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ORIGINAL ARTICLE
A PROSPECTIVE STUDY OF NON-FATAL HEROINOVERDOSE
D. M. FATOVICH1, A. BARTU2, & F. F. S. DALY1
1Department of Emergency Medicine, University of Western Australia, and 2School of Nursing and
Midwifery, Curtin University of Technology, Australia
AbstractAims: We aimed to study the prevalence, characteristics and outcomes of patients presenting withnon-fatal heroin overdose.Design: Prospective observational study.Setting: Emergency Department (ED).Participants: Patients attending with non-fatal heroin overdose.Intervention: Nil.Measurement: Descriptive and epidemiological data.Findings: Two-hundred-and-forty-nine overdoses in 224 patients (61.2% male, range 15–49 years).Mean reported age of first heroin use was 18.8 years (range 10–42). Forty-two per cent reported aprevious heroin overdose requiring hospital intervention. Co-ingestants included benzodiazepines(61, 27.2%), alcohol (35, 15.6%), cannabis (25, 11.1%), amphetamines (13, 5.8%) andhallucinogens (3, 1.3%). Most patients experienced a benign course; 81 of 115 ambulancepresentations (70.4%) received prehospital naloxone and 23 (9.2%) received naloxone in the ED;67.9% had no investigations and complications were uncommon (two aspiration, one hypoxic braininjury). Median length of stay was 180 min (15 min to 48 h). Only 29 (11.6%) presentations requiredadmission. There were 15 individuals (6.7%) who had 40 (16.1% of the total) repeat presentations.Conclusions: Heroin overdose tends to occur in experienced users who commonly co-ingest otherdrugs. There is a trend of overdose occurring with increasing frequency in teenage females. Repeatoverdosing is common. However, while morbidity is low, these patients require considerableresources.
Keywords: Heroin overdose, emergency department, naloxone.
Introduction
Heroin overdose is a significant cause of morbidity and mortality in young people, peaking
at 1084 deaths in 1999 (5.6 deaths/100,000 age standardized (Australian Bureau of
Statistics, 2003). In Australia, the majority of deaths occur in the 15–44-year age group
Correspondence: Professor D. M. Fatovich, Department of Emergency Medicine, Royal Perth Hospital, Box X2213 GPO, Perth
WA 6847, Australia. Tel: +61 8 9224 2244. Fax: +61 8 9224 7045. E-mail: [email protected]
Journal of Substance Use, October 2008; 13(5): 299–307
ISSN 1465-9891 print/ISSN 1475-9942 online # 2008 Informa UK Ltd.
DOI: 10.1080/14659890802040773
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(English, Holman, Milne, Winter, Hulse, Coddek, Bower, Corti, De Klerk, Knuiman,
Kurinczuk, Lewin, & Ryan, 1995; Zador, Sunjic & Darke, 1996). Death is predominantly
due to overdose, rather than trauma, suicide or infective causes (Darke & Zador, 1996).
There is, however, little data regarding the epidemiology of non-fatal heroin overdose
presenting to Emergency Departments (EDs) in Australia. Whilst there is a growing body
of literature on drug related presentations to the ED, most studies have focused on alcohol.
The aim of this study was to describe the characteristics, disposition and resource use of
patients presenting to the ED with non-fatal heroin overdose.
Background/literature
Overdose is a common phenomenon among heroin users (Sporer, 1999). Data from
international and Australian studies suggest an annual fatal overdose rate of 0.8%
(Degenhardt, 2002; Darke, Mattick, & Degenhardt, 2003). It has been estimated that the
standardized mortality rate of heroin users is 13 times that of their peers (Hulse, English,
Milne, & Holman, 1999). Non-fatal heroin overdoses are common (Bradvik, Hulenvik,
Frank, Medvedeo, & Berglund, 2007; Darke, Ross, & Hall, 1996; Gossop, Griffiths, Powis,
Williamson, & Strang, 1996; McGregor, Darke, Ali, & Christie, 1998; Neale, 2003; Pollini,
McCall, Mehta, Vlahov, & Strathdee, 2006; Warner-Smith, Darke, & Day, 2002).
