July 2012 | VOL. 10, ED. 6

volume 10 edition 6

INTERNATIONAL OVERDOSE AWARENESS DAY Anex is leading INTERNATIONAL OVERDOSE AWARENESS DAY which is on August 31. We hope that all services find ways to recognise the Day and become involved. Founded by Sally Finn, International Overdose Awareness Day is about prevention and remembering loved ones. It’s an opportunity for people to mourn, some for the first time, without feelings of guilt or shame. It’s also about people supporting each other to raise awareness about the preventable tragedies of overdose.

Visit www.overdoseday.com to learn how your service can be involved.

Keith Hassett, now 70, looked in on his sleeping son Shane and decided to give him an extra hour of rest. It was another act of parental love for a son whose deep snoring was actually an unrecognised sign of being on death’s doorstep.

Shane was accidentally overdosing. Hooked on doctor-shopped opioid-based painkillers, he was suffering from an undiagnosed bout of pneumonia. With his respiratory system already compromised, the depressant effects of the drugs proved deadly.

“Pneumonia and the drugs together just didn’t go,” said Keith, who still works as a backyard mechanic based out the house - in a regional city - where he lives with his wife.

Shane, 29, had come up from the city that night 18 months ago and was staying at mum and dad’s. He was looking forward to meeting his wife and their newborn baby the next afternoon. As was common, Shane paced the house until nearly dawn.

At 6am Keith told him to lie down in his childhood bedroom and have a good sleep, adding that he would wake him at about midday and then they would go and see Shane’s daughter. “I came in at about 12.15, and he was snoring his head off. I thought, ‘no, I won’t wake him. I’ll leave him lie there for a little bit longer’.”

Keith went outside to work on a car. “I came back in at about ten past one. And I thought, ‘That’s strange - he’s not snoring anymore.’

I didn’t think anything more of it. I washed my hands, came back in and said, ‘Shane, come on.

Wake up’.” There was silence, and no response.

“Then I realised he was gone.”

Snoring or ‘gurgling’ is one sign of overdose, but one that too few people are aware of.

According to Narelle, her sister heard Shane “gurgling horribly, which she will never forget” the previous two nights before he died.

The Facebook rumour mill cranked up just hours after his death. Shane’s sister Narelle, who works in residential care for intellectually disabled adolescents, was furious when she saw how wild some of the stories were.

Beware Snoring or Gurgling: page 5

Up In Flames: page 6

“On the day he passed away, I saw on Facebook… all these comments. Someone saying that they’d heard there had been a police chase and he had thrown himself in front of a train. Someone said they heard there was a big shoot-out with the police.

And I thought, ‘Are they talking about my brother?’ So I just wrote something and said, ‘If you are, remove it’. I told them to remove it.”

Shane’s wife Alicia had not long given birth to their first child.

“There were a lot of rumours,” Alicia said.

“All this bizarre stuff started coming out.

We didn’t want people thinking that [that he jumped under a train], because he didn’t.

He didn’t commit suicide. He didn’t want to leave me and his child and his family.

We wanted to make sure that people knew that it was an accident, a tragic accident.”

Alicia and Narelle have decided to speak publicly about pharmaceutical drug prescribing to highlight the tragic consequences it can have upon any family.

“That’s why I decided to speak out by writing to my local newspaper,” said Narelle. “I was thinking about it from when all this started.

Our family, and me and Alicia in particular, felt so alone with it. We didn’t feel like anyone in the world had the same issue.

“We didn’t know where to go for help, we didn’t know how to tackle any of the big problems coming up. We didn’t know how to do anything. And when he actually did pass away, I just found myself so angry with the fact that we hadn’t found any help. We were unable to sort of talk about it with anyone, and I just wanted other people to know that there are other people out there.

“Mum was completely against me writing a letter to the newspaper and telling anyone, really. She didn’t want anyone to know. It’s because of the perception that people have.

I think she was worried people would think she was a bad mum…all of that.”

Continued on page five.

Read Shane’s story on pages four and five.

AUGUST 31 - Local Ideas: page 7

Anex’s vision is for a society in which all individuals and communities enjoy good health and wellbeing, free from drug-related harm. A community-based, not-for-profit organisation, Anex promotes and supports Needle and Syringe Programs (NSPs) and the evidence-based approach of harm reduction. We strive for a supported and effectively resourced NSP sector that is perceived as being part of the solution to drug-related issues.

Chief Editor John Ryan

Editor Dr Patrick Griffiths

Writers Royal Abbott Nicola Cowling Kelly Eng Dr Patrick Griffiths Paul Hines

Correspondence Anex Bulletin Suite 1, Level 2, 600 Nicholson Street Fitzroy North VIC 3068 Australia Telephone: 61 3 9486 6399 Facsimile: 61 3 9486 7844 Email: info@anex.org.au Website: www.anex.org.au

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Production L&R Print Services The content of the Bulletin is intended to stimulate discussion and information sharing and does not necessarily represent the views of Anex. It does not encourage anyone to break the law or use illicit drugs.

While not intending to censor or change their meaning, Anex reserves the right to edit articles for length, grammar and clarity.

news briefs Investigation shows US soldiers OD-ing in Afghanistan

UN calls for naloxone to be in overdose prevention programs

United States Army investigative reports have found that eight American soldiers died of overdoses during deployments in Afghanistan in 2010 and 2011.

