Opioid-overdose laws association with opioid use and overdose mortality

Using qualitative system dynamics modeling to understand overdose bystander behavior in the context of Connecticut's Good Samaritan Laws and identify effective policy options

BACKGROUND

Good Samaritan Laws are a harm reduction policy intended to facilitate a reduction in fatal opioid overdoses by enabling bystanders, first responders, and health care providers to assist individuals experiencing an overdose without facing civil or criminal liability. However, Good Samaritan Laws may not be reaching their full impact in many communities due to a lack of knowledge of protections under these laws, distrust in law enforcement, and fear of legal consequences among potential bystanders. The purpose of this study was to develop a systems-level understanding of the factors influencing bystander responses to opioid overdose in the context of Connecticut's Good Samaritan Laws and identify high-leverage policies for improving opioid-related outcomes and implementation of these laws in Connecticut (CT).

METHODS

We conducted six group model building (GMB) workshops that engaged a diverse set of participants with medical and community expertise and lived bystander experience. Through an iterative, stakeholder-engaged process, we developed, refined, and validated a qualitative system dynamics (SD) model in the form of a causal loop diagram (CLD).

RESULTS

Our resulting qualitative SD model captures our GMB participants' collective understanding of the dynamics driving bystander behavior and other factors influencing the effectiveness of Good Samaritan Laws in the state of CT. In this model, we identified seven balancing (B) and eight reinforcing (R) feedback loops within four narrative domains: Narrative 1 - Overdose, Calling 911, and First Responder Burnout; Narrative 2 - Naloxone Use, Acceptability, and Linking Patients to Services; Narrative 3 - Drug Arrests, Belief in Good Samaritan Laws, and Community Trust in Police; and Narrative 4 - Bystander Naloxone Use, Community Participation in Harm Reduction, and Cultural Change Towards Carrying Naloxone.

CONCLUSIONS

Our qualitative SD model brings a nuanced systems perspective to the literature on bystander behavior in the context of Good Samaritan Laws. Our model, grounded in local knowledge and experience, shows how the hypothesized non-linear interdependencies of the social, structural, and policy determinants of bystander behavior collectively form endogenous feedback loops that can be leveraged to design policies to advance and sustain systems change.

"Addiction is Not a Choice." #narcansaveslives: Collective Voice in Harm Reduction on TikTok

Using 100 videos posted to TikTok by harm reduction creators with the hashtags #narcansaveslives and #naloxonesaveslives, this study examines who is posting, what they are saying, and how they are explaining Narcan/naloxone to their followers. Incorporating the concept of reverse agenda setting, we examine how, through hashtags, TikTok creators can set the agenda for what is important to discuss in the harm reduction space. Findings demonstrate that harm reduction creators have developed a collective voice and created an affective public, attempting to educate others, shed stigma, and normalize the conversation around harm reduction. These creators are using TikTok to educate followers about the prevalence of opioid use, the availability of Narcan/naloxone, correcting misinformation, and discussing the reality of recovery. Echoing prior studies, this research illustrates how TikTok has become an essential resource for health questions, including opioid use. Practical implications are also discussed.

Naloxone distribution programs in the emergency department: A scoping review of the literature

This scoping review summarized the literature regarding naloxone distribution from emergency departments (EDs) without a prescription. Our intention was to examine various naloxone distribution programs, their methodologies, and the level of effectiveness of each. Understanding these key aspects of naloxone distribution could lead to improved standardized protocols, saving countless additional lives from opioid overdose. This review evaluated studies reporting naloxone distribution from EDs in the United States. The included studies were written in English and published between January 1, 2017, and December 31, 2022. Searches were performed using PubMed and Embase. A total of 129 studies were reviewed, with only 12 meeting the necessary criteria for analysis. Heterogeneity was found across naloxone distribution programs, including how patients were identified, how naloxone was dispensed to patients, and the specific naloxone products made available. The protocols included various methods, such as patient screening, where information used for this screening was sometimes obtained from health records or patient interviews. Some programs detailed only the distribution of naloxone, while others included additional interventions such as behavior counseling, peer support, and education. In four studies, patients received buprenorphine with naloxone kits. The various programs differed in their implementation but were generally successful in improving naloxone distribution. However, among the studies reviewed, the percentage of ED patients receiving naloxone varied from ∼30% to 70%, suggesting that certain program elements may be more impactful. Further research is needed to identify key elements of the most impactful programs in order to improve naloxone distribution and improve patient odds of surviving an opioid overdose.

Access to, Experience with, and Attitudes towards Take Home Naloxone: An Online Survey

The opioid public health crisis continues to burden individuals, communities, and economies. Public health opinion has emphasized the need for increased access to harm reduction services, but there is a dearth of information on the views and experiences of people who use opioids. Our study aimed to investigate the prevalence of naloxone use, attitudes, and experiences with naloxone among an online community of people who use drugs. We performed a cross-sectional survey looking at experiences with and attitudes towards take-home naloxone. Data is presented descriptively, with analysis of the differences between people who do and do not use opioids using the χ2 and Fisher's exact tests. There were 1,143 respondents, of whom 70% were from the United States. Only 38% of participants who use opioids had received naloxone training, but 56% of these individuals said that they felt comfortable using a naloxone kit. Nearly all respondents (95%) said they would be willing to use naloxone on someone who had overdosed and approximately 90% would want naloxone used on them in case of an overdose. Regarding harm reduction, 24% of respondents said they had access to safe use programs, and 33% said they had access to clean needle exchange programs. A majority of the participants who use opioids were in favor of having naloxone with them when using drugs and believed naloxone should be freely available. This study demonstrates the receptiveness of take-home naloxone and highlights the need for better implementation of naloxone within communities that use opioids.

Reducing overdose deaths among persons with opioid use disorder in connecticut

BACKGROUND

People in Connecticut are now more likely to die of a drug-related overdose than a traffic accident. While Connecticut has had some success in slowing the rise in overdose death rates, substantial additional progress is necessary.

METHODS

We developed, verified, and calibrated a mechanistic simulation of alternative overdose prevention policy options, including scaling up naloxone (NLX) distribution in the community and medications for opioid use disorder (OUD) among people who are incarcerated (MOUD-INC) and in the community (MOUD-COM) in a simulated cohort of people with OUD in Connecticut. We estimated how maximally scaling up each option individually and in combinations would impact 5-year overdose deaths, life-years, and quality-adjusted life-years. All costs were assessed in 2021 USD, employing a health sector perspective in base-case analyses and a societal perspective in sensitivity analyses, using a 3% discount rate and 5-year and lifetime time horizons.

RESULTS

Maximally scaling NLX alone reduces overdose deaths 20% in the next 5 years at a favorable incremental cost-effectiveness ratio (ICER); if injectable rather than intranasal NLX was distributed, 240 additional overdose deaths could be prevented. Maximally scaling MOUD-COM and MOUD-INC alone reduce overdose deaths by 14% and 6% respectively at favorable ICERS. Considering all permutations of scaling up policies, scaling NLX and MOUD-COM together is the cost-effective choice, reducing overdose deaths 32% at ICER $19,000/QALY. In sensitivity analyses using a societal perspective, all policy options were cost saving and overdose deaths reduced 33% over 5 years while saving society $338,000 per capita over the simulated cohort lifetime.

CONCLUSIONS

Maximally scaling access to naloxone and MOUD in the community can reduce 5-year overdose deaths by 32% among people with OUD in Connecticut under realistic budget scenarios. If societal cost savings due to increased productivity and reduced crime costs are considered, one-third of overdose deaths can be reduced by maximally scaling all three policy options, while saving money.

Overdose Risk and Brain Injury (Traumatic Brain Injury/Acquired Brain Injury), A Commentary

OBJECTIVE

This commentary seeks to evaluate existing knowledge about the relationship between brain injury (BI) and overdose (OD), to unify distant bodies of literature, and to enhance prevention and treatment for opioid OD among individuals with BI.

BACKGROUND

There is a hidden epidemic of undiagnosed BI in the United States. Due to lack of screening, the vast majority of BI sufferers do not know they have a BI. Not only are those with BI at elevated risk for opioid use, misuse, and opioid use disorder, but also they are at elevated risk for OD. Conversely, those with OUD and those who experienced an OD, are more likely to sustain BI. Key Findings/Conclusions: The existing literature suggests that primary strategies to reduce ABI (Acquired Brain Injury)/TBI (Traumatic Brain Injury) harms involve addressing: screening, stigma, racial disparities, and popular misconceptions about OD. The association between TBI and OD is an underexamined public health issue, exacerbated by the bidirectional nature of the relationship. Not only is TBI a risk factor for opioid OD; opioid OD was also found to be a major cause of ABI, which can have lifelong effects similar to Alzheimer's disease. Screening tools for BI were underutilized and inconsistently implemented across reviewed studies. Enhanced screening population wide is a promising intervention, complemented with expanded treatment and research. Black individuals face worse outcomes in BI and treatment outcomes. Anti-racist strategies must fight inequity while addressing social and structural drivers of overdose and BI within the opioid and opioid overdose crises.

Emergency Department Take-Home Naloxone Improves Access Compared with Pharmacy-Dispensed Naloxone

BACKGROUND

Opioid overdose is a major cause of mortality in the United States. In spite of efforts to increase naloxone availability, distribution to high-risk populations remains a challenge.

