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Death Holds No Fear: Overdose Risk Perceptions Among People Who Inject Drugs
Abstract
Drug overdose is an important public health problem. Despite well-known risk factors and various preventive measures, the overdose mortality rate has increased substantially in several countries worldwide over the past decade. There is therefore a need to understand overdoses on the basis of how people who inject drugs (PWID) perceive and experience risk. Based on qualitative interviews with 80 PWID recruited from low-threshold settings in Norway, this study explores the complex lived experiences and perceptions of overdose. The qualitative approach is sensitive towards lived experiences and provides new understandings of overdoses. The analysis revealed three types of accounts concerning perceived overdose risk. First, interviewees described death as natural and not frightening, based on perceptions of death as universal, a part of their high-risk lifestyle and their previous overdose experiences. Second, they presented accounts of how they perceived others to be at greater risk of overdose than themselves, in respect of experience, skills and tolerance. Finally, interviewees described an indifference towards death, on a continuum between the wish to live and death as relief from various life challenges. This study illustrates how PWID inhabit drug-using environments which entail a high-risk lifestyle. Faced with these risks, the interviewees presented stories which may serve several functions, such as neutralizing feelings of risk and stigma and gaining a sense of agency and control. They also created symbolic boundaries in order to form positive perceptions of self, by distancing themselves from other stereotypical people who use drugs. The participants additionally expressed an indifference towards overdose death. This may entail that avoiding death, the main rationale of overdose interventions, is viewed with indifference by some PWID. This is important for understanding the complexity of overdose mortality and should be reflected in future harm-reduction initiatives.
... Qualitative studies of individuals with substance use disorder provide evidence that self-reported desire to die lies along a dimensional continuum of severity and that over half of individuals report some desire to die immediately prior to their most recent non-fatal opioid overdose [10][11][12]. In fact, overdose-related intent spans a spectrum that includes recreation/fun, to feel good or not to feel bad, attention-seeking or rebelliousness, feelings of immortality/invincibility (often related to youth), habit or compulsion, disregard for risk, increasingly risky use despite knowledge of overdose risk, ambivalence to living or dying, a wish to obliterate consciousness, desire to die, and deliberately attempting to kill oneself [13][14][15][16][17][18][19]. moreover, suicidal cognitions in those with high suicide risk are notably variable in severity and transient in duration, with some individuals experiencing brief "bursts" of elevated suicidal cognitions (lasting about 1-3 h) superimposed on a baseline of absence of suicide cognitions and others experiencing more continuous suicidal cognitions that change in severity over time [20,21]. ...
Background:
Overdose is frequently categorized dichotomously: an inadvertent therapeutic or recreational misadventure versus a deliberate overdose for self-injurious or suicidal purposes. Categorizing overdoses based on this dichotomy of intention is fraught with methodological problems and may result in potentially inappropriate and/or divergent care pathways.
Overdose-related intent lies along a continuum:
Suicidality can rapidly shift in magnitude and frequency at different points in time. A patient's overdose may reflect varying degrees of desire to die, ambivalence about living, disregard for risk, or pleasure-seeking. Careful assessment of overdose-related cognitions is warranted in all overdose patients.
The clinical interview is key to understanding an overdose:
There is an irreducibly subjective character to an overdose such that a collaborative understanding of an overdose episode can only be discovered by spending time in dialogue with the patient. At the same time, the objective risk factors for and circumstances of the overdose need to be integrated with the subjective experience for a comprehensive prevention approach.
There can be several motivations underlying an overdose:
Some overdoses might be wholly inadvertent or simply impulsive. However, if there is some degree of intent present, then the patient who overdosed has attempted to communicate something by means of that overdose, and this message might include something other than the desire to die.
Attending to both the subjective and objective perspectives of an overdose can assist in identifying modifiable risk factors:
Overdose-related intent and motivation may be targeted with treatment plans to reduce elevated risk states. Some patient-specific overdose risk factors are modifiable, such as managing mental health and other psychosocial issues, reducing access to lethal means, and promoting safe prescribing and medication administration practices. Other risk factors are either unmodifiable (e.g., personal history of overdose) or involve public health systems.
Conclusions:
Overdose-whether involving medications, illicit substances, hazardous chemicals, or otherwise-can be conceptualized as a single behavioral episode with variable intentionality, personal motivations, and risk factors. Clinical/medical toxicologists are uniquely positioned to contribute to personalized risk reduction post-overdose.
... This disparity could be attributed to several factors: For one, non-users may have less familiarity with the substance and thus perceive its risks as more severe, possibly influenced by external sources such as media or secondhand bad experiences. In contrast, heavy users might downplay the negative consequences, due to desensitization, normalization, or cognitive dissonance [41][42][43][44][45]. Desensitization reduces the perceived severity of risks through repeated exposure -for instance, frequent experiences with overdoses may make such events feel less shocking. ...
Background
Gamma-hydroxybutyrate (GHB) and its precursors gamma-butyrolactone (GBL) and 1,4-butanediol (BD) have become a significant concern due to the increase in their recreational use and the high risks associated with it (e.g., overdose, addiction, life-threatening withdrawal syndromes). However, targeted prevention and treatment strategies are lacking, and little is known about the specific needs of users regarding supportive approaches.
Methods
To address this gap, a mixed-methods longitudinal study was conducted with two waves of online data collection (11/2022–01/2023; 11/2023–01/2024) in Germany. The adult convenience sample (N = 2,196, with n = 240 participating in the follow-up) was mostly connected to Berlin’s nightlife scene and included GHB/GBL/BD users and their (non-user) social environment. Perceptions and needs regarding prevention and harm-reduction, reasons and measures of decreasing use, and the impact of GHB/GBL/BD use were analyzed both quantitatively and qualitatively.
Results
Education, harm reduction strategies, and specialized support options were welcomed by users and non-users, while restrictive approaches were viewed negatively, particularly by heavy users. Many participants expressed a desire to reduce GHB/GBL/BD use, driven primarily by health concerns, immediate use risks, and addiction, but only few participants had previously accessed preventive/therapeutic services. The follow-up showed little change in perceptions and experiences over time.
Conclusions
The findings underscore the need for comprehensive and integrative prevention and treatment strategies for GHB/GBL/BD use, with harm reduction approaches prioritized over restrictions. They provide a crucial foundation for future research and interventions and emphasize the necessity of adequately addressing the growing issues related to GHB/GBL/BD use.
Trial registration
The study protocol was pre-registered with the German registry for clinical studies (Deutsches Register Klinischer Studien; drks.de/search/de/trial/DRKS00030608) on October 28, 2022.
... Common approaches to addressing this crisis include government control and law enforcement aimed at curbing substance use and trafficking in areas frequented by people using drugs (Olsen, 2017). Consequently, these efforts often result in individuals who use drugs avoiding medical assistance for fear of encountering law enforcement and may attempt to manage overdoses independently (Collins et al., 2019b;Hanoa et al., 2023). ...