Approximately 3.1% or one in 20 to one in 30 overdose events result in death (Darke et al.,
2003).
Non-fatal overdoses have been studied from different perspectives in different countries.
Bradvik et al. investigated the experience of overdoses among 149 heroin users recruited
from a Syringe Exchange Programme in Malmo, Sweden. Polydrug use was common, 74%
had overdosed and 96% had observed an overdose in others (Bradvik et al., 2007).
McGregor et al. investigated the prevalence and risk factors of non-fatal overdoses
among 218 heroin users in Adelaide, South Australia (McGregor et al., 1998). Forty-eight
per cent had experienced at least one overdose and 70% had been present at someone else’s
overdose. This is similar to the 48% of overdoses reported in a study of 1427 street
recruited heroin injectors in San Francisco (Seal, Kral, Gee, Moore, Bluthenthal, Lorvick,
& Edlin, 2001).
In a study of 135 opioid users from southern England, Glasgow and Edinburgh 56% had
overdosed (Man, Best, Gossop, Stillwell, & Strang, 2004). Risk of overdose has been found
to vary as a result of prescribed and non-prescribed drug use. Yin et al assessed the
prevalence and risk factors for non-fatal overdoses among 731 heroin users in Sichuan
province China (Yin, Qin, Ruan, Qian, Hao, Xie, Chen, Zhang, Xia, Wu, Lai, & Shao,
2007). Twelve per cent had experienced at least one drug overdose and 51% had
experienced two or more. Risk factors included recent release from prison, use of
benzodiazepines, longer duration of drug use and longer duration of methadone treatment
in the past year.
Brugal et al examined factors associated with non-fatal overdoses among 2556 subjects
being treated for heroin dependence in Spain (Brugal, Barrio, Regidor, Royuela, & Suelves,
2002). The prevalence of overdose was 10%. Factors associated with risk of overdose were
polydrug use, positive HIV status and route of heroin administration (injecting). Others
have used ambulance data to estimate characteristics of non-fatal overdose victims,
circumstances of overdose and trends over time (Schulz-Schaeffer, Peters, & Puschel,
1993; Bammer, Ostini, & Sengoz, 1995; Degenhardt, Hall, & Adelstein, 2001).
Ambulances have been called to from 44 to 56% of overdoses witnessed by other heroin
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users (Darke et al., 1996; Thackaway & Poder, 2000). The number of presentations of
non-fatal heroin overdoses to emergency departments is similar to ambulance callouts for
these events (Cook, Indig, Grayj, & McGrath, 2004). Despite the high prevalence of non-
fatal overdoses among heroin users, data on the impact on emergency departments is
relatively sparse.
Afghanistan has recently experienced an opium ‘boom’. Supply of opium from that
country exceeds global demand by over 3000 tons (United Nations Office on Drugs and
Crime, 2007). If this over-supply reaches current and potential users of heroin, it is likely
that non-fatal and possibly fatal heroin overdoses will increase, as will ambulance call-outs
and presentations to emergency departments. Given this, data on the impact of non-fatal
heroin overdoses on emergency departments is particularly relevant.
Methods
A prospective cohort study was undertaken at Royal Perth Hospital, from 1 September
1998 to 31 August 1999. The study was granted exemption from ethics committee review
as it was regarded as a quality improvement project. Royal Perth Hospital is the largest
hospital in Western Australia (WA). It is located on the edge of the inner city. The annual
census of the ED is some 53,000, with an admission rate of 40%.
All patients presenting with a clinical diagnosis of heroin overdose were enrolled. Heroin
overdose was determined clinically at presentation, using a validated case definition
(Hoffman, Schriger, & Luo, 1991) and confirmed by subsequent history. Patients were
considered to have suffered a heroin overdose if there was clinical evidence of opioid
intoxication (pupillary meiosis, respiratory rate ,12, Glasgow Coma Scale ,12) with
either a history of opiate use from the patient or bystanders, or circumstantial evidence of
intravenous drug abuse (e.g. presence of drug paraphernalia at the scene).
