Effectiveness of Scotland's National Naloxone Programme for reducing opioid-related deaths: a before (2006-10) versus after (2011-13) comparison

Modelling the combined impact of interventions in averting deaths during a synthetic-opioid overdose epidemic

BACKGROUND AND AIMS

The province of British Columbia (BC) Canada has experienced a rapid increase in illicit drug overdoses and deaths during the last 4 years, with a provincial emergency declared in April 2016. These deaths have been driven primarily by the introduction of synthetic opioids into the illicit opioid supply. This study aimed to measure the combined impact of large-scale opioid overdose interventions implemented in BC between April 2016 and December 2017 on the number of deaths averted.

DESIGN

We expanded on the mathematical modelling methodology of our previous study to construct a Bayesian hierarchical latent Markov process model to estimate monthly overdose and overdose-death risk, along with the impact of interventions.

SETTING AND CASES

Overdose events and overdose-related deaths in BC from January 2012 to December 2017.

INTERVENTIONS

The interventions considered were take-home naloxone kits, overdose prevention/supervised consumption sites and opioid agonist therapy MEASUREMENTS: Counterfactual simulations were performed with the fitted model to estimate the number of death events averted for each intervention and in combination.

FINDINGS

Between April 2016 and December 2017, BC observed 2177 overdose deaths (77% fentanyl-detected). During the same period, an estimated 3030 (2900-3240) death events were averted by all interventions combined. In isolation, 1580 (1480-1740) were averted by take-home naloxone, 230 (160-350) by overdose prevention services and 590 (510-720) were averted by opioid agonist therapy.

CONCLUSIONS

A combined intervention approach has been effective in averting overdose deaths during British Columbia's opioid overdose crisis in the period since declaration of a public health emergency (April 2016-December 2017). However, the absolute numbers of overdose deaths have not changed.

Cost-effectiveness analysis of alternative naloxone distribution strategies: First responder and lay distribution in the United States

BACKGROUND

The U.S. is facing an unprecedented number of opioid-related overdose deaths, and an array of other countries have experienced increases in opioid-related fatalities. In the U.S., naloxone is increasingly distributed to first responders to improve early administration to overdose victims, but its cost-effectiveness has not been studied. Lay distribution, in contrast, has been found to be cost-effective, but rising naloxone prices and increased mortality due to synthetic opioids may reduce cost-effectiveness. We evaluate the cost-effectiveness of increased naloxone distribution to (a) people likely to witness or experience overdose ("laypeople"); (b) police and firefighters; (c) emergency medical services (EMS) personnel; and (d) combinations of these groups.

METHODS

We use a decision-analytic model to analyze the cost-effectiveness of eight naloxone distribution strategies. We use a lifetime horizon and conduct both a societal analysis (accounting for productivity and criminal justice system costs) and a health sector analysis. We calculate: the ranking of strategies by net monetary benefit; incremental cost-effectiveness ratios; and number of fatal overdoses.

RESULTS

High distribution to all three groups maximized net monetary benefit and minimized fatal overdoses; it averted 21% of overdose deaths compared to minimum distribution. High distribution to laypeople and one of the other groups comprised the second and third best strategies. The majority of health gains resulted from increased lay distribution. In the societal analysis, every strategy was cost-saving compared to its next-best alternative; cost savings were greatest in the maximum distribution strategy. In the health sector analysis, all undominated strategies were cost-effective. Results were highly robust to deterministic and probabilistic sensitivity analysis.

CONCLUSIONS

Increasing naloxone distribution to laypeople and first responder groups would maximize health gains and be cost-effective. If feasible, communities should distribute naloxone to all groups; otherwise, distribution to laypeople and one of the first responder groups should be emphasized.

Justice involvement patterns, overdose experiences, and naloxone knowledge among men and women in criminal justice diversion addiction treatment

Background

Persons in addiction treatment are likely to experience and/or witness drug overdoses following treatment and thus could benefit from overdose education and naloxone distribution (OEND) programs. Diverting individuals from the criminal justice system to addiction treatment represents one treatment engagement pathway, yet OEND needs among these individuals have not been fully described.

Methods

We characterized justice involvement patterns among 514 people who use opioids (PWUO) participating in a criminal justice diversion addiction treatment program during 2014–2016 using a gender-stratified latent class analysis. We described prevalence and correlates of naloxone knowledge using quasi-Poisson regression models with robust standard errors.

Results

Only 56% of participants correctly identified naloxone as an opioid overdose treatment despite that 68% had experienced an overdose and 79% had witnessed another person overdose. We identified two latent justice involvement classes: low involvement (20.3% of men, 46.5% of women), characterized by older age at first arrest, more past-year arrests, and less time incarcerated; and high involvement (79.7% of men, 53.5% of women), characterized by younger age at first arrest and more lifetime arrests and time incarcerated. Justice involvement was not associated with naloxone knowledge. Male participants who had personally overdosed more commonly identified naloxone as an overdose treatment after adjustment for age, race, education level, housing status, heroin use, and injection drug use (prevalence ratio [95% confidence interval]: men 1.5 [1.1–2.0]).

Conclusions

All PWUO in criminal justice diversion programs could benefit from OEND given the high propensity to experience and witness overdoses and low naloxone knowledge across justice involvement backgrounds and genders.

Electronic supplementary material

The online version of this article (10.1186/s12954-019-0317-3) contains supplementary material, which is available to authorized users.

Balancing opioid analgesia with the risk of nonmedical opioid use in patients with cancer

The current opioid crisis has brought renewed attention and scrutiny to opioid prescriptions. When patients receiving opioid therapy for pain engage in nonmedical opioid use (NMOU) or diversion, untoward consequences can occur. New evidence suggests that patients with cancer might be at a higher risk of NMOU than was previously thought, but clinical evidence still supports the use of opioid analgesics as the gold standard to treat cancer-related pain, creating a dilemma in patient management. Clinicians are encouraged to adopt a universal precautions approach to patients with cancer receiving opioids, which includes screening all patients; discussing the risks, benefits, adverse effects and alternatives of opioid therapy; and providing education on safe use, storage and disposal. Use of urine drug tests, prescription drug monitoring programmes and close observation of behaviours related to opioid use help to ensure treatment adherence, detect NMOU and support therapeutic decision-making. These measures can optimize the risk-benefit ratio while supporting safe opioid use. In this Review, we examine the role of opioids in cancer pain, the risk of substance use disorder and methods to achieve the right balance between the two in order to ensure safe opioid use.

Implementing an Opioid Risk Reduction Program in the Acute Comprehensive Inpatient Rehabilitation Setting

OBJECTIVE

To describe the implementation and evaluation of an interdisciplinary quality improvement (QI) project to increase prescription of take-home naloxone (THN) to reduce risks associated with opioids for patients admitted to an acute inpatient rehabilitation unit.

DESIGN

Prospective cohort quality improvement project.

SETTING

Eighteen-bed acute comprehensive inpatient rehabilitation (ACIR) unit at a large academic institution.

PARTICIPANTS

Patients admitted to ACIR between December 2015-November 2016 (N=788).

INTERVENTIONS

An interdisciplinary QI model comprised of planning, education, implementation, and maintenance was used to implement a THN and opioid risk-reduction program involving provider and patient education. Analyses consisted of comparisons between baseline, early, and late phases of the project.

MAIN OUTCOME MEASURES

(1) The proportion of eligible patients who received a prescription for naloxone upon discharge from ACIR; (2) the proportion of patients originally admitted to ACIR on opioids that were weaned off upon discharge.

RESULTS

The adjusted odds of eligible patients being discharged from ACIR with a naloxone prescription during the late QI period were 7 (95% confidence interval [CI]: 3-21) times higher than during the early QI period (late QI period: 43%, 95% CI: 25%-63%; early QI period: 10%, 95% CI: 3%-28%; P<.001). For patients admitted on opioids, the adjusted odds of being weaned off opioids during the late QI period were 10 (95% CI: 4-25) times higher than during baseline (late QI period: 29%, 95% CI: 17%-45%; baseline: 4%, 95% CI: 1%-10%; P<.001).

