Recording of clinical information in a Scotland-wide drug deaths study.

The aim of this study was to analyse the nature and extent of data extracted from case files of deceased individuals in contact with services 6 months prior to drug deaths in Scotland during 2003. A cross-sectional descriptive analysis of 317 case notes of 237 individuals who had drug-related deaths was undertaken, using a data linkage process. All contacts made with services in the 6 months prior to death were identified. Information on clinical and social circumstances obtained from social care, specialist drug treatment, mental health, non-statutory services, the Scottish Prison Service and Criminal Records Office was collated. More than 70% (n = 237) were seen 6 months prior to their drug death. Sociodemographic details were reported much more frequently than medical problems, for example, ethnicity (49%), living accommodation (66%), education and income (52%) and dependent children (73%). Medical and psychiatric history was recorded in only 12%, blood-borne viral status in 17% and life events in 26%. This paucity of information was a feature of treatment plans and progress recorded. The 237 drug deaths were not a population unknown to services. Highly relevant data were missing. Improved training to promote in-depth recording and effective monitoring may result in better understanding and reduction of drug deaths.

Aftercare attendance and post-treatment functioning of severely substance dependent residential treatment clients.

The present study evaluated the impact of a structured aftercare programme following residential treatment for severe alcohol and/or heroin dependent clients. Over 17 months, 77 participants were recruited to the study and allocated randomly to either a structured aftercare (SA) programme or to unstructured aftercare (UA) of crisis counselling on request. Independent clinicians interviewed participants and collaterals, at 4-month (median) intervals, for 12 months following residential treatment. SA compared to UA was associated with a fourfold increase in aftercare attendance and one-third the rate of uncontrolled principal substance use at follow-up. Participants who attended either type of aftercare relapsed a median of 134 days later than those who attended no aftercare. Overall, 23% of monitored participants remained abstinent throughout, 21% maintained controlled substance use and 56% relapsed, within a median of 36 days following residential treatment. The only significant predictor of days to relapse, controlling for age, was pretreatment use of additional substances. Participants with pretreatment additional substance use relapsed a median of 192 days earlier than those who had used no other substances. The degree of agreement between participant self-reports and collateral reports was fair-to-moderate and moderate among collaterals. Intention-to-treat analyses revealed significant and clinically meaningful reductions in substance use in this sample of severely dependent residential treatment clients. The generalizability of these results is limited because of significant differences in age and presenting substance between the study sample and other clients admitted to the service during the study. This latter group of younger, male, heroin-dependent clients with polydrug use who refuse opioid pharmacotherapy, are more likely to drop out of treatment or relapse early following treatment and continue to present a challenge to treatment services.

Injectable opiate maintenance in the UK: Is it good clinical practice?

This paper reviews the current practice of injectable opiate treatment (IOT) in the United Kingdom, i.e. the "British system" of prescribing injectable heroin and methadone, and considers some of the clinical and ethical issues it raises. There is very limited research evidence supporting either the safety or effectiveness of IOT as practised in Britain. In particular there is almost no evaluation of long-term outcomes of IOT, which is of potential concern given the possibility of some patients remaining indefinitely in IOT, the risk of vascular complications, and its higher cost compared with oral maintenance. It would be easy to assess this controversial intervention as in need of further research. However, striving towards best practice in IOT involves more than generating evidence. The likelihood of a patient receiving IOT in the United Kingdom appears to be influenced more by the personal inclinations of prescribers than by outcome data (if any), or identified community needs for access to IOT. The author asks is this good clinical practice and is it sustainable? The "British system" needs to modernise itself consistent with international paradigms of continuous quality improvement, and the NHS's own agenda of clinical governance.

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.

A risk-benefit analysis of methadone maintenance treatment.

Methadone maintenance treatment for heroin (diamorphine) addiction has been extensively researched. There is consistent evidence that while in treatment, heroin addicts are at a lower risk of death, are less involved in crime, and feel and function better than while using heroin. Despite the research evidence supporting methadone treatment, there remains widespread public scepticism about this form of treatment. This scepticism is frequently expressed in terms of the perceived risks of methadone treatment. The perceived risk that methadone treatment may maintain people in an addicted lifestyle is not supported by research literature. The risks of treatment include an increased risk of death during induction into treatment, and risks of diversion of drugs to the black market. For some patients, adverse effects of methadone pose a problem and the availability of new pharmacotherapies may provide useful options for these patients. Risks can be reduced and benefits increased by directing greater attention to the quality of treatment.

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.

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.

Fatal heroin 'overdose': a review.

