Review of naloxone safety for opioid overdose: practical considerations for new technology and expanded public access

A descriptive study of racial and ethnic differences of drug overdoses and naloxone administration in Pennsylvania

INTRODUCTION

Drug overdose is a significant public health problem, yet little is known about racial/ethnic differences in drug overdose rates and/or in responses to a drug overdose following naloxone administration. This paper examines differences in rates of survivorship, response, revival and administration of naloxone by race and ethnicity among those who experienced a drug overdose in Pennsylvania between January 1, 2018 and December 31, 2019. Spatio-temporal variations in drug overdose locations were examined to facilitate understanding of service development, planning, and delivery of effective treatment need.

METHODS

Ten thousand two hundred and ninety drug overdose incidents were analyzed from the Pennsylvania Overdose Information Network (ODIN). The ODIN is a centralized repository that contains information on drug overdoses victims including age, gender and race/ethnicity, naloxone administrations and survivorship, drug(s) suspected of causing the overdose, victim outcomes (e.g. hospitalizations and arrests) and average naloxone dosage per victim. Between group differences were tested using χ2 -tests of independence. Multivariate logistic regression was used to estimate the predicted probability of survivorship according to victim characteristics. All statistical analyses and mapping were performed using the R statistical programming environment.

RESULTS

About eighty-seven percent of drug overdose response victims were white, and seventy-one percent were between the ages of 20-39. White females were more likely to receive an overdose response compared to black or Hispanic females. A non-opioid was indicated more frequently in overdoses involving black victims compared to either whites or Latinos. Latinos and blacks were more likely to survive a drug overdose. However, following naloxone administration, no racial or ethnic differences in survivorship were noted. Differences in responsiveness to naloxone and transitions to care following the drug overdose event were also found. Finally, overdoses among Blacks and Latinos demonstrated a stronger spatial patterning across counties compared to whites.

CONCLUSIONS

This study found a significant, disparate impact of race/ethnicity on fatal drug overdoses when naloxone is not administered. Further, individuals who were administered naloxone and subsequently received medical care in a hospital experienced lower drug-related mortality, suggesting that first responders are critical intervention points for individuals in need of medical treatment following a drug overdose. However, while naloxone administration is a necessary first step in the recovery process, longitudinal pathways towards treatment are critical to stem the drug overdose crisis.

Comparison of the efficacy of an infusion pump or standard IV push injection to deliver naloxone in treatment of opioid toxicity

Background:

The optimal goal of naloxone infusion in intensive care units is to ameliorate opioid-induced side effects in therapy or eliminate the symptoms of opioid toxicity in overdoses. Accurately monitoring and regulating the doses is critical to prevent adverse effects related to naloxone administration. The present study aimed to compare treatment outcomes when using two methods of intravenous naloxone infusion: an infusion pump or the standard method.

Methods:

This study involved 80 patients with signs and symptoms of opioid overdose. The patients were randomly assigned into two groups with respect to intravenous infusion of naloxone by either an infusion pump or the standard method.

Results:

Comparison of study parameters between the two groups at 12 and 24 hours after intervention showed significantly more compensatory acid-base imbalance in the naloxone infusion pump group. In the group that received naloxone by pump, only one patient experienced withdrawal symptoms, but withdrawal symptoms appeared in 12 patients (30.0%) in the standard intravenous infusion group within 12 hours and in seven additional patients (17.5%) within 24 hours of intervention. In the group receiving pump-based naloxone infusion therapy, no another complications were reported; however in the standard infusion group, the 12-hour and 24-hour complication rates were 55.0% and 32.5%, respectively. The length of hospital stay was 2.85±1.05 and 4.22±0.92 days for the pump and standard infusion groups, respectively (P<0.001).

Conclusions:

Naloxone infusion using an infusion pump may be safer with regard to hemodynamic stability, resulting in shorter hospitalization periods, and fewer posttreatment complications.

Regional and temporal effects of naloxone access laws on opioid overdose mortality

BACKGROUND

Naloxone is a drug that reverses opioid overdose. Naloxone Access Laws (NALs) increase public access to naloxone and have been considered as one promising solution to reducing opioid-related harm. However, previous studies on whether NALs are effective in reducing opioid overdose mortality found somewhat contradictory results. Our study attempts to provide a more definitive answer to this question by utilizing an approach that matches NAL vs non-NAL states and stratifies by US region and years of implementation. Methods: We assess the causal impact of NALs on state-level opioid-related mortality rate by constructing a comparison group using matching to produce a valid counterfactual scenario, and estimating the effects of NAL using a semi-dynamic staggered difference in differences (DID) model that allows heterogeneous effects across regions and years of implementation. State-level opioid-related mortality data from CDC's WONDER database and NALs effective from 1999 to 2014 were utilized. Results: We find that NAL effects have reduced fatal opioid-related overdose in western states and have produced minimal or no effects for other regions. Conclusions: The effects of NALs vary across regions and years of implementation. It is important to study the successful experience of the western states.

Silver nanoparticles (Ag-NPs) in the central amygdala protect the rat conditioned by morphine from withdrawal attack due to naloxone via high-level nitric oxide

Repeated injection of morphine during conditioned place preference (CPP) leads to spatial craving due to high-level nitric oxide (NO) in the central nucleus of amygdala (CeA). Silver nanoparticles (Ag-NPs) can produce oxygen-free radicals that lead to NO formation. We aimed to show the Ag-NPs protective effect on naloxone (NLX)-induced morphine withdrawal in the conditioned rats. Wistar rats (300-350 g) were implanted with cannulae in the CeA. After recovery, they were randomly divided into experimental and saline groups. CPP was conducted by three-phase unbiased program. Morphine (0.5-7.5 mg/kg) was injected subcutaneously (s.c.) once/per day during the conditioning phase. Naloxone (NLX) (0.05-0.4 μg/rat) was given, intra-CeA, 10 min before the CPP test. Ag-NPs (0.0001-0.01 μg/rat) were administered alone or prior to the NLX effective dose (0.4 μg/rat), intra-CeA. Conditioning score and withdrawal signs (wet dog shaking and scratching) were obtained and compared with saline group data. All rats' brains were collected in formalin 10% and after 48-72 h stained with NADPH-diaphorase, the NO marker. All data were analyzed by one-way or two-way ANOVA. Morphine (2.5-7.5 mg/kg, s.c.) induced a significant CPP vs. saline (1 mL/kg, s.c.). The single Ag-NPs had no significant effect, whereas the NLX caused meaningful WDS and scratching. However, the NLX pre-treatment in combination with Ag-NPs eliminated these signs. Furthermore, the NO level increased in the CeA. The Ag-NPs may protect the morphine-conditioned rats against the NLX-induced withdrawal symptoms due to high-level NO in the CeA.

