Posts Tagged ‘overdose deaths’

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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Harm Reduction: Use Precautions

aaaaaainjecting

 

 

I’m worried about the people in my community who have opioid use disorders. The rate of opioid overdoses appears to have risen, according to my local newspaper, along with the number of overdose deaths. I think it’s at least partly due to the arrival of heroin in our county. I think it’s time I re-posted some harm reduction suggestions for people who are using opioids.

The ultimate harm reduction measure is to get treatment and get into recovery, but if you aren’t ready for that, please be careful when you use drugs.

You can access all the following information, and more, at: http://harmreduction.org/drugs-and-drug-users/drug-tools/getting-off-right/

This is a link to a booklet about how to inject drugs more safely, downloadable for free, or available in hard copy for a small fee. It contains excellent information which could be life-saving.

  1. Don’t use alone. Use a buddy system, to have someone who can call 911 in case you stop breathing. Do the same for another addict. Obviously you shouldn’t inject at the same time. Stagger your injection times.

Many states now have Good Samaritan laws that protect the overdose victim and the person calling 911 for help, so that police don’t give criminal charges to people who do the right thing by calling for help for an overdose.
Take a class on how to give CPR so that you can revive a friend or acquaintance with an overdose while you wait on EMS to arrive.

  1. Get a naloxone kit. I’ve blogged these kits before, and they are becoming more available. So far, about seven or eight of my opioid treatment program patients have used their kits to save other people. The kits are easy to use and very effective. You can read more about these kits at the Project Lazarus website: http://projectlazarus.org/

Evzio is a commercially available kit, very easy to use, that gives verbal instructions about how to use the kit.

Some states, like North Carolina, now have third party prescribing, meaning if you have a loved one with opioid use disorder, you can request a naloxone kit prescription from your own doctor, to have on hand for your loved one with addiction.

  1. Use new equipment. Many pharmacies sell needles and syringes without asking questions. Other people with opioid use disorder probably can tell you which pharmacies are the most understanding.

    Don’t use a needle and syringe more than once. Repeated use dulls the needle’s point and causes more damage to the vein and surrounding tissue. Don’t try to re-sharpen on a matchbook – frequently this can cause burrs on the needle point which can cause even more tissue damage.

  2. Don’t share any equipment. Many people who wouldn’t think of sharing a needle still share cottons, cookers, or spoons, but hepatitis C and HIV can be transmitted by sharing any of this other equipment. If you have to share or re-use equipment, wash needle and syringe with cold water several times, then do the same again with bleach. Finally, wash out the bleach with cold water. This reduces the risk of transmitting HIV and Hepatitis C, but isn’t foolproof.
  3. Use a tester shot. Since heroin varies widely in its potency, use small amount of the drug to assess its potency. You can always use more, but once it’s been injected you can’t use less. The overdoses on heroin are thought to be due to fentanyl added to the heroin, making it more powerful and more dangerous.
  4. Use clean cotton to filter the drug. Use cotton from a Q-tip or cotton ball; cigarette filters are not as safe because they contain glass particles.
  5. Wash your hands thoroughly before preparing your shot, and clean the injection site with an alcohol wipe if possible. Don’t use lemon juice to help dissolve heroin, as it carries a contaminant that can cause a serous fungal infection.
  6. Opioid overdoses are much more likely to occur in a person who hasn’t used recently or has used less than usual for a few days, weeks, or longer. Overdose risks are much higher in people just getting out of jail and just getting out of a detox. Patients who have recently stopped using Suboxone or Subutex may be more likely to overdose if they resume their usual amount of IV opioids.
  7. Don’t mix drugs. Many opioid overdoses occur with combinations of opioids and alcohol or benzodiazepines, though overdose can certainly occur with opioids alone.
  8. Don’t inject an overdosed person with salt water, ice water, or a stimulant such as cocaine or crystal methamphetamine – these don’t work and may cause harm. Don’t put the person in an ice bath and don’t leave them alone. Call for help, and give mouth-to-mouth resuscitation if you can. And use naloxone if you have it.

To people who believe I’m giving addicts permission to use, I’d like to remind them that people using opioids don’t care if someone gives them permission or not. If they want to use, what other people think matters little. But giving people information about how to inject more safely may help keep them alive.