Background: The use of drugs is an escalating concern, with significant implications for the health and daily functionality for individuals. It has proven challenging to provide accessible health and social services. In the context of addressing substance use issues in urban areas, public gathering places for individuals who use drugs play a multifaceted role, serving as sites of belonging, support and potential illicit activity. This qualitative study explores the experiences of healthcare and social workers regarding a public gathering place, referred to as “the Bench”, in a medium-sized Norwegian city. Methods: A qualitative research design consisting of semi-structured focus group interviews and individual interviews with 13 participants representing various support agencies. Results: The analysis resulted in four thematic areas: (1) belonging and a gateway to support and services; (2) balancing user autonomy at the Bench and systems support; (3) the role of a centralised location; and (4) the preventive role of support workers at the Bench. Conclusion: While the Bench fosters a sense of community and provides access to vital services, concerns about illicit activities persist due to its visibility. Nevertheless, its central location facilitates outreach efforts and ensures easy access to support services. The study underscores the preventive role of healthcare and social workers in stabilising the environment and mitigating conflicts. Furthermore, it highlights the importance of central locations for public gathering places, emphasising the proximity to low-threshold services. The Bench represents a crucial venue for establishing relationships and providing assistance to individuals who use drugs, contributing to harm reduction efforts in the community.
... Common approaches to addressing this crisis include government control and law enforcement aimed at curbing substance use and tra cking in areas frequented by people using drugs 3 . Consequently, these efforts often result in individuals who use drugs avoiding medical assistance for fear of encountering law enforcement and may attempt to manage overdoses independently 1,4 . ...
In the context of addressing substance use issues in urban areas, public gathering places for individuals who use drugs play a multifaceted role, serving as sites of belonging, support, and potential criminal activity. As these gathering places, often referred to as open drug scenes, are associated with drug dealing, violence, and harm, numerous attempts to close or control them by law enforcement have been made, resulting in increased violence, stigma, and risk of overdoses. This qualitative study explores the experiences of health and social workers regarding a public gathering place, referred to as “the Bench,” in a medium-sized Norwegian city. Through semi-structured interviews with thirteen participants representing various support agencies, four thematic areas emerged: 1) Belonging and a gateway to support and services, 2) Balancing user autonomy at the Bench and systems support, 3) The role of a centralized location, and 4) The preventive role of support workers at the Bench. While the Bench fosters a sense of community and provides access to vital services, concerns about illicit activities persist due to its visibility. Nevertheless, its central location facilitates outreach efforts and ensures easy access to support services. The study underscores the preventive role of healthcare and social workers in stabilizing the environment and mitigating conflicts. Furthermore, it highlights the importance of central locations for public gathering places, emphasizing the proximity to low-threshold services for overdose prevention. Despite some challenges, the Bench represents a crucial venue for establishing relationships and providing assistance to individuals who use drugs, contributing to harm reduction efforts in the community.
Symbolic boundaries are used for establishing narrative identities and have critical impact on behavior and interpersonal interactions. Using data from a photo-ethnography of people who use methamphetamine in Alabama we show how women use stories and images to draw symbolic boundaries between themselves and others. These boundaries made sense of their meth use, but also guided behavior, controlled drug use, and aided in negotiating personal relationships. Maintaining boundaries through stories and images is important for people with drug problems, as such boundaries provide self-worth and serve as ideals to be lived up to. Symbolic boundaries can thus reduce harmful drug use and be an important means for exercising control and agency at the margins of society.
Background
People who inject drugs are subjected to great stigmatization in many parts of the world. How they deal with stigma is closely linked to how stigma means to them. Understanding the strategies individuals employ to cope with these negative attitudes and what resources they mobilize in this process gives useful insights for clinical work and policy development.
Methods
We conducted 12 months of field observation in 2017 and 2018 and 54 in-depth interviews with people who inject drugs in Haiphong, Vietnam. Grounded theory underpinned our sampling and data analysis.
Results
The strategies participants used to manage stigma were both information and tension management. Many participants not only concealed their drug use but actively cultivated a pro-social image based on Vietnamese cultural virtues such as selflessness, hard work or harmonious living with others. Participants withdrew from social relationships to distance themselves from the stereotype of a money-begging drug user. They used techniques of neutralization to emphasize their good character and reframe their drug-related issues in a different light in order to negotiate their social status with their interlocutors.
Conclusion
People who inject drugs endorse the same social values and aspirations as nonusers. A good support structure and resources could help them to cope more effectively with stigma.
Background
We study the significance of stories about bad trips among users of psychedelics. Drawing on narrative theory, we describe the characteristics of such stories and explore the work they do.
Methods
In-depth qualitative interviews with 50 Norwegian users of psychedelics.
Results
Almost all participants had frightening experiences when using psychedelics and many described these as bad trips. The key feature of a bad trip was a feeling of losing oneself or going crazy, or ego dissolution. Most users said that these experiences could be avoided by following certain rules, based on tacit knowledge in the subcultures of users. Possessing such knowledge was part of symbolic boundary work that distinguished between drug culture insiders and outsiders. Some also rejected the validity of the term bad trip altogether, arguing that such experiences reflected the lack of such competence. Finally, and most importantly, most participants argued that unpleasant experiences during bad trips had been beneficial and had sometimes given them deep existential and life-altering insights.
Conclusion
Bad trip experiences are common among users of psychedelics. Such experiences are often transformed into valuable experiences through storytelling. Bad trip narratives may be a potent coping mechanism for users of psychedelics in non-controlled environments, enabling them to make sense of frightening experiences and integrate these into their life stories. Such narrative sense-making, or narrative work, facilitates the continued use of psychedelics, even after unpleasant experiences with the drugs.
Introduction and aims:
Opioid overdose fatalities are a significant concern globally. Non-fatal overdoses have been described as a strong predictor for future overdoses, and are often attended by the ambulance services. This paper explores characteristics associated with non-fatal overdoses and aims to identify possible trends among these events in an urban area in Norway.
Design and methods:
This is a retrospective analysis of non-fatal overdoses from Bergen ambulance services from 2012 to 2013. Demographic, temporal and geographic data were explored.
Results:
During the two years, 463 non-fatal opioid overdoses were attended by ambulance services. Ambulance call-outs occurred primarily during the late afternoon and evening hours of weekdays. Summer months had more overdoses than other seasons, with a peak in August. Overdoses were nearly twice as likely to occur in a public location in August (risk ratio 1.92, P = 0.042). Ambulance response times were more likely to be longer to private locations, and these victims were more likely to be treated and left at the scene. There was no difference in arrival time for drug-related and non-drug related dispatch.
Discussion and conclusions:
The temporal patterns suggest that non-fatal overdoses occur during non-recreational time periods. The longer ambulance response time and disposition for private addresses indicate potential opportunities for peer interventions. Our analysis describes circumstances surrounding non-fatal overdoses and can be useful in guiding relevant, targeted prevention interventions. [Madah-Amiri D, Clausen T, Myrmel L, Brattebø G, Lobmaier P. Circumstances surrounding non-fatal opioid overdoses attended by ambulance services. Drug Alcohol Rev 2016;00:000-000].