Naloxone Hydrochloride has been used to safely reverse the effects of opioid intoxication in hospitals and by paramedics for decades.

Its only action is to reduce the effect of opioids.

The overdoses (involving heroin, morphine or other opioids) came to light during an investigation into 56 soldiers who were suspected of possession, use or distribution of drugs. Although the results of the investigation, which was undertaken by Army Criminal Investigation Command during 2010 and 2011, show that some soldiers were using heroin, they reveal that much of the opioid abuse by the US military in Afghanistan involves prescription drugs such Percocet (a combination of acetaminophen and oxycodone). It should be noted that the data does not reflect the statistics released by the Army in early 2012 that reported close to 70,000 drug offences by approximately 36,000 soldiers between 2006 and 2011.

The UN’s supreme voice on drug policy, the United Nations Commission on Narcotic Drugs, has passed a resolution recommending that naloxone be provided to potential overdose witnesses as part of overdose prevention and treatment strategies. Naloxone’s inclusion in prevention programs is now a mainstream topic in the US, with even the Centers for Disease Control providing financial support to their evaluation to inform the evidence base.

Fentanyl overdoses in border area Gateway Community Health in Wodonga has expressed concern about another spate of overdose deaths from fentanyl injection in the Albury-Wodonga region.

Fentanyl, which is marketed in Australia as Durogesic®, Actiq® and Sublimaze®, is intended for use as a painkiller for people with high tolerance to opioids. It is around 80 to 100 times more potent than morphine (100mcg/hr fentanyl being approximately equivalent to 10mg of morphine and 75mg of pethidine). It is intended for use with people experiencing extreme pain that cannot be controlled by other medications.

The Gateway Community Health alcohol and other drugs team said use of fentanyl was becoming more widespread. They reported having been informed by clients that a doctor in nearby rural NSW was providing scripts for the drug, which was then transformed into an injectable liquid.

In light of evidence from around the world that naloxone provision is safe and effective, in March 2012 the United Nations made the following recommendations: “Opioid overdose treatment, including the provision of opioid receptor antagonists such as naloxone, is part of a comprehensive approach to services for drug users and can reverse the effects of opioids and prevent mortality”; The Commission added that it: “Encourages all Member States to include effective elements for the prevention and treatment of drug overdose, in particular opioid overdose, in national drug policies, where appropriate, and to share best practices and information on the prevention and treatment of drug overdose, in particular opioid overdose, including the use of opioid receptor antagonists such as naloxone.”

Additionally, on 12 April in Washington DC, the United States’ leading drug regulatory agency, the Food and Drug Administration, held its first-ever scientific symposium on naloxone distribution.

Endorsement by the UN Commission comes as Australia’s first program to train potential overdose witnesses (including drug users) in administering naloxone has begun in the Australian Capital Territory.

The South Australian Alcohol and Other Drugs Strategy 2011-2016 has listed trialling the provision of naloxone as one of its priorities.

Anex takes no responsibility for any loss or damage that may result from any actions taken based on materials within the Bulletin and does not indemnify readers against any loss or damage incurred.

This publication has a targeted readership and is not intended for general distribution.

All written material in this publication may be reproduced with the following citation: ‘Reprinted from vol. 10, ed. 6 of Anex Bulletin, published by Anex’ and with credit to the author(s).

An Editorial Reference Group provides advice on the content and issues that the Bulletin includes.

The Anex Bulletin is funded by the Australian Government. The views expressed in this publication are not necessarily those of the Australian Government.

Citations for the edition are available online at http://www.anex.org.au/publications/anex-bulletin ISSN: 1447 - 7483 July/August 2012

OVERDOSE PERSPECTIVES Drug safety worker

People who live in areas with high drug use

“I remember attending an overdose one night when working in the CBD on NSP outreach. A couple of boozed-up young men were doubled over laughing outside a convenience store and made some reference to the ‘junkie’ lying on the floor. My colleague and I hurried over to investigate and found a man lying flat on his back and unconscious under the bright fluorescent lights. The shop assistant, perhaps in a moment of panic, had locked the doors. We banged on the door and yelled for him to let us in. He looked terrified but, after a little hesitation, opened the doors. We promptly asked if he had called an ambulance. He hadn’t, but did so on our instruction.

“Last time I saw a guy … lying on the ground where I live, so I come close by, I kick, not kick, I touch his head and we say, ‘are you all right?’ like that and, yeah, he answer me back and I know he is ok.

But once I just go and tell the security and let them go and check.

“We recognised the man on the floor as he had accessed the NSP earlier in the evening. He was pale and clammy and his lips were turning blue. My colleague and I performed expired air resuscitation on him - this was back in the days before CPR changes were brought in by the Australian Resuscitation Council. The whole process was much trickier than on the Annie mannequin, but all that first aid information certainly comes rushing back to you.

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“Within minutes the ambulance crew arrived, took over the resuscitation process and administered Narcan. The ambos were great, very quick and very considerate. After what seemed like hours (but was probably more like five to 10 minutes), the man regained consciousness He eventually sat up looking overwhelmed by the situation he had suddenly found himself in, and within moments jumped up, out the door and ran off down the street.

