Thursday, October 20, 2011

Overdose in Eastern Europe and Central Asia

The Eurasian Harm Reduction Network, which represents harm reduction groups in Central and Eastern Europe and Central Asia, recently launched a newsletter, and the first issue covers overdose in the region. You can download the English edition here, and the Russian here.

The whole issue is worth reading. It starts off with an article by OPA's own Dan Bigg on overdose as a fundamental, uniting issue in harm reduction. Other pieces present an overview of what we know about overdose in a region that stretches from the Afghan border to the heart of Europe, stories by people who have been saved from overdose by naloxone or used it on others, a story about a great overdose project in Tomsk, Russia, and much more.

Monday, October 17, 2011 relaunched!

From: Hill Duncan (NHS LANARKSHIRE)

Dear all

We are pleased to announce that the take-home naloxone website has successfully relaunched.
Please note the website address has slightly changed from .com to .org, see below:

Please update your records and links accordingly.

I hope you will find the site useful. We are still keen to add as many services as possible to populate the maps and provide website visitors with as much information to naloxone services as possible. We would be grateful if you could pass this information to others who are delivering or interested in delivering take-home naloxone services and encourage them to provide details of their service if not already included on the website. Suggestions are also welcome on how we can improve the website as we move forward.

Best wishes

Duncan Hill
Specialist Pharmacist in Substance Misuse
NHS Lanarkshire
Torrance House
504 Windmillhill Street
T: 01698 210068
M: 0792 0711131

Friday, October 7, 2011

New VOCAL report on methadone in NY State highlights need for overdose education

The great organization VOCAL, which is led by and represents people who use drugs, people living with HIV and people affected by mass incarceration in New York, has just released a report called "Beyond Methadone: Improving the Health of Patients in Opioid Treatment Programs." The information in the report is relevant well beyond New York - issues related to patient rights, access to harm reduction services, hepatitis care and treatment, policing, and other areas will be familiar to anyone working on opioid substitution therapy anywhere in the world.

So the whole thing is worth a read, but on OPA we'd like to highlight the report's findings related to overdose. Among people interviewed for the report - all current methadone patients - 10% had experienced overdose themselves in the past 2 years, 20% had been with someone who had overdosed, but 70% of them had no overdose education or naloxone access through their methadone program.

This is changing. Not long ago I spoke with some folks from the Beth Israel Medical Center methadone program (New York's largest methadone provider), who had recently started ramping up overdose education and prescribing naloxone. But VOCAL's report is an important reminder that programs need to move, and now.

Wednesday, October 5, 2011

NIH/CDC solicits development of automated naloxone delivery device

The NIH and CDC have issued a solicitation for small businesses to develop an automated device to administer naloxone in the case of an opioid overdose.

This may just fit in the department of weird - of much more interest would be an easy, concentrated intranasal delivery system - but here it is in the interest of an open mind.


Feedback-regulated Naloxone Delivery Device to Prevent Opiate Overdose Deaths

(Fast-Track proposals will be accepted)

Number of Anticipated Awards: 1

Budget (total costs): Phase I: $150,000 for 6 months; Phase II: $1,000,000 for 2 years

It is strongly suggested that proposals adhere to the above budget amounts and project periods. Proposals with budgets exceeding the above amounts and project periods may not be funded.

Drug overdose is currently the second leading cause of unintentional death in the United States, second only to motor vehicles crashes. The population at risk for opioid overdose is diverse and includes, for example, more than 3% of U.S. adults currently receiving long-term opioid therapy for chronic noncancer pain, in addition to drug/substance abusing population. Opioids are now more often being prescribed for patients with moderate to severe pain.

Thus, effective measures that would prevent/avert opioid overdoses are needed as overdoses and death often occur inadvertently in private settings where no one is present to offer assistance. Furthermore, patients with opioid addiction are prone to overdose on injected opiates or on excessive oral doses of opioid medications. These overdoses also often happen when no help is available and patient’s lives are at risk.

The objective of this project is to develop an automated device that would administer standard doses of naloxone to a patient in overdose, thus reversing the effects of excess opiate. Naloxone has been used for decades in medical settings to avert opioid overdose, and recent pilot programs demonstrated the feasibility of proper use of naloxone by non-medical personnel. Patients expressing physiologic signals of opiate overdose (e.g. hypoxia, respiratory rate below a critical threshold for a critical period of time, etc.) could be administered an appropriate dose of naloxone even if unconscious. Due to the short duration of action of naloxone, the unit should be capable of repeating the injection after resetting itself and detecting another set of critical information.