The narrative study of identity promotes the idea that people develop social identities by telling stories about themselves and others. Through these stories, people associate with desired groups and create social boundaries separating them from the less desirable. While all people engage in boundary work, it is especially important for those who are physically or socially near members of stigmatized groups (e.g. drug users). My aim here is to examine how drug users narratively create symbolic boundaries to differentiate types of users (i.e. functional vs. dysfunctional). To elaborate on the general characteristics of these symbolic boundaries, I rely on qualitative meta-synthesis of research on boundary work among drug users and insights from my own research with people who use drugs. I draw from narrative identity theory to locate the places from which they derive their stories when creating symbolic boundaries and the content of the symbolic boundaries. I discuss the role of symbolic boundaries in facilitating drug use and inhibiting recovery and conclude by discussing the theoretical importance of using narrative criminology for understanding boundary development, boundary maintenance, and the content of boundaries.
Suicide-related behavior (SRB) among heroin users is a complex and multifaceted continuum, including such fringe areas as indifference and "risky" behavior. The article investigates the nuances and intersections of SRB, using qualitative semi-structured interviews with 60 regular heroin users recruited primarily from syringe programs in Geelong, Australia. Twenty-eight percent of interviewees reported a previous suicide attempt and 45% reported serious consideration of it. Types of SRB reported included: Suicide attempts, instrumental suicide-related behaviors, suicidal ideation, indifference and risk-taking thoughts and behaviors. Heroin users engage in much behavior which inhabits a grey area of SRB. The use of a nomenclature which addresses the elements of lethality and intent improves the ability of research to properly define and categorize SRB in drug-using populations. But the categories should not be overinclusive; indifferent attitudes towards death and risk-taking behaviors can sometimes be a functional response to the risk environment of heroin users.<br /
Background:
Drug overdose is an important, yet an inadequately understood, public health problem. Global attention to unintentional drug overdose has been limited by comparison with the scope of the problem. There has been a substantial increase in drug overdose incidence and prevalence in several countries worldwide over the past decade, contributing to both increased costs and mortality.
Objectives:
The aim of this study was to systematically synthesize the peer-reviewed literature to document the global epidemiological profile of unintentional drug overdoses and the prevalence, time trends, mortality rates, and correlates of drug overdoses. We searched different combinations of Medical Subject Headings (MeSH) terms in PubMed for articles published from 1980 until July 2013, and we organized these results in tabular spreadsheets and compared them. We restricted the search to English-language articles that deal with unintentional overdose, focusing on 1 or more of the following key constructs: prevalence, time trends, mortality rates, and correlates. The term "overdose" as a MeSH major topic yielded 1076 publications. In addition, we searched the following combinations of nonmajor MeSH terms: "street drugs" and "overdose" yielded 180, "death" and "overdose" yielded 114, and "poisoning" and "drug users" yielded 17. There was some overlap among the searches. Based on the search and inclusion and exclusion criteria, we selected a total of 169 relevant articles for this article based on a close review of abstracts.
Results:
We found wide variability in lifetime prevalence of experiencing a nonfatal overdose or witnessing an overdose, and in mortality rates attributable to overdose. Lifetime prevalence of witnessed overdose among drug users (n = 17 samples) ranged from 50% to 96%, with a mean of 73.3%, a median of 70%, and a standard deviation of 14.1%. Lifetime prevalence of drug users personally experiencing a nonfatal overdose (n = 27 samples), ranged from 16.6% to 68.0% with a mean of 45.4%, a median of 47%, and a standard deviation of 14.4%. Population-based crude overdose mortality rates (n = 28 samples) ranged from 0.04 to 46.6 per 100 000 person-years. This range is likely attributable to the diversity in regions, time periods, and samples. Most studies on longitudinal trends of overdose death rates or overdose-related hospitalization rates showed increases in overdose death rates and in overdose-related hospitalization rates across time, which have led to peaks in these rates at the present time. An overall trend of increasing deaths from prescription opioid use and decreasing deaths from illicit drug use in the past several years has been noted across most of the literature. With the increase in prescription opioid overdose deaths, drug overdose is not just an urban problem: rural areas have seen an important increase in overdose deaths. Lastly, cocaine, prescription opioids, and heroin are the drugs most commonly associated with unintentional drug overdoses worldwide and the demographic and psychiatric correlates associated with unintentional drug overdoses are similar globally.
Conclusions:
There is a need to invest in research to understand the distinct determinants of prescription drug overdose worldwide. Several other countries need to collect in a systematic and continuous fashion such data on sales of prescription opioids and other prescription drugs, nonmedical use of prescription drugs, and hospitalization secondary to overdoses on prescription drugs. The sparse evidence on the environmental determinants of overdose suggests a need for research that will inform the types of environmental interventions we can use to prevent drug overdose. Methodological issues for future studies include enhancing data collection methods on unintentional fatal and nonfatal overdoses, and collecting more detailed information on drug use history, source of drug use (for prescription drugs), and demographic and psychiatric history characteristics of the individual who overdosed.
We investigate how participants in the street economy of crack cocaine construct a “hustler” identity by contrasting their social behaviors and styles with a dialectically contrastive crackhead identity. For those who are proximate to, or involved in, the crack cocaine economy, effort is required to avoid being labeled a crackhead. Would-be hustlers construct boundaries that separate them from others on the street through talk and behavior. We draw on interviews conducted with 28 men convicted of committing violent street crimes to explore how they distance themselves from those exhibiting distasteful symptoms of crack addiction. By examining the boundaries between these two street-based identities we increase sociological understanding of the significance of offenders’
identity work for shaping their conceptions of self and other, as well as their interactions in everyday street life.
Keywords: identity, boundary maintenance, hustlers, crackhead, crack.
Sykes and Matza's neutralization theory, though a popular framework for understanding deviant behavior, remains badly underdeveloped in the criminological literature. In particular, few attempts have been made to connect it to narrative and sociocognitive research in psychology and related fields. From the perspective of this wider context, it appears that one reason neutralization theory has received only mixed empirical support is that it has been understood as a theory of criminal etiology. This makes little sense (how can one neutralize something before they have done it?). It also makes the theory difficult to test. Neutralization should instead be seen as playing a role in persistence in or desistance from criminal behavior. Additionally, the theory's central premises need to be substantially complicated. The notions that all excuses or justifications are ''bad'' and that reform involves ''accepting complete responsibility'' for one's actions are not tenable. Sykes and Matza were right to draw attention to self-understandings and attributions, but criminology was wrong in seeing neutralization theory as the last word on cognition in criminal behavior.
To systematically review cohort studies of mortality among people who inject drugs, examine mortality rates and causes of death in this group, and identify participant- and study-level variables associated with a higher risk of death.
Tailored search strings were used to search EMBASE, Medline and PsycINFO. The grey literature was identified through online grey literature databases. Experts were consulted to obtain additional studies and data. Random effects meta-analyses were performed to estimate pooled crude mortality rates (CMRs) and standardized mortality ratios (SMRs).