CONCLUSIONS

Implementation of a THN and opioid risk reduction QI project in an inpatient rehabilitation setting led to significantly more eligible patients receiving naloxone and more patients weaned off schedule II opioids.

Documenting need for naloxone distribution in the Los Angeles County jail system

BACKGROUND

The Los Angeles County Jail system is the largest jail system in the United States, with an average daily inmate population of 17,024 in 2017. Existing literature shows the weeks following release from incarceration are associated with increased risk of overdose death among individuals who previously used opioids. One response is to train inmates in overdose prevention and response (OPR) and to provide the opioid antagonist naloxone on release. However, in large jail systems training all inmates can be logistically and financially difficult, leading to interest identifying individuals most likely to benefit from such programs.

METHOD

In 2017, the Los Angeles County Office of Diversion and Reentry collaborated with the Los Angeles County Sheriff Department to conduct an OPR needs assessment evaluation with all inmates entering the jail over a two week period.

RESULTS

3781 inmates provided complete data for this analysis (3315 men, 466 women). 17% reported using opioids within the last 12 months, 7% reported witnessing an overdose within the last 12 months, and 5% report ever having received medication assisted treatment (MAT). 39% reported interest in being trained in overdose prevention and response. The single largest predictor of interest in OPR was being present at an overdose in the past year.

CONCLUSION

Our results suggest OPR should be provided to all inmates who opt-in to receiving training regardless of other risk factors. Our results also suggest this population has had little prior exposure to MAT and incarceration could represent a significant opportunity to provide such evidence-based treatments.

Non drug-related and opioid-specific causes of 3262 deaths in Scotland's methadone-prescription clients, 2009-2015

BACKGROUND

Opioid drug use is a major cause of premature mortality, with opioid substitution therapy the leading intervention. As methadone-clients age, non-drug-related deaths (non-DRDs) predominate and DRD-risks increase differentially, quadrupling at 45+ years for methadone-specific DRDs.

METHODS

36,606 methadone-prescription-clients in Scotland during 2009-2015 were linked to mortality records to end-2015 by their Community Health Index (CHI). Cohort-entry, also baseline quantity of prescribed methadone, were defined by clients' first CHI-identified methadone-prescription during 2009-2015. National Records of Scotland identified non-DRDs from DRDs; and provided ICD10 codes for underlying and co-present causes of death. Methadone-specific DRD means methadone was implicated in DRD but neither heroin nor buprenorphine.

RESULTS

During 193,800 person-years of follow-up, 1939 non-DRDs (59%) and 1323 DRDs occurred, of which 546 were methadone-specific. Predominant underlying ICD10 chapters for non-DRDs were: neoplasm (377); external causes (341); diseases of digestive (303), circulatory (286) or respiratory (212) system. As methadone-clients aged, the non-DRD proportion of their deaths increased from 54% (717/1318) at 35-44 years to 89% (372/417) at 55+ years. After allowing for DRDs' opioid-specificity, age-group and quintile for last-prescribed methadone, there was a significant, positive interaction for co-present circulatory disease between top-quintile for prescribed methadone and 45+ years at death (p = 0.033 after Bonferroni); not for digestive or respiratory co-presence.

CONCLUSIONS

Circulatory disease is the co-morbidity most likely implicated in the quadrupling of methadone-specific DRD-risk at 45+ years; followed by digestive disease. Cultural shift is needed in treatment-services because degenerative non-DRDs predominate as methadone-clients age. Future linkage-studies should access hospitalizations and methadone-daily-dose.

How competent are people who use opioids at responding to overdoses? Qualitative analyses of actions and decisions taken during overdose emergencies

BACKGROUND AND AIMS

Providing take-home naloxone (THN) to people who use opioids is an increasingly common strategy for reversing opioid overdose. However, implementation is hindered by doubts regarding the ability of people who use opioids to administer naloxone and respond appropriately to overdoses. We aimed to increase understanding of the competencies required and demonstrated by opioid users who had recently participated in a THN programme and were subsequently confronted with an overdose emergency.

DESIGN

Qualitative study designed to supplement findings from a randomized controlled trial of overdose education and naloxone distribution. Interviews were audio-recorded, transcribed, systematically coded and analysed via Iterative Categorization.

SETTING

New York City, USA.

PARTICIPANTS

Thirty-nine people who used opioids (32 men, 7 women; aged 22-58 years).

INTERVENTION

Trial participants received brief or extended overdose training and injectable or nasal naloxone.

MEASUREMENTS

The systematic coding frame comprised deductive codes based on the topic guide and more inductive codes emerging from the data.

FINDINGS

In 38 of 39 cases the victim was successfully resuscitated; the outcome of one overdose intervention was unknown. Analyses revealed five core overdose response 'tasks': (1) overdose identification; (2) mobilizing support; (3) following basic first aid instructions; (4) naloxone administration; and (5) post-resuscitation management. These tasks comprised actions and decisions that were themselves affected by diverse cognitive, emotional, experiential, interpersonal and social factors over which lay responders often had little control. Despite this, participants demonstrated high levels of competency. They had acquired new skills and knowledge through training and brought critical 'insider' understanding to overdose events and the resuscitation actions which they applied.

CONCLUSIONS

People who use opioids can be trained to respond appropriately to opioid overdoses and thus to save their peers' lives. Overdose response requires both practical competency (e.g. skills and knowledge in administering basic first aid and naloxone) and social competency (e.g. willingness to help others, having the confidence to be authoritative and make decisions, communicating effectively and demonstrating compassion and care to victims post-resuscitation).

Mortality, cause of death and risk factors in patients with alcohol use disorder alone or poly-substance use disorders: a 19-year prospective cohort study

BACKGROUND

This study investigated cause of death, mortality rates and explored if baseline characteristics were associated with risk of death in patients with alcohol use disorder alone or poly-substance use disorders.

METHODS

This was a prospective, longitudinal study of patients followed for 19 years after entering specialized treatment for substance use disorders. At baseline 291 patients (mean age 38.3 years, standard deviation 11.4 years, 72% male) with high psychiatric co-morbidity were recruited; 130 (45%) had lifetime alcohol use disorder alone, while 161 (55%) had poly-substance use disorders. Time and causes of death were gathered from the Norwegian Cause of Death Registry. Lifetime psychiatric symptom disorders and substance use disorders at baseline were measured with The Composite International Diagnostic Interview and personality disorders at baseline were measured with The Millon Clinical Multiaxial Inventory II.

RESULTS

Patients with alcohol use disorder alone more often died from somatic diseases (58% versus 28%, p = 0.004) and more seldom from overdoses (9% versus 33%, p = 0.002) compared with patients with poly-substance use disorders. The crude mortality rate per 100 person year was 2.2 (95% confidence interval: 1.8-2.7), and the standardized mortality rate was 3.8 (95% confidence interval: 3.2-4.6) in the entire cohort during 19 years after entering treatment. Having lifetime affective disorder at baseline was associated with lower risk of death (Hazard Ratio 0.58, 95% confidence interval: 0.37-0.91). Older age was associated to increased risk of death among men (p < 0.001) and non-significantly among patients with poly-substance use (p = 0.057). The difference in association between age and risk of death was significantly different between men and women (p = 0.011) and patients with alcohol use disorder alone and poly-substance use disorders (p = 0.041).

CONCLUSIONS

Patients with alcohol use disorder alone died more often from somatic disease than patients with poly-substance use disorders, and all subgroups of patients had an increased risk of death compared with the general population. Men with long-lasting substance use disorders are a priority group to approach with directed preventive measures for somatic health before they reach 50 years of age.

