Preven&ng heroin overdose deaths :
Cri&cal situa&ons including release from prison
Professor John Strang
National Addiction Centre, King’s College London, UK
Declaration (personal & institutional)
• DH, NTA, Home Office, NACD, EMCDDA, WHO, UNODC, FDA, NIDA.
• NHS provider (community & in-‐paDent); also Phoenix House, Lifeline, Clouds House, KCA (Kent Council on AddicDons).
• Work with pharmaceuDcal companies re actual or potenDal development of new medicines for use in the addicDon treatment field (incl re naloxone products), including (past 3 years) MarDndale, ReckiU-‐Benkiser/Indivior, UCB, MundiPharma, Lundbeck, Alkermes, Teva,
Rusan/iGen and also discussions with Lightlake, Lanacher, Fidelity InternaDonal and Titan.
• UKDPC (UK Drug Policy Commission), SSA (Society for the Study of AddicDon); and two Masters degrees (taught MSc and IPAS) and an AddicDons MOOC.
• Work also with several chariDes (and received support) including AcDon on AddicDon, and also with J Paul GeUy Charitable Trust (JPGT) and Pilgrim Trust.
• The university (King’s College London) has registering intellectual property on a novel
naloxone product, and JS has been named in a patent registraDon by a Pharma company as inventor of another naloxone product.
Thanks
• PaDents and advocates and their families
• Immediate and internaDonal colleagues
Why does the take-‐home naloxone issue ma<er?
• Overdose is the major cause of death among drug users – mainly opiates
• Most heroin overdoses are witnessed
• Most witnesses intervene acDvely (even if wrongly)
• Many family members witness overdose (rarely taught)
• We now know when and where it is more likely to occur
and we know how to prevent fatality
Why does the take-‐home naloxone issue ma<er?
• Overdose is the major cause of death among drug users – mainly opiates
• Most heroin overdoses are witnessed
• Most witnesses intervene acDvely (even if wrongly)
• Many family members witness overdose (rarely taught)
• We now know when and where it is more likely to occur
and we know how to prevent fatality
Prison release and naloxone – key issues
• Heroin/opiates as the specific implicated drug
• Prison release and other times and places of
particular concern
Drug use prevalence and Drug-‐related deaths:
England &Wales 2011/12 (ONS)
Drug Prevalence in
general
population (use in last year, age 16-59)
No. of deaths in 2011
Cannabis 6.9% 7
Cocaine 2.2% 112
Amphetamine 0.8% 62
Ecstasy 1.4% 13
Opiates (inc heroin &
methadone)
0.3% 1,082
Oxygen saturation: case series
Prison release and naloxone – key issues
• Heroin/opiates as the specific implicated drug
• Prison release and other times and places of
particular concern
When in particular excess?
• During methadone early treatment
• Post-detox/rehab
• Prison release
Risk of death during and after treatment
Cornish et al, BMJ 2010; 341: c5475
When in particular excess?
• During methadone early treatment
• Post-detox/rehab
• Prison release
(1998)
0 5 10 15 20 25 30 35 40 45
Up to 1 1 up to 2 2 up to 4 4 up to 8 8 up to 13 13 up to 26 26 up to 52 >=52
Total
Excess mortality ratio
Time since release (weeks)
Not drug-related Drug-related deaths
Singleton et al, 2002
Conclusions: the con&nuing challenge
• Some easy acDons (doctors treat paDents; paDents live with their families)
• Some challenging areas (the deadly gap between prison and community; treatment authorisaDon for unknown recipient;
difficult to conduct rigidly-‐designed research trials)
• Self-‐applied ‘inerDa’ (societal ambivalence; also inerDa
within the field as well as external)
• All work
• None perfect
First-responder overdose management and emergency naloxone; the challenge
• New category of preventing deaths (EpiPen; de-fibrillator; etc)
• Incremental technology transfer (wider workforce)
• Better understanding of the product and application
• Institutional inertia (‘whilst we dither, overdose victims die’)
Ongoing issues that create hesitation
• Route
• Dose
• Legal (third party; family; outreach; OTC)
• Opt-in or maybe opt-out
First-responder overdose management and emergency naloxone; necessary next steps
• The emergency context
(pre-preparation; ABC-naloxone; rescue breathing; ambulance)• The regulatory context
(pre-supply; OTC?; Samaritan; message)• Improving the product
(dose/effect; IM good but needs to be easier;right dose, pre-filled, stake needle; non-injecting potential?; longer-acting?)