Non-fatal overdose and subsequent drug treatment among injection drug users

Using RE-AIM Framework to Evaluate Recovery Opioid Overdose Team Plus: A Peer-Led Post-overdose Quick Response Team

Peer recovery coaches utilize their lived experiences to support overdose survivors, a role gaining prominence across communities. A convergent mixed methods design, informed by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework, was used to evaluate the Recovery Opioid Overdose Team Plus (ROOT +), through an iterative evaluation using web-based surveys and qualitative interviews. Reach: Over 27 months, ROOT + responded to 83% of suspected overdose referrals (n = 607) and engaged with 41% of survivors (n = 217) and 7% of survivors' family/friends (n = 38). Effectiveness: Among those initially engaged with ROOT +, 36% of survivors remained engaged, entered treatment, or were in recovery at 90 days post-overdose (n = 77). Adoption: First responders completed 77% of ROOT + referrals (n = 468). Implementation: Barriers included lack of awareness of ROOT + , working phones, and access to treatment from community partner interviews (n = 15). Maintenance: Adaptations to ROOT + were made to facilitate implementation. Peer-led teams are promising models to engage with overdose survivors.

Higher perceived stress during admission is associated with shorter retention in short-term residential substance use disorder treatment

Introduction

Over one million people in the U.S. received residential treatment for a substance use disorder (SUD) in 2020. Longer treatment retention is associated with better outcomes (e.g., reduced substance use). Entering treatment with higher stress may be associated with shorter retention. This paper examines the impact of perceived stress at admission on SUD treatment retention in short-term residential treatment.

Methods

A sample of 271 treatment episodes with admissions between October 2019 and February 2020 were collected from de-identified records of an urban mid-Atlantic adult 28-day short-term residential SUD treatment facility. Treatment completion involved finishing 28 days. Sociodemographic, substance use, perceived stress, and treatment discharge variables were analyzed. Bivariate analyses examined differences between treatment completion and early discharge, and Cox regression investigated the effect of perceived stress on treatment retention with covariates.

Results

The sample was primarily male (73.8%) and non-Hispanic Black (71.6%). A majority used heroin as their primary substance (54.6%) and reported polysubstance use (72.3%). About half (51.3%) completed treatment, and completed an average of 18.7 (SD = 10.7) days. Those who prematurely discharged from treatment stayed an average of 8.9 (SD = 7.0) days. The Cox regression model found that higher perceived stress (adjusted hazard ratio (AHR) = 1.028; 95% CI = [1.005, 1.053], p =.019) and a race/ethnicity other than non-Hispanic Black (AHR = 1.546, 95% CI = [1.037, 2.305], p =.033) predicted premature discharge.

Conclusions

Perceived stress at admission is associated with shorter treatment retention. Early stress management interventions may help increase treatment retention.

Implications of epidemic-pandemic convergence for routine care adoption of contingency management: A case study

The significant increase in opioid-related drug overdoses during the coronavirus disease (COVID-19) pandemic has put an unprecedented burden on hospital emergency departments, who saw as high as an approximate 150% increase in emergency department (ED) admission rates in the initial months of the pandemic. Although overdose is a clear sign of problem drug use, only a small proportion of nonfatal overdose patients enroll in treatment within 30 days of their overdose. To bridge the gap between opioid overdoses and treatment entry, a smartphone-smart debit card contingency management program was developed to promote entry into medication-assisted treatment by out-of-treatment opioid users who have recently received care in a hospital emergency department. The case study described in this article highlights a successful implementation of this intervention despite numerous disruptions related to COVID-19 that would have made engagement difficult without the remote access to contingency management provided by this technology. Patient status over time is presented in conjunction with contingency management earnings. Technology-based contingency management may provide improved scalability, rigorous outcomes metrics, and lower costs than prior onsite, manual contingency management (CM) approaches. The COVID-19 pandemic, in combination with the opioid epidemic has created a context in which historical obstacles to the adoption of contingency management may be overcome. This case study demonstrates the potential utility of smartphone-based contingency management when in-person care is difficult to access or disrupted. The requirement for further research demonstrating the efficacy of these approaches is discussed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Evaluation of post-discharge engagement for emergency department patients with opioid use history who received telehealth recovery coaching services

BACKGROUND

In recent years, emergency departments (EDs) across the nation have implemented peer recovery coach (PRC) services to support patients who use opioids. The majority of such interventions discussed in the literature follow an in-person modality where PRCs engage patients directly at the ED bedside. However, the use of telehealth services in EDs is becoming more popular. These services connect PRCs with ED patients in real-time via secure communications technology, and very little is known about the service- and clinical-based outcomes with which they are associated. The current study sought to assess factors associated with successful post-discharge follow-up of patients with a history of opioid use who received PRC telehealth services while in the ED.

METHOD

Data come from records for 917 patients who engaged with a telehealth PRC one or more times (1208 total engagements) at 1 of 13 EDs within the same health system. A multilevel Poisson regression model was used to assess the degree to which variables predicted successful post-discharge follow-up, defined as the number of times a PRC successfully spoke with the patient each month after ED discharge.

RESULTS

At least one follow-up was successfully completed by a PRC for 23% of enrolled patients. Significant predictors of successful follow-up included patient employment at baseline (Incidence Rate Ratio [IRR]: 2.8, CI: 2.05-3.9), living in a rural area (IRR: 1.8, CI: 1.04-3.2), PRC provision of referrals (IRR: 1.7, CI: 1.2-2.2), number of ED encounters in the previous 365 days (IRR: 0.99, CI: 0.98-0.99), and duration of the initial PRC telehealth interaction (IRR: 0.87, CI: 0.85-0.88).

CONCLUSION

Given that relationship development is a key tool in the PRC profession, understanding successful follow-up associated with telehealth engagement has unique importance. The results have potential utility for planning and implementing peer telehealth services in EDs and other locations, which is needed for the development of the PRC profession and the likely expansion of peer telehealth services.

Post-overdose follow-up in the community with peer recovery specialists: the Lake Superior Diversion and Substance Use Response Team

Background

As the overdose epidemic continues to worsen, nonfatal overdose calls for service represent a critical touchpoint for intervention. While most studies have focused on law enforcement led post-overdose follow-up, the current study describes the programmatic characteristics and outcomes of a non-law enforcement post overdose program comprised of peer specialists embedded within a local police department.

Methods

We examined information on 341 follow-up responses occurring over a 16-month study period using administrative data. We assessed programmatic characteristics including demographic information on clients, referral source, engagement type, and goal completion.

Results

The results indicate that over 60% of client referrals ended in the goal of in-person contact. Of those, about 80% went on to complete an engagement goal with the peer specialist. We found no significant variation in client demographics and referral source or follow-up engagement (in-person or not); however, client referrals from law enforcement first responders, the most common source, are significantly less likely to result in an in-person contact, though, if contact is made, similarly likely to complete an engagement goal.

Conclusions

Post overdose response programs that do not involve law enforcement are exceedingly rare. Given that some research has shown that police involvement in post overdose response can have unexpected, associated harms, it is important to assess the effectiveness of post overdose programs that do not involve the police. Findings here suggest that this type of program is successful at locating and engaging community members into recovery support services who have experienced an overdose.

The estimated costs and benefits of a hypothetical supervised consumption site in Providence, Rhode Island

BACKGROUND

Overdose deaths have increased dramatically in the United States, including in Rhode Island. In July 2021, the Rhode Island government passed legislation supporting a two-year pilot program authorizing supervised consumption sites (SCSs) in response to this crisis. We estimated the costs and benefits of a hypothetical SCS in Providence, Rhode Island.