Use of online opioid overdose prevention training for first-year medical students: A comparative analysis of online versus in-person training

Purpose: In response to the opioid epidemic and efforts to expand substance use education in medical school, the authors introduced opioid overdose prevention training (OOPT) with naloxone for all first-year medical students (MS1s) as an adjunct to required basic life support training (BLST). The authors previously demonstrated improved knowledge and preparedness following in-person OOPT with BLST; however, it remains unclear whether online-administered OOPT would produce comparable results. In this study, the authors perform a retrospective comparison of online-administered OOPT with in-person-administered OOPT. Objectives: To compare the educational outcomes: knowledge, preparedness, and attitudes, for online versus in-person OOPT. Methods: In-person OOPT was administered in 2014 and 2015 during BLST, whereas online OOPT was administered in 2016 during BLST pre-work. MS1s completed pre- and post-training tests covering 3 measures: knowledge (11-point scale), attitudes (66-point scale), and preparedness (60-point scale) to respond to an opioid overdose. Online scores from 2016 and in-person scores from 2015 were compared across all 3 measures using analysis of covariance (ANCOVA) methods. Results: After controlling for pre-test scores, there were statistical, but no meaningful, differences across all measures for in-person- and online-administered training. The estimated differences were knowledge: -0.05 (0.5%) points (95% confidence interval [CI]: -0.47, 0.36); attitudes: 0.65 (1.0%) points (95% CI: -0.22, 1.51); and preparedness: 2.16 (3.6%) points (95% CI: 1.04, 3.28). Conclusions: The educational outcomes of online-administered OOPT compared with in-person-administered OOPT were not meaningfully different. These results support the use of online-administered OOPT. As our study was retrospective, based on data collected over multiple years, further investigation is needed in a randomized controlled setting, to better understand the educational differences of in-person and online training. Further expanding OOPT to populations beyond medical students would further improve generalizability.

Correlates of seeking emergency medical help in the event of an overdose in British Columbia, Canada: Findings from the Take Home Naloxone program

BACKGROUND

British Columbia (BC), Canada, is experiencing an unprecedented number of opioid overdoses mainly due to the contamination of illicit drugs with fentanyl and its analogues. Reluctance to seek emergency medical help (i.e., by calling 9-1-1) has been identified as a barrier to optimal care for overdose victims. This study aimed to identify the correlates of seeking help during an overdose event when naloxone was administered via BC's Take Home Naloxone (THN) program.

METHODS

In this cross-sectional study, we reviewed administrative records (from July 2015 to December 2017) about overdose events submitted by THN participants when they received their replacement naloxone kits (n = 2350). The primary outcome of the study was reported calling 9-1-1 and modified Poisson regression models were built to investigate the factors associated with help-seeking during an overdose event.

RESULTS

Most overdose victims were men (69.0%) and >30 years old (61.5%). Overall, participants reported calling 9-1-1 in 1310 (55.7%) overdose events. In the multivariable model, the likelihood of calling 9-1-1 was significantly and positively associated with the overdose victim being male and receiving rescue breathing. The likelihood of calling 9-1-1 was significantly and negatively associated with the overdoses occurring in private residences and health regions other than Vancouver Coastal which delivers services to mostly urban residents.

CONCLUSION

Overall, medical help was sought for 55.7% of overdoses where naloxone was administered. Overdoses occurring among male victims as well as those receiving higher doses of naloxone and mouth-to-mouth rescue breathing were associated with a higher likelihood of help-seeking by responders. Future interventions need to encourage people who witness an overdose to seek emergency medical help.

Naloxone distribution and possession following a large-scale naloxone programme

AIMS

To examine uptake following a large-scale naloxone programme by estimating distribution rates since programme initiation and the proportion among a sample of high-risk individuals who had attended naloxone training, currently possessed or had used naloxone. We also estimated the likelihood of naloxone possession and use as a function of programme duration, individual descriptive and substance use indicators.

DESIGN

(1) Distribution data (June 2014-August 2017) and date of implementation for each city and (2) a cross-sectional study among a sample of illicit substance users interviewed September 2017.

SETTING

Seven Norwegian cities.

PARTICIPANTS

A total of 497 recruited users of illegal opioids and/or central stimulants.

MEASUREMENTS

Primary outcomes: naloxone possession and use. Random-intercepts logistic regression models (covariates: male, age, homelessness/shelter use, overdose, incarceration, opioid maintenance treatment, income sources, substance use indicators, programme duration).

FINDINGS

Overall, 4631 naloxone nasal sprays were distributed in the two pilot cities, with a cumulative rate of 495 per 100 000 population. In the same two cities, among high-risk individuals, 44% and 62% reported current naloxone possession. The possession rates of naloxone corresponded well to the duration of each participating city's distribution programme. Overall, in the six distributing cities, 58% reported naloxone training, 43% current possession and 15% naloxone use. The significant indicators for possession were programme duration [adjusted odds ratios (aOR) = 1.44, 95% confidence interval (CI = 0.82-2.37], female gender (aOR = 1.97, 95% CI = 1.20-3.24) and drug-dealing (aOR = 2.36, 95% CI = 1.42-3.93). The significant indicators for naloxone use were programme duration (aOR = 1.49 95%, CI = 1.15-1.92), homelessness/shelter use (aOR = 2.06, 95% CI = 1.02-4.17), opioid maintenance treatment (OMT) (aOR = 2.07, 95% CI = 1.13-3.78), drug-dealing (aOR = 2.40, 95% CI = 1.27-4.54) and heroin injecting (aOR = 2.13, 95% CI = 1.04-4.38).

CONCLUSIONS

A large-scale naloxone programme in seven Norwegian cities with a cumulative distribution rate of 495 per 100 000 population indicated good saturation in a sample of high-risk individuals, with programme duration in each city as an important indicator for naloxone possession and use.

Time to look beyond ageing as a factor? Alternative explanations for the continuing rise in drug related deaths in Scotland

Purpose

The purpose of this paper is to examine the reasons and risk factors that explain the threefold increase in drug-related deaths from 267 in 1996 to 934 in 2017 in Scotland. The authors explore the known links between deprivation and problem drug use (PDU) and discuss the impact of drug policy and service provision on PDU and drug-related deaths.

Design/methodology/approach

Using quantitative data sets from the National Records of Scotland (NRS) for drug-related deaths registered in 2017 and data sets from the Scottish Index of Multiple Deprivation (SIMD), we produce statistical data on mortality rates relating to areas of deprivation, gender and age.

Findings

The data highlight the disproportionate number of deaths in the most deprived areas in comparison to the least deprived areas and the national average. Findings indicate that one quarter of male and female DRD in 2017 were under 35. When examining the least deprived vingtile, drug-related deaths account for 2.84 per 100,000 population. Based on this mortality rate calculation, the amount of drug-related deaths are 23 times higher in the most deprived area than the least deprived area.

Research limitations/implications

The research design uses data obtained from the NRS and data from Scottish Multiple Index of Deprivation. Due to the limitations of available data, the research design focused on SIMD population vingtiles.

Practical implications

This research contributes to making unarguable links between entrenched structural inequality and increased drug-related death.

Social implications

This paper contributes to knowledge on the need for drug policy advisors to recognise the importance of deprivation that plays a major part in risks of problematic drug use and harms.

Originality/value

While several national data sets have published information by SIMD vingtile, no published research has sought to investigate the disproportionate number of deaths by population in the most deprived areas.

Frequency and associated risk factors of non-fatal overdose reported by pregnant women with opioid use disorder

BACKGROUND

Little is known about opioid overdose or naloxone access among pregnant women.

OBJECTIVES

The objectives of this study were to determine the prevalence of non-fatal overdose, risk factors for overdose, and naloxone access among third trimester women in treatment for opioid use disorder.

METHODS

We collected baseline data from a case management parental-support intervention study. To explore the association of variables with past year overdose, we used Wilcoxon rank-sum test, Chi square or Fisher's exact tests.

RESULTS

Among 99 participants, 14% (95% CI 7-21%) reported past year overdose and 67% (95% CI 57-76%) had received overdose education and a naloxone kit. Younger age was the only variable associated with past year overdose.

CONCLUSIONS

In this sample, past year non-fatal overdose was common, younger age was a risk factor, and most participants had received a naloxone kit. Further work is needed to understand whether younger age is a risk factor in the general population of pregnant women with opioid use disorder and to identify other potential risk factors for overdose in this population.

