Heroin-related deaths in New South Wales, Australia, 1992-1996.

The coronial files of all heroin-related fatalities that occurred in New South Wales (NSW) over the period 1992-1996 were inspected. There were 953 heroin-related fatalities in NSW over the study period. There was a substantial, statistically significant increase in heroin-related fatalities over the study period, from 152 deaths in 1992 to 226 during 1996. The mean age of cases was 31.0 years, 85% were male, and 85% were classified as dependent on heroin at the time of death. There was a significant increase in the age of cases over the study period and the proportion of cases that were employed. Fatalities predominantly occurred in home settings (61%). No intervention occurred in 79% of cases. Fifty deaths (5%) occurred in the month following release from prison, 16 of which occurred the first 24 hours after release. Morphine concentrations rose from 0.24 mg/l in 1992 to 0.38 mg/l in 1996. Seventy six percent of cases involved heroin in combination with other drugs: alcohol (46%), benzodiazepines (27%), antidepressants (7%) and cocaine (7%). In only 24% of cases was morphine the sole drug detected. Males were significantly more likely to have alcohol detected at autopsy (49 vs. 24%), while females were more likely to have benzodiazepines detected (41 vs. 17%). The median blood morphine concentration among cases in which alcohol was detected was significantly lower than other cases (0.27 vs. 0.39 mg/l). It is concluded that heroin-related deaths continued to rise throughout the study period, and that deaths were predominantly among older, untreated males. Despite the rise in blood morphine concentrations, polydrug use remained the predominant toxicological pattern.

Deaths in methadone maintenance treatment in New South Wales, Australia 1990-1995.

AIMS: To determine the number and causes of deaths in methadone maintenance treatment (MMT). DESIGN: Cross-sectional survey. SETTING: New South Wales (NSW), Australia. PARTICIPANTS: Two hundred and thirty-eight patients who died while registered in MMT from 1990 to 1995. MEASUREMENTS: Data on number and causes of death in MMT were obtained from data on file at the NSW Health Department, NSW Registry of Births, Deaths and Marriages, and NSW Department of Courts Administration. FINDINGS: The most common cause of death was drug-related (44%), followed by medical illness (24%). Fifty deaths (21%) occurred in the first week of MMT, 88% of which were drug-related. In 92% of these drug-related deaths, there was evidence of polydrug use. In all, 42% of all drug-related deaths occurred during the first week of MMT. Nearly half the cases of drug-related death (46%) in the first week were noted by the medical practitioner at assessment to have a history of polydrug abuse or dependence. Four (9%) drug-related cases were prescribed doses of methadone in excess of the-then current national methadone clinical guidelines. CONCLUSION: The first 7 days of MMT is a high-risk period. Inadequate clinical review of subjects' tolerance to methadone and/or subjects' use of other central nervous system (CNS) depressant drugs probably contributed to most of these cases' deaths during induction. The findings from this study reinforce the importance of a thorough drug and alcohol assessment of people seeking MMT, cautious prescribing of methadone, frequent clinical review of patients' tolerance to methadone during induction and education about the dangers of additional drug use during this period.

Transitions between routes of heroin administration: a study of Caucasian and Indochinese heroin users in south-western Sydney, Australia.

AIM: To examine patterns and correlates of routes of heroin use among Caucasian and Indochinese heroin users. DESIGN: A cross-sectional survey. SETTING AND PARTICIPANTS: Two hundred heroin users resident in South West Sydney. The sample was divided between Caucasian and Indochinese users (each n = 100), with half of each group on methadone maintenance. MEASUREMENTS: A semi-structured interview was administered, based on previous studies of transitions between routes of administration. Measures included patterns of drug use, transitions, social, health and legal issues and cultural correlates of use. FINDINGS: Almost two-thirds (61%) had smoked heroin. Smoking was more common among the Indochinese (40% were predominantly or exclusively smokers), although injecting was the dominant route for both groups. More than one-quarter (29%) had made a transition from smoking to injecting, primarily due to drug effect and perceived cost-effectiveness. Reverse transitions were rare. Smoking appeared to be more culturally acceptable than injecting among Indochinese users. Among both groups, there was a small but significant risk for the transmission of HIV and other blood-borne viruses. Polydrug use and age were positively associated with having experienced a non-fatal overdose. CONCLUSIONS: This research documents the existence of smoking as a popular route of administration among both Indochinese and Caucasian heroin users in the study sample. There is an urgent need to provide smokers and injectors with information explaining the potential risks and ways to minimize harms associated with both routes of use.

A comparison of blood toxicology of heroin-related deaths and current heroin users in Sydney, Australia.

Blood toxicology results for deaths attributed to heroin overdose during 1995 in the South Western Sydney (SWS) region (n = 39) were compared with those of a sample of 100 current SWS heroin users who had injected within the preceding 24 h. Heroin-related deaths had a higher median concentration of morphine than current heroin users (0.35 versus 0.09 mg/l). However, there was substantial overlap between the blood morphine concentrations of the two groups, ranging from 0.08-1.45 mg/l. This range incorporated 90% of heroin-related deaths. A third of current users had morphine concentrations over twice the toxic blood morphine concentration employed by the analytical laboratories, and 7% had morphine levels higher than the median recorded for fatal cases. Alcohol was detected in 51% of fatal cases (median = 0.10 g/100 ml) compared with 1% of current heroin user. There was a significant negative correlation among fatal cases between blood morphine and blood alcohol concentrations (r2 = -0.41). There was no significant difference between groups in the proportions of subjects positive for blood benzodiazepines. The results raise questions about the mechanisms of death in what are termed overdoses, and about the role of alcohol in these fatalities.

"Non injectables": methadone syrup and benzodiazepine injection by methadone-maintained clients.

To obtain more information about anecdotal reports of injection of methadone syrup and benzodiazepine drugs among injecting drug users, interviews were conducted with 32 subjects as part of a larger study into drug use patterns of clients in methadone maintenance treatment. Subjects were asked about frequency of injection of methadone and benzodiazepines, reasons for injection and methods of preparation for injection. The study found that 78% had injected methadone and 25% had injected benzodiazepines at some time during their drug using careers. Service providers can play an important role in promoting harm minimization strategies, and utilizing behaviour modification techniques.

Heroin-related deaths in New South Wales, 1992: toxicological findings and circumstances.

OBJECTIVE: To describe the circumstances of death and toxicological findings in all heroin-related deaths in New South Wales in 1992. DESIGN: Coronial files of all cases of heroin-related deaths were reviewed. A standardised form was used to collect information on sociodemographics, history of drug use, circumstances of death, and results of toxicological analysis for each case. RESULTS: 152 heroin-related deaths were identified. Subjects had a mean age of 29.7 years, 82% were male, and 98% were not enrolled in a methadone treatment program at the time of their deaths. Deaths occurred in the home environment in 68% of cases and in the company of at least one other person in 58%. There was intervention before the subject's death in only 21% of cases. Two or more drug classes were detected in 71% of subjects; alcohol was detected in 45%, with a mean blood alcohol concentration of 0.14 g/100mL. CONCLUSIONS: Fatal heroin overdose is potentially preventable. Educating users about the risks of co-administering alcohol and other depressant drugs with heroin, the comparative safety of injecting heroin in the company of others and the need to call for intervention sooner may reduce the frequency of heroin-related deaths.