Overdose, naloxone, and HIV risk in Seattle, USA Phillip Coffin 1 , Lara Coffin 2 , Tom Fitzpatrick 2 , Shilo Murphy 2 1. San Francisco Department of Public Health, SF, CA USA 2. Peoples’ Harm Reduction Alliance, Seattle, WA USA Materials and methods To evaluate the association of and overdose with drug-related risk behaviors, we analyzed data from a cross-sectional, anonymous survey at a community-based organization providing free access to syringes and other injection equipment, non-glass equipment for crack smokers, condoms, vein-care, and take-home naloxone. Staff approached all participants during 12 operating hours over 2 weeks in August of 2011; a piece of candy was provided as incentive for the 2- minute interview. Questions addressed demographics, injection practices, crack use, and overdose history. Results 151 (87%) of 174 participants approached agreed to complete the survey; this analysis was limited to the 122 (81%) who injected drugs. Sharing syringes in the past month was associated with: • Fewer years injecting drugs (OR 0.9, 95%CI 0.87-1.00) • Sharing other injection equipment Past-year witnessed opioid overdose was associated with: • Past-month sharing of water used for drug preparation (OR 2.9, 95%CI 1.2-7.1). Lay naloxone administration was associated only with: • Less past-month syringe sharing (OR 0.15, 95%CI 0.03- 0.77). Figure 1. 53% of PWID saw an OD last year and 44% of them gave naloxone. Although those who witness ODs have real risk for sharing syringes, those who gave naloxone at the most recent OD were MUCH LESS likely to have shared syringes in the month preceding the survey. Background Opioid overdose is responsible for about half the mortality among heroin users throughout the world, 1 and drug overdose is now the leading cause of accidental death among U.S. adults. 2 Overdose and subsequent death is more common among HIV+ drug users. 3,4 Where drug use drives HIV, opioid overdose is a major source of mortality for those at risk for HIV. Distribution of the opioid antagonist naloxone (see photos) to opioid users for lay overdose reversal has emerged as a low-cost and effective means to reduce overdose fatalities. 5 The reduced mortality suggested by ecologic studies (see charts) greatly exceeds that predicted in mathematical modeling, suggesting a potential behavioral effect of naloxone distribution. What happens in an overdose? Our understanding of what happens at an overdose event —and how drug users manage overdose—remains under-developed. In this survey, all respondents (not just drug injectors) also reported the interventions and outcomes of the most recent witnessed overdose. Overall, 91% survived, 41% received naloxone, and 48% received EMS care. The high proportion dying after receiving emergency medical care (EMS) suggests that witnesses may be delaying medical help until there is a very high risk of death. Table 1: Characteristics of injectors (N=122) by past-year witnessed overdose Conclusions Sharing works has been associated with past-year witnessed overdose, 6 yet having administered naloxone in the past year is strongly associated with less past-month syringe sharing. These results suggest the possibility of a behavioral effect to naloxone distribution. How to interpret these results: • Drug injectors who used naloxone to reverse overdose engaged in less last past-month sharing of syringes. • These data do not inform causal pathways. That is, we do not know if people who use naloxone are the same people who are cautious about other risk behaviors or if experience with naloxone leads to changes in other drug- related risk behaviors. Literature cited 1. Sporer KA. Acute heroin overdose. Ann Intern Med. 1999; 130(7): 584-90. 2. Vital signs: overdoses of prescription opioid pain relievers---United States, 1999--2008. MMWR Morbidity and mortality weekly report. 2011; 60(43): 1487-92. 3. Wang C, Vlahov D, Galai N, et al. The effect of HIV infection on overdose mortality. Aids. Jun 10 2005;19(9):935-942. 4. Zaccarelli M, Gattari P, Rezza G, et al. Impact of HIV infection on non-AIDS mortality among Italian injecting drug users. Aids. Mar 1994;8(3):345-350. 5. Community-based opioid overdose prevention programs providing naloxone - United States, 2010. MMWR Morbidity and mortality weekly report. 2012; 61(6): 101-5. 6. Jenkins LM, Banta-Green CJ, Maynard C, et al. Risk factors for nonfatal overdose at Seattle-area syringe exchanges. J Urban Health. Feb 2011;88(1):118-128. Presented at AIDS 2012 – Washington, D.C., USA 27% 35% 12% 26% Figure 2: What happens when drug users witness overdose? Lay naloxone No naloxone or EMS EMS only Naloxone & EMS = Died (outlined blocks) 0 25 50 75 100 125 PWID Witnessed OD past year Gave naloxone 17% 21% 7% Number Figure 1: Syringe Sharing by OD & Naloxone Use No OD (N=56) PY witnessed OD (N=63) Female 27% 35% Age 18-29 42% 47% 30-39 25% 26% 40-49 16% 23% >49 16% 5% White 86% 81% Housing Homeless/shelter 20% 19% Own place 48% 52% Opiates as drug of choice 93% 94% Also smoke crack 34% 30% Mean time injecting drugs 7.7y 9.0y Inject into muscle this year 57% 63% Inject into femoral vein this year 20% 24% Had an abscess this year 34% 40% Able to get enough needles at exchange 96% 90% Get needles from exchange for others 61% 69% Use lemon juice to dissolve drugs 18% 18% Shared any works in the past month 51% 56% Syringes 11% 22% Cookers 49% 49% Cotton 33% 41% Water 16% 37%* Shared syringes Did NOT share syringes 0 40 80 120 160 1993 1995 1997 1999 2003 2005 2007 2009 Heroin-related Deaths, San Francisco Naloxone distribution starts Opioid OD deaths, NYC Naloxone distribution starts NYC Vital Signs, Vol 9, 2010 SF Medical Examiner Reports, compiled by E. Wheeler