Category: Overdose

Annual review: Summaries, essays and productive conferences

The post on 27 deaths out of 100 people receiving methadone in primary care over 17 years was the most frequently visited of the year but also the gloomiest.
I’ve had an inspired year here at the Be-seen, with a brilliant string of posts about new research articles ranging from a progressive post from the Irish Journal of Psychological Medicine on improving writing groups for addiction researchers, to emerging treatments for cocaine addiction, and along the same theme a series covering my topic of interest in drinking by people who also use other drugs. Here’s the list of new paper summaries in chronological order:
Summaries of new papers 
* First or senior author papers
In sum, the main themes of this year were not only summaries of new papers but also essays on writing and conference reports.
Conferences April-June

With three new entries on academic and cultural meetings, these may be of great interest to my readers fascinated by communication in science and art and blending the boundaries between the two disciplines:

Write well
The fastest start is to listen to patients’ stories – make evidence based responses part of your toolkit, whether it’s responding to the iatrogenic overdose epidemic or writing effective paragraphs.  Secondly, consider making scientific writing something that sticks to the brain. Have a try at writing groups or writing classes – they can help. Have the courage to promote simplicity of writing in your field. I’m positive this is not all that I will have to say on the topic – watch this space.
Essays

Literary editors who helped
Adam Nanji, Vancouver is Awesome http://vancouverisawesome.com/
Tara Siebarth and Ashleigh VanHouten, University Affairs www.universityaffairs.ca
Stephen Strauss, Canadian Science Writers http://sciencewriters.ca/4072583
Journal editors who helped
Twelve addiction journal editors helped with publishing 16 papers:
Roger Jones, BJGP www.bjgp.org
Jeffrey Samet, Addict Sci& Clin Practice https://ascpjournal.biomedcentral.com/
Richard Saitz, J Addict Medicine www.journals.lww.com/journaladdictionmedicine/Pages/default.aspx
Richard Pates, J Substance Use www.tandfonline.com/loi/ijsu20
Tim Rhodes, J Int Drug Policy www.ijdp.org 
Michael Morgan, Addiction www.addictionjournal.org
John Lyne, Irish J Psychol Medicine www.journals.cambridge.org/article_S0790966700017535
Pedro Ruiz, Addict Disorders& Their Treatment www.journals.lww.com/addictiondisorders/Pages/default.aspx
Donata Kurpas, BMC Family Practice www.bmcfampract.biomedcentral.com
Axel Klein, Drugs and Alcohol Today www.emeraldinsight.com/toc/dat/15/4
Wim van den Brink, European Addict Research www.karger.com/EAR/
Jelle Stoffers, Eur J Gen Practice www.tandfonline.com/loi/igen20
In the meantime, I also continued to write in Slovak magazines and in my community of writers. In Slovak, I wrote for Slovo and Zpravodaj edited by Jozef Starosta and Marta Jamborova, respectively.
Early in the January and late in December, I wrote poems with my community of writers from the Thursdays Writing Collectivefacilitated by the fantastic Elee Kralji Gardiner and Amber Dawn. During the year, I wrote with the writers from the Writer’s Studio. Some of those poems landed on stage of the Vancouver Poetry Slam and on their video channel.
Thanks to all of my readers. It’s been over four years for the Be-seen blog now and I owe a lot to the editors and readers. I hope readers will continue to feel that this is a resource for them to visit and engage with.


Alcohol holding up methadone treatment

This review asked whether excessive drinking can get in the way of treating heroin addiction.

No current evidence supports the clinical requirement asking people to stop their medicines for opioid addiction if they want to enter alcohol treatment.


Although there is a lot of research behind effective strategies for the screening, diagnosis and management of an alcohol or opioid use disorder individually, less is known about how best to care for those who also use other drugs, especially since the usual treatments for opioid addiction may not be allowed in a setting of alcohol use treatment.

For example, some fellowship meetings discourage people from continuing their medication for opioid addiction (methadone).  Or some residential treatment centres require people to be “drug free” upon enrolment, which includes not using their suboxone. For safety reasons, methadone clinics reduce the dose for patients who drink excessively.

This review summarizes existing research and characterizes the prevalence, clinical implications and management options for heavy drinking among people who also use other illicit drugs.

