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Journal of Urban Health: Bulletin of the New York Academy of Medicine Vol. 80, No. 2, June 2003
2003 The New York Academy of Medicine
SPECIAL FEATURE: OVERDOSE
Drug Overdose: New Insights, Innovative
Surveillance, and Promising Interventions
Sandro Galea and Phillip O. Coffin
In New York City, where we work, fatalities due to drug abuse, primarily overdose
deaths, in 2000 accounted for 924 deaths.
1
This was an increase from a low of 729
deaths in 1999, which followed a steady decline from 1,082 deaths in 1996. Of
638,484 drug-related emergency department visits reported in the United States in
2001, more than 5% took place in New York City, twice as many as would be
expected on a population basis.
2
City emergency department admissions for heroin,
the drug most frequently responsible for overdose fatalities, peaked at 136 per
100,000 in 1996 and then again at 128 and 127 per 100,000 in 2000 and 2001,
respectively.
2
Unlike other localities, cocaine accounts for a substantial portion of
overdose mortality in New York City.
3
Cocaine admissions in the city declined
steadily, from 264 per 100,000 in 1996 to 166 per 100,000 in 2000 and 2001.
Thus, while estimates of overdose prevalence evidence waxing and waning over the
past decade, drug overdose persists as a significant cause of morbidity and mortality
in our city and in many others worldwide.
This issue of the Journal brings together 11 original research articles that focus
attention on the persistent problem of drug overdose. These articles summarize
the burden of overdose that persists worldwide, as well as promising research and
interventions that may contribute to a reduction in both the incidence of overdose
and its consequences.
In a review, Darke and Hall, who have made seminal contributions to overdose
research, summarize the known determinants of heroin overdose and suggest prin-
cipal areas for urgent research—the role of polydrug use in overdose, demographics
and circumstances of overdose, and interventions that can affect the incidence and
outcome of overdose. Additions to this list by other contributors include the intro-
duction of innovative surveillance and monitoring methods and the role of mental
health conditions in the etiology of overdose. The articles that follow elaborate on
these points, suggest answers, and raise more questions.
Two articles in this issue highlight areas in the study of overdose demographics
and their correlates that have thus far received inadequate attention. Galea et al.
discuss the racial/ethnic disparities in overdose mortality in New York City during
the past decade. The authors show that, although rates of overdose death were con-
sistently higher among blacks and Latinos compared to whites throughout the
Correspondence: Sandro Galea, MD, MPH, Center for Urban Epidemiologic Studies, Room 556, New
York Academy of Medicine, 1216 Fifth Avenue, New York, NY 10029-5283. (E-mail: sgalea@nyam.
org)
186
DRUG OVERDOSE: INTRODUCTION 187
1990s, these differences cannot be readily ascribed to drug use patterns, suggesting
that situational factors may in part explain the observed differences. An article by
Sergeev et al. provides some of the first evidence about the rising prevalence of
opiate overdose among injection drug users in the Russian Federation. These two
articles, taken in combination, suggest that although the basic demographics of
overdose victims are well known, the fundamental determinants of overdose mor-
bidity and mortality and the emergence of overdose in new locations may lie be-
yond individual drug users and may warrant creative structural thinking to bring
about long-term solutions.
Two articles in this issue suggest that mental health may play an important role
in shaping the risk of drug overdose. Tobin and Latkin show that active opiate and
cocaine users who reported depressive symptoms were three times more likely to
report having overdosed within the previous 12 months. An article by Heale et al.
shows that while the majority of overdoses are unintentional, almost one in five of
heroin overdose survivors interviewed said that they had, at some point, had an
“intentional” overdose. Although, as the authors rightly point out, suicidal thought
and behavior are complex and both studies are limited by cross-sectional designs
and potential selective recall biases, the suggested association between mental health
and risk of overdose deserves further attention. Meanwhile, it would seem prudent
for health providers addressing overdose prevention to pay particular attention to
persons with a history of mental health problems, particularly depression.
Studies by Clark and Bates and by Dietze et al. show how ambulance call
systems can provide valuable population-based data to describe the incidence and
correlates of overdose episodes. These studies, from different regions of Australia,
highlight the role that ambulance-based surveillance can play in monitoring over-
dose and targeting overdose prevention interventions. We hope that the work pub-
lished here may encourage collaboration among different branches of the medical/
public health systems in the rest of the world to develop viable ambulance-based
monitoring similar to that which has been demonstrably successful in Australia.
Two articles in this issue introduce spatial analytic methods as useful tools in
overdose intervention efforts. Dietze et al. used their ambulance surveillance data
to examine small-area variation in nonfatal heroin overdose. Their article is a par-
ticularly useful illustration of how small-area analysis can guide public health re-
source allocation in a timely fashion. A complementary contribution by Davidson
et al. used medical examiner data to show that, in San Francisco, California, over
one third of fatal overdoses over a 3-year period occurred in a small, delineated
section of the city. These analyses both suggest that application of innovative sur-
veillance methods (using disparate data sources such as medical examiner and am-
bulance call data) can lead to more efficient use of resources that can, it is hoped,
translate into more efficacious overdose intervention. Hickman et al. report on an
ambitious pilot cohort study of heroin users, linking data from specialist drug treat-
ment sites in London, England. Overcoming formidable logistical and confidential-
ity obstacles, the authors illustrate a creative use of existing data to monitor over-
dose morbidity and mortality.
The addition of naloxone (Narcan) to the public health armamentarium is a
critical step forward in the battle to reduce drug overdose mortality. Two articles in
this issue suggest that naloxone, thus far introduced widely in only a few locations
worldwide, will likely be well received by health care practitioners and clients alike.
An article by Coffin et al. shows that, even in the absence of structured education
about naloxone, more than a third of New York City clinicians in one survey would
188 GALEA AND COFFIN
consider prescribing naloxone to patients at risk of an opiate overdose. Perhaps
more important, close to 90% of injection drug users surveyed by Seale et al. fa-
vored participating in an overdose management and naloxone training program.
This article also raises some of the key issues about widespread naloxone use, in-
cluding concerns that recipients might be even less likely to activate emergency
medical services, or that they might use more or stronger drugs in light of the
security conferred by naloxone. These issues are important and need to be explored
and understood as naloxone is released into more widespread use. Naloxone is
emerging as probably the most promising intervention to minimize overdose mor-
tality. Work to address lingering concerns, together with research that prospectively
evaluates the effect of naloxone introduction in different settings, will open a new
phase in the history of drug overdose prevention and management.
The articles brought together in this issue of the Journal summarize the state
of science in overdose research, monitoring, and intervention. In spite of growing
sophistication in detecting and understanding drug overdose, it persists as a sub-
stantial cause of morbidity and mortality, particularly among habitual drug users.
Some broad questions remain, such as the means through which polydrug use and
cocaine use contribute to overdose and the contribution of structural factors (and
policies) to overdose fatality.
Nonetheless, drug overdose is a preventable medical condition. Application of
better monitoring and targeted interventions should reduce the incidence of over-
dose. Widespread introduction of naloxone should bring reductions in overdose
mortality. Innovative structural interventions (e.g., the recent introduction of bu-
prenorphine as a treatment for opiate addiction; policies to minimize fear of reprisal
by police for alerting emergency medical services when witnessing or experiencing
an overdose) may substantially reduce the incidence of overdose and its conse-
quences.
Unfortunately, as the persistent prevalence of overdose in Western countries
(particularly in minority racial/ethnic groups) and the emerging prevalence of over-
dose in eastern Europe suggest, our practical application of this knowledge falls
short. We hope that the work featured here stimulates further research and evi-
dence-based interventions that bring us closer to the goal of preventing drug over-
dose and eliminating attendant mortality.
ACKNOWLEDGEMENT
We would like to thank Tinka Markham Piper for assistance with the preparation
of this special issue.
REFERENCES
1. Substance Abuse and Mental Health Services Administration, Office of Applied Studies.
Mortality Data from the Drug Abuse Warning Network, 2000. DAWN Series D-19.
Rockville, MD: 2002. DHHS Publication (SMA) 02-3633.
2. Substance Abuse and Mental Health Services Administration, Office of Applied Studies.
Emergency Department Trends From the Drug Abuse Warning Network, Final Estimates
1994–2001. DAWN Series D-21. Rockville, MD: 2002. DHHS Publication (SMA) 02-
3635.
3. Coffin PO, Galea S, Ahern J, Leon AC, Vlahov D, Tardiff K. Opiates, cocaine and alcohol
combinations in drug overdose deaths in New York City, 1990–1998. Addiction.In
press.
