Peer-initiated overdose resuscitation: fellow drug users could be mobilised to implement resuscitation
Introduction
Opiate addicts have been found to have an increased mortality rate, with an annual mortality approximately 10–20 times greater than for an age-matched non-addict population (Ghodse et al., 1978, Davoli et al., 1993, Frischer et al., 1993, Oppenheimer et al., 1994, Hammersley et al., 1995, Farrell et al., 1996, Darke and Zador, 1996).
Overdose is a not an infrequent occurrence amongst opiate misusers. In studies in the UK (Gossop et al., 1996, Powis et al., 1999) and in Australia (Darke et al., 1996, McGregor et al., 1998), about half of the interviewed injecting heroin users had themselves previously experienced an overdose, with an even larger number having witnessed an overdose by another drug misuser. Specific enquiry into the reasons for the overdose have established that only a minority of these overdoses are associated with suicidal intent (Vingoe et al., 1999, Neale, 2000, Best et al., 2000a), and hence such overdoses may usefully be considered as an occupational hazard of a career as an injecting heroin user, and one whose likelihood the user may be particularly keen to find ways to reduce.
These overdoses are extensively witnessed. In earlier work from our group (Powis et al., 1999, Strang et al., 1999a), specific enquiry was made about the circumstances of the last occasion of overdose for the 117 subjects who had previously overdosed, of whom 95 (81%) had been with someone else when they had last overdosed, usually a close friend or sexual partner. Further enquiry was made from this group about their witnessing of the overdoses of other drug users, where the closeness of their relationship to the drug user who had overdosed was again evident, including in the instances where the overdose had resulted in death (Strang et al., 1999a, Strang et al., 1999b).
Management of witnessed overdoses (by fellow drug takers) is often inept, flawed or even counterproductive. Folklore includes such inefficient or dangerous advice as intravenous salt, stimulants, immersion in a cold bath and, perhaps most extraordinarily, intravenous milk (Drenick, 1970). Both Darke et al. (1996) and Powis et al. (1999) report on the delay and reluctance to call an ambulance. Written and film media contain examples of desperate and inefficient interventions including, classically, the fictional scene of heroin overdose in the film ‘Pulp fiction’, in which, in utter desperation, fellow drug users attempt resuscitation with direct intra-cardiac adrenalin (certainly not a recommended course of action).
Given the extensive witnessing of overdoses, serious consideration is now being given to the possibility that peer drug takers might be a valuable target group for training in resuscitation techniques. However, as yet, only minimal data have been collected on whether drug users would generally be willing to consider involvement in such resuscitation or whether the fear of involvement (and possible involvement with ambulance personnel and police) might represent insuperable obstacles. We report on the exploration of these issues amongst a sample of opiate addicts undergoing treatment in London.
Section snippets
Method
The sample consisted of 115 opiate addicts attending a methadone maintenance clinic in South London in 1999. As has previously been reported (Gossop et al., 1988, Strang et al., 1992, Griffiths et al., 1994, Strang et al., 1998), London samples of heroin users now contain a substantial proportion who take their heroin by ‘chasing the dragon’ (Gossop et al., 1988, Griffiths et al., 1994) amongst whom a history of overdose has been found to be rare with almost all of the overdose histories being
Characteristics of the study sample and their personal overdose histories
The study sample comprised 115 opiate addicts in methadone maintenance treatment, of whom 80 (69.6%) were male (male/female ratio of 2.3/1). Mean age of the sample was 36.1 years (S.D.=7.6). Mean age of first heroin use was 19.8 years, as was mean age of first injection. The mean age at which the subjects had first commenced methadone treatment was 27.4 years.
A history of previous overdose was obtained from 49.6% (57) of the 115 subjects, amongst whom there had been an average of 4.1 overdoses.
Discussion
Two important observations can be made from these findings which lend further support to observations made by ourselves and others from earlier studies. Firstly, as observed earlier (Darke et al., 1996, Darke and Zador, 1996, Powis et al., 1999) there is widespread experience of the witnessing of the overdoses of fellow drug users — virtually all (97%) of this study sample from a methadone treatment programme had at some time witnessed an overdose, including more than a quarter who had
Acknowledgements
The authors wish to acknowledge the family research grant support provided from a trust fund through the charity Action on Addiction. Data from this paper were presented at the international conference on drug overdose in Seattle, Washington, USA in January 2000.
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