We followed him to check he was okay and to give our well rehearsed harm reduction messages about the Narcan wearing off and so on. Feeling a little deflated and concerned, we were both suddenly elated as the man stopped suddenly, turned back to us and called out ‘Thank you!’ before disappearing into the night.”

“I saw a guy lie down on the floor and I went near to his shoulder on the head side but I don’t stand near the feet because I was taught you never stand near the feet because they can just get up and hit you. I said, ‘Are you all right?’ One was okay, but another didn’t respond so I go back to my building and I report to the security that there was an overdose. But people don’t care, they just go past.”

MICA Paramedic “I recently went to a Gamma-Hydroxybutyric acid overdose call-out at 7am. A bloke had had a fight with his girlfriend the night before and took a small bottle of the stuff first thing in the morning. His dad rang us. We got there and he looked pretty fine. He was about to get into the ambulance when he said, “Hang on a minute, I’ve got to get something”. He disappeared inside and came out again eating a piece of cold pizza.

“He got in the back, [but] after a few minutes he was fading in and out. We got him going again, but when we got to Emergency at the hospital he just blacked out. He went straight into the intensive care unit and was intubated [had a tube passed down his throat to control his breathing]. He was unconscious for a couple of days. He would have died without the intubation.

“It just shows how lucky he was that someone called the ambulance, or he’d have been dead.”

From little things big things grow In the late 1990s, newspaper headlines trumpeted that people were dropping like flies from drug overdoses. The analogy accurately reflected the view of the public, many of whom saw dead drug users as pests or worse. Even the families of the dead were affected by public condemnation.

Community health worker Sally Finn was managing a busy needle and syringe program at the time and saw her clients wrestling with their sorrow over friends’ overdose deaths.

She saw victims’ families struggle with the notion that “good people don’t take drugs” and she sensed oceans of unwept tears that needed release.

Out of this was born Overdose Awareness Day, a commemoration that has been adopted around the world.

There is also Remembrance Day which was established in 1996 by Family and Friends for Drug Law Reform (ACT) and focuses on commemorating all those who have died from the use of illicit drugs, and not just from overdose.

“I was talking to a lot of people who were clients of the exchange, and some of them had lost up to 17 friends,” Finn told the Bulletin.

Yet she found that the families of the overdose victims were often in denial about drug issues and refused to allow friends who used drugs to attend funerals. “Some people hadn’t even been invited to their partner’s funeral. In fact they were told to stay away. As a friend it was even more difficult sometimes to attend their friend’s funeral. They weren’t welcome.”

Finn decided to try and break down the barriers of shame and guilt that prevented families from accepting their lost relatives as people being worthy of recognition for who they were, rather than of being denigrated for what they were doing when they died.

“It occurred to me that not only was there not a spot for them to pause and reflect on all that loss, but that we had no way of telling them they were important.”

Finn was trained as a social worker in child psychology. “I’m a family therapist and a social worker and I’d left the [Royal)] Children’s Hospital and taken a job with the Salvation Army crisis services at the Health Information Exchange (HIE) needle and syringe program [in St Kilda, Melbourne] in 1998. I was asked to manage the program in ’99.”

This was when the heroin scene was near its historical peak.

She said the impetus for doing something came when, early in 2001, a community development worker from the City of Port Phillip told her there was some money for drug and alcohol services in the St Kilda area.

Sally Finn who established Overdose Awareness Day in 2001.

‘Our hearts go out to people who have lost loved ones, and good luck.’

The funding was a meagre $750. With assistance from the council, Finn and the HIE team began making and distributing silver ribbon pins both through the NSP and at other local outlets such as municipal libraries and town halls. “We bought ribbons and pins, we set a date and we organised a small event at the backyard of the crisis centre in St Kilda. In the lead-up to the day we were thinking we would probably give out 500 ribbons - but we gave out 6000 that first year.

Joan Nicholas, whose son had died of a drug overdose, spoke movingly about loss that first year.

“She was very much able to express all of this, not only to me, but to the audience that day,” comments Finn. Her story, as in all these stories, is not straightforward. It gave a chance for people’s siblings, who perhaps aren’t in this world of drug using, to realise other people care. This is something we are taking note of.

It is not just a hidden epidemic or a hidden reality.”

There was also a broader message to Overdose Awareness Day, about drug dangers. “Right from the beginning, Overdose Awareness Day

up drugs over the course of their life and have inevitably struggled.”

was about all drugs; it wasn’t just about heroin or opioid-related drugs. Right from the beginning, we talked about pharmaceutical medicines and alcohol as being a contributing factor if not an absolute factor. There are people dying of alcohol overdoses - there is no doubt about it.

Finn is still surprised at how the day caught on. “In early 2000s, India acknowledged the day in Bangalore and Hyderabad. A couple of doctors got together and held huge events.

Then in Minnesota there was one woman running a needle exchange and she got heavily involved.

“We talked non-fatal overdoses. There is a whole group of people living in our society with permanent injuries from non-fatal overdoses, and that manifests in a physical sense. They may be paralysed or have strokelike symptoms, so we really wanted to highlight all the different aspects of overdose, not just the mainstream stereotype version of what people perceive as somebody dying from an overdose.

“Then I started to see a few things on the internet. Early in 2008, I wrote to Antonio Maria Costa heading up the United Nations Office on Drugs and Crime (UNODC), who wrote to me and said he would definitely wear a badge on the day and said: ‘Our hearts go out to people who have lost loved ones, and good luck’.