OBJECTIVE

To assess the effects of multiple different naloxone distribution methods on patient obtainment of naloxone in the emergency department (ED) setting.

METHODS

Naloxone was provided to patients in three 12-month phases between February 2020 and February 2023. In Phase 1, physicians could offer patients electronic prescriptions, which were filled in a nearby in-hospital discharge pharmacy. In Phase 2, physicians directly provided patients with take-home naloxone at discharge. In Phase 3, distribution was expanded to allow ED staff to hand patients take-home naloxone at time of discharge. The total number of prescriptions, rate of prescription filling, and amount of take-home naloxone kits provided to patients were then statistically analyzed using 95% confidence intervals (CI) and chi-squared testing.

RESULTS

In Phase 1, 348 naloxone prescriptions were written, with 133 (95% CI 112.5-153.5) filled. In Phase 2, 327 (95% CI 245.5-408.5) take-home naloxone kits were given to patients by physicians. In Phase 3, 677 (95% CI 509.5-844.5) take-home naloxone kits were provided to patients by ED staff. There were statistically significant increases in naloxone distribution from Phase 1 to Phase 2, and Phase 2 to Phase 3.

CONCLUSIONS

Take-home naloxone increases access when compared with naloxone prescriptions in the ED setting. A multidisciplinary approach combined with the removal of regulatory and administrative barriers allowed for further increased distribution of no-cost naloxone to patients.

The availability of fentanyl test strips in Georgia community pharmacies

BACKGROUND

Fentanyl test strips (FTS) are increasingly being used to test counterfeit pharmaceuticals and illicit drugs for fentanyl before consumption. On July 1, 2022, Georgia legalized the distribution of FTS. One strategy for expanding FTS distribution in the community involves leveraging community pharmacies. However, less is known about FTS distribution through community pharmacies.

OBJECTIVES

This preliminary study aimed to assess the availability of FTS in Georgia community pharmacies and examine pharmacists' knowledge and attitudes regarding FTS provision.

METHODS

This study used a cross-sectional design. A randomized telephone survey of 700 pharmacies, stratified by pharmacy type, was carried out from September 2022 to January 2023. Survey questions assessed FTS stock status, pharmacists' awareness of Georgia's FTS legalization, willingness to receive FTS information, and comfort in providing FTS education. Descriptive statistics and multivariate logistic regression analyses were used to analyze the data.

RESULTS

Of the 376 survey respondents, the vast majority were not aware of the Georgia FTS legalization (82.71% [n = 311]) and did not have FTS stocked in their pharmacies (94.91% [n = 354]). While most participants were willing to receive FTS information (70.21% [n = 264]), only slightly over half reported feeling comfortable providing FTS education (54.70% [n = 205]). Multivariate analyses showed that female participants were less likely to feel comfortable providing FTS education to patients/clients at the pharmacy (adjusted odds ratio: 0.58; confidence interval: 0.36 to 0.92).

CONCLUSION

Findings suggest that Georgia community pharmacies may not stock FTS and that pharmacists may be unaware of the state's FTS legalization, but they are willing to receive information about FTS. Future studies should use a representative sample to design and implement strategies to support pharmacists' provision of FTS, including a destigmatization approach for those not comfortable discussing FTS.

Community Support for Harm Reduction and Treatment of Opioid Use Disorder

As the opioid epidemic continues, availability of evidence-based strategies for harm reduction and treatment in communities is critical to reduce overdose and other consequences of opioid use disorder. Community members' support of harm reduction and treatment services is needed for new programs and to maintain existent programs. This study sought to understand beliefs and attitudes associated with support for three community-based strategies to address opioid misuse and addiction: naloxone, needle exchange, and medication-assisted treatment. We conducted a cross-sectional online survey with 545 adults. Results of the survey showed that participants supported all three strategies, with the strongest support for medication-assisted treatment. Multiple regression showed that stigma and perceived stigma were significant predictors for all three strategies, with inverse relationships. Stigmatizing beliefs predicted less support while perceiving stigma among others was associated with greater support for the strategies. Normative beliefs also significantly predicted support for all three strategies, such that stronger belief that others were supportive of each strategy was associated with greater support for that strategy. Other predictors varied across the three strategies. Support for harm reduction and treatment programs in communities affected by the opioid epidemic may be bolstered by reducing stigma and increasing normative beliefs. Stronger support for medication-assisted treatment may be leveraged and extended to harm reduction strategies. Results of our study contribute insights for bolstering community support for harm reduction and treatment, which is vital for adoption and maintenance of these important programs.

Harm reduction in undergraduate and graduate medical education: a systematic scoping review

BACKGROUND

Substance use increasingly contributes to early morbidity and mortality, which necessitates greater preparation of the healthcare workforce to mitigate its harm. The purpose of this systematic scoping review is to: 1) review published curricula on harm reduction for substance use implemented by undergraduate (UME) and graduate medical education (GME) in the United States and Canada, 2) develop a framework to describe a comprehensive approach to harm reduction medical education, and 3) propose additional content topics for future consideration.

METHODS

PubMed, Scopus, ERIC: Education Resources Information Center (Ovid), and MedEdPORTAL were searched. Studies included any English language curricula about harm reduction within UME or GME in the United States or Canada from 1993 until Nov 22, 2021. Two authors independently reviewed and screened records for data extraction. Data were analyzed on trainee population, curricula objectives, format, content, and evaluation.

RESULTS

Twenty-three articles describing 19 distinct educational programs across the United States were included in the final sample, most of which created their own curricula (n = 17). Data on educational content were categorized by content and approach. Most programs (85%) focused on introductory substance use knowledge and skills without an understanding of harm reduction principles. Based on our synthesis of the educational content in these curricula, we iteratively developed a Harm Reduction Educational Spectrum (HRES) framework to describe curricula and identified 17 discrete content topics grouped into 6 themes based on their reliance on harm reduction principles.

CONCLUSIONS

Harm reduction is under-represented in published medical curricula. Because the drug supply market changes rapidly, the content of medical curricula may be quickly outmoded thus curricula that include foundational knowledge of harm reduction principles may be more enduring. Students should be grounded in harm reduction principles to develop the advanced skills necessary to reduce the physical harm associated with drugs while still simultaneously recognizing the possibility of patients' ongoing substance use. We present the Harm Reduction Educational Spectrum as a new framework to guide future healthcare workforce development and to ultimately provide the highest-quality care for patients who use drugs.

The effect of untargeted naloxone distribution on opioid overdose outcomes

Opioid overdose has claimed the lives of over 340,000 Americans in the last decade. Over that same period, policymakers have taken steps to increase the availability of naloxone-an opioid antagonist used to rescue overdose victims-to people in the community. Previous studies, most of which have examined the effects of state laws designed to facilitate access to naloxone, have reached mixed conclusions about the effects of naloxone access on fatal and non-fatal overdoses. This paper exploits a unique policy experiment provided by two naloxone giveaways intended to increase naloxone possession among the general public in Pennsylvania to estimate the causal impact of naloxone distribution on fatal overdoses and opioid-related emergency department (ED) visits. Using a difference-in-differences design, I find evidence that opioid overdose deaths fell immediately following the first giveaway but increased following the second giveaway and discuss these apparently contradictory findings in the context of the changing composition of the opioid supply. I also find some evidence of a decline in opioid overdose-related ED visits following the giveaways. This study is the first to examine the effects of untargeted naloxone distribution and has implications for other novel, naloxone distribution efforts currently underway.

Why is naloxone prescription not more common in emergency departments? A survey of physician practices and attitudes

OBJECTIVE

Emergency physicians (EPs) have a singular opportunity to prescribe naloxone and decrease fatal overdoses in opioid users. We surveyed EPs patterns of naloxone prescription and identified barriers to prescribing naloxone.

DESIGN

Surveys were conducted at an emergency medicine conference from 2018 to 2019. We used a Likert scale for all questions and a chi-square or chi-square for trend tests to determine statistical significance.

SETTING

Emergency medicine conferences and emergency departments.

PARTICIPANTS

Forty-one EPs were surveyed.

INTERVENTION

Oral survey.

MAIN OUTCOME MEASURES

Prevalence of naloxone prescription and EP attitude toward naloxone.

RESULTS

65.0 percent of residents and 33.3 percent of attending physicians had never prescribed naloxone to patients. 90.2 percent believed ED naloxone prescription is safe, 82.9 percent did not refrain from prescribing due to ethical concerns, and 73.2 percent believed it is not a waste of resources.

CONCLUSIONS

Many resident physicians had never prescribed naloxone despite agreeing it was safe, ethical, and a productive use of resources. The time needed to counsel patients on naloxone use was a barrier to prescription, and various interventions are needed to make this practice more common.

