This is the second book of a field guide series for drug user activist  organizations and harm reduction workers in Eastern Europe. More  guides are available at www.soros.org/harm-reduction. 

NOTE - While the content of this book has been reviewed by  physicians in the United States and Russia, the information is  for educational purposes and is not intended as a substitute  for professional medical advice.

The authors of this book  strongly recommend that emergency medical personnel are  contacted immediately to respond to an overdose.5

Contents

1. Preface  7  2. Introduction  9 3.  Drug Overdose in Eastern Europe and Central Asia  11 4.  Overdose Background and Basics  15 5. Overdose Prevention  21 6. Recognizing Overdose  31 7.  Responding to an Overdose  35 8.  Overdose Risk of Specific Drugs  57 9.  Frequently Asked Questions  69 10.  How to Use This Information: A Guide for Trainers  737 1. Preface  By Dan Bigg*

Overdose has reached our friends, seemingly in near random ways, and taken their lives.   In response we develop superstitions to protect ourselves.

We avoid people, places, and things associated with  overdose—except the drugs themselves. We use home remedies— walk people around, throw them in the shower, slap them, put ice on  their crotches, inject them with salt or milk or a stimulant like coke or speed.

While these approaches may possibly have worked once or twice to avoid a lethal breathing posture or to help someone avoid  throwing up into their lungs, what they really have in common is the strong and admirable desire to save a life.

In an overdose emergency, despite a lack of accurate information and materials about overdose  prevention and response, people using drugs wanted to save the life of a family member, a friend, or another drug user in need.

This is  the true character of drug users.  

*  Dan Bigg is executive director of the Chicago Recovery Alliance, a  pioneering American harm reduction organization. Dan was the  architect of the first naloxone distribution project in the United  States, and worked for several years as an advisor to new harm  reduction organizations in Eastern Europe. 

The approach to overdose prevention and response described in this  guide book is based on information, techniques, and medications that have been used in modern medicine for decades. The philosophy  of harm reduction brings this proven, lifesaving technology into  practice where it is truly needed: among drug users, where overdoses  first occur and opportunities for intervention are the greatest.

I am a co-founder and the current director of the Chicago Recovery  Alliance, a harm reduction organization that provides comprehensive  services to drug users in the Chicago area, including distributing  35,000 syringes per week. I, too, have seen friends die needlessly  from overdose, and because of this I champion efforts to give drug  users the power to prevent and effectively respond to overdoses  when and where they occur.

In Chicago, heroin users, motivated by  the overdose death of our brother John, first learned about naloxone  (an antidote to opioid overdose) and brought it into our world in  1997. Between 1997 and 1999, Chicago Recovery Alliance started  the first program in the United States to train drug users in overdose  prevention and response.

The program is working, and fatal overdose  deaths in the Chicago area dropped from 466 in 2000 to 324 in  2003. As of March 2009, people trained by our organization have  reported 1,011 successful overdose reversals.

In John’s memory, we  hope you harness the techniques described here. The information in this field guide will help you make sense of what  might have looked like random flashes of lightning, killing some but  sparing others.

You may also become angry as you realize that these  tools have been around for many years and, despite minimal cost and  little capacity for misuse, have been kept from drug users.

Whatever  the reasons for this state of affairs, we must take responsibility for  sharing this open secret.  

None of what you will read here was hidden,  yet we may have imagined such care for ourselves impossible or have been too overcome with shame, isolation, and self-loathing to bring  it into our world.

The fact is, no one deserves to die because of their drug use.

We can learn to protect ourselves and our communities from  overdose—and respond effectively when it does happen—to ensure  that we are around to be part of life together.9 2.

Introduction

This book, created by experienced overdose trainers and reviewed  by peers and medical professionals, is intended as a resource for  the development and implementation of overdose prevention  and response programs by drug user activist groups and harm  reduction organizations in Eastern Europe and Central Asia.

It  combines practical information about overdose risk with strategies  for preventing, identifying, and responding effectively. It includes  descriptions of commonly used drugs, sample training curricula,  and a collection of “tips from the field” from experienced overdose  trainers and harm reduction experts.

We hope it will empower  people who use drugs, harm reduction organizations, social workers,  family and friends of drug users, and all others interested in acting  to prevent and respond to overdose.  By the time you finish reading this guide, you will understand:   

What happens to the body during an overdose   

What kinds of drugs can cause overdose, and how drugs can interact with each other   

How to recognize an overdose   

How to respond by supporting someone during and after an  overdose (providing rescue breathing, administering naloxone,  and calling for help)   

How to use this information to talk to your peers, provide training  to others, and set up overdose programs in your community11 3.

Drug Overdose in Eastern Europe and  Central Asia

By Dr. Mikhail Torban*

The first thing noticed by anyone who looks at the issue of overdose  in the former Soviet countries is the grand scale of the problem.  Recent data show that at least 7,500 people died from drug overdose  in 2006 in Russia alone. 1 

A regional survey on overdose in Latvia,  Kyrgyzstan, Romania, Russia, Tajikistan, and Ukraine conducted by  the Eurasian Harm Reduction Network2  in 2008 suggests overdose  to be a major cause of mortality among people who use drugs. For many reasons, there are no truly reliable statistics on overdose  incidence and mortality in the region.