“We wanted to make sure that people and families were able to attend and, for maybe the first time, felt they didn’t need to hide the facts surrounding their child’s death or their parent’s death. It’s very easy for mainstream Australia just to think of overdose victims as a kind of cardboard cut-out person. So it’s really about elucidating the facts and struggles around people that have often tried to give

London-based Harm Reduction International has also taken up marking the day, as has the United States’ Drug Policy Alliance.

“It has really probably been through the internet that it has taken on a presence in the calendar and that’s what’s really important to me: that the more people you can get talking about the same thing on the same day, the better we are in terms of influencing change.”

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Killers of hurt bring pain to normal families In the dead of night, Shane, addicted to doctor-shopped prescription drugs, stuck a samurai sword down his trouser leg and walked into the service station that he intended to rob.

“It was a cry for help,” said his wife Alicia, who is still grieving after her husband died from an overdose in December 2010 before he could be sentenced for the robbery. Her view seems reasonable in light of the fact that the service station Shane robbed, by the modus operandi of pointing to the handle of the allegedly fake sword, was opposite a police station.

system the day he passed away. You don’t tend to think that someone is going to, you know, abuse prescription drugs, and you trust that the doctor wouldn’t keep giving it out.”

Narelle and Alicia explained to the Bulletin that Shane was so freely able to organise a network of loosely prescribing doctors and dispensing pharmacies that they are joining the chorus of people calling for genuine implementation of widespread and interlinked “real-time” monitoring systems.

Alicia said that on weekends Shane would get into his car early on a Saturday and be gone all day as he drove hundreds of kilometres on a well-worn round of regional and rural doctors. He had told his family that one doctor would not record the appointment and would take cash in hand to write the script.

“Speaking to Shane afterwards, he felt he couldn’t do anything else other than to do something to get locked up to stop using. He thought that by going to jail he could get off the drugs,” Alicia told the Bulletin.

Cry for help or not, the service station attendant, who is married with a young family, was deeply traumatised by the experience and has since suffered nightmares and panic attacks. He had to quit his job for psychological reasons. While he has no sympathy at all for Shane, he does feel for the family that survived the accidental overdose.

Never a heroin user, rarely a drinker and holding down a steady job throughout the greater part of his addiction, Shane became dependent after being prescribed Panadeine Forte®. Alicia explained how innocently her husband’s ultimately fatal use of painkillers began.

Deadly escalating cocktails “It started with his ears. He had constant earaches and we went to the local hospital.

This happened constantly. One night we went up there and they gave him Panadeine Forte®.

That helped for about a month. He went to the doctor again and again, and, rather than doing something about it, they kept giving him panadeine.

“The ear-aches went on and off for a couple of months. Then he got glandular fever. He then had his ears, his teeth and his throat flaring up on and off, and all the time he was given painkillers. Before he knew it, all he was doing was taking painkillers.”

Shane’s sister Narelle added: “I didn’t really think too much of it when he was having a lot of Panadeine Forte® and tramadol and stuff.

Tramadol was the big one. That was in his

Unlike her sister-in-law, Narelle does have knowledge of addiction and overdose, which somehow makes it all the more traumatic to her that she is alive while her brother is not.

“I used to be the heroin addict. I moved to the city when I was young and was homeless for a while. It was in 1998-9 and heroin was just everywhere. I overdosed once and nearly died [she was revived with naloxone].

“Shane thought I was off my tree for even thinking of doing drugs, and being an addict.

He was horrified,” she said.

Narelle moved back to the country and got on a program with a doctor who would travel out from the city, and was off methadone and illicit drugs by 2003.

“Nothing really prompted me to get onto methadone, except for the fact that I thought one day, ‘I just don’t want to die’. And because of family: I could see what I was doing to

“He thought by doing that across the road from a police station, that they would be there in minutes, but that wasn’t how it panned out and he handed himself in a week later.

“So for me, in a strange kind of way, it felt like we had turned a corner, if you know what I mean. I wasn’t happy with what he had done, and how it affected everyone, and, like, I didn’t condone it all - but there was a part of me that thought, maybe he will get some help now that it’s come to that. Something will change now.’’

Experience with heroin

Even though he earned at least $1000 a week, Shane’s spending on pills and the petrol to get them meant he’d be almost out of money within days of being paid.

“It just started out with your regular painkillers,” said Narelle. “In the last two years it got to the point where he was hiding stuff.

We found out he was having Endone®, OxyContin®, Largactil®.”

He was also taking Panafen®, Nurofen Plus® and tramadol.

“There was one doctor who had prescribed him Largactil® and then prescribed him something for the tremors that the Largactil® was causing. It got to the point where Shane had to have 80 codeine tablets (Nurofen Plus) just to feel normal.

“At the time of the robbery, that’s where he was at. Plus he’d had 50 Xanax® [used to treat anxiety disorders], half a packet of Endone® and Valium® as well.”

Treatment attempts According to both Narelle and Alicia, Shane approached local drug treatment agencies several times many years ago to try to get into a program. The treatment teams were unable to offer him a spot because, not being a heroin or amphetamine user, they couldn’t prioritise him over those who were.

“That happened so many times,” said Alicia.

“He’d be at the point where he would want help, and you’d ring around detox places, and there’d be no beds. Unless you have a lot of money to pay upfront, you can’t get someone in that day, or that moment.”

