Facilitators and Barriers to Naloxone Kit Use Among Opioid-Dependent Patients Enrolled in Medication Assisted Therapy Clinics in North Carolina

BACKGROUND Naloxone-an opioid antagonist that reverses the effects of opioids-is increasingly being distributed in non-medical settings. We sought to identify the facilitators of, and barriers to, opioid users using naloxone kits in North Carolina.METHODS In 2015, we administered a 15-item survey to a convenience sample of 100 treatment seekers at 4 methadone/buprenorphine Medication Assisted Therapy (MAT) clinics in North Carolina.RESULTS Seventy-four percent of participants reported having ever gotten a naloxone kit; this percentage was higher for females (81%) than males (63%) (P = .06). The primary reason given for not having a kit was not knowing where to get one. Only 6% had heard of kits from the media and only 5% received one from a medical provider. Among kit recipients, 56% of both females and males reported mostly or sometimes carrying the kit, with additional participants reporting always. Reasons for not carrying a kit were no longer being around drugs, forgetting it, and the kit being too large. Men discussed the difficulties of carrying the naloxone kits, which are currently too large to fit in a pocket. Ninety-four percent of naloxone users reported intending to call emergency services in case of an overdose emergency.LIMITATIONS Study limitations included a small sample, participants limited to MAT clinics, and a predominantly white sample.CONCLUSIONS MAT treatment seekers reported a willingness to carry and use naloxone kits. Education, outreach, media, and medical providers need to promote naloxone kits. A smaller kit may increase the likelihood of men carrying one.

Access to Syringe Services Programs - Kentucky, North Carolina, and West Virginia, 2013-2017

The Appalachian region of the United States is experiencing a large increase in hepatitis C virus (HCV) infections related to injection drug use (IDU) (1). Syringe services programs (SSPs) providing sufficient access to safe injection equipment can reduce hepatitis C transmission by 56%; combined SSPs and medication-assisted treatment can reduce transmission by 74% (2). However, access to SSPs has been limited in the United States, especially in rural areas and southern and midwestern states (3). This report describes the expansion of SSPs in Kentucky, North Carolina, and West Virginia during 2013-August 1, 2017. State-level data on the number of SSPs, client visits, and services offered were collected by each state through surveys of SSPs and aggregated in a standard format for this report. In 2013, one SSP operated in a free clinic in West Virginia, and SSPs were illegal in Kentucky and North Carolina; by August 2017, SSPs had been legalized in Kentucky and North Carolina, and 53 SSPs operated in the three states. In many cases, SSPs provide integrated services to address hepatitis and human immunodeficiency virus (HIV) infection, overdose, addiction, unintended pregnancy, neonatal abstinence syndrome, and other complications of IDU. Prioritizing development of SSPs with sufficient capacity, particularly in states with counties vulnerable to epidemics of hepatitis and HIV infection related to IDU, can expand access to care for populations at risk.

Community Readiness to Prevent Opioid Overdose

Effective community-based actions are urgently needed to combat the ongoing epidemic of opioid overdose. Community readiness (CR) has been linked to communities' support for collective action, which in turn has been associated with the success of community-wide prevention strategies and resulting behavior change. Our study, conducted in North Carolina, assessed the relationship between CR and two indices of opioid overdose. County-level data included a survey of health directors that assessed CR to address drug overdose prevention programs, surveillance measures of opioid overdose collected from death records and emergency departments, and two indicators of general health-related status. We found that counties' rates of CR were positively associated with their opioid-related mortality (but not morbidity) and that this relationship persisted when we controlled for health status. North Carolina counties with the highest opioid misuse problems appear to be the most prepared to respond to them.

