by Andrew Byrne ..
The press has been full of the disastrous toll from heroin overdoses in recent weeks, especially from Victoria. As doctors, we must face our responsibility to the community to address these matters in any way possible.
The overdose death rate in Australia rose gradually from 30 to 40 per million over a number of years in the mid 1990's. Although official figures are not available, this rate appears to have gone up from 4 deaths per week to almost 14 as reported from Victoria this year. One newspaper described it as "the overdose epidemic Australia had to have". Mostly in metropolitan Melbourne, 2 deaths per day are causing great tragedy to the families who are both ill-prepared and perplexed.
It is clear that every one of these heroin overdoses is preventable.
The means of prevention are a number of well known proven strategies as well as some proposed innovations which have shown promise in trials here and overseas. It is accepted that preventive education of addicts, availability of needles and syringes as well as methadone treatment are all effective in stemming some of the potentially lethal complications of drug use. 'Safe injecting rooms', heroin prescription, rapid detoxification, oral morphine, long acting methadone and buprenorphine are among other strategies which deserve further examination.
Improvements to our emergency services are unlikely to reduce the toll much since, in most areas, they are prompt and effective at saving lives when they are called in time.
Educating drug users about the means to save lives is important. 'Do not inject while alone'. 'Use small quantities initially'. 'Call emergency services immediately if overdose is suspected'. 'Use clean syringes'. 'Do not mix drugs and alcohol'. These are all simple but life-saving messages.
Increasing the accessibility of good quality methadone treatment will certainly reduce the death rates. It is well established that once in treatment, the mortality diminishes significantly. Methadone treatment should be available to all who require it, like any other effective pharmacotherapy. The indications are simple: chronic compulsive opiate use with proven inability to withdraw. For historical reasons this is still restricted in some states and has been banned altogether in the Northern Territory. A recent review in the Journal of the American Medical Association stated that "All persons dependent on opiates should have access to methadone hydrochloride maintenance therapy under legal supervision" [ref 1].
It is likely that bringing addicts out of secluded locations and into 'safe houses' will also spare some lives. Supervision is available and help can be summoned if overdose occurs. Most importantly, these marginalised folk can come into contact with treatment services.
Switzerland and Holland both have official death rates of less than 5 per million compared to our rates of over 40. If we could copy their examples, over 500 young Australian lives could be saved each year. These countries must be 'doing something right'. Injecting is far less common among the young in Holland where the average age of heroin injectors is around 40 years of age. The Swiss introduced 'safe injecting rooms' over 6 years ago. Switzerland has had heroin prescribed for certain groups of resistant addicts for over 5 years. Cannabis is decriminalised in Holland.
Whatever the reasons for our high overdose death rates, we desperately need to investigate all these means for reducing it. The prime reason for NOT having a heroin trial, 'sending the wrong message,' is now out of date. The second reason sometime proffered is that it 'has not worked' overseas. This is intriguing as the reported outcomes of the London, Zurich and Geneva based trials all showed benefits to addicts and society generally and a referendum in Switzerland endorsed the practice of heroin prescription to seriously addicted patients under strict supervision.
Politics, personal prejudice and international pressure must be put aside since Australian lives are too important. We need to approach this epidemic from a scientific standpoint as we did with HIV. If we can match our successes there is very much to gain.
Ref 1: Effective Medical Treatment of Opiate Addiction. National Consensus Development Panel on Effective Medical Treatment of Opiate Addiction. JAMA 1998 280:1936-1943