Narelle added that the mother of one of Shane’s friends was a pensioner who was able to get multiple scripts for painkillers and would then sell the pills. Her brother was paying $300 a packet.

Doctors lack knowledge of addictions It is a well established that there are not enough doctors with extensive knowledge of - or experience in - treating people with substance-misuse-related problems. This is particularly the case in regional and rural areas.

“At one point about five or six years ago, when we realised things were getting bad, Shane went to the family practice and asked to see a different doctor than normal. Just by luck, he saw a doctor who had come from Canberra and had experience with [treating] addiction,” Alicia explained.

“The doctor was worried about the potential liver damage of paracetamols, so he put him on codeine and then worked on a program to reduce the dosages. And we were seeing him constantly, and I was going with him and he got down to quite a low level. But the doctor moved away so they just had another doctor, who wasn’t experienced with it.”

The problems resumed, and with tragic consequences.

Beware snoring or gurgling COMMENTS FROM AN EXPERT

Gurgling and snoring is due to collapse of the airway because in coma, the normal muscle tone that keeps the airway open is compromised by the depressant effects of drugs, usually combined drug toxicity involving opioids, benzodiazepines and/or alcohol.

Other Central Nervous System depressants can also contribute to coma, such as antidepressants and antipsychotic drugs.

The other thing about prolonged coma, whether prior to death or not, is the retention of secretions in the airway and lungs, or also described as failure to cough up and clear normal secretions.

This often results in infection of these secretions, leading to pneumonia.

Many people die from unrecognised coma, like Shane, whose father heard him snoring loudly. People mistake this for someone sleeping deeply, when in fact it is unrecognised coma, and the person has a collapsed airway - one of the cardinal signs of coma.

INTERNATIONAL OVERDOSE AWARENESS DAY

everyone else,” she said.

“And that’s what I find absolutely bizarre: that he’s gone now, and I’m here alive.”

Real-time monitoring Narelle said she had begun to campaign for real-time prescription and dispensing monitoring out of both a sense of anger and the need to raise public awareness to destigmatise the loss of loved ones through overdose.

Continued from page one.

“It’s actually getting worse [pharmaceutical misuse], and that makes me angry. We have these health professionals that are meant to be looking after people, giving them the best outcomes, yet a lot of these doctors are creating drug addicts.

“Whether they are doing that intentionally or not, that’s a fact: they are giving out all these strong painkillers, and it’s legal so they’re getting away with it. That’s what I started telling people.

“Perhaps if there was a bit more communication - hence me wanting to get the real-time system in - between doctors and pharmacists and Medicare, then someone could be alerted more quickly as to how often someone is going to the doctors and getting those prescriptions. It could have been monitored a bit more closer in Shane’s case.”

Shane and Alicia Hassett with their newborn girl months before Shane passed away.

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“But I just said, ‘It’s more important to let people know that Shane was a really great guy, and not just a drug addict who would die one day’. I think telling his story is far more important that what your neighbours think.”

Shane’s parents, who are well known in the regional city they live in, are now more able to discuss the circumstances leading up to his death. For her part, Alicia remembers her husband as a meticulously presented person who studied a Bachelor of Arts and then finished a trade apprenticeship. He worked and was a fitness fanatic whose addiction to opioids - never illicit drugs - started after being prescribed painkillers for an earache.

Alicia and Narelle have harnessed the positive potential of Facebook by starting a page to highlight the risks of prescription drug misuse to encourage networking for people affected by addiction, particularly those who have lost loved ones.

“I think the hardest thing for me was just seeing the person that I knew and loved unravel before my eyes and not having anywhere to go,” Alicia said. “It was just a constant daily struggle, with no solution.

“I know drug addiction doesn’t have an easy solution anyway, but it just felt for me - I know Narelle was there as well helping, but I was living with Shane, dealing with it 24 hours a day. And it was just seeing him go downhill so quickly, and what felt like irreversibly, and not just having anything in place to help him. That was the hardest part.”

“He used to run everyday - he’d run anywhere, five or 10 kilometres at a time,” said Keith. “Then he’d come back and do weights. He had his own set-up. He was super fit. For a person to be that fit and go like that; it’s just not right.”

Keith is hoping that doctor-shopping can be reduced through real-time monitoring and is supporting Alicia and Narelle’s mini-campaign.

“Hopefully we can achieve something out of all this. And this is what my aim is - we can’t help Shane, but we might be able to help somebody else.”

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Someone’s sister, someone’s brother Young offenders can be voracious and indiscriminate drug users. Juvenile Justice workers try their utmost to prepare young offenders in detention for release knowing they will be prime candidates for overdose. They do not always succeed.

“It was just like living in a big share house, except with bedroom doors that are locked from the outside” is how youth worker Luke Mitchell describes his time mentoring juvenile offenders between 1998 and 2004.

“Normally [in detention] they were very sweet young men or women. But then they were drug-free,” he said in a tone heavy with resignation and the recollection of the all-too-frequent tragic sequel. “I remember one girl. She said she’d get out and have just one last hit and that would be it. So she caught up with a couple of friends.

“The three had a hit. Only two of them woke up. That was the night after she got out. She was only 15 or 16.”

