Heroin

36. Feasibility of Naloxone Distribution to People Who Use Injection Drugs

"This pilot trial is the first in North America to prospectively evaluate a program of naloxone distribution to IDUs [Injection Drug Users] to prevent heroin overdose death. After an 8-hour training, our study participants' knowledge of heroin overdose prevention and management increased, and they reported successful resuscitations during 20 heroin overdose events. All victims were reported to have been unresponsive, cyanotic, or not breathing, but all survived. These findings suggest that IDUs can be trained to respond to heroin overdose by using CPR and naloxone, as others have reported. Moreover, we found no evidence of increases in drug use or heroin overdose in study participants. These data corroborate the findings of several feasibility studies recommending the prescription and distribution of naloxone to drug users to prevent fatal heroin overdose."

Seal, Karen H., Robert Thawley, Lauren Gee, Joshua Bamberger, Alex H. Kral, Dan Ciccarone, Moher Downing, and Brian R. Edlin, "Naloxone Distribution and Cardiopulmonary Resuscitation Training for Injection Drug Users to Prevent Heroin Overdose Death: A Pilot Intervention Study," Journal of Urban Medicine (New York, NY: New York Academy of Medicine, 2005), Vol. 82, No. 2, p. 308.
http://www.ncbi.nlm.nih.gov/pm...

37. Effectiveness of Naloxone Against Opiate Overdoses

"Treatment with naloxone can reverse respiratory failure within a few minutes (Darke and Hall, 1997; Physician’s Desk Reference, 2000). Naloxone is an opiate antagonist, and is thought to displace heroin at the Mu2 receptors. Physicians and emergency personnel treat patients suspected of heroin overdose by administering an initial dose of naloxone parenterally. While 2 mg are almost always sufficient to revive a patient, additional doses can be administered if the desired improvement does not occur, and smaller doses are often used to minimize the discomfort of sudden heroin withdrawal (Physician’s Desk Reference, 2000). In adults, naloxone has a half-life of between 30 and 81 minutes (Physician’s Desk Reference, 2000). Therefore, repeated administration could be necessary to reverse the effect of particularly large or long-lasting doses of heroin. (Sporer, 1999; Physician’s Desk Reference, 2000). In practice, however, a single 2 mg does is almost always sufficient. If a patient has not taken opioids, naloxone has no pharmacological effect (Darke and Hall, 1997).
"While administration of naloxone may produce acute withdrawal symptoms in patients with heroin dependence (Physician’s Desk Reference, 2000), the drug does not have long-term or life threatening adverse effects when it is administered at therapeutic doses (Strang, et al, 1996). Naloxone has been associated with complications such as seizures and arrhythmia, (Physician’s Desk Reference, 2000) but more recent research suggests that complications are exceedingly rare, that past reports of complications may have been erroneous (Goldfrank and Hoffman, 1995), or that complications occur, if at all, in patients with pre-existing heart disease (Goldfrank and Hoffman, 1995). Naloxone is not addictive, and has no psycho-pharmacological effects."

Burris, Scott; Norland, Joanna; and Edlin, Brian, "Legal Aspects of Providing Naloxone to Heroin Users in the United States," International Journal of Drug Policy, 2001, Vol. 12, pp. 237-48.
http://papers.ssrn.com/sol3/pa...

