Abundance of data, army of eager support staff, in-house statisticians and hi-tech infrastructure – what else could an addiction researcher dream of? The Urban Health Program at the British Columbia Centre of Excellence in HIV/AIDS offers endless opportunities for investigators. My first week in this paradise was full of awe, new learning and new people.
Starting on Tuesday, October 21st, Carmen Rock, the Project Coordinator, gave me an orientation to the Urban Health Research Initiative (UHRI), tour of office, and let me sign the confidentiality agreement. UHRI is located on the top, 6th, floor of the St Paul’s hospital, which was recently renovated to meet the needs of researchers. As we walked down the hallway, Carmen stopped for a moment and we could “hear” the data buzzing in the ether.
Chanson Brumme, Data Analyst, gave me a tour of the laboratory. More precisely, tour of laboratories. Although lab research isn’t my specialty, I soon realised the importance and extent of the blood analyses that went on around us. Robots and laboratory assistants were lifting, extracting, ejecting and processing samples taken from the research participants.
|photo credit: uhri.cfenet.ubc.ca
Mint Ti, Research Associate, sat down and went through a UHRI 101 tutorial with me. This introductory set of slides is available to all staff and faculty through the local intranet. Having seen the slides in advance, I was able to ask her more focused questions, such as the process of research product development and data requests to statisticians.
My last meetings of the day were with Drs. Evan Wood, Director, and Michaela Montaner, Special Projects Coordinator. Michaela’s work focuses on knowledge translation, including the Addiction Medicine education, which will be the focus of my fellowship. With Dr Wood, we were able to sketch out and quickly dip into the endless opportunities which the centre offers for investigators.
Continuing on Wednesday, October 22nd, Cody Callon, Research Coordinator, told us about the At-Risk Youth Study (ARYS), and its office systems; Amy, a Master’s student, joined us. Together, we travelled to the VIDUS (Vancouver Injection Drug Users Study) office. Elaine Fernandes, Clinical Trials Research Coordinator and Steve Kain, Nurse Coordinator, briefed us on the history of the study and new studiesthat take place in the building.
Ethnographic Tour with Ryan McNeil, Postdoctoral Research Fellow, finished my orientation on Tuesday, October 28th. Downtown Eastside (DTES) is a well-known deprived area. We walked by and talked about the key agencies and objects of the area: the Vancouver Drug Users Union (VANDU), Insite supervised injecting room and many single-room occupancy hotels SRO’s. Ryan’s radiated excitement as he described the socio-cultural phenomena happening in the area which give an ethnographer a chance to study them in vivo. Gentrification of the area is a problem for many neighbourhood citizens. The policy of the Canadian conservative government poses serious challenges for the injecting room. The authorities try to push the scene out of downtown, for example by relocating the bottle depo site. The scientists are eager to “see what happens” next.
The department of health
is reviewing distribution of Naloxone, a drug that reverses overdose, to buddies and families of heroin users. A similar scheme is in use in Britain
. The department is in discussions with the Health service executive
(HSE) to make the emergency drug more widely available. Currently, it is a prescription-only medication and can only be used by the person for whom it is prescribed, or by ambulance crews and medical staff.
On July 6th
, 2012, The Ana Liffey Drug Project
, a national addiction service, set up a Naloxone Advisory Group
. Tony Duffin, the group’s director, said that while the government’s discussions on Naloxone are welcome, it would be more beneficial to fast-track legislative changes. “I don’t know why we haven’t prioritized this in Ireland,” he said. “It’s an innocuous drug. Its only purpose is to stop opioids working. If you haven’t taken opioids, it won’t have any effect. It’s a WHO recommended medicine, so the evidence is clear. It is important that we see it widely available so we can save people’s lives.”
A [our] study* published last week, which was compiled by the medical school at UCD and the Dublin Fire Brigade
recorded 496 overdoses over a 12-month period, 13 of which were fatal. The majority of these were young men on the street, including in affluent areas of south Dublin. Most overdoses occurred in daytime, with a high incidence within 1000 meters radius of addiction services. Gerard Bury
, a professor in general practice at UCD
and one of the authors of the research, said: “Literature from other countries shows that bystanders, peers, or family members of overdose victims are most often the initial emergency responders and are best positioned to intervene immediately when the first overdose symptoms appear. These lay persons save lives if they are provided with Naloxone.”
Bury said Naloxone in a form of intranasal spray, available in America and Scotland, may be a more effective intervention than the injectable type planned by the department. “The Department of Health statement doesn’t indicate any intention to address the issue of the intranasal route, which, they told us, contravened the current regulations,” he said. “There isn’t any of the sense of urgency which you might expect in dealing with a situation in which people are literally dying in the streets.”