There are more than 300,000 heroin users, nearly 5 million prescription opiate users, plus millions of chronic pain patients receiving end-of-life opiate analgesic pain care. The number of poisoning deaths and the percentage of these deaths involving opioid analgesics increase each year. From 1999 through 2006, the number of fatal poisonings involving opioid analgesics more than tripled from 4,000 to 13,800 deaths. Potentially, everyone who has been prescribed opioids, for pain or addiction, and heroin users, could be offered this device by their treatment provider who may be an addiction specialist, primary care physician or pain doctor. There is a crucial need to provide this device to these populations to prevent unintended overdose and deaths and to address public health need.

Phase I Activities and Expected Deliverables

Design the prediction algorithm for opioid overdose requiring the intervention and establish the endpoints for algorithm development

Design and assemble a prototype of detectors, injector and supporting hardware

Propose a strategy to prevent un-indicated use, such as in a person who is unresponsive due to the reasons other than an opioid overdose

Field-test the prototype with focus group participants.

Phase II Activities and Expected Deliverables

Conduct the initial clinical testing in appropriate user population which is sufficiently powered to adequately inform Phase II

Develop detailed plans for initial production model with cost projections

Plan regulatory approval strategy

Establish an FDA-compliant system

Conduct clinical testing necessary for FDA approval.

Tuesday, October 4, 2011

Pubmed October 2011 Update

My PubMed search was missing a lot of good papers, so here goes with a broader approach pulling 8 interesting papers ...

Britton PC, Bohnert AS, Wines JD Jr, Conner KR.
Addict Behav. 2011 Sep 2.
*The intentionality of overdose is a recurrent issue. I read this article and frankly do not understand what the authors did.

Hedrich D, Alves P, Farrell M, Stöver H, Møller L, Mayet S.
Addiction. 2011 Sep 29. doi: 10.1111/j.1360-0443.2011.03676.x.
*Some data that agonist maintenance therapy in prison reduces post-release overdose mortality

Yokell MA, Green TC, Bowman S, McKenzie M, Rich JD.
Med Health R I. 2011 Aug;94(8):240-2.
*A review of programmatic data from the Rhode Island naloxone distribution program

Roxburgh A, Bruno R, Larance B, Burns L.
Med J Aust. 2011 Sep 5;195(5):280-4.
*Oxycodone is becoming an issue in Australia, although not nearly as substantial as in the U.S.

Weimer MB, Korthuis PT, Behonick GS, Wunsch MJ.
J Addict Med. 2011 Sep;5(3):188-202.
*Interesting data suggesting that two-thirds of methadone-related fatalities were from diverted drug (i.e. not prescribed to the person who died); 28% were prescribed methadone for analgesia. I can't access the full article, but regardless this suggests very few were agonist maintenance patients.

Webster LR, Cochella S, Dasgupta N, Fakata KL, Fine PG, Fishman SM, Grey T, Johnson EM, Lee LK, Passik SD, Peppin J, Porucznik CA, Ray A, Schnoll SH, Stieg RL, Wakeland W.
Pain Med. 2011 Jun;12 Suppl 2:S26-35.
*A review of structural and individual factors related to opioid overdose increases in the U.S.

Bennett AS, Bell A, Tomedi L, Hulsey EG, Kral AH.
J Urban Health. 2011 Jul 20.
*A very useful review of the PA naloxone distribution program, including the rate of survival among those administered naloxone.

Nielsen K, Nielsen SL, Siersma V, Rasmussen LS.
Resuscitation. 2011 Jun 15.
*These data from Denmark again demonstrate the increasing risk of mortality among those who have overdosed multiple times

Internet Outreach Ideas for Overdose Awareness and Prevention

You may have noticed the nifty "overdose prevention program locator" on the bottom of each page of this blog. There's also a tab for it at the top of the screen. Its creator, Maya Doe-Simkins, provides info about it, and other ideas for internet outreach, in the post below:

The South Boston Hope and Recovery Coalition has an important physical presence in the neighborhood known as “Southie”- a neighborhood that has long struggled with high rates of overdose and suicide. But because the Coalition members know that some members of the small community might not want to physically visit the Coalition offices due to fear of judgment or reproach from neighbors, the Coalition developed a website that has many different resources for people who would prefer to get information anonymously over the internet. On International Overdose Awareness Day, we added an additional function to the website: a search function for overdose education and naloxone distribution (OEND) programs in the United States. We asked all the OENDs that we know of if they wanted to be listed as a resource and now people can enter their location and get results that show the closest programs.

