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Official websites use. Share sensitive information only on official, secure websites. To identify the self-perceived reasons for unintentional opioid overdose of young heroin users in three Spanish cities and their agreement with objective risk factors for overdose. The general reasons for overdose and the reasons for the last overdose suffered were explored with open-ended OEQs and pre-coded questions PCQs. Limited knowledge of overdose risk factors was defined as mention of fewer than two objective risk factors for unintentional overdose in the OEQ. Univariate, bivariate, and logistic regression methods were used. Residence in Seville and not having attended courses or meetings on overdoses were significantly associated with limited knowledge, after adjusting for other factors. Most reasons were selected more frequently in PCQ than in OEQ, especially rapid injection of the entire dose and using heroin shortly after using tranquilizers or alcohol, by injection, or after a period of abstinence. The results were similar for overdoses suffered by participants. Most young heroin users do not have sufficient knowledge of overdose risk factors, especially the use of heroin by injection, after a period of abstinence, or together with alcohol or methadone. Specific informational or educational programs adapted to the local context are critically needed. The main objective risk factors for opioid overdose detected in epidemiological studies of association are injecting heroin, using opioids together with benzodiazepines or alcohol, not being in methadone treatment, and using opioids after a period of abstinence, generally due to having been in prison or drug-dependency treatment. Risk factors that have been cited less frequently are the use of very pure or a large amount of heroin, the presence of some health problems, the use of heroin together with cocaine, the use of methadone alone or together with benzodiazepines or alcohol, and attempted suicide. The objective of this study is to examine the reasons for opioid overdose self-perceived by heroin users in three Spanish cities Madrid, Barcelona and Seville and how well these agree with objective risk factors for overdose. There are important differences in the mortality rate from overdose in these cities, as previously indicated, as well as in their patterns of heroin use. For example, they represent three very different epidemiological profiles with respect to the main route of heroin administration: in Barcelona, the intravenous route predominates; in Madrid, smoking has been the most frequently employed route since the mid nineties; and in Seville, smoking has predominated since the end of the eighties. The methodology used in this study has been described in detail elsewhere. All subjects were between 18 and 30 years of age, had used heroin at least 12 days in the 12 months before the baseline visit and at least one day in the three previous months, and resided in the metropolitan areas of Madrid, Barcelona or Seville. The entire sample was street recruited by chain-referral procedures targeted sampling and respondent-driven sampling—RDS , 27 regardless of whether or not they were in treatment. Recruitment from treatment or health centers was avoided. Research workers visited all the important targets drug scenes , mainly areas of drug sales or major drug use, to recruit the initial participants We attempted to keep direct recruitment of participants in the first wave proportional to the assumed size of each target. To construct the section on non-fatal opioid overdoses, in-depth interviews were held with 20 heroin users. Overdose was defined as an episode occurring after heroin or opioid use characterized by extreme difficulty in breathing, loss of consciousness and problems waking up or recovering consciousness, and possibly bluish skin or lips. We first investigated the self-perceived reasons for overdose in general. To do this, all participants were asked in an open-ended question OEQ to list all the reasons for overdose they could think of and then to select three reasons in order of importance from a closed list of pre-coded questions PCQ. We then investigated the reasons for overdoses experienced by asking those who had suffered an overdose to explain in an OEQ all the reasons for the last such episode, including the most important one. By using OEQs, it is possible to determine the importance that users spontaneously give to different reasons for overdose, some of which might not have been considered in the PCQ. This approximation to the free-listing technique, 31 as a way to explore the free and spontaneous discourse of the person interviewed, was carried out before presenting the PCQ, to avoid suggesting any particular reason to the study subjects. The reasons cited in each OEQ were transcribed verbatim. Before coding the reasons, two investigators, A and B, independently grouped those with a similar underlying concept and created two detailed lists of categories. The differences were then discussed, and a single list was agreed on. The coding was done by two new investigators, C and D, who independently classified each reason in one category of the list, and the discrepancies Some of the reasons cited included two or more concepts; therefore, they were classified in two or more categories. The proportion of participants who cited each category was calculated in relation to all those who answered the question. Some persons cited reasons that were inappropriate, meaningless or could not be classified 1. About 7. The proportion of non-responses in the PCQ was 2. To make the list easier to read, the detailed reasons were grouped into larger categories groups of reasons. These nine factors represent the main risk factors for unintentional overdose identified in epidemiological studies or mentioned in the scientific literature. The PCQ was not used to construct this indicator because it was defined based on the total number of overdose risk factors identified, and only the three most important reasons could be selected in the PCQ. The variables significantly associated in the bivariate analysis were introduced into the models: age, sex, educational level, city of residence, length of heroin use, having suffered or witnessed overdoses, having received treatment to stop or control drug use, having attended courses or meetings related with overdose prevention and treatment, and variables with reference to the last 12 months before the interview time in prison, frequency of heroin use, frequency of tranquilizer use, drug injection and obtaining sterile syringes in syringe exchange or distribution programs. Interactions with regard to city of residence were evaluated in logistic models. All the statistical analyses were made using SPSS ver. The general characteristics of the sample have been described in detail elsewhere 26 and are summarized in Table 1. Injection was the usual route of heroin administration for most participants in Barcelona However, a larger proportion of participants had injected heroin or other drugs in the last 12 months In Seville, heroin and cocaine were usually mixed in the same dose Cocaine use was very widespread in the three cities, frequently in the form of base or crack, and there was a tendency to use heroin and cocaine in the same chemical form and by the same route. In addition to cocaine, most participants used alcohol, cannabis or tranquilizers. Important differences among cities were seen in the prevalence of drug use, with generally higher prevalences in Barcelona. Most participants had at some time received treatment to abandon or control their drug use, and more than two of every three injectors About In addition, 8. Some A few 5. The most frequently mentioned reasons in the OEQ, in decreasing order, were using a large amount of heroin, using highly adulterated heroin, using heroin together with tranquilizers without specifying in what order the two were used , using heroin that was stronger and purer than usual, and using tranquilizers shortly before heroin Table 2. After grouping the reasons, it was seen that the responses of A much smaller number of participants mentioned reasons referring to concurrent heroin and alcohol or cocaine use, the form of heroin administration injected use, very rapid injection , low tolerance to the drug, and constitutional, psychological or health factors. When participants were distributed by the number of unintentional overdose risk factors mentioned in the OEQ, it was seen that This proportion was higher in Seville The pre-coded question for the remaining reasons was formulated exactly as shown in the corresponding label in the table. If these labels are compared with those in Table 2, constructed from the verbatim responses in the open-ended questions, some slight differences in meaning may be found. The nine main overdose risk factors were considered. However, most reasons were selected much more frequently, except for use of a large amount of heroin or opioids and concurrent use of tranquilizers and heroin, without specifying the order. In fact, some reasons in the PCQ were selected many times more often than they were mentioned in the OEQ: injecting the whole dose at once or very rapidly In the analysis of the proportion of participants who identified each reason in the OEQ or PCQ, the smallest proportions were seen for use of methadone or opioids other than heroin 0. The largest proportions were seen for using heroin in large amounts There were important differences among cities in the frequency of reasons cited in the OEQ Table 3. These differences were in the same direction in the PCQ. The most frequent reasons for overdoses suffered by participants that were cited in the OEQ were, in decreasing order of frequency, using a large amount of heroin, using heroin together with tranquilizers without specifying the order , using heroin after a period of abstinence or very occasionally, using very pure heroin, and using tranquilizers shortly before heroin Table 3. When the reasons were grouped, it was seen that When participants were asked about the most important reason for the overdose, the order of the specific and grouped reasons was very similar to the preceding, although in this case the use of tranquilizers shortly before heroin was more important and came in third place. In comparing the general reasons for overdose with the reasons for overdoses suffered by the participant, it was seen that, in the former case, participants more often mentioned reasons related with the amount or characteristics of heroin especially using heroin that had been cut or adulterated , whereas the opposite occurred with the use of heroin after a period of abstinence Tables 2 and 3. A comparison by city of the frequency of reasons for overdoses suffered by participants showed differences in the same direction as described in the general reasons for overdose. In the logistic regression model the factors associated with limited knowledge of overdose risk factors were residence in Seville OR for Seville vs. No interaction terms with regard to city of residence were retained in the model. With respect to the factors associated with the identification of certain specific or grouped reasons in the OEQ or PCQ, the factor retained by the largest number of models was the city of residence, which was significantly associated with identification of the following reasons for overdose: use of heroin together with tranquilizers or alcohol, after a period of abstinence, by the intravenous route; highly adulterated heroin; and constitutional, psychological or health reasons Table 4. There was also a rather strong association between identification of intravenous use of heroin as a reason for overdose and not having injected in the previous 12 months and between identification of concurrent use of heroin and tranquilizers or alcohol as a reason for overdose and having used heroin weekly during the previous 12 months or ever having suffered or witnessed an overdose Table 4. No interaction terms with regard to city of residence were retained in the models, except for use of highly adulterated heroin. In this case the association with frequency of heroin use disappeared and was replaced with the interaction term city of residence by frequency of heroin use, specifically, living in Madrid by using heroin less than weekly OR vs. Factors associated with identification of various general reasons for overdose in open-ended or pre-coded question. The main findings of this study are as follows: 1 In — most young heroin users in the cities studied still did not have sufficient knowledge of the overdose risk factors: In contrast, only a small proportion of users recognized as reasons for overdose certain risk factors widely recognized by the scientific community, such as concurrent use of heroin and alcohol, using heroin after a period of abstinence or by the intravenous route, and using methadone together with heroin or other depressants benzodiazepines or alcohol. Furthermore, there was rather widespread belief in what is generally considered an erroneous idea— that highly adulterated heroin as such was a risk factor for overdose. The fact that most heroin users have poor knowledge of the risk factors for overdose strongly limits or impedes the adoption of appropriate precautions or measures to avoid overdoses in this population. It is surprising that this type of situation continues to exist in a country like Spain, where in the last decades heroin has been responsible for thousands of deaths from overdose, especially among males in urban areas, and where major investments have been made in treatment and harm reduction programs for these users. It is commonly accepted that overdose is the result of introducing more opioids in the organism than the user can tolerate at that time 12 ; therefore, using heroin in larger amounts or that is purer than usual could contribute to the cause of many overdoses. It is not surprising, then, that as in other studies, 22 — 24 , 32 this factor was by far the most frequent reason for overdose recognized by the young heroin users in the cities studied. In fact, Previous studies have found that use of a larger than usual amount of heroin greatly increases the risk of overdose, 15 , 33 although there is also evidence that the blood concentration of morphine is relatively low in most overdose fatalities, 12 especially when other respiratory depressants are present. Furthermore, there is only moderate evidence of a relation between fluctuations in heroin purity and overdose. Another widely accepted risk factor for overdose is the use of heroin together with other central nervous system depressors such as tranquilizers mainly benzodiazepines and alcohol. An interesting issue for discussion is whether the order in which tranquilizers and heroin are taken affects the risk of overdose. In the pilot study, some heroin users said that the danger was in using the tranquilizer before heroin and not their concurrent use in the opposite order. The proportion of persons in the OEQ who mentioned the concurrent use of heroin and tranquilizers as an overdose risk factor, without specifying the order of use, was Although this issue has not been explored in the scientific literature, we believe it is reasonable to test this hypothesis because the plasma elimination half-life of heroin is very short, which is not the case with the tranquilizers usually consumed by heroin users in Spain and other countries, such as alprazolam, flunitrazepam