title: High prevalence of non-fatal overdose among people who inject drugs in Malaysia: Correlates of overdose and implications for overdose prevention from a cross-sectional study.
abstract: BACKGROUND
  Overdose is the leading cause of death among opioid users, but no data are available on overdose among people who inject drugs in Malaysia. We present the first estimates of the prevalence and correlates of recent non-fatal overdose among people who inject drugs in Malaysia.
  
  
  METHODS
  In 2010, 460 people who inject drugs were recruited using respondent-driven sampling (RDS) in Klang Valley to assess health outcomes associated with injection drug use. Self-reported history of non-fatal overdose in the previous 6 months was the primary outcome. Sociodemographic, behavioral and structural correlates of non-fatal overdose were assessed using multivariable logistic regression.
  
  
  RESULTS
  All 460 participants used opioids and nearly all (99.1%) met criteria for opioid dependence. Most injected daily (91.3%) and were male (96.3%) and ethnically Malay (90.4%). Overall, 20% of participants had overdosed in the prior 6 months, and 43.3% had ever overdosed. The RDS-adjusted estimate of the 6-month period prevalence of overdose was 12.3% (95% confidence interval [CI] 7.9-16.6%). Having injected for more years was associated with lower odds of overdose (adjusted odds ratio [AOR] 0.6 per 5 years of injection, CI: 0.5-0.7). Rushing an injection from fear of the police nearly doubled the odds of overdose (AOR 1.9, CI: 1.9-3.6). Alcohol use was associated with recent non-fatal overdose (AOR 2.1, CI: 1.1-4.2), as was methamphetamine use (AOR 2.3, CI: 1.3-4.6). When adjusting for past-month drug use, intermittent but not daily methadone use was associated with overdose (AOR 2.8, CI: 1.5-5.9).
  
  
  CONCLUSIONS
  This study reveals a large, previously undocumented burden of non-fatal overdose among people who inject drugs in Malaysia and highlights the need for interventions that might reduce the risk of overdose, such as continuous opioid substitution therapy, provision of naloxone to prevent fatal overdose, treatment of polysubstance use, and working with police to improve the risk environment.
authors.affiliation: Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA; Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, 135 College St., Suite 323, New Haven, CT 06510, USA. Electronic address: alexander.bazazi@yale.edu.
authors.forename: Alexander R
authors.initials: AR
authors.lastname: Bazazi
authors.affiliation: Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, 135 College St., Suite 323, New Haven, CT 06510, USA.
authors.forename: Alexei
authors.initials: A
authors.lastname: Zelenev
authors.affiliation: Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA; Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, 135 College St., Suite 323, New Haven, CT 06510, USA; Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
authors.forename: Jeannia J
authors.initials: JJ
authors.lastname: Fu
authors.affiliation: Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
authors.forename: Ilias
authors.initials: I
authors.lastname: Yee
authors.affiliation: Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, 135 College St., Suite 323, New Haven, CT 06510, USA; Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia; Infectious Diseases Unit, Faculty of Medicine, University of Malaya, Lembah Pantai, 50603 Kuala Lumpur, Malaysia.
authors.forename: Adeeba
authors.initials: A
authors.lastname: Kamarulzaman
authors.affiliation: Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA; Department of Internal Medicine, Section of Infectious Diseases, AIDS Program, Yale School of Medicine, 135 College St., Suite 323, New Haven, CT 06510, USA; Centre of Excellence for Research in AIDS (CERiA), Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.
authors.forename: Frederick L
authors.initials: FL
authors.lastname: Altice
mesh_terms: D000428:Alcohol Drinking / Q000009:adverse effects / Q000453:epidemiology; D003430:Cross-Sectional Studies; D062787:Drug Overdose / Q000453:epidemiology*; D005239:Fear / Q000523:psychology; D005260:Female; D006801:Humans; D016015:Logistic Models; D008296:Malaysia / Q000453:epidemiology; D008297:Male; D008694:Methamphetamine / Q000008:administration & dosage / Q000009:adverse effects; D009293:Opioid-Related Disorders / Q000453:epidemiology*; D016495:Police; D015995:Prevalence; D012307:Risk Factors; D015819:Substance Abuse, Intravenous / Q000453:epidemiology*
chemical_list: D008694:Methamphetamine
keywords: Harm reduction; Injection drug use; Malaysia; Non-fatal overdose; Opioids