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Overdose experiences among injection drug users in Bangkok, Thailand Milloy, M-J; Fairbairn, Nadia; Hayashi, Kanna; Suwannawong, Paisan; Kaplan, Karyn; Wood, Evan; Kerr, Thomas May 13, 2010

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Milloy et al. Harm Reduction Journal 2010, 7:9http://www.harmreductionjournal.com/content/7/1/9Open AccessR E S E A R C HResearchOverdose experiences among injection drug users in Bangkok, ThailandM-J Milloy†1, Nadia Fairbairn†2, Kanna Hayashi†2, Paisan Suwannawong†3, Karyn Kaplan†3, Evan Wood†2,4 and Thomas Kerr*†2,4AbstractBackground: Although previous studies have identified high levels of drug-related harm in Thailand, little is known about illicit drug overdose experiences among Thai drug users. We sought to investigate non-fatal overdose experiences and responses to overdose among a community-recruited sample of injection drug users (IDU) in Bangkok, Thailand.Methods: Data for these analyses came from IDU participating in the Mit Sampan Community Research Project. The primary outcome of interest was a self-reported history of non-fatal overdose. We calculated the prevalence of past overdose and estimated its relationship with individual, drug-using, social, and structural factors using multivariate logistic regression. We also assessed the prevalence of ever witnessing an overdose and patterns of response to overdose.Results: These analyses included 252 individuals; their median age was 36.5 years (IQR: 29.0 - 44.0) and 66 (26.2%) were female. A history of non-fatal overdose was reported by 75 (29.8%) participants. In a multivariate model, reporting a history of overdose was independently associated with a history of incarceration (Adjusted Odds Ratio [AOR] = 3.83, 95% Confidence Interval [CI]: 1.52 - 9.65, p = 0.004) and reporting use of drugs in combination (AOR = 2.48, 95% CI: 1.16 - 5.33, p = 0.019). A majority (67.9%) reported a history of witnessing an overdose; most reported responding to the most recent overdose using first aid (79.5%).Conclusions: Experiencing and witnessing an overdose were common in this sample of Thai IDU. These findings support the need for increased provision of evidence-based responses to overdose including peer-based overdose interventions.BackgroundAccidental illicit drug-related overdose is a leading causeof preventable morbidity and mortality. In many settings,fatal overdose is the primary contributor to highly ele-vated mortality rates among injection drug users (IDU)[1,2]. According to several studies of community-recruited IDU, non-fatal overdose is common and associ-ated with factors including having a prior history of over-dose, recent incarceration and higher-intensity forms ofdrug use, such as poly-drug use [3-6]. Several interven-tions to lower the incidence or reduce the damagingsequelae of overdose events have been implemented,including treatment for drug use [7], drug substitutiontherapy [8], supervised injection facilities [9] and peer-driven responses, such as naloxone distribution [10].Despite reports of injection drug use from all majorregions of the world [11,12], the phenomenon of acciden-tal drug overdose has not been well described outside ofWestern settings. In northern Vietnam, over 80% of out-of-treatment male opiate injectors reported a history ofoverdose in a cross-sectional survey [13]. Overdose in theprevious 12 months was common among 731 IDU inSichuan province, China, and associated with daily her-oin use and an injection career of at least seven years induration [14].In Thailand, some aspects of drug-related harm,including high levels of incarceration [15], persecution by* Correspondence: uhri-tk@cfenet.ubc.ca2 British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 667-BioMed Central© 2010 Milloy et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.police [16] and infection with HIV [17,18] hepatitis C [19]1081 Burrard Street, Vancouver, British Columbia, V6Z 1Y6, Canada† Contributed equallyFull list of author information is available at the end of the articleMilloy et al. Harm Reduction Journal 2010, 7:9http://www.harmreductionjournal.com/content/7/1/9Page 2 of 7and other pathogens [20] have been identified among