METHODS

We utilized a decision analytic mathematical model to compare costs and outcomes for people who inject drugs under two scenarios: (1) a SCS that includes syringe services provision, and (2) a syringe service program only (i.e., status quo). We assumed 0.95% of injections result in overdose, the SCS would serve 400 clients monthly and have a net cost of $783,899 annually, 46% of overdoses occurring outside of the SCS result in an ambulance run and 43% result in an emergency department (ED) visit, 0.79% of overdoses occurring within the SCS result in an ambulance run and ED visit, and the SCS would lead to a 25.7% reduction in fatal overdoses near the site. The model was developed from a modified societal perspective with a one-year time horizon.

RESULTS

A hypothetical SCS in Providence would prevent approximately 2 overdose deaths, 261 ambulance runs, 244 ED visits, and 117 inpatient hospitalizations for emergency overdose care annually compared to a scenario that includes a syringe service program only. The SCS would save $1,104,454 annually compared to the syringe service program only, accounting only for facility costs and short-term costs of emergency overdose care and ignoring savings associated with averted deaths. Influential parameters included the percentage of injections resulting in overdose, the total annual injections at the SCS, and the percentage of overdoses outside of the SCS that result in an ED visit.

CONCLUSION

A SCS in would result in substantial cost savings due to prevention of costly emergency overdose care.

Investigating the sociodemographic and behavioural factors associated with hepatitis C virus testing amongst people who inject drugs in England, Wales and Northern Ireland: A quantitative cross-sectional analysis

BACKGROUND

Hepatitis C virus (HCV) transmission in the UK is driven by injecting drug use. We explore HCV testing uptake amongst people who inject drugs (PWID) in England, Wales and Northern Ireland, and identify factors associated with i) ever having an HCV test amongst people who have ever injected drugs, and ii) recently having an HCV test (within the current or previous year) amongst people who currently inject drugs (reported injecting drugs within the last year).

METHODS

We analysed data from the 2019 'Unlinked Anonymous Monitoring Survey' of PWID, using logistic regression.

RESULTS

Of 3,127 PWID, 2,065 reported injecting drugs within the last year. Most (86.7%) PWID had a lifetime history of HCV testing. In multivariable analysis, higher odds of ever testing were associated with: female sex (aOR=1.54; 95%CI 1.11-2.14), injecting duration ≥3 years (aOR=2.94; 95%CI 2.13-4.05), ever receiving used needles/syringes (aOR=1.74; 95%CI 1.29-2.36), ever being on opioid agonist treatment (aOR=2.91; 95%CI 2.01-4.21), ever being imprisoned (aOR=1.86; 95%CI 1.40-2.48) and ever being homeless (aOR=1.54; 95%CI 1.14-2.07). Amongst PWID who had injected drugs within the last year, 49.9% had recently undertaken an HCV test. After adjustment, factors associated with higher odds of undertaking a recent HCV test included: injecting crack in the last year (aOR=1.29; 95%CI 1.03-1.61), experiencing a non-fatal overdose in the last year (aOR=1.39; 95%CI 1.05-1.85), ever being on opioid agonist treatment (aOR=1.48; 95%CI 0.97-2.25), receiving HCV information in the last year (aOR=1.99; 95%CI 1.49-2.65) and using a healthcare service in the last year (aOR=1.80; 95%CI 1.21-2.67).

CONCLUSION

Results suggest that PWID who have experienced homelessness and incarceration - amongst the most vulnerable and marginalised in the PWID population - are engaging with HCV testing, but overall there remain missed testing opportunities. Recent initiates to injecting have highest HCV infection risk but lower odds of testing, and peer-education may help target this group.

Housing Instability, Structural Vulnerability, and Non-Fatal Opioid Overdoses Among People Who Use Heroin in Washington Heights, New York City

Nationally, opioid overdose remains strikingly persistent among people experiencing homelessness and housing instability. Limited information is available about the characteristics of this phenomenon in economically disadvantaged communities of color. This study sought to evaluate the association between key contextual factors and experiencing a non-fatal opioid overdose among people who use heroin in Washington Heights, New York City. We conducted a cross-sectional survey (N = 101) among participants seeking harm reduction services who reported heroin use in the last three months. Binary logistic regression models examined the association between key social and structural factors and the likelihood of ever experiencing a non-fatal opioid overdose and recently experiencing a non-fatal opioid overdose. The majority of the sample reported housing instability and lived in poverty; almost 42% were homeless. After adjustment, participants who injected heroin were more likely to have ever experienced a non-fatal opioid overdose. Also, younger participants who reported hunger in the last six months were more likely to have experienced a non-fatal opioid overdose in the last three months. Findings suggest the role of structural vulnerability in shaping overdose risk among the participants. Overdose prevention strategies should consider factors of the social and economic environment to mitigate barriers to accessing health and social services within the context of the current opioid crisis.

Modeling of overdose and naloxone distribution in the setting of fentanyl compared to heroin

BACKGROUND

Fentanyl has replaced most other non-prescribed opioids in much of North America. There is controversy over whether a hypothetical reduced efficacy of naloxone in reversing fentanyl is a major contributor to the coincident rising overdose mortality.

METHODS

We modified an existing Markov decision analytic model of heroin overdose and naloxone distribution to account for known risks of fentanyl by adjusting overdose risk, the likelihood of death in the event of overdose, and the proportion of cases in which available naloxone was administered in time to prevent death. We assumed near-universal survival when naloxone was administered promptly for heroin or fentanyl overdose, but allowed that to decline in sensitivity analyses for fentanyl. We varied the proportion of use that was fentanyl and adjusted the modified parameters accordingly to estimate mortality as the dominant opioid shifted.

RESULTS

Absent naloxone, the annual overdose death rate was 1.0% and 4.1% for heroin and fentanyl, respectively. With naloxone reaching 80% of those at risk, the overdose death rate was 0.7% and 3.6% for heroin and fentanyl, respectively, representing reductions of 26.4% and 12.0%. Monte Carlo simulations resulted in overdose mortality with fentanyl of 3.3-5.2% without naloxone and 2.6-4.9% with naloxone, with 95% certainty. Positing reduced efficacy for naloxone in reversing fentanyl resulted in 3.6% of fentanyl overdose deaths being prevented by naloxone.

CONCLUSIONS

Heightened risk for overdose and subsequent death, alongside the time-sensitive need for naloxone administration, fully account for increased mortality when fentanyl replaces heroin, assuming optimal pharmacologic efficacy of naloxone.

Mortality among people who inject drugs: a prospective cohort followed over three decades in Baltimore, MD, USA

BACKGROUND AND AIMS

During the past decades, people who inject drugs (PWID) have been impacted by the development of combination antiretroviral therapy (cART) to combat HIV/AIDS, the prescription opioid crisis and increased use of lethal synthetic opioids. We measured how these dynamics have impacted mortality among PWID in an urban US city.

DESIGN

Prospective cohort study using data from the AIDS Linked to the Intravenous Experience (ALIVE).

SETTING

Baltimore, MD, USA from 1988 to 2018.

PARTICIPANTS

A total of 5506 adult PWIDs (median age at baseline 37 years).

MEASUREMENTS

Mortality was identified by linkage to National Death Index-Plus (NDI-Plus) and categorized into HIV/infectious disease (HIV/ID) deaths, overdose and violence-related (drug-related) deaths and chronic disease deaths. Person-time at risk accrued from baseline and ended at the earliest of death or study period. All-cause and cause-specific mortality were calculated annually. The Fine & Gray method was used to estimate the subdistribution hazards of cause-specific deaths accounting for competing risks.