38. Cost-Effectiveness of Naloxone Distribution

"Naloxone distribution was cost-effective in our base-case and all sensitivity analyses, with incremental costs per QALY [Quality-Adjusted Life-Year] gained much less than $50 000 (Table 2 and Appendix Figure 3, available at www.annals.org; see Appendix Table 3, available at www.annals.org, for detailed results of selected analyses). Cost-effectiveness was similar at starting ages of 21, 31, and 41 years; the greater QALY gains of younger persons were roughly matched by higher costs. In scenarios where naloxone administration reduced reliance on EMS, naloxone distribution was cost-saving and dominated (that is, less costly and more effective than) the no-distribution comparison. Cost-effectiveness was somewhat sensitive to the efficacy of lay-administered naloxone and the cost of naloxone but was relatively insensitive to the breadth of naloxone distribution, rates of overdose and other drug-related death, rates of abstinence and relapse, utilities, or the absolute cost of medical services. Naloxone was no longer cost-effective if the relative increase in survival was less than 0.05%, if 1 distributed kit cost more than $4480, or if average emergency care costs (as a proxy for downstream health costs) exceeded $1.1 million. A worst-case scenario, in which the likelihood of an overdose being witnessed, the effectiveness of naloxone, and the likelihood of naloxone being used were minimized and the cost of naloxone was maximized, resulted in an incremental cost of $14,000 per QALY gained. A best-case scenario, in which naloxone distribution reduced the risk for overdose, was dominant."

Coffin, Phillip O., MD, and Sullivan, Sean D. PhD, "Cost-Effectiveness of Distributing Naloxone to Heroin Users for Lay Overdose Reversal," Annals of Internal Medicine 2013 Jan 1;158(1):1-9. doi: 10.7326/0003-4819-158-1-201301010-00003.
http://www.ncbi.nlm.nih.gov/pu...

39. Impact Of Good Samaritan Laws On Arrests

"Ninety-three percent of police respondents had attended a serious opioid overdose (defined in the survey) in their career, with 64 % having attended one in the past year. While 77 % of officers felt it was important they were at the scene of an overdose to protect medical personnel, a minority, 34 %, indicated it was important they were present for the purpose of enforcing laws. Arrest during the last overdose officers encountered was rare, with only 1 % of overdose victims and 1 % of bystanders being arrested. In cases in which no arrest was made, 25 % reported confiscating drugs or paraphernalia.
"The majority, 62 %, indicated the law would not change their behavior at a future overdose because they would not have arrested anyone at the scene of an overdose anyway. Smaller proportions indicated they would be less likely to arrest (14 %), did not know what they would do (20 %), or would continue to arrest people at the scene of an overdose (4 %)."

Banta-Green C J, Beletsky L, Schoeppe JA, Coffin PO, Kuszler PC. Police officers’ and paramedics' experiences with overdose and their knowledge and opinions of Washington State's drug overdose-naloxone-Good Samaritan law. Journal of Urban Health: Bulletin of the New York Academy of Medicine. 2013;90(6):1102-;11.
http://www.ncbi.nlm.nih.gov/pu...
http://www.ncbi.nlm.nih.gov/pm...

40. 911 Calls, Good Samaritan Laws, And Opiate Overdoses

"Among heroin users, research indicates fear of police response as the most common barrier to not calling 911 during overdoses.12,13 In a Baltimore study, 37 % of injection drug users who did not call 911 during an overdose endorsed concerns about police as the most important reason they did not call.13 Several states have enacted laws, commonly called Good Samaritan laws, to encourage calling 911 during overdoses on controlled substances; these laws are in part modeled on college campus alcohol Good Samaritan policies.14 Overdose Good Samaritan laws had been adopted in ten states as of the end of 2012, but they have not yet been evaluated.15 Generally, the laws include provisions that provide immunity from criminal prosecution for drug possession to overdose victims and to those who seek medical aid. Eight states have passed laws that ease access to take-home-naloxone by allowing the prescription of naloxone (an opioid antagonist or antidote) to persons at risk for having or witnessing an overdose, enabling bystanders to quickly respond in the event of an overdose.3,15 Previous research suggests that police are sometimes under-informed, and often ambivalent to public health laws, especially those based in a risk reduction framework.16,17"

Banta-Green C J, Beletsky L, Schoeppe JA, Coffin PO, Kuszler PC. Police officers’ and paramedics' experiences with overdose and their knowledge and opinions of Washington State's drug overdose-naloxone-Good Samaritan law. Journal of Urban Health: Bulletin of the New York Academy of Medicine. 2013;90(6):1102-;11.
http://www.ncbi.nlm.nih.gov/pu...
http://www.ncbi.nlm.nih.gov/pm...

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