Behavioral Pharmacology of Drugs Acting at Mu Opioid Receptors

Despite the therapeutic utility of opioids for relieving pain, other behavioral effects, including their potential for abuse and overdose, can be quite detrimental to individuals as well as society and have contributed to the ongoing opioid crisis. The dramatic escalation in overdose deaths over the last 15 years was initially driven by abuse of prescription opioids, although abuse of heroin, fentanyl, and fentanyl analogs has been increasing, largely due to increased availability and lower cost compared with prescription opioids. All of these opioids share pharmacological properties, acting as agonists at mu opioid receptors, and produce similar behavioral effects, including abuse-related, pain-relieving, dependence-producing, and respiratory-depressant effects. Despite their similarities, opioids are not pharmacologically identical. In fact, drugs that act at mu opioid receptors, including abused opioids, can vary on a number of dimensions, including pharmacological efficacy, drug-receptor interactions, receptor selectivity, and pharmacokinetics. Overall, these differences impact behavioral effects of drugs acting at mu opioid receptors, and this chapter describes variations in those behavioral effects and how these differences continue to provide new strategies that can be developed to address the ongoing opioid epidemic.

Impact of the take ACTION Train-the-Trainer model of opioid overdose education with naloxone distribution- who benefits?

BACKGROUND

Overdose education with naloxone distribution (OEND) is a key national strategy to reduce morbidity and mortality related to opioid overdoses. Train-the-trainer model has been one method to increase the pool of trainers to facilitate greater dissemination of OEND. This exploratory study seeks to (1) evaluate participant's change in knowledge and confidence, (2) examine if pre- and post-training test outcomes differed by occupation and level of experience, and (3) determine if train-the-trainer participants trained others 6 months later. Methods: Fifteen train-the-trainer sessions were delivered to staff from community organizations who served high-risk clients in four counties whose overdose death rates ranged from 11.2 to 32.8 per 100,000. Participants were administered pre- and post-training tests from September 2017 to December 2018. A follow-up survey was conducted 6 months post-training to evaluate outcomes. Final paired pre-and post-training surveys of 109 participants were used for analysis. Paired sample t-tests were used to evaluate changes in the knowledge and confidence in teaching others. One-way ANOVA compared the change scores across groups with different demographic or experiential characteristics. Kruskal-Wallis Test was used for Likert scales. Results: The one and one-half hour train-the-trainer curriculum increased participants' knowledge and confidence to teach others (p < .001). This was particularly true for participants who had no prior experience compared to those who had some experience with naloxone (p = .0003). Changes in confidence to teach others significantly improved among demographic subgroups of participants. At 6 months after completing the train-the-trainer curriculum, 14 participants had trained 243 new trainees. Conclusions: Implementing a train-the-trainer model for OEND increases knowledge and participants' confidence to teach others. This demonstrates the important potential of the train-the-trainer model to respond to the growing opioid overdose epidemic.

Covalent Poly(lactic acid) Nanoparticles for the Sustained Delivery of Naloxone

The opioid epidemic currently plaguing the United States has been exacerbated by an alarming rise in fatal overdoses as a result of the proliferated abuse of synthetic mu opioid receptor (MOR) agonists, such as fentanyl and its related analogues. Attempts to manage this crisis have focused primarily on widespread distribution of the clinically approved opioid reversal agent naloxone (Narcan); however, due to the intrinsic metabolic lability of naloxone, these measures have demonstrated limited effectiveness against synthetic opioid toxicity. This work reports a novel polymer-based strategy to create a long-acting formulation of naloxone with the potential to address this critical issue by utilizing covalent nanoparticle (cNP) drug delivery technology. Covalently loaded naloxone nanoparticles (Nal-cNPs) were prepared via the naloxone-initiated, ring-opening polymerization (ROP) of l-lactide in the presence of a bifunctional thiourea organocatalyst with subsequent precipitation of the resulting naloxone-poly(l-lactic acid) polymer. This protocol afforded well-defined nanoparticles possessing a drug loading of approximately 7% w/w. The resulting Nal-cNPs demonstrated excellent biocompatibility, while exhibiting sustained linear release kinetics in vitro and blocking the effects of high dose (10 mg/kg) acute morphine for up to 98 h in an in vivo rodent model of neuropathic pain.

Who receives naloxone from emergency medical services? Characteristics of calls and recent trends

Background: With the rapid rise in opioid overdose-related deaths, state policy makers have expanded policies to increase the use of naloxone by emergency medical services (EMS). However, little is known about changes in EMS naloxone administration in the context of continued worsening of the opioid crisis and efforts to increase use of naloxone. This study examines trends in patient demographics and EMS response characteristics over time and by county urbanicity. Methods: We used data from the 2013-2016 National EMS Information System to examine trends in patient demographics and EMS response characteristics for 911-initiated incidents that resulted in EMS naloxone administration. We also assessed temporal, regional, and urban-rural variation in per capita rates of EMS naloxone administrations compared with per capita rates of opioid-related overdose deaths. Results: From 2013 to 2016, naloxone administrations increasingly involved young adults and occurred in public settings. Particularly in urban counties, there were modest but significant increases in the percentage of individuals who refused subsequent treatment, were treated and released, and received multiple administrations of naloxone before and after arrival of EMS personnel. Over the 4-year period, EMS naloxone administrations per capita increased at a faster rate than opioid-related overdose deaths across urban, suburban, and rural counties. Although national rates of naloxone administration were consistently higher in suburban counties, these trends varied across U.S. Census Regions, with the highest rates of suburban administration occurring in the South. Conclusions: Naloxone administration rates increased more quickly than opioid deaths across all levels of county urbanicity, but increases in the percentage of individuals requiring multiple doses and refusing subsequent care require further attention.

Simple minimally-invasive automatic antidote delivery device (A2D2) towards closed-loop reversal of opioid overdose

With approximately 48,000 attributed deaths in 2017, the opioid overdose is now the leading cause of death amongst Americans under the age of 50. The overdose process can be interrupted by the administration of naloxone, a safe and effective opiate antagonist that can reverse the effects of overdose and minimizing the delay in administering the antidote is critical in preventing permanent damage to patients. A closed-loop implantable drug delivery system is an ideal solution to minimize the response time, however, they often feature complex designs that are expensive to fabricate and require a more invasive surgical implantation. Here we propose a simple, low-cost, minimally-invasive automatic antidote delivery device (A2D2) that can administer a large dose of naloxone upon detection of overdose-induced respiratory failure. The subcutaneously placed device can be activated using an externally applied time varying magnetic field from a wearable device. Using a custom magnetic field generator, we were able to release the drug within 10 s. Our bench-top evaluation showed that A2D2 can release 1.9 mg of powdered drug within 60 s and up to 8.8 mg in 600 s. We also performed in vivo evaluation to demonstrate rapid drug releasing capability in the subcutaneous space of mice. However, we saw a small amount of leakage (1.75% of payload) over the course of 1000 h of simulated implantation. Thus, additional research is needed to verify the long term stability of our device and to demonstrate the closed-loop release mechanism to revive overdosed animals. Nevertheless, our preliminary results show the potential of using a simple, low-cost, subcutaneous device for emergency drug delivery application.

