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Perspectives on Overdose

Perspectives on Overdose

NOTE: Quotes are presented word for word apart from minor editing for readability and clarity. Identifying details have been removed. Square brackets show text that has been added or, where ellipses (three dots) appear, removed. For example, ‘Since I actually participated in this Narcan [training], I’ve administered it to two people and it’s brought them around […] I wouldn’t think twice about [doing] it. Saving someone’s life is the main thing.’

The project on which this website was based collected a range of views about the issue of opioid overdose, and risks of drug consumption more generally. Many participants say they think about overdose regularly, while others don’t see it as relevant to them. In some interviews, they emphasise political aspects of overdose, mentioning that people who consume drugs have human rights, or arguing that, as a way of caring for the ‘whole person’, doctors should discuss overdose risks with patients using pain medication.

Many also speak of the stigma associated with taking opioids, and overdose. The word ‘stigma’ refers to stereotypes, negative generalisations and judgements based on assumptions about a particular group of people. It can lead to exclusion and unfair treatment (often referred to as ‘discrimination’). Stigma and discrimination can also change the way people think of themselves: they may come to accept as true the negative judgements expressed by others. Individually and together, these aspects of stigma can impact on self-esteem, mental health and general well-being. Also contributing to stigma and discrimination for people who consume drugs are media coverage and policing and criminal justice practices.

While not everyone says overdose is relevant to them, many participants speak about different strategies they use or have used to reduce the risk of overdose. Trying a small amount of their heroin first to test for strength is a common strategy, but others are discussed too.

Participants also offer their perspectives on broader strategies to tackle overdose. For example, some speak of the harms caused by the ‘war on drugs’ and of the potential benefits of decriminalisation.

Overall, participants argue there is nothing to lose from learning overdose response strategies such as how to use take-home naloxone, even if it isn’t immediately relevant to them.


Concerns about overdose

Most of the people we interviewed suggested that overdose is relevant to people who consume opioids. Many describe experiencing or witnessing overdoses themselves, while others say it’s important even though they haven’t encountered an overdose.

For Skye-Lee (F, early 30s, NSW, non-prescribed opioids), who consumes heroin, the issue of overdose is intertwined with human rights. She argues that overdoses should be addressed in the same way as other health emergencies. (Read her personal story here)

Say someone overdoses, they should be treated in the same way as someone having a heart attack. You know, we have human rights. People don’t do it on purpose – they use, but they don’t overdose on purpose. They’ve got a problem [but] it’s not anyone’s business whether they’re trying to [get treatment] or not. [If] they overdosed, [any witness] has a duty of care and he or she needs to follow through and not disrespect the person. [That’s what] I believe anyway. There should be a law against [walking away].

For Zippy (M, late 50s, Vic, non-prescribed opioids), overdoses are hard to predict, so he likes to be prepared just in case. (Read his personal story here)

Yeah, like, I do want to be ready, prepared, if one of my friends […] overdoses, you know. Because you just never know when someone’s susceptible to dropping. They [just] might not have used for a few days and their tolerance has dropped way down.

Concerns about how hard it is to predict the strength of opioid drugs appeared in many of the interviews. For instance, Lenny (M, early 40s, Vic, non-prescribed opioids) says this issue makes overdose a part of life for people who consume opioids. (Read his personal story here)

[Overdose] is sort of like, it’s part of life, it’s part of the package and [you have] to be aware of yourself. Like, [you need think about] how much you can intake of an actual drug. Some people, they reckon they can handle this and that [amount]. [Then] they get it [the heroin] from someone else [and it’s] totally of a different quality – different stuff – and it affects you totally different, so it can [cause you to] drop.

