New Resource! HRC Guide to Developing and Managing Overdose Prevention Projects

Just in time for the holiday season, the Harm Reduction Coalition has an excellent new Guide to Developing and Managing Overdose Prevention and Take-Home Naloxone Projects. This is the best thing I've seen so far on the subject, and while it focuses on the experience of programs in the Unites States, most of the information in the manual should be relevant worldwide. 

Follow the link to download the manual as well as other resources, worksheets and appendices. Print copies should be ready soon and can be had by contacting HRC through their website.

Cocaine, Speed, and “Overdose”: What Should We Be Doing? Part 2

By Eliza Wheeler, DOPE Project, Harm Reduction Coalition, San Francisco

This is part 2 of a series about cocaine and stimulant-related deaths and what harm reductionists can start doing about it.  We published the first part last week, which was a collection of thoughts about how to move forward to address stimulant-related deaths. This second part deals specifically with stimulants and “overdose” (not the right word, but we’ll get to that). This is a draft of a manual for speed users created as a result of a meeting with some folks from the Speed Project here in San Francisco. We are looking for suggestions on how to improve this document and welcome any feedback on this draft. We’ve included some great quotes from our discussion.

OVERAMPING!

or speed “overdose”

“When I’m talking about overamping, to me when I’m on speed, right, I’m not happy until the second or third day. I’m trying to get there…the first one is just the preliminaries, the first time you’re not there yet, you’re not in the euphoria or where you wanna be. So I got my sack, the first one I’m snorting, now I’m gonna go look for my rigs, now I take my first shot, ok, now I’m gonna go look for who we’re gonna spend time with. It’s like a whole little adventure, I’m in Alice in Wonderland and all this shit’s happening, and then when you’re into your 3^rd or 4^th day and then you take that one shot, still a lot of dope around, still a lot of people around, whatever, it’s fun, it’s casual, everything’s happening cool, and you take that one shot all of a sudden you go damn, I shouldn’t have done that, you did one too many and you just crossed the line and I’m gonna tell you how that feels. It feels like if you’ve ever had an experience with crack and you’re takin a hit and you’re taking a hit and everything’s fine, and you take that one hit all of a sudden, paranoid, everybody’s looking at you, you’re in a fishbowl, but with crystal it’s different because it lasts 12 fucking hours…and the shadow people are watching, everyone’s just on that side of the door looking at you, the cops have binoculars three stories away…”—R

At your service: Overdose Q&A from the Thai national overdose training

The Thai AIDS Treatment Action Group (TTAG) recently organized a national overdose training for harm reduction groups in Thailand. Participants raised a number of questions about overdose, some of which were passed on to me by TTAG’s Karyn Kaplan. We thought it made for a nice Q&A, and so we share the results below.  ---Matt Curtis

Karyn Kaplan: There was definitely confusion about the role of CPR in a heroin OD, or a poly-drug OD. They got the breathing-is-essential thing, but does one STOP the breathing to administer CPR and when? Or, never with heroin OD, just do rescue breathing?

Matt and Karyn on the Chao Phraya River in Bangkok

Matt Curtis: The point is that you don't want to do chest compressions on someone who's heart is still doing its job, which will be the case in most heroin/opioid or benzo overdoses. Opioids don't cause the heart to stop; in this case an extended period of oxygen deprivation causes the heart to stop, at which point chest compressions are indicated, but probably not going to help much.

In treating an opioid OD, it's best to focus on airway management, breathing, and naloxone, and even better to do all that plus get the person professional medical attention. I’d say it’s also especially important to focus in on this point in our OD prevention work, like when delivering a short (e.g. 5-10 min) training in a harm reduction setting. If there's time, it's always appropriate to teach people to check the ulnar (wrist) and jugular (neck) pulse, but again I'd stress oxygen always + naloxone if available.

Also, a small nomenclature issue: CPR = rescue breathing + chest compressions, which isn't really the normal recommended standard of care for any situation anymore – see for example the American Heart Association guidelines on rapid chest compression for heart failure, which the Harm Reduction Coalition has nicely summarized specifically in relation to overdose.  

KK: Once naloxone wears off, can you OD again from any residual heroin? There was this question about heroin still being in your body.

MC: Yes. Heroin continues to be metabolized while naloxone is active, but naloxone does not remove heroin from the body. This is why people will generally stop feeling dopesick and potentially high again as naloxone starts wearing off after 30 minutes or so. Although there is risk of OD’ing again after naloxone is administered – and certainly a much greater risk of OD if people use again soon after being revived – in practice this seems to be very rare.

A typical example is from a 2006 paper published out of the Chicago Recovery Alliance overdose project. Among 319 documented overdose reversals with naloxone there were NO cases of re-treatment being needed after the initial dose of naloxone wore off.  And for that matter, there were only five cases where more than one dose of naloxone was needed, two cases of non-withdrawal complications (1 vomiting, 1 seizure), and only one death. Other studies, including ones that have looked for deaths after people were discharged from hospital emergency departments after treatment for heroin overdose, have confirmed the Chicago findings.

All that said, it’s important to promote aftercare, because the risk of going back into OD is real, because there can be other complications of nonfatal overdose, and because it’s just good to take care of people.