Challenges with take-home naloxone in reducing heroin mortality: a review of fatal heroin overdose cases in Victoria, Australia

AIM

Take-home naloxone (THN) programs have been implemented in order to reduce the number of heroin-overdose deaths. Because of recent legislative changes in Australia, there is a provision for a greater distribution of naloxone in the community, however, the potential impact of these changes for reduced heroin mortality remains unclear. The aim of this study was to examine the characteristics of the entire cohort of fatal heroin overdose cases and assess whether there was an opportunity for bystander intervention had naloxone been available at the location and time of each of the fatal overdose events to potentially avert the fatal outcome in these cases.

METHODS

The circumstances related to the fatal overdose event for the cohort of heroin-overdose deaths in the state of Victoria, Australia between 1 January 2012 and 31 December 2013 were investigated. Coronial data were investigated for all cases and data linkage was performed to additionally investigate the Emergency Medical Services information about the circumstances of the fatal heroin overdose event for each of the decedents.

RESULTS AND DISCUSSION

There were 235 fatal heroin overdose cases identified over the study period. Data revealed that the majority of fatal heroin overdose cases occurred at a private residence (n = 186, 79%) and where the decedent was also alone at the time of the fatal overdose event (n = 192, 83%). There were only 38 cases (17%) where the decedent was with someone else or there was a witness to the overdose event, and in half of these cases the witness was significantly impaired, incapacitated or asleep at the time of the fatal heroin overdose. There were 19 fatal heroin overdose cases (8%) identified where there was the potential for appropriate and timely intervention by a bystander or witness.

CONCLUSION

This study demonstrated that THN introduction alone could have led to a very modest reduction in the number of fatal heroin overdose cases over the study period. A lack of supervision or a witness to provide meaningful and timely intervention was evident in most of the fatal heroin overdose cases.

An overview of take-home naloxone programs in Australia

INTRODUCTION AND AIMS

Take-home naloxone (THN) programs commenced in Australia in 2012 in the Australian Capital Territory and programs now operate in five Australian jurisdictions. The purpose of this paper is to record the progress of THN programs in Australia, to provide a resource for others wanting to start THN projects, and provide a tool for policy makers and others considering expansion of THN programs in this country and elsewhere.

DESIGN AND METHODS

Key stakeholders with principal responsibility for identified THN programs operating in Australia provided descriptions of program development, implementation and characteristics. Short summaries of known THN programs from each jurisdiction are provided along with a table detailing program characteristics and outcomes.

RESULTS

Data collected across current Australian THN programs suggest that to date over 2500 Australians at risk of overdose have been trained and provided naloxone. Evaluation data from four programs recorded 146 overdose reversals involving naloxone that was given by THN participants.

DISCUSSION AND CONCLUSIONS

Peer drug user groups currently play a central role in the development, delivery and scale-up of THN in Australia. Health professionals who work with people who use illicit opioids are increasingly taking part as alcohol and other drug-related health agencies have recognised the opportunity for THN provision through interactions with their clients. Australia has made rapid progress in removing regulatory barriers to naloxone since the initiation of the first THN program in 2012. However, logistical and economic barriers remain and further work is needed to expand access to this life-saving medication.

Identification, Management, and Transition of Care for Patients With Opioid Use Disorder in the Emergency Department

Because of a soaring number of opioid-related deaths during the past decade, opioid use disorder has become a prominent issue in both the scientific literature and lay press. Although most of the focus within the emergency medicine community has been on opioid prescribing-specifically, on reducing the incidence of opioid prescribing and examining alternative pain treatment-interest is heightening in identifying and managing patients with opioid use disorder in an effective and evidence-based manner. In this clinical review article, we examine current strategies for identifying patients with opioid use disorder, the treatment of patients with acute opioid withdrawal syndrome, approaches to medication-assisted therapy, and the transition of patients with opioid use disorder from the emergency department to outpatient services.

Acceptability of prison-based take-home naloxone programmes among a cohort of incarcerated men with a history of regular injecting drug use

Background

Take-home naloxone (THN) programmes are an evidence-based opioid overdose prevention initiative. Elevated opioid overdose risk following prison release means release from custody provides an ideal opportunity for THN initiatives. However, whether Australian prisoners would utilise such programmes is unknown. We examined the acceptability of THN in a cohort of male prisoners with histories of regular injecting drug use (IDU) in Victoria, Australia.

Methods

The sample comprised 380 men from the Prison and Transition Health (PATH) Cohort Study; all of whom reported regular IDU in the 6 months prior to incarceration. We asked four questions regarding THN during the pre-release baseline interview, including whether participants would be willing to participate in prison-based THN. We describe responses to these questions along with relationships between before- and during-incarceration factors and willingness to participate in THN training prior to release from prison.

Results

Most participants (81%) reported willingness to undertake THN training prior to release. Most were willing to resuscitate a friend using THN if they were trained (94%) and to be revived by a trained peer (91%) using THN. More than 10 years since first injection (adjusted odds ratio [AOR] 2.22, 95%CI 1.03–4.77), having witnessed an opioid overdose in the last 5 years (AOR 2.53, 95%CI 1.32–4.82), having ever received alcohol or other drug treatment in prison (AOR 2.41, 95%CI 1.14–5.07) and injecting drugs during the current prison sentence (AOR 4.45, 95%CI 1.73–11.43) were significantly associated with increased odds of willingness to participate in a prison THN programme. Not specifying whether they had injected during their prison sentence (AOR 0.37, 95%CI 0.18–0.77) was associated with decreased odds of willingness to participate in a prison THN training.

Conclusion

Our findings suggest that male prisoners in Victoria with a history of regular IDU are overwhelmingly willing to participate in THN training prior to release. Factors associated with willingness to participate in prison THN programmes offer insights to help support the implementation and uptake of THN programmes to reduce opioid-overdose deaths in the post-release period.

Acceptability and feasibility of naloxone prescribing in primary care settings: A systematic review

Naloxone access through established healthcare settings is critical to responding to the opioid crisis. We conducted a systematic review to assess the acceptability and feasibility of prescribing naloxone to patients in primary care. We queried PubMed, EmBase and CINAHL for US-based, peer-reviewed, full-length, original articles relating to acceptability or feasibility of prescribing naloxone in primary care. Searches yielded 270 unduplicated articles; one analyst reviewed all titles and abstracts. Two analysts independently reviewed eligible articles for study design, study outcome, and acceptability and/or feasibility. Analyses were compared and a third reviewer consulted if discrepancies emerged. Seventeen articles were included. Providers' willingness to prescribe naloxone appeared to increase over time. Most studies provided prescribers in-person naloxone trainings, including how to write a prescription and indications for prescribing. Most studies implemented universal prescribing, whereby anyone prescribed long-term opioids or otherwise at risk for overdose was eligible for naloxone. Patient education was largely provided by prescribers and most studies provided take-home educational materials. Providers reported concerns around naloxone prescribing including lack of knowledge around prescribing and educating patients. Providers also reported benefits such as improving difficult conversations around opioids and resetting the culture around opioids and overdose. Current literature supports the acceptability and feasibility of naloxone prescribing in primary care. Provision of naloxone through primary care may help normalize such medication safety interventions, support larger opioid stewardship efforts, and expand access to patients not served by a community distribution program.

Lessons learned in methods and analyses for pragmatic studies

Pragmatic studies are common in nursing research. These studies range from secondary analysis of large observational datasets to prospective randomized multisite clinical trials. The common elements in pragmatic studies are the real-world settings in which the research occurs: settings that decrease threats to external validity, but may increase threats to internal validity of the research. This manuscript presents a pragmatic study and the methodological considerations in design and analytic approaches that were undertaken to decrease all threats to validity while maintaining study feasibility. A pragmatic study design and analytic choices are presented and evaluated. To increase robustness of the study and internal and external validity of findings, while maintaining feasibility, unique approaches to design and analyses were chosen. Like efficacy studies, pragmatic studies are essential to nursing research and require additional a priori considerations in design and analyses to increase internal validity of findings.