Drinking by people using agonist medications like methadone or suboxone for opioid use disorders is common and brings along many unwanted side effects. Over time, people die.

We don’t know how to treat people who have alcohol use disorder and who also use other drugs but asking them to come off their prescribed medications isn’t based on evidence.

Nolan, S., Klimas, J., & Wood, E. (2016). Alcohol use in opioid agonist treatment. Addiction Science & Clinical Practice11, 17. http://doi.org/10.1186/s13722-016-0065-6  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5146864/

Heroin on prescription: patient stories

The hard science behind heroin-assisted treatment says: it’s save, effective and saves money. If this was a treatment for cancer or diabetes, we would give it to all for free. It would be the first line treatments for everyone. The medical insurance companies would reimburse it. But what are the patients’ stories behind this mountain of evidence? What do they think of heroin on prescription?


Story from:

Andrew Duffy: Clinic prescribes medical-grade heroin to chronic addicts. Published in Ottawa Citizen on: June 22, 2016

Story from:

Ellis, Erin: Injecting common painkiller an alternative to heroin, study finds. Published in Vancouver Sun on: April 7, 2016



“Dave Murray is a plaintiff in a legal challenge that seeks to legitimize prescription heroin. In a signed affidavit, he explains the sort of addict for which heroin maintenance could be deemed an appropriate treatment. “I have been injecting heroin and other opioids for approximately 42 years,” it reads. “I estimate that I have attempted methadone maintenance treatment (“MMT”) for my addiction at least 10 times over my life. Each of those times MMT has been ineffective for me and I returned to injecting illicit street heroin.”
“Dianne Tobin, a long-time opioids addict, suggested heroin maintenance can be especially beneficial for female addicts. “The women aren’t working the streets anymore,” she said. “I bet you 90 per cent of the women who came into the program were working (as prostitutes) or were dealing … They were mistreated and beaten up and all that by their pimps or whoever. And now they are working in the community instead.”

“Kevin McGarragan recounted how he lost his arm. He was the passenger in a car being driven to a drug buy when the driver fell asleep. “Car accident in 1993,” he said, looking at where his arm used to be. “Heroin was behind it.”
McGarragan said today, he recalls those stories as if they were from another life.”
Story from
Travis Lupick: Heroin prescriptions help addicts rebuild their lives. Published in the Star, Feb. 17, 2016


“If you met Lisa James, chances are you’d never guess she injects herself with heroin twice a day. “I did my shot an hour ago,” James says. “Do I look high? I am just normal.”
“Nobody knows I am an addict,” James says. “I share with some people and they are always shocked. ‘You’re an addict? Really? A heroin addict?’ They would just never know. And that’s a nice feeling.”
“My relationship with my daughter is better than it’s ever been,” “We appreciate the little things together,” “We all need our moms,” she says. “I am able to be her mom.”

Story from: 
Nick Purdon, Leonardo Palleja: Free heroin enables addicts to ‘have a meaningful life again,’ co-ordinator says. Published in CBC News on Sep 28, 2016

Insite Inside Out

Insite, “is that the place where people shoot up heroin? Do you shoot heroin?” a border officer asked me when he saw the sign on my T-shirt. I was puzzled by his questions, but glad he knew about Insite.

Inside works; inside out! The research proved it. This blog pays tribute to the enormous efforts of researchers, administrators, staff and clients of the supervised injection facility (SIF), who keep Insite working. Setting up SIF is feasible and other sites should be encouraged to do so.
 

