Phillip Coffin* - Report from the first international
conference on heroin overdose prevention
Background
From 1996-1998, nine teenagers from Plano, Texas - a wealthy
suburb of Dallas-Fort Worth - died of heroin overdoses. In most
cases, the individual had recently come out of a period of abstinence,
was also consuming alcohol and had not received prompt medical
attention because friends feared police and parental reprisal.
In other respects, however, these tragedies were atypical -
the users were young, well-off and some were sniffers rather
than injectors - thus drawing national media attention. Localities
from all over North America briefly focused on heroin overdose
fatalities, opening a window of opportunity for a harm reduction
response to what is, in most countries, the number one and most
long-running cause of death among heroin injectors.
Although AIDS traditionally kills more injectors than overdoses
in the United States, overdose fatalities rose about 50% from
1990-1997, to between 10,000 and 16,000. Smaller cities took
the brunt of the increase - for example, from 1988-1997, fatalities
rose almost 1300% in Kansas City to 99/100,000 pop while dropping
almost 50% in New York City to 15/100,000. Whites experienced
more dramatic increases in fatalities relative to Blacks and
Latinos and users over the age of 35 were the only group that
experienced a rise in fatalities (65%) - all age other groups
experienced a slight decline.
Australia also had been experiencing a rise in overdose fatalities
since the 1960s (although researchers believe the causes to
be different) and had developed a series of responses involving
multi-agency collaboration, begun in South Australia. Health
authorities and providers worked with users' groups to design
and disseminate educational materials based on published research
and focus groups; police and ambulances services tried to encourage
the use of emergency medical services by developing protocols
granting a degree of immunity on overdose calls and by publicizing
those changes; and intensive research efforts were focused on
understanding heroin overdose and evaluating the impact of prevention
efforts. Providers also reviewed heroin prescription programs
and safer injection rooms that had been established in Germany,
Switzerland and the Netherlands and programs to distribute naloxone,
the opiate antagonist, directly to drug users, such as are established
in Italy and have been piloted in Berlin. Likewise, Vancouver,
Canada, faced a major overdose fatality problem and was seeking
public health solutions.
Meanwhile, in the United States, several regions responded to
the renewed overdose problem by prosecuting survivors, witnesses
and colleagues through "Len Bias laws" - enacted following the
1986 alcohol and cocaine death of basketball star Len Bias.
According to 1999 news reports, individuals in 13 U.S. states
were charged with or convicted of crimes defined by a heroin
overdose. Back in Plano, a well-connected father had contacted
the FBI, which soon arrested and prosecuted several local youths.
But when local Plano youth were locked up for low-level drug
crimes related to overdoses and the deaths continued nonetheless,
parents began to regret the decision to resort to criminal law
enforcement.
The Conference
Hoping to seize the opportunity to cut the longstanding death
toll from heroin overdose, to share experiences from Australia
and Europe and to further establish harm reduction as a legitimate
public health approach to drug use, in early 1999 The Lindesmith
Center and the Alcohol and Drug Abuse Institute (University
of Washington) teamed up to prepare the first international
conference on heroin overdose prevention. Seattle was chosen
primarily because the northwest region of the continent - from
California through British Columbia - faced high numbers of
heroin overdose fatalities in the 1990s, but also because the
local government had expressed a firm commitment to improve
the city's public health response to drug use. The health and
police departments both co-sponsored the event (along with several
other groups) and both directors presented. Speakers were selected
through a cascade process based on extensive literature review
and pre-existing contacts of both organizations. As there is
no field of overdose prevention per se and because proposed
strategies would involve emergency services, law enforcement
and other professionals not necessarily accustomed to drug service
provision, significant outreach was required.
Speakers included physicians, researchers, toxicologists, paramedics,
officials, activists, lawyers, drug users, epidemiologists,
professors, harm reduction providers, methadone providers, police
officers, nurses, parents and ethnographers from several regions
of Canada, Australia and the United States, the UK, France,
Italy, Germany, Switzerland and the Netherlands. Four hundred
attendees from all related fields arrived from these countries
and Slovenia. The first session included a noted physician and
prominent user, setting the tone of the conference as a place
for discussion and interaction between groups that rarely communicate
outside of tense settings. Presentations on overdose trends
and risk factors provided the framework for discussion by clarifying
the commonalties across borders.
The first afternoon included discussion of first aid training
and naloxone distribution to drug users and the role of drug
services and harm reduction agencies and staff in preventing
and responding to heroin overdose.
The second day began with presentations from South Australia,
Amsterdam, Bern and Frankfurt describing intensive efforts to
cut the death toll, ranging from education to heroin prescription
and from coordination of municipal agencies to safer injection
rooms. The session on emergency response illuminated the emergency
medical system through detailed descriptions of everything from
what the dispatcher sees on her computer screen when help is
first called to how the physician decides whether or not to
hospitalize a patient.
The luncheon speaker, in a powerful presentation on the loss
of his son and other Australians, brought the audience to quiet
tears, many in memory of their own losses. A small memorial
was prepared by attendees to honor those who have died.
Break-out sessions that afternoon - covering drug treatment,
methadone maintenance, toxicology, ethnography, naloxone distribution,
heroin prescription, safer injection rooms, ambulance and hospital
care, research priorities and community organizing - concluded
the busy two-day schedule of the main conference. Several participants
stayed on through the weekend to discuss future efforts in North
America. Mass media coverage included the New York Times, Vancouver
Sun, Seattle Times, Seattle Post-Intelligencer, Stranger and
radio shows in several countries.
Conclusion
Although overdose-related prosecutions have not let up in the
United States, this conference documented the feasibility and
effectiveness of overdose prevention based on a public health
model. Overdose trends appear to be local and thus cannot be
addressed with a blanket approach, but sufficient commonalties
exist to develop transferable initiatives. Finally, and most
important, a multi-agency, cross-disciplinary approach is essential
to any effort to decrease heroin overdose fatalities, and any
such approach can and must include full involvement of drug
user groups and communities.
The audio presentation of "Preventing Heroin Overdose: Pragmatic
Approaches" (Sheraton Hotel, Seattle, WA, USA, 13-14 January
2000) is available at http://www.lindesmith.org/library/
ODconferenceaudio.html - with links to numerous scholarly
and popular articles and the conference agenda with photos.
Phillip Coffin, MIA, was a research associate at The Lindesmith
Center and principal coordinator of the conference. He can be
reached at poc2@columbia.edu
testo in italiano•indice
del mese