Systems analysis and improvement approach to improve naloxone distribution within syringe service programs: study protocol of a randomized controlled trial

BACKGROUND

More than half a million Americans died of an opioid-related overdose between 1999 and 2020, the majority occurring between 2015 and 2020. The opioid overdose mortality epidemic disproportionately impacts Black, Indigenous, and people of color (BIPOC): since 2015, overdose mortality rates have increased substantially more among Black (114%) and Latinx (97%) populations compared with White populations (32%). This is in part due to disparities in access to naloxone, an opioid antagonist that can effectively reverse opioid overdose to prevent death. Our recent pilot work determined that many barriers to naloxone access can be identified and addressed by syringe service programs (SSPs) using the Systems Analysis and Improvement Approach to Naloxone distribution (SAIA-Naloxone). This randomized controlled trial will test SAIA-Naloxone's ability to improve naloxone distribution in general and among BIPOC specifically.

METHODS

We will conduct a trial with 32 SSPs across California, randomly assigning 16 to the SAIA-Naloxone arm and 16 to receive implementation as usual. SAIA-Naloxone is a multifaceted, multilevel implementation strategy through which trained facilitators work closely with SSPs to (1) assess organization-level barriers, (2) prioritize barriers for improvement, and (3) test solutions through iterative change cycles until achieving and sustaining improvements. SSPs receiving SAIA-Naloxone will work with a trained facilitator for a period of 12 months. We will test SAIA-Naloxone's ability to improve SSPs' naloxone distribution using an interrupted time series approach. Data collection will take place during a 3-month lead-in period, the 12-month active period, and for an additional 6 months afterward to determine whether impacts are sustained. We will use a structured approach to specify SAIA-Naloxone to ensure strategy activities are clearly defined and to assess SAIA-Naloxone fidelity to aid in interpreting study results. We will also assess the costs associated with SAIA-Naloxone and its cost-effectiveness.

DISCUSSION

This trial takes a novel approach to improving equitable distribution of naloxone amid the ongoing epidemic and associated racial disparities. If successful, SAIA-Naloxone represents an important organizational-level solution to the multifaceted and multilevel barriers to equitable naloxone distribution.

Changes in Opioid and Benzodiazepine Poisoning Deaths After Cannabis Legalization in the US: A County-level Analysis, 2002-2020

BACKGROUND

Cannabis legalization for medical and recreational purposes has been suggested as an effective strategy to reduce opioid and benzodiazepine use and deaths. We examined the county-level association between medical and recreational cannabis laws and poisoning deaths involving opioids and benzodiazepines in the US from 2002 to 2020.

METHODS

Our ecologic county-level, spatiotemporal study comprised 49 states. Exposures were state-level implementation of medical and recreational cannabis laws and state-level initiation of cannabis dispensary sales. Our main outcomes were poisoning deaths involving any opioid, any benzodiazepine, and opioids with benzodiazepines. Secondary analyses included overdoses involving natural and semi-synthetic opioids, synthetic opioids, and heroin.

RESULTS

Implementation of medical cannabis laws was associated with increased deaths involving opioids (rate ratio [RR] = 1.14; 95% credible interval [CrI] = 1.11, 1.18), benzodiazepines (RR = 1.19; 95% CrI = 1.12, 1.26), and opioids+benzodiazepines (RR = 1.22; 95% CrI = 1.15, 1.30). Medical cannabis legalizations allowing dispensaries was associated with fewer deaths involving opioids (RR = 0.88; 95% CrI = 0.85, 0.91) but not benzodiazepine deaths; results for recreational cannabis implementation and opioid deaths were similar (RR = 0.81; 95% CrI = 0.75, 0.88). Recreational cannabis laws allowing dispensary sales was associated with consistent reductions in opioid- (RR = 0.83; 95% CrI = 0.76, 0.91), benzodiazepine- (RR = 0.79; 95% CrI = 0.68, 0.92), and opioid+benzodiazepine-related poisonings (RR = 0.83; 95% CrI = 0.70, 0.98).

CONCLUSIONS

Implementation of medical cannabis laws was associated with higher rates of opioid- and benzodiazepine-related deaths, whereas laws permitting broader cannabis access, including implementation of recreational cannabis laws and medical and recreational dispensaries, were associated with lower rates. The estimated effects of the expanded availability of cannabis seem dependent on the type of law implemented and its provisions.

Pathways to racial disparities in the effects of Good Samaritan Laws: A mixed methods pilot study

BACKGROUND

Drug overdose deaths continue to rise, and considerable racial inequities have emerged. Overdose Good Samaritan laws (GSLs) are intended to encourage overdose witnesses to seek emergency assistance. However, evidence of their effectiveness is mixed, and little is known regarding racial disparities in their implementation. This study examined GSL impact by assessing racial differences in awareness of and trust in New York state's GSL.

METHODS

Using a sequential mixed methods design, Black and white participants were recruited from an existing longitudinal cohort study of people who use illicit opioids in New York City to participate in a quantitative survey and qualitative interviews. Racially stratified survey responses were analyzed using chi-squared tests, Fisher exact tests, or t-tests. Qualitative interviews were analyzed using a hybrid inductive-deductive approach.

RESULTS

Participants (n=128) were 56% male and predominantly aged 50 years or older. Most met criteria for severe opioid use disorder (81%). Fifty-seven percent reported that the New York GSL makes them more likely to call 911 even though 42% reported not trusting law enforcement to abide by the GSL; neither differed by race. Black people were less likely to have heard of the GSL (36.1% vs 60%) and were less likely to have accurate information regarding its protections (40.4% vs 49.6%).

CONCLUSIONS

Though GSLs may reduce negative impacts of the criminalization of people who use drugs, their implementation may exacerbate existing racial disparities. Resources should be directed towards harm reduction strategies that do not rely on trust in law enforcement.

Barriers and facilitators of naloxone and safe injection facility interventions to reduce opioid drug-related deaths: A qualitative analysis

BACKGROUND

Opioid drug-related deaths continue to be a significant public health concern in the Republic of Ireland (ROI) and Northern Ireland (NI). While both regions have implemented naloxone to reduce drug related deaths, there remains a gap in the implementation of a supervised injection facility (SIF). This study aimed to identify barriers and facilitators to implementing naloxone and a SIF to reduce opioid drug-related deaths in ROI and NI.

METHODS

Semi-structured interviews (n=23) were conducted in ROI and NI with experts by experience (n=8), staff from low threshold services (n=9), and individuals involved in policy making (n= 6). Data were analyzed using coding reliability Thematic Analysis and were informed by the Risk Environmental Framework.

RESULTS

The findings illustrated that stigma within the media, health centers, and the community was a significant barrier to naloxone distribution and SIF implementation. Policing and community intimidation were reported to hinder naloxone carriage in both the ROI and NI, while threats of paramilitary violence towards people who use drugs were unique to NI. Municipal government delays and policy maker apathy were reported to hinder SIF implementation in the ROI. Participants suggested peer-to-peer naloxone delivery and amending legislation to facilitate non-prescription naloxone would increase naloxone uptake. Participants recommended using webinars, Town Halls, and a Citizens' Assembly as tools to advocate for SIF implementation.

CONCLUSION

Local and regional stigma reduction campaigns are needed in conjunction with policy changes to advance naloxone and a SIF. Tailoring stigma campaigns to incorporate the lived experience of people who use drugs, their family members, and the general community can aid in educating the public and change negative perceptions. This study highlights the need for ongoing efforts to reduce stigma and increase accessibility to evidence-based interventions to address opioid drug-related deaths in the ROI, NI, and internationally.

Dimension reduction of 911 Good Samaritan Laws: Drawing inferences from policy surveillance

BACKGROUND

911 Good Samaritan Laws (GSLs) extend legal protection to people reporting drug overdoses who may otherwise be in violation of controlled substance laws. Mixed evidence suggests GSLs decrease overdose mortality, but these studies overlook substantial heterogeneity across states. The GSL Inventory exhaustively catalogs features of these laws into four categories: breadth, burden, strength, and exemption. The present study reduces this dataset to reveal patterns in implementation, facilitate future evaluations, and to produce a roadmap for the dimension reduction of further policy surveillance datasets.

METHODS

We produced multidimensional scaling plots visualizing the frequency of co-occurring GSL features from the GSL Inventory as well as similarity among state laws. We clustered laws into meaningful groups by shared features; produced a decision tree identifying salient features predicting group membership; scored their relative breadth, burden, strength, and exemption of immunity; and associated groups with state sociopolitical and sociodemographic variables.

RESULTS

In the feature plot, breadth and strength features segregate from burdens and exemptions. Regions in the state plot differentiate quantity of substances immunized, burden of reporting requirements, and immunity for probationers. State laws may be clustered into five groups distinguished by proximity, salient features, and sociopolitical variables.

DISCUSSION

This study reveals competing attitudes toward harm reduction that underly GSLs across states. These analyses provide a roadmap for the application of dimension reduction methods to policy surveillance datasets, accommodating their binary structure and longitudinal observations. These methods preserve higher-dimensional variance in a form amenable to statistical evaluation.

National survey findings on law enforcement agency drug response practices, overdose victim outcomes, and Good Samaritan Laws

BACKGROUND

The United States continues to experience unprecedented rates of overdose mortality. Addressing the overdose epidemic has been challenging for policy makers given the lack of effectiveness of existing drug control policy measures. More recently, the implementation of harm reduction-based policies such as Good Samaritan Laws has led to increasing scholarly attention aimed at evaluating their effectiveness at reducing the likelihood of criminal justice-related sanctions for individuals following an overdose incident. The results of these studies, however, have been mixed.