Reflecting similar concerns to Zippy and Lenny, Jake (M, early 20s, Vic, non-prescribed opioids) explains that the unreliable quality of heroin increases the risk of overdose. (Read his personal story here)

Depends on your habit and how much you use. Some people, you know, like I can go and score a $30 or a $50 worth and, I mean for me, that would usually smash me. Then you go to other people and that wouldn’t even touch the sides for them […] The risk of overdose, because if you are buying [heroin] off the street, you don’t know how good the quality is going to be. Like, your normal intake of that particular batch could vary.

While most of those who consumed non-prescription opioids we interviewed position overdose as an important issue, others, such as Simone (F, late 40s, Vic), say that it isn’t something they think about very often. Similarly, Mark (M, early 40s, Vic) and James (M, early 40s, NSW) say overdose was more of an issue for them in the past, and that changes in their current drug consumption practices mean they don’t think about it as much these days.

According to Riley (M, mid 20s, Vic, non-prescribed opioids) overdose wasn’t something he actively thought about when he took opioids.

[Overdose] wasn’t something I used to think about, [not in a way] that prevented me from using anyway. With OxyContin, you knew what the amount was going to feel like [but] you never know with heroin how strong it’s going to be [or] how much it’s going to take to get the same effect. Whereas with the pharmaceuticals, you knew what you were getting each time. So I guess [while I was taking opioids] overdose was a concern, thinking about it. Yeah [… it was] not at the forefront [of my mind] but thinking about it now it probably was in the back of my mind.

Among people whose opioids are accessed via prescription, the issues raised were slightly different. Claudia (F, late 20s, NSW, prescribed opioids) says that while most people taking opioids for chronic pain are not at high risk of overdose, doctors should still raise the issue, as a way of caring for the ‘whole person’.

I honestly think that most [people who use opioids for chronic pain] will probably be okay. This is speculating from my own kind of response where, if you’re going to the doctor for care with your pain, then you want them to kind of be thinking about you as a whole person, and so you’d be wanting them to be thinking of the risks that are associated with prescribing particular drugs. So, I mean, there’s no problem talking about possible side effects that come from antibiotics and stuff like that, so why not the same discussion around opioids? […] If it is sort of framed in a way that’s, like, you know, ‘I’ve determined that I think that you will benefit, or the benefits are greater than the risks or harms of opioids use. I’m having this conversation not because you’re addicted or not because you are a druggie or something like that, but because this is, like, just a known risk, or there are issues where people can sometimes either intentionally or accidentally overdose. So it’s better for you to know what to do if that happens.’

According to Farez (M, early 40s, NSW, prescribed opioids), overdose isn’t discussed enough with people who consume opioids to manage chronic pain.

It’s an important issue and [one] that is often not counselled. The issue of overdose is not even broached most of the time. And that’s not just me, I mean, many people I know, especially in these [chronic pain] support groups, they’ve had these conversations, and most people have never been counselled on the proper use of opiates, let alone overdose.

Similarly, Charlie (M, late 40s, Vic, prescribed opioids) suggests overdose is an important issue for people consuming strong opioid medications for chronic pain, especially when they may also be taking other medications.

I know that overdose […] renders you unconscious and eventually kills you through stopping your breathing […] I know in a clinical setting it’s easily reversed with medication, but it also kills a lot of heroin users […] I think [overdose is an important issue] for people that have chronic pain and are on opiate [medications], particularly people that are having dose adjustments or are new to a powerful opiate, and especially if they have other central nervous system depressants and so forth in their body. I [also] think there needs to be good [medical] history taken on people who may be naive to these medications.

This time focussing on the media, Ken (M, mid 30s, Vic, prescribed opioids) describes how the coverage of opioid issues and overdose in the United States makes him think about the issue.

I read a fair bit of news and listen to a lot of rhetoric about, particularly in the [United] States and here, about increased opioid use and misuse and that kind of stuff, and it’s pretty … I think if it wasn’t perhaps for the news articles and radio articles, I probably wouldn’t be as worried about it as I am. Do you know what I mean? Particularly in the last 18 months, I mean, before that as well in the States, but in the last 18 months, it’s like … it’s making its way into general political discourse about it being a big problem.

