title: Death matters: understanding heroin/opiate overdose risk and testing potential to prevent deaths.
abstract: OBJECTIVE
  To describe work undertaken over a 20-year period, investigating overdose characteristics among survivors, effects of acute heroin administration, clustering of risk of overdose fatality and potential interventions to reduce this fatal outcome.
  
  
  METHODS
  Privileged-access interviewers obtained data from non-treatment as well as treatment samples; experimental study of drop in oxygen saturation following heroin/opiate injection; investigation of clusterings of death following prison release and treatment termination; and study of target populations as intervention work-force, including family as well as peers, and action research built into pilot implementation.
  
  
  RESULTS
  Overdose has been experienced by about half of heroin/opiate misusers, with even higher proportions having witnessed an overdose, and with high levels of willingness to intervene. Heroin/opiates are associated with the majority of drug-related deaths, despite relative scarcity of use. Heroin injection causes a rapid drop in oxygen saturation, recovering only slowly over the next half hour. Deaths from drug overdose are greatly more likely on prison release and post-discharge from detoxification and other in-patient or residential settings. High levels of declared willingness to intervene are matched by active interventions. Both drug-using peers and family members show ability to improve knowledge and gain confidence from training. Audit study of take-home schemes finds approximately 10% of dispensed naloxone is used in real-life emergency situations.
  
  
  CONCLUSIONS
  Overdose is experienced by most users, with heroin/opiates contributing disproportionately to drug overdose deaths. High-risk times (e.g. after prison release) are now clearly identified. Peers and family are a willing potential intervention work-force, but are rarely trained or given pre-supply of naloxone. Large-scale naloxone provision (e.g. national across Scotland and Wales) is now being delivered, while large-scale randomized trials (e.g. N-ALIVE prison-release trial) are finally under way. Better naloxone products and better-organized provision are needed. The area does not need more debate; it now needs proper implementation alongside good scientific study.
authors.affiliation: National Addiction Centre (Institute of Psychiatry/The Maudsley), London, UK.
authors.forename: John
authors.initials: J
authors.lastname: Strang
mesh_terms: D000701:Analgesics, Opioid / Q000506:poisoning*; D003645:Death, Sudden / Q000517:prevention & control; D062787:Drug Overdose / Q000517:prevention & control; D004739:England / Q000453:epidemiology; D003932:Heroin / Q000506:poisoning*; D006801:Humans; D009270:Naloxone / Q000627:therapeutic use; D009292:Narcotic Antagonists / Q000627:therapeutic use; D058850:Opiate Substitution Treatment / Q000401:mortality; D012307:Risk Factors; D012606:Scotland / Q000453:epidemiology; D015819:Substance Abuse, Intravenous / Q000401:mortality / Q000517:prevention & control; D019966:Substance-Related Disorders / Q000401:mortality / Q000517:prevention & control*
chemical_list: D000701:Analgesics, Opioid; D009292:Narcotic Antagonists; D009270:Naloxone; D003932:Heroin
keywords: Death; emergency; heroin; naloxone; opiate; policy; prevention; take-home