Increased access to treatment OST in particular Prevention protocols Discharge from prison/treatment Education for users Key messages: poly drug use, using alone, reduced tolerance Overdose management and response Recognising overdose signs, call ambulance, airway management and EAR Naloxone for peer administration Protocols around ambulance attendances at overdose Reduce risks associated with calling ambulance
  • 18. (Green, Heimer & Grau, 2008) New Mexico (Piper et al, 2007) NYC (Chicago Recovery Alliance, 2008) (Seal et al, 2005) San Francisco Peer naloxone
  • 19. Distributing naloxone
  • 20. Peer Naloxone - U.S. research From Green, Heimer & Grau (2008)
    • Chicago since 1997 Chicago Recovery Alliance (CRA) 2001
      • 6200 10-dose vials, 465 reversals
    • NYC through Harm Reduction Coalition (HRC) since 2005
      • To 2005, Overall 150 trained, over 100 reversals
    • New Mexico Dept of Health since 2001
      • To 2005, 700 enrolled, 200 reversals
    • San Francisco Drug Overdose Prevention & Education (DOPE) since 2001
      • To 2006, 1300 prescribed pre-loaded syringes, 160 reversals
    • Baltimore Staying Alive OD Prevention Program since 2004
      • To 2006, 960 trained, over 114 reversals
  • 21. Issues with Peer Administration
    • Will it delay 000 call?
    • Could it lead to aseptic administration, Hepatitis C risk?
    • How to manage drug storage and expiry?
    • Affected peers: can they recognise the problem, administer the drug, ventilate appropriately and manage overdose patients after response to treatment?
    • What is the correct dosage in this environment? What extra dosage should be used if needed?
  • 22.
    • Delivery device
    • Dose
    • Training
      • Content
      • Response
      • Competency
      • Target group
    Program Issues
  • 23. Effect of naloxone on overdose death: Chicago, US See http://www.anypositivechange.org
  • 24. Research Issues
    • Levels of evidence
      • Qualitative interviews
      • Process evaluations
      • Case series - retrospective recall
      • Observational epidemiology
      • RCTs?
  • 25. Prisoners Opioid use 19% heroin 18% other analgesics 10% on OST Overdose risk Major elevation following release Responses OST in prison OST linkages OST subsidy
  • 26. Conclusions Research questions Can peer naloxone prevent deaths in the Australian context? Managing pharmaceuticals Real time monitoring of prescription and dispensing Services Enhancing OST National Drug Strategy Harm minimisation (supply reduction, demand reduction, harm reduction) National Pharmaceutical Drug Misuse Strategy Currently being finalised