What you need to know to stay safe and prevent overdose
By Andrew Reynolds @projectinform

To say that media coverage of the opioid crisis is a hot topic would be an understatement: A quick Google keyword search of “opioid crisis” will get you over 84 million hits! This attention is certainly warranted, as opioid use has increased dramatically and has led to significant death, disease, and suffering in the United States.

This article will provide you with a broad overview of the scope of the problem, basic information to understand what opioids are and how they lead to overdoses, and some harm reduction tips and resources so that you, or someone you know who uses drugs, can be safe.

The scope of the problem: Opioid use and its medical consequences

When you look at the numbers, the scope of drug use in the U.S., including opioids, is quite astounding. According to the Centers for Disease Control and Prevention (CDC), there are over 48.5 million Americans who have used illegal drugs or misused prescription drugs. Among this group, 11.5 million people have misused prescription opioids. To put opioid use in context, the U.S. makes up 5% of the world’s population, yet we account for 80% of opioid use.

For many in the U.S., the transition to injecting heroin starts with taking prescription opioids, becoming physically dependent upon them, and then moving to injection. There are several reasons why this leap is made, including but not limited to job loss and a resulting loss of health insurance to cover the cost of the medications, or changes in prescribing after a person has become addicted to them without the medical and social support to withdraw safely. In the face of terrible opioid withdrawal symptoms, people often turn to heroin. Heroin use has increased by 60% from 2002 to 2013. In 2016, the last year data were available, approximately 950,000 Americans reported using heroin in the past year, with younger individuals aged 18 to 25 having the greatest increases.

The consequences of this opioid use have been devastating.

Overdose death rates now exceed death rates due to AIDS during the 1990s. There were over 72,000 overdose deaths in 2017, and this number has been on the rise year after year and shows no sign of stopping. The death rate is so bad, and hitting such a young portion of the U.S. population, that the average life expectancy in this country has actually dropped for two years running.

In addition to the dramatic increase in overdose deaths, we’re also seeing an increase in infectious diseases associated with injection drug use.

Rates of hepatitis C (HCV) are also on the rise, with over 41,000 newly infected persons in 2016, a number that is more than three times what it was in 2010. Mirroring the increase in injection heroin use among young people, we are seeing dramatic increases of HCV infections among youth, with people aged 18 to 29 experiencing the highest rates of new infections.

While we have seen dramatic increases in overdose deaths and HCV infections related to the opioid crisis, we’ve had a remarkable success in preventing HIV from injection drug use. In 1990, injection drug use accounted for 40% of new HIV infections, but it was just 6% as recently as 2015. The success is due to the expansion of harm reduction services such as needle exchange (aka syringe access services) and other interventions aimed at reducing HIV in people who inject drugs (PWID).

That said, there have been warning signs that this progress is in danger. For the first time in 20 years, HIV infections among PWID increased in 2015. This was in large part due to an HIV outbreak in Scott County, Indiana, where over 200 PWID were infected with HIV. Since then, we have seen an HIV outbreak in Massachusetts, and the CDC has identified 220 other counties that are vulnerable to an HIV (and HCV) outbreak as a result of injection drug use and a lack of harm reduction services.

What are opioids?

Opioids are a class of drugs that create a morphine-like effect for pain relief and have other medical uses. They are naturally occurring substances, such as heroin (derived from some varieties of the poppy plant), or synthetic, like oxycodone (brand name Oxycontin) or hydrocodone (brand name Vicodin). They are also very addictive. Modes of administration can vary, but opioids are often injected, smoked or snorted.

The introduction of fentanyl into the drug supply has had a devastating impact. Fentanyl is a synthetic opioid that can be 50–100 times stronger than morphine. It is a legitimate medication with some positive therapeutic benefits when administered properly, but unfortunately it has entered the illegal drug market and has dramatically increased the risk of overdose. When it’s included in a person’s drug, say heroin, it can lead to an overdose because the person doesn’t know it has been added and the drug’s effect is too strong to handle.

What is an overdose?

An overdose happens when too much of a drug is in one’s body and leads to a toxic health problem. You can overdose on any number of drugs, both legal and illegal: Binge drinking alcohol can lead to acute liver failure. Too much cocaine can lead to heart attack, seizures, or a stroke. With opioids, when someone gets too much of it, the person’s breathing will slow and eventually stop. Everything else is working in the short-term—the heart is pumping, the kidneys are functioning and the brain is firing—but without breathing a person will die. Fortunately, overdose deaths can be prevented by administering rescue breathing and/or Narcan (naloxone)—see the sidebar "How to prevent an opioid overdose" for more information about this.