FINDINGS

Among 5506 participants with 84 226 person-years of follow-up, 43.9% were deceased by 2018. Among all deaths, 30.5% were HIV/ID deaths, 24.4% drug-related deaths and 33.3% chronic disease deaths. Age-standardized all-cause mortality increased from 23 to 45 per 1000 person-years from 1988 to 1996, declined from 1996 to 2014, then trended upward to 2018. HIV/ID deaths peaked in 1996 coincident with the availability of cART, then continuously declined. Chronic disease deaths increased continuously as the cohort aged. Drug-related deaths declined until 2011, but increased more than fourfold by 2018. HIV/HCV infection and active injecting were independently associated with HIV/ID and drug-related deaths. Female and black participants had a higher risk of dying from HIV/ID deaths and a lower risk of dying from drug-related deaths than male and non-black participants.

CONCLUSIONS

Deaths in Baltimore, MD, USA attributable to HIV/ID appear to have declined following the widespread use of combination antiretroviral therapy. Increases in the rates of drug-related deaths in Baltimore were observed prior to and continue in conjunction with national mortality rates associated with the opiate crisis.

Prevalence of co-occurring mental illness and substance use disorder and association with overdose: a linked data cohort study among residents of British Columbia, Canada

AIMS

To estimate the treated prevalence of mental illness, substance use disorder (SUD) and dual diagnosis and the association between dual diagnosis and fatal and non-fatal overdose among residents of British Columbia (BC), Canada.

DESIGN

A retrospective cohort study using linked health, income assistance, corrections and death records.

SETTING

British Columbia (BC), Canada.

PARTICIPANTS

A total of 921 346 BC residents (455 549 males and 465 797 females) aged 10 years and older.

MEASUREMENTS

Hospital and primary-care administrative data were used to identify a history of mental illness only, SUD only, dual diagnosis or no history of SUD or mental illness (2010-14) and overdoses resulting in medical care (2015-17). We calculated crude incidence rates of non-fatal and fatal overdose by dual diagnosis history. Andersen-Gill and competing risks regression were used to examine the association between dual diagnosis and non-fatal and fatal overdose, respectively, adjusting for age, sex, comorbidities, incarceration history, social assistance, history of prescription opioid and benzodiazepine dispensing and region of residence.

FINDINGS

Of the 921 346 people in the cohort, 176 780 (19.2%), 6147 (0.7%) and 15 269 (1.7%) had a history of mental illness only, SUD only and dual diagnosis, respectively; 4696 (0.5%) people experienced 688 fatal and 6938 non-fatal overdoses. In multivariable analyses, mental illness only, SUD only and dual diagnosis were associated with increased rate of non-fatal [hazard ratio (HR) = 1.8, 95% confidence interval (CI) = 1.6-2.1; HR = 9.0, 95% CI = 7.0-11.5, HR = 8.7, 95% CI = 6.9-10.9, respectively] and fatal overdose (HR = 1.6, 95% CI = 1.3-2.0, HR = 4.3, 95% CI = 2.8-6.5, HR = 4.1, 95% CI = 2.8-6.0, respectively) compared with no history.

CONCLUSIONS

In a large sample of residents of British Columbia (Canada), approximately one in five people had sought care for a substance use disorder or mental illness in the past 5 years. The rate of overdose was elevated in people with a mental illness alone, higher again in people with a substance use disorder alone and highest in people with a dual diagnosis. The adjusted hazard rates were similar for people with substance use disorder only and people with a dual diagnosis.

Caregiver drug use in Ontario child welfare investigations: The need for coordinated intervention

BACKGROUND

Caregiver substance abuse is associated with harmful parenting behaviors, increased child welfare involvement, and negative child outcomes, and the opioid epidemic has brought increased attention to the safety and wellbeing of children living with caregivers who abuse substances.

OBJECTIVE

This paper investigates the impact of primary caregiver drug abuse concerns on child welfare investigations in Ontario, Canada and examines how different drug abuse categories impact out-of-home placements in a Canadian setting, with a focus on opioids, opiates, and morphine derivatives.

PARTICIPANTS AND SETTING

Secondary analyses of data from the Ontario Incidence Study of Reported Child Abuse and Neglect 2018 (OIS-2018) were conducted. The OIS-2018 collected information on child welfare investigations from workers who conducted the investigations. The final unweighted sample of the OIS-2018 included 7590 investigations involving children under 18 years old.

METHODS

Descriptive and bivariate analyses were conducted as well as a logistic regression predicting out-of-home placement.

RESULTS

Investigations involving noted primary caregiver drug abuse concerns involved increased household and family risks as well as more intrusive forms of child welfare involvement. Results of the logistic regression controlling for family, child, and case characteristics revealed that investigations involving noted primary caregiver drug abuse were more likely to involve out-of-home placements, and investigations that involved caregivers who abused opioids specifically were approximately 3.5 times more likely to result in a placement.

CONCLUSIONS

A coordinated response involving the child welfare, addictions treatment, and other allied systems is warranted to support families with substance abuse concerns and provide appropriate services.

The mobile emergency recovery intervention trial (MERIT): Protocol for a 3-year mixed methods observational study of mobile recovery outreach teams in Nevada's emergency departments

Background

The Substance Abuse and Mental Health Administration awarded State Targeted Response grants to support states’ efforts to address the opioid epidemic. In Nevada, one component of this grant was mobile recovery outreach teams (MROTs) that utilized peer recovery support specialists to provide care for qualifying patients in emergency departments (EDs). The Mobile Emergency Recovery Intervention Trial (MERIT) is a mixed methods study to assess the feasibility/acceptability and effectiveness of the MROT intervention. This protocol mainly describes the R33 research activities and outcomes. The full protocol can be found protocols.io.

Methods

Data will be derived from state-level data sets containing de-identified emergency department visits, substance use disorder treatment records, and mortality files; in-person mixed methods interviews; participant observation; and self-report process evaluation forms. Primary outcomes include Medication Assisted Treatment (MAT) initiation and non-fatal overdose; secondary outcomes include MAT retention and fatal overdose. Quantitative hypotheses will be tested using generalized linear mixed effects models, Bayesian hierarchical models, and marginal Cox models. Qualitative interview data will be analyzed using an inductive thematic analysis procedure.

Discussion

Understanding Fatal and Non-Fatal Drug Overdose Risk Factors: Overdose Risk Questionnaire Pilot Study-Validation

Background: Drug overdoses (fatal and non-fatal) are among the leading causes of death in population with substance use disorders. The aim of the current study was to identify risk factors for fatal and non-fatal drug overdose for predominantly opioid-dependent treatment-seeking population. Methods: Data were collected from 640 adult patients using a self-reported 25-item Overdose Risk (OdRi) questionnaire pertaining to drug use and identified related domains. The exploratory factor analysis (EFA) was primarily used to improve the interpretability of this questionnaire. Two sets of EFA were conducted; in the first set of analysis, all items were included, while in the second set, items related to the experience of overdose were removed. Logistic regression was used for the assessment of latent factors' association with both fatal and non-fatal overdoses. Results: EFA suggested a three-factor solution accounting for 75 and 97% of the variance for items treated in the first and second sets of analysis, respectively. Factor 1 was common for both sets of EFA analysis, containing six items (Cronbach's α = 0.70) focusing around "illicit drug use and lack of treatment." In the first set of analysis, Factors 2 (Cronbach's α = 0.60) and 3 (Cronbach's α = 0.34) were focusing around "mental health and emotional trauma" and "chronic drug use and frequent overdose" domains, respectively. The increase of Factor 2 was found to be a risk factor for fatal drug overdose (adjusted coefficient = 1.94, p = 0.038). In the second set of analysis, Factors 2 (Cronbach's α = 0.65) and 3 (Cronbach's α = 0.59) as well as Factor 1 were found to be risk factors for non-fatal drug overdose ever occurring. Only Factors 1 and 3 were positively associated with non-fatal overdose (one in a past year). Conclusion: The OdRi tool developed here could be helpful for clinical studies for the overdose risk assessment. However, integrating validated tools for mental health can probably help refining the accuracy of latent variables and the questionnaire's consistency. Mental health and life stress appear as important predictors of both fatal and non-fatal overdoses.