Medical staff in the ED used a preformatted data sheet to contemporaneously record
demographic, historical, and clinical data on all patients with heroin overdose. A
retrospective review of ED computer records demonstrated 100% capture of heroin
overdose cases. Ancillary investigations were ordered according to clinical need.
Confirmatory qualitative urine drug screens for drugs of abuse were not performed, as
this did not comply with normal clinical practice.
Data were recorded and analysed with SPSS (version 8; SPSS Inc, Chicago, IL, USA).
Standard descriptives were obtained and percentages given. Summary statistics were
performed on all variables. Group differences were analysed using chi-square tests for
categorical variables. The alpha level was set at 0.05.
Results
During the 12-month study period, 249 (0.5%) of the 52842 ED presentations were for
heroin overdose. These 249 presentations occurred in 224 patients. Heroin overdoses
represented 25.2% of the 988 drug intoxications that occurred during the study period,
averaging 21 per month (range 16–29).
The distribution of patients by age, sex, ethnicity, marital status and accommodation is
shown in Table I. These results were based on the patient’s first presentation. The age at
which patients reported first using heroin is shown in Table II. The mean reported age was
18.8 years (range 10–42). More males than females commenced heroin use in the 22 years
and over group.
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Only two patients presented after their first use of heroin, one requiring admission to
ICU for a hypoxic brain injury. There were no deaths in this cohort. However, one fatality
due to heroin occurred in the public toilet of the ED waiting room. This person had not
attended the ED for assessment and was not included in the study. Two-hundred-and-one
(80.7%) presentations were in Australasian Triage Scale (ATS) categories 1–3 (ATS 1
patients should be seen immediately by a doctor, ATS 2 within 10 min and ATS 3 within
30 min; Australasian College for Emergency Medicine, 2006).
The highest proportion of heroin overdoses occurred on Wednesdays (n550, 19.6%).
Sundays and Mondays had the lowest proportion. The highest proportion of heroin
overdoses arrived at ED between 12.00 and 18.00 hours (113, 45.4%) then 18.00–24.00
hours (92, 37.0%), 06.00–12.00 hours (27, 10.8%) and 00.00–06.00 (17, 6.8%). The
location of the overdose and method of transport to the ED are described in Table III.
Eighty (42.3%) patients of the 189 who provided data reported at least one previous
heroin overdose requiring hospital intervention, and 57 (34.8%) patients of the 164 who
provided data reported at least one previous heroin overdose for which they did not present
to hospital (Table IV).
Self-reported co-ingestion of other drugs included benzodiazepines (61, 27.2%), alcohol
(35, 15.6%), cannabis (25, 11.1%), amphetamines (13, 5.8%), hallucinogens (3, 1.3%)
and other drugs (9, 4%). Only 15 (6.0%) of 249 presentations presented with a Glasgow
Coma Score of less than or equal to 8, and 66 (26.5%) of presentations had a respiratory
rate of less than or equal to 8 breaths per minute on arrival.
Table I. Demographic characteristics of 224 patients (mean age525.7 years, range 14.5–49.3 years) with non-
fatal heroin overdose
n %
Gender (224)
Male 137 61.2
Female 87 38.8
Ethnicity (216)
Caucasian 193 89.4
Aboriginal 12 5.5
Other 11 5.1
Marital status (208)
Single/divorced/separated 169 81.2
Married/de facto 39 18.8
Accommodation (199)
Living with others 144 72.4
Living alone 38 19.1
No fixed abode 17 8.5
n5( ). Numbers vary because of missing values.
Table II. Age of initial heroin use
Age Male (n598) Female (n571)
10–14 years 13 (13.3%) 14 (19.7%)
15–17 years 28 (28.6%) 21 (29.6%)
18–21 years 32 (32.6%) 23 (32.4%)
22 years and over 25 (25.5%) 13 (18.3%)
x252.038, df53, p50.565.