Sixty-seven cohorts of people who inject drugs were identified, 14 of them from low- and middle-income countries. The pooled CMR was 2.35 deaths per 100 person-years (95% confidence interval, CI: 2.12-2.58). SMRs were reported for 32 cohorts; the pooled SMR was 14.68 (95% CI: 13.01-16.35). Comparison of CMRs and the calculation of CMR ratios revealed mortality to be higher in low- and middle-income country cohorts, males and people who injected drugs that were positive for human immunodeficiency virus (HIV). It was also higher during off-treatment periods. Drug overdose and acquired immunodeficiency syndrome (AIDS) were the primary causes of death across cohorts.
Compared with the general population, people who inject drugs have an elevated risk of death, although mortality rates vary across different settings. Any comprehensive approach to improving health outcomes in this group must include efforts to reduce HIV infection as well as other causes of death, particularly drug overdose.
In qualitative interviews with 100 cannabis users in Norway, three discursive repertoires were particularly frequent. The first emphasized how users were ‘normal’ with statements, such as ‘everyone smokes cannabis’ or ‘cannabis users are not different from others’. The second discursive repertoire emphasized the fascinating difference of both users and the drug. Many cannabis users, stated that cannabis was used by ‘free-thinking, open people’ and triggered creativity. The third discursive repertoire was different techniques of risk denial, arguing that cannabis ‘is just a plant’ or that cannabis use did not have any harmful consequences. These three discursive repertoires are the empirical foundations for three conflicting theoretical traditions in studies of illegal drugs. Cannabis has been described as ‘normalized’, interpreted in a subcultural framework, or researchers have emphasized how illegal drug use is neutralized by users. The interdiscursivity of Norwegian cannabis users challenge all three theoretical frameworks and can only be understood by analysing talk as action. This article argues that all three discursive repertoires can be understood as responses to stigmatization. The conclusion is that the theoretical framework of ‘normalization’ is not the best way to understand cannabis use in Norway and possibly elsewhere.
The aim of the study was to illuminate the experiences of suicidal behaviour in young Norwegian men with long-term substance abuse and to interpret their narratives with regard to meaning. Data were collected using open-ended, in-depth interviews. A phenomenological hermeneutic approach, inspired by the philosophy of Ricoeur, was used to analyse the data. The naïve reading involved awareness of the perceived sense of pain and hope in the participants. In the structural analysis, three themes were identified: (1) the meaning of relating, (2) the meaning of reflecting and (3) the meaning of acting. A comprehensive understanding of data indicated that the meaning of living with suicidal behaviour could be understood as a movement between different positions of wanting death as an escape from pain and hope for a better life. Our conclusion is that suicidal behaviour in men with substance abuse is a communicative activity about the individual's lived experience of pain and hope. How the participants experienced and constructed masculinity influenced the suicidal behaviour. To reduce pain and create hope by being seen and confirmed in social relationships, and being helped to verbalize existential thoughts and openly discuss possible solutions, are of importance.
Health promotion strategies ultimately rely on people perceiving the consequences of their behaviour as negative. If someone is indifferent towards death, it would logically follow that health promotion messages such as safe using messages would have little resonance. This study aimed to investigate attitudes towards death in a group of injecting drug users (IDUs) and how such attitudes may impact upon the efficacy/relevance of 'safe using' (health promotion) messages.
Qualitative, semi-structured interviews in Geelong, Australia with 60 regular heroin users recruited primarily from needle and syringe programs.
Over half of the interviewees reported having previously overdosed and 35% reported not engaging in any overdose prevention practices. 13% had never been tested for either HIV or hepatitis C. Just under half reported needle sharing of some description and almost all (97%) reported previously sharing other injecting equipment. Many interviewees reported being indifferent towards death. Common themes included; indifference towards life, death as an occupational hazard of drug use and death as a welcome relief.
Most of the interviewees in this study were indifferent towards heroin-related death. Whilst interviewees were well aware of the possible consequences of their actions, these consequences were not seen as important as achieving their desired state of mind. Safe using messages are an important part of reducing drug-related harm, but people working with IDUs must consider the context in which risk behaviours occur and efforts to reduce said behaviours must include attempts to reduce environmental risk factors at the same time.
Research Report from Evaluation of the Norwegian National Overdose Strategy 2014-2017
Background and Aims
Opioid overdose deaths among adolescents and young adults have risen sharply in the US over recent decades. This study aimed to explore the nature of adolescent and young adult perspectives on overdose experiences.
Design
This study involved thematic analysis of interviews undertaken as part of a mixed methods, randomised trial of extended release naltrexone (XR‐NTX) versus treatment‐as‐usual (TAU) for adolescents and young adults (15‐21 years) with opioid use disorder (OUD).
Setting
Participants were recruited during a residential treatment episode at Mountain Manor Treatment Center, in Baltimore, Maryland, USA.
Participants/Cases
As part of the qualitative component of this study, 35 adolescents/young adults completed up to three interviews: at baseline, 3 months, and 6 months after release from residential opioid use disorder treatment.
Measurements
Semi‐structured interviews solicited participant experiences with opioid use disorder treatment; their satisfaction with the medications used to treat opioid use disorder; counseling received; current substance use; issues related to treatment retention; their treatment goals; and their future outlook.
Findings
Four broad themes emerged: 1) adolescents/young adults had difficulty identifying overdoses due to interpreting subjective symptoms and a lack of memory of the event, 2) this sample had difficulty perceiving risk that is misaligned with traditional understandings of overdose intentionality, 3) adolescents/young adults did not interpret personal overdose events as a catalyst for behavior change, and 4) this sample experienced a greater impact to behavior change through witnessing an overdose of someone in their social network.
Conclusions
The sample of US adolescents and young adults in treatment for opioid use disorder expressed difficulty identifying whether or not they had experienced an overdose, expressed fluctuating intentionality for those events, and did not have clear intentions to change their behaviour. Witnessing an overdose appeared to be as salient an experience as going through an overdose oneself.
Background
Suicidal thinking during non-fatal overdose may elevate risk for future completed suicide or intentional overdose. Long-term outcomes following an intentional non-fatal overdose may be improved through specific intervention and prevention responses beyond those designed for unintentional overdoses, yet little research has assessed suicidal intent during overdoses or defined characteristics that differentiate these events from unintentional overdoses.
Methods
Patients with a history of opioid overdose (n = 274) receiving residential addiction treatment in the Midwestern United States completed self-report surveys to classify their most recent opioid overdose as unintentional, actively suicidal (“wanted to die”), or passively suicidal (didn’t care about the risks). We characterized correlates of intent using descriptive statistics and prevalence ratios. We also examined how intent related to thoughts of self-harm at the time of addiction treatment.