Beyond the walls: Risk factors for overdose mortality following release from the Philadelphia Department of Prisons

BACKGROUND

High overdose mortality after release from state prison systems is well documented; however, little is known about overdose mortality following release from local criminal justice systems (CJS). The purpose of this study was to assess overdose mortality following release from a local CJS in Philadelphia, PA.

METHODS

We conducted a retrospective cohort study of individuals released to the community from a local CJS between 2010 and 2016. Incarceration records were linked to overdose fatality data from the Medical Examiner's Office and death certificate records. All-cause, overdose, and non-overdose mortality were examined.

RESULTS

Of the 82,780 individuals released between 2010 and 2016, 2,522 (3%) died from any cause, of which 837 (33%) succumbed to overdose. Individuals released from incarceration had higher risk of overdose death compared to the non-incarcerated population (Standardized Mortality Ratio [SMR]: 5.29, 95% CI 4.93-5.65), and risk was greatest during the first two weeks following release (SMR: 36.91, 95% CI: 29.92-43.90). Among released individuals, black, non-Hispanic individuals (Hazard Rate [HR]: 0.17, 95% CI: 0.14-0.19) and Hispanic individuals (HR: 0.41, 95% CI: 0.34-0.50) were at lower risk for overdose than white, non-Hispanic individuals. Individuals released with a serious mental illness (SMI) were at higher risk of overdose (HR: 1.54, 95% CI: 1.27-1.87) than those without a SMI.

DISCUSSION

Previously incarcerated individuals are at high risk of overdose death following release from a local CJS, especially in the earliest weeks following release. Prevention measures including behavioral health treatment and referral and take-home naloxone may reduce overdose mortality after release.

[Interest of take-home naloxone for opioid overdose]

Over the course of these last decades, we observed a change on opioid use with the marketing of opiate maintenance treatment, an increase of opioids used for pain management and recent concerns have arisen around the use of synthetic opioid. The World Health Organization (WHO) reports around 70,000 people opioid overdose death each year. In France, according to the DRAMES program (fatalities in relation with abuse of licit or illicit drugs) of the French addictovigilance network, most of deaths are related to opioids overdose (especially methadone, following by heroin, buprenorphine and opioid used for pain management). Opioid overdose is treatable with naloxone, an opioid antagonist which rapidly reverses the effects of opioids. In recent years, a number of programs around the world have shown that it is feasible to provide naloxone to people likely to witness an opioid overdose. In 2014, the WHO published recommendations for this provision and the need to train users and their entourage in the management of opioid overdose. In this context, in July 2016, French drug agency has granted a temporary authorization for use of a naloxone nasal spray Nalscue^®. Because different opioids can be used and because each opioid has specific characteristics (pharmacodynamics, pharmacokinetics, galenic form…), the risk of overdose may differ from one opioid to another and it may be necessary, depending on the clinical context, to use larger and repeated doses of naloxone.

Predicting pharmacy naloxone stocking and dispensing following a statewide standing order, Indiana 2016

BACKGROUND

While naloxone, the overdose reversal medication, has been available for decades, factors associated with its availability through pharmacies remain unclear. Studies suggest that policy and pharmacist beliefs may impact availability. Indiana passed a standing order law for naloxone in 2015 to increase access to naloxone.

OBJECTIVE

To identify factors associated with community pharmacy naloxone stocking and dispensing following the enactment of a statewide naloxone standing order.

METHODS

A 2016 cross-sectional census of Indiana community pharmacists was conducted following a naloxone standing order. Community, pharmacy, and pharmacist characteristics, and pharmacist attitudes about naloxone dispensing, access, and perceptions of the standing order were measured. Modified Poisson and binary logistic regression models attempted to predict naloxone stocking and dispensing, respectively.

RESULTS

Over half (58.1%) of pharmacies stocked naloxone, yet 23.6% of pharmacists dispensed it. Most (72.5%) pharmacists believed the standing order would increase naloxone stocking, and 66.5% believed it would increase dispensing. Chain pharmacies were 3.2 times as likely to stock naloxone. Naloxone stocking was 1.6 times as likely in pharmacies with more than one full-time pharmacist. Pharmacies where pharmacists received naloxone continuing education in the past two years were 1.3 times as likely to stock naloxone. The attempted dispensing model yielded no improvement over the constant-only model.

CONCLUSIONS

Pharmacies with larger capacity took advantage of the naloxone standing order. Predictors of pharmacist naloxone dispensing should continue to be explored to maximize naloxone access.

"Once I'd done it once it was like writing your name": Lived experience of take-home naloxone administration by people who inject drugs

BACKGROUND

The supply of naloxone, the opioid antagonist, for peer administration ('take-home naloxone' (THN)) has been promoted as a means of preventing opioid-related deaths for over 20 years. Despite this, little is known about PWID experiences of take-home naloxone administration. The aim of this study was to advance the evidence base on THN by producing one of the first examinations of the lived-experience of THN use among PWID.

METHODS

Qualitative, face to face, semi-structured interviews were undertaken at a harm reduction service with individuals known to have used take-home naloxone in an overdose situation in a large urban area in Scotland. Interpretative Phenomenological Analysis (IPA) was then applied to the data from these in-depth accounts.

RESULTS

The primary analysis involved a total of 8 PWID (seven male, one female) known to have used take-home naloxone. This paper focuses on the two main themes concerning naloxone administration: psychological impacts of peer administration and role perceptions. In the former, the feelings participants encounter at different stages of their naloxone experience, including before, during and after use, are explored. In the latter, the concepts of role legitimacy, role adequacy, role responsibility and role support are considered.

CONCLUSION

This study demonstrates that responding to an overdose using take-home naloxone is complex, both practically and emotionally, for those involved. Although protocols exist, a multitude of individual, social and environmental factors shape responses in the short and longer terms. Despite these challenges, participants generally conveyed a strong sense of therapeutic commitment to using take-home naloxone in their communities.

Methods for delivering the UK's multi-centre prison-based naloxone-on-release pilot randomised trial (N-ALIVE): Europe's largest prison-based randomised controlled trial

INTRODUCTION AND AIMS

Naloxone is an opioid antagonist used for emergency resuscitation following opioid overdose. Prisoners with a history of heroin use by injection have a high risk of drug-related death in the first weeks after prison-release. The N-ALIVE trial was planned as a large prison-based randomised controlled trial (RCT) to test the effectiveness of naloxone-on-release in the prevention of fatal opiate overdoses soon after release. The N-ALIVE pilot trial was conducted to test the main trial's assumptions on recruitment of prisons and prisoners, and the logistics for ensuring that participants received their N-ALIVE pack on release.

DESIGN AND METHODS

Adult prisoners who had ever injected heroin, were incarcerated for ≥7 days and were expected to be released within 3 months were eligible. Participants were randomised to receive, on liberation, a pack containing a single 'rescue' injection of naloxone or a control pack with no naloxone syringe. The trial was double-blind prior to prison-release.

RESULTS

We randomised 1685 prisoners (842 naloxone; 843 control) across 16 prisons in England. We stopped randomisation on 8 December 2014 because only one-third of administrations of naloxone-on-release were to the randomised ex-prisoner; two-thirds were to others whom we were not tracing.

DISCUSSION AND CONCLUSIONS

Prevention RCTs are seldom conducted within prisons; we demonstrated the feasibility of conducting a multi-prison RCT to prevent fatality from opioid overdose in the outside community. We terminated the N-ALIVE trial due to the infeasibility of individualised randomisation to naloxone-on-release. Large RCTs are feasible within prisons.

Distribution of take-home opioid antagonist kits during a synthetic opioid epidemic in British Columbia, Canada: a modelling study

BACKGROUND

Illicit use of high-potency synthetic opioids has become a global issue over the past decade. This misuse is particularly pronounced in British Columbia, Canada, where a rapid increase in availability of fentanyl and other synthetic opioids in the local illicit drug supply during 2016 led to a substantial increase in overdoses and deaths. In response, distribution of take-home naloxone (THN) overdose prevention kits was scaled up (6·4-fold increase) throughout the province. The aim of this study was to estimate the impact of the THN programme in terms of the number of deaths averted over the study period.