Comparative Human Factors Evaluation of Two Nasal Naloxone Administration Devices: NARCAN® Nasal Spray and Naloxone Prefilled Syringe with Nasal Atomizer

INTRODUCTION

Opioid overdose rescue situations are time-critical, high-stress scenarios that frequently require nonmedical first responders or bystanders to intervene and administer naloxone to avoid opioid-induced fatalities. Training nonmedical personnel to respond during such mentally constraining situations presents the human factors challenge of how best to design a safe and effective lay delivery system. This paper comparatively evaluates the ease of use of two nasal naloxone administration products: NARCAN^® Nasal Spray and a naloxone prefilled syringe with nasal atomizer (PFS-NA).

METHODS

We evaluated the use requirements and usability of NARCAN^® Nasal Spray versus a naloxone PFS-NA using a systems-oriented method. First, we determined the use requirements of different user groups. Next, we focused on constructing a human factors task analysis of both products. Finally, we conducted a comparative risk assessment of the tasks that were different between the two products.

RESULTS

Inexperienced users, such as nonmedical first responders and bystanders, are at the highest risk of incorrectly administering naloxone, particularly in high-stress emergency opioid overdose situations. The device Preparation and Medication Delivery tasks most differentiate the use of NARCAN^® Nasal Spray and a PFS-NA. The level of task complexity and number of steps within those tasks is substantially greater for a PFS-NA than for the NARCAN^® Nasal Spray.

CONCLUSIONS

NARCAN^® Nasal Spray requires fewer steps and is easier to administer than a naloxone PFS-NA. Thus, using NARCAN^® Nasal Spray should increase the likelihood that nonmedical personnel correctly deliver naloxone in time-critical, high-stress opioid overdose rescue situations.

FUNDING

ADAPT Pharma, Inc.

Will converting naloxone to over-the-counter status increase pharmacy sales?

Objective

To estimate the own‐price elasticity of demand for naloxone, a prescription medication that can counter the effects of an opioid overdose, and predict the change in pharmacy sales following a conversion to over‐the‐counter status.

Data Sources/Study Setting

The primary data source was a nationwide prescription claims dataset for 2010‐2017. The data cover 80 percent of US retail pharmacies and account for roughly 90 percent of prescriptions filled. Additional covariates were obtained from various secondary data sources.

Study Design

We estimated a longitudinal, simultaneous equation model of naloxone supply and demand. Our primary variables of interest were the quantity of naloxone sold, measured as total milligrams sold at pharmacies, and the out‐of‐pocket price paid per milligram, both measured per ZIP Code and quarter‐year.

Data Collection/Extraction Methods

Primary data came directly from payers and processors of prescription drug claims.

Principal Findings

We found that, on average, a 1 percent increase in the out‐of‐pocket price paid for naloxone would result in a 0.27 percent decrease in pharmacy sales. We predict that the total quantity of naloxone sold in pharmacies would increase 15 percent to 179 percent following conversion to over‐the‐counter status.

Conclusions

Naloxone is own‐price inelastic, and conversion to over‐the‐counter status is likely to lead to a substantial increase in total pharmacy sales.

DARK Classics in Chemical Neuroscience: Opium, a Friend or Foe

Opium has found great use medicinally for its analgesic properties and has been witnessed as one of the most popular medications used in psychiatry. Opium derivatives have been shown as efficacious for relieving pain and the treatment of epileptic seizures, but progressive research toward their use in the treatment of neurodegenerative diseases remain elusive. To gain more insight into the other properties of opium such as anti-inflammatory properties, herein we discuss basic information regarding opium, opium content and mechanism of action, pharmacology of opium derivatives, the role of opium in the prevention of neurodegeneration, and adverse effects of opium derivatives on neuronal health.

Reversal of Pediatric Opioid Toxicity with Take-Home Naloxone: a Case Report

BACKGROUND

Take-home naloxone, an opioid antagonist, has become part of a multimodal approach to curbing opioid-related mortality. However, there is little information about the utility of take-home naloxone in pediatric patients. We report a case of opioid toxicity after exposure to methadone in a pediatric patient, which was successfully reversed with take-home naloxone.

CASE

A previously healthy 22-month-old girl ingested an unknown amount of liquid methadone. The child became progressively somnolent. The mother administered intranasal naloxone at home with reversal of somnolence. The patient presented to the emergency department and had recurrence of symptoms. The patient was placed on a naloxone infusion and discharged from a tertiary care facility, uneventfully, 2 days after ingestion.

RESULTS

To our knowledge, we report the first case of pediatric opioid toxicity reversed by take-home naloxone. In the setting of rising opioid-related mortality, providers and public health officials should consider expanding access of take-home naloxone for children at high risk for opioid overdose.

Newly Emerging Drugs of Abuse

Drug use and the associated overdose deaths have been a serious public health threat in the United States and the world. While traditional drugs of abuse such as cocaine remain popular, recreational use of newer synthetic drugs has continued to increase, but the prevalence of use is likely underestimated. In this review, epidemiology, chemistry, pharmacophysiology, clinical effects, laboratory detection, and clinical treatment are discussed for newly emerging drugs of abuse in the following classes: (1) opioids (e.g., fentanyl, fentanyl analogues, and mitragynine), (2) cannabinoids [THC and its analogues, alkylindole (e.g., JWH-018, JWH-073), cyclohexylphenol (e.g., CP-47,497), and indazole carboxamide (e.g., FUB-AMB, ADB-FUBINACA)], (3) stimulants and hallucinogens [β-keto amphetamines (e.g., methcathinone, methylone), pyrrolidinophenones (e.g., α-PVP, MDPV), and dimethoxyphenethylamine ("2C" and "NBOMe")], (4) dissociative agents (e.g., 3-MeO-PCP, methoxetamine, 2-oxo-PCE), and (5) sedative-hypnotics (e.g., gabapentin, baclofen, clonazolam, etizolam). It is critically important to coordinate hospital, medical examiner, and law enforcement personnel with laboratory services to respond to these emerging threats.

Incidence of mortality due to rebound toxicity after ‘treat and release’ practices in prehospital opioid overdose care: a systematic review

Introduction

Death due to opioid overdose was declared a public health crisis in Canada in 2015. Traditionally, patients who have overdosed on opioids that are managed by emergency medical services (EMS) are treated with the opioid antagonist naloxone, provided ventilatory support and subsequently transported to hospital. However, certain EMS agencies have permitted patients who have been reversed from opioid overdose to refuse transport, if the patient exhibits capacity to do so. Evidence on the safety of this practice is limited. Therefore, our intent was to examine the available literature to determine mortality and serious adverse events within 48 hours of EMS treat and release due to suspected rebound opioid toxicity after naloxone administration.

Methods

A systematic search was performed on 11 May 2017 in PubMed, Cochrane Central, Embase and CINHAL. Studies that reported on the outcome of patients treated with prehospital naloxone and released at the scene were included. Analyses for incidence of mortality and adverse events at the scene were conducted. Risk of bias and assessment of publication bias was also done.