Results
Of opioid overdoses, 51% involved suicidal intent (44% passive and 7% active). Active suicidal intent was positively associated with hospitalization. Active/passive intent (vs. no intent, aPR: 2.2, 95% CI: 1.4-3.5) and use of ≥5 substances (vs. 1 substance, aPR: 3.6, 95% CI: 1.2-10.6) at the last opioid overdose were associated with having thoughts of self-harm or suicide in the two weeks before survey completion in adjusted models. Participants who reported active/passive intent more commonly used cocaine or crack (27%) with opioids during their last overdose relative to unintentional overdoses (16%).
Conclusions
Over half of opioid overdoses among individuals in addiction treatment involved some degree of suicidal thinking. Identifying patients most at risk will facilitate better targeting of suicide prevention and monitoring services.
Background:
Prior studies in heroin use disorder reported low rates (10%) of suicidal intention with non-fatal opioid overdose but did not assess dimensional ratings of suicidal ideation. This study aims to quantify the frequency and intensity of ratings of desire to die and perceived overdose risk proximal to the most recent opioid overdose event among individuals admitted for opioid use disorder detoxification/stabilization.
Methods:
Cross-sectional study (June 2017-July 2018) assessing patterns of opioid use and variables related to overdose history was conducted in a not-for-profit psychiatric hospital. Adults (>18 years) with opioid use disorder were eligible and 120 of 122 participants completed all measures. Forty-one percent were women and 85% self-identified as white. Participants' perceptions of the likelihood of overdose and their suicidal motivations (defined as desire to die) prior to most recent opioid overdose was self-rated on a scale of 0 (no desire to die/no risk of death) to 10 (I definitely wanted to die/I definitely thought I would die).
Results:
Most (92%) surviving opioid overdose used heroin/fentanyl; over half reported some desire to die prior to their most recent overdose, with 36% reporting strong (>7/10) desire to die and 21% reporting 10/10 "I definitely wanted to die." Perceptions of overdose risk were also variable, with 30% reporting no (0/10) likelihood of overdose and 13% reporting a high (10/10) likelihood.
Conclusions:
Suicidal motivation prior to opioid overdose is common and falls along a continuum of severity. Longitudinal studies are needed to determine if suicide prevention interventions may reduce opioid overdose in those at risk.
Rates of suicide and unintentional overdose in the United States have climbed during the past two decades. Opioid use plays a critical role in fueling both of these public health problems. Consequently, interventions that address the shared causes and risk factors, such as programs to improve the quality of pain care, expand access to psychotherapy, and increase access to medication-assisted treatment for opioid use disorders, have the potential to be high-value investments by addressing both problems simultaneously.
Patients in opioid substitution treatment (OST) in Norway are assigned a treatment modality based on their risk profiles, with an emphasis on overdose risk. One of several medications may be administered, including methadone, buprenorphine, buprenorphine–naloxone, and occasionally morphine. OST patients who are not satisfied with the assigned treatment are required to negotiate with OST staff to switch treatment modalities. During these negotiations, some inherent paradoxes arise: (1) OST contains both a harm reduction approach and an ideology that emphasizes abstinence and a drug-free life and (2) legal requirements for patient involvement in the choice of treatment clash with the clinicians’ intrinsic suspicion toward patients’ knowledge, experience, and pharmacological preferences. Drawing upon a year of ethnographic fieldwork, I discuss in this article how OST simultaneously reduces and reproduces risks. OST medications are primarily designed to manage withdrawal, with the patient’s survival as the priority rather than quality of life. But this corporeal focus combined with a mantra of harm reduction reduces patients to their physiology. Consequently, many OST patients live in a chronic survival modus—“I am surviving, not living”—which complicates their ability to acquire new social roles. As they struggle with medication side effects, poor health, isolation, and a need for recognition, many abandon their rehabilitation plans and disengage further from society. Thus, OST can produce a new kind of vulnerability, creates new subjects at risk, and by extension maintains risk of diversion, polydrug use, and overdose.
Aims:
To examine the mortality risk in a cohort of "hard-to-reach" polysubstance users and its putative associations with substance use. Specifically, we estimated all-cause mortality risk as a function of individual substance use indicators, and then as a function of their complex, "real-life" patterns as identified through Latent Class Analysis (LCA).
Design:
Prospective cohort study among street-and low-threshold-service-recruited polysubstance users included between September and November 2013 and followed through the National Cause of Death Registry until 31 October 2015.
Setting:
Seven Norwegian cities.
Participants:
884 users of illegal opioids and/or stimulants. Of these, 357 were in opioid substitution treatment (OST) at the time of inclusion. Forty-four participants died during follow-up.
Measurements:
Primary outcome: All-cause mortality risk. Unadjusted and adjusted Cox proportional hazard (PH) regression models (covariates: male, age, homelessness/shelter use, overdose experience, OST status, years of injecting, individual substance use indicators, city, use patterns). LCA models estimated separately for those in and those not in OST due to measurement invariance.
Findings:
The crude mortality rate was 2.52 per 100 person-years. Standardized mortality ratio was 26.11 (95% confidence interval (CI) 10.06-54.87) for women and 10.71 (95% CI 6.39-16.81) for men. No single drug use indicator, such as "heroin injection" or "number of drugs used", was associated with the mortality risk. However, meaningful use patterns were identified; three OST and non-OST patterns each. The non-OST patterns "Polysubstance injectors" (HR=3.44 95% CI 0.98-12.14) and "Low frequent injectors" (HR=3.17 CI 1.05-9.56) were significantly associated with the mortality risk even when adjusted for other known risk factors.
Conclusions:
In a Norwegian prospective cohort study, "hard-to-reach" polysubstance users had more than ten times higher mortality risk than the general population. Mortality risk was not a function of any single drug use indicator, but two distinct combinations of substances, frequencies and routes of administration were associated with the mortality risk.
Gresham Sykes and David Matza argue that, when offenders contemplate committing criminal acts, they use linguistic devices to neutralize the guilt of committing crime. The most common neutralization techniques that offenders use include denial of responsibility, denial of harm, denial of victim, appeal to higher loyalties, and condemnation of the condemners. Despite mixed empirical support, the neutralization theory has gained widespread acceptance within criminology. The theory has been incorporated into many mainstream criminological approaches (e.g., differential association, social control, and reintegrative shaming). Recent theoretical advancements have focused on elaborating upon how neutralization use varies according to the types of offenders who use them and the type of offense committed.
Background:
Drug overdose is an important, yet an inadequately understood, public health problem. Global attention to unintentional drug overdose has been limited by comparison with the scope of the problem. There has been a substantial increase in drug overdose incidence and prevalence in several countries worldwide over the past decade, contributing to both increased costs and mortality.