METHODS

We estimated the impact of THN kits on the ongoing epidemic among people who use illicit opioids in British Columbia and explored counterfactual scenarios for the provincial response. A Markov chain model was constructed explicitly including opioid-related deaths, fentanyl-related deaths, ambulance-attended overdoses, and uses of THN kits. The model was calibrated in a Bayesian framework incorporating population data between Jan 1, 2012, and Oct 31, 2016.

FINDINGS

22 499 ambulance-attended overdoses and 2121 illicit drug-related deaths (677 [32%] deaths related to fentanyl) were recorded in the study period, mostly since January, 2016. In the same period, 19 074 THN kits were distributed. We estimate that 298 deaths (95% credible interval [CrI] 91-474) were averted by the THN programme. Of these deaths, 226 (95% CrI 125-340) were averted in 2016, following a rapid scale-up in distribution of kits. We infer a rapid increase in fentanyl adulterant at the beginning of 2016, with an estimated 2·3 times (95% CrI 2·0-2·9) increase from 2015 to 2016. Counterfactual modelling indicated that an earlier scale-up of the programme would have averted an additional 118 deaths (95% CrI 64-207). Our model also indicated that the increase in deaths could parsimoniously be explained through a change in the fentanyl-related overdose rate alone.

INTERPRETATION

The THN programme substantially reduced the number of overdose deaths during a period of rapid increase in the number of illicit drug overdoses due to fentanyl in British Columbia. However, earlier adoption and distribution of the THN intervention might have had an even greater impact on overdose deaths. Our findings show the value of a fast and effective response at the start of a synthetic opioid epidemic. We also believe that multiple interventions are needed to achieve an optimal impact.

FUNDING

Canadian Institutes of Health Research Partnerships for Health Systems Improvement programme (grant 318068) and Natural Science and Engineering Research Council of Canada (grant 04611).

Lay responder naloxone access and Good Samaritan law compliance: postcard survey results from 20 Indiana counties

Background

To reduce fatal drug overdoses, two approaches many states have followed is to pass laws expanding naloxone access and Good Samaritan protections for lay persons with high likelihood to respond to an opioid overdose. Most prior research has examined attitudes and knowledge among lay responders in large metropolitan areas who actively use illicit substances. The present study addresses current gaps in knowledge related to this issue through an analysis of data collected from a broader group of lay responders who received naloxone kits from 20 local health departments across Indiana.

Methods

Postcard surveys were included inside naloxone kits distributed in 20 Indiana counties, for which 217 returned cards indicated the person completing it was a lay responder. The survey captured demographic information and experiences with overdose, including the use of 911 and knowledge about Good Samaritan protections.

Results

Few respondents had administered naloxone before, but approximately one third had witnessed a prior overdose and the majority knew someone who had died from one. Those who knew someone who had overdosed were more likely to have obtained naloxone for someone other than themselves. Also, persons with knowledge of Good Samaritan protections or who had previously used naloxone were significantly more likely to have indicated calling 911 at the scene of a previously witnessed overdose. Primary reasons for not calling 911 included fear of the police and the person who overdosed waking up on their own.

Conclusions

Knowing someone who has had a fatal or non-fatal overdose appears to be a strong motivating factor for obtaining naloxone. Clarifying and strengthening Good Samaritan protections, educating lay persons about these protections, and working to improve police interactions with the public when they are called to an overdose scene are likely to improve implementation and outcomes of naloxone distribution and opioid-related Good Samaritan laws.

Fentanyl and heroin contained in seized illicit drugs and overdose-related deaths in British Columbia, Canada: An observational analysis

BACKGROUND

Due to the alarming rise in opioid-related overdose deaths, a public health emergency was declared in British Columbia (BC). In this study, we examined the relationship between illicit fentanyl and heroin found in seized drugs and illicit overdose deaths in BC.

METHODS

An observational cross-sectional survey was conducted using BC data from Health Canada's Drug Analysis Service, which analyzes drug samples seized by law enforcement agencies, and non-intentional illicit overdoses from the BC Coroner's Service, from 2000 to 2016. Initial scatter plots and subsequent multivariate regression analysis were performed to describe the potential relationship between seized illicit fentanyl samples and overdose deaths and to determine if this differed from seized heroin and overdose deaths. Fentanyl samples were analyzed for other drug content.

RESULTS

Fentanyl is increasingly being found combined with other opioid and non-opioid illicit drugs. Strong positive relationships were found between the number of seized fentanyl samples and total overdose deaths (R2 = 0.97) as well as between seized fentanyl and fentanyl-detected overdose deaths (R2 = 0.99). A positive association was found between the number of seized heroin samples and total overdose deaths (R2 = 0.78).

CONCLUSION

This research contributes to the expanding body of evidence implicating illicit fentanyl use (often combined with heroin or other substances) in overdose deaths in BC. Policy makers and healthcare providers are urged to implement drug treatment and harm reduction strategies for people at risk of overdose associated with current trends in illicit opioid use.

Cost-Effectiveness of Take-Home Naloxone for the Prevention of Overdose Fatalities among Heroin Users in the United Kingdom

BACKGROUND

Heroin overdose is a major cause of premature death. Naloxone is an opioid antagonist that is effective for the reversal of heroin overdose in emergency situations and can be used by nonmedical responders.

OBJECTIVE

Our aim was to assess the cost-effectiveness of distributing naloxone to adults at risk of heroin overdose for use by nonmedical responders compared with no naloxone distribution in a European healthcare setting (United Kingdom).

METHODS

A Markov model with an integrated decision tree was developed based on an existing model, using UK data where available. We evaluated an intramuscular naloxone distribution reaching 30% of heroin users. Costs and effects were evaluated over a lifetime and discounted at 3.5%. The results were assessed using deterministic and probabilistic sensitivity analyses.

RESULTS

The model estimated that distribution of intramuscular naloxone, would decrease overdose deaths by around 6.6%. In a population of 200,000 heroin users this equates to the prevention of 2,500 premature deaths at an incremental cost per quality-adjusted life year (QALY) gained of £899. The sensitivity analyses confirmed the robustness of the results.

CONCLUSIONS

Our evaluation suggests that the distribution of take-home naloxone decreased overdose deaths by around 6.6% and was cost-effective with an incremental cost per QALY gained well below a £20,000 willingness-to-pay threshold set by UK decision-makers. The model code has been made available to aid future research. Further study is warranted on the impact of different formulations of naloxone on cost-effectiveness and the impact take-home naloxone has on the wider society.

Ageing opioid users' increased risk of methadone-specific death in the UK

BACKGROUND

The first evidence that the hazard ratio (HR) for methadone-specific death rises more steeply with age-group than for all drug-related deaths (DRDs) came from Scotland's cohort of 33,000 methadone-prescription clients. We aim to examine, for England, whether illicit opioid users' risk of methadone-specific death increases with age; and to pool age-related HRs for methadone-specific deaths with those for Scotland's methadone-prescription clients.

METHODS

The setting is all services in England that provide publicly-funded, structured treatment for illicit opioid users, the methodology linkage of the English National Drug Treatment Monitoring System and mortality database, and key measurements are DRDs, methadone-specific DRDs, or heroin-specific DRDs, by age-group and gender, with proportional hazards adjustment for substances used, injecting status and periods in/out of treatment.

RESULTS

Linkage was achieved for 129,979 adults receiving prescribing treatment modalities for opioid dependence during April 2005 to March 2009 and followed-up for 378,009 person-years (pys). There were 1,266 DRDs: 271 methadone-specific (7 per 10,000 pys: irrespective of gender) and 473 heroin-specific (15 per 10,000 pys for males, 7 for females). Methadone-specific DRD-rate per 10,000 person-years was 3.5 (95% CI: 2.7-4.4) at 18-34 years, 8.9 (CI: 7.3-10.5) at 35-44 years and 18 (CI: 13.8-21.2) at 45+ years; heroin-specific DRD-rate was unchanged with age. Relative to 25-34 years, pooled HRs for UK clients' methadone-specific deaths were: 0.87 at <25 years (95% CI: 0.56-1.35); 2.14 at 35-44 years (95% CI: 1.76-2.60); 3.75 at 45+ years (95% CI: 2.99-4.70).