METHODS

This study utilizes data from a nationally representative survey of law enforcement agencies designed to provide national information on services, policies, practices, operations, and resources of law enforcement drug response around overdoses to assess whether state Good Samaritan Laws reduce the likelihood of overdose victims being cited or being jailed following an overdose incident.

RESULTS

In general, findings indicate that although most agencies reported that overdose victims were not incarcerated or cited following an overdose incident, that this did not vary by whether agencies were in a state that had a GSL arrest protection for possession of controlled substances.

CONCLUSIONS

GSLs are often written in complex and confusing language that officers and people who use drugs do not fully understand, which may deter their being used for their intended purpose. Although GSLs are well-intentioned, these findings highlight the need for training and education for law enforcement and people who use drugs around the scope of these laws.

Association of Implementation of Postoverdose Outreach Programs With Subsequent Opioid Overdose Deaths Among Massachusetts Municipalities

Importance

Nonfatal opioid overdose is the leading risk factor for subsequent fatal overdose and represents a critical opportunity to reduce future overdose and mortality. Postoverdose outreach programs emerged in Massachusetts beginning in 2013 with the main purpose of linking opioid overdose survivors to addiction treatment and harm reduction services.

Objective

To evaluate whether the implementation of postoverdose outreach programs among Massachusetts municipalities was associated with lower opioid fatality rates compared with municipalities without postoverdose outreach programs.

Design, Setting, and Participants

This retrospective interrupted time-series analysis was performed over 26 quarters (from January 1, 2013, through June 30, 2019) across 93 municipalities in Massachusetts. These 93 municipalities were selected based on a threshold of 30 or more opioid-related emergency medical services (EMS) responses in 2015. Data were analyzed from November 2021 to August 2022.

Exposures

The main exposure was municipality postoverdose outreach programs. Municipalities had various program inceptions during the study period.

Main Outcomes and Measures

The primary outcome was quarterly municipal opioid fatality rate per 100 000 population. The secondary outcome was quarterly municipal opioid-related EMS response (ambulance trips) rates per 100 000 population.

Results

The mean (SD) population size across 93 municipalities was 47 622 (70 307), the mean (SD) proportion of female individuals was 51.5% (1.5%) and male individuals was 48.5% (1.5%), and the mean (SD) age proportions were 29.7% (4.0%) younger than 25 years, 26.0% (4.8%) aged 25 to 44 years, 14.8% (2.1%) aged 45 to 54 years, 13.4% (2.1%) aged 55 to 64 years, and 16.1% (4.4%) aged 65 years or older. Postoverdose programs were implemented in 58 municipalities (62%). Following implementation, there were no significant level changes in opioid fatality rate (adjusted rate ratio [aRR], 1.07; 95% CI, 0.96-1.19; P = .20). However, there was a significant slope decrease in opioid fatality rate (annualized aRR, 0.94; 95% CI, 0.90-0.98; P = .003) compared with the municipalities without the outreach programs. Similarly, there was a significant slope decrease in opioid-related EMS response rates (annualized aRR, 0.93; 95% CI, 0.89-0.98; P = .007). Several sensitivity analyses yielded similar findings.

Conclusions and Relevance

In this study, among Massachusetts municipalities with high numbers of opioid-related EMS responses, implementation of postoverdose outreach programs was significantly associated with lower opioid fatality rates over time compared with municipalities that did not implement such programs. Program components, including cross-sectoral partnerships, operational best practices, involvement of law enforcement, and related program costs, warrant further evaluation to enhance effectiveness.

Modeling Opioid Abuse: A Case Study of the Opioid Crisis in New England

For the past two decades, the USA has been embroiled in a growing prescription drug epidemic. The ripples of this epidemic have been especially apparent in the state of Maine, which has fought hard to mitigate the damage caused by addiction to pharmaceutical and illicit opioids. In this study, we construct a mathematical model of the opioid epidemic incorporating novel features important to better understanding opioid abuse dynamics. These features include demographic differences in population susceptibility, general transmission expressions, and combined consideration of pharmaceutical opioid and heroin abuse. We demonstrate the usefulness of this model by calibrating it with data for the state of Maine. Model calibration is accompanied by sensitivity and uncertainty analysis to quantify potential error in parameter estimates and forecasts. The model is analyzed to determine the mechanisms most influential to the number of opioid abusers and to find effective ways of controlling opioid abuse prevalence. We found that the mechanisms most influential to the overall number of abusers in Maine are those involved in illicit pharmaceutical opioid abuse transmission. Consequently, preventative strategies that controlled for illicit transmission were more effective over alternative approaches, such as treatment. These results are presented with the hope of helping to inform public policy as to the most effective means of intervention.

The Impact of Naloxone Coprescribing Mandates on Opioid-Involved Overdose Deaths

INTRODUCTION

Since 2017, a total of 10 states have mandated naloxone coprescribing intended to prevent fatal opioid overdoses. This study aims to assess the association between naloxone coprescribing/offering mandates and opioid-involved overdose deaths on the basis of the opioid type.

METHODS

Data on overdose deaths from 1999 to 2020 came from the National Center for Health Statistics CDC WONDER Online Database. This study examined deaths stratified by illicit/synthetic opioids and prescription/treatment opioids. Difference-in-difference negative binomial regression models estimated average marginal effects and 95% CIs. Covariates included opioid dispensing rate, Good Samaritan law, pharmacy-based naloxone access law, mandatory use of prescription drug monitoring program, and recreational cannabis dispensaries. Data collection and analysis were conducted in 2022.

RESULTS

Ten states implemented naloxone coprescribing/offering mandates during the period. Coprescribing/offering mandates significantly reduced the number of prescription/treatment overdose deaths by 8.61 per state per quarter (95% CI= -15.13, -2.09), a 16% reduction from the counterfactual estimates. Coprescribing/offering mandates did not significantly impact illicit/synthetic overdose deaths (average marginal effect=0.32; 95% CI= -18.27, 18.91).

CONCLUSIONS

Coprescribing/offering mandates prevent overdose deaths for its target population, individuals using prescription/treatment opioids. These mandates do not appear to impact populations using illicit/synthetic opioids; thus, expanded efforts are needed to reach these individuals.

Evaluating the Use of Parenteral Naloxone in the Emergency Department of a Community Hospital

Background:Thousands of patients die every year from opioid overdose. Naloxone is a lifesaving medication FDA approved for opioid overdose reversal. Many patients may present to the emergency department (ED) and require naloxone administration. The purpose of this study was to evaluate parenteral naloxone usage in the ED. It assessed parenteral naloxone indication of use and the patient population requiring its administration in order to support the need of a take home naloxone distribution program. Methods: This study was a retrospective, randomized, single center, chart review that took place at a community hospital ED. A computerized report was generated to identify all patients 18 years of age or older who were administered naloxone in the ED from June 2020 to June 2021. The charts of 100 patients randomly selected from the generated report were reviewed to collect the following information: gender, age, indication for use, dosing, drug being reversed, risk factors for overdose, ED revisits within 1 year. Results: Out of the 100 patients randomly reviewed, 55 (55%) patients were administered parenteral naloxone for overdose indication. Eighteen (32%) of overdose patients revisited the hospital within 1 year for overdose. Thirty-six (65%) of patients administered naloxone for overdose had history of substance abuse with 45 (82%) being under the age of 65 years. Conclusion: These results support the need for a take home naloxone distribution program to be implemented for patients at risk for opioid overdose or individuals at risk of witnessing a drug overdose.

Opioid overdose prevention education in Texas during the COVID-19 pandemic

BACKGROUND

Distribution of naloxone and training on its proper use are evidence-based strategies for preventing opioid overdose deaths. In-person naloxone training was conducted in major metropolitan areas and urban centers across Texas as part of a state-wide targeted opioid response program. The training program transitioned to a live, virtual format during the COVID-19 public health emergency declaration. This manuscript describes the impact of this transition through analyses of the characteristics of communities reached using the new virtual training format.

CASE PRESENTATION

Training participant addresses were compared to county rates of opioid overdose deaths and broadband internet access, and census block comparison to health services shortages, rural designation, and race/ethnicity community characteristics.

CONCLUSIONS

The virtual training format reached more learners than the in-person events. Training reached nearly half of the counties in Texas, including all with recent opioid overdose deaths. Most participants lived in communities with a shortage of health service providers, and training reached rural areas, those with limited broadband internet availability, and majority Hispanic communities. In the context of restrictions on in-person gathering, the training program successfully shifted to a live, online format. This transition increased participation above rates observed pre-pandemic and reached communities with the need for equipping those most likely to witness an opioid overdose with the proper use of naloxone.

Are We Witnessing a New Wave of Substance Use Disorders?: A Spotlight on Stimulant Use Disorders

Stimulant use disorders are emerging as a serious global threat to health. Although research, clinical, and policy efforts have largely concentrated on opioid use disorders over the past decade, exponential rises in prevalence and overdose deaths attributable to stimulant use disorders warrant renewed attention. To date, no approved medications are available to treat stimulant use disorders; however, behavioral interventions have been effective and should be proactively promoted. Similarly, complementary and integrative therapies and harm reduction services have emerging evidence for effectiveness in treating these conditions. Research, practice, and policy interventions should address stigma for medications for stimulant use disorders when available, vaccine hesitancy if vaccines are approved and safe, environmental surveillance to reduce population exposure to toxic effects of methamphetamines, and educational interventions for health providers to increase competency to reduce the long-term effects on various body systems. [Journal of Psychosocial Nursing and Mental Health Services, 61(3), 13-18.].