Between 80 and 90 per cent of the young detainees at the Youth Residential Centre Luke worked at had been heroin users before they were arrested and incarcerated. The high

heroin use rate was all the more shocking in that Juvenile Justice incarcerated boys only up to 15 years old (the girls were aged up to 21).

Keeping these young people off heroin once they’d been released was a significant challenge.

“Every time you released a young person, you wondered whether you were going to see her back or go to her funeral,” Luke told the Bulletin.

Preparing young drug users for survival in a dangerous post-release drug environment was one of the officers’ and youth workers’ top priorities, said Luke. Staff tried to protect the youngsters by educating them about different drugs and telling them to take care when they were back on the street because they would have no tolerance to heroin. They also tried to get them onto pharmacotherapy to give them a protective buffer against street opioids.

Getting them onto pharmacotherapy programs and in touch with a good prescribing doctor and an understanding dispensing pharmacist was crucial pre-release preparation. As the detainees drew close to their release date, they became entitled to go out of the centre on leave. Luke said their case workers would take them to their doctor and, a week before getting out, they would start being dosed at a pharmacy.

But they could not force detainees to go onto pharmacotherapy; some chose not to, sometimes with tragic results.

“We lost quite a few who wouldn’t go on a program.”

Luke says coming to terms with the lost potential in those young lives was very traumatic.

Luke was contacted when one client, who had only recently been released, didn’t turn up at her job one day. “Part of my role was to keep an eye on them, and when I phoned she said she was at home. She sounded a bit upset so I went over there and said I was coming for a cup of tea. Little did I realise that, just before I got there, she hit herself up with a big dose.

So I’m sitting there having a cuppa and she’s dropped in front of me. Luckily the ambos were able to save her.”

He believed most of the young people he worked with took drugs for self-medication

after a history of trauma. Mainly arrested for possession and dealing on the street, they were the bottom of the food chain in the drug world, usually dealing just to support a habit.

He said one of the difficulties was that they had very little drug education and would mix uppers and downers and take cocktails.

Luke’s six years as a Juvenile Justice youth worker took a heavy toll. “We’d try and equip them with harm reduction strategies, but, despite all the warnings, you just cannot control what they do once they get out. You make follow-up phone calls to make sure they’re alright.”

Hearing about clients overdosing was devastating, he said. “You work with them on a daily basis and to do it well you need to connect with them and have compassion.

Inside you get to know them well because they’re not on drugs and you see these are just normal kids. They’re kids in need of help.

“I went to a funeral of a girl who’d been out for five years. I’d kept in touch through the employment program. You don’t go because you need to, it’s because you have a relationship with these people. You want them to succeed. You certainly don’t want any harm to come to them.

“It wrecks you when it happens. And you have to look their parents in the eye.”

Living to tell the tale - survivors stories Continued from page eight.

Cora was living in a Sydney squat with five others and studying shiatsu. She had been a user but had stopped for several months to finish her studies. “Everyone that lived there was using at the time, except me because I was doing the course. There was constant shooting up around me.

“I’d get ready for school in the morning and step over someone mixing up in my room, walk past someone with their forehead on the ground in the lounge room, [and] when I’d get home from school in the evening everyone would be on the nod.”

It was just four days before her exams that her willpower broke. Her friend returned from the dealer with two caps.

“I was like ‘Do you think I’ll be okay? I haven’t used for over four months’, and he said, ‘Yeah, you’ll be fine’. Alarm bells should have sounded then, but I was too keen to get the drugs into me.

“So we had it and all I remember is starting to take my clothes off, and then I hear a voice, a male’s voice: ‘Just be careful when you get up. You don’t have any clothes on, but there is a blanket over you. You’ve overdosed and you’re out on the street. We’ve just Narcaned you twice.’”

She ran back into the house and asked her friend why she was naked. As it turned out, they had been engaged in sex when she went into overdose. He said he’d panicked and dragged her out into the street. Someone passing by started mouth-to-mouth on her and called the ambulance.

Not only did her friend drag her into the street, when the ambos asked what had happened, he lied and said she’d had an asthma attack, a story he persisted with

6

even when they explained it was a matter of life and death.

“They happened to see a needle mark on my arm and hoped they were doing the right thing by giving me Narcan, even though the dick I was with wasn’t any help. I’m so glad they did or I wouldn’t be here today recalling this story for you all to read.”

As for the chap who dragged her into the street naked: “I punched him in the face.”

Up in flames Gino was someone whose overdose had an especially costly ending. He was a partner in a restaurant and had been off heroin for a couple of months when he decided “in a rush of blood to the head” to score as a treat to himself. He borrowed his business partner’s brand new Saab turbo to pick up heroin.

With drugs in hand, he returned to the car and started the engine, intending to drive off.

But then, with the car still in park, but idling, he decided to try the gear he’d just bought.

“It knocked me socks off, and when I fell unconscious I fell forward with all my weight on the accelerator. With the car running at maximum revs, the turbo blew. When it blew it started a fire under the bonnet.

“The flames came under the firewall. Next thing they were at my feet, and with all the plastic (the car interior) caught fire pretty quickly. The whole car filled with smoke and then caught fire seriously. The fire went from my feet, my shoes, up my legs, my neck, my right shoulder, my ear.”

At this stage the police arrived, called by neighbours who had heard the car revving.

“They smashed the window to let the smoke out and did a pretty good job dragging me out of there because I was still unconscious.