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Most patients experienced a benign course with little medical intervention required. Of
the 249 presentations, 115 (46.2%) arrived by ambulance and naloxone was given by
ambulance personnel in 81 (70.4%) cases; another 23 (9.2%) received naloxone in the ED.
No adverse effects resulted from the use of naloxone. The majority of presentations (237,
92.9%) required no assisted ventilation. No investigations were performed in 169 (67.9%)
presentations. Complications in this cohort were uncommon, with two patients
experiencing aspiration, and one patient suffering a hypoxic brain injury.
The median time that these patients spent in the ED was 180 min (mode 120, range
15 min–48 h). Only 29 (11.6%) presentations required admission. Of these, 28 (96.6%)
were admitted to the ED Observation ward. One patient required admission to the
intensive care unit. The majority of presentations (181, 72.7%) were discharged directly
from the ED. A proportion (33, 13.3%) were either discharged against medical advice, or
simply absconded. Deliberate self harm was identified in only 12 (4.8%) episodes.
There were 15 individuals (seven male) who had 40 repeat presentations. This included
12 patients who presented twice, and single patients who presented four, five and seven
times. No factor was identified that was predictive of repeat presentations.
Discussion
Heroin overdose appears to occur in experienced users who also ingest other central
nervous system depressants. Most patients were Caucasian and single, and lived with their
friends, parents or a partner. A third had used heroin alone, which is a risk factor for poor
Table III. Overdose location, used with and mode of conveyance
n %
Overdose location (249)
Public place 108 49.8
Home (own friends) 93 42.8
Other (e.g. hostel) 16 7.4
Used heroin with (204)
Others 138 67.6
Alone 66 32.4
Conveyed to ED by (249)
Ambulance 115 61.5
Friends 27 14.4
Police 20 10.7
Self 10 5.4
Other 9 4.8
Parents 6 3.2
n5( ). Numbers vary because of missing values.
Table IV. Self-report of previous heroin overdoses
Previous overdoses Required hospital intervention (n5189) No hospital intervention (n5164)
Nil 109 (57.7%) 107 (65.2%)
Once 31 (16.4%) 9 (5.5%)
Twice 14 (7.4%) 16 (9.8%)
Three times 11 (5.8%) 6 (3.6%)
Four or more 24 (12.7%) 26 (15.9%)
Non-fatal heroin overdose 303
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outcome after accidental overdose. Most patients were conveyed to the ED by ambulance.
This is considerably higher than the 12–15% reported elsewhere (Darke et al., 1996;
McGregor et al., 1998), but is consistent with recent Australian ambulance service data
(Dietze, Jolley, Cvetkovski, Cantwell, Jacobs, & Indig, 2004).
This study reveals a trend of overdose occurring in teenage females. It is noteworthy that
some patients reported their first use of heroin between the ages of 10–14 years. These were
more likely to be females. This is consistent with reports that there has been a steady
decline in the age of initiation to heroin use, particularly amongst females (Hall W, 1999).
The average length of stay in the ED was 4 h. This is similar to the 2–4 h reported by
(Smith, Leake, Loflin, & Yealy, 1992), but much less than the 20 h reported by (Cook,
Moeschler, Michaudk. & Yersin, 1998). There has been some discussion in the literature
on the optimal duration for observation of patients with heroin overdose (Osterwalder,
1995; Smith et al., 1992). This mainly revolves around concerns of the relatively shorter
half life of naloxone (20 min) versus heroin (2–3 h). Early discharge of a patient with heroin
overdose who has received naloxone may result in subsequent deterioration. Recently,
Vilke reviewed 998 out of hospital patients who received naloxone and refused further
treatment, and 601 coroners’ cases of opioid overdose deaths. There were no cases in which
a patient was treated by paramedics with naloxone within 12 hours of being found dead
(Vilke, Sloane, Smith, & Chan, 2003). Importantly, we found no adverse events associated
with naloxone use. This contrasts with the 45% adverse event rate reported previously
(Buajordet, Naess, Jacobsen, & Brors, 2004).
