Elsevier

Addictive Behaviors

Volume 26, Issue 3, May–June 2001, Pages 453-460
Addictive Behaviors

Brief report
Overdosing among young injection drug users in San Francisco

In memory of Jennifer Lynne Hopkins, November 7, 1973–April 9, 2000.
https://doi.org/10.1016/S0306-4603(00)00115-5Get rights and content

Abstract

Heroin overdoses increased sharply in the US in the 1990s, but few studies have addressed overdose risk. We examined overdosing and injection-related risk behavior in young injection drug users (IDUs). We interviewed all consenting injectors under age 30 at needle exchanges and youth outreach sites in San Francisco. Their median age was 22, and their median number of years of injecting was 4. About 48% reported at least one overdose, with a median of two overdoses reported. Overdosing was associated with injecting “speedballs” (i.e. mixtures of heroin and cocaine), with borrowing syringes, and (with P-values of borderline statistical significance) with heroin injection and with gay or bisexual behavior. It was not associated with age, sex, years of injecting, or frequency of injecting. In multivariate analysis, only borrowing syringes and gay or bisexual behavior were independent statistically significant predictors, probably because gay and bisexual subjects were more likely to be heroin or “speedball” injectors. Most subjects (65%) reported that they had not received medical attention at time of last overdose. Risk of overdose in young injectors is acute and closely associated with HIV risk. HIV interventions should include overdose prevention. Emergency response protocols should minimize risk of arrest. Injectors and providers should be trained in overdose prevention, and developing overdose interventions should be a priority among drug educators.

Introduction

In the 1990s, the street price of heroin in the US decreased while the purity increased National Narcotics Intelligence Consumers Committee (NNICC), 1997, Office of National Drug Control Policy, 1997. The accessibility of heroin and the number of young injection drug users (IDUs) in the US are thought to have increased correspondingly (Office of National Drug Control Policy, 1998). Heroin-related emergency department (ED) visits increased 99% from 1988 to 1995, with more than a third of the visits involving an overdose (National Institute of Drug Abuse, 1995). A 241% increase in heroin/morphine ED episodes occurred in young people from 1995 to 1997 (OAS, 1999).

San Francisco, with 314 admissions per 100,000 people per year, has the highest heroin-related hospitalization rate in the US (Public Statistics Institute, 1997). Drug overdoses in San Francisco account for 31% of preventable deaths and are the leading cause of injury death in the city (San Francisco Department of Public Health and Injury Prevention Center, 1996). In California as a whole, heroin overdose deaths have risen 52% in the last 5 years (Public Statistics Institute, 1997).

Along with the increase in overdoses, the 1990s have seen the rise of harm reduction approaches in public health. In practice, however, harm reduction programs for injectors have usually focused on reducing morbidity and mortality due to HIV. Overdose mortality, though high, has remained a largely unexplored problem in the US. In other countries, overdosing has been identified as the leading cause of death among heroin users, exceeding AIDS Darke et al., 1996, Darke & Zador, 1996, Gossop et al., 1996.

Young IDUs are probably at higher risk of overdose than older injectors (Frischer, Goldberg, et al., 1997) and engage in more high-risk behaviors for HIV infection than older injectors (Fennema, Van Ameijden, et al., 1997). However, no US studies have yet examined overdosing in this population. We report a study of overdosing among young IDUs in San Francisco.

Section snippets

Methods

In September–November 1996, we used “peer-access” interviewers, i.e. young persons who were familiar with drug use and the street scene, to contact and interview persons in San Francisco aged 14–29 who had injected drugs in the previous 6 months. Interviewers were recruited from service organizations for street youth and were trained by us in interviewing techniques.

Study subjects were recruited and interviewed at six needle exchanges and three youth outreach sites. The needle exchanges were

Results

A total of 124 young IDUs were recruited. Most were white (73%) and male (70%) (Table 1). Almost half the subjects reported living on the street, and only 15% had a home, apartment, or room of their own. The median age of subjects was 22, and the median number of years injecting was 4. The majority of subjects had not completed a high school education. Thirty-seven percent reported gay or bisexual behavior.

The drug which the highest proportion of subjects reported injecting in the last 30 days

Discussion

Overdosing is strikingly common among young IDUs. With a median age of 22, after a median of 4 years of injecting, 48% of young injectors in our study had experienced an overdose. Those who had overdosed reported a median of 0.5 overdoses per year of injecting.

A history of overdosing was associated with speedball injection in the prior month, with the borrowing and lending of syringes, and (with P-values of borderline statistical significance) with heroin injection and with gay or bisexual

Acknowledgements

This study was approved by the Committee on Human Research, Office of Research Affairs, University of California-San Francisco, approval no. H9099-13223-01. Funded in part by the Department of Medicine, University California-San Francisco and the Universitywide AIDS Research Program, University of California.

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