Recreational marijuana laws and the misuse of prescription opioids: Evidence from National Survey on Drug Use and Health microdata

Several studies have concluded that legalizing medical marijuana can reduce deaths from opioid overdoses. Drawing on micro data from the National Survey on Drug Use and Health, a survey uniquely suited to assessing patterns of substance use, we examine the relationship between recreational marijuana laws (RMLs) and the misuse of prescription opioids. Using a standard difference-in-differences (DD) regression model, we find that RML adoption reduces the likelihood of frequently misusing prescription opioids such as OxyContin, Percocet, and Vicodin. However, using a two-stage procedure designed to account for staggered treatment and dynamic effects, the DD estimate of relationship between RML adoption and the likelihood of frequently misusing prescription opioids becomes positive. Although event study estimates suggest that RML adoption leads to a decrease in the frequency of prescription opioid abuse, this effect appears to dissipate after only 2 or 3 years.

The Effect of Naloxone Access Laws on Fatal Synthetic Opioid Overdose Fatality Rates

BACKGROUND

Increases in fatal synthetic opioid overdoses over the past 8 years have left states scrambling for effective means to curtail these deaths. Many states have implemented policies and increased service capacity to address this rise. To better understand the effectiveness of policy level interventions we estimated the impact of the presence of naloxone access laws (NALs) on synthetic opioid fatalities at the state level.

METHODS

A multivariable longitudinal linear mixed model with a random intercept was used to determine the relationship between the presence of NALs and synthetic opioid overdose death rates, while controlling for, Good Samaritan laws, opioid prescription rate, and capacity for medication for opioid use disorder (MOUD), utilizing a quadratic time trajectory. Data for the study was collected from the National Vital Statistics System using multiple cause-of-death mortality files linked to drug overdose deaths.

RESULTS

The presence of an NAL had a significant (univariate P-value = .013; multivariable p-value = .010) negative relationship to fentanyl overdose death rates. Other significant controlling variables were quadratic time (univariate and multivariable P-value < .001), MOUD (univariate P-value < .001; multivariable P-value = .009), and Good Samaritan Law (univariate P-value = .033; multivariable P-value = .018).

CONCLUSION

Naloxone standing orders are strongly related to fatal synthetic opioid overdose reduction. The effect of NALs, MOUD treatment capacity, and Good Samaritan laws all significantly influenced the synthetic opioid overdose death rate. The use of naloxone should be a central part of any state strategy to reduce overdose death rate.

Persistent Criminalization and Structural Racism in US Drug Policy: The Case of Overdose Good Samaritan Laws

The US overdose crisis continues to worsen and is disproportionately harming Black and Hispanic/Latino people. Although the "War on Drugs" continues to shape drug policy-at the disproportionate expense of Black and Hispanic/Latino people-states have taken some steps to reduce War on Drugs-related harms and adopt a public health-centered approach. However, the rhetoric regarding these changes has, in many cases, outstripped reality. Using overdose Good Samaritan Laws (GSLs) as a case study, we argue that public health-oriented policy changes made in some states are undercut by the broader enduring environment of a structurally racist drug criminalization agenda that continues to permeate and constrict most attempts at change. Drawing from our collective experiences in public health research and practice, we describe 3 key barriers to GSL effectiveness: the narrow parameters within which they apply, the fact that they are subject to police discretion, and the passage of competing laws that further criminalize people who use illicit drugs. All reveal a persisting climate of drug criminalization that may reduce policy effectiveness and explain why current reforms may be destined for failure and further disadvantage Black and Hispanic/Latino people who use drugs. (Am J Public Health. 2023;113(S1):S43-S48. https://doi.org/10.2105/AJPH.2022.307037).

Drug overdoses, geographic trajectories, and the influence of built environment and neighborhood characteristics

Much research has analyzed the spatial patterns of drug overdose events and identified features of the environment associated with heightened overdose levels. Generally absent from the literature are studies that analyze how unique trajectories of overdoses vary over time. We address this gap in the literature through an analysis of drug overdoses occurring in Passaic County, New Jersey from 2015 through 2019. A group-based trajectory analysis classifies block groups according to their overdose trends. A mixed-effects panel negative binomial regression model then examines the built environment and neighborhood characteristics associated with overall overdose levels. Results indicate that Passaic County block groups can be classified across three groups based upon their overdose levels over the study period: low and stable, low with moderate increase, and elevated and increasing. While the largest effects were observed for concentrated disadvantage in the regression analysis, most variables positively associated with overdose levels were built environment measures.

Survival Outcomes Associated With the Size of Opioid Prescriptions in the Management of Chronic Pain Related to Advanced Nasopharyngeal Carcinoma

OBJECTIVE

Patients with advanced nasopharyngeal carcinoma (ANC) often experience chronic pain. Opioids are generally recommended to treat tumor-related pain, but increased opioid use may lead to detrimental aftereffects, particularly with respect to tumor progression, resulting in reduced quality of life and increased risk of death. Our objective was to investigate whether the high size of opioid prescriptions is associated with poor overall survival (OS) in patients with ANC.

METHODS

A consecutive cohort of patients with newly diagnosed ANC who underwent high or low opioid prescription size treatment during 2012-2019 was retrospectively identified from our medical institutions. Survival was estimated with the Kaplan-Meier method with a log-rank test. Multivariate binary logistic regression was used to assess the association between opioid use and OS, adjusting for age, sex, body mass index (BMI), Eastern Collaborative Oncology Group performance status (ECOG PS), and ANC histology. The criterion to distinguish between the high opioid prescription size group [HD] and the low opioid prescription size group [LD] was 5 mg of oral morphine equivalents (OME) per 24 hours.

RESULTS

The cohort consisted of 244 consecutive patients (HD: n = 120, median age = 66 years [range, 40-81 years]; LD: n = 124, median age = 65 years [40-82 years]. Patients who underwent treatment with a high opioid prescription size had a worse median OS than those who underwent treatment with a low opioid prescription size (5.1 vs 6.6 months), and the high opioid prescription size was associated with a remarkable 48% higher risk of death than the low opioid prescription size (HR 1.48, 95% CI 1.11-1.98; P = .005). The cumulative dose of opioids greater than or equal to 500 mg of OME was associated with a higher risk of death, adjusted for age, sex, BMI, ECOG PS, and ANC histology.

CONCLUSIONS

In patients with newly diagnosed ANC experiencing palliative care, a high opioid prescription size may be associated with shorter OS than a low opioid prescription size.

Awareness and knowledge of the Good Samaritan Drug Overdose Act among people at risk of witnessing an overdose in British Columbia, Canada: a multi-methods cross sectional study

Introduction

Bystanders to drug overdoses often avoid or delay calling 9–1-1 and cite fear of police involvement as a main reason. In 2017, the Good Samaritan Drug Overdose Act (GSDOA) was enacted by the Canadian government to provide people present at an overdose with legal protection from charges for simple drug possession, and conditions stemming from simple possession. Few studies have taken a multi-methods approach to evaluating the GSDOA. We used quantitative surveys and qualitative interviews to explore awareness, understanding, and perceptions of the GSDOA in people at risk of witnessing an overdose.

Methods

Quantitative cross-sectional surveys and qualitative telephone interviews were conducted with adults and youth at risk of witnessing an overdose across British Columbia. Cross-sectional survey participants were recruited at 19 Take Home Naloxone sites and online through Foundry. Multivariable logistic regression models were constructed hierarchically to determine factors associated with GSDOA awareness. Telephone interview participants were recruited by research assistants with lived/living experience of substance use. Deductive and inductive thematic analyses were conducted to identify major themes.

Results

Overall, 52.7% (n = 296) of the quantitative study sample (N = 453) reported being aware of the GSDOA. In multivariable analysis, cellphone possession (adjusted odds ratio [AOR] = 2.19; 95% confidence interval [CI] 1.36, 3.54) and having recently witnessed an opioid overdose (AOR = 2.34; 95% CI 1.45, 3.80) were positively associated with GSDOA awareness. Young adults (25 – 34 years) were more likely to be aware of the Act (AOR = 2.10; 95% CI 1.11, 3.98) compared to youth (16–24 years). Qualitative interviews (N = 42) revealed that many overestimated the protections offered by the GSDOA. To increase awareness and knowledge of the Act among youth, participants recommended adding the GSDOA to school curricula and using social media. Word of mouth was suggested to reach adults.

Conclusion

Both awareness and knowledge of the GSDOA remain low in BC, with many overestimating the protections the Act offers. Dissemination efforts should be led by people with lived/living experience and should target those with limited awareness and understanding of the Act as misunderstandings can erode trust in law enforcement and harm reduction policy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13011-022-00472-4.

Review and inventory of 911 Good Samaritan Law Provisions in the United States

BACKGROUND

911 Good Samaritan Laws (GSLs) confer limited legal immunity to bystanders in possession of controlled substances who report emergency overdoses. While these laws may decrease opioid overdose mortality, current literature reduces GSLs to a small number of variables, overlooking substantial differences in implementation and statutory context which dramatically alter their applicability.