Results

1401 records were screened after duplicate removal. Eighteen full-text studies were reviewed with seven selected for inclusion. None were found to be high risk of bias. In most studies, heroin was the source of the overdose. Mortality within 48 hours was infrequent with only four deaths among 4912 patients ﴾0.081%﴿ in the seven studies. Only one study reported on adverse events and found no incidence of adverse events from their sample of 71 released patients.

Conclusion

Mortality or serious adverse events due to suspected rebound toxicity in patients released on scene post-EMS treatment with naloxone were rare. However, studies involving longer-acting opioids were rare and no study involved fentanyl.

EMS naloxone administration as non-fatal opioid overdose surveillance: 6-year outcomes in Marion County, Indiana

BACKGROUND AND AIMS

Despite rising rates of opioid overdose in the United States, few studies have examined the frequency of non-fatal overdose events or mortality outcomes following resuscitation. Given the widespread use of naloxone to respond to overdose-related deaths, naloxone administration may provide a useful marker of overdose events to identify high-risk users at heightened risk of mortality. We used naloxone administration by emergency medical services as a proxy measure of non-fatal overdose to examine repeat events and mortality outcomes during a 6-year period.

METHODS

We conducted a retrospective investigation of all cases in Marion County, Indiana between January 2011 and December 2016 where emergency medical services used naloxone to resuscitate a patient. Cases were linked to vital records to assess mortality and cause of death during the same time-period. We used Cox regression survival analysis to assess whether repeat non-fatal overdose events during the study period were associated with the hazard of mortality, both overall and by cause of death.

RESULTS

Of 4726 patients administered naloxone, 9.4% (n = 444) died an average of 354 days [standard deviation (SD) = 412.09, range = 1-1980] following resuscitation. Decedents who died of drug-related causes (34.7%, n = 154) were younger and more likely to have had repeat non-fatal overdose events. Patients with repeat non-fatal overdose events (13.4%, n = 632) had a ×2.07 [95% confidence interval (CI) = 1.59, 2.71] higher hazard of all-cause mortality and a ×3.06 (95% CI = 2.13, 4.40) higher hazard of drug-related mortality.

CONCLUSIONS

Among US emergency medical service patients administered naloxone for opioid overdose, those with repeat non-fatal opioid overdose events are at a much higher risk of mortality, particularly drug-related mortality, than those without repeat events.

Reversal and Prevention of the Respiratory-Depressant Effects of Heroin by the Novel μ-Opioid Receptor Antagonist Methocinnamox in Rhesus Monkeys

One consequence of the ongoing opioid epidemic is a large number of overdose deaths. Naloxone reverses opioid-induced respiratory depression; however, its short duration of action limits the protection it can provide. Methocinnamox (MCAM) is a novel opioid receptor antagonist with a long duration of action. This study examined the ability of MCAM to prevent and reverse the respiratory-depressant effects (minute volume [V_E]) of heroin in five monkeys. MCAM (0.32 mg/kg) was given before heroin to determine whether it prevents respiratory depression; heroin dose-effect curves were generated 1, 2, 4, and 8 days later, and these effects were compared with those of naltrexone (0.032 mg/kg). Heroin dose dependently decreased V_E MCAM and naltrexone prevented respiratory depression, shifting the heroin dose-effect curve rightward at least 10-fold. MCAM, but not naltrexone, attenuated these effects of heroin for 4 days. MCAM (0.1-0.32 mg/kg) was given 30 minutes after heroin to determine whether it reverses respiratory depression; heroin dose-effect curves were generated 1, 2, 4, 8, and 16 days later, and these effects were compared with those of naloxone (0.0032-0.1 mg/kg). MCAM and naloxone reversed respiratory depression within 30 minutes, although only MCAM antagonized heroin on subsequent days. Thus, MCAM prevents and reverses respiratory depression, the potentially lethal effect of heroin, longer than opioid receptor antagonists currently in use. Because of its sustained effects, MCAM might provide more effective rescue from and protection against the fatal respiratory-depressant effects of opioids, thereby improving treatment of opioid overdose.

Naloxone access for Emergency Medical Technicians: An evaluation of a training program in rural communities

INTRODUCTION

Opioid-related overdose death rates in rural communities in the United States are much higher than their urban counterparts. However, basic life support (BLS) personnel, who are more common in rural areas, have much lower rates of naloxone administration than other levels of emergency medical services (EMS). Training and equipping basic level Emergency Medical Technician (EMTs) to administer naloxone for an opioid overdose could yield positive outcomes.

METHODS

Following a legislative change that allowed EMTs to administer naloxone in one rural state, we evaluated an EMT training program by examining EMTs' opioid overdose knowledge and attitudes before and after the training.

RESULTS

One-hundred-seventeen rural EMTs participated the training. They demonstrated statistically significant improvements on almost all of the knowledge questions after the training (p's = 0.0469 to <0.0001). The opioid overdose competency and concern scales showed statistically significant improvement (p < 0.0001) and reduction (p < 0.0001), respectively. Furthermore, statistically significant changes in knowledge and opinions of state law regarding naloxone administration were observed. Significantly more EMTs supported the idea of expanding naloxone to people at risk for overdose (p = 0.0026) after the training.

CONCLUSIONS

At a time when states are passing legislation to expand first responders' access to naloxone, this study provides evidence about authorizing EMTs to administer naloxone.

Cost-effectiveness of naloxone kits in secondary schools

BACKGROUND

We seek to identify conditions under which a plan by the Toronto District School Board (TDSB) to equip high schools with naloxone kits would be cost-effective.

METHODS

We developed a decision-analytic model to evaluate the costs, benefits, and cost-effectiveness of a school-based naloxone program. We estimated model inputs from the medical literature and used Toronto-specific sources whenever available. We present our results varying both the expected total number of opioid overdoses per year across all 112 TDSB high schools and the effectiveness of a school-based naloxone program in reducing mortality.

RESULTS

A school naloxone program likely costs less than CAD$50,000 per quality-adjusted life-year gained if the overdose frequency is at least once each year and it reduces opioid poisoning mortality by at least 40% (from 10% to <6.0%) or if the overdose frequency is at least two per year and the program reduces mortality by at least 20% (from 10% to <8.0%). The results are sensitive to the intensity and cost of staff training, the lifetime costs and life-expectancy of overdose survivors, and the probability of an overdose being fatal in the absence of a school naloxone program.

CONCLUSIONS

School naloxone programs are relatively inexpensive, but that does not ensure that they are a cost-effective use of resources. While potentially cost-effective, if the risk of an overdose in a Toronto high school is low, then other programs aimed at improving the health and wellbeing of students may be better use of limited resources.

Prediction Model for Two-Year Risk of Opioid Overdose Among Patients Prescribed Chronic Opioid Therapy

BACKGROUND

Naloxone is a life-saving opioid antagonist. Chronic pain guidelines recommend that physicians co-prescribe naloxone to patients at high risk for opioid overdose. However, clinical tools to efficiently identify patients who could benefit from naloxone are lacking.

OBJECTIVE

To develop and validate an overdose predictive model which could be used in primary care settings to assess the need for naloxone.

DESIGN

Retrospective cohort.