I awoke on a stretcher inside an ambulance.

“Outside was the car. I looked over and the car was a bare metal hull. You could see the springs in the seats, it was so burned out.

I thought, Jesus Christ! I just couldn’t put together what had happened.

“My face and head was completely bandaged, with only holes for my eyes and mouth. And the thing I learned from that was how it must feel to have some deformity, because people treated me like a freak, a monster.

“The cops were questioning me. I was still out of it. Then the pain starts kicking in from the burns. But the paramedics couldn’t do anything because they know you’ve just overdosed on heroin.

“It’s just the way people stared and acted. You could tell they weren’t seeing you as a person - you were an object of horror. They stand just a bit more distant. I can’t imagine how people live with that.”

“The first person to see me at the hospital was my girlfriend, and from her reaction I was pretty bad. When I looked at myself I was blackened from head to toe, just black and swollen. Took me months to recover.

Gino has been on methadone for several years now and says he struggles with his addiction daily. On the subject of overdose, he can only say: “There have been more overdoses, some in even more bizarre circumstances. I’ve been way too lucky.”

Do something locally for August 31 Local events are an extremely effective way to spread the message of Overdose Awareness Day at a personal level. Overdose stories splashed across newspapers or television screens reach a mass audience, but cannot match the intimacy and effectiveness of a locally-based function, however low key it may be.

A local event gives people touched by overdose a chance to speak with sympathetic, like-minded folk. It can be cathartic, therapeutic or simply educational. Anex will be supporting local groups across the country with downloadable resources from the www.overdoseday.com website ahead of the day.

Post a tribute

Wear the badge, inform clients and public

“But they didn’t take off, did they?” Nicole told The Bulletin. “(It was) Murphy’s Law that we had one of the stillest days in yonks. So we tied them to a native tree in the park.”

Services can hold information and education campaigns for staff, clients and members of the public - including family members of those at risk of overdose.

In the lead-up to the Day, and on August 31, it’s a good idea to have as many staff as possible wear the Overdose Awareness Day badge. For information on how to order badges go to www.overdoseday.com Getting the word out to the general public, which obviously includes people at risk or their family members, can be done in a variety of ways. Please consider approaching local media outlets well in advance and explain the significance of the Day and see if there are ways you can cooperate on an article, or a radio or even a television piece.

Contact Anex if you would like some help with media (info@overdoseday.com). There are already some draft media releases on the Overdose Awareness Day website.

If your service has a website, consider putting a notice on it with a link to www.overdoseday.com

Hold a memorial service From the outset, the idea behind International Overdose Awareness Day was to create a platform to allow grieving families and friends of countless fatal overdose victims to acknowledge their losses without shame or blame. Therefore the solemn remembrance aspect remains a cornerstone of the day.

In the lead-up to the day, some groups keep a well signposted message box somewhere prominent in which people can post notes in remembrance of lost friends or loved ones.

These messages can form part of a remembrance event on the day, when they can be read out to the gathering.

Others have pinned a large piece of fabric to a wall on which people may write tributes to overdose victims. Once again, this banner can ultimately be used as part - or even the centrepiece - of a memorial.

High Tea The AIDS Council of South Australia last year took a novel approach in organising its event, announcing a “high tea”. The occasion was put together by Nicole Skelley of SAVIVE, the AIDS Council’s injecting drug users’ group.

“As a free event for the people who inject drugs, we offered clients a high tea with nice china cups and saucers and scones and jam and coffee.”

SAVIVE had no money to spend on the event so they brought crockery and cutlery from home and had staff and volunteers tackle the job of making home-baked cup cakes and scones.

Sent up the balloons SAVIVE also bought bio-degradable silver balloons and rice paper on which to write messages about lost loved ones. After high tea they went to the parklands nearby and heard speeches before releasing the balloons, expecting them to be borne aloft on the wind like free spirits.

Hold a barbeque This has been a popular, traditionally Australian way of marking 31 August and an effective draw-card for the drug-using client community. Combined with a short talk on overdose (and possibly a reading), it can be a very effective grassroots event. Groups the length and breadth of the country have made barbeque lunches or brunches the focal point of their remembrance event.

Plant a tree Some groups have convened a memorial service in a local park where they have planted a remembrance tree. One tree that was planted in 2001 has now grown into a sizeable specimen and has had a plaque attached. Make sure you have the appropriate council permission if you are considering doing something similar.

These initiatives by no means exhaust the possibilities for marking International Overdose Awareness Day. What may be done is only limited by one’s imagination and resources.

The memorial need not be elaborate, ritualised or religious. Sometimes simplicity can give participants a stronger sense of connection and be more touching than a mass ceremony attended by hundreds. A few words to catch people’s attention, a minute’s respectful silence and allowing attendees to speak their minds and unburden themselves about lost loved ones can be sufficient. It’s all about maintaining a sense of dignity, caring and paying respect to both the living and the dead. Also remember that keeping any memorial non-denominational will make it more inclusive.

www.overdoseday.com Write details of your local events on the bottom of the poster that came with this Bulletin

7

Storm clouds building with harmaceuticals Conditions may exist for a “perfect storm” in which pharmaceutical drugs misuse, addictions and overdoses climb to their highest levels, according to a prominent Addiction Medicine Specialist.

“We could see ourselves going the way of other countries, such as the United States. I don’t see much evidence to say otherwise the patterns are very similar,” said Dr Matthew Frei, Head of Clinical Services at Turning Point Alcohol & Drug Centre.

“The only real [major] difference is the phenomenon of ‘pill mills’ in America. I think because it’s more a privatised medical system [in the US], so we don’t get these pain clinics that get set up, particularly in Florida.”

“Pill mills” are large-scale clinics (especially pain clinics) that dispense enormous amounts of pharmaceuticals for non-medical purposes.

The Drug Enforcement Agency has a program called “Operation Pill Mill” to clamp down on the multi-million dollar dispensing rorts.

“But in other ways there is evidence that we are tracking the US in both the growth and the use of these drugs,” Dr Frei said.

The number of fatal overdoses from opioid analgesics recorded in the United States rose from around 4000 in 1999 to around 15,000 by 2009, far outstripping deaths from heroin overdoses.

Amanda Roxburgh of the National Drug and Alcohol Research Centre is one of the leading analysts of Australian drug overdose data. She is currently updating national-level overdose analysis, and, although hers is a work in progress, she is seeing worrying trends.

“It’s always tragic for communities when a fatal overdose occurs.

Although the number of opioid-related deaths in Australia remains much lower than in the late 90s, we are starting to see an upward trend occurring,” Ms Roxburgh said.

“Part of this is likely to be due to changes in data collation, but it’s also likely that we’re starting to see an upward trend in pharmaceutical opioid overdose. Many of these deaths are due to multiple drug toxicity, which clearly increases the risk of fatal overdose.”

Said Dr Frei: “We are an affluent country. Like most affluent countries, we have a population who are living longer. The longer you live, the more likely you are to develop chronic degenerative conditions, which are often what these drugs are prescribed for - back pain and so on.”

“It can happen at any age, but pain conditions seem to be more prevalent as your bones get older and so on. Like the United States, we are also getting fatter. Obesity, and the strain it puts on joints.

This is just my theory.

“I think the other things are, particularly in Australia, that pharmaceutical opioids are cheap. They are affordable. We have a really good health care system in Australia that allows access to doctors, medical care and medications. For most of the population treatment is accessible.

“It’s easy to see a doctor and in many cases not be billed out of pocket for seeing a doctor. And pharmaceuticals, particularly the ones used for management of pain, have a price ceiling on them.”

Living to tell the tale - survivors’ stories While overdoses claim many lives among people who use drugs, it is estimated that for every death there are 40 to 50 near-misses. The Bulletin spoke to some survivors about their experiences.

Drug users find injecting attractive largely because it gets them high as quickly as possible. Someone who used narcotics for 30 years told the Bulletin that, apart from the speed of getting stoned, shooting up was also a lot about pushing boundaries and likened the experience to walking to the edge of a high cliff and looking down. While falling and dying would of course represent a serious miscalculation, part of the allure for injectors involves getting close.

Even if longer-term users do not see their habit in terms of going to extremes, they will still be injecting amounts verging on overdose.

This can be the case even if their use is about holding the sickness of withdrawal at bay while they maintain a normal life. Maintaining a regular working life and daily heroin use demands balance, the basic tenets of which are not getting too stoned to function at work and not getting too sick from withdrawals to function at work.

Newcomers to injecting heroin are less often overdose casualties than older ones. Research on heroin overdoses has shown very few fatalities among under-20s, with the mean age in the early 30s.

But sometimes bad things just happen.

of heroin before heading to the office and another after arriving home.

One particular day he was planning to have a taste and listen to the radio news on ABC before going to work. While he was in the shower, his partner mixed up for both of them.

He reports that at the time they had a block weighing several grams - more than enough for one hit, which was not normal. So Dan’s partner mixed a generous amount in two spoons, and when he returned from the shower he injected himself. Withdrawing the syringe from his arm was the last thing he remembered.

“I came to feeling foul, and, as I surfaced, saw uniformed trouser legs. Disembodied voices said: ‘Don’t worry mate, we’re the ambos.

Do you want to go to hospital?’

Barbwire through veins

“I sat up, feeling more and more terrible as the seconds passed, then started to get up.

With a feeling of intense horror, I realised what had happened. I’d overdosed and been revived.

Dan was working office hours and trying to keep a habit under control. He told the Bulletin that normally he would have a taste

“‘Just stay where you are for a moment, mate,’ one of the ambos said to me. ‘Are you sure you don’t want to go to hospital? We had to give

you Narcan - twice. You were pretty much dead, so just relax. But if you don’t want to go to hospital, we’ll be off. But just take it easy for a bit, ok?’”

Narcan (or, to give it its generic name, naloxone) purges opioids from receptors. The result was that, as the ambo was talking, Dan started to go into severe withdrawal.

“I felt so sh#*, the rapid comedown magnified the dawning awareness of how close I’d come to death. I felt as if barbed wire had been dragged through my veins. I was shaking and sweating.”

Dan claims the close shave with the overdose did some good in driving him to seek out pharmacotherapy and start quitting. “Minor overdoses become par for the course for heroin users. But when you drop and start turning blue, you can’t beat Narcan,” he said.

Revived naked in street Cora is another survivor of a near-fatal overdose. “I was young, silly and felt invincible,” she told the Bulletin.

Continued on page six.