 

*  Dr. Mikhail Torban is a Research Fellow at the Bekhterev Psycho-neurological  Research Institute in St. Petersburg, and a leading expert on overdose in the  Russian Federation.

1  Koshkina, E.A. “Drug Use Associated Mortality by Medical Statistics Data.”  Presentation at Petrozavodsk. 2008 2  Eurasian Harm Reduction Network.

Overdose: A Major Cause of Preventable  Death in Central and Eastern Europe and Central Asia. Recommendations and  Overview of the Situation in Latvia, Kyrgyzstan, Romania, Russia and Tajikistan.  2008. Available online at www.harm-reduction.org.  

But surveys among people who use drugs show it to be a tragically common occurrence.

One  published study, 3  for example, interviewed 763 injection drug users  in 16 Russian cities. Nearly two in three of them had experienced  overdose themselves, while more than 80 percent had witnessed an  overdose and 15 percent had witnessed a fatal overdose.

A majority  of the people interviewed felt that they were not prepared to respond  effectively to overdose. Concerned about the situation, staff of the Bekhterev Institute  investigated overdose in St. Petersburg during 2006 and 2007. We  interviewed 60 people who used drugs, and a number of people  representing ambulance staff, police, and narcologists. 

Our investigation found that 65 percent of overdose cases took place  at home or at a friend’s home. In 70 percent of cases, the people  present at the time of an overdose were friends and acquaintances  who also use drugs, which suggests that there is usually someone  who could help.

Throughout the region, many drug users live with  their parents, but these parents often know nothing about how to  recognize overdose and what to do to help. That is why it is very  important to teach them (to give them this book for instance) what  to do in the event of overdose—it is very basic information that can  save many lives.

In examining what drugs people were using at the time of overdose,  heroin and other opiates were most common.

A significant number  of overdose deaths occurred in people who combined heroin use  with alcohol or pills. According to medical examiner reports in  Leningrad oblast from 2001 to 2005, 65 percent of people who died  from overdose had alcohol in their blood. 3 

Sergeev, Boris, Andrey Karpats, Anya Sarang and Mikhail Tikhonov.  “Prevalence and Circumstances of Opiate Overdose Among Injection Drug  Users in the Russian Federation.”  Journal of Urban Health, vol. 80, no. 2  (2003).

Importantly, according to our research about 42 percent of overdoses  occurred soon after a person had left drug treatment or had been  incarcerated. These individuals came back home, used their usual  dose, and had an overdose. Many of the people we interviewed also  said they often used drugs in a rush, especially if they lived with  relatives or somebody was at home.

In such situations it may be  harder to calculate the dose and to inject slowly, and the risk of  overdose increases.  The great majority of our respondents tried to help when witnessing  an overdose, by giving rescue breathing or through physical  stimulation.

Very few people reported doing nothing, though in  only 25 percent of cases did people call an ambulance. Perhaps  surprisingly, when we asked if people had encountered situations  when ambulance staff called the police, the answer was always  no, except when someone had died.

In addition, our respondents  reported that in all cases in which an ambulance arrived in time,  the overdose victim was revived. We heard from police that we  interviewed that they have no intention of arresting either victims  or witnesses.

Clearly, given the widespread fear by people who use  drugs that police will respond to overdose calls, and conflicting  information from other cities, more study is needed. But our research  nonetheless reinforces the importance of calling for medical aid as  soon as an overdose occurs.  Now, in Russia and other former Soviet countries, a number of  organizations are organizing overdose prevention projects and  providing trainings for people who use drugs.

Some projects are  also distributing free naloxone, a medication that safely reverses  opioid overdose, and which is difficult to buy through the pharmacy  system. We have received very good feedback from people who use  drugs about the work of such projects in places like Samara and  Naberzhnye Chelny in Russia, and Khorog in Tajikistan.

More  programs like these are urgently needed, alongside further research  and more reliable data collection systems, if we are to impact the  overdose epidemic in our region.15 4. Overdose Background  and Basics Overdose  happens when a person takes more of a drug or combination  of drugs than the body can handle.

As a consequence, the central  nervous system (CNS) is not able to control basic life functions. The  person may pass out, stop breathing, have heart failure, or experience  seizures. Overdose can be fatal, although in a majority of cases it is  not.

However, there are ways to prevent overdose from happening  and ways to respond if it does. The difference between life and death  in the event of an overdose greatly depends on how witnesses react  and take care of the person who has overdosed.

It is important to remember that anyone can overdose. First-time  users, long-time users, old people, young people, and everyone in  between are susceptible. There is no exact formula for determining  how much of a certain drug, or combination of drugs, will lead to  an overdose.

Individual characteristics such as a person’s weight,  health, tolerance for a drug at a particular time, drug potency, route  of administration, and speed of use all play a role in determining  how much a person’s body can handle.

This will be discussed in  more detail later in the guide book. The amount of a drug (or drug  combination) that causes a person to overdose can fluctuate, so users  should be advised that there is no such thing as a real “safe dose.”  

ISBN: 978-1-891385-86-5 Published by Open Society Institute 400 West 59th Street New York, NY 10019 USA www.soros.org  For more information, contact: International Harm Reduction Development Program Open Society Institute www.soros.org/harm-reduction Telephone:  1 212 548 0600 Fax:  1 212 548 4617 Email: IHRD@sorosny.org

Continued in PDF: HARM REDUCTION FIELD GUIDE