CONCLUSION

International testing and explanation are needed of UK's sharp age-related increase in the risk of methadone-specific death. Clients should be alerted that their risk of methadone-specific death increases as they age.

Reducing opioid overdose in Kazakhstan: A randomized controlled trial of a couple-based integrated HIV/HCV and overdose prevention intervention "Renaissance"

OBJECTIVES

To evaluate the efficacy of a couple-based integrated HIV/HCV and overdose prevention intervention on non-fatal and fatal overdose and overdose prevention behaviors among people who use heroin or other opioids in Almaty, Kazakhstan.

METHODS

We selected 479 participants who reported lifetime heroin or opioid use from a sample of 600 participants (300 couples) enrolled in a randomized controlled trial (RCT) conducted between May 2009 and February 2013. Participants were randomized to either (1) a 5-session couple-based HIV/HCV and overdose prevention intervention condition or (2) a 5-session Wellness Promotion and overdose prevention comparison condition. We used multilevel mixed-effects model with modified Poisson regression to estimate effects of the intervention as risk ratios (RR) and the corresponding 95% CIs.

RESULTS

About one-fifth (21.9%) of the sample reported that they had experienced an opioid overdose in the past 6 months at baseline. At the 12-month follow-up, both the intervention and comparison conditions reported significant reductions in non-fatal overdose and injection heroin/opioid use and significant increases in drug treatment attendance and naloxone use to prevent death from overdose. However, we found no differences between the study arms on any of these outcomes. There were three intervention condition participants (1.3%), compared to seven comparison condition participants (2.9%) who died from opioid overdose during the 12-month follow up period although this difference was not significant.

DISCUSSION

There were no significant conditions on any outcomes: both conditions showed promising effects of reducing non-fatal overdose and overdose risks. Integrating overdose prevention into a couple-based HIV/HCV intervention may be an efficient strategy to target the syndemic of opioid overdose, HIV and HCV in Kazakhstan.

Overdose prevention training with naloxone distribution in a prison in Oslo, Norway: a preliminary study

BACKGROUND

Prison inmates face a ten times increased risk of experiencing a fatal drug overdose during their first 2 weeks upon release than their non-incarcerated counterparts. Naloxone, the antidote to an opioid overdose, has been shown to be feasible and effective when administered by bystanders. Given the particular risk that newly released inmates face, it is vital to assess their knowledge about opioid overdoses, as well as the impact of brief overdose prevention training conducted inside prisons.

METHODS

Prison inmates nearing release (within 6 months) in Oslo, Norway, voluntarily underwent a brief naloxone training. Using a questionnaire, inmates were assessed immediately prior to and following a naloxone training. Descriptive statistics were performed for main outcome variables, and the Wilcoxon signed-rank test was used to compare the participants' two questionnaire scores from pre-and post-training.

RESULTS

Participating inmates (n = 31) were found to have a high baseline knowledge of risk factors, symptoms, and care regarding opioid overdoses. Nonetheless, a brief naloxone training session prior to release significantly improved knowledge scores in all areas assessed (p < 0.001). The training appears to be most beneficial in improving knowledge regarding the naloxone, including its use, effect, administration, and aftercare procedures.

CONCLUSIONS

Given the high risk of overdosing that prison inmates face upon release, the need for prevention programs is critical. Naloxone training in the prison setting may be an effective means of improving opioid overdose response knowledge for this particularly vulnerable group. Naloxone training provided in the prison setting may improve the ability of inmates to recognize and manage opioid overdoses after their release; however, further studies on a larger scale are needed.

Is systematic training in opioid overdose prevention effective?

The objectives were to analyze the knowledge about overdose prevention, the use of naloxone, and the number of fatal overdoses after the implementation of Systematic Training in Overdose Prevention (STOOP) program. We conducted a quasi-experimental study, and held face-to-face interviews before (n = 725) and after (n = 722) implementation of systematic training in two different samples of people who injected opioids attending harm reduction centers. We asked participants to list the main causes of overdose and the main actions that should be taken when witnessing an overdose. We created two dependent variables, the number of (a) correct and (b) incorrect answers. The main independent variable was Study Group: Intervention Group (IG), Comparison Group (CG), Pre-Intervention Group With Sporadic Training in Overdose Prevention (PREIGS), or Pre-Intervention Group Without Training in Overdose Prevention (PREIGW). The relationship between the dependent and independent variables was assessed using a multivariate Poisson regression analysis. Finally, we conducted an interrupted time series analysis of monthly fatal overdoses before and after the implementation of systematic program during the period 2006–2015. Knowledge of overdose prevention increased after implementing systematic training program. Compared to the PREIGW, the IG gave more correct answers (IRR = 1.40;95%CI:1.33–1.47), and fewer incorrect answers (IRR = 0.33;95%CI:0.25–0.44). Forty percent of people who injected opioids who received a naloxone kit had used the kit in response to an overdose they witnessed. These courses increase knowledge of overdose prevention in people who use opioids, give them the necessary skills to use naloxone, and slightly diminish the number of fatal opioid overdoses in the city of Barcelona.

Behavioral intervention to reduce opioid overdose among high-risk persons with opioid use disorder: A pilot randomized controlled trial

OBJECTIVE

The United States is amidst an opioid epidemic, including synthetic opioids that may result in rapid death, leaving minimal opportunity for bystander rescue. We pilot tested a behavioral intervention to reduce the occurrence of opioid overdose among opioid dependent persons at high-risk for subsequent overdose.

MATERIALS AND METHODS

We conducted a single-blinded randomized-controlled trial of a repeated dose motivational interviewing intervention (REBOOT) to reduce overdose versus treatment as usual, defined as information and referrals, over 16 months at the San Francisco Department of Public Health from 2014-2016. Participants were 18-65 years of age, had opioid use disorder by Structured Clinical Interview, active opioid use, opioid overdose within 5 years, and prior receipt of naloxone kits. The intervention was administered at months 0, 4, 8, and 12, preceded by the assessment which was also administered at month 16. Dual primary outcomes were any overdose event and number of events, collected by computer-assisted personal interview, as well as any fatal overdose events per vital records.

RESULTS

A total of 78 persons were screened and 63 enrolled. Mean age was 43 years, 67% were born male, 65% White, 17% African-American, and 14% Latino. Ninety-two percent of visits and 93% of counseling sessions were completed. At baseline, 33.3% of participants had experienced an overdose in the past four months, with a similar mean number of overdoses in both arms (p = 0.95); 29% overdosed during follow-up. By intention-to-treat, participants assigned to REBOOT were less likely to experience any overdose (incidence rate ratio [IRR] 0.62 [95%CI 0.41-0.92, p = 0.019) and experienced fewer overdose events (IRR 0.46, 95%CI 0.24-0.90, p = 0.023), findings that were robust to sensitivity analyses. There were no differences between arms in days of opioid use, substance use treatment, or naloxone carriage.

CONCLUSIONS

REBOOT reduced the occurrence of any opioid overdose and the number of overdoses.

TRIAL REGISTRATION

clinicaltrials.gov NCT02093559.

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.

Naloxone use among overdose prevention trainees in New York City: A longitudinal cohort study

BACKGROUND

Providing naloxone to laypersons who are likely to witness an opioid overdose is now a widespread public health response to the national opioid overdose epidemic. Estimating the proportion of individuals who use naloxone can define its potential impact to reduce overdose deaths at a population level. We determined the proportion of study participants who used naloxone within 12 months following training and factors associated with witnessing overdose and naloxone use.