SETTING

Derivation site was an integrated health system in Colorado; validation site was a safety-net health system in Colorado.

PARTICIPANTS

We developed a predictive model in a cohort of 42,828 patients taking chronic opioid therapy and externally validated the model in 10,708 patients.

MAIN MEASURES

Potential predictors and outcomes (nonfatal pharmaceutical and heroin overdoses) were extracted from electronic health records. Fatal overdose outcomes were identified from state vital records. To match the approximate shelf-life of naloxone, we used Cox proportional hazards regression to model the 2-year risk of overdose. Calibration and discrimination were assessed.

KEY RESULTS

A five-variable predictive model showed good calibration and discrimination (bootstrap-corrected c-statistic = 0.73, 95% confidence interval [CI] 0.69-0.78) in the derivation site, with sensitivity of 66.1% and specificity of 66.6%. In the validation site, the model showed good discrimination (c-statistic = 0.75, 95% CI 0.70-0.80) and less than ideal calibration, with sensitivity and specificity of 82.2% and 49.5%, respectively.

CONCLUSIONS

Among patients on chronic opioid therapy, the predictive model identified 66-82% of all subsequent opioid overdoses. This model is an efficient screening tool to identify patients who could benefit from naloxone to prevent overdose deaths. Population differences across the two sites limited calibration in the validation site.

Mechanisms and the clinical relevance of complex drug-drug interactions

As a result of an increasing aging population, the number of individuals taking multiple medications simultaneously has grown considerably. For these individuals, taking multiple medications has increased the risk of undesirable drug–drug interactions (DDIs), which can cause serious and debilitating adverse drug reactions (ADRs). A comprehensive understanding of DDIs is needed to combat these deleterious outcomes. This review provides a synopsis of the pharmacokinetic (PK) and pharmacodynamic (PD) mechanisms that underlie DDIs. PK-mediated DDIs affect all aspects of drug disposition: absorption, distribution, metabolism and excretion (ADME). In this review, the cells that play a major role in ADME and have been investigated for DDIs are discussed. Key examples of drug metabolizing enzymes and drug transporters that are involved in DDIs and found in these cells are described. The effect of inhibiting or inducing these proteins through DDIs on the PK parameters is also reviewed. Despite most DDI studies being focused on the PK effects, DDIs through PD can also lead to significant and harmful effects. Therefore, this review outlines specific examples and describes the additive, synergistic and antagonistic mechanisms of PD-mediated DDIs. The effects DDIs on the maximum PD response (E_max) and the drug dose or concentration (EDEC₅₀) that lead to 50% of E_max are also examined. Significant gaps in our understanding of DDIs remain, so innovative and emerging approaches are critical for overcoming them.

State naloxone access laws are associated with an increase in the number of naloxone prescriptions dispensed in retail pharmacies

BACKGROUND

In response to the ongoing opioid overdose epidemic, many states have enacted laws increasing naloxone access by lay people, such as friends and family members of people who use drugs (PWUD), as well as PWUD themselves.

METHOD

We utilized Symphony Health Solutions' PHAST Prescription data from 2007 to 2016 to investigate whether naloxone access laws were associated with an increase in naloxone dispensed from retail pharmacies in the United States.

RESULT

Using a negative binomial regression, we found that naloxone access laws were associated with an average increase of 78 prescriptions dispensed per state per quarter. This represents an average 79% increase in naloxone dispensed from U.S. retail pharmacies, compared with states where there were no such laws.

CONCLUSION

Our study suggests that naloxone access laws can increase the availability and accessibility of naloxone.

Awareness and access to naloxone necessary but not sufficient: Examining gaps in the naloxone cascade

BACKGROUND

Despite promising findings of opioid overdose education and naloxone distribution (OEND) programs, overdose continues to be a major cause of mortality. The "cascade of care" is a tool for identifying steps involved in achieving optimal health outcomes. We applied the cascade concept to identify gaps in naloxone use.

METHODS

Data came from a cross-sectional survey of 353 individuals aged 18 and older who self-reported lifetime history of heroin use.

RESULTS

The sample was majority male (65%) and reported use of heroin (74%) and injection (57%) in the past 6 months. Ninety percent had ever witnessed an overdose and of these 59% were in the prior year. Awareness of naloxone (90%) was high. Of those aware, over two-thirds reported having ever received (e.g. access) (69%) or been trained to use naloxone (60%). Of those who had ever received naloxone (n = 218) over one-third reported possession never (36%) or rarely/sometimes carrying naloxone (38%), while 26% reported always carrying. Nearly half of those who had ever received naloxone reported ever use to reverse an opiate overdose (45%). Among individuals who had ever received naloxone, possession often/always compared to never was associated with being female (RRR = 2.88, 95%CI = 1.31-6.27) and ever used naloxone during an overdose (RRR = 4.68, 95%CI = 2.00-11.0).

CONCLUSIONS

This study identifies that consistent possession is a gap in the naloxone cascade. Future research is needed to understand reasons for not always carrying naloxone.

[Diagnosis, differential diagnosis and therapy of substance use disorders in general hospital (general section)]

Substance use disorders are becoming an increasingly significant problem in general hospitals and hence play a key role in consultation- and liaison psychiatry. Diverse psychotropic effects of various substances mimic psychiatric disorders. An alcohol intoxication can present depressive or manic symptoms, a cannabis delirium can present as a psychosis while stimulants use can suggest the diagnosis of an anxiety disorder. Obtaining dual diagnoses by identifying substance-induced and non-substance-induced psychopathologies is clinically challenging.The aim of this article is to systematically describe the psychopathology, pathophysiology and therapeutic options of substance-use disorders particularly relevant for consultation and liaison psychiatry.

Pharmacokinetic properties of intranasal and injectable formulations of naloxone for community use: a systematic review

Aim: To assess the pharmacokinetic properties of community-use formulations of naloxone for emergency treatment of opioid overdose. Methods: Systematic literature review based on searches of established databases and congress archives. Results: Seven studies met inclusion criteria: two of US FDA-approved intramuscular (im.)/subcutaneous (sc.) auto-injectors, one of an FDA-approved intranasal spray, two of unapproved intranasal kits (syringe with atomizer attachment) and two of intranasal products in development. Conclusion: The pharmacokinetics of im./sc. auto-injector 2 mg and approved intranasal spray (2 and 4 mg) demonstrated rapid uptake and naloxone exposure exceeding that of the historic benchmark (0.4 mg im.), indicating that naloxone exposure was adequate for reversal of opioid overdose.