Objectives:
The aim of this study was to systematically synthesize the peer-reviewed literature to document the global epidemiological profile of unintentional drug overdoses and the prevalence, time trends, mortality rates, and correlates of drug overdoses. We searched different combinations of Medical Subject Headings (MeSH) terms in PubMed for articles published from 1980 until July 2013, and we organized these results in tabular spreadsheets and compared them. We restricted the search to English-language articles that deal with unintentional overdose, focusing on 1 or more of the following key constructs: prevalence, time trends, mortality rates, and correlates. The term "overdose" as a MeSH major topic yielded 1076 publications. In addition, we searched the following combinations of nonmajor MeSH terms: "street drugs" and "overdose" yielded 180, "death" and "overdose" yielded 114, and "poisoning" and "drug users" yielded 17. There was some overlap among the searches. Based on the search and inclusion and exclusion criteria, we selected a total of 169 relevant articles for this article based on a close review of abstracts.
Results:
We found wide variability in lifetime prevalence of experiencing a nonfatal overdose or witnessing an overdose, and in mortality rates attributable to overdose. Lifetime prevalence of witnessed overdose among drug users (n = 17 samples) ranged from 50% to 96%, with a mean of 73.3%, a median of 70%, and a standard deviation of 14.1%. Lifetime prevalence of drug users personally experiencing a nonfatal overdose (n = 27 samples), ranged from 16.6% to 68.0% with a mean of 45.4%, a median of 47%, and a standard deviation of 14.4%. Population-based crude overdose mortality rates (n = 28 samples) ranged from 0.04 to 46.6 per 100 000 person-years. This range is likely attributable to the diversity in regions, time periods, and samples. Most studies on longitudinal trends of overdose death rates or overdose-related hospitalization rates showed increases in overdose death rates and in overdose-related hospitalization rates across time, which have led to peaks in these rates at the present time. An overall trend of increasing deaths from prescription opioid use and decreasing deaths from illicit drug use in the past several years has been noted across most of the literature. With the increase in prescription opioid overdose deaths, drug overdose is not just an urban problem: rural areas have seen an important increase in overdose deaths. Lastly, cocaine, prescription opioids, and heroin are the drugs most commonly associated with unintentional drug overdoses worldwide and the demographic and psychiatric correlates associated with unintentional drug overdoses are similar globally.
Conclusions:
There is a need to invest in research to understand the distinct determinants of prescription drug overdose worldwide. Several other countries need to collect in a systematic and continuous fashion such data on sales of prescription opioids and other prescription drugs, nonmedical use of prescription drugs, and hospitalization secondary to overdoses on prescription drugs. The sparse evidence on the environmental determinants of overdose suggests a need for research that will inform the types of environmental interventions we can use to prevent drug overdose. Methodological issues for future studies include enhancing data collection methods on unintentional fatal and nonfatal overdoses, and collecting more detailed information on drug use history, source of drug use (for prescription drugs), and demographic and psychiatric history characteristics of the individual who overdosed.
Background:
Little is known on the effect of stigma on the health and behavior of people who inject drugs (PWID). PWID may internalize these negative attitudes and experiences and stigmatize themselves (internalized stigma). With previous research suggesting a harmful effect of internalized stigma on health behaviors, we aimed to determine socio-demographic characteristics and injection risk behaviors associated with internalized PWID-related stigma in New York City (NYC).
Methods:
Three NYC pharmacies assisted in recruiting PWID. Pharmacy-recruited PWID syringe customers received training in recruiting up to three of their peers. Participants completed a survey on injection behaviors and PWID-related stigma. Among HIV-negative PWID (n=132), multiple linear regression with GEE (to account for peer network clustering) was used to examine associations with internalized PWID-related stigma.
Results:
Latinos were more likely to have higher internalized stigma, as were those with lower educational attainment. Those with higher internalized stigma were more likely to not use a syringe exchange program (SEP) recently, although no association was found with the recent use of pharmacies for syringes. Lastly, higher internalized stigma was related to less than 100% use of pharmacies or SEPs for syringe needs.
Conclusions:
These data suggest that PWID with higher internalized stigma are less likely to consistently use sterile syringe sources in urban settings with multiple sterile syringe access points. These results support the need for individual- and structural-level interventions that address PWID-related stigma. Future research is needed to examine why PWID with higher internalized stigma have less consistent use of public syringe access venues.
The current paper examines critically the literature on deaths attributed to heroin overdose, and examines the characteristics and circumstances of such deaths. In particular, the dominance of the widely held belief that heroin-related fatalities are a consequence of overdose is challenged. Deaths attributed to overdose represented in the literature are typically older, heroin-dependent males not in drug treatment at the time of death. Fatalities involving only heroin appear to form a minority of overdose occasions, the presence of other drugs (primarily central nervous system depressants such as alcohol and benzodiazepines) being commonly detected at autopsy. Furthermore, deaths attributed to overdose are likely to have morphine levels no higher than those who survive, or heroin users who die from other causes. It is concluded that the term overdose is, in many cases, a misleading term, since it implies the same mechanism of death in all cases, an implication that is neither clinically useful nor consistent with published data. Implications for the prevention of heroin-related deaths are discussed.
Background: A stigma is a long-lasting mark of social disgrace that has a profound effect on interactions between the stigmatized and the unstigmatized. Factors governing the extent of stigmatization attached to an individual include the perceived danger posed by that person and the extent to which she/he is seen as being to blame for the stigma.
Methods: Systematic database searches identified 185 papers for inclusion in the review, all of which were read and findings analysed and compared.
Results: Stigmatizing attitudes towards problem drug users (PDUs) are common among the general public and non-specialist professionals. The impact on users is profound and represents a significant barrier to recovery. Reasons for this extreme stigmatization include negative reactions to injecting and widespread attributions concerning danger and blame. Advocacy and practice responses include challenging media language and stereotypes, encouraging public figures to speak out about their personal experiences, improved training for non-specialist staff and greater contact between PDUs and the public.
Conclusion: Stigmatization has a profound effect on PDUs’ lives and their chances of recovery. Efforts need to be made to diminish inflated fears about users and help people to understand that PDUs are not simply and solely ‘to blame’ for their condition.
O’Malley and Valverde point out that in the 21st century, pleasure is a warrantable motive for drug and alcohol use only when it is attached to the idea of moderation. This presents a problem for those researchers who wish to theorise about those individuals who use drugs deliberately to induce intoxication. This paper uses unconventional means to come to an understanding of intoxication. It uses the stories of interviewed former heroin addicts, published autobiographies, biographies and even some fictional accounts to come to an understanding of the difficulties of dealing with intoxication and the drug-using subject. It also uses the accounts that Michel Foucault gave about his own use of drugs and its relationship to an ethics of pleasure and resistance. The article uses theories of risk and edgework to understand the underlying meanings of intoxication to many drug users.
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This paper investigates the competing rationalities of scientific and lay epidemiology and how the tension between the two impacts on the efficacy of health promotion messages for injecting drug users (IDUs). It proposes that behaviours, which may be difficult to understand when viewed at an individual level, are, in fact, rational within particular cultural contexts. The study used qualitative semi-structured interviews with 60 heroin users. A number of different types of risk neutralisation were observed in this group of interviewees, including: scapegoating, self-confidence and risk comparison. Interviewees commonly used lay epidemiology to justify and rationalise their risk neutralisation strategies. The paper provides concrete examples of the ways in which this group of IDUs neutralise risk through the use of these strategies. The findings illustrate how many of the psychological constructs surrounding the perception of risk which focus on individual behaviour are fundamentally simplistic and often unhelpful in understanding the behaviours of this group of people. It is concluded that some ‘risk’ behaviours are often functional and rational within the context of prohibitionist drug policies which create an environment in which the IDU often has little real agency to reduce the risks associated with their drug use.