Issues in Developing a Surveillance Case Definition for Nonfatal Suicide Attempt and Intentional Self-harm Using International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) Coded Data

Suicide and intentional self-harm are among the leading causes of death in the United States. To study this public health issue, epidemiologists and researchers often analyze data coded using the International Classification of Diseases (ICD). Prior to October 1, 2015, health care organizations and providers used the clinical modification of the Ninth Revision of ICD (ICD-9-CM) to report medical information in electronic claims data. The transition in October 2015 to use of the clinical modification of the Tenth Revision of ICD (ICD-10-CM) resulted in the need to update methods and selection criteria previously developed for ICD-9-CM coded data. This report provides guidance on the use of ICD-10-CM codes to identify cases of nonfatal suicide attempts and intentional self-harm in ICD-10-CM coded data sets. ICD-10-CM codes for nonfatal suicide attempts and intentional self-harm include: X71-X83, intentional self-harm due to drowning and submersion, firearms, explosive or thermal material, sharp or blunt objects, jumping from a high place, jumping or lying in front of a moving object, crashing of motor vehicle, and other specified means; T36-T50 with a 6th character of 2 (except for T36.9, T37.9, T39.9, T41.4, T42.7, T43.9, T45.9, T47.9, and T49.9, which are included if the 5th character is 2), intentional self-harm due to drug poisoning (overdose); T51-T65 with a 6th character of 2 (except for T51.9, T52.9, T53.9, T54.9, T56.9, T57.9, T58.0, T58.1, T58.9, T59.9, T60.9, T61.0, T61.1, T61.9, T62.9, T63.9, T64.0, T64.8, and T65.9, which are included if the 5th character is 2), intentional self-harm due to toxic effects of nonmedicinal substances; T71 with a 6th character of 2, intentional self-harm due to asphyxiation, suffocation, strangulation; and T14.91, Suicide attempt. Issues to consider when selecting records for nonfatal suicide attempts and intentional self-harm from ICD-10-CM coded administrative data sets are also discussed.

Assessment of Selected Overdose Poisoning Indicators in Health Care Administrative Data in 4 States, 2012

OBJECTIVES

In 2012, a consensus document was developed on drug overdose poisoning definitions. We took the opportunity to apply these new definitions to health care administrative data in 4 states. Our objective was to calculate and compare drug (particularly opioid) poisoning rates in these 4 states for 4 selected Injury Surveillance Workgroup 7 (ISW7) drug poisoning indicators, using 2 ISW7 surveillance definitions, Option A and Option B. We also identified factors related to the health care administrative data used by each state that might contribute to poisoning rate variations.

METHODS

We used state-level hospital and emergency department (ED) discharge data to calculate age-adjusted rates for 4 drug poisoning indicators (acute drug poisonings, acute opioid poisonings, acute opioid analgesic poisonings, and acute or chronic opioid poisonings) using just the principal diagnosis or first-listed external cause-of-injury fields (Option A) or using all diagnosis or external cause-of-injury fields (Option B). We also calculated the high-to-low poisoning rate ratios to measure rate variations.

RESULTS

The average poisoning rates per 100 000 population for the 4 ISW7 poisoning indicators ranged from 11.2 to 216.4 (ED) and from 14.2 to 212.8 (hospital). For each indicator, ED rates were usually higher than were hospital rates. High-to-low rate ratios between states were lowest for the acute drug poisoning indicator (range, 1.5-1.6). Factors potentially contributing to rate variations included administrative data structure, accessibility, and submission regulations.

CONCLUSIONS

The ISW7 Option B surveillance definition is needed to fully capture the state burden of opioid poisonings. Efforts to control for factors related to administrative data, standardize data sources on a national level, and improve data source accessibility for state health departments would improve the accuracy of drug poisoning surveillance.

Use of syndromic surveillance data to monitor poisonings and drug overdoses in state and local public health agencies

BACKGROUND

The incidence of poisoning and drug overdose has risen rapidly in the USA over the last 16 years. To inform local intervention approaches, local health departments (LHDs) in North Carolina (NC) are using a statewide syndromic surveillance system that provides timely, local emergency department (ED) and Emergency Medical Services (EMS) data on medication and drug overdoses.

OBJECTIVE

The purpose of this article is to describe the development and use of a variety of case definitions for poisoning and overdose implemented in NC's syndromic surveillance system and the impact of the system on local surveillance initiatives.