Co-prescribing naloxone does not increase liability risk

The opioid overdose epidemic claims the lives of tens of thousands of Americans every year. Opioid overdose is reversible by the administration of naloxone, a pure antagonist now available in formulations specifically designed and labeled for layperson use. Despite broad support for layperson access to naloxone from professional organizations, health officials, and clinical experts, qualitative studies suggest that some providers have concerns about legal risks associated with naloxone prescribing, particularly co-prescribing naloxone to pain patients. Such concerns are unfounded. The legal risk associated with prescribing naloxone is no higher than that associated with any other medication and is lower than many. Additionally, laws in a majority of states provide explicit legal protections for providers who prescribe or dispense naloxone, in many cases extending this protection to prescriptions issued to friends, family members, and others. In this large and increasing number of states, the liability risk of prescribing or dispensing naloxone in good faith to a patient at risk of overdose (or, in states where such prescribing is permitted, to an associate of such a patient) is either extremely low or absent entirely. Where a prescriber determines, in his or her clinical judgment, that a patient is at risk of overdose, co-prescribing naloxone is a reasonable and prudent clinical and legal decision. No clinician should fail or refuse to issue such a prescription based on liability concerns.

Validation of a Screening Risk Index for Serious Prescription Opioid-Induced Respiratory Depression or Overdose in a US Commercial Health Plan Claims Database

Objective

To validate a risk index that estimates the likelihood of overdose or serious opioid-induced respiratory depression (OIRD) among medical users of prescription opioids.

Subjects and Methods

A case-control analysis of 18,365,497 patients with an opioid prescription from 2009 to 2013 in the IMS PharMetrics Plus commercially insured health plan claims database (CIP). An OIRD event occurred in 7,234 cases. Four controls were selected per case. Validity of the Risk Index for Overdose or Serious Opioid-induced Respiratory Depression (RIOSORD), developed previously using Veterans Health Administration (VHA) patient data, was assessed. Multivariable logistic regression was used within the CIP study population to develop a slightly refined RIOSORD. The composition and performance of the CIP-based RIOSORD was evaluated and compared with VHA-based RIOSORD.

Results

VHA-RIOSORD performed well in discriminating OIRD events in CIP (C-statistic = 0.85). Additionally, re-estimation of logistic model coefficients in CIP yielded a 0.90 C-statistic. The resulting comorbidity and pharmacotherapy variables most highly associated with OIRD and retained in the CIP-RIOSORD were largely concordant with VHA-RIOSORD. These variables included neuropsychiatric and cardiopulmonary disorders, impaired drug excretion, opioid characteristics, and concurrent psychoactive medications. The average predicted probability of OIRD ranged from 2% to 83%, with excellent agreement between predicted and observed incidence across risk classes.

Conclusions

RIOSORD had excellent predictive accuracy in a large population of US medical users of prescription opioids, similar to its performance in VHA. This practical risk index is designed to support clinical decision-making for safer opioid prescribing, and its clinical utility should be evaluated prospectively.

Progress in understanding mechanisms of opioid-induced gastrointestinal adverse effects and respiratory depression

Opioids evoke analgesia through activation of opioid receptors (predominantly the μ opioid receptor) in the central nervous system. Opioid receptors are abundant in multiple regions of the central nervous system and the peripheral nervous system including enteric neurons. Opioid-related adverse effects such as constipation, nausea, and vomiting pose challenges for compliance and continuation of the therapy for chronic pain management. In the post-operative setting opioid-induced depression of respiration can be fatal. These critical limitations warrant a better understanding of their underpinning cellular and molecular mechanisms to inform the design of novel opioid analgesic molecules that are devoid of these unwanted side-effects. Research efforts on opioid receptor signalling in the past decade suggest that differential signalling pathways and downstream molecules preferentially mediate distinct pharmacological effects. Additionally, interaction among opioid receptors and, between opioid receptor and non-opioid receptors to form signalling complexes shows that opioid-induced receptor signalling is potentially more complicated than previously thought. This complexity provides an opportunity to identify and probe relationships between selective signalling pathway specificity and in vivo production of opioid-related adverse effects. In this review, we focus on current knowledge of the mechanisms thought to transduce opioid-induced gastrointestinal adverse effects (constipation, nausea, vomiting) and respiratory depression.

Is naloxone the best antidote to reverse tramadol-induced neuro-respiratory toxicity in overdose? An experimental investigation in the rat

CONTEXT

Since the banning of dextropropoxyphene from the market, overdoses, and fatalities attributed to tramadol, a WHO step-2 opioid analgesic, have increased markedly. Tramadol overdose results not only in central nervous system (CNS) depression attributed to its opioid properties but also in seizures, possibly related to non-opioidergic pathways, thus questioning the efficiency of naloxone to reverse tramadol-induced CNS toxicity.

OBJECTIVE

To investigate the most efficient antidote to reverse tramadol-induced seizures and respiratory depression in overdose.

MATERIALS AND METHODS

Sprague-Dawley rats overdosed with 75 mg/kg intraperitoneal (IP) tramadol were randomized into four groups to receive solvent (control group), diazepam (1.77 mg/kg IP), naloxone (2 mg/kg intravenous bolus followed by 4 mg/kg/h infusion), and diazepam/naloxone combination. Sedation depth, temperature, number of seizures, and intensity, whole-body plethysmography parameters and electroencephalography activity were measured.

RESULTS

Naloxone reversed tramadol-induced respiratory depression (p < .05) but significantly increased seizures (p < .01) and prolonged their occurrence time. Diazepam abolished seizures but significantly deepened rat sedation (p < .05) without improving ventilation. Diazepam/naloxone combination completely abolished seizures, significantly improved rat ventilation by reducing inspiratory time (p < .05) but did not worsen sedation. None of these treatments significantly modified rat temperature.

CONCLUSIONS

Diazepam/naloxone combination is the most efficient antidote to reverse tramadol-induced CNS toxicity in the rat.

Antidote to cannabinoid intoxication: the CB1 receptor inverse agonist, AM251, reverses hypothermic effects of the CB1 receptor agonist, CB-13, in mice

BACKGROUND AND PURPOSE

Cannabis is a recreational drug leading to intoxication, following stimulation of cannabinoid CB1 receptors. However, more recently, herbs mixed with synthetic cannabinoids sometimes known as 'Spice' and 'Black Mamba' have been increasingly used, and their high CB1 receptor affinity has led not only to marked intoxication but also life-threatening complications and an increasing number of deaths. Although many studies have indicated that prophylactic treatment with CB1 receptor antagonists can block cannabimimetic effects in animals and humans, the aim of this study was to determine whether CB1 receptor antagonism could reverse physical cannabimimetic effects.

EXPERIMENTAL APPROACH

Cannabimimetic effects, measured by the hypothermic response following sedation and hypomotility, were induced by the synthetic CB1 receptor agonist CB-13 (1-naphthalenyl[4-(pentyloxy)-1-naphthalenyl]methanone) in Biozzi Antibody High mice. The CB1 receptor antagonist/inverse agonist AM251 (N-(piperidin-1-yl)-5-(4-iodophenyl)-1-(2, 4-dichlorophenyl)-4-methyl-1H-pyrazole-3-carboxamide) was administered 20 min after the injection of CB-13 and its effects on the cannabimimetic responses were assessed.

KEY RESULTS

In this study, the CNS-related cannabimimetic effects, as measured by the hypothermic effect, induced by the CB1 receptor agonist were therapeutically treated and were rapidly reversed by the CB1 receptor antagonist/inverse agonist. There was also a subjective reversal of visually evident sedation.