theestimated 20,000 - 160,000 IDU in the country [11,12].However, we are unaware of any study that analyses thephenomenon of overdose among Thai drug users. Thus,we sought to estimate the prevalence and correlates ofnon-fatal overdose, as well as investigate patterns ofresponse to overdose in a community-recruited sample ofactive IDU in Bangkok, Thailand.MethodsData for these analyses was obtained from the Mit Sam-pan Community Research Project (MSCRP), a collabora-tive research effort involving the Mit Sampan HarmReduction Center (Bangkok, Thailand), the Thai AIDSTreatment Action Group (Bangkok, Thailand), Chula-longkorn University (Bangkok, Thailand) and the BritishColumbia Centre for Excellence in HIV/AIDS (Vancou-ver, Canada). In 2008, the research partners designed andundertook a cross-sectional epidemiological study of IDUrecruited through peer-based outreach and word-of-mouth. Invited participants were asked to attend the MitSampan Harm Reduction Center to be included in thestudy. All participants provided informed consent andcompleted an interviewer-administered questionnaire.The survey instrument elicited demographic data, infor-mation about past and current drug use, HIV risk behav-iour, overdose experiences, interactions with the criminaljustice system including police forces and incarceration,and experience with health care. Upon completion of thequestionnaire participants were provided a stipend of 250Thai baht. The study was approved by the research ethicsboards at the University of British Columbia and Chula-longkorn University.For these analyses, the primary endpoint of interest wasreporting a history of non-fatal overdose by answering"Yes" to the question: "Have you ever overdosed by acci-dent (i.e., a period of loss of consciousness or breathing?)"In follow-up questions, individuals reporting a history ofnon-fatal overdose were also asked the type of drug ordrugs they were using at the time of their last overdose, ifthey were helped, and by who, during their last overdose.As a first step, we investigated the characteristics ofindividuals with a history of overdose. Explanatory vari-ables included: Age; gender (male vs. female); educationlevel (<prathom suksa [elementary-level] vs. ≥ prathomsuksa); reporting any income from illegal sources (yes vs.no); participation in the sex trade (yes vs. no); history ofheroin injection (yes vs. no); history of Midazolam (abenzodiazepine) injection (yes vs. no); history of yaba(methamphetamine and caffeine) injection (yes vs. no);history of ice (methamphetamine) injection (yes vs. no);ever incarcerated (yes vs. no); ever on methadone mainte-nance therapy (MMT) (yes vs. no); and ever in forceddrug treatment (yes vs. no). Pearson's X2-test and Fisher'sexact test were used to determine bivariate relationships.Next, we used an a priori-defined statistical protocolbased on examination of the Akaike Information Crite-rion (AIC) and p-values to construct an explanatory mul-tivariate logistic regression model. First, we constructed afull model including all variables analysed in bivariateanalyses. After noting the AIC of the model, we removedthe variable with the largest p-value and built a reducedmodel. We continued this iterative process until no vari-ables remained for inclusion. We selected the multivari-ate model with the lowest AIC score.In a secondary analysis, all participants were asked ifthey had ever witnessed an overdose. Those with a his-tory of witnessing overdose were asked about theirresponse to the most recently witnessed overdose. Finally,all participants were asked if they believed they hadenough information to prevent and manage overdose andwhat steps they believe should be taken to effectivelymanage overdose.ResultsTwo-hundred fifty-two individuals were recruited andincluded in these analyses, of whom 66 (26.1%) werewomen. The median age at time of interview was 36.5years (IQR: 29.0 - 44.0 years.) In total, 75 participants(29.8%) reported a history of non-fatal overdose. Whenasked about the type and routes of administration of alldrugs consumed prior to their last overdose, almost all(70, 93.3%) reported injection heroin, followed by injec-tion Midazolam (24, 32.0%), non-injection heroin (11,14.7%) and non-injection midazolam (4, 5.3%). No otherresponse (including injection and non-injection yaba,non-injection ecstasy, injection and non-injection metha-done, injection and non-injection benzodiazepine andinjection and non-injection alcohol) exceeded three(4.0%) reports.Of the 75 participants with a history of overdose, 59(78.7%) reported being helped by another individual dur-ing their last overdose. Most reported being assisted by afriend (46, 78.0%), relative (11, 18.6%) or sex partner (3,5.1%). Of all individuals reporting an overdose, only 28(33.5%) reported being seen by a healthcare professional.Results of the univariate analyses of factors associatedwith reporting a history of non-fatal overdose are pre-sented in Table 1. As shown, the outcome was associatedat the p < 0.05 level with: reporting a history of incarcera-tion (Odds Ratio [OR] = 4.40, 95% Confidence Interval[CI]: 1.80 - 10.79); a history of using drugs in combinationhistory of using drugs in combination (yes vs. no); historyof methadone injection (yes vs. no); ever using an unster-ile syringe (yes vs. no); ever lending syringes (yes vs. no);(OR = 3.05, 95% CI: 1.53 - 6.07); and a history of injectingMidazolam (OR = 2.20, 95% CI: 1.67 - 4.12). A history ofinjecting heroin was significantly associated with report-Milloy et al. Harm Reduction Journal 2010, 7:9http://www.harmreductionjournal.com/content/7/1/9Page 3 of 7Table 1: Univariate analyses of factors associated with reporting a history of non-fatal overdose among IDU in MSHRC cohort (n = 252 individuals).Characteristic History of overdose n (%) OR1 95% CI2 p-valNo: 177 (70.2) Yes: 75 (29.8)AGEMedian (IQR) 37.0 (29.5 - 44.5) 35.0 (28.0 - 42.0) 0.99 0.97 - 1.03 0.843GENDERMale 130 (73.4) 56 (74.7)Female 47 (26.6) 19 (25.3) 0.93 0.51 - 1.74 0.877EDUCATION≥ Secondary 110 (62.1) 50 (66.7) 1.00< Secondary 37 (37.9) 25 (33.4) 0.82 0.47 - 1.45 0.568SEX TRADENo 167 (94.4) 71 (94.7) 1.00Yes 10 (5.6) 4 (5.3) 0.94 0.29 - 3.10 0.841EVER INJECT HEROINNo 18 (10.1) 0 (0.0)Yes 159 (89.9) 75 (100.0 0.002EVER INJECT YABANo 66 (37.3) 25 (33.3) 1.00Yes 111 (62.7) 50 (66.7) 1.19 0.67 - 2.10 0.570EVER INJECT MIDAZOLAMNo 66 (37.3) 16 (21.3) 1.00Yes 111 (62.7) 59 (78.7) 2.20 1.67 - 4.12 0.018EVER INJECT BENZODIAZEPINESNo 174 (98.3) 73 (97.3) 1.00Milloy et al. Harm Reduction Journal 2010, 7:9http://www.harmreductionjournal.com/content/7/1/9Page 4 of 7ing ever experiencing a non-fatal overdose (p = 0.002);however, as all individuals with a history of overdose alsoreported a history of heroin injection, an Odds Ratiocould not be calculated and that explanatory factor wasremoved from further consideration. The final multivari-ate model, presented in Table 2, included two factorsindependently associated with the outcome: Ever usingdrugs in combination (Adjusted Odds Ratio [AOR] =2.48, 95% CI: 1.16 - 5.33) and reporting a history of incar-ceration (AOR = 3.83, 95% CI: 1.52 - 9.65).Experience witnessing an overdose was reported by 171(67.9%) participants. When asked their response to theReduction Centre; 1 (0.6%) contacted the police. Twelveindividuals (7.0%) reported they did nothing in response.Approximately half of the participants reported theybelieved they had enough information to prevent (139,55.2%) and manage (128, 50.8%) an overdose. Whenasked how to manage an overdose, responses were: per-form first aid (115, 45.6%); inject salt water (109, 43.2%);perform CPR (90, 35.7%); slap (105, 41.7%); administernaloxone (16, 6.3%); or take to a hospital (74, 29.4%).DiscussionIn these analyses, we found a history of non-fatal over-Yes 3 (1.7) 2 (2.7) 1.59 0.26 - 9.71 0.636EVER INJECT METHADONENo 150 (84.7) 63 (84.0) 1.00Yes 27 (15.3) 12 (16.0) 1.06 0.50 - 2.22 0.851EVER USE DRUGS IN COMBINATIONNo 65 (36.7) 12 (16.0) 1.00Yes 112 (63.3) 63 (84.0) 3.05 1.53 - 6.07 < 0.001EVER INCARCERATEDNo 49 (27.7) 6 (8.0) 1.00Yes 128 (72.3) 69 (92.0) 4.40 1.80 - 10.79 < 0.001EVER ON MMTNo 102 (57.7) 39 (52.0) 1.00Yes 75 (42.3) 36 (48.0) 1.26 0.73 - 2.16 0.488EVER IN FORCED DRUG TREATMENTNo 127 (71.8) 45 (60.0) 1.00Yes 50 (28.2) 30 (40.0) 1.69 0.96 - 2.82 0.0761. Odds Ratio; 2. 