or diazepam. The extremely large proportion of participants who did not identify the use of heroin together with alcohol as a reason for overdose This cause has been recognized in numerous studies 13 , 14 , 16 , 39 — 42 and is consistent with the fact that most overdose fatalities have relatively low blood concentrations of morphine. That most users have a better knowledge of the risk of using more or purer heroin than usual than they do of the risk of loss of tolerance is consistent with the results of other studies 22 — 24 , 32 and may lead users to take more precautions in relation with the former factor than the latter. Many young heroin users in the cities studied are also not conscious of the high risk of overdose from using heroin by the intravenous as opposed to other routes of administration This is of great concern because heroin injection is known to be associated with a much higher risk of overdose than other routes, 1 — 4 , 10 , 11 , 13 , 14 , 35 , 43 especially when combined with a situation of possible loss of tolerance sporadic heroin injections. This is consistent with recent evidence suggesting that only a small proportion of overdoses are deliberate, 14 , 33 , 45 although symptoms of depression seem to be more common among users who have suffered an overdose. Participants did not perceive methadone use to be an important reason for overdose. In recent years there have been increased reports of methadone involvement in deaths from overdose, 19 , 47 , 48 although some studies do not support this relation. The concurrent use of heroin and methadone increases the risk of overdose, yet very few heroin users listed this as a reason for overdose. Consequently, in Spain the role of street methadone in the risk of overdose and in overdose education should be emphasized. On the other hand, the possible effect of street methadone in increasing the risk of overdose should be assessed together with the evidence that methadone maintenance programs are a very important protective factor for overdose mortality. As previously noted, participants frequently identified the use of highly adulterated heroin as a reason for overdose. Such an interpretation could be useful knowledge as it reinforces the need to have stable heroin suppliers or to test the purity of heroin before using the whole dose. The results of this study indicate that the factor most strongly associated with limited knowledge of the reasons for overdose was the city of residence. Specifically, users in Seville most frequently had limited knowledge. We also detected important differences in knowledge of the various specific reasons for overdose by city of residence, especially for low tolerance to heroin, but also for using heroin together with tranquilizers or alcohol, use of adulterated or cut heroin, use of heroin by the intravenous route, and constitutional, psychological or health reasons. Nor could they be explained by unequal direct exposure to specific programs for overdose prevention, although given that these programs seem to be effective, there may be an indirect effect ecological effect not controlled for in the models that would partly explain the differences among cities. The weak association between limited knowledge of overdose risk factors and higher educational level was unexpected and difficult to explain but may suggest a state of unfounded or excessive confidence in one's own ability to identify the causes of overdose from experience or a resistance to learning from professionals or services on the part of users with a higher level of education. The data in Table 4 suggest that knowledge of a certain risk factor may be driven by exposure to this particular risk factor and the individual drug user's risk profile. For example, it is understandable that injectors are less likely to mention injection as a risk factor for overdose because within this group factors other than injection will differentiate those who overdose from those who do not. Also, some injectors do not recognize alternatives to injection or injection as a modifiable risk behavior. Similarly, daily heroin users may have more reliable sources of heroin than sporadic users and, thus, would be less likely to cite the use of adulterated heroin as an overdose risk factor. In fact, this was the case in the study sample, especially in Madrid. It is also probable that users have a certain tendency to justify their own conduct for example, using heroin by the intravenous route when asked to identify the reasons for overdose. Accordingly, when interventions aimed at overdose education and prevention are designed, differences in exposures and risk profiles among cities and user subgroups should be taken into account. Taken as a whole, these findings suggest a strong need to develop informational and educational programs workshops, meetings, training programs to make users more aware of the overdose risk factors and to eliminate groundless beliefs such as heroin adulteration being the reason for overdose. It should be emphasized in this regard that few study participants had been exposed to these types of programs: Only On the other hand, the geographical differences in the