METHODS

We identified all state GSLs and their legislative history, characterizing features into four categories using a novel framework: breadth of protected activities, burden placed on Good Samaritans, strength of protection, and exemption in coverage. When protections depended on the nature of the controlled substance, heroin served as a common point of comparison.

RESULTS

GSLs vary substantially across states and time. Protections depend on the quantity of substances involved and may extend to the person experiencing the overdose or persons reporting their own overdose. Protected offenses range from possession of controlled substances to drug-induced homicide. In some states, Good Samaritans must complete substance use treatment or administer naloxone to retain protections. Immunity ranges from protection from arrest to merely procedural protections at trial, and may even exclude persons in possession of opioids. Exemptions target persons engaging in chronic substance use, such as persons invoking protection multiple times or previously reporting an overdose.

CONCLUSION

States offer Good Samaritans substantially different protections even when the statutes confer nominally comparable immunities. Accommodating this heterogeneity will enhance the validity of future studies into these laws and their efficacy.

Intention to seek emergency medical services during community overdose events in British Columbia, Canada: a cross-sectional survey

Introduction

Canada and the United States continue to experience increasing overdose deaths attributed to highly toxic illicit substances, driven by fentanyl and its analogues. Many bystanders report being hesitant to call 9-1-1 at an overdose due to fears around police presence and arrests. In Canada, a federal law was enacted in 2017, the Good Samaritan Drug Overdose Act (GSDOA), to provide protection from simple drug possession and related charges when 9-1-1 is called to an overdose. There is limited evidence, however, that the GSDOA has improved rates of intention to call 9-1-1 at overdose events. We therefore sought to examine intent to call 9-1-1 among persons who received GSDOA education and were at risk of witnessing an overdose.

Methods

A cross-sectional survey was conducted with people at risk of witnessing an overdose recruited at 19 Take Home Naloxone (THN) program sites across British Columbia as well as online through Foundry from October 2020 to April 2021. Descriptive statistics were used to examine intention to call 9-1-1 at future overdoses. Multivariable logistic regression models were built in hierarchical fashion to examine factors associated with intention to call 9-1-1.

Results

Overall, 89.6% (n = 404) of the eligible sample reported intention to call 9-1-1. In the multivariable model, factors positively associated with intention to call 9-1-1 included identifying as a cisgender woman (adjusted odds ratio [AOR]: 3.37; 95% CI: 1.19–9.50) and having previous GSDOA awareness ([AOR]: 4.16; 95% CI: 1.62–10.70). Having experienced a stimulant overdose in the past 6 months was negatively associated with intention to call 9-1-1 ([AOR]: 0.24; 95% CI: 0.09–0.65).

Conclusion

A small proportion of the respondents reported that, despite the enactment of GSDOA, they did not intend to call 9-1-1 and those who were aware of the act were more likely to report an intention to call at future overdose events. Increasing GSDOA awareness and/or additional interventions to support the aims of the GSDOA could address ongoing reluctance to seek emergency medical care by people who use drugs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13011-022-00484-0.

Comparing Projected Fatal Overdose Outcomes and Costs of Strategies to Expand Community-Based Distribution of Naloxone in Rhode Island

IMPORTANCE

In 2021, the state of Rhode Island distributed 10 000 additional naloxone kits compared with the prior year through partnerships with community-based organizations.

OBJECTIVE

To compare various strategies to increase naloxone distribution through community-based programs in Rhode Island to identify one most effective and efficient strategy in preventing opioid overdose deaths (OODs).

DESIGN, SETTING, AND PARTICIPANTS

In this decision analytical model study conducted from January 2016 to December 2022, a spatial microsimulation model with an integrated decision tree was developed and calibrated to compare the outcomes of alternative strategies for distributing 10 000 additional naloxone kits annually among all individuals at risk for opioid overdose in Rhode Island.

INTERVENTIONS

Distribution of 10 000 additional naloxone kits annually, focusing on people who inject drugs, people who use illicit opioids and stimulants, individuals at various levels of risk for opioid overdose, or people who misuse prescription opioids vs no additional kits (status quo). Two expanded distribution implementation approaches were considered: one consistent with the current spatial distribution patterns for each distribution program type (supply-based approach) and one consistent with the current spatial distribution of individuals in each of the risk groups, assuming that programs could direct the additional kits to new geographic areas if required (demand-based approach).

MAIN OUTCOMES AND MEASURES

Witnessed OODs, cost per OOD averted (efficiency), geospatial health inequality measured by the Theil index, and between-group variance for OOD rates.

RESULTS

A total of 63 131 simulated individuals were estimated to be at risk for opioid overdose in Rhode Island based on current population data. With the supply-based approach, prioritizing additional naloxone kits to people who use illicit drugs averted more witnessed OODs by an estimated mean of 18.9% (95% simulation interval [SI], 13.1%-30.7%) annually. Expanded naloxone distribution using the demand-based approach and focusing on people who inject drugs had the best outcomes across all scenarios, averting an estimated mean of 25.3% (95% SI, 13.1%-37.6%) of witnessed OODs annually, at the lowest mean incremental cost of $27 312 per OOD averted. Other strategies were associated with fewer OODs averted at higher costs but showed similar patterns of improved outcomes and lower unit costs if kits could be reallocated to areas with greater need. The demand-based approach reduced geospatial inequality in OOD rates in all scenarios compared with the supply-based approach and status quo.

CONCLUSIONS AND RELEVANCE

In this decision analytical model study, variations in the effectiveness, efficiency, and health inequality of the different naloxone distribution expansion strategies and approaches were identified. Future efforts should be prioritized for people at highest risk for overdose (those who inject drugs or use illicit drugs) and redirected toward areas with the greatest need. These findings may inform future naloxone distribution priority settings.

'It's the same thing as giving them CPR training': rural first responders' perspectives on naloxone

The Substance Abuse and Mental Health Services Administration's (SAMHSA) Harm Reduction grant program expanded access to several harm reduction strategies to mitigate opioid overdose fatalities, including expanding access to naloxone. Interviews with first responders in a frontier and remote (FAR) state were conducted to understand their job responsibilities in relation to overdose response and prevention and their perceptions of training laypersons to administer naloxone. This study includes 22 interviews with law enforcement, EMS and/or fire personnel, and members of harm reduction-focused community organizations. The study finds widespread support for increasing access to naloxone and training laypersons in naloxone administration throughout Montana, due to rural first responders' inability to meet the needs of residents and an overall lack of resources to address addiction and the effects of fentanyl. Participants from harm reduction-focused community organizations convey support for training lay persons, but also illuminate that real and perceived cultural opposition to harm reduction strategies could reduce the likelihood that laypeople enroll in naloxone training. This study adds to the literature because it focuses on first responders in a FAR area that would benefit from layperson naloxone education and administration training due to its geographic expansiveness and the area's overall lack of access to medications for opioid use disorder or other treatment services. Expanding harm reduction approaches, like increasing access and training laypersons to administer naloxone, might be FAR residents' best chance for surviving an opioid overdose.

Use of an Inverted Synthetic Control Method to Estimate Effects of Recent Drug Overdose Good Samaritan Laws, Overall and by Black/White Race/Ethnicity

Overdose Good Samaritan laws (GSLs) aim to reduce mortality by providing limited legal protections when a bystander to a possible drug overdose summons help. Most research into the impact of these laws is dated or potentially confounded by coenacted naloxone access laws. Lack of awareness and trust in GSL protections, as well as fear of police involvement and legal repercussions, remain key deterrents to help-seeking. These barriers may be unequally distributed by race/ethnicity due to racist policing and drug policies, potentially producing racial/ethnic disparities in the effectiveness of GSLs for reducing overdose mortality. We used 2015-2019 vital statistics data to estimate the effect of recent GSLs on overdose mortality, overall (8 states) and by Black/White race/ethnicity (4 states). Given GSLs' near ubiquity, few unexposed states were available for comparison. Therefore, we generated an "inverted" synthetic control method (SCM) to compare overdose mortality in new-GSL states with that in states that had GSLs throughout the analytical period. The estimated relationships between GSLs and overdose mortality, both overall and stratified by Black/White race/ethnicity, were consistent with chance. An absence of effect could result from insufficient protection provided by the laws, insufficient awareness of them, and/or reticence to summon help not addressable by legal protections. The inverted SCM may be useful for evaluating other widespread policies.

Implementation of a multidisciplinary inpatient opioid overdose education and naloxone distribution program at a large academic medical center

DISCLAIMER

In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time.

PURPOSE

Opioid overdose-related deaths continue to rise. Despite public health efforts, there is still variability in obtainment of naloxone, a lifesaving antidote. We share our experience in the implementation of a novel opioid overdose education and naloxone distribution (OEND) program at a large academic medical center.

METHODS

Collaborative efforts by pharmacists, pharmacy students, physicians, nurses, and recovery coaches were employed in the design of the program. The service was available Monday through Friday, 9 AM to 6 PM, and primarily carried out by pharmacy students on a rotating basis. Services offered included bedside delivery of naloxone and education prior to the day of discharge. In preparation for their role, the pharmacy students were required to complete a series of trainings and competency assessments.