Moving Beyond Narcan: A Police, Social Service, and Researcher Collaborative Response to the Opioid Crisis

The opioid crisis is the most persistent, long-term public health emergency facing the United States, and available evidence suggests the crisis has worsened during the COVID-19 global pandemic. Naloxone is an effective overdose response that saves lives, but the drug does not address problematic drug use, addiction, or the underlying conditions that lead to overdoses. The opioid crisis is at its core a multidisciplinary, multisystem problem, and an effective response to the crisis requires collaboration across those various systems. This paper describes such a collaborative effort. The Tempe First-Responder Opioid Recovery Project is a multidisciplinary partnership that includes police officers, social workers, substance use peer counselors, public health professionals, police researchers, and drug policy/harm reduction researchers. The project, 10 months underway, trained and equipped Tempe (AZ) police officers to administer Narcan. In addition, a 24/7 in-person "Crisis Outreach Response Team" rapidly responds to any suspected overdose and offers follow-up support, referrals, and services to the individual (and loved ones) for up to 45 days after the overdose. We present preliminary project data including interviews with project managers, counselors, and police officers, descriptions of Narcan administrations in the field, and aggregate data on client service engagement. These data highlight the complexity of the opioid crisis, the collaborative nature of the Tempe project, and the importance of initiating a multidisciplinary, comprehensive response to effectively deal with the opioid problem.

Barriers and Motivators to Opioid Treatment Among Suburban Women Who Are Pregnant and Mothers in Caregiver Roles

Women of childbearing age who misuse opioids are a particularly vulnerable population, and their barriers to treatment are unique because of their caregiver roles. Research on treatment for opioid use generally draws from urban and rural areas. This study fills a gap in research that focuses on barriers and motivators to opioid treatment in suburban areas. The aim of this study was to give voice to suburban pregnant women and mothers caring for children while using opioids. Ethnographic methods were used for recruitment, and 58 in-depth interviews were analyzed using a modified grounded theory approach. Barriers to medication-assisted treatment (MAT) included stigma, staff attitudes, and perceptions the women had about MAT treatment. Barriers associated with all types of treatment included structural factors and access difficulties. Relationships with partners, friends, family, and providers could be barriers as well as motivators, depending on the social context of the women’s situation. Our findings suggest increasing treatment-seeking motivators for mothers and pregnant women by identifying lack of resources, more empathetic consideration of social environments, and implementing structural changes to overcome barriers. Findings provide a contemporary understanding of how suburban landscapes affect mothers’ treatment-seeking for opioid dependence and suggest the need for more focus on emotional and structural resources rather than strict surveillance of women with opioid dependence who are pregnant or caring for children.

Analysis of 39 drugs and metabolites, including 8 glucuronide conjugates, in an upstream wastewater network via HPLC-MS/MS

Pharmaceutical compounds ingested by humans are metabolized and excreted in urine and feces. These metabolites can be quantified in wastewater networks using wastewater-based epidemiology (WBE) methods. Standard WBE methods focus on samples collected at wastewater treatment plants (WWTPs). However, these methods do not capture more labile classes of metabolites such as glucuronide conjugates, products of the major phase II metabolic pathway for drug elimination. By shifting sample collection more upstream, these unambiguous markers of human exposure are captured before hydrolysis in the wastewater network. In this paper, we present an HPLC-MS/MS method that quantifies 8 glucuronide conjugates in addition to 31 parent and other metabolites of prescription and synthetic opioids, overdose treatment drugs, illicit drugs, and population markers. Calibration curves for all analytes are linear (r2 > 0.98), except THC (r2 = 0.97), and in the targeted range (0.1-1,000 ng mL-1) with lower limits of quantification (S/N = 9) ranging from 0.098 to 48.75 ng mL-1. This method is fast with an injection-to-injection time of 7.5 min. We demonstrate the application of the method to five wastewater samples collected from a manhole in a city in eastern Massachusetts. Collected wastewater samples were filtered and extracted via solid-phase extraction (SPE). The SPE cartridges are eluted and concentrated in the laboratory via nitrogen-drying. The method and case study presented here demonstrate the potential and application of expanding WBE to monitoring labile metabolites in upstream wastewater networks.

Facilitating rapid access to addiction treatment: a randomized controlled trial

Background

Obtaining timely access to addiction medicine treatment for patients with substance use disorders is challenging and patients often have to navigate complex referral pathways. This randomized controlled trial examines the effect of providing an expedited pathway to addiction medicine treatment on initial treatment engagement and health care utilization.

Methods

Individuals with possible alcohol or opioid use disorder were recruited from three residential withdrawal management services (WMS). Subjects randomized to the Delayed Intervention (DI) group were given contact information for a nearby addiction medicine clinic; those randomized to the Rapid Intervention (RI) group were given an appointment at the clinic within 2 days and were accompanied to their first appointment.

Results

Of the 174 individuals who were screened, 106 were randomized to either the DI or RI group. The two groups were similar in demographics, housing status, and substance use in the last 30 days. In the 6-month period following randomization, 85% of the RI group attended at least one clinic appointment, compared to only 29% in the DI group (p < 0.0001). The RI group had a mean of 6.39 ED visits per subject in the 12 months after randomization, while the DI group had a mean of 13.02 ED visits per subject in the same 12-month period (p = 0.0469). Other health utilization measures did not differ between the two groups.

Conclusion

Providing immediate facilitated access to an addiction medicine service resulted in greater initial engagement and reduced emergency department visits at 6 months.

Trial registration This trial is registered at the National Institutes of Health (ClinicalTrials.gov) under identifier #NCT01934751.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13722-021-00240-y.

Periods of altered risk for non-fatal drug overdose: a self-controlled case series

BACKGROUND

Being recently released from prison or discharged from hospital, or being dispensed opioids, benzodiazepines, or antipsychotics have been associated with an increased risk of fatal drug overdose. This study aimed to examine the association between these periods and non-fatal drug overdose using a within-person design.

METHODS

In this self-controlled case series, we used data from the provincial health insurance client roster to identify a 20% random sample of residents (aged ≥10 years) in British Columbia, Canada between Jan 1, 2015, and Dec 31, 2017 (n=921 346). Individuals aged younger than 10 years as of Jan 1, 2015, or who did not have their sex recorded in the client roster were excluded. We used linked provincial health and correctional records to identify a cohort of individuals who had a non-fatal overdose resulting in medical care during this time period, and key exposures, including periods of incarceration, admission to hospital, emergency department care, and supply of medications for opioid use disorder (MOUD), opioids for pain (unrelated to MOUD), benzodiazepines, and antipsychotics. Using a self-controlled case series, we examined the association between the time periods during and after each of these exposures and the incidence of non-fatal overdose with case-only, conditional Poisson regression analysis. Sensitivity analyses included recurrent overdoses and pre-exposure risk periods.

FINDINGS

We identified 4149 individuals who had a non-fatal overdose in 2015-17. Compared with unexposed periods (ie, all follow-up time that was not part of a designated risk period for each exposure), the incidence of non-fatal overdose was higher on the day of admission to prison (adjusted incidence rate ratio [aIRR] 2·76 [95% CI 1·51-5·04]), at 1-2 weeks (2·92 [2·37-3·61]), and 3-4 weeks (1·34 [1·01-1·78]) after release from prison, 1-2 weeks after discharge from hospital (1·35 [1·11-1·63]), when being dispensed opioids for pain (after ≥4 weeks) or benzodiazepines (entire use period), and from 3 weeks after discontinuing antipsychotics. The incidence of non-fatal overdose was reduced during use of MOUD (aIRRs ranging from 0·33 [0·26-0·42] to 0·41 [0·25-0·67]) and when in prison (0·12 [0·08-0·19]).

