Category: Overdose

Families of opioid users in Ireland may be given drug to stop overdose deaths

Article from The Sunday Times, 21 September 2014, p4

The department of healthis 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 UCDand 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/
Related articles:
*Cited study: Urban Overdose Hotspots: A 12-Month Prospective Study in Dublin Ambulance Services http://www.ajemjournal.com/article/S0735-6757(14)00510-5/abstractby Jan Klimas, PhD, Martin O’ReillyMairead Egan, Bc, Helen Tobin, BSc, Gerard Bury, MD. Published Online: July 30, 2014
See also, my previous posts summarizing the quoted study: Urban Overdose Hotspots: New Paper out Now
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 Education and Naloxone: Workshop for Family Medicine Trainees in Ireland

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

Urban Overdose Hotspots: New Paper out Now

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.
Cited study: Urban Overdose Hotspots: A 12-Month Prospective Study in Dublin Ambulance Services http://www.ajemjournal.com/article/S0735-6757(14)00510-5/abstract
Study authors:
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

Shooting Overdose video

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.

Figure 2 Eric Schneiderman. Image: AP/Press association images
http://jrnl.ie/1574998


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:

  • Recognition
  • Assembly (Figure 3)
  • Administration – spraying (Figure 4)
Figure 3

Figure 4

Our work has been financed by the Irish College of General Practitioners. The college had no input into this post and the opinions aren’t theirs. They are mine.

76th Annual Conference of College on Problems of Drug Dependence: Decide to be fearless& fabulous

Not one, but two conferences in Puerto Rico made my trip fantastic. As usual, the NIDA International forum happened for the 15th time on the weekend before the Conference of the College on Problems of Drug Dependence. The lines below offer some insights from these meetings.

Integration of addiction treatment into primary care: the portals of entry

Is abstinence related with good health? Is decreased drug use related with good health?
Tae Woo Park and Richard Saitz asked these questions in a secondary analysis of data from a clinical trial of 589 patients using cocaine or cannabis with very low dependence proportion among the sample (ASSIST score >27). To answer their questions, they used clinical measures of good health, such as, SIP-D, PHQ-9, and EUROQoL. Health outcomes were associated with decreases in illicit drug use in primary. However, abstinence and decreased use may represent very different magnitudes. Self-reports related dysphoria could also play a role in the differences. It takes a long time to make improvement in those consequences? 6 months of follow up observations may not be enough. Patient-preferred outcomes are paramount: do they want to have a score lower than XY on PHQ-9? What outcomes are important for them?
The TOPCARE (www.mytopcare.org) project implemented guidelines for potential opioid misuse (Jan Liebschutz). Her slides blew up half-way through the presentation but she delivered the talk excellently. Nurse care management was a component of the guideline implementation trial. Academic detailing (45min, with opioid prescribing expert) included principles of prescribing brochure and difficult case discussion. Is academic detailing effective? The Cochranesystematic review of literature found small-to-medium variable effects. The preliminary results of the project show that the nurse manager programme is a no brainer.
Rich Saitz commented on the sad state of affairs in the addiction treatment, where only 10% of people with addiction are in treatment. Integrated care is the best thing since the sliced bread, but where’s the evidence? His research showed no added benefit of integrated versus care as usual. Why? Maybe, addiction is not a one thing, but we treat it like one thing. Dr Tai provoked the audience with a question: “Do our patients with addiction have the capability to participate in the treatment planning and referral?” If they seek medical care for their broken leg and we refer them to an addiction specialist, will they go? most likely not.
But it is the same with hypertension. Referral is a process and not a once-off thing. Although they may not follow our advice at the first visit, a rapport built by a skilled professional over a series of discussions can help them get the most appropriate care.

Does the efficacy of medications for addiction decrease over time?

An old saying among doctors states “One should prescribe a new medication quickly before it loses its efficacy”. Elias Klemperer pooled the data from several Cochrane systematic reviews on addiction medicines, such as, NIRT gum, Acamprosate, or Buproprion. Their effectiveness decreased over time. The changes in methodologies might have caused the decline; also the sponsorship of trials, target populations or publication bias.

Write, wrote, written

Primary author is in the driver’s seat, others are passengers. Primary author pulls the train. Dr Adam Carrico(UCSF) asked us “What are you really passionate about?” Find it and use your passion for those themes to drive your writing habit. Decide to be fearless& fabulous. Develop a writing routine. Put together a queue of writing projects and don’t churn out 2 products at the same time, one of them will suffer. Schedule writing retreats with colleagues. Set Timelines for writing grant and programme time for reviews by trusted people, give people a warning that this is what you’re planning to do. The JAMA June 2014 issue offers useful tips on how to write an editorial.

Dr Knudsen reported on the editorial internship of the Journal of Substance Abuse Treatment – JSAT, which started in 2006, with Dr McGovern (current editor) and Knudsen as the 1stfellows. Success rate of the fellowship applications is 2/30-45, prior involvement is appreciated (peer reviewer, submission). The new 2014 fellows are: Drs Madson and Rash. In the one year of the fellowship, the fellows typically review 12-15 manuscripts, some years, as a managing editor of a special issue. The Drug and Alcohol Dependence journal has a similar scheme.

Check out the http://www.cpddblog.com/