Peer-initiated overdose resuscitation: fellow drug users could be mobilised to implement resuscitation

Abstract

Research interviews about overdose experiences were conducted with 115 patients attending a methadone maintenance clinic in south London, UK. While almost half (49.6%) reported having experienced overdose personally (on an average of four occasions each), almost all (97.4%) reported that they had witnessed overdoses (on an average of six occasions each). This represents a total of 706 overdoses witnessed, of which 106 had resulted in fatalities. The vast majority of patients (86/97) reported that they had taken actions when they had witnessed overdoses with those acting taking an average of nearly threee different actions on the last occasion on which they had seen someone overdosing. Most respondents reported that they would be willing to act, even if they did not know the overdose victim personally and that they had not been deterred from acting by the previous response from the emergency services. Fear of punishment was not a strong deterrent from acting certainly not for this sample, with many participants also expressing an interest in expanding their repertoire of overdose interventions, for example through training in resuscitation techniques and by keeping naloxone at home for use in overdose emergency.

Introduction

Opiate addicts have been found to have an increased mortality rate, with an annual mortality approximately 10–20 times greater than for an age-matched non-addict population (Ghodse et al., 1978, Davoli et al., 1993, Frischer et al., 1993, Oppenheimer et al., 1994, Hammersley et al., 1995, Farrell et al., 1996, Darke and Zador, 1996).

Overdose is a not an infrequent occurrence amongst opiate misusers. In studies in the UK (Gossop et al., 1996, Powis et al., 1999) and in Australia (Darke et al., 1996, McGregor et al., 1998), about half of the interviewed injecting heroin users had themselves previously experienced an overdose, with an even larger number having witnessed an overdose by another drug misuser. Specific enquiry into the reasons for the overdose have established that only a minority of these overdoses are associated with suicidal intent (Vingoe et al., 1999, Neale, 2000, Best et al., 2000a), and hence such overdoses may usefully be considered as an occupational hazard of a career as an injecting heroin user, and one whose likelihood the user may be particularly keen to find ways to reduce.

These overdoses are extensively witnessed. In earlier work from our group (Powis et al., 1999, Strang et al., 1999a), specific enquiry was made about the circumstances of the last occasion of overdose for the 117 subjects who had previously overdosed, of whom 95 (81%) had been with someone else when they had last overdosed, usually a close friend or sexual partner. Further enquiry was made from this group about their witnessing of the overdoses of other drug users, where the closeness of their relationship to the drug user who had overdosed was again evident, including in the instances where the overdose had resulted in death (Strang et al., 1999a, Strang et al., 1999b).

Management of witnessed overdoses (by fellow drug takers) is often inept, flawed or even counterproductive. Folklore includes such inefficient or dangerous advice as intravenous salt, stimulants, immersion in a cold bath and, perhaps most extraordinarily, intravenous milk (Drenick, 1970). Both Darke et al. (1996) and Powis et al. (1999) report on the delay and reluctance to call an ambulance. Written and film media contain examples of desperate and inefficient interventions including, classically, the fictional scene of heroin overdose in the film ‘Pulp fiction’, in which, in utter desperation, fellow drug users attempt resuscitation with direct intra-cardiac adrenalin (certainly not a recommended course of action).

Given the extensive witnessing of overdoses, serious consideration is now being given to the possibility that peer drug takers might be a valuable target group for training in resuscitation techniques. However, as yet, only minimal data have been collected on whether drug users would generally be willing to consider involvement in such resuscitation or whether the fear of involvement (and possible involvement with ambulance personnel and police) might represent insuperable obstacles. We report on the exploration of these issues amongst a sample of opiate addicts undergoing treatment in London.