DESIGN, SETTING, PARTICIPANTS

Thirteen new poisoning and overdose-related case definitions were added to NC's syndromic surveillance system and LHDs were trained on their use for surveillance purposes. Twenty-one LHDs were surveyed on the utility and impact of these new case definitions.

RESULTS/CONCLUSIONS

Ninety-one per cent of survey respondents (n = 29) agreed or strongly agreed that their ability to access timely ED data was vital to inform community-level overdose prevention work. Providing LHDs with access to local, timely data to identify pockets of need and engage stakeholders facilitates the practice of informed injury prevention and contributes to the reduction of injury incidence in their communities.

Cohort Study of the Impact of High-Dose Opioid Analgesics on Overdose Mortality

OBJECTIVE

Previous studies examining opioid dose and overdose risk provide limited granularity by milligram strength and instead rely on thresholds. We quantify dose-dependent overdose mortality over a large spectrum of clinically common doses. We also examine the contributions of benzodiazepines and extended release opioid formulations to mortality.

DESIGN

Prospective observational cohort with one year follow-up.

SETTING

One year in one state (NC) using a controlled substances prescription monitoring program, with name-linked mortality data.

SUBJECTS

Residential population of North Carolina (n = 9,560,234), with 2,182,374 opioid analgesic patients.

METHODS

Exposure was dispensed prescriptions of solid oral and transdermal opioid analgesics; person-years calculated using intent-to-treat principles. Outcome was overdose deaths involving opioid analgesics in a primary or additive role. Poisson models were created, implemented using generalized estimating equations.

RESULTS

Opioid analgesics were dispensed to 22.8% of residents. Among licensed clinicians, 89.6% prescribed opioid analgesics, and 40.0% prescribed ER formulations. There were 629 overdose deaths, half of which had an opioid analgesic prescription active on the day of death. Of 2,182,374 patients prescribed opioids, 478 overdose deaths were reported (0.022% per year). Mortality rates increased gradually across the range of average daily milligrams of morphine equivalents. 80.0% of opioid analgesic patients also received benzodiazepines. Rates of overdose death among those co-dispensed benzodiazepines and opioid analgesics were ten times higher (7.0 per 10,000 person-years, 95 percent CI: 6.3, 7.8) than opioid analgesics alone (0.7 per 10,000 person years, 95 percent CI: 0.6, 0.9).

CONCLUSIONS

Dose-dependent opioid overdose risk among patients increased gradually and did not show evidence of a distinct risk threshold. There is urgent need for guidance about combined classes of medicines to facilitate a better balance between pain relief and overdose risk.

Informing Best Practice With Community Practice: The Community Change Chronicle Method for Program Documentation and Evaluation

Health promotion professionals are increasingly encouraged to implement evidence-based programs in health departments, communities, and schools. Yet translating evidence-based research into practice is challenging, especially for complex initiatives that emphasize environmental strategies to create community change. The purpose of this article is to provide health promotion practitioners with a method to evaluate the community change process and document successful applications of environmental strategies. The community change chronicle method uses a five-step process: first, develop a logic model; second, select outcomes of interest; third, review programmatic data for these outcomes; fourth, collect and analyze relevant materials; and, fifth, disseminate stories. From 2001 to 2003, the authors validated the use of a youth empowerment model and developed eight community change chronicles that documented the creation of tobacco-free schools policies (n = 2), voluntary policies to reduce secondhand smoke in youth hangouts (n = 3), and policy and program changes in diverse communities (n = 3).

The use of a prescription drug monitoring program to develop algorithms to identify providers with unusual prescribing practices for controlled substances

The misuse, abuse and diversion of controlled substances have reached epidemic proportion in the United States. Contributing to this problem are providers who over-prescribe these substances. Using one state's prescription drug monitoring program, we describe a series of metrics we developed to identify providers manifesting unusual and uncustomary prescribing practices. We then present the results of a preliminary effort to assess the concurrent validity of these algorithms, using death records from the state's vital records database pertaining to providers who wrote prescriptions to patients who then died of a medication or drug overdose within 30 days. Metrics manifesting the strongest concurrent validity with providers identified from these records related to those who co-prescribed benzodiazepines (e.g., valium) and high levels of opioid analgesics (e.g., oxycodone), as well as those who wrote temporally overlapping prescriptions. We conclude with a discussion of a variety of uses to which these metrics may be put, as well as problems and opportunities related to their use.