METHODS

We conducted a prospective, observational study of individuals completing overdose prevention training (OPT) between June and September 2013. Participants were recruited from New York City's six largest overdose prevention programs, all operated by syringe exchange programs. Questionnaires were administered at four time points over 12 months. Main outcomes were witnessing or experiencing overdose, and naloxone administration.

RESULTS

Of 675 individuals completing OPT, 429 (64%) were approached and 351 (52%) were enrolled. Overall, 299 (85%) study participants completed at least one follow-up survey; 128 (36%) witnessed at least one overdose. Of 312 witnessed opioid overdoses, naloxone was administered in 241 events (77%); 188 (60%) by the OPT study participant. Eighty-six (25%) study participants administered naloxone at least once. Over one third of study participants (30, 35%) used naloxone 6 or more months after training.

CONCLUSIONS

Witnessing an overdose and naloxone use was common among this study cohort of OPT trainees. Training individuals at high risk for witnessing overdoses may reduce opioid overdose mortality at a population level if sufficient numbers of potential responders are equipped with naloxone.

Twenty years of take-home naloxone for the prevention of overdose deaths from heroin and other opioids-Conception and maturation

BACKGROUND

Opioid overdose is a major cause of mortality, but injury and fatal outcomes can be prevented by timely administration of the opioid antagonist naloxone. Pre-provision of naloxone to opioid users and family members (take-home naloxone, THN) was first proposed in 1996, and WHO Guidelines were issued in 2014. While widespread in some countries, THN is minimally available or absent elsewhere. This review traces the development of THN over twenty years, from speculative harm reduction proposal to public health strategy.

METHOD

Medline and PsycINFO were searched for peer-reviewed literature (1990-2016) using Boolean queries: 1) "naloxone OR Narcan"; 2) "(opioid OR opiate) AND overdose AND prevention". Grey literature and specialist websites were also searched. Data were extracted and synthesized as narrative review, with key events presented as chronological timeline.

RESULTS

Results are presented in 5-year intervals, starting with the original proposal and THN pilots from 1996 to 2001. Lack of familiarity with THN challenged early distribution schemes (2001-2006), leading to further testing, evaluation, and assessment of challenges and perceived medicolegal barriers. From 2006-2011, response to social and legal concerns led to the expansion of THN programs; followed by high-impact research and efforts to widen THN availability from 2011 to 2016.

CONCLUSIONS

Framed as a public health tool for harm reduction, THN has overcome social, clinical, and legal barriers in many jurisdictions. Nonetheless, the rising death toll of opioid overdose illustrates that current THN coverage is insufficient, and greater public investment in overdose prevention will be required if THN is to achieve its full potential impact.

Patient Simulation for Assessment of Layperson Management of Opioid Overdose With Intranasal Naloxone in a Recently Released Prisoner Cohort

INTRODUCTION

Investigators applied simulation to an experimental program that educated, trained, and assessed at-risk, volunteering prisoners on opioid overdose (OD) prevention, recognition, and layperson management with intranasal (IN) naloxone.

METHODS

Consenting inmates were assessed for OD-related experience and knowledge then exposed on-site to standardized didactics and educational DVD (without simulation). Subjects were provided with IN naloxone kits at time of release and scheduled for postrelease assessment. At follow-up, the subjects were evaluated for their performance of layperson opioid OD resuscitative skills during video-recorded simulations. Two investigators independently scored each subject's resuscitative actions with a 21-item checklist; post hoc video reviews were separately completed to adjudicate subjects' interactions for overall benefit or harm.

RESULTS

One hundred three prisoners completed the baseline assessment and study intervention and then were prescribed IN naloxone kits. One-month follow-up and simulation data were available for 85 subjects (82.5% of trained recruits) who had been released and resided in the community. Subjects' simulation checklist median score was 12.0 (interquartile range, 11.0-15.0) of 21 total indicated actions. Forty-four participants (51.8%) correctly administered naloxone; 16 additional subjects (18.8%) suboptimally administered naloxone. Nonindicated actions, primarily chest compressions, were observed in 49.4% of simulations. Simulated resuscitative actions by 80 subjects (94.1%) were determined post hoc to be beneficial overall for patients overdosing on opioids.

CONCLUSIONS

As part of an opioid OD prevention research program for at-risk inmates, investigators applied simulation to 1-month follow-up assessments of knowledge retention and skills acquisition in postrelease participants. Simulation supplemented traditional research tools for investigation of layperson OD management.

Does exposure to opioid substitution treatment in prison reduce the risk of death after release? A national prospective observational study in England

BACKGROUND AND AIMS

People with opioid use disorder (OUD) in prison face an acute risk of death after release. We estimated whether prison-based opioid substitution treatment (OST) reduces this risk.

DESIGN

Prospective observational cohort study using prison health care, national community drug misuse treatment and deaths registers.

SETTING

Recruitment at 39 adult prisons in England (32 male; seven female) accounting for 95% of OST treatment in England during study planning.

PARTICIPANTS

Adult prisoners diagnosed with OUD (recruited: September 2010-August 2013; first release: September 2010; last release: October 2014; follow-up to February 2016; n = 15 141 in the risk set).

INTERVENTION AND COMPARATOR

At release, participants were classified as OST exposed (n = 8645) or OST unexposed (n = 6496). The OST unexposed group did not receive OST, or had been withdrawn, or had a low dose.

MEASUREMENTS

Primary outcome: all-cause mortality (ACM) in the first 4 weeks.

SECONDARY OUTCOMES

drug-related poisoning (DRP) deaths in the first 4 weeks; ACM and DRP mortality after 4 weeks to 1 year; admission to community drug misuse treatment in the first 4 weeks. Unadjusted and adjusted Cox regression models (covariates: sex, age, drug injecting, problem alcohol use, use of benzodiazepines, cocaine, prison transfer and admission to community treatment), tested difference in mortality rates and community treatment uptake.

FINDINGS

During the first 4 weeks after prison release there were 24 ACM deaths: six in the OST exposed group and 18 in the OST unexposed group [mortality rate 0.93 per 100 person-years (py) versus 3.67 per 100 py; hazard ratio (HR) = 0.25; 95% confidence interval (CI) = 0.10-0.64]. There were 18 DRP deaths: OST exposed group mortality rate 0.47 per 100 py versus 3.06 per 100 py in the OST unexposed group (HR = 0.15; 95% CI = 0.04-0.53). There was no group difference in mortality risk after the first month. The OST exposed group was more likely to enter drug misuse treatment in the first month post-release (odds ratio 2.47, 95% CI = 2.31-2.65). The OST mortality protective effect on ACM and DRP mortality risk was not attenuated by demographic, overdose risk factors, prison transfer or community treatment (fully adjusted HR = 0.25; 95% CI = 0.09-0.64 and HR = 0.15; 95% CI = 0.04-0.52, respectively).

CONCLUSIONS

In an English national study, prison-based opioid substitution therapy was associated with a 75% reduction in all-cause mortality and an 85% reduction in fatal drug-related poisoning in the first month after release.

Naloxone for heroin, prescription opioid, and illicitly made fentanyl overdoses: Challenges and innovations responding to a dynamic epidemic

Community-based overdose prevention programs first emerged in the 1990's and are now the leading public health intervention for overdose. Key elements of these programs are overdose education and naloxone distribution to people who use opioids and their social networks. We review the evolution of naloxone programming through the heroin overdose era of the 1990's, the prescription opioid era of the 2000's, and the current overdose crisis stemming from the synthetic opioid era of illicitly manufactured fentanyl and its analogues in the 2010's. We present current challenges arising in this new era of synthetic opioids, including variable potency of illicit drugs due to erratic adulteration of the drug supply with synthetic opioids, potentially changing efficacy of standard naloxone formulations for overdose rescue, potentially shorter overdose response time, and reports of fentanyl exposure among people who use drugs but are opioid naïve. Future directions for adapting naloxone programming to the dynamic opioid epidemic are proposed, including scale-up to new venues and social networks, new standards for post-overdose care, expansion of supervised drug consumption services, and integration of novel technologies to detect overdose and deliver naloxone.