RESULTS

A total of 40 patients were included in the program evaluation. Of the completed consults 96.7% (n = 30) of patients received both counseling and naloxone delivery. Eighty percent of patients had a history of nonfatal opioid overdose, but only 37.5% had naloxone listed as a home medication. Fifteen percent of patients had patient-directed discharges but still received OEND services.

CONCLUSION

Implementation of an inpatient OEND program by mobilizing trained student pharmacists is feasible and expands naloxone access to patients during transitions of care. A similar model could be considered in the future for the delivery of harm reduction supplies to this patient population.

When Effects Cannot be Estimated: Redefining Estimands to Understand the Effects of Naloxone Access Laws

Violations of the positivity assumption (also called the common support condition) challenge health policy research and can result in significant bias, large variance, and invalid inference. We define positivity in the single- and multiple-timepoint (i.e., longitudinal) health policy evaluation setting, and discuss real-world threats to positivity. We show empirical evidence of the practical positivity violations that can result when attempting to estimate the effects of health policies (in this case, Naloxone Access Laws). In such scenarios, an alternative is to estimate the effect of a shift in law enactment (e.g., the effect if enactment had been delayed by some number of years). Such an effect corresponds to what is called a modified treatment policy, and dramatically weakens the required positivity assumption, thereby offering a means to estimate policy effects even in scenarios with serious positivity problems. We apply the approach to define and estimate the longitudinal effects of Naloxone Access Laws on opioid overdose rates.

Prevalence and correlates of incarceration following emergency medical services response to overdose

BACKGROUND

To describe the prevalence of incarceration among survivors of non-fatal overdose addressed through an emergency medical services (EMS) response, and compare incarceration by whether the emergency was for opioid-involved or stimulant-involved overdose.

METHODS

Administrative records on 192,113 EMS incidents and 70,409 jail booking events occurring between January 1, 2019 and December 31, 2020 in Indianapolis, Indiana were record-linked at the event level. Incarceration taking place within 6-hours of an EMS incident was associated with that incident. Logistic regression was used to calculate adjusted odds ratios (AOR) of incarceration after an overdose.

RESULTS

Among all EMS incidents, 2.6% were followed by incarceration. For overdose EMS incidents, the prevalence of incarceration was 10.0%. Overdose incidents had higher odds than non-overdose incidents of leading to a charge of felony, booked on a warrant, and transferred to another law enforcement agency upon release. Prevalence of incarceration following a stimulant-involved overdose was 21.3%, compared to 9.3% for opioid-involved overdose survivors. Compared to persons from other EMS incidents, overdose survivors had greater odds of incarceration (AOR=3.48, 95% confidence interval (CI)= 3.22, 3.75, p < .001), with opioid-involved overdoses (AOR=3.03, 95% CI=2.76, 3.33, p < .001) and stimulant-involved overdoses (AOR=6.70, 95% CI=5.26, 8.55, p < .001) leading to higher odds of incarceration.

CONCLUSION

Incarceration in county jail followed one in ten overdose-involved EMS responses. As illicit drug consumption increasingly involves stimulants, the frequency of incarceration following these events is likely to increase. Policy changes and interventions are needed to reduce incarceration after overdose emergencies.

A qualitative examination of naloxone access in three states: Connecticut, Kentucky, and Wisconsin

BACKGROUND

Prevention of opioid-involved overdose deaths remains a public health priority in the United States. While expanding access to naloxone is a national public health strategy, it is largely implemented at the state and local level, where significant variability in policies, resources, and norms exist. The aims of the current study were to examine the social context of naloxone access in three different states (Connecticut, Kentucky, Wisconsin) from the perspectives of key informants (first responders, harm reduction personnel, and pharmacists), who play some role in dispensing or administering naloxone within their communities.

METHODS

Interviews were conducted with key informants who were in different local areas (urban, suburban, rural) across Connecticut, Kentucky, and Wisconsin. Interview guides explored the key informants' experiences with administering or dispensing naloxone, and their perspectives on opioid overdose prevention efforts in their areas. Data analysis was conducted using multistage inductive coding and comparative methods to identify dominant themes within the data.

RESULTS

Key informants in each of the three states noted progress toward expanding naloxone access, especially among people who use opioids, but also described inequities. The key role of harm reduction programs in distributing naloxone within their communities was also highlighted by participants, as well as barriers to increasing naloxone access through pharmacies. Although there was general consensus regarding the effectiveness of expanding naloxone access to prevent overdose deaths, the results indicate that communities are still grappling with stigma associated with drug use and a harm reduction approach.

CONCLUSION

Findings suggest that public health interventions that target naloxone distribution through harm reduction programs can enhance access within local communities. Strategies that address stigmatizing attitudes toward people who use drugs and harm reduction may also facilitate naloxone expansion efforts, overall, as well as policies that improve the affordability and awareness of naloxone through the pharmacy.

Methodological considerations for estimating policy effects in the context of co-occurring policies

Understanding how best to estimate state-level policy effects is important, and several unanswered questions remain, particularly about the ability of statistical models to disentangle the effects of concurrently enacted policies. In practice, many policy evaluation studies do not attempt to control for effects of co-occurring policies, and this issue has not received extensive attention in the methodological literature to date. In this study, we utilized Monte Carlo simulations to assess the impact of co-occurring policies on the performance of commonly-used statistical models in state policy evaluations. Simulation conditions varied effect sizes of the co-occurring policies and length of time between policy enactment dates, among other factors. Outcome data (annual state-specific opioid mortality rate per 100,000) were obtained from 1999 to 2016 National Vital Statistics System (NVSS) Multiple Cause of Death mortality files, thus yielding longitudinal annual state-level data over 18 years from 50 states. When co-occurring policies are ignored (i.e., omitted from the analytic model), our results demonstrated that high relative bias (> 82%) arises, particularly when policies are enacted in rapid succession. Moreover, as expected, controlling for all co-occurring policies will effectively mitigate the threat of confounding bias; however, effect estimates may be relatively imprecise (i.e., larger variance) when policies are enacted in near succession. Our findings highlight several key methodological issues regarding co-occurring policies in the context of opioid-policy research yet also generalize more broadly to evaluation of other state-level policies, such as policies related to firearms or COVID-19, showcasing the need to think critically about co-occurring policies that are likely to influence the outcome when specifying analytic models.

Impact of a publicly funded pharmacy-dispensed naloxone program on fatal opioid overdose rates: A population-based study

BACKGROUND

Studies examining the impact of pharmacy-dispensed naloxone programs on fatal opioid overdose rates are lacking. We examined the impact of the publicly funded Ontario Naloxone Program for Pharmacies (ONPP), implemented in June 2016, on provincial rates of opioid overdose deaths.

METHODS

We conducted a population-based interrupted time-series study between July 1, 2012 and December 31, 2018. We considered a parsimonious model with terms for time, ONPP implementation, and time following the ONPP implementation. Models were adjusted for population characteristics, number of pharmacies and rate of naloxone distributed through non-pharmacy sites within provincial public health units.

RESULTS

In the parsimonious model, the ONPP was associated with a non-significant 9% reduction in the level of fatal opioid overdoses (rate ratio [RR] 0.91; 95% confidence interval [CI] 0.79-1.06), a finding that was most pronounced in regions in the lowest tertile of implementation (RR 0.75; 95% CI 0.62-0.91). Following multivariable adjustment, there was an increase in the level (RR 1.06; 95% CI 0.94-1.19) and slope change (RR 1.06; 95% CI 1.02-1.10) of fatal overdose rates.

CONCLUSION

The ONPP is insufficient as a single intervention to meaningfully reduce rates of fatal opioid overdoses during a period in which the cause of these deaths shifted from prescription opioids to highly potent fentanyl analogs. Access to additional harm reduction, treatment, and other interventions is necessary to prevent deaths and optimize the health of people who use drugs.

Expert views on state-level naloxone access laws: a qualitative analysis of an online modified-Delphi process

Background

Expanding availability to naloxone is a core harm reduction strategy in efforts to address the opioid epidemic. In the US, state-level legislation is a prominent mechanism to expand naloxone availability through various venues, such as community pharmacies. This qualitative study aimed to identify and summarize the views of experts on state-level naloxone access laws.

Methods

We conducted a three-round modified-Delphi process using the online ExpertLens platform. Participants included 46 key stakeholders representing various groups (advocates, healthcare providers, human/social service practitioners, policymakers, and researchers) with expertise naloxone access laws. Participants commented on the effectiveness and implementability of 15 state-level naloxone access laws (NALs). We thematically analyzed participant comments to summarize views on NALs overall and specific types of NAL.

Results

Participants commented that the effectiveness of NALs in reducing opioid-related mortality depends on their ability to make sustained, significant impacts on population-level naloxone availability. Participants generally believed that increased naloxone availability does not have appreciable negative impacts on the prevalence of opioid misuse, opioid use disorder (OUD), and non-fatal opioid overdoses. Implementation barriers include stigma among the general public, affordability of naloxone, and reliance on an inequitable healthcare system.