Introduction and aims:
Drug overdose and suicide are the two leading causes of death among street youth. The literature discusses the two faces of drug overdose: accidental act and suicide attempt. Some authors have stated that accidental overdoses may be a hidden expression of suicidal ideation. This study longitudinally examined the relationship between recent suicidal ideations and non-fatal accidental drug overdoses among street youth.
Design and methods:
Between July 2001 and December 2005, 858 street youth (14-23 years old) were recruited for a prospective cohort study. Youth were eligible if, in the previous year, they had been without a place to sleep more than once or had used the services of street youth agencies on a regular basis (≥3). Participants completed baseline questionnaires and follow-up interviews were carried out every 6 months. Mixed-effect logistic regression models were conducted. Apart from suicidal ideation and accidental drug overdose, variables considered in the model were age, sex, problematic alcohol use, homelessness, injection drug use and polydrug use (≥3 drugs).
Results:
Accidental drug overdose was significantly associated with suicidal ideation (adjusted odds ratio 1.88; 95% confidence interval 1.23-2.54). Homelessness, injection drug use and polydrug use were also significant in the final model.
Discussion and conclusions:
Results show that, during follow up, suicidal ideation independently increased risks of accidental overdose. They also underscore the need for interventions beyond educational prevention. Primary care practitioners should investigate suicidal ideations and behaviours of street youth in treatment for accidental overdose.
A sample of 312 heroin users were interviewed about their experience of non-fatal heroin overdose. Non-fatal overdose was common, with 61 % of subjects reporting one, on a median of 2 occasions. Those subjects who had used heroin in the preceding 6 months were interviewed about overdose risk perceptions and risk behaviours (n = 266). The majority of these subjects (80%) believed they had a low risk of overdose, there being no difference in risk perception between those who had overdosed in the last 6 months and those who had not. While the majority (73%) claimed to use various strategies to avoid overdose, these were sporadically practised. Those who had overdosed in the past 6 months had used heroin on more days in that time, had higher levels of heroin dependence, more often used alcohol and benzodiazepines in combination with heroin, and were less likely to be enrolled in methadone maintenance during that time. Methadone maintenance thus had a protective effect against overdose, even for patients who continued heroin use over the preceding 6 months.
In this commentary, we critically review the contribution of the sociologist Erving Goffman (1922–1982) to understanding recovery from problem drug use. Previous research has indicated that drug users have a ‘spoiled identity’ and must restore a ‘normal’ or ‘unspoiled’ identity in order to recover. This argument has been linked to Goffman's classic work Stigma: Notes on the management of a spoiled identity [1963, Harmondsworth: Penguin]. Despite its evident appeal, linking recovery to repairing a spoiled identity has a number of problems. These include the derogatory connotations of ‘spoiled’, and the fact that the ‘momentary’ spoiled identity that Goffman likely intended is easily lost to a more ‘totalizing’ spoiled identity, from which it can be difficult for individuals to escape. Given such shortcomings, we consider how Goffman's broader dramaturgical work might contribute to our understanding of recovery processes. Dramaturgy, which focuses on the performative aspects of selfhood and the relational and situational nature of identity, suggests ways that individuals can work on their identity (and recovery) projects without over-prioritizing abstinence. We suggest that dramaturgy is more useful than the notion of repairing a spoiled identity for understanding and facilitating recovery. Nonetheless, it has limitations and other sociological perspectives provide fertile ground for future debate.
‘Risk’ and ‘risk behaviour’ have become keywords in discourses about AIDS. Notions of risk behaviour in the field of HIV prevention and the addictions largely derive from epidemiological categorisations which have had a key role in constructing lay and scientific understandings of the ‘problems’ of AIDS and injecting drug use. This has encouraged are stricted vision which inadequately captures risk as it is understood and experienced by drug users themselves. Drawingon case examples from qualitative research with illicit drug users, this paper explores the utility of current theories of risk behaviour in understanding how risk behaviour is socially organised. Two key developments in risk behaviour theory are examined. These are situated rationality and social action theories. Findings illustrate that situated rationality theoriestend to be conceptually limited to an analysis of individual rationality which fails to capture the distribution and influence of power in negotiated actions and the habituated nature of risk behaviour. In contrast, social action theories aim to understand the interplay of social factors which give rise to individuals’ situated risk perceptions and actions. Findings highlight the important role that qualitative research plays in questioning, as well as complementing, dominant scientific constructions of risk. Future theories of risk behaviour in the field of HIV prevention, as well as other health domains, need to consider risk as a socially organised rather than individual phenomenon. The paper concludes by asserting that understanding what risk actually means to participants themselves provides the necessary data for public health interventions to create the conditions where risk reduction becomes possible.
This paper is about intimacy and its role in relationship risk management. Drawing on qualitative interviews with HIV positive people and their primary sexual partners it becomes apparent that a key tension in relationship risk management is the balance struck between ‘relationship safety’ and ‘viral danger’. We find ‘love’ and ‘intimacy’ to be key features of relationship survival, with relationship intimacy and security signalled or strengthened by unprotected sex. Focusing on ‘discordant’ partnerships in particular, we note that relationship risk management is a fragile process characterised by contradiction and anxiety, at once involving risk reduction and risk opportunity. We conclude that the intimate relationship is a prime source of everyday risk management which may be defended, even at potentially high cost, in the time of sexual epidemic. We also note that previous research has painted an overly calculative picture of risk decision-making in which the lived experiences of intimacy and emotions are largely missing.
To review the literature on mortality among dependent or regular users of opioids across regions, according to specific causes, and related to a number of demographic and clinical variables.
Multiple search strategies included searches of Medline, EMBASE and PsycINFO, consistent with the methodology recommended by the Meta-analysis of Observational Studies in Epidemiology (MOOSE) group; grey literature searches; and contact of experts for any additional unpublished data from studies meeting inclusion criteria. Random-effects meta-analyses were conducted for crude mortality rates (CMRs) and standardized mortality ratios (SMRs), with stratified analyses where possible. Meta-regressions examined potentially important sources of heterogeneity across studies.
Fifty-eight prospective studies reported mortality rates from opioid-dependent samples. Very high heterogeneity across studies was observed; pooled all-cause CMR was 2.09 per 100 person-years (PY; 95% CI; 1.93, 2.26), and the pooled SMR was 14.66 (95% CI: 12.82, 16.50). Males had higher CMRs and lower SMRs than females. Out-of-treatment periods had higher mortality risk than in-treatment periods (pooled RR 2.38 (CI: 1.79, 3.17)). Causes of death varied across studies, but overdose was the most common cause. Multivariable regressions found the following predictors of mortality rates: country of origin; the proportion of sample injecting; the extent to which populations were recruited from an entire country (versus subnational); and year of publication.