INTERPRETATION

Expanding access to and increasing support for stable and long-term medication for the management of opioid use disorder, improving continuity of care when transitioning between service systems, and ensuring safe prescribing and medication monitoring processes for medications that reduce respiratory function (eg, benzodiazepines) could decrease the incidence of non-fatal overdose.

FUNDING

Murdoch Children's Research Institute and National Health and Medical Research Council.

Engagement in drug treatment following nonfatal overdose among people who inject drugs in Appalachia

BACKGROUND

Immediately after experiencing a non-fatal overdose, many people who inject drugs (PWID) engage in harm-minimizing behavior change, including engagement in drug treatment. To inform the implementation of tailored interventions designed to facilitate drug treatment engagement in rural communities, we sought to identify correlates of starting any form of drug treatment after their most recent overdose among PWID who reside in a rural county in West Virginia.

METHODS

Data are from a PWID population estimation study in Cabell County, West Virginia. We used multivariable logistic regression to identify independent sociodemographic and substance use-related correlates of any form of drug treatment engagement after an overdose among 179 PWID who had overdosed in the past 6 months.

RESULTS

One-third of our sample (33.0%) started any form of drug treatment in the 30 days following their most recent overdose. Factors associated with engaging in drug treatment included: recent buprenorphine or Suboxone injection (aOR: 2.39, 95% CI: 1.15, 4.96), someone calling 911 after their most recent overdose (aOR: 3.29, 95% CI: 1.63, 6.65), and older age (aOR per year of age: 0.95, 95% CI: 0.91, 0.99).

CONCLUSIONS

Our results suggest that contact with emergency personnel after an overdose may represent an important opportunity to link PWID to drug treatment. The implementation of response teams trained in linking PWID to the services they require and helping persons navigate treatment systems maybe be a valuable intervention to reduce the harms of the opioid overdose crisis.

Correlates of recent nonfatal overdose among people who inject drugs in West Virginia

Aim

Experiencing a nonfatal overdose (NFOD) is a significant risk factor for a subsequent nonfatal or fatal overdose. Overdose mortality rates in rural Appalachian states are some of the highest in the USA, but little is known about correlates of overdose among rural populations of people who inject drugs (PWID). Our study aimed to identify correlates of experiencing a recent (past 6 months) NFOD among rural PWID in Cabell County, West Virginia.

Methods

Using data from a June–July 2018 cross-sectional survey that was designed to estimate the size and characteristics of the PWID population in Cabell County, West Virginia, we used log binomial regression to identify correlates (e.g., structural vulnerabilities and substance use) of NFOD in the past 6 months.

Results

The majority of our sample of 420 PWID were male (61.2%), White, non-Hispanic (83.6%), and reported recent heroin injection (81.0%). More than two-fifths (42.6%) experienced a recent NFOD. Independent correlates of NFOD included witnessing an overdose in the past 6 months (adjusted prevalence ratio [aPR] = 2.28; 95% CI 1.48–3.50), attempting to quit using drugs in the past 6 months (aPR = 1.54; 95% CI 1.11–2.14), and the number of drugs injected (aPR = 1.16; 95% CI 1.10–1.23)

Conclusions

A large proportion of rural PWID in Appalachia reported having recently overdosed. The associations between witnessing an overdose, attempting to quit using drugs, and number of drugs injected with recent nonfatal overdose underscore the need for expanded access to overdose prevention resources that are tailored to the needs of this population. Expanding access to evidence-based overdose prevention strategies—such as take-home naloxone programs, treatment with methadone or buprenorphine, and harm reduction services—may decrease overdose morbidity and mortality among rural PWID in Appalachia.

Buprenorphine for Opioid Use Disorder in the Emergency Department: A Retrospective Chart Review

Introduction

Emergency care providers routinely treat patients with acute presentations and sequelae of opioid use disorder. An emergency physician and pharmacist implemented a protocol using buprenorphine for the treatment of patients with opioid withdrawal at an academic, Level I trauma center. We describe our experience regarding buprenorphine implementation in the emergency department (ED), characteristics of patients who received buprenorphine, and rates of outpatient follow-up.

Methods

We conducted a retrospective chart review of all patients in the ED for whom buprenorphine was administered to treat opioid withdrawal during an 18-month period from January 30, 2017–July 31, 2018. Data extraction of a priori-defined variables was recorded. We used descriptive statistics to characterize the cohort of patients.

Results

A total of 77 patients were included for analysis. Thirty-three patients (43%) who received buprenorphine did not present with the chief complaint of opioid withdrawal. Most patients (74%) who received buprenorphine last used heroin, and presented in moderate opioid withdrawal. One case of precipitated withdrawal occurred after buprenorphine administration. Twenty-three (30%) patients received outpatient follow-up.

Conclusions

This study underscores the safety of ED-initiated buprenorphine and that buprenorphine administration in the ED is feasible and effective.

Best Practices for a Novel EMS-Based Naloxone Leave behind Program

BACKGROUND

Increasing naloxone access has been identified as a primary strategy to reduce opioid overdose deaths. To supplement community naloxone training and distribution access points, EMS systems have instituted public safety-based naloxone leave behind (NLB) programs that allow emergency medical responders to distribute "leave behind" naloxone kits on the scene of an overdose. This model presents an opportunity to expand naloxone access for individuals at high risk for future overdoses. Objectives: To evaluate the preliminary outcomes of a novel EMS-based NLB program in Howard County, Maryland. Methods: This exploratory study involved analysis of data from the Howard County NLB Program. Basic statistical analysis of program performance metrics and participant demographic characteristics were performed. Results: From June 2018 to June 2019, Howard County Department of Fire and Rescue Services responded to 239 overdose calls and distributed 120 naloxone kits to individuals on the scene of an overdose, a 50.21% distribution rate. The HCNLB program connected 143 patients (59.83%) to peer recovery specialists. Among the 143 patients linked to peer recovery support specialist services, 87 (60.84%) had accepted an NLB kit from EMS. The fully adjusted logistic regression model revealed that those whose kit was left with a family member on the scene were 5.16 times more likely to be connected to peer support specialists (OR = 5.16, CI= 2.35 - 11.29, p = 0.000) while those whose kit was left with a friend or given directly to the patient were 3.69 times (OR = 3.69, CI= 1.13 - 12.06, p < 0.05) and 2.37 times (OR = 2.37, CI= 1.10 - 5.14, p < 0.05) more likely, respectively, to be connected to follow up services as compared to those who did not accept a kit, controlling for other variables in the model. Conclusion: This study highlights the importance of engaging an individual's family and social network when offering connections to treatment and recovery resources. NLB initiatives can potentially augment existing community-based naloxone training structures, thus widening the scope of the life-saving drug and reaching those most at risk of dying from an opioid overdose.

Appointment wait-times and arrival for patients at a low-barrier access addiction clinic

INTRODUCTION

Same-day or next-day access to outpatient medication for addiction treatment (MAT) for both alcohol and opioid use disorders may facilitate sustained treatment with evidence-based therapies for substance use disorders (SUD). This study evaluates the association between appointment wait-times and odds of arrival to appointment for patients seeking outpatient MAT.