95% Confidence IntervalTable 1: Univariate analyses of factors associated with reporting a history of non-fatal overdose among IDU in MSHRC cohort (n = 252 individuals). (Continued)last overdose witnessed, most (136, 79.5%) reported per-forming first aid; 78 (45.6%) took the overdose sufferer toa hospital; 4 (2.3%) took them to the Mit Sampan Harmdose was common among Thai IDU, with more than one-quarter of the sample (29.8%) reporting a previous over-dose event. The predominant drug implicated in over-Milloy et al. Harm Reduction Journal 2010, 7:9http://www.harmreductionjournal.com/content/7/1/9Page 5 of 7dose events was heroin, with the majority of individualsreporting injecting heroin before their last overdose andevery individual with a history of overdose also reportinga history of heroin use. In a multivariate model, a historyof overdose was linked to poly-drug use and incarcera-tion. Most of the participants also reported experiencewitnessing an overdose (67.9%) and the most commonresponses included performing first aid and taking thevictim to a hospital. When asked how to manage an over-dose, the most common responses included performingfirst aid or artificial respiration and injecting salt water.The level of non-fatal overdose observed in this sampleis on the lower end of the range of estimates calculated insimilar studies of community-based IDU in Baltimore,Maryland (24.7%) [21]; London, England (37.8%) [22] andSan Francisco, California (47.9%) [23]. We are unable todetermine if this comparatively lower level is the result ofa lower incidence of overdose among Thai IDU or agreater risk of death at each overdose event. Severalpoints of evidence support a contribution from the lattereffect, including the high prevalence of witnessing over-doses; the pervasive level of misperceptions concerninghow to manage an overdose; the high prevalence of over-dose as the reported cause of death among Thai IDU intwo HIV vaccine preparatory studies [24,25]; and theongoing violent crackdown by Thai police against drugusers, a phenomenon linked to a greater risk of overdosemortality in other settings [26-28].Our findings identify the need for enhanced educationfor Thai IDU to prevent and manage overdoses. Specifi-cally, approximately half of respondents indicated theydid not have the information required to prevent andmanage overdoses. This lack of knowledge was reflectedin the substantial proportion of participants reportinghours to develop [29,30], the need to improve peerresponses is clear. Inappropriate or suboptimal responsesby IDU to overdose are not uncommon and have beenreported from a number of settings [26,29,31]. However,overdose management education has been shown to beeffective at training IDU to respond appropriately tooverdose [26,32].These findings also support the distribution of nalox-one to drug users. Naloxone, an opiate antagonist, is thestandard treatment used by healthcare professionals inresuscitation efforts following opioid overdose. Programsto train IDU in overdose response alongside distributionof naloxone would likely benefit Thai IDU, given that opi-ates were the most common class of drugs reported bythis sample prior to their last overdose. Additionally,given pervasive anti-drug user stigma [33,34] and theongoing violent campaign by police [35], many IDU maybe unwilling to seek professional health care in the eventof an overdose. Evaluations of analagous interventions inChicago [36], New York City [10] and San Francisco [37]have observed positive impacts, including hundreds ofsuccessful peer opioid overdose resuscitations. Currently,naloxone is only available to IDU in Thailand at theMSHRC.In the multivariate model, a history of incarcerationwas independently associated with ever overdosing. Thisis in line with previous analyses that have identified ahigh risk of overdose, including fatal overdose, associatedwith incarceration, especially in the first weeks followingrelease from detention [38,39]. In the Thai context, previ-ous studies have described the links between exposure tocorrectional environments and an elevated risk of HIVinfection among IDU [40,41]. Our findings add evidencesupporting the need for an expansion of harm reductionTable 2: Multivariate logistic regression analysis of factors associated with reporting a history of non-fatal overdose in MSHRC cohort (n = 252 individuals).Characteristic AOR1 95% CI2 p-valueEver injected Midazolam (Yes vs. no)1.38 0.68 - 2.81 0.379Ever used in combination (Yes vs. no)2.48 1.16 - 5.33 0.020Ever incarcerated (Yes vs. no) 3.83 1.52 - 9.65 0.004Ever in forced treatment (Yes vs. no)1.25 0.69 - 2.28 0.4571. Adjusted Odds Ratio; 2. 