Karlijn (F, late 50s, Vic, prescribed opioids) explains that all people who use a drug with an overdose potential should be warned about the issue.

It is important, yes. If someone is taking any form of drug where there’s a potential for overdose […] I think they should be warned about [it] when they’re given [it]. I mean, what’s the harm in doing it? I don’t think people are going to go out of their way to overdose […] So I think everyone should know.

Strategies for mitigating overdose risks

Many participants (mostly those consuming non-prescribed opioids) describe strategies they use to reduce or manage the risk of overdose. For example, Andrew (M, early 40s, Vic, non-prescribed opioids) and Lenny (M, early 40s, Vic, non-prescribed opioids) both mention trying to buy heroin from a reliable and regular source so they could better guess its strength. Others such as Dylan (M, early 30s, Vic, non-prescribed opioids) and Gabrielle (F, late 40s, Vic, non-prescribed opioids) speak about avoiding certain drug combinations they considered to be high risk. Many others mention first taking a small sample amount of their heroin to test its strength. Others speak about keeping an eye on friends or asking those in their company to monitor them.

Emma (F, mid 50s, NSW, non-prescribed opioids) describes learning ways to lessen overdose risk from books, and makes sure to test the strength of her heroin by first consuming a small amount. (Read her personal story here)

I buy, like, even if I bought [$]100 [worth of heroin], I’d do like [a quarter of it] and see what it was like. Or if it’s someone I hadn’t bought [heroin] from [before], I would always ask the person how strong it was, like, how much they think I should use. I almost always bought from people that I know are sensible, you know, they’re not idiots. But, you know, there are always occasions when you buy from someone you’ve never seen before in your life […] Yeah, because I’ve always read a lot, Hunter [S. Thompson] and Junky [by William Burroughs], I read all the literature there is and, you know, if you read stuff like that, you can’t help but get descriptions of people ODing and you get to hear about what works and what doesn’t.

Recounting different overdose experiences, Ghassan (M, late 30s, NSW, non-prescribed opioids) says he is ‘really aware’ of it, and, like Emma, consumes small amounts of heroin first to test for strength. (Read his personal story here)

I’m really aware of [overdose…] like, three or four months [ago], I was [not taking any heroin] and I relapsed. That first shot I had, I was really careful to have like a quarter of a cap. So even [from] that quarter of a cap, I’d be on the blink in the toilet for eight hours. I’d wake up, I’d still have that fit in my arm. So, it’s, like, yeah, really, really aware of it.

While Gabrielle (F, late 40s, Vic, non-prescribed opioids) says she doesn’t feel her drug consumption carries a significant overdose risk, like Ghassan, she makes sure to inject small amounts of heroin at a time, rather than giving herself one large dose. (Read her personal story here)

Yeah, I don’t use benzos. So, a lot of people I know who have overdosed, it’s been a combination of heroin and other drugs. So I think that’s the reason why I haven’t overdosed. I was also … I had instilled into me right from the beginning that ‘two holes in the arm is better than one in the ground’ […] It’s a good way to look at things […] There’s been more than eight or 10 times, at least, where that theory has saved me.

According to Julian (M, late 40s, Vic, non-prescribed opioids) overdose isn’t on his mind any more now that he isn’t consuming heroin, but he describes his past safety strategy, which, as with the others, focuses on testing for strength by injecting a reduced dose. (Read his personal story here)

Yeah. Well, if the guy I was scoring off, if his gear looked different, he wouldn’t actually say, ‘Oh, this is a bit different.’ Everyone always says, ‘Oh, this is the best’ and all the rest, but you never know. I’ve had people tell me ‘this is the best’ and I’ve had to have five times as much, because it didn’t do anything. If you think that way all the time, well, you’re not going to be around for long. So […] if my guy is not [available] and I go somewhere else and it’s different gear, [it may] be much stronger. So there’s always the taste test, and if it tastes stronger, I’d have half as much.