METHODS

The study sample consisted of patients who scheduled an appointment with a low-barrier access addiction clinic between August 1, 2016, and July 31, 2017. The outcome of interest was the status of the appointment as a dichotomous variable: arrive or no-show/cancel. The primary independent variable (wait-time) was the number of overnights between the date a patient scheduled a clinic appointment and the date of service, categorized as 0 days, 1 day, and 2+ days. We conducted bivariable and multivariable logistic regressions to calculate unadjusted and adjusted odds ratios for arrival. Multivariable analyses were adjusted for gender, age, distance of residence from the clinic, and insurance type.

RESULTS

Our analysis included 657 patients, of whom 410 (62%) arrived to their first appointment. Among the 657 patients, 47% (308) were scheduled the same day (0 days) and 82% (252) of them were seen, 23% (151) waited 1 day (next-day) and 53% (80) of them were seen, and 30% (198) waited 2+ days and 39% (78) of them were seen. Patients were more likely to be seen when they had a same-day (OR 6.9 [95% CI 4.6-10.4]; AOR 7.5 [4.9-11.4]) or next-day (OR 1.7 [1.1-2.7]; AOR 1.7 [1.1-2.6]) appointment compared to waiting 2+ days.

CONCLUSION

Patients seeking MAT through a clinic that schedules same-day and next-day appointments for treatment are more likely to attend addiction appointments compared to patients who wait longer. Clinics should strive to reduce wait-times for patients seeking MAT.

Routes of non-traditional entry into buprenorphine treatment programs

BACKGROUND

Excessive prescribing, increased potency of opioids, and increased availability of illicit heroin and synthetic analogs such as fentanyl has resulted in an increase of overdose fatalities. Medications for opioid use disorder (MOUD) significantly reduces the risk of overdose when compared with no treatment. Although the use of buprenorphine as an agonist treatment for opioid use disorder (OUD) is growing significantly, barriers remain which can prevent or delay treatment. In this study we examine non-traditional routes which could facilitate entry into buprenorphine treatment programs.

METHODS

Relevant, original research publications addressing entry into buprenorphine treatment published during the years 1989-2019 were identified through PubMed, PsychInfo, PsychArticles, and Medline databases. We operationalized key terms based on three non-traditional paths: persons that entered treatment via the criminal justice system, following emergencies, and through community outreach.

RESULTS

Of 462 screened articles, twenty studies met the inclusion criteria for full review. Most studies were from the last several years, and most (65%) were from the Northeastern region of the United States. Twelve (60%) were studies suggesting that the criminal justice system could be a potentially viable entry route, both pre-release or post-incarceration. The emergency department was also found to be a cost-effective and viable route for screening and identifying individuals with OUD and linking them to buprenorphine treatment. Fewer studies have documented community outreach initiatives involving buprenorphine. Most studies were small sample size (mean = < 200) and 40% were randomized trials.

CONCLUSIONS

Despite research suggesting that increasing the number of Drug Addiction Treatment Act (DATA) waived physicians who prescribe buprenorphine would help with the opioid treatment gap, little research has been conducted on routes to increase utilization of treatment. In this study, we found evidence that engaging individuals through criminal justice, emergency departments, and community outreach can serve as non-traditional treatment entry points for certain populations. Alternative routes could engage a greater number of people to initiate MOUD treatment.

Comparing the predictive capability of self-report and medically-verified non-fatal overdose in adults released from prison: A prospective data linkage study

BACKGROUND

Self-reported non-fatal overdose (NFOD) is a predictor of future overdose and is often used to target overdose prevention for people released from prison. However, the level of agreement between self-reported and medically-verified NFOD history remains unknown. This study aimed to determine the agreement between, and predictive value of, self-reported and medically-verified history of NFOD in people recently released from prison.

METHODS

Pre-release baseline survey data from 1307 adults in prison surveyed from 2008 to 2010 in Queensland, Australia were linked to ambulance, emergency department, and hospital records. We compared the agreement of self-reported NFOD history in the baseline survey and medically-verified NFOD ascertained through linked medical data. Unadjusted and adjusted regression models were used to determine the association between self-reported and medically verified NFOD history and medically-verified NFOD after release from prison.

RESULTS

224 (19 %) participants self-reported NFOD history only, 75 (5 %) had medically-verified NFOD history only, and 56 (4 %) both self-reported and had medically-verified NFOD history. Compared to those with no NFOD history, those who self-reported and had a medical history of NFOD (adjusted hazard ratio (AHR) 6.1, 95 %CI 3.1-11.9), those with a medical history only (AHR 3.4, 95 %CI 1.7-7.0), and those who self-reported only (AHR 1.8, 95 %CI 1.0-3.5) were at increased risk of medically-verified NFOD after release from prison.

CONCLUSIONS

Relying on self-report of NFOD is likely to miss people at increased risk of future NFOD, many of whom could be identified through medical records. Wherever possible, data related to NFOD should be triangulated from multiple sources.

Non-fatal drug overdose after release from prison: A prospective data linkage study

BACKGROUND

Adults released from prison are at increased risk of poor health outcomes and preventable mortality, including from overdose. Non-fatal overdose (NFOD) is a strong predictor of future overdose and associated with considerable morbidity. This study aims to the determine the incidence, predictors and clinical characteristics of NFOD following release from prison.

METHODS

We used pre-release interview data collected for a randomised controlled trial in 2008-2010, and linked person-level, state-wide ambulance, emergency department, and hospital records, from a representative sample of 1307 adults incarcerated in Queensland, Australia. The incidence of NFOD following release from prison was calculated. A multivariate Andersen-Gill model was used to identify demographic, health, social, and criminal justice predictors of NFOD.

RESULTS

The crude incidence rate (IR) of NFOD was 47.6 (95%CI 41.1-55.0) per 1000 person-years and was highest in the first 14 days after release from prison (IR = 296 per 1000 person-years, 95%CI 206-426). In multivariate analyses, NFOD after release from prison was positively associated with a recent history of substance use disorder (SUD), dual diagnosis of mental illness and SUD, lifetime history of injecting drug use, lifetime history of NFOD, being dispensed benzodiazepines after release, a shorter index incarceration, and low perceived social support. The risk of NFOD was lower for people with high-risk alcohol use and while incarcerated.

CONCLUSIONS

Adults released from prison are at high risk of non-fatal overdose, particularly in the first 14 days after release. Providing coordinated transitional care between prison and the community is likely critical to reduce the risk of overdose.

Findings from the recovery initiation and management after overdose (RIMO) pilot study experiment

This pilot study evaluated the feasibility of the Recovery Initiation and Management after Overdose (RIMO) intervention to link individuals to medication-assisted treatment (MAT) following an opioid overdose. The study team worked with the Chicago Fire Department to train Emergency Medical Service (EMS) teams to request permission from individuals after an opioid overdose reversal to release their contact information; individuals were subsequently contacted by the study team for participation. A mixed-methods study design comprised: (1) an experimental pilot study that examined participation at each stage of the intervention and compared the odds of treatment received for individuals who were randomly assigned to either the RIMO intervention (n = 16) or a passive referral control (n = 17); and (2) a focus group that was subsequently conducted with participants in the RIMO group to obtain their feedback on the intervention components. Quantitative data was collected on participant characteristics at study intake and treatment received was based on self-report at a 30-day follow-up. The RIMO group had higher odds of receiving any treatment for opioid use (OR = 7.94) and any MAT (OR = 20.2), and received significantly more days of opioid treatment (Ms=15.2 vs. 3.4) and more days of MAT in the 30 days post-randomization (Ms=11.2 vs. 0.76), relative to the control group (all p < .05). Qualitative data illustrated that participants valued the assertive outreach, engagement, and persistent follow-up components of RIMO, which differed from their prior experiences. The pilot study suggests that the RIMO intervention is able to address the challenges of linking and engaging individuals into MAT after an opioid overdose.