North Carolina's Operation Medicine Drop: Results From One of the Nation's Largest Drug Disposal Programs

INTRODUCTION

In 2013, a total of 1,085 North Carolina residents died due to unintentional poisoning; 91% of these deaths were attributed to medications or drugs (over-the-counter, prescription, or illicit). Proper disposal of unused, unneeded, and/or expired medications is an essential part of preventing these unintentional deaths, as well as averting the other adverse consequences of these drugs on the environment and population health.

METHODS

Operation Medicine Drop is a medication take-back program coordinated by Safe Kids North Carolina, a county-level, coalition-based injury prevention organization. The Operation Medicine Drop program and event registration system were used to review and validate the number of events, the counties where the events were held, and the number of unit doses (pills) collected from March 2010 to June 2014. SAS version 9.4 was used to generate basic counts and frequencies of events and doses, and ArcGIS version 10.0 was used to create the map.

RESULTS

From March 2010 to June 2014, Operation Medicine Drop held 1,395 events with 245 different participating law enforcement agencies in 91 counties in North Carolina, and it collected 69.6 million unit doses of medication. More than 60 local Safe Kids North Carolina community coalitions had participated as of June 2014. Every year, Operation Medicine Drop has witnessed increases in events, participating agencies, participating counties, and the number of doses collected.

CONCLUSION

Operation Medicine Drop is an excellent example of a successful and ongoing collaboration to improve public health. Medication take-back programs may play an important role in preventing future overdose deaths in North Carolina.

Adverse Childhood Experiences Related to Poor Adult Health Among Lesbian, Gay, and Bisexual Individuals

OBJECTIVES

We explored the association of sexual orientation with poor adult health outcomes before and after adjustment for exposure to adverse childhood experiences (ACEs).

METHODS

Data were from the 2012 North Carolina, 2011 Washington, and 2011 and 2012 Wisconsin Behavioral Risk Factor Surveillance System (BRFSS) surveys regarding health risks, perceived poor health, and chronic conditions by sexual orientation and 8 categories of ACEs. There were 711 lesbian, gay, and bisexual (LGB) respondents and 29,690 heterosexual respondents.

RESULTS

LGB individuals had a higher prevalence of all ACEs than heterosexuals, with odds ratios ranging from 1.4 to 3.1. After adjustment for cumulative exposure to ACEs, sexual orientation was no longer associated with poor physical health, current smoking, and binge drinking. Associations with poor mental health, activity limitation, HIV risk behaviors, current asthma, depression, and disability remained, but were attenuated.

CONCLUSIONS

The higher prevalence of ACEs among LGB individuals may account for some of their excess risk for poor adult health outcomes.

Disability and Exposure to High Levels of Adverse Childhood Experiences: Effect on Health and Risk Behavior

BACKGROUND

Health disparities among persons with disabilities have been previously documented. However, there is little research specific to adverse childhood experiences (ACEs) in this population and how ACE exposure affects health outcomes in adulthood.

METHODS

Data from the 2012 North Carolina Behavioral Risk Factor Surveillance System (BRFSS) survey were analyzed to compare the prevalence of ACEs between adults with and without disabilities and high ACE exposure (3-8 ACEs). Adjusted risk ratios of health risks and perceived poor health by disability status were calculated using predicted marginals.

RESULTS

A higher percentage of persons with disabilities (36.5%) than those without disabilities (19.6%) reported high ACE exposure. Among those with high ACE exposure, persons with disabilities were more likely to report several ACE categories, particularly childhood sexual abuse. In adjusted analyses, persons with disabilities had an increased risk of smoking (relative risk [RR] = 1.29; 95% CI, 1.10-1.51), poor physical health (RR = 4.34; 95% CI, 3.08-6.11), poor mental health (RR = 4.69; 95% CI, 3.19-6.87), and doctor-diagnosed depression (RR = 2.16; 95% CI, 1.82-2.56) compared to persons without disabilities.