Participants also acknowledge that overdoses are stressful situations, and that it’s hard to know exactly what to do in the moment.

Emma (F, mid 50s, NSW, non-prescribed opioids) has noticed that bystanders often panic during an overdose. (Read her personal story here)

Because one thing is that every overdose I’ve been at, people panic. You can’t underestimate how stupid people get. Really they do. I mean, people want to walk them around. I mean, if you’re kind of on the verge of overdosing, I sometimes think walking around is good because there’s some breathing and stuff, but really it’s just easier to just give someone some Narcan.

Karen (F, early 30s, Vic, non-prescribed opioids) describes overdoses as ‘high-pressure situations’. She feels people need to learn the most effective way to respond to them. (Read her personal story here)

Yeah, especially in a high-pressure situation, you are trying to think … like, if you’ve just had a car accident and you’re just in shock, who are you going to think to call? Like, fair enough, you’d call the ambulance, but then after that, who would you call after? It’s the same situation. You are in a high-pressure situation, you don’t know how you are going to respond, because every single time could be totally different, so you don’t know how you are going to react until that time comes, and that is one thing that sort of needs to be broken down. You don’t know. Every situation is totally different to the first one. They could have dropped, fair enough, but the main thing they all have in common is they’ve dropped. But they could be 1,001 different nationalities, 1,001 different sizes, 1,001 different amounts of drugs or different drug combinations in the system. [What we need is] to get the right combination [of responses] together and put it out there, so everyone gets the right idea.

Participants who consume opioids accessed via prescription were also among those discussing concerns about overdose.

Asking someone to monitor her potential overdose is a strategy that Laurie (non-binary, age early 40s, NSW, prescribed opioids) used after taking too much pain medication. (Note: strong language)

It felt like a panic attack, but I kind of knew that I’d taken a shit-ton of painkillers, so it was just like, ‘Oh, maybe that was like one too many’, whatever. I think it was like Panadeine Forte and [OxyContin] or something. One hadn’t kicked in, so I go, ‘Fuck this! I’m just taking more,’ and probably hadn’t quite allowed enough time. [I thought] ‘Oh shit! You’re really anxious, you’re freaking out, you should just go to lie down quietly and just wait.’ I mean, we all know from years of clubbing, it’ll pass at some point. I don’t really know what to do about it. I don’t think I’m going to die. I just think I’m like a bit twitchy. I should just go and sit in the corner quietly. [I said to my partner] ‘please monitor [me]’.

Rachael (F, mid 30s, Vic, prescribed opioids) regularly looks up how much of her pain medication someone of her gender, age and weight can consume before health risks are likely to emerge. She also describes increasing her dose step by step until it gives her the desired effect.

I’m not sure where my limits are […] So I’ve repeatedly looked up how much someone my gender and basic weight and age should be taking as a maximum dose of any medications that I have access to before potential damage to kidneys and liver starts occurring, which was my main concern. Overdose was the secondary concern. The only thing I can do is monitor myself when I do go near that potential line […] So like I said, I have been as smart as I can be, I think, but it’s kind of the usual way you approach things. You start with a small dose and if that doesn’t do enough or anything, then you increase and increase and increase until you get the desired the effect. But I’ve monitored everything throughout to try and gauge, ‘Well, okay, is this actually affecting me more than I think it is? Is there the potential for me to [experience respiratory depression]?’

Lacey (F, late 20s, Vic, prescribed opioids) says that her fear of overdose means she tries to fall asleep in the recovery position.

Yeah, so I did have thoughts about overdosing, and I had read articles about other health professionals sort of overdosing in the toilets and I guess I wasn’t too scared about the fentanyl, but I was scared that another staff member might have labelled a syringe incorrectly and [what would happen if] I then went in and stole it – you know, diverted, as they call it [in medicine], and used it on myself and it was the wrong medication. [It] had the potential for, you know, a number of things to happen, so the thought of overdose was there. And a few times I felt myself sort of unable to keep my eyes open and very groggy. When I would use opiates before bed, I would make sure that I fell asleep in the recovery position to protect my airway, because respiratory depression is the main cause for concern, I guess. So yeah, I tried a few, sort of, harm minimisation strategies.

How should we tackle overdose?

While participants generally support take-home naloxone, some offer perspectives on other ways to reduce overdose deaths.

Riley (M, mid 20s, Vic, non-prescribed opioids) suggests that tackling stigma and helping people who consume drugs feel cared for may reduce the risks of taking drugs. (Note: Strong language)

If people don’t judge people who use drugs, and people try and make [them] feel cared for and not stigmatised, and stuff, I think that would reduce the risk of taking drugs. Or [reduce the] feel[ing], like, [that] they need to take drugs, if they feel like people love them and care about them and stuff like that […] It’s different having someone who’s loving and caring and you can express how you feel, and they will support you and, you know, [will] tell you ‘everything is okay’ and stuff like that. [Stigma] just makes people feel shit about themselves even more. People who use drugs [often] lack a lot of self-esteem [and] self-confidence. [Having to] worry about what people think about them and then to have people [judge] them sort of strengthens [negative] beliefs about yourself.

Lewis (M, mid 40s, Vic, non-prescribed opioids) argues that decriminalising drug consumption may reduce overdose deaths*. (Read his personal story here)

Decriminalisation. From what I gather in Portugal, is that it’s been tremendously positive in terms of the way people use drugs, and resulted in lower drug taking and much lower rates of overdose […] Anything that destigmatises it and actually presents people with real information. Obviously it’s going to be a different landscape if it’s treated as a health problem [rather] than a criminal problem […] It just becomes something that you don’t have to hide […] I just think if it was destigmatised, it would make room for people to be much more honest and transparent and accurate in terms of talking about it.

Also using Portugal as an example, Tony (M, mid 40s, NSW, non-prescribed opioids) argues that the ‘war on drugs’ increases drug problems*. (Read his personal story here)

It’s like the war on drugs – it’s not a war on drugs, they’re never going to win that – it’s a war on drug addicts. So it’s the addicts that the war is getting taken out on […] They’ve got 15-16 years now of hard data out of Portugal. Homelessness is down, employment is up, you know, so health conditions of the using addicts are so much better. Less spread of HIV and hep[atitis] C, they’ve got hard data out of Portugal […] The black market. Well, that’s where all the crime comes into it, the secretiveness, [and] the disease you’re catching because you’re sharing [injecting equipment], that’s where all those things come into it, because it’s in the black market.

Also questioning the ways illicit drugs are governed, Karen (F, early 30s, Vic, non-prescribed opioids) suggests that some policing strategies make overdose more likely. (Read her personal story here)

There’ll be a big sweep [by the police], [which will] get [drugs] off the street for a couple of days. All you are doing is pushing them into the houses, into people’s backyards and all that. Where[as] if they had a place where people could go in, do what they do, go in there, you know what I mean? […These strategies] push people into hiding. Not just their homes, anywhere … nooks, crannies, dark ways, alleys and therefore, people won’t know if they’ve got a dead corpse behind the back of their property because they’ve had a shot. That’s all they’re doing. It’s not like they are cleaning the streets up, the streets are going to be the streets no matter how much you pretend [otherwise].

*This website presents participants’ views as expressed in their interviews. For further discussion of Portuguese drug policy see Caitlin Hughes and Alex Stevens’ (2015) book chapter entitled ‘A resounding success or a disastrous failure: Re-examining the interpretation of evidence on the Portuguese decriminalization of illicit drugs’ in New approaches to drug policies: A time for change (edited by Marten Brienen and Jonathan Rosen).