A scoping review of post opioid-overdose interventions

INTRODUCTION

Nonfatal opioid overdose is a significant risk factor for subsequent fatal overdose. The time after a nonfatal overdose may provide a critical engagement opportunity to both reduce subsequent overdose risk and link individuals to treatment. Post-overdose interventions have emerged in affected communities throughout the United States (US). The objective of this scoping review is to identify US-based post-overdose intervention models (1) described in peer-reviewed literature and (2) implemented in public health and community settings.

METHODS

Using the adapted PRISMA Checklist for Scoping Reviews, we searched PubMed, PsychInfo, Academic OneFile, and federal and state databases for peer-reviewed and gray literature descriptions of post-overdose programs. We developed search strings with a reference librarian. We included studies or programs with at least the following information available: name of program, description of key components, intervention team, and intervention timing.

RESULTS

We identified a total of 27 programs, 3 from the peer-reviewed literature and 24 from the gray literature. 9 programs operated out of the ED, while 18 programs provided post-overdose support in other ways: through home or overdose location visits, mobile means, or as law enforcement diversion. Commonly, they include partnerships among public safety and community service providers.

CONCLUSIONS

Programs are emerging throughout the US to care for individuals after a nonfatal opioid overdose. There is variability in the timing, components, and follow-up in these programs and little is known about their effectiveness. Future work should focus on evaluation and testing of post-overdose programs so that best practices for care can be implemented.

Knowledge of Fentanyl and Perceived Risk of Overdose Among Persons Who Use Drugs in Vancouver, Canada

OBJECTIVES

In North America, the illicit drug supply is increasingly contaminated by illicitly manufactured fentanyl. We sought to assess the level and source of fentanyl risk knowledge, defined as knowledge of the overdose risks associated with fentanyl, and characterize the prevalence and correlates of perceived risk of personally having a fentanyl overdose among persons who use illicit drugs (PWUD) in Vancouver, British Columbia.

METHODS

We derived data from 3 prospective cohorts of PWUD in Vancouver from December 2016 through May 2017. We used multivariable ordinal regression analysis to identify factors associated with a lower perceived risk of having a fentanyl overdose.

RESULTS

Of 1166 participants, 1095 (93.9%) had fentanyl risk knowledge. Of 1137 participants who answered questions about their perceived risk of having a fentanyl overdose, 398 (35.0%) perceived having no risk, 426 (37.5%) perceived having low risk, and 313 (27.5%) perceived having moderate or high risk. Never or rarely using opioids (n = 541, 65.7%) was the most common reason for reporting no or low perceived risk (n = 824), whereas 137 (16.6%) participants reported daily heroin use. In multivariable analysis, compared with participants who perceived a moderate or high risk, participants who perceived a lower risk were less likely to report a recent nonfatal overdose (adjusted odds ratio [aOR] = 0.28; P < .001), recent injection drug use (aOR = 0.34; P < .001), and awareness of recent exposure to fentanyl (aOR = 0.34; P < .001).

CONCLUSION

Despite a high level of fentanyl risk knowledge, most study participants did not translate this knowledge into a risk of having an overdose. Although participants who perceived a lower risk were less likely to have had an overdose, a considerable proportion was engaged in daily opioid use, suggesting the need to improve overdose prevention efforts.

Adoption and Utilization of an Emergency Department Naloxone Distribution and Peer Recovery Coach Consultation Program

OBJECTIVE

Rising rates of opioid overdose deaths require innovative programs to prevent and reduce opioid-related morbidity and mortality. This study evaluates adoption, utilization, and maintenance of an emergency department (ED) take-home naloxone and peer recovery coach consultation program for ED patients at risk of opioid overdose.

METHODS

Using a Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework, we conducted a retrospective provider survey and electronic medical record (EMR) review to evaluate implementation of a naloxone distribution and peer recovery coach consultation program at two EDs. Provider adoption was measured by self-report using a novel survey instrument. EMRs of discharged ED patients at risk for opioid overdose were reviewed in three time periods: preimplementation, postimplementation, and maintenance. Primary study outcomes were take-home naloxone provision and recovery coach consultation. Secondary study outcome was referral to treatment. Chi-square analysis was used for study period comparisons. Logistic regression was conducted to examine utilization moderators. Poisson regression modeled utilization changes over time.

RESULTS

Most providers reported utilization (72.8%, 83/114): 95.2% (79/83) provided take-home naloxone and 85.5% (71/83) consulted a recovery coach. There were 555 unique patients treated and discharged during the study periods: 131 preimplementation, 376 postimplementation, and 48 maintenance. Postimplementation provision of take-home naloxone increased from none to more than one-third (35.4%, p < 0.001), one-third received consultation with a recovery coach (33.1%, 45/136), and discharge with referral to treatment increased from 9.16% to 20.74% (p = 0.003). Take-home naloxone provision and recovery coach consultation did not depreciate over time.

CONCLUSIONS

ED naloxone distribution and consultation of a community-based peer recovery coach are feasible and acceptable and can be maintained over time.

Prescription-, Illicit-, and Self-Harm Opioid Overdose Cases Treated in Hospital

OBJECTIVE

Research suggests unintentional overdose on prescription drugs and intentional self-harm cases differ fundamentally from unintentional illicit drug overdoses, but there are few data on opioid overdose per se.

METHOD

We analyzed consecutive opioid overdose patients age 13 and over (N = 435) treated by a toxicology consult service to compare three poisoning groups: unintentional illicit drug (illicit, n = 128), unintentional prescription drug (prescription, n = 217), and intentional self-harm (self-harm, n = 90). The groups were compared on key characteristics of the poisoning events (severity, co-ingestion of non-opioid) and the hospital-based treatments required to manage the poisonings (use of antidote, provision of pharmacological support). Logistic regressions yielded incident rate ratios (IRRs) and 95% confidence intervals (CI) adjusted for age and sex.

RESULTS

Compared to the illicit group, the prescription group was more likely to co-ingest a non-opioid drug (IRR [95% CI] = 1.594 [1.077, 2.358], p = .020. Compared to illicit cases, self-harm cases were more likely to co-ingest a non-opioid drug (IRR = 3.181 [1.620, 6.245], p = .001) and had a lower poisoning severity score (IRR = 0.750 [0.564, 0.997], p = .048). There were no statistically significant differences between the self-harm and prescription groups.

CONCLUSIONS

The similarities between the self-harm and prescription poisoning groups suggest that they may benefit from common interventions including appropriate restriction on prescription of opioids and other medications that may be misused (e.g., sedative-hypnotic/muscle relaxants). The characteristics of the illicit poisoning group (use of heroin; more severe overdose events) suggest the need for initiation of intensive substance use treatment interventions during hospitalization.

Prescription-, Illicit-, and Self-Harm Opioid Overdose Cases Treated in Hospital

OBJECTIVE

Research suggests unintentional overdose on prescription drugs and intentional self-harm cases differ fundamentally from unintentional illicit drug overdoses, but there are few data on opioid overdose per se.

METHOD

We analyzed consecutive opioid overdose patients age 13 and over (N = 435) treated by a toxicology consult service to compare three poisoning groups: unintentional illicit drug (illicit, n = 128), unintentional prescription drug (prescription, n = 217), and intentional self-harm (self-harm, n = 90). The groups were compared on key characteristics of the poisoning events (severity, co-ingestion of non-opioid) and the hospital-based treatments required to manage the poisonings (use of antidote, provision of pharmacological support). Logistic regressions yielded incident rate ratios (IRRs) and 95% confidence intervals (CI) adjusted for age and sex.

RESULTS

Compared to the illicit group, the prescription group was more likely to co-ingest a non-opioid drug (IRR [95% CI] = 1.594 [1.077, 2.358], p = .020. Compared to illicit cases, self-harm cases were more likely to co-ingest a non-opioid drug (IRR = 3.181 [1.620, 6.245], p = .001) and had a lower poisoning severity score (IRR = 0.750 [0.564, 0.997], p = .048). There were no statistically significant differences between the self-harm and prescription groups.