photocredit: huffingtonpost.ca

June 2009: 33studies in 15 journals
(Full summaries of quoted studies are available from http://uhri.cfenet.ubc.ca/images/Documents/insite_report-eng.pdf)
1)     SIFs (Insite) may have a unique ability to address several outstanding public health and public order concerns related to injection drug use
2)     The primary cohort used to evaluate Insite was based on a random sample of IDUs recruited from within Insite
3)     Insite was being successfully integrated into the community
4)     Insite attracts drug users who are at a particularly high risk of health problems and who were previously public drug users.
5)     Frequent users of Insite are most likely to be those individuals who are also at highest risk of HIV and overdose as a result of their high-intensity injection practices
6)     Insite is used by IDUs with a high burden of HCV infection, as well as a substantial number of uninfected individuals, and therefore has the potential to help reduce risk of disease transmission.
7)     Insite has attracted a large number of hard-to-reach IDUs and that the existence of the facility presents an excellent opportunity to enhance HIV prevention through education, the provision of clean injecting equipment, and the availability of a supervised and sterile environment to self-inject.
8)     Insite has succeeded in attracting young highrisk injection drug users.
9)     Insite’s benefits on reducing the high-risk behaviours of IDUs and on increasing public order have not been offset by negative effects on drug use patterns among Vancouver’s IDU population
10)   Insite has not promoted illicit drug injecting, but rather that it has attracted individuals with long histories of injection drug use.
11)   Insite is facilitating entry into detoxification services among its clients
12)   Insite encourages IDUs to enter detox
13)   Insite has not contributed to an increase in drug-related crime in surrounding neighbourhoods.
14)   Improvement in public order was a result of the presence of Insite
15)   Insite successfully plays a role in managing overdoses among IDUs
16)   people who use heroin at least daily are more likely to report overdose
17)   Insite plays an important role in reducing overdose risk and in safely managing those overdoses that do occur
18)   Prompt medical attention at Insite prevented as many as 12 overdose deaths per year over a recent four-year period
19)   Reductions in syringe sharing observed among Insite users only occurred after Insite opened, suggesting that Insite may have been responsible for this important behavioural change
20)   Insite appears to be helping to reduce syringe sharing, the key risk factor for HIV transmission
21)   Regular SIF (Insite) users have reduced their likelihood of sharing syringes by 69%
22)   Insite’s clients who are HIV-positive used condoms with their sex partners
23)   Individuals who require help injecting were among those most likely to receive safer injecting education within Insite
24)   Insite is helping to reduce some of the health risks associated with unsafe injecting
25)   Insite nurses are reaching the high-risk injectors, particularly female injection drug users
26)   Insite is providing a safe environment in which people who inject drugs are able to learn about and adopt practices that will help them to avoid serious injection-related harms
27)   Insite may help to address barriers which normally make it difficult for injection drug users to access medical services
28)   Insite clients’ lower rate of skin infections could be a result of the medical care and treatment provided
29)   Insite is providing an opportunity to coordinate policing and public health efforts
30)   Insite’s waiting time limits its use by IDUs who continue to inject in public
31)   Insite was associated with an array of community and public health benefits and, despite rigorous evaluation, no identified adverse impacts
32)   Insite might be improved by longer hours of operation, a washroom and reduced wait times
33)   Insite is providing a safe space, away from the dangers of the street-based drug scene, for women who inject drugs
List of Published Studies until June 2009
1.     Wood E, Kerr T, Montaner JS, Strathdee SA, Wodak A, Hankins C, Schechter MT, Tyndall MW. Rationale for evaluating North America’s first medically supervised safer-injecting facility. Lancet Infectious Diseases, 2004; 4(5): 301-306.