Repeat overdosing is common, with 42% of patients reporting at least one previous
heroin overdose involving hospital intervention, and 12.7% reporting four or more previous
heroin overdoses requiring hospital intervention. About a third of patients reported a
previous overdose that had not required hospital intervention. It is likely that repeat
overdosing increases the mortality risk.
There were limitations to this study. The main limitation is that much of the data were
obtained by self-report. The validity of self-report of recent drug use has been demonstrated
to vary by site, drug types and subject characteristics (Skelton, Dann, Ong, Hamilton, &
Ilett, 1998). A significant proportion of the cohort left the ED prior to answering the
questions on the preformatted data sheet, thus increasing the proportion of missing data.
However, working with heroin overdose patients in a busy ED is fraught with difficulty,
especially in terms of collecting data that is not essential for their emergency treatment. So
while the majority of those who left before answering the questions on the preformatted data
sheet were those who absconded or discharged against medical advice, some patients refused
to co-operate with the study and in some it was not clinically appropriate. One has to accept
this as part of the natural behaviour of this cohort. Nevertheless, to our knowledge, this is the
largest prospective series of such a group in the ED.
The other limitations are that toxicological testing was not used to confirm the clinical
diagnosis of heroin overdose. Also, the complications of heroin overdose may have been
under-estimated as patients with trauma were not screened for the presence of opioids, and
radiographic and laboratory investigations were only performed when clinically indicated.
Data on the use of pharmacotherapeutic strategies, such as methadone and naltrexone was
limited in this cohort as we had a very high proportion of missing data for these variables.
This study was performed at a time of peak heroin related deaths, with rates of opiate
overdose declining in recent years (Australian Crime Commission, 2005). Indeed, we had
only 23 heroin overdose presentations to our ED in 2006, reflecting a lack of heroin
availability and the increased use of amphetamines (Gray, Fatovich, McCoubrie, & Daly,
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2007). However, heroin related overdose and deaths appear volatile (Degenhardt, Conroy,
Gilmour, & Hall, 2005; Drug and Alcohol Office, 2005). Currently, EDs are overcrowded
and at capacity (Fatovich, Nagree, & Sprivulis, 2005). Hence, our report is a timely
reminder of the potential impact that heroin overdose can have on the hospital system, as
these patients require considerable clinical resources during their stay.
Each heroin overdose is potentially a life-threatening event. Given the fact that most
patients are discharged, presentation to the ED is an opportunity to implement harm
minimization strategies to avert the risk of future overdose. Brief interventions could readily
be incorporated into ED management and has already been used in outpatient settings
(Bernstein, Bernstein, Tassiopoulos, Heeren, Levensons, & Hingson, 2005). Further
research on counselling strategies is needed. Additional research on the mortality and
longitudinal use of health services by this cohort is ongoing.
Conclusions
The main findings of this study were that heroin overdose tends to occur in experienced
users who commonly co-ingest other drugs. There is a trend of overdose occurring with
increasing frequency in teenage females and repeat overdosing is common. However, while
morbidity is low, these patients require considerable resources.
Acknowledgements
The authors are grateful to all staff who participated in the study, especially Lisa Evans,
Research Assistant, Next Step, and Bevis Kay, Department of Emergency Medicine, Royal
Perth Hospital. We thank Dr Alan Quigley, Director of Clinical Services, Next Step
Specialist Drug and Alcohol Services, for his support.
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Author contributions
DF supervised the research and wrote the paper. AB was involved in the intellectual
planning and conduct of the research, performed the analysis and contributed to writing
the paper. FD conceived and implemented the project and critically reviewed the paper.
Declaration of interest
The authors report no conflicts of interest. The authors alone are responsible for the
content and writing of the paper.
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