We realized that we needed to make sure that people who might be interested in
OEND programs know about this search function so they can go get signed up, so we began to do some promotion through Facebook and Twitter and also with targeted internet outreach. The two “places” where we’ve had success with internet outreach are posting referrals in the “Comments” section of news articles about overdose or drug use/abuse and posting referrals on drug information forums where people are sharing huge amounts of drug use information. To remain on top of current news about overdose, setting up a Google Alert was useful. Daily, this is what our inbox looks like:

Then I can quickly review what is being said in the news and blogs and choose where is a good article to post a referral
, like this one that was in response to the New York Times Small Fixes article about naloxone kits:

This is a good way to raise awareness among people who care about overdose, like loved ones of drug users or professionals who work with substance users.

good way to talk with people who get their drug use information on the internet is to sign up for an account with a drug forum or a place where people can answer and respond to questions that people post. There are relatively few conversations about naloxone on these sites (though overdose is a common topic). A few examples:

In the month that we have been doing internet outreach for a few hours a week, we have tripled the number of visitors to the website (not including paid traffic). We think that we are better serving the visitors, too, because the bounce rate has dropped from 66% to 37% in the month that we have been doing internet outreach. “Bounce rate” is the percent of visitors who com
e to a page and "bounce" (exit the site) from the same page without diving down into the rest of the site; effectively, this means it wasn’t what they were searching for in terms of content.

The South Boston Hope and Recovery Coalition can pass along a
piece of code that can be pasted into any website so that the box with the search function appears on your own website. It will look similar to the image on the right and it shouldn’t take your web administrator more than a few minutes. If interested, please send an email to:

Finally, if you operate an overdose prevention and naloxone program that isn’t listed, but you would like it to be, please send an email to: The search function is currently showing results for US-based programs, but we are thinking of expanding to other countries - let us know if you have thoughts!

Message from Thomas Kerr on the Canadian Supreme Court decision

On Friday, September 30th the Supreme Court of Canada ordered the Canadian Health Minister to grant an immediate exemption to allow for the continued operation of Insite - Vancouver's supervised injection facility. This facility has successfully managed over 1500 overdose events, and a recent analysis showed that there had been a 35% decline in overdose deaths in the first two years after Insite opened. In the summary statement of their judgement the Supreme Court justices said the following: "The Minister’s failure to grant [an exemption] to Insite…contravened the principles of fundamental justice…Insite has been proven to save lives with no discernable negative impact on the public safety and health objectives of Canada… Where, as here, a supervised injection site will decrease the risk of death and disease, and there is little or no evidence that it will have a negative impact on public safety, the Minister should generally grant an exemption." This decision establishes the primacy of science over ideology, and in this case ensures that people who inject drugs in Vancouver's Downtown Eastside will continue to have access to a program that has been show to reduce the morbidity and mortality associated with overdose. This is a great victory for both public health and science, and this decision should send a message to policy makers around the world that, despite the ongoing global war on drugs, ALL individuals have an inherent right to life, liberty and security of the person.

Monday, October 3, 2011

News: Canadian Supreme Court keeps Vancouver injection facility open

This is a very exciting endorsement of public health aims in drug laws. And highly relevant to this blog as Insite investigators documented an impressive and convincing association with reduced overdose fatalities.

As you'll read below, the Court not only kept the facility open, but wrote that shutting the facility down under federal drug laws would undermine those very laws.

This is a major victory for all parties - a rare moment when humanity and rationale discourse (and as a scientist I must add - rigorous investigations) have won.

CBC News

In a unanimous decision, the court ruled that not allowing the clinic to operate under an exemption from drug laws would be a violation of the Charter of Rights and Freedoms.

The court ordered the federal minister of health to grant an immediate exemption to allow Insite to operate.

"Insite saves lives. Its benefits have been proven. There has been no discernible negative impact on the public safety and health objectives of Canada during its eight years of operation," the ruling said, written by Chief Justice Beverley McLachlin.