The Harm Reduction Coalition has excellent information on its website: http://harmreduction.org

In North Carolina, we are fortunate to have a robust Harm Reduction Coalition chapter. You can read more about their remarkable work at:   http://www.nchrc.org/

If you are a person who uses drugs and never plan to quit, your life has purpose and meaning. Use these safety tips to stay around for it.

Overdose Deaths: Opioids and Benzodiazepines

Any opioid, mixed with any benzodiazepine, alcohol, or barbiturate, can be deadly.

Part of our brainstem, the medulla, tells our bodies to breath while we sleep. Opioids inhibit the neurons (individual nerve cells) of this area of the brain, potentially interfering with this automatic breathing. This is how overdose deaths occur. People go to sleep, stop breathing, and die from lack of oxygen to main organs like the brain and the heart. Even a relatively small dose of opioid can kill a person who isn’t accustomed to taking them, and a larger dose can kill even those who are used to opioids. If you are wondering what constitutes a small or larger dose, that’s unanswerable, because of the considerable differences between individuals.

Benzodiazepines, alcohol, and barbiturates all also inhibit this same brain center, and have the potential to slow breathing, just like opioids. We don’t see many doctors prescribing barbiturates any more, with the possible exception of phenobarbital for seizures, and butalbital for headaches. Sometimes carisoprodol (Soma) is prescribed as muscle relaxant, and it gets metabolized to a barbiturate. We do see a great many people prescribed benzodiazepines, which can be dangerous for a person also taking opioids. And of course, alcohol flows freely in the U.S. society.

When a person with addiction mixes opioids with benzos, alcohol, or barbiturates, he often ends up taking more of the drug than he planned, making it easy to have a fatal overdose. Addiction is all about the loss of control. So for example, an addict may decide to take one Xanax with an opioid, but ultimately take three or four Xanax’s with the opioid. Compounding the problem, the effects of the two drugs together is usually more than would be expected, due to synergy. Synergy means that instead of 1+1=2, suddenly 1+1=4. There’s more of an effect than the person expected.

Some people are able to take both opioids and benzodiazepines without complications, but these people usually don’t have the disease of addiction, and are able to take their medication just as prescribed by their doctor. Even for these patients, benzodiazepines are rarely indicated for use for more than three months (fodder for a future blog).

But benzodiazepines can harm patients with addiction. Except for unusual circumstances, it’s a bad idea to mix any benzodiazepines with any opioid in people with addiction, because of the risk of overdose death. Rarely, a situation may arise that warrants use of benzodiazepines in a patient on opioids, but it’s for a short-term situation, and safer long-term treatments for anxiety usually can be found.

When my patients on methadone or buprenorphine (Suboxone) take benzodiazepines for anxiety, I get anxious. I worry those patients will die from an overdose. It’s a dilemma. Often, patients are clearly benefitting from methadone or buprenorphine, because they’re no longer using illicit opioids, but we now have the risk of an overdose death. So, the methadone or buprenorphine are helping them – unless it kills them… in which case it’s no longer helping.

What to do??

Some doctors say if the patient is benefitting even a small amount, because death rates are so high for opioid addicts who leave treatment, that patient should never be dismissed from a methadone clinic for using benzodiazepines.

I don’t agree with that. The first thing doctors learn in medical school is, “First, do no harm.” In other words, please try to kill as few patients as possible.

And yet, many of these patients can stop using benzodiazepines if they get the right kind of help. I ask my patients “Why do you use benzos?” and base my intervention of what they say. If they’re getting medication from a doctor, I’d like to talk to that doctor, and often a better long-term solution can be found. Benzodiazepines have very few indications for long-term use, because patients develop tolerance to the anti-anxiety properties of these medications fairly quickly. However, it’s dangerous to stop benzodiazepines suddenly in a patient who has been taking them for months or years, because of the risk of withdrawal seizures. We have to decide on the best way to handle the situation. If patients take benzos for the high it produces with methadone, they have to decide if it’s worth risking not only their treatment but their lives. If they take benzos for sleep, often I can prescribe a more suitable medication.

As long a patient has a willing spirit, and does not look like an overdose is imminent, I try to work with him or her. In each case, there are risks in stopping methadone treatment, and risks in continuing methadone treatment. The decision should be made by a physician who is well-educated and well-trained in addiction medicine. We make the best decision we can for the patient in front of us. We are the most qualified to make those – literally – life and death decisions.