Avoiding Overdoses

August 31: Overdose Awareness Day

 

 

 

“I’m not gonna overdose. I know my limits.”

I really hate hearing these words. Usually patients say this in response to my concerns about their pattern of drug use while I’m prescribing methadone or buprenorphine. But many patients feel like they are the experts. They can’t imagine making a deadly mistake with their drug use. But I’ve heard this phrase, or something close to it, from at least five people who are now dead from overdoses.

I was reminded of this situation after reading an article in the latest issue of Journal of Addiction Medicine. Najman et al. wrote an article titled “When Knowledge and Experience Do Not Help: A Study of Nonfatal Drug Overdoses.”

The author of the study looked at nonfatal overdoses in Australia in 2013, where overdose deaths have risen steadily since 2007. In that country, unlike the U.S., heroin use is declining while pharmaceutical opioid misuse is rising.

This study looked at nonfatal overdoses in people who inject drugs. These people, identified by the needle and syringe exchange programs in Australia, were interviewed about the circumstances surrounding these overdoses, in order to get a better understanding of the risks. A total of 50 people were interviewed for this study.

Most of these people were male, middle-aged, single, and unemployed. Nearly all were smokers. Half had a diagnosis of liver disease and almost all reported a mental health diagnosis. Most injected pharmaceutical opioids, though some also injected heroin and methamphetamine. These were very experienced drug users, with an average of 21 years of intravenous drug use.

Surprisingly, more than half of the study subjects were in some form of treatment for substance use disorder. This finding is contrary to other studies, which have found being in treatment lowered the risk for overdose. Around 46% were in medication-assisted treatment with either methadone or buprenorphine. However, some of the overdoses happened on days that the person missed dosing for some reason, and substituted another opioid such as heroin or fentanyl. Thirty-two percent of study subjects dosed with either methadone or buprenorphine in the twenty-four hours prior to experiencing their overdose.

Most of these overdoses happened in private homes, and around half received some sort of folk remedy for overdose such as being slapped, put into cold water, or being shaken. Naloxone kits weren’t routinely being distributed at the time of this study.

When asked about the cause of their overdose, many the subjects said they were impaired by alcohol or benzodiazepines. Over half said they used benzodiazepines within twenty-four hours of their overdose. Of the 50 subjects, 64% said they had been prescribed anti-anxiety medications sometime in the year prior to overdose, and 38% said they’d been prescribed sleeping pills. Another 36% said they’d been prescribed some sort of tranquilizer in the year prior to overdose. I’m assuming many of the subjects were prescribed more than one of these groups of medications.

Alcohol was not as prominent as sedative medications as contributory cause of overdose; only 34% of subjects said they had some amount of alcohol in the twenty-four hours prior to their overdose.

Over a third of subjects had used fentanyl, a very powerful opioid, leading up to the overdose.

The authors of the study concluded that these experienced drug users were aware of common risks for overdose, yet drug intoxication from sedatives such as alcohol or benzodiazepines may have clouded the user’s thinking when injecting opioids. They also found that unexpected availability of drugs contributed to overdoses.

It’s an interesting study, and a little disturbing to me, particularly the data about overdoses in people who were enrolled in medication-assisted treatments. It does underline the importance of daily dosing of MAT, and the importance of avoiding alcohol and benzodiazepines in patients on MAT.

And if you didn’t know…August 31 is International Overdose Awareness Day.

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4 responses to this post.

  1. Thank you for sharing. This is a common thing my clinical teams encounter. I am the Clinical Director of a Housing First organization that among other services features what I believe is the first exclusive team in America focused on housing chronically homeless individuals with severe opioid use disorder. My staff regularly have this conversation and because we come from a harm reduction perspective we will still house and support folks who are heavily active in their use. Are there specific ways you would then recommend for those who feel they are not at the risk they really are? I don’t find stats or figures are all that effective. They speak to me but don’t seem to make the impact I wish they did. Unfortunately it’s the overdoses or even deaths of those close to them that seem to push folks to change behaviors. That’s a razor line and not one I want to intentionally walk…

    Reply

  2. […] Burson provides a synopsis of a recent study on the role of the user’s knowledge in OD. (Her blog provides her perspective as a doctor who prescribes buprenorphine. It is worth your […]

    Reply

  3. This is a fascinating study. On one hand, you can argue that it shows that MAT doesn’t prevent overdose; on the other hand, you can argue that it shows that OD victims who survive are more likely to use MAT.
    Although it would be a morbid undertaking (no pun intended), it would help to review the use of MAT (in the same population) in those who died from their overdose and compare it to those who survived.
    I think it’s clear that this study identifies the use of sedatives as a major risk factor for OD due to multiple reasons.

    Carl Christensen MD, Ann Arbor, MI, USA

    Reply

  4. Yes, people forget about the possible drug interactions. I’d dare say there’s a concurrent benzodiazepine abuse epidemic.

    Reply

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