95% Confidence Intervalinappropriate responses, including injecting the suffererwith salt water. Given that witnessing an overdose wascommon in this setting and fatal overdoses typically takeopportunities in Thai correctional settings, such as sub-stitution therapies, shown effective at reducing HIV riskMilloy et al. Harm Reduction Journal 2010, 7:9http://www.harmreductionjournal.com/content/7/1/9Page 6 of 7behaviours [42] and improving outcomes post-release[43].While the implementation of peer-based interventionsmight lower the incidence and severity of overdose eventsamong Thai IDU, our findings also have implications forother social- and structural-level policies. In particular,our findings are another example of how the reliance onenforcement-based strategies to respond to illicit druguse can produce further drug-related harms [44,45]. Justas some observers have identified deaths resulting fromthe Thai government's crackdown on drug users [35], ourfindings describe how criminal justice interventions canincrease the risks associated with overdose events. Weecho other authors who have credited the country's suc-cessful efforts to reduce the incidence of sexually-trans-mitted HIV infections to the government's adoption ofevidence-based policies [41,46] and urge a similar prag-matic initiative to replace dominant enforcement- andsuppression-based policies with harm reduction pro-grammes.Our study has limitations. First, cross-sectional analy-ses are unable to determine the temporal relationshipbetween outcome and exposure. Second, although ourmeasures are based on self-reports from IDU, we do notbelieve participants would have been more or less likelyto report a history of overdose based on the covariates weexamined. Finally, our sample of IDU was not recruited atrandom and thus may not necessarily generalize to othersamples of IDU in Thailand or other settings.ConclusionsWe observed that non-fatal overdose events were com-mon in this sample of Thai IDU. In a multivariate analy-sis, reporting a history of non-fatal overdose wasindependently associated with ever being incarceratedand ever using drugs in combination. A majority of par-ticipants reported witnessing overdoses as well as need-ing more information to respond appropriately. Ourfindings support the need to expand appropriate harmreduction strategies for drug users in Thailand, such aspeer-based overdose management including naloxonedistribution, and further highlight the need to balance thecurrent emphasis on enforcement-based responses toillicit drug use with health-focused interventions.Competing interestsThe authors declare that they have no competing interests.Authors' contributionsTK, EW, PS and KK conceived and designed the study; KK, PS, NF and KH imple-mented the study design, including data acquisition; M-JM performed the sta-tistical analysis, wrote the manuscript and coordinated all revisions; all authorsrevised the manuscript and read and approved the final draft.Social Pharmacy Research Unit (SPR), Faculty of Pharmaceutical Sciences, Chu-lalongkorn University, for her assistance with developing this project. We also thank Deborah Graham and Calvin Lai for their assistance with data manage-ment; Prempreeda Pramoj Na Ayutthaya and Donlachai Hawangchu for their assistance with data collection. This work was funded by the Canadian Insti-tutes of Health Research (Grant RAA-79918).Author Details1School of Population and Public Health, University of British Columbia, 5804 Fairview Avenue, Vancouver, British Columbia, V6T 1C3, Canada, 2British Columbia Centre for Excellence in HIV/AIDS, St. Paul's Hospital, 667-1081 Burrard Street, Vancouver, British Columbia, V6Z 1Y6, Canada, 3Thai AIDS Treatment Action Group, 18/89 Vipawadee Road, soi 40, Chatuchak, Bangkok, Thailand and 4Department of Medicine, University of British Columbia, Room 10203, 2775 Laurel Street, Vancouver, British Columbia, V5Z 1M9, CanadaReferences1. 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