2.     Wood E, Kerr T, Lloyd-Smith E, Buchner C, March DC, Montaner JSG, Tyndall MW. Methodology for evaluating Insite: Canada’s first medically supervised safer injection facility for injection drug users. Harm Reduction Journal, 2004; 1(1): 9.
3.     Tyndall MW, Kerr T, Zhang R, King E, Montaner JG, Wood E. Attendance, drug use patterns, and referrals made from North America’s first supervised injection facility. Drug and Alcohol Dependence, 2006; 83(3): 193-198.
4.     Wood E, Tyndall MW, Li K, Lloyd-Smith E, Small W, Montaner JSG, Kerr T. Do supervised injecting facilities attract higher-risk injection drug users? American Journal of Preventive Medicine, 2005; 29(2): 126-130.
5.     Wood E, Tyndall MW, Qui Z, Zhang R, Montaner JSG, Kerr T. Service uptake and characteristics of injection drug users utilizing North America’s first medically supervised safer injecting facility. American Journal of Public Health, 2006; 96(5): 770-773.
6.     Wood E, Kerr T, Stoltz J, Qui Z, Zhang R, Montaner JSG, Tyndall MW. Prevalence and correlates of hepatitis C infection among users of North America’s first medically supervised safer injection facility. Public Health, 2005; 119(12): 1111-1115.
7.     Tyndall MW, Wood E, Zhang R, Lai C, Montaner JSG, Kerr T. HIV seroprevalence among participants at a supervised injection facility in Vancouver, Canada: Implications for prevention, care and treatment. Harm Reduction Journal, 2006; 3(1): 36.
8.     Stoltz JA, Wood E, Miller C, Small W, Li K, Tyndall MW, Montaner J, Kerr T. Characteristics of young illicit drug injectors who use North America’s first medically supervised safer injecting facility. Addiction Research & Theory, 2007; 15(1): 63-69.
9.     Kerr T, Stoltz JA, Tyndall M, Li K, Zhang R, Montaner J, Wood E. Impact of a medically supervised safer injection facility on community drug use patterns: A before and after study. British Medical Journal, 2006; 332(7535): 220-222.
10.   Kerr T, Tyndall M, Zhang R, Lai C, Montaner J, Wood E. Circumstances of first injection among illicit drug users accessing a medically supervised safer injection facility. American Journal of Public Health, 2007; 97(7): 1228-1230.
11.   Wood E, Tyndall MW, Zhang R, Stoltz J, Lai C, Montaner JSG, Kerr T. Attendance at supervised injecting facilities and use of detoxification services. New England Journal of Medicine, 2006; 354(23): 2512-2514.
12.   Wood E, Tyndall MW, Zhang R, Montaner JS, Kerr T. Rate of detoxification service use and its impact among a cohort of supervised injecting facility users. Addiction, 2007; 102(6): 916-919.
13.   Wood E, Tyndall MW, Lai C, Montaner JSG, Kerr T. Impact of a medically supervised safer injecting facility on drug dealing and other drug-related crime. Substance Abuse Treatment, Prevention, and Policy, 2006; 1(1): 13.
14.   Wood E, Kerr T, Small W, Li K, Marsh D, Montaner JS, Tyndall MW. Changes in public order after the opening of a medically supervised safer injecting facility for illicit injection drug users. Canadian Medical Association Journal, 2004; 171(7): 731-734.
15.   Kerr T, Tyndall MW, Lai C, Montaner JSG, Wood E. Drug-related overdoses within a medically supervised safer injection facility. International Journal of Drug Policy, 2006; 17(5): 436-441.
16.   Milloy M-JS, Kerr T, Mathias R, Zhang R, Montaner JS, Tyndall Mark, Wood E. Non-fatal overdose among a cohort of active injection drug users recruited from a supervised injection facility. American Journal of Drug and Alcohol Abuse, 2008; 34(4): 499-509.
17.   Kerr T, Small W, Moore D, Wood E. A micro-environmental intervention to reduce the harms associated with drug-related overdose: Evidence from the evaluation of Vancouver’s safer injection facility. International Journal of Drug Policy, 2007; 18(1): 37-45.
18.   Milloy M-J, Kerr T, Tyndall M, Montaner J, Wood E. Estimated drug overdose deaths averted by North America’s first medically-supervised safer injection facility. PLoS ONE, 2008; 3(10): e3351.
19.   Kerr T, Tyndall M, Li K, Montaner J, Wood E. Safer injection facility use and syringe sharing in injection drug users. Lancet, 2005; 366(9482): 316-318.
20.   Wood E, Tyndall MW, Stoltz JA, Small W, Lloyd-Smith E, Zhang R, Montaner JSG, Kerr T. Factors associated with syringe sharing among users of a medically supervised safer injecting facility. American Journal of Infectious Diseases, 2005; 1(1): 50-54.
21.   Milloy M-J, Wood E. Emerging role of supervised injecting facilities in human immunodeficiency virus prevention. Addiction, 2009; 104(4): 620-621.