Harm reduction and opioid use: What you need to know

There are many things that you can do to reduce your risk of overdose, and acquiring HIV or HCV. This top 10 list can serve as a guide to keep you safer if you are using opioids. It may be difficult to do some or all of these, as you may not have a syringe access program in your area or an ability to get naloxone.

1. Never use alone

This tip by itself can help prevent overdose deaths. Most overdose deaths happen when a person uses opioids alone and then overdoses with no one around to step in and help with rescue breathing, naloxone administration, or calling 911. Use with someone you trust, make an overdose plan, and watch out for each other. Make sure you have naloxone on hand, know how to do rescue breathing, and have a phone (or be able to get to a phone) if needed.

Making the case for safer consumption spaces

2. Don’t mix your drugs

Mixing some drugs can lead to an overdose, especially ones that might interact with each other and make the overdose risk worse. Never mix alcohol with opioids or benzodiazepines (like Xanax, Valium, or Ativan) as they can greatly increase your risk of overdose.

Be careful even if you aren’t using opioids.

Fentanyl is being found in other drugs such as cocaine, crystal meth, and ketamine. So, you might not think you’re taking opioids, but if your drug is laced with fentanyl, drinking alcohol on top of it could increase your risk of overdose.

3. Test your drugs

There are a couple of different ways to do this. If you have access to something called “fentanyl test strips,” you can use them to test for fentanyl in your drugs. If there’s fentanyl in it, you can make plans to be safer when using and be on heightened awareness for an overdose.

If you don’t have these test strips, try a tester shot, where you use less than you normally would and watch for its effect. This is especially important if your tolerance has changed (perhaps you haven’t used in a while or you’ve been sick lately and feeling a little weaker than usual) or if you have a new source for your drugs. If you hear stories of people in your area overdosing, be careful with your drugs and watch out for each other.

4. Carry naloxone (Narcan) with you

Related to never using alone, carry naloxone with you so you can reduce an overdose should one happen. Check out “How to prevent an opioid overdose” on page 31 for how to use Narcan. It is available for free at various community places, such as needle exchanges.

In addition to lowering your risk for overdose, there are steps to take to help prevent disease transmission.

5. Don’t share syringes

This helps prevent HIV, HCV, and HBV. It’s is an obvious disease prevention tip, but because of politics and stigma, it may be hard for you to get unused syringes and enough injection equipment. It is well established that both HIV and HCV can be transmitted from sharing syringes and injection equipment, and that needle exchange reduces the risk of these infections. The science is unimpeachable, but the resistance to allowing them remains strong. Check out the North American Syringe Exchange Network’s directory to see syringe access services in your area: nasen.org/directory/search.

6. Take a break from injecting

If you can take a break from injecting or switch to smoking or snorting drugs, it could reduce your risk of HIV and HCV as it reduces your risk for blood-to-blood transmission. Don’t share straws or pipes, as blood can be on them and potentially transmit HCV—the risk is low, but not zero.

7. Test for HIV and HCV routinely

Testing for HIV and HCV in and of itself won’t prevent these diseases, but knowing your status as soon as possible is good for both your health and the health of your injection or sexual partners so that you can take action to prevent new infections. If you test positive for HIV, you can start medications ASAP, get your viral load to undetectable, and minimize both the damage to your immune system and risk of transmitting HIV to others.

8. Get treated for hepatitis C

If you test positive for HCV, you can get cured. The older treatments were tough: You had to have an injection and pills; they had very difficult side effects and not everyone was cured. Thankfully, the new HCV treatments, called direct-acting antivirals or DAAs, are easier to take than ever before: They are all pills, usually taken once per day for 8–12 weeks, and have very high cure rates with very few side effects, even for people living with HIV. For more information, call HELP-4-HEP, a non-profit HCV education, support, and referral phone line at 877-HELP-4-HEP (877-435-7443).

9. Get vaccinated against hepatitis A (HAV) and hepatitis B (HBV)

Make sure you’ve been vaccinated against HAV and HBV. Hepatitis A and B are both viral infections that can affect the liver. The vaccine is safe and effective for everyone, including those living with HIV or HCV.

10. Get on Medication Assisted Therapy (MAT)

This is another strong, evidence-based intervention that has been shown to reduce overdoses, and HIV and HCV infections. It makes sense: If someone is on methadone or buprenorphine, then they are not injecting opioids and thus not at risk. That said, access to MAT can be challenging and may not be available in your area. Call the SAMHSA National Helpline at 800-662-HELP (4357) for a free and confidential referral and for information about drug treatment.

Andrew Reynolds is the Hepatitis C Education Manager at Project Inform, and facilitates several HCV support groups in the San Francisco Bay Area. He's also a counselor on the HELP-4-HEP HCV phoneline (877-435-7443). Call him if you have any questions about HCV care and treatment.

Also see "Making the case for safer consumption spaces" in this issue.