CONCLUSIONS

The similarities between the self-harm and prescription poisoning groups suggest that they may benefit from common interventions including appropriate restriction on prescription of opioids and other medications that may be misused (e.g., sedative-hypnotic/muscle relaxants). The characteristics of the illicit poisoning group (use of heroin; more severe overdose events) suggest the need for initiation of intensive substance use treatment interventions during hospitalization.

Incentives in a public addiction treatment system: Effects on waiting time and selection

Program-level financial incentives are used by some payers as a tool to improve quality of substance use treatment. However, evidence of effectiveness is mixed and performance contracts may have unintended consequences such as creating barriers for more challenging clients who are less likely to meet benchmarks. This study investigates the impact of a performance contract on waiting time for substance use treatment and client selection. Admission and discharge data from publicly funded Maine outpatient (OP) and intensive outpatient (IOP) substance use treatment programs (N = 38,932 clients) were used. In a quasi-experimental pre-post design, pre-period (FY 2005-2007) admission data from incentivized (IC) and non-incentivized (non-IC) programs were compared to post-period (FY 2008-2012) using propensity score matching and multivariate difference-in-difference regression. Dependent variables were waiting time (incentivized) and client selection (severity: history of mental disorders and substance use severity, not incentivized). Despite financial incentives designed to reduce waiting time for substance use treatment among state-funded outpatient programs, average waiting time for treatment increased in the post period for both IC and non-IC groups, as did client severity. There were no significant differences in waiting time between IC and non-IC groups over time. Increases in client severity over time, with no group differences, indicate that programs did not restrict access for more challenging clients. Adequate funding and other approaches to improve quality may be beneficial.

Examining Barriers as Risk Factors for Relapse: A focus on the Canadian Treatment and Recovery System of Care

Objectives:

In 2016, the Canadian Centre on Substance Use and Addiction (CCSA) conducted the first survey of individuals in recovery from addiction in Canada. The findings revealed that many individuals in recovery lead meaningful lives, contributing to their families and society. However, participants also identified a number of barriers to starting and maintaining recovery. The current study examined the relationship between the barriers experienced and relapse during recovery.

Methods:

Data from the 2016 Life in Recovery (LIR) from Addiction in Canada survey were analyzed using descriptive and logistic regression analyses. Participants comprised 855 individuals (M_age = 47.3 years), all of whom self-reported being in recovery from addiction.

Results:

Logistic regressions revealed that upon starting recovery, long delays for treatment, odds ratio (OR) = 1.77, 95% confidence interval (CI) = 1.21–2.60, P < 0.01, and not having stable housing, OR = 1.83, 95% CI = 1.14–2.95, P < 0.05, were associated with increased risk of relapse. Moreover, upon examining barriers to maintaining recovery, a lack of supportive social networks, OR = 2.10, 95% CI = 1.26–3.48, p < 0.01, a lack of programs or supports, OR = 1.75, 95% CI = 1.03–2.98, P < 0.05, and the costs of recovery services OR = 1.73, 95% CI = 1.02–2.91, P < 0.05 were associated with increased risk of relapse.

Conclusions:

Targeted investments to address the treatment-related barriers that most strongly relate to relapse, could significantly improve the lives of individuals struggling with addiction and those beginning and maintaining their recovery journey.

Objectifs:

En 2016, le Centre canadien de lutte contre l’alcoolisme et les toxicomanies (CCLAT) a mené un premier sondage auprès des personnes en rétablissement à la suite d’une dépendance au Canada. Les résultats ont révélé que de nombreuses personnes en rétablissement mènent des vies significatives, contribuant ainsi à leur famille et à la société. Cependant, les participants ont également identifié un certain nombre d’obstacles au démarrage et au maintien du rétablissement. La présente étude a examiné la relation entre les obstacles rencontrés et la rechute pendant le rétablissement.

Méthodes:

Les données de l’enquête Life in Recovery (LIR) de l’Enquête sur la toxicomanie au Canada de 2016 ont été analysées à l’aide d’analyses de régression descriptives et logistiques. Les participants comprenaient 855 individus (Moyenne d’âge = 47,3 ans), qui ont tous déclaré être en rétablissement après une dépendance.

Résultats:

Les régressions logistiques ont révélé qu’au début du rétablissement, de longs délais de traitement, chance de réussite (CR) = 1,77, intervalle de confiance à 95% (IC) = 1,21-2,60, p < 0,01, et n’ayant pas de logement stable, CR = 1,83, IC 95% = 1,14-2,95, p < 0,05, étaient associés à un risque accru de rechute. De plus, en examinant les obstacles au maintien du rétablissement, un manque de réseaux sociaux de soutien, CR = 2.10, IC à 95% = 1.26-3.48, p < 0.01, manque de programmes ou de soutien, CR = 1.75, IC à 95% = 1.03–2,98, p < 0,05, et les coÛts des services de récupération CR = 1,73, IC 95% = 1,02–2,91, p < 0,05 étaient associés à un risque accru de rechute.

Conclusions:

Des investissements ciblés visant à surmonter les obstacles liés au traitement les plus étroitement liés à la rechute pourraient améliorer considérablement la vie des personnes aux prises avec une dépendance et de celles qui amorcent et poursuivent leur chemin vers le rétablissement.

Medication for Opioid Use Disorder After Nonfatal Opioid Overdose and Association With Mortality: A Cohort Study

Background

Opioid overdose survivors have an increased risk for death. Whether use of medications for opioid use disorder (MOUD) after overdose is associated with mortality is not known.

Objective

To identify MOUD use after opioid overdose and its association with all-cause and opioid-related mortality.

Design

Retrospective cohort study.

Setting

7 individually linked data sets from Massachusetts government agencies.

Participants

17 568 Massachusetts adults without cancer who survived an opioid overdose between 2012 and 2014.

Measurements

Three types of MOUD were examined: methadone maintenance treatment (MMT), buprenorphine, and naltrexone. Exposure to MOUD was identified at monthly intervals, and persons were considered exposed through the month after last receipt. A multivariable Cox proportional hazards model was used to examine MOUD as a monthly time-varying exposure variable to predict time to all-cause and opioid-related mortality.

Results

In the 12 months after a nonfatal overdose, 2040 persons (11%) enrolled in MMT for a median of 5 months (interquartile range, 2 to 9 months), 3022 persons (17%) received buprenorphine for a median of 4 months (interquartile range, 2 to 8 months), and 1099 persons (6%) received naltrexone for a median of 1 month (interquartile range, 1 to 2 months). Among the entire cohort, all-cause mortality was 4.7 deaths (95% CI, 4.4 to 5.0 deaths) per 100 person-years and opioid-related mortality was 2.1 deaths (CI, 1.9 to 2.4 deaths) per 100 person-years. Compared with no MOUD, MMT was associated with decreased all-cause mortality (adjusted hazard ratio [AHR], 0.47 [CI, 0.32 to 0.71]) and opioid-related mortality (AHR, 0.41 [CI, 0.24 to 0.70]). Buprenorphine was associated with decreased all-cause mortality (AHR, 0.63 [CI, 0.46 to 0.87]) and opioid-related mortality (AHR, 0.62 [CI, 0.41 to 0.92]). No associations between naltrexone and all-cause mortality (AHR, 1.44 [CI, 0.84 to 2.46]) or opioid-related mortality (AHR, 1.42 [CI, 0.73 to 2.79]) were identified.

Limitation

Few events among naltrexone recipients preclude confident conclusions.

Conclusion

A minority of opioid overdