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Chapter 6: Experiences of overdose survivors

What is in this chapter? This section of the report describes the findings from extended interviews with a sample of overdose survivors.

Where did the information come from? Injectors were interviewed as part of an ongoing study of IDUs' risk behaviours. Those who had survived an overdose in the six months prior to interview were invited to take part in an extended interview of structured open-ended questions to obtain relevant information surrounding their experiences that may inform prevention strategies.

Sample characteristics

Of the 595 living injectors recruited into the ongoing study evaluating the change in the Lord Advocate's guidelines on the supply of needle and syringes to injecting drug users, ninety-seven (16.3%) had overdosed at least once in the previous 6 months and, of these, 40 (41.2%) completed an extended interview.

At least one attempt was made to contact most overdose survivors. However, some IDUs had either changed their address and contact details in between the first and follow-up interviews, were not available when interviewers called at their address or had changed their minds about being interviewed.

Table 6.1 shows the characteristics of the 40 IDUs who were followed up. The majority (32, 80%) were male, mean age was 33.5 years and mean length of injecting was 11.8 years. Respondents had experienced a mean of 1.6 overdoses in the previous six months and five (13%) survivors had overdosed intentionally at their last overdose.

Table 6.1: Characteristics of 40 overdose survivors who completed an extended interview

Knowledge of risk factors/overdose prevention

Several factors were mentioned as overdose risks by IDUs. "Mixing drugs", particularly heroin and benzodiazepines was the most frequently cited (n=18). Alcohol in conjunction with either or both heroin and benzodiazepines was also mentioned by 6 IDUs.

After mixing drugs, loss of tolerance was the next most recognised risk, cited by 17 respondents. In a few cases (n=8) this factor was mentioned in association with release from prison.

On the same theme as tolerance, 11 IDUs mentioned that "having too much heroin" was risky and five blamed the purity of heroin for overdoses.

Other risks identified included being on one's own when injecting (n=7), "greed" (n=3) and "chasing"/wanting to experience an overdose" (n=2).

Risk taking behaviour

All respondents were asked about the drugs they had taken on the day of their last overdose. Number of drugs taken ranged from one to four. One drug had been involved in 6 cases, two drugs in 14 overdoses, three drugs in 6 cases and four drugs were reported in 3 overdoses. Eleven overdoses had involved alcohol; on five occasions this had been taken in conjunction with two drugs, on three occasions with three drugs and another three overdoses had involved alcohol and one drug (table 6.2).

Table 6.2: Number of drugs taken at last overdose

Heroin had been taken in all but one of the reported overdoses. In all 31 overdoses involving two or more substances, heroin and diazepam were involved together in 21 cases. In the 14 overdoses involving two drugs, the most common combination was heroin and diazepam (n=9). In all 39 overdoses involving heroin, it was administered intravenously. Diazepam had been taken in 22 overdoses, in all but one of these episodes it was taken orally and on one occasion it was injected. In the only overdose in which heroin was not consumed the cocktail of drugs included methadone, cocaine, benzodiazepine (type of benzodiazepine was not stated by respondent) and alcohol.

Methadone was implicated in 7 overdoses, always in combination with other substances. Cocaine was involved in 9 overdoses, in combination with other substances, and injected on all occasions.

Dosages ranged widely. Four overdose survivors claimed to have overdosed on one £10.00 bag of heroin. At the other end of the spectrum, one respondent reported drinking two bottles of vodka, half a bottle of bourbon, swallowing 100mg of diazepam and injecting £20.00 of heroin in the course of one day. Another reported consuming 300mg of diazepam, £20.00 of cocaine, £20.00 of heroin (the latter two injected) and one bottle of whisky.

Seven of the forty IDUs reported that they had recently (within the previous two weeks) been released from prison. Amounts of substances consumed on the day of overdose amongst this group tended to be lower compared with other respondents. Two of those recently released had each overdosed on one £10.00 bag of heroin; another had overdosed on £10.00 of heroin and 50mg of diazepam and one had overdosed on one quarter of a £10.00 bag of heroin and 170mg of diazepam. Reported substance consumption of the remaining three who were recently liberated was 80mgs of diazepam, one bottle of fortified wine and an unspecified amount of other alcohol; one £10.00 bag of heroin, 10mg of diazepam and four cans of super lager; a half gram of cocaine and one £20.00 bag of heroin, respectively.

Reasons for surviving overdose

When asked why they thought they had survived their most recent overdose, by far the most common response (n=25) was that someone else had been present at the time. A further four IDUs had had someone present when they overdosed but ascribed their survival to "luck". Nine respondents had been on their own and attributed their survival to "luck", "God" or having been found in time. Amongst the five who had overdosed intentionally, four had been on their own and, of these, three had been found by someone.

Why treatment did not help prevent overdose

Fourteen overdose survivors had been in treatment at the time of their last overdose. All but one was receiving prescribed methadone. Respondents were asked why they thought treatment had not prevented them from overdosing. Four could not give a reason; five IDUs attributed their overdose to topping up on other substances whilst prescribed methadone; two of these claimed that their methadone was "not enough"; a further two respondents believed it to be due to the purity of heroin they had taken (although these two IDUs were also receiving methadone). One respondent said that it was "a bad mood" which led to the overdose and another IDU claimed that treatment staff " did not give enough time to talk". Two of the 14 in treatment had overdosed intentionally.

Why not in treatment

The 26 IDUs who had not been in treatment at the time of overdose gave a wide variety of reasons for this. These included "just out of prison" (n=6) or out of rehabilitation (n=1), not wanting methadone (described by one IDU as "the devil") because of severe withdrawal effects (n=3); laziness or apathy, "just couldn't be bothered", "hadn't got round to it" (n=3); not being able to access treatment (n=3); wanting to control/cut down consumption by themselves (n=2), not wanting to stop drug use (n=2), treatment being a waste of time (n=1); to get access to children (n=1); not needing treatment (n=1); not encouraged by anyone to seek treatment (n=1). Two respondents gave no response to this question.

Overdose Prevention

The most frequently quoted prevention strategy was to inject when someone else was present (n=13) (table 6.3). Nine IDUs suggested that safe injecting facilities would help prevent overdoses. Respondents also suggested ways in which awareness of overdose could be raised among IDUs. These included the provision of videos (n=8) or leaflets (n=7), although two respondents pointed out that leaflets were not suitable for IDUs with reading difficulties. It was also suggested that life-saving or resuscitation methods should be taught to IDUs (n=3). Four respondents thought that heroin should be legalised and two suggested that there should be a facility to test the purity of heroin.

Table 6.3: Overdose prevention strategies most frequently suggested by 40 overdose survivors who completed an extended interview

*Respondents could give more than one answer

Overdose Interventions

When asked what should be done when someone has overdosed, half (n=20) of the sample mentioned the recovery position. Nine referred to giving the "kiss of life" and four to giving CPR. Calling an ambulance was cited by nine respondents.

Inflicting physical pain, however, was the most commonly reported intervention method. Twenty-eight respondents stated that slapping or punching was the way to bring someone out of an overdose. Some serious physical assaults were reported, including one respondent who showed the interviewers two burn marks that had been inflicted on him by a friend on one overdose occasion. Twenty-one IDUs mentioned water as a revival mechanism. This ranged from applying a damp cloth to the person's face to throwing a bucket of water over them or putting ice down the person's back. Other revival methods included walking the victim around (mentioned by 17 IDUs) or talking to the victim (n=9). The most frequently mentioned interventions are set out in Table 6.4 below.

Table 6.4: Overdose interventions most frequently mentioned among 40 overdose survivors who completed an extended interview

*Respondents could give more than one answer

Nineteen IDUs had received training in resuscitation techniques, mainly in prison or treatment agencies. Yet, despite their training, even some of these respondents reported inflicting pain. One respondent explained why:

"In the jail I have been taught……[that] all that walking about and slapping, putting water on is doing the wrong thing. Put them in the recovery position, phone an ambulance. But it is hard to [do this] when one of your own is lying there going pure blue…..and even if I know the right thing to do is to put them in the recovery position, and I've done it a few times in jails but that is all dummies and there is no panic, but see at the real thing you panic, you don't know what to do….. All you can think of is, if you go away and leave him and then come back and he is dead, my family would never forgive me".

Respondents also spoke of barriers to intervening in an overdose situation. Fear of the police, particularly fear that they would be arrested and blamed if the victim died, was the greatest barrier. This concern often resulted in IDUs either not reporting the overdose or not staying to help the overdose victim. One hostel dweller claimed "a lot of people die because others don't want to go downstairs [in the hostel] and say "he's overdosed"".

Personal perceptions of overdose risk

Thirteen IDUs thought that they would not have another overdose. This belief was mainly based on the changes they had made following their last overdose. Respondents reported that they had either cut down or stopped consumption of all or some drugs. Nine IDUs thought that they would have another overdose; one respondent replied that overdose "goes with the territory". Six respondents believed that they probably would overdose and the remaining sample did not know if another overdose was likely.

Half of the sample (n=20) reported that they were worried about having another overdose and 17 IDUs stated that they did not worry about this. However, when probed a bit further, some of the 17 explained that they were not worried because they did not care if they lived or died. "Yes and no [I'm worried] because I don't want to die but at the same time I don't see much point in living at times".

Overdose myths

In the course of the interviews it became apparent that some IDUs held erroneous beliefs about overdose. Five IDUs believed that smoking heroin would not lead to overdose; one respondent claimed that overdose would not occur if heroin was injected by itself and not in combination with other substances; one thought that it was not possible to overdose on methadone; another stated that, in a drug cocktail of heroin and diazepam, if the diazepam was consumed first there would be a danger of overdose, if heroin was taken first there would be no danger of overdose.

Other myths surrounded appropriate overdose interventions. One IDU stated that "you won't overdose if somebody is with you, if they are slapping you". On the same theme, another respondent claimed that "If you keep saying their name and you really care about that person, then they'll come round".

Key points

• Injecting drug users are aware, to some extent, of the overdose risks, although this knowledge is not extensive. Less than half mentioned loss of tolerance as a factor and less than half considered that a mixture of drugs could be risky.
• The majority of overdoses occurred amongst those who had taken more than one substance on the day of overdose.
• Heroin had been taken in all but one overdose. Heroin and diazepam taken together or on the same day was the most common combination, taken in 22 cases. In fifteen overdoses heroin and diazepam were the only drugs consumed; in the remaining five episodes they were taken in combination with one or two other substances and/or alcohol.
• Injecting with someone else present was the most frequently cited prevention strategy.
• Inflicting physical pain was the most common intervention used by injecting drug users. Although putting the overdose victim into the recovery position was cited by half the sample, the infliction of pain was still regarded as the most effective strategy.
• There were some misconceptions about overdose risk factors. Some injecting drug users believed that overdose would not occur if heroin was smoked or if it was injected by itself.
• Half of the sample was worried about having another overdose. Among those who were not worried, some claimed not to care whether they lived or died.

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