The current paper examines critically the literature on deaths attributed to heroin overdose, and examines the characteristics and circumstances of such deaths. In particular, the dominance of the widely held belief that heroin-related fatalities are a consequence of overdose is challenged. Deaths attributed to overdose represented in the literature are typically older, heroin-dependent males not in drug treatment at the time of death. Fatalities involving only heroin appear to form a minority of overdose occasions, the presence of other drugs (primarily central nervous system depressants such as alcohol and benzodiazepines) being commonly detected at autopsy. Furthermore, deaths attributed to overdose are likely to have morphine levels no higher than those who survive, or heroin users who die from other causes. It is concluded that the term overdose is, in many cases, a misleading term, since it implies the same mechanism of death in all cases, an implication that is neither clinically useful nor consistent with published data. Implications for the prevention of heroin-related deaths are discussed.

High sugar intake in a group of women on methadone maintenance in south western Sydney, Australia.

Nutritional assessment comprising dietary and anthropometric measurements was conducted in a group of 86 women attending a methadone maintenance clinic in South Western Sydney, Australia. Dietary data were obtained by two 24-hour recall interviews using a standardized interview format. Nutrient intake was analysed using the NUTTAB data base of Australian foods (1992). Mean age of the sample was 29.8 (range 18-46) years and mean body mass index was 22.7 (range 16.2-43.4) kg/m2. The diet of the study group was characterized by a low energy intake of 6.48 MF (95% CI 6.02-6.94), a high sugars intake of 122 g (95% CI 112-132), a high percentage of total energy (31%, 95% CI 29-32) derived from sugars, and a low dietary fibre intake of 10.7 g (95% CI 9.7-12.3). This eating pattern may contribute to the high prevalence of a dental caries and chronic constipation observed in the group. The results pattern also support anecdotal evidence of a craving for sweetness described by addicts. Despite the low energy intake, body mass indices of the group were no different from the normal population. It is possible that 2 days' intake was insufficient to accurately measure accustomed diet in this group of women. Alternatively, the low intake may be a consequence of their largely sedentary life-styles.

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.

Sexual behaviour and contraceptive practices of year 10 schoolgirls in inner metropolitan Sydney.

PIP: 308 female students from six State high schools in inner metropolitan Sydney responded to self-administered questionnaires on their sex behavior and contraceptive use. Respondents were in their tenth year of school and of mean age 15.6 years. The survey was conducted with no refusals over the period March-June 1991 upon the sample from four coed and two single-sex schools. 18% of the sample reported ever having sexual intercourse, although substantial interschool variation was observed; less than 5% of girls in one school with a predominantly non-English speaking population were sexually experienced, while almost 45% were experienced in another school with a predominantly Anglo-Saxon population. The mean age at first intercourse for the sexually active group was 14.5 years. 72% used condoms at first intercourse, while 17% used no form of contraception. There were no significant differences in the mean ages of sexually active and nonactive girls, nor between the percentage of sexually active girls in coed schools and in single-sex schools. 25 girls had ever had a total of one sex partner, 27 had 2-5, and two had more than five. The condom is the most commonly used form of contraception, with 38% of sexually active girls using condoms every time. The rest of the girls used them either occasionally or not at all. Oral contraceptive pills (OCP) were used by less than 15% of the sexually active group, with effective contraception overall used by only 43% of the group. Effective contraception is defined as either condom use during every act of sexual intercourse during the preceding six months or daily compliance with the OCP. Eight subjects used no contraception at all during the preceding six months. These findings indicate the need for more education targeted to adolescents and health professionals, especially general practitioners.^ieng

A scale for estimating the health status of opioid users.

The health status of injecting drug users has both clinical and research relevance. In order to evaluate the impact of treatments for opiate dependence on drug users' health status we need valid and reliable instruments which are short and easily administered by non-medical personnel. This paper describes the construction of a brief interviewer administered scale for assessing the current health status of injecting drug users. Data evaluating its reliability and validity are presented which indicate that the scale has excellent psychometric properties.

Nutritional status on admission to a general surgical ward in a Sydney hospital.

To assess the nutritional status of patients on admission to a general surgical ward in a major teaching hospital in Sydney, we examined 84 men and women. We measured, recorded, and/or calculated: history of weight loss, body mass index (BMI), triceps skinfold, arm muscle circumference, hemoglobin, total lymphocyte count, and plasma albumin level. Measurements were graded normal, borderline, or abnormal and patients were considered malnourished if they had two or more abnormal measurements, three or more borderline measurements, or one abnormal and two borderline measurements. Thirty-one patients (37%) were found to have one or more measurements below the reference range. Twelve patients (14%) were considered malnourished and of this group more than half were of normal weight or overweight. But if indices of overnutrition are included in a definition of malnutrition then a high BMI was the most common abnormal index of nutritional status. Forty-six patients (55%) had a BMI of greater than 25, that is, were overweight. This single study showed a higher percentage of overnutrition amongst hospital patients than previous work has indicated and secondly that malnourished patients are not necessarily underweight.