Drugscope Harm Reduction Workshop Drugscope Harm Reduction Workshops Overdose Prevention

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Drugscope Harm Reduction Workshop
Drugscope Harm Reduction
WorkshopsOverdosePrevention

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• Dr Linda Harris
• Clinical Director
• Wakefield Integrated Substance Misuse Service

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What we will attempt to cover

• Overview of overdose what do we know about it
  and who is at risk
• Policy and guidance in relation to overdose and
  the prevention of drug related deaths
• The responsibilities of commissioners and service
  providers in reducing deaths from overdose
• Overdose training initiatives
• A look at how to apply learning from the study of
  actual cases

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Overdose is the largest cause of death amongst
injecting drug abusers

• People who inject heroin are 14x more likely to
  die than their peers
• About a third of injecting heroin users report
  having experienced an overdose
• Drug users (many of them in contact with
  services) are often present at fatal overdoses
• Deaths would be prevented if drug services
  provide appropriate information, training and
  support on how to respond to an overdose

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Dispelling Myths

• Patients who OD from opiates have used an
  excessive amount of heroin
• In the case of heroin OD death is shortly after
  the drug is injected

• WRONG - Blood levels of opiates in those who die
  is often less than that of a person who is not
  used to taking heroin
• WRONG in many cases death is more than 3 hours
  after the heroin is injected

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Getting the message across

• Stop injecting
• Dont mix drugs and alcohol
• Dont mix opiates with other drugs
• Avoid using opiates when tolerance is low, after
  a break in use e.g. on release from prison
• Encourage people who might witness an overdose to
  give appropriate first aid and call an ambulance

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Causes of overdose

• Only a minority are reported as heroin overdose
  or methadone overdose
• The majority of deaths are opiates in combination
  with other CNS depressants (especially alcohol
  and benzodiazepines)
• Failure to recognise the signs and act quickly to
  give first aid when someone is suspected to have
  gone over

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Risk factors and behaviours that are linked to OD

• who is most likely to be at risk of OD?
• Injector
• lt 30 years
• History of previous nonfatal overdose
• Longer history of injecting
• High levels of drug use and presentations of
  intoxication
• High levels of alcohol use
• Low tolerance
• Depression feelings of hopelessness and suicidal
  ideation
• History of one additional mental disorder (
  mainly depression)
• History of using drugs in combination
• Higher risk injecting behaviours
• Out of treatment not on a methadone

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Policies and guidelines

• 2000 - Advisory Council on Misuse of Drugs (ACMD)
  report Reducing Drug Related Deaths 1
• 2001 - DoH publish their response to the ACMD
  report 2
• 2002 - DATs receive guidance on providing
  resuscitation for overdose from DoH 3
• Publication of guidance for DATs on the
  development of local confidential enquiries 4

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Mortality surveillance

• Three main sources of information-
• National Programme on Substance Abuse Deaths (np
  SAD)
• Based on reports from coroner ( form F97) taking
  into account both the verdict and the cause of
  death
• Office for National Statistics (ONS)
• Publishes annual mortality figures in February of
  each year for the year ending 14 months earlier.
• Includes all deaths in England and Wales where
  the underlying cause of death is assigned to a
  given criteria of ICD 10 code using the cause of
  death reported on death certificates
• Home Office Bulletin
• Derived from Deaths reported to Coroners in
  England and Wales. Based on inquests where
  verdict on cause of death recorded as drug
  dependence or non dependent abuse of drugs

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The important role of the coroner

• Establish the circumstances and cause of death
• Investigate any possible criminal involvement
• To order a post mortem and include a request for
  toxicology when indicated
• To conduct an inquest where reports from
  police/GP/hospital are considered to decide the
  cause of death and give a verdict
• Complete the relevant mortality surveillance
  forms

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The importance of mortality studies

• Informing treatment provision, and commissioning
• E.g. evidence to back the role diverted methadone
  plays in drug related deaths 10
• higher death rate from methadone overdose
  noted over weekend 11
• CARATS team activities prison discharge
• Used to identify at risk population and
  lifestyles
• Used to influence national and local harm
  reduction interventions
• Used by drug prevention organisation and
  charities in drugs awareness campaigns
• Inform the NTA and DoH in policy initiatives and
  influences resource allocations

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Drug related deaths in Britain

• Britain has highest rate of drug related deaths
  in Europe 5
• Newly released offenders 40X more likely to die
  from a drug related cause than the general
  population 6
• 40 of the deceased have suffered from at least
  one additional mental disorder 7
• Deceased 60 more likely to have a history of
  use of concomitant drug of misuse - most
  commonly benzodiazepines and/or alcohol 8

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Drug related deaths in Britain (ONS database
1998 2002 9)

• In the period 1998 2002 around 30 of deaths
  were due to a multiple drug overdose (ONS 2004)
• ¼ of drug related deaths included alcohol
  another drug
• Deaths involving heroin are decreasing but deaths
  involving cocaine have risen to their highest
  level ever
• Deaths involving amphetamine and benzodiazepine
  increased during this period

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Govt supports local action on preventing DRDs

• Increasing concern at the rising numbers of
  preventable drug related deaths
• Almost as many life years are now lost due to
  drug-related deaths, as are lost from all road
  traffic accidents
• DoH Action Plan(2001) sets target of 20
  reduction in drug-related deaths by March 2004
  (N.T.A, 2004)

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Performance monitoring the reduction of drug
related deaths

• The NTA looks for evidence of prioritisation of
  the monitoring of drug related deaths in the DAT
  Treatment plan
• DATs are tasked with setting up local
  confidential enquiries into drug related deaths
• DRD audit along with recommendations to be
  published and disseminated
• Evidence of service user involvement crucial
  throughout the process

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DRD monitoring in Wakefield

• DAT priority area.
• Work picked up by the harm minimisation task
  group to look at local issues
• Work with local paramedics (WYMAS) and police to
  develop a relevant OD policy
• Establish DRD working group specifically to
  identify and audit those who die as a result of
  taking illicit drugs
• Purchase videos Going Over which are run in the
  waiting rooms of street agencies
• Design and display leaflets to promote key
  messages around OD
• Develop a training module on Overdose for service
  users and project workers

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Why Overdose Training?

• Evidence to suggest most overdose deaths
  preventable
• Needs assessment research in this area has
  demonstrated poor levels of basic first aid
  knowledge amongst service users
• Many misconceptions
• A way of getting the message directly to the
  service using community

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Overdose training in Wakefield

• Follows national guidance (DOH, mainliners and
  other leading groups)
• Aims to give users the information they need to
  respond to overdose situations
• Training used as a vehicle to discuss experiences
  and dispel myths
• Provides basic first aid training

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The Session

• Three hours with refreshments
• Key messages Dial 999, recovery position,
  principles of CPR
• Delivered in partnership with WYMAS, with help
  from Turning Point to recruit participants
• Neutral, local venues
• Some incentives to attend

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Feedback/evaluation

• I think it is far better to let the participants
  speak for themselves.

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A case study
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Learning Lessons

• Users and carers need to know what to do in the
  case of an overdose
• Overdose training needs to be accessible and
  skills updated regularly
• Specific advice and prioritisation should be made
  in the case of prison releasers, dual diagnosis,
  young people
• Steps taken to reduce poly drug misuse
• There is a case for training service users and or
  carers to carry and use naltrexone

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The future

• Recruit and support users to be involved in
  delivery of sessions and cascading of key
  messages
• Identify at risk groups to target
• Develop training modules to incorporate lessons
  learnt from case studies