knowledge of different reasons suggest that the target groups for these programs, their content, and most certainly the communication strategy, should be adapted to the local context and different risk profiles of user subgroups. In this respect, in the three cities studied it is important to emphasize the role in the risk of overdose of such factors as use of the intravenous route, situations with low tolerance to heroin, use of heroin together with alcohol, and use of methadone concurrently with heroin, benzodiazepines or alcohol. However, different factors may need to be emphasized depending on the city. For example, in Barcelona the role of the intravenous route should be emphasized more than in Seville or Madrid, whereas low tolerance to heroin is a more important risk factor in the latter two cities. It is also important that other services for drug users mainly drug-dependency treatment services and syringe exchange programs should include effective advice to make users more aware of the factors and situations that increase the risk of overdose, since our results show that these services are not currently effective in this regard. An advantage of this study is that it was carried out in a large sample of young heroin users in three cities. The study also permitted a highly detailed exploration of the perceived reasons for overdose by using both OEQs and PCQs. However, some limitations must be taken into account when interpreting the results. In the first place, it is not known to what extent the results can be generalized to all heroin users in the cities studied or to those in Spain as a whole, since we used non-probabilistic sampling. The sample included a larger proportion of young and of occasional users than some previous studies in samples recruited in treatment centers or other areas. It should also be kept in mind that the reasons for overdose expressed by users are the result of experiences and information received throughout their drug-use careers and of the myths and stereotypes that circulate within their social networks. It would have been interesting to explore possible differences in the knowledge of risk factors among recruitment networks. However, such an analysis was difficult because of the very small number of participants in most networks. Consequently, it is possible that this sampling approach might artificially affect the findings of the study. Furthermore, in the case of overdoses suffered, the events may have occurred long before the interview, thus it may have been difficult for participants to clearly remember the reasons. Nevertheless, we found no important differences in the reasons cited by those who had suffered the overdose recently in the last 24 months and those who had suffered it before that time. However, it fits well with the multifactorial etiology of opioid overdose. Individual heroin users with well-defined risk profiles for example, non-injection heroin users who use heroin only with alcohol might consider themselves to be sufficiently protected against overdose by knowing and avoiding the main risk factors to which they are currently exposed in the example, the concurrent use of heroin and alcohol. However, such a belief is dangerous because risk profiles are often unstable and frequently change the heroin user could start to inject heroin one day and would not be aware of exposure to a very high risk of overdose. Furthermore, the definition seems quite robust with regard to the data analyzed. In conclusion, most young heroin users in Barcelona, Madrid and Seville do not have sufficient knowledge of overdose risk factors. Residence in Seville and not having attended courses or meetings on overdoses were significantly associated with limited knowledge of these risk factors, after adjusting for other factors. The most frequently unknown risk factors for overdose were the use of heroin by injection, after a period of abstinence, or together with alcohol and the use of methadone together with heroin or other depressants, with important differences between cities. Furthermore, there was rather widespread belief that highly adulterated heroin was a risk factor for overdose, especially in Madrid. Consequently, specific informational or educational programs adapted to the local context are critically needed. We also thank Kathryn M. Fitch for translation and suggestions. As a library, NLM provides access to scientific literature. J Urban Health. Gregorio Barrio Find articles by Gregorio Barrio. Luis de la Fuente Find articles by Luis de la Fuente. Rosario Ballesta Find articles by Rosario Ballesta. Issue date May. Open in a new tab. Similar articles. Add to Collections. Create a new collection. Add to an existing collection. Choose a collection Unable to load your collection due to an error Please try again. Add Cancel. Most income obtained by stealing, selling drugs and marginal activities A. Yes, less than half of the sterile syringes obtained from syringe exchange programs. Yes, at least half of sterile syringes obtained from syringe exchange programs. Yes, less than half of sterile syringes obtained from syringe exchange programs.

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