Mortality among opioid-dependent users varies across countries and populations. Treatment is clearly protective against mortality even in non-randomized observational studies. Study characteristics predict mortality levels; these should be taken into account in future studies.
Substance use is a risk factor for suicide, suicide attempts, and fatal and non-fatal overdose, but to date, little has been done to integrate the research on suicidal behavior and overdose among substance users. This study reviews the literature on suicide and overdose among substance users with the goal of illuminating the similarities and differences between these two events. A structured review resulted in 15 articles (describing 14 unique studies) published between 1990 and 2010 that examined both overdose and suicide in samples of substance users. There is some evidence that substance users who attempt suicide are more likely to report an overdose and vice versa. This relationship may be partially explained by the fact that overdose is a common method of suicide. The results of the literature review also indicate that substance users with a history of both events may represent a group with particularly poor psychological and social functioning and severe drug-related problems. Further research is needed to understand the overlap of, and differences between, suicide and accidental overdose among individuals who misuse substances, particularly individuals who primarily use substances other than heroin. An improved understanding of the interrelationships between suicide and unintentional overdose among individuals who use alcohol or drugs is necessary to guide the development of effective prevention and intervention approaches.
A 'risk environment' framework promotes an understanding of harm, and harm reduction, as a matter of 'contingent causation'. Harm is contingent upon social context, comprising interactions between individuals and environments. There is a momentum of interest in understanding how the relations between individuals and environments impact on the production and reduction of drug harms, and this is reflected by broader debates in the social epidemiology, political economy, and sociology of health. This essay maps some of these developments, and a number of challenges. These include: social epidemiological approaches seeking to capture the socially constructed and dynamic nature of individual-environment interactions; political-economic approaches giving sufficient attention to how risk is situated differentially in local contexts, and to the role of agency and experience; understanding how public health as well as harm reduction discourses act as sites of 'governmentality' in risk subjectivity; and focusing on the logics of everyday habits and practices as a means to understanding how structural risk environments are incorporated into experience. Overall, the challenge is to generate empirical and theoretical work which encompasses both 'determined' and 'productive' relations of risk across social structures and everyday practices. A risk environment approach brings together multiple resources and methods in social science, and helps frame a 'social science for harm reduction'.
A sample of 329 heroin users were interviewed regarding their personal experience of non-fatal heroin overdose. Experience of overdose was widespread, with two-thirds of subjects (68%) reporting having overdosed. The median number of life-time overdoses was three, with males and females equally likely to have overdosed. The majority (62%) of most recent heroin overdoses occurred in conjunction with the consumption of other central nervous system depressants (alcohol, benzodiazepines and other opioids). Logistic regression analyses indicated three independent factors associated with having overdosed: longer heroin using careers, greater heroin dependence and higher levels of alcohol consumption. Implications for the reduction in the prevalence and frequency of overdose are discussed.
The current paper examines critically the literature on deaths attributed to heroin overdose, and examines the characteristics and circumstances of such deaths. In particular, the dominance of the widely held belief that heroin-related fatalities are a consequence of overdose is challenged. Deaths attributed to overdose represented in the literature are typically older, heroin-dependent males not in drug treatment at the time of death. Fatalities involving only heroin appear to form a minority of overdose occasions, the presence of other drugs (primarily central nervous system depressants such as alcohol and benzodiazepines) being commonly detected at autopsy. Furthermore, deaths attributed to overdose are likely to have morphine levels no higher than those who survive, or heroin users who die from other causes. It is concluded that the term overdose is, in many cases, a misleading term, since it implies the same mechanism of death in all cases, an implication that is neither clinically useful nor consistent with published data. Implications for the prevention of heroin-related deaths are discussed.
To ascertain the prevalence and risk factors for non-fatal overdose among heroin users to assist in the development of an effective intervention.
Cross-sectional design.
Community setting, principally metropolitan Adelaide.
Current heroin users (used heroin in the previous six months).
A structured questionnaire including the Severity of Dependence Scale.
Of 218 current South Australian heroin users interviewed in 1996, 48% had experienced at least one non-fatal overdose their life-time (median: two overdoses), and 11% had overdosed in the previous 6 months. At some time, 70% had been present at someone else's overdose (median: three overdoses). At the time of their own most recent overdose, 52% had been using central nervous system depressants in addition to heroin, principally benzodiazepines (33%) and/or alcohol (22%). The majority of overdoses occurred in a private home (81%) and in the presence of other people (88%). Unrealistic optimism regarding the risk of overdose was evident across the sample. Despite almost half the sample reporting having had an overdose, and the belief expressed by respondents that on average about 50% of regular heroin users would overdose during their life-time 73% had, during the previous 6 months, "rarely" or "never" worried about possibly overdosing. Optimism regarding the possibility of future overdose was reduced in those with recent experience of overdose in comparison to the rest of the sample. A targeted intervention aimed at the reduction of overdose among heroin users is outlined.
Assessment of prevalence of non-fatal overdoses and suicide attempts and predictors of and co-variation between such behaviours among drug addicts.
Cross-sectional survey.
Inpatient and outpatient treatment units in Norway.
National sample of 2051 drug addicts admitted to treatment in Norway in 1992-93.
Self-reports of suicide attempts and of life-threatening overdoses from structured interviews with therapists.
Almost half (45.5%) the clients reported having experienced one or more life-threatening overdoses. A third (32.7%) reported one or more suicide attempts. Suicide attempts were more often reported among those who had overdosed (odds ratio (OR) = 6.3), and the number of life-threatening overdoses and number of suicide attempts were positively and moderately associated (Pearson's r = 0.39). Drug addicts who had exhibited both life-threatening behaviours were characterized by polydrug use, poor social functioning and HIV risk-taking behaviour. Suicide attempters were also characterized by psychiatric problems.
The substantial co-variation between suicide attempts and drug overdose suggests some common underlying causal factors. These seem to be related to heavy drug use and poor social integration.
To explore suicidal intent among drug users experiencing non-fatal overdose.
Semi-structured interviews.
Seventy-seven drug users experiencing non-fatal overdose and attending six hospital accident and emergency departments in two Scottish cities during 1997 and 1998.
The extent of suicidal intent and motivations for intentional overdosing were examined.
The incidence of suicidal intent was high, with 38 respondents (49%) reporting suicidal thoughts or feelings before overdosing. Suicidal actions were significantly associated with a self-reported history of life-time mental health problems and with not using heroin prior to overdosing, but not with other demographic or drug history data. Qualitative data indicated that intentional overdosing was frequently not driven by a clear and unambiguous desire to die. Furthermore, suicidal actions were motivated by a range of psychosocial factors, including: (i) predisposing personal circumstances; (ii) precipitating events; and (iii) poor individual coping strategies.
The issue of suicidal intent needs to be addressed routinely in hospital wards and accident and emergency departments so that the need for support can be assessed.