Conclusions

Experts believe NALs that significantly increase naloxone access are associated with less overdose mortality without risking substantial unintended public health outcomes. To maximize impacts, high-value NALs should explicitly counter existing healthcare system inequities, address stigmatization of opioid use and naloxone, maintain reasonable prices for purchasing naloxone, and target settings beyond community pharmacies to distribute naloxone.

Naloxone administration among opioid-involved overdose deaths in 38 United States jurisdictions in the State Unintentional Drug Overdose Reporting System, 2019

BACKGROUND

The majority of drug overdose deaths in the United States involve opioids, and synthetic opioid-involved overdose death rates are increasing. Naloxone is a key prevention strategy yet estimates of its administration are limited.

METHODS

We analyzed 2019 data from 37 states and the District of Columbia in CDC's State Unintentional Drug Overdose Reporting System to estimate the percentage of decedents, by sociodemographic subgroup, who experienced a fatal opioid-involved overdose and had no evidence of naloxone administration.

RESULTS

A total of 77.3% of 33,084 opioid-involved overdose deaths had no evidence of naloxone administration. Statistically significant subgroup differences were observed for all sociodemographic groups examined except housing status. The highest percentages of decedents lacking evidence of naloxone administration were those with highest educational attainment (doctorate or professional degree, 87.0%), oldest (55-64 years, 83.4%; ≥65 years, 87.3%) and youngest ages (<15 years, 87.5%), and single marital status (84.5%). The lowest percentages of no evidence of naloxone administration were observed for non-Hispanic American Indian/Alaskan Native persons (66.2%) and those ages 15-24 years (70.8%).

CONCLUSIONS

More than three-quarters of opioid-involved overdose deaths had no evidence of naloxone administration, underscoring the need to ensure sufficient naloxone access and capacity for utilization. While fatal overdose data cannot fully characterize sociodemographic disparities in naloxone administration, naloxone education and access efforts can be informed by apparent inequities. Public health partners can assist persons who use drugs (PWUD) by maintaining naloxone supply and amplifying messages about the high risk of using drugs alone among PWUD and their social networks.

Impact of the naloxone standing order on trends in opioid fatal overdose: an ecological analysis

Background: Maryland expanded its "Statewide Naloxone Standing Order" (NSO) in 2017 to eliminate training and prescription requirements for obtaining naloxone, improve naloxone access, help reverse opioid overdose, and reduce overdose fatality rates.Objectives: To assess the change in the trends of fatal opioid overdose rates following the expansion of the Naloxone Standing Order (eNSO) and its association with the social determinants of health (SDoH).Methods: Data on overdose deaths and SDoH from 2015-2019 was collected and analyzed using interrupted time series and multivariate Poisson regression models to study the change in trends and the associations.Results: There was a significant decrease in the rate of fatal overdoses after the intervention: prescription opioid estimate number of deaths declined by .25 per 100,000 (p = .02), heroin estimate number of deaths declined by 1.83 per 100,000 (p < .001), fentanyl estimate number of deaths declined by 2.54 per 100,000 (p < .001). After controlling for eNOS implementation in Maryland, state-level estimates with high proportions of female residents and those with bachelor's degree or higher were associated with reduction in overdose, while state-level estimates with high proportions of African Americans and higher employment rates were associated with an increase in overdose.Conclusions: Our analysis shows that the expanded naloxone standing order is associated with reducing opioid-related overdose death rates. Even though we observed a significant reduction in overdose death rate in fentanyl-related deaths, the rate of deaths post-eNSO was still increasing, suggesting the need for additional measures to impact the rates of fentanyl.

Patient and medication-related factors associated with opioid use disorder after inpatient opioid administration

BACKGROUND

Examine baseline factors associated with a new diagnosis of opioid use disorder (OUD) within 12 months postdischarge among opioid-naïve patients who received an opioid prescription in the inpatient setting.

DESIGN/SETTING

Retrospective cohort (surgery and nonsurgery) study of opioid-naive patients who had at least one prescription for an opioid during an inpatient hospitalist between 2014 and 2017.

PARTICIPANTS

Twenty-three thousand and thirty-three patients were included.

OBJECTIVE

The primary objective was to determine baseline factors associated with a new OUD diagnosis within 12 months of discharge. Baseline covariates included demographic information, clinical characteristics, medication use, characteristics related to index hospital encounter, and discharge location.

FINDINGS

2.1% of the sample had a new diagnosis of OUD within a year after receiving an opioid during hospital admission. Patients between ages 25 and 34 had higher odds of a new OUD diagnosis compared to those 65 years of age and older (odds ratio [OR]: 6.98, 95% confidence interval [CI]: 4.02-12.1 [nonsurgery] and 4.69, 95% CI: 2.63-8.37 [surgery]). Patients from a high opioid geo-rank region had higher odds of OUD diagnosis (OR: 2.08, 95% CI: 1.31-3.31 [nonsurgery] and 1.80, 95% CI: 1.03-3.15 [surgery]). History of nonopioid-related drug disorder, tobacco use disorder, mental health conditions, and gabapentin use 12 months prior to index date and white race were associated with higher odds of new OUD diagnosis.

CONCLUSIONS

It is important to identify and evaluate factors associated with developing a new diagnosis of OUD following hospitalization. This can inform pain management strategies within the hospital and at discharge, and prompt clinicians to screen for risk of OUD.

If we build it, will they come? Perspectives on pharmacy-based naloxone among family and friends of people who use opioids: a mixed methods study

BACKGROUND

Expanding access to the opioid antagonist naloxone to reduce overdose mortality is a public health priority in the United States. Naloxone standing orders (NSOs) have been established in many states to increase naloxone dispensing at pharmacies, but increased pharmacy access does not ensure optimal uptake among those likely to witness an overdose. In a prior statewide purchase trial, we documented high levels of naloxone access at Massachusetts pharmacies under a statewide NSO. In this study, we characterize barriers to pharmacy-based naloxone uptake among potential opioid overdose "bystanders" (friends or family of people who use opioids) that may be amenable to intervention.

METHODS

Eligible bystanders were Massachusetts residents ≥ 18 years of age, did not use illicit opioids in the past 30 days, and knew someone who currently uses illicit opioids. We used a sequential mixed methods approach, in which a series of semi-structured qualitative interviews (N = 22) were conducted April-July 2018, to inform the development of a subsequent quantitative survey (N = 260), conducted February-July 2020.

RESULTS

Most survey participants (77%) reported ever obtaining naloxone but few (21%) attempted to purchase it at a pharmacy. Qualitative participants revealed that barriers to utilizing the NSO included low perceived risk of overdose, which was rooted in misconceptions regarding the risks of prescription opioid misuse, denial about their loved one's drug use, and drug use stereotypes; inaccurate beliefs about the impact of naloxone on riskier opioid use; and concerns regarding anticipated stigma and confidentiality. Many participants had engaged in mutual support groups, which served as a source of free naloxone for half (50%) of those who had ever obtained naloxone.

CONCLUSIONS

Despite high levels of pharmacy naloxone access in Massachusetts, few bystanders in our study had attempted to obtain naloxone under the NSO. Low perceived risk of overdose, misinformation, stigma, and confidentiality were important barriers to pharmacy naloxone uptake, all of which are amenable to intervention. Support groups provided a setting for addressing stigma and misinformation and provided a discreet and comfortable setting for naloxone access. Where these groups do not exist and for bystanders who do not participate in such groups, pharmacies are well-positioned to fill gaps in naloxone availability.

Where Opioid Overdose Patients Live Far From Treatment: Geospatial Analysis of Underserved Populations in New York State

BACKGROUND

Opioid addiction and overdose have a large burden of disease and mortality in New York State (NYS). The medication naloxone can reverse an overdose, and buprenorphine can treat opioid use disorder. Efforts to increase the accessibility of both medications include a naloxone standing order and a waiver program for prescribing buprenorphine outside a licensed drug treatment program. However, only a slim majority of NYS pharmacies are listed as participating in the naloxone standing order, and less than 7% of prescribers in NYS have a buprenorphine waiver. Therefore, there is a significant opportunity to increase access.

OBJECTIVE

Identifying the geographic regions of NYS that are farthest from resources can help target interventions to improve access to naloxone and buprenorphine. To maximize the efficiency of such efforts, we also sought to determine where these underserved regions overlap with the largest numbers of actual patients who have experienced opioid overdose.

METHODS

We used address data to assess the spatial distribution of naloxone pharmacies and buprenorphine prescribers. Using the home addresses of patients who had an opioid overdose, we identified geographic locations of resource deficits. We report findings at the high spatial granularity of census tracts, with some neighboring census tracts merged to preserve privacy.

RESULTS

We identified several hot spots, where many patients live far from the nearest resource of each type. The highest density of patients in areas far from naloxone pharmacies was found in eastern Broome county. For areas far from buprenorphine prescribers, we identified subregions of Oswego county and Wayne county as having a high number of potentially underserved patients.

CONCLUSIONS

Although NYS is home to thousands of naloxone pharmacies and potential buprenorphine prescribers, access is not uniform. Spatial analysis revealed census tract areas that are far from resources, yet contain the residences of many patients who have experienced opioid overdose. Our findings have implications for public health decision support in NYS. Our methods for privacy can also be applied to other spatial supply-demand problems involving sensitive data.