22.   Marshall B, Wood E, Zhang R, Tyndall M, Montaner JS, Kerr T. Condom use among injection drug users accessing a supervised injecting facility. Sexually Transmitted Infections, 2009; 85(2): 121-126.
23.   Wood E, Tyndall MW, Stoltz J, Small W, Zhang R, O’Connell J, Montaner JSG, Kerr T. Safer injecting education for HIV prevention within a medical supervised safer injecting facility. International Journal of Drug Policy, 2005; 16(4): 281-284.
24.   Stoltz JA, Wood E, Small W, Li K, Tyndall MW, Montaner JSG, Kerr T. Changes in injecting practices associated with the use of a medically supervised safer injection facility. Journal of Public Health, 2007; 29(1): 35-39.
25.   Wood RA, Wood E, Lai C, Tyndall, MW, Montaner JSG, Kerr T. Nurse-delivered safer injection education among a cohort of injection drug users: Evidence from the evaluation of Vancouver’s supervised injection facility. International Journal of Drug Policy, 2008; 19(3): 183-188.
26.   Fast D, Small W, Wood E, Kerr T. The perspectives of injection drug users regarding safer injecting education delivered through a supervised injecting facility. Harm Reduction Journal, 2008; 5(1): 32.
27.   Small W, Wood E, Lloyd-Smith E, Tyndall M, Kerr T. Accessing care for injection-related infections through a medically supervised injecting facility: A qualitative study. Drug and Alcohol Dependence, 2008; 98(1-2): 159-162.
28.   Lloyd-Smith E, Wood E, Zhang R, Tyndall MW, Montaner JSG, Kerr T. Risk factors for developing a cutaneous injection-related infection among injection drug users: A cohort study. BMC Public Health, 2008; 8(1): 405.
29.   DeBeck K, Wood E, Zhang R, Tyndall M, Montaner J, Kerr T. Police and public health partnerships: Evidence from the evaluation of Vancouver’s supervised injection facility. Substance Abuse Treatment, Prevention, and Policy, 2008; 3(1): 11.
30.   McKnight I, Maas B, Wood E, Tyndall MW, Small W, Lai C, Montaner JS, Kerr T. Factors associated with public injecting among users of Vancouver’s supervised injection facility. American Journal of Drug and Alcohol Abuse, 2007; 33(2): 319-325.
31.   Wood E, Tyndall MW, Montaner JS, Kerr T. Summary of findings from the evaluation of a pilot medically supervised safer injecting facility. Canadian Medical Association Journal, 2006; 175(11): 1399-1404.
32.   Petrar S, Kerr T, Tyndall MW, Zhang R, Montaner JS, Wood E. Injection drug users’ perceptions regarding use of a medically supervised safer injecting facility. Addictive Behaviors, 2006; 32(5): 1088-1093.
33.   Fairbairn N, Small W, Shannon K, Wood E, Kerr T. Seeking refuge from violence in street-based drug scenes: Women’s experiences in North America’s first supervised injection facility. Social Science & Medicine, 2008; 67(5): 817-823.
I wrote this post using conclusion quotes from summaries of research summed up in the document
Findings from the Evaluation of Vancouver’s Pilot Medically Supervised Safer Injection Facility – Insite. Vancouver: British Columbia Centre for Excellence in HIV/AIDS (June 2009). 

The evaluation of Insite keeps going. Check out the newest research at http://uhri.cfenet.ubc.ca.

General practice is a key route for distribution of naloxone in the community

Naloxone
Naloxone is an antidote to opioid overdose also known as Narcan.

Irish family doctors in training want Narcan to be more available and want to distribute it.    

We poled 136 Irish family doctors attending a training conference. They were in their third and final years of residency.

photocredit: oxywatchdog.com

We found that trainees have real experience of the problem at an early phase of their careers, and
trainees are conscious of the needs of people with opioid use disorders and the potential of family medicine to meet these needs, but trainees receive little structured preparation for this role.

Irish family doctors in training are keen to distribute Naloxone in the community.

More people die in Ireland due to opioid overdoses than in car accidents.
Naloxone can save lives. Ireland has approximately 640 doctors in specialist training for family medicine at any time. Although 60% of them have administered Naloxone to a person in overdose, only 13% of their training clinics prescribe methadone to people with opioid use disorders.

Reference:
Klimas, J., Tobin, H., Egan, M., Barry, T., Bury, G. (2016) General Practice – a key route for distribution of naloxone in the community. Experience, interest and training needs in Ireland. J Int Drug Policy, 38:1-3