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

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

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

23. Effect of naloxone on overdose death: Chicago, US See http://www.anypositivechange.org

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