LIMITATIONS

The definition of disability derived from the BRFSS survey does not allow for those with disabilities to be categorized according to physical disabilities versus mental or emotional disabilities. In addition, we were unable to determine the timing of ACE exposure in relation to disability onset.

CONCLUSIONS

A better understanding of the life course associations between ACEs and disability and the impact of exposure to multiple types of childhood adversity on disability and health is needed to inform research and services specific to this vulnerable population.

Using GIS to evaluate a fire safety program in North Carolina

Evaluating program impact is a critical aspect of public health. Utilizing Geographic Information Systems (GIS) is a novel way to evaluate programs which try to reduce residential fire injuries and deaths. The purpose of this study is to demonstrate the application of GIS within the evaluation of a smoke alarm installation program in North Carolina. This approach incorporates national fire incident data which, when linked with program data, provides a clear depiction of the 10 years impact of the Get Alarmed, NC! program and estimates the number of potential lives saved. We overlapped Get Alarmed, NC! program installation data with national information on fires using GIS to identify homes that experienced a fire after an alarm was installed and calculated potential lives saved based on program documentation and average housing occupancy. We found that using GIS was an efficient and quick way to match addresses from two distinct sources. From this approach we estimated that between 221 and 384 residents were potentially saved due to alarms installed in their homes by Get Alarmed, NC!. Compared with other program evaluations that require intensive and costly participant telephone surveys and/or in-person interviews, the GIS approach is inexpensive, quick, and can easily analyze large disparate datasets. In addition, it can be used to help target the areas most at risk from the onset. These benefits suggest that by incorporating previously unutilized data, the GIS approach has the potential for broader applications within public health program evaluation.

National estimates of noncanine bite and sting injuries treated in US Hospital Emergency Departments, 2001-2010

OBJECTIVE

Injuries resulting from contact with animals and insects are a significant public health concern. This study quantifies nonfatal bite and sting injuries by noncanine sources using data from the National Electronic Injury Surveillance System-All Injury Program (NEISS-AIP).

METHODS

The NEISS-AIP is an ongoing nationally representative surveillance system used to monitor all types and causes of injuries treated in US hospital emergency departments (EDs). Cases were coded by trained hospital coders using information from medical records on animal and insect sources of bite and sting injuries being treated. Data were weighted to produce national annualized estimates, percentages, and rates based on the US population.

RESULTS

From 2001 to 2010 an estimated 10.1 million people visited EDs for noncanine bite and sting injuries, based on an unweighted case count of 169,010. This translates to a rate of 340.1 per 100,000 people (95% CI, 232.9-447.3). Insects accounted for 67.5% (95% CI, 45.8-89.2) of bite and sting injuries, followed by arachnids 20.8% (95% CI, 13.8-27.9). The estimated number of ED visits for bedbug bite injuries increased more than 7-fold-from 2156 visits in 2007 to 15,945 visits in 2010.

CONCLUSIONS

This study provides an update of national estimates of noncanine bite and sting injuries and describes the diversity of animal exposures based on a national sample of EDs. Treatment of nonfatal bite and sting injuries are costly to society. Direct medical and work time lost translates to an estimated $7.5 billion annually.

Relationship of opioid prescription sales and overdoses, North Carolina

BACKGROUND

In the United States, fatal drug overdoses have tripled since 1991. This escalation in deaths is believed to be driven primarily by prescription opioid medications. This investigation compared trends and patterns in sales of opioids, opioid drug overdoses treated in emergency departments (EDs), and unintentional overdose deaths in North Carolina (NC).

METHODS

Our ecological study compared rates of opioid sales, opioid related ED overdoses, and unintentional drug overdose deaths in NC. Annual sales data, provided by the Drug Enforcement Administration, for select opioids were converted into morphine equivalents and aggregated by zip code. These opioid drug sales rates were trended from 1997 to 2010. In addition, opioid sales were correlated and compared to opioid related ED visits, which came from a Centers for Disease Control and Prevention syndromic surveillance system, and unintentional overdose deaths, which came from NC Vital Statistics, from 2008 to 2010. Finally, spatial cluster analysis was performed and rates were mapped by zip code in 2010.