To read the magazine article, go to: http://www.thesundaytimes.co.uk/sto/
Dublin ambulances see an opioid overdose every day; many times near the methadone clinics. Do people shoot heroin around methadone clinics? Yes. The common sense confirms anecdotal evidence from everyday experience of clinic staff and methadone users. Although this is no rocket science for most of us, it’s much harder to prove it. Regardless of the location, the high number of overdoses in Dublin calls for an immediate distribution of the heroin antidote – Naloxone. Visit my previous post for more info on our pilot Naloxone project.
Overdose is the most common cause of deaths among heroin users. Our previous research has shown that the ambulances in Dublin see one overdose every day*. Naloxone is a life-saving nasal spray for reversing heroin overdose. It has no addictive properties, no potential for abuse and a low cost. In Ireland, it is currently used by ambulance and emergency care services as an injection into muscle, into the bone or under the skin.
Irish family doctors treat many heroin users users who are in the methadone treatment. This makes family doctors ideal to use naloxone themselves or to show patients how to use it. The new Clinical Practice Guideline of the Pre-hospital Emergency Council of Ireland advises that trained professionals can use intranasal naloxone.
Today, we ran a pilot workshop with doctors in training. It was designed to help trainees identify and manage opioid overdose with naloxone spray. The trainees listened to a short presentation, watched a video clip about how to use naloxone (Figure 1), and tried it themselves. However, they did not get the spray to take home with them.
|Figure 1 Jano simulating overdose in a pilot educational video for general practice trainees
23 young doctors from one postgraduate training scheme in Ireland participated in an hour long lunchtime workshop. We have asked them to self-assess their own knowledge of and attitudes towards naloxone using the validated Opioid Overdose Knowledge (OOKS) and Attitudes (OOAS) Scales. They did the scales before and after the workshop. Another questionnaire measured the acceptability and satisfaction with workshop. The doctors gave us valuable feedback on the session which will be analysed and published in an academic paper.
The take home message from today is that adequate training is essential for distribution of naloxone through Family Practitioners. In future studies, the knowledge from this pilot may be used to inform a train-the-trainer model. Healthcare professionals and other front-line service providers may be trained to instruct heroin users and their families in overdose prevention and naloxone use. Today’s workshop was timed perfectly, because the deaths due to overdose in the country are peaking.
*Study by: Klimas, J., O’Reilly, M., Egan, M., Tobin, H., Bury, G. (2014) Urban Overdose Hotspots: A 12-Month Prospective Study in Dublin Ambulance Services. American Journal of Emergency Medicine (Online July 30) doi: 10.1016/j.ajem.2014.07.017
Dublin ambulances see an opioid overdose every day; many times near the methadone clinics. Do people shoot heroin around methadone clinics? Yes. The common sense confirms anecdotal evidence from everyday experience of clinic staff and methadone users. Although this is no rocket science for most of us, it’s much harder to prove it.
Just as the presence of storks doesn’t cause the explosion in birth rates, methadone clinics don’t cause people to use and overdose on heroin at their door steps. Most overdoses in our study were within 1000 metres radius around the clinics, it means that they were not in the immediate vicinity of clinics. Regardless of the location, the high number of overdoses in Dublin calls for an immediate distribution of the heroin antidote – Naloxone. Visit my previous post for more info on our pilot Naloxone project.
Received: June 6, 2014; Received in revised form: June 26, 2014; Accepted: July 2, 2014; Published Online: July 30, 2014
Publication stage: In Press Accepted Manuscript
Do we need another educational video about overdose prevention? No. A simple internet search reveals hundreds of these clips. However, as the saying goes “If it hasn’t been done in Ballydehob, it can’t be true.” Of course, I tweaked the saying a bit. My point is that local problems need local(-ised) solutions.
In Dublin, Ireland, ambulance services attend to an opioid overdose every day. No surprises, the third highest rate of deaths due to drugs – 70 per million – in Europe. Reasons are complex – consequences fatal. But there is a simple solution. Naloxone, a heroin antidote, can be sprayed into an overdosed person by anybody. It is safe, harmless and cheap.
|Figure 1 Naloxone
In USA, 10,171 lives have been saved by Naloxone which have been distributed to 53,032 persons. Naloxone saves lives. And yet, “If it hasn’t been done in Ballydehop, it can’t work.” Ballydehob is a small village on the Irish coast, very far from Dublin. We can’t show that Naloxone works there, but we can do so in the University College Dublin. And so we are, developing and piloting an educational intervention on overdose prevention and naloxone distribution by general practice trainees. Why GP trainees? Reasons are complex – consequences fatal. Plus, we need to start somewhere. Irish actors and accents will help us get a buy in from the local stakeholders who can help make naloxone fully available in Ireland.
On July 1st, the UCD Centre for Emergency MedicalScience started production of a short educational video. The video shows 3 steps of response to opioid overdose with Naloxone spray:
- Assembly (Figure 3)
- Administration – spraying (Figure 4)