Rising illegal drug use & injection of drugs since 1990s

Transcription

1 Characterizing the overdose risk environment in St. Petersburg, Russia Traci C. Green, Lauretta E. Grau, Ksenia Blinnikova, Mikhail Torban, Evgeny Krupitsky, Ruslan Ilyuk, Andrei Kozlov, Robert Heimer Yale School of Public Health Center for Interdisciplinary i Research on AIDS New Haven, Connecticut Bekhterev State Research Psychoneurological Institute The Biomedical Center St. Petersburg, Russia

2 A Russian overdose epidemic Rising illegal drug use & injection of drugs since 1990s >5% of adults in some cities inject drugs Increasing supply of heroin to area History of nonfatal overdose is extremely common St. Petersburg: 75% ever overdosed, 60% >1 in the past year (Grau et al., under review) (vs % in US) 16 Russian cities: >80% witnessed an opioid overdose; 15% witnessed a fatal overdose (Sergeev, Karpets, Sarang, & Tikhonov, 2003) More Russian IDU die of overdose than AIDS each year 100, drug overdose deaths 23,037 from AIDS, 2007

3 Individual overdose risk factors Quality/quantity of opioid Concurrent use of other CNS depressants alcohol, benzodiazepines Injecting drugs while alone Comorbidities HCV, HIV Not tasting drug first May obscure role of other important aspects May obscure role of other important aspects contributing to overdose risk & prevention

4 Risk environment Social & structural factors influence production of risk HIV transmission i lack of sources for clean syringes (Platt et al., 2006; Rhodes et al., 2003) Antiretroviral adherence in FSU ARV for those drug free but ineffective drug treatment available (Wolfe, 2007) Micro vs. macro level factors (Kerr, Small, Moore, & Wood, 2007) Local/proximal vs. structural/distal Micro Norms Rules Values Neighborhood networks Macro Laws Policies Inequality

5 Rationale & Study Aim Overdose risk encompasses more than just individual actions & reactions Better understanding these factors will help determine feasibility & shape the specific contours of an effective public health intervention To describe factors at the micro & macro level characterizing the overdose risk environment in St. Petersburg & to assess prevention intervention feasibility

6 21 interviews Drug users (n=6) Dispensary narcologist (n=3) Ambulance staff (n=3) Interview guide Methods Toxicologists-poisoning i i i ward (n=3) Narcologists, inpatient (n=3) Police (n=3) Overdose prevention & response knowledge: opioid & non opioid Overdose experience (personal, witnessed), context & circumstances, typical responses Awareness of & openness to overdose intervention Thematic content analysis Survey of drug users (N=60) Overdose knowledge, perception of overdose problem in St. Petersburg History of overdose witnessed, experienced Clinical measures (Addiction severity index, SCL-90) Willingness to attend naloxone training

7 Themes Overdose & risk environment at micro/macro levels home & family conditions micro fear as a component of risk micro medical response to overdose macro inefficient emergency medical services (EMS) infrastructure macro inadequacy of drug users current interventions micro/macro

8 Home & Family Conditions Recent personal, witnessed overdoses associated with recent family conflict IDU younger, most living with family, spouses Family may influence use & overdose risk Inject in secret at home under physical/ time constraints My last overdose was a heroin overdose [it] happened at home. I d been in the toilet and I made an injection. My relatives felt that something was wrong, that I was in the toilet for too long, and then they opened the door and called an ambulance and began to slap my cheeks. User 3 Inject at other/ less safe locations to hide drug use from family Usually I inject at home or when my parents are not at home, but sometimes I have to inject on the street. User 2

9 Fear as a component of risk Fear of disease, deviance & thus drug users Legitimizes inaction to a witnessed overdose We have no instructions on how to respond [to] an overdose and I will not perform rescue breathing on a drug user- he can have AIDS! Police 2 Rationale for greater control over emergency response alter protocols to include police escort, opening possibility of harassment, arrest Gives impression that a call for help=call for police Fear of police by drug users engage in protective behaviors When we call the ambulance, we never tell them that it s an overdose, because we are afraid that they will call the police. I know some people who called an ambulance and told them it was an overdose and the police came. We never do that, that s why the police never come. When we call an ambulance, we say that something is wrong with the person s heart, unconscious, drunk on alcohol On the question about drug use, we say that we don t know, but think that he didn t take any. User 1

10 Emergency Infrastructure Emergency calls triaged Drug-involved: narcological ambulance,, otherwise non-specialized car responds 2 narcological of 190 ambulances in St.Petersburg Victim treated at hospital toxicology unit 40% of patient load are overdoses Saline solution IV, possible naloxone re-administration

11 Medical Response se to Overdose Misinformation about naloxone at professional level Contraindications, reservations about administering in hospital, side effects Missing first responder No training for police Compartmentalized, stratified structure; medical professionals perform, motivated to intervene We come only if there is a corpse. We have no instructions on what to do in cases of overdose. I don t know what to do to save a life. Maybe rescue breathing, but I will not do it. Police 1 Detoxification, treatment protocols 7-14 days; tranquilizers antipsychotics anticonvulsants 7-14 days; tranquilizers, antipsychotics, anticonvulsants cocktail; methadone & buprenorphine illegal

12 The last heroin overdose I witnessed was my brother s overdose. He had just come home from the hospital and he asked me to prepare a dose of heroin for him. The overdose happened on the stairs [outside]; it was only me and him. I did CPR on him. I was trained to do CPR - I m a professional driver - all drivers are trained to do that. And in the army they trained us, too. I called the ambulance, but it came too late. So, they called the police for the corpse. The police worked that t case as routine-they th just asked what [drug] and what dose he had injected. --User 4

13 Inefficient EMS Infrastructure Systemic delay, graft, & bureaucratization of care Poor reliability: 3 mins-1 hour response time Payment for services, not to call police The ambulance works effectively. They gave me an injection of medicine when they came and saved my life. But you should give them money so that they will not call the police - $12 is enough. User 5 Impression that ambulance will call police Impression of discriminatory treatment of drug-involved calls I think that the ambulance doesn t respond properly to an overdose call. They come too late. And I think that it s better not to tell them that it s an overdose, because they will come later or not come at all. User 6 Compartmentalization: overdoses not responded to by narcological acoogca ambulances a

14 Inadequacy of Drug Users Current Interventions Opioid overdose knowledge high but response knowledge variable Some effectual, ineffectual 41% doubted their ability to respond effectively, others overly confident As a rule, drug users know about and recognize the symptoms of overdose. But their actions in response to an overdose are not enough. All they do is slap the face and/or pour cold water [on the person]. Sometimes, they try to perform CPR but this usually leads to rib fractures. Ambulance 1 CPR, rescue breathing trainings limited Military, certain professions Community-based CPR training gprograms rare; no known programs in St. Petersburg

15 Overdose Prevention & Response Programs May include naloxone distribution, training of first responders, recognition of signs of opioid overdose Constitute effective structural interventions that alter overdose risk environment fundamentally Naloxone hydrochloride in Russia NOT on dangerous drugs list available by prescription in pharmacies $6 for 10 vial package

16 Window of Opportunity Surveyed & interviewed drug users willing to be trained in overdose prevention & response Police apathetic, supportive Medical professionals disapprove of interventions, especially naloxone distribution Only they can administer naloxone Endorses drug use Encourages more/careless drug use Underscored side effects, complications of naloxone Support overdose curriculum & training in continued medical education

17 Limitations Small sample size for interviews & survey This is the largest & only study of overdose in St. Petersburg Possible interviewer, i reporting bias Generalizability limited Local not regional, national scale Appropriateness of scale given geographic, cultural, contextual differences including in drug use

18 Conclusions & Recommendations Structural, social factors contribute to overdose risk Targeted structural interventions warranted to alter risk environment Family-based overdose, harm reduction interventions needed Community-based overdose prevention & naloxone distribution programs feasible Include drug users, families of drug users, other community members Consensus building with medical professionals Dispel myths about naloxone, side effects Provide evidence of naloxone distribution program effectiveness (Seal et al. 2001; Maxwell et al., 2006; Galea et al., 2006; Tobin et al., 2008; Green et al., 2008) Overcome resistance to training drug users CME for medical professionals; comprehensive training i on overdose risk, prevention & response for police Equip more ambulances with naloxone & staff trained in use

19 Acknowledgements e Thank you to the participants p & interviewees,, and to. Yale Center for Interdisciplinary Research on AIDS (CIRA) Alexandr Fialko, City Narcological Hospital, St. Petersburg Nikolay Blinnikov, Deputy Chief, International Division, Public Health Committee, St.Petersburg Mark Kinzly Dan Bigg Greg Scott Sharon Stancliff Monique Rucker This study was funded d by a NIH/Fogarty International ti Center as part of the International Clinical Operational and Health Services Research and Training Award (ICOHRTA; Grant #5U2RTW006893) and by a NIH/NIMH institutional training grant (Grant #5T32MH020031) for predoctoral fellowship (TCG) at CIRA