RESULTS

Opioid sales increased substantially from 1997 to 2010. From 2008 to 2010, the quarterly rates of opioid drug overdoses treated in EDs and opioid sales correlated (r=0.68, p=0.02). Specific regions of the state, particularly in the southern and western corners, had both high rates of prescription opioid sales and overdoses.

CONCLUSIONS

Temporal trends in sales of prescription opioids correlate with trends in opioid related ED visits. The spatial correlation of opioid sales with ED visit rates shows that opioid sales data may be a timely way to identify high-risk communities in the absence of timely ED data.

Evaluation of the North Carolina Violent Death Reporting System, 2009

BACKGROUND

Violence is a leading cause of death in North Carolina. The North Carolina Violent Death Reporting System (NC-VDRS) is part of the National Violent Death Reporting System (NVDRS), which monitors violent deaths and collects information about injuries and psychosocial contributors. Our objective was to describe and evaluate the quality, timeliness, and usefulness of the system.

METHODS

We used the Centers for Disease Control and Prevention's guidelines for evaluating public health surveillance systems to assess the system. We performed subjective assessment of system attributes by reviewing system documents and interviewing stakeholders. We estimated NC-VDRS's reporting completeness using a capture-recapture method.

RESULTS

Stakeholders considered data provided by NC-VDRS to be of high quality. Reporting to the national system has taken place before the specified 6-month and 18-month deadlines, but local stakeholder reports have been delayed up to 36 months. Stakeholders reported using NC-VDRS data for program planning and community education. The system is estimated to capture all NVDRS-defined cases, but law enforcement officers report only 61% of suicides.

LIMITATIONS

The law enforcement agencies we interviewed may not be representative of all participating agencies in the state. Data sources used to assess completeness were not independent.

CONCLUSION

NC-VDRS is useful and well-accepted. However, completeness of suicide reporting is limited, and reporting to local stakeholders has been delayed. Improving these limitations might improve the usefulness of the system for planning and appropriately targeting violence prevention interventions.

Variables associated with use and susceptibility to use of cigarettes among North Carolina adolescents: results from the 2007 statewide survey of high school students

BACKGROUND

As North Carolina works to sustain recent reductions in smoking among adolescents, more knowledge is needed to design effective prevention programs. This study examined the variables associated with use and susceptibility to use of cigarettes use among North Carolina students in high school (ie, grades 9-12).

METHODS

Data were collected from the 2007 North Carolina Youth Tobacco Survey (NCYTS). The NCYTS is a biannual public school- and charter school-based survey of North Carolina students in grades 6-12. Seventy-four of 115 school districts from 3 distinct geographic regions of the state were selected for participation in the 2007 NCYTS. The survey was completed by 3,364 students (81.6%) at participating high schools, for an overall completion rate of 78.3% among all North Carolina high school students. Logistic regression models examined variables associated with current use of cigarettes, ever having used cigarettes (also referred to as "ever use"), and susceptibility to use of cigarettes. All analyses included sampling weights, which enabled results to be generalized to all high school students in North Carolina.

RESULTS

A total of 48.9% of students reported ever use, 19.0% were classified as current users, and 33.5% were classified as susceptible to use. Females, nonminorities, and older students had higher odds than males, minorities, and younger students, respectively, of being a current smoker. Minorities, however, had higher odds than nonminorities of ever smoking. Use of other forms of tobacco increased the odds of current use and ever use of cigarettes. Agreement with the statement that smoking makes one look cool or fit in increased the odds of being susceptible to smoking. Having a willingness to wear an item promoting a tobacco company and having close friends who smoked individually increased the odds of each of the 3 outcomes.

LIMITATIONS

Data are from a cross-sectional survey conducted every other year, in which students self-report use of, attitudes about, and perceptions about tobacco products.

CONCLUSIONS

Many variables should be taken into account to optimize efforts to prevent tobacco use, countermarket campaigns, and policy initiatives in North Carolina.