CONCLUSIONS AND IMPLICATIONS

Cannabinoid receptor antagonists have been widely used and so may provide an acceptable single-dose antidote to cannabinoid intoxication. This use may save human life, where the life-threatening effects are mediated by cannabinoid receptors and not off-target influences of the synthetic cannabinoids or non-cannabinoids within the recreational drug mixture.

Intranasal naloxone and related strategies for opioid overdose intervention by nonmedical personnel: a review

Deaths due to prescription and illicit opioid overdose have been rising at an alarming rate, particularly in the USA. Although naloxone injection is a safe and effective treatment for opioid overdose, it is frequently unavailable in a timely manner due to legal and practical restrictions on its use by laypeople. As a result, an effort spanning decades has resulted in the development of strategies to make naloxone available for layperson or "take-home" use. This has included the development of naloxone formulations that are easier to administer for nonmedical users, such as intranasal and autoinjector intramuscular delivery systems, efforts to distribute naloxone to potentially high-impact categories of nonmedical users, as well as efforts to reduce regulatory barriers to more widespread distribution and use. Here we review the historical and current literature on the efficacy and safety of naloxone for use by nonmedical persons, provide an evidence-based discussion of the controversies regarding the safety and efficacy of different formulations of take-home naloxone, and assess the status of current efforts to increase its public distribution. Take-home naloxone is safe and effective for the treatment of opioid overdose when administered by laypeople in a community setting, shortening the time to reversal of opioid toxicity and reducing opioid-related deaths. Complementary strategies have together shown promise for increased dissemination of take-home naloxone, including 1) provision of education and training; 2) distribution to critical populations such as persons with opioid addiction, family members, and first responders; 3) reduction of prescribing barriers to access; and 4) reduction of legal recrimination fears as barriers to use. Although there has been considerable progress in decreasing the regulatory and legal barriers to effective implementation of community naloxone programs, significant barriers still exist, and much work remains to be done to integrate these programs into efforts to provide effective treatment of opioid use disorders.

Beyond rescue: Implementation and evaluation of revised naloxone training for law enforcement officers

OBJECTIVE

This study describes the implementation and evaluation of revised opioid overdose prevention and education of naloxone training for law enforcement officers (LEOs) that added: (1) a recovery testimony and (2) the process for deputy-initiated referrals postnaloxone administration.

DESIGN AND SAMPLE

Evaluation regarding the naloxone training included a pre- and postopioid overdose knowledge surveys (N = 114) and subsequent 1-year postnaloxone training outcomes.

RESULTS

Pre- and posttest scores for all knowledge outcome measures were statistically significant (p < .001) with favorable comments pertaining to the recovery testimony. Out of 31 individuals who received naloxone, 6 individuals (19.4%) continue to be in treatment or received some treatment services. The most common symptoms reported were unconsciousness/unresponsiveness (40.5%), abnormal breathing patterns (24.3%), and blue lips (16.2%). The majority of the calls (65.6%) were to a residential area, and the time for naloxone revival ranged <1-10 min (M = 3.48; SD = 2.27).

CONCLUSION

As nearly 20% of individuals sought treatment after a LEO-initiated referral, it is recommended that other agencies consider the referral process into the training. Future research will investigate the impact of the recovery testimony in reducing the stigma of addiction.

Naloxone prolongs cutaneous nociceptive block by lidocaine in rats

We aimed to investigate the local anesthetic properties of naloxone alone or as an adjunct for the local anesthetic lidocaine. After the block of the cutaneous trunci muscle reflex (CTMR) with drugs delivery by subcutaneous infiltration, cutaneous nociceptive block was tested on the ratsꞌ backs. We demonstrated that naloxone, as well as lidocaine, elicited cutaneous analgesia dose-dependently. The relative potency in inducing cutaneous analgesia was lidocaine [22.6 (20.1 - 25.4) μmol/kg] > naloxone [43.2 (40.3 - 46.4) μmol/kg] (P < 0.05). On an equianesthetic basis [50% effective dose (ED₅₀ ), ED₂₅ , and ED₇₅ ], naloxone displayed a greater duration of cutaneous analgesic action than lidocaine (P < 0.01). Coadministration of lidocaine (ED₉₅ or ED₅₀ ) and ineffective-dose naloxone (13.3 μmol/kg) intensifies sensory block (P < 0.01) with prolonged duration of action (P < 0.001) compared with lidocaine (ED₉₅ or ED₅₀ ) alone or naloxone (13.3 μmol/kg) alone on infiltrative cutaneous analgesia. The preclinical data showed that naloxone is less potent than lidocaine as an infiltrative anesthetic, but its analgesic duration was longer than that of lidocaine. Furthermore, naloxone prolongs lidocaine analgesia, acting synergistically for nociceptive block.

Cardiac Arrest Following Drug Abuse with Intravenous Tapentadol: Case Report and Literature Review

BACKGROUND Tapentadol is a centrally acting opioid analgesic, with a dual mode of action, as a norepinephrine reuptake inhibitor and an agonist of the μ-opioid receptor (MOR). Tapentadol is used for the management of musculoskeletal pain, and neuropathic pain associated with diabetic peripheral neuropathy. CASE REPORT A 32-year-old woman attended hospital for evaluation of an intractable headache. Computed tomography and magnetic resonance imaging of the brain were negative. She was found unresponsive in the bathroom on the day following hospital admission, and despite resuscitative measures, the patient died following cardiac arrest. Autopsy toxicology revealed significantly elevated levels of tapentadol, and bedside evidence suggested that the patient had self-administered this medication intravenously before her death. CONCLUSIONS We report a rare adverse effect of tapentadol causing respiratory depression leading to cardiac arrest. Medical examiners and forensic toxicologists should be aware of the toxicity of this novel opiate drug.

A New Tool to Tackle the Opioid Epidemic: Description, Utility, and Results from the Maine Diversion Alert Program

STUDY OBJECTIVE

The opioid epidemic continues to impact the United States, and new strategies are needed to combat this epidemic. The objective of this study was to analyze 2015 drug arrest data from Maine's Diversion Alert (DA) program (diversionalert.org), compare arrest data between the first quarters of 2015 and 2016, and provide an analysis of the sex differences in the arrests as well as information about DA use.

STUDY DESIGN

This was a population-based descriptive study using data from the Maine DA program. The study population consisted of persons arrested for prescription, nonprescription, or illicit drugs.

DATA SOURCE

DA database.

