International Journal of Drug Policy - 2014

Volume 25 Issue 3 May 2014

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Page 73 of 153

574 A. Siegler et al. / International Journal of Drug Policy 25 (2014) 569–574 While home was the most common setting for opioid overdose deaths, a substantial proportion of overdoses did, however, occur outside of the home, most commonly in institutional residences. Overdoses occurring in institutions most commonly involved heroin or methadone. For this reason, overdose prevention efforts located in institutions such as homeless shelters, supportive hous- ing facilities, and SRO's, should target both heroin and methadone users. Interventions could include training institution staff and resi- dents in first aid and naloxone administration, instituting policies that minimize risk for fatal overdose such as medication storage policies, and educating institution residents on reducing overdose risk and recognizing opioid overdose symptoms. We were unable to discern whether differences in setting of overdose by drug type reflect differences in drug use patterns or an interaction between drug type and setting. We hypothesize that the risk for unintentional overdose in a particular setting may vary by drug type or drug user characteristics. Heroin use, for example, may be riskier outside of the home because the user has less control of the environment and may fear arrest, as previous studies have found (Bohnert et al., 2011; Kerr, Small, Moore & Wood, 2007) while opioid analgesic and benzodiazepine use may be riskier inside the home, where opportunities for bystander rescue may be slimmer. Our study has several limitations in addition to those already discussed. By excluding all decedents with missing boroughs of res- idence, we may be systematically excluding homeless individuals who may be more likely to overdose in settings such as institu- tions or outdoors. Decedents with missing residential information, however, comprised less than 5% of the total sample and would con- tribute minimal selection bias. Setting of overdose may be subject to misclassification bias if some research staff coded settings dif- ferently than others, but duplicate recording and validation efforts were undertaken to minimize this risk. Our study was not able to assess the proportion of overdoses that were witnessed, which is a necessary precondition for successful intervention. Future research will need to determine this proportion in order to confirm and cap- italize on the findings of this study and its implications for policy. Last, it is possible that had we analyzed more than six years of data, we would have identified variations in setting of overdose over time, thus, reporting findings by year rather than in aggregate. Despite these limitations, this study has several strengths. The NYC Office of the Chief Medical Examiner is responsible for inves- tigating all deaths believed to be homicides, suicides or accidents; deaths of a suspicious unnatural nature; and deaths not attended by a physician. Drug overdose deaths often fall within these param- eters. Thus the study sample, we believe, is a near census of the population of overdose decedents in NYC during this time period. The large sample size allows patterns to emerge within settings and demographic and drug-using categories. We had the unique oppor- tunity to link death certificate information with biomarkers from medical examiner records, offering greater validity of toxicological information beyond those written in 'cause of death' death certifi- cate fields. Regardless of the demographic subgroup or what drug was pos- itive in toxicology, the majority of unintentional opioid overdoses occurred in the home. By both reducing risks in the home and training friends and family members to respond to overdoses, it is possible to reduce the number of fatal opioid overdoses in the home and make home a safer place. While mortality due to opioid anal- gesic overdose continues to increase both in NYC and nationally, attention is turning to potential prevention strategies. Interven- tions that aim to reduce overdose mortality can maximize their success by using this study's findings to focus on preventing fatal overdoses in the home. Conflict of interest statement None declared. References Bernstein, K. T., Bucciarelli, A., Piper, T. M., Gross, C., Tardiff, K., & Galea, S. (2007). Cocaine- and opioid-related fatal overdose in New York City, 1990–2000. BMC Public Health, 7, 31. Bohnert, A. S. B., Tracy, M., & Galea, S. (2009). Circumstances and witness charac- teristics associated with overdose fatality. Annals of Emergency Medicine, 54(4), 618–624. Bohnert, A. S. B., Arijit, N., Tracy, M., Cerda, M., Tardiff, K. J., Vlahov, D., & Galea, S. (2011). Policing and risk of overdose mortality in urban neighborhoods. Drug and Alcohol Dependence, 113(1), 62–68. Bradley O'Brien, D., Paone, D., Shah, S., & Heller, D. (2011). Drugs in New York City: Mis- use, morbidity and mortality update. New York. NY: New York City Department of Health and Mental Hygiene. Centers for Disease Control and Prevention. (2012). Community-based opioid over- dose prevention programs providing naloxone – United States, 2010. Morbidity and Mortality Weekly Report, 61, 101–105. Cerdá, M., Ransome, Y., Keyes, K. M., Koenen, K. C., Tracy, M., Tardiff, K. J., Vla- hov, D., & Galea, S. (2013). Prescription opioid mortality trends in New York City, 1990–2006: Examining the emergence of an epidemic. Drug and Alco- hol Dependence, 12.027. Advanced online publication Darke, S., Ross, J., Zador, D., & Sunjic, S. (2000). Heroin-related deaths in New South Wales, Australia, 1992-1996. Drug and Alcohol Dependence, 60, 141–150. Davidson, P. J., McLean, R. L., Kral, A. H., Gleghorn, A. A., Edlin, B. R., & Moss, A. R. (2003). Fatal heroin-related overdose in San Francisco, 1997–2000: A case for targeted intervention. Journal of Urban Health, 80(2), 261–273. Kerr, T., Small, W., Moore, D., & Wood, E. (2007). A micro-environmental intervention to reduce the harms associated with drug-related overdose: Evidence from the evaluation of Vancouver's safer injection facility. International Journal of Drug Policy, 18(1), 37–45. New York City Department of Health and Mental Hygiene. (2013). Bureau of Alco- hol and Drug Use Prevention Care and Treatment [Unintentional drug poisoning mortality surveillance data, NYC, 2010]. Unpublished raw data. Warner, M., Chen, L. H., Makuc, D. M., Anderson, R. N., & Mini ˜ no, A. M. (2011). Drug poisoning deaths in the United States, 1980–2008. Hyattsville, MD: National Center for Health Statistics. Zimmerman, R., Li, W., Begier, E., Davis, K., Gambatese, M., Kelley, D., Kennedy, J., Lasner-Frater, L., Madsen, A., Maduro, G., & Sun, Y. (2013). Summary of vital statis- tics, 2011: Mortality. New York, NY: New York City Department of Health and Mental Hygiene, Office of Vital Statistics.

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