MEASUREMENTS AND MAIN RESULTS

The DA program addresses Maine's prescription drug abuse epidemic with innovative resources that provide access to drug arrest data for health care providers to identify and respond to patients at risk for overdose, those engaged in illegal prescription drug distribution, and those who need treatment. Drug arrest data from 2015 (2723 arrests) and the first quarter of 2016 (788 arrests) were compared and analyzed. The drugs implicated in the arrests were organized by Drug Enforcement Agency (DEA) schedule category and whether they were pharmaceuticals (synthesized and distributed by a pharmaceutical company) or nonpharmaceuticals (grown or synthesized in clandestine laboratories). Most arrests were for possession (64.5%) followed by trafficking (23.8%). Heroin was listed in more than three-quarters (76.4%) of the Schedule I arrests, followed by marijuana (11.7%) and "bath salts" (6.3%). Cocaine and crack cocaine were implicated in almost half (46.7%) of the Schedule II arrests, followed by oxycodone (21.0%) and methamphetamine/amphetamine (15.8%). Buprenorphine was responsible for almost all (96.7%) of the Schedule III arrests. The benzodiazepines alprazolam (34.3%), clonazepam (33.8%), diazepam (11.9%), and lorazepam (8.5%) were listed in the preponderance of the Schedule IV arrests. Arrests increased in 2016 by 49.2% for heroin (p<0.01) and 170.0% for methamphetamine (p≤0.0005) relative to 2015. Arrests for trafficking increased by 42.9% (p<0.05). Males outnumbered females 2:1 in DA. Schedule IV agents accounted for only 6.8% of arrests for males versus 11.5% for females (p≤0.0001). Conversely, Schedule I agents were implicated in 33.0% of arrests for males versus only 27.3% for females (p<0.005).

CONCLUSION

DA is an important tool for providing timely information for health care providers regarding individuals with a history of past misuse of psychotherapeutic agents, particularly opioids and stimulants.

Opioid Addiction: Social Problems Associated and Implications of Both Current and Possible Future Treatments, including Polymeric Therapeutics for Giving Up the Habit of Opioid Consumption

BACKGROUND

Detoxification programmes seek to implement the most secure and compassionate ways of withdrawing from opiates so that the inevitable withdrawal symptoms and other complications are minimized. Once detoxification has been achieved, the next stage is to enable the patient to overcome his or her drug addiction by ensuring consumption is permanently and completely abandoned, only after which can the subject be regarded as fully recovered.

METHODS

A systematic search on the common databases of relevant papers published until 2016 inclusive.

RESULTS AND CONCLUSION

Our study of the available oral treatments for opioid dependence has revealed that no current treatment can actually claim to be fully effective. These treatments require daily oral administration and, consequently, regular visits to dispensaries, which in most cases results in a lack of patient compliance, which causes fluctuations in drug plasma levels. We then reviewed alternative treatments in the available scientific literature on polymeric sustained release formulations. Research has been done not only on release systems for detoxification but also on release systems for giving up the habit of taking opioids. These efforts have obtained the recent authorization of polymeric systems for use in patients that could help them to reduce their craving for drugs.

Combating Opioid Overdose With Public Access to Naloxone

PURPOSE

Opioid overdose deaths have become an escalating epidemic in the United States. To combat this complex issue, naloxone distribution to the public has been initiated in many states as a harm reduction strategy. While supportive legislation develops and community programs expand, research- and policy-focused literature surrounding this timely topic require exploration, compilation, and analysis. The purpose of this systematic review is to identify trends in the current literature, gaps in the findings, nursing implications, and opportunities for further exploration.

METHODS

Following a systematic approach, the keywords "naloxone" and "opioid overdose" were used to retrieve articles through the search engines Academic Search Premier, CINAHL Complete, MEDLINE Complete, PubMed, and Psychology and Behavior Sciences Collection.

FINDINGS

In the 38 articles selected for the final review, six categories were discussed: global trends, U.S. overdose education programs with naloxone distribution, barriers to public access of naloxone, political opposition and support, financial impact, and recommendations. After reviewing the findings, gaps in the literature were examined, and nursing implications were acknowledged.

ORIGINALITY AND VALUE

Although many authors have researched and discussed public naloxone distribution, a comprehensive review of the current evidence is useful and necessary to enhance future research, practice, and policy efforts. By discovering significant gaps in the literature and by recognizing opportunities for nursing practice, this literature review provides valuable input for healthcare professionals, public health officials, policymakers, and laypersons to better understand an ethically, politically, and socially complicated public health initiative.

Characterization and Management of Patients with Heroin versus Nonheroin Opioid Overdoses: Experience at an Academic Medical Center

STUDY OBJECTIVES

To characterize the differences between patients who had heroin and nonheroin opioid overdoses and to determine whether there were any significant differences in their management with regard to the naloxone use.

DESIGN

Retrospective cohort study.

SETTING

Large academic medical center.

PATIENTS

A total of 923 patients admitted to the medical center who were identified for overdose by heroin or other opiate-related narcotics between January 2010 and September 2015; 480 patients experienced a nonheroin opioid overdose event, and 443 patients experienced a heroin overdose event.

MEASUREMENTS AND MAIN RESULTS

Patients presenting with heroin overdose tended to be younger and male, with higher rates of hepatitis C virus (HCV) infection compared with those presenting with nonheroin opioid overdose (p<0.05). Patients in the heroin group were also more likely to have a previous overdose event, history of injection drug use, and history of prescription opioid abuse compared with the nonheroin group (p<0.05). Those presenting with heroin overdose were more likely to receive naloxone in the prehospital setting (p<0.05) but were less likely to receive naloxone once admitted (p<0.05). Patients with nonheroin opioid overdoses required more continuous infusions of naloxone (p<0.05) and admission to the intensive care unit (p<0.05). Of all 923 patients, 178 (19.3%) had a repeat admission for any reason, and 70 (7.6%) were readmitted over the course of the study period for another overdose event with the same drug. The proportion of patients presenting with a heroin overdose steadily increased from 2010-2015; the number of patients presenting to the emergency department with nonheroin opioid overdoses steadily decreased. As rates of heroin overdose increased each year, the incidence of HCV infection increased dramatically.

CONCLUSION

This study indicates that the incidence of heroin overdoses has significantly increased over the last several years, and the rates of HCV infection 4-fold since the start of the study period. Patients admitted for nonheroin opioid overdose were more likely to be admitted to the hospital and intensive care unit compared with those admitted for heroin overdose. The rise in overdose events only further illustrates a gap in our understanding of the cycle of addiction, drug abuse, and overdose events.

A review: Fentanyl and non-pharmaceutical fentanyls

BACKGROUND

Fentanyl and non-pharmaceutical fentanyls (NPFs) have been responsible for numerous outbreaks of overdoses all over the United States since the 1970s. However, there has been a growing concern in recent years that NPFs are contributing to an alarming rise in the number of opioid-related overdoses.

METHODS

The authors conducted a narrative review of the published and grey literature on fentanyl and NPFs in PubMed, Google Scholar, and Google using the following search terms: "fentanyl", "non-pharmaceutical fentanyl", "fentanyl analogs", "fentanyl laced heroin" and "fentanyl overdose". References from relevant publications and grey literature were also reviewed to identify additional citations for inclusion.

RESULTS

The article reviews the emergence and misuse of fentanyl and NPFs, their clinical pharmacology, and the clinical management and prevention of fentanyl-related overdoses.

CONCLUSIONS

Fentanyl and NPFs may be contributing to the recent rise in overdose deaths in the United States. There is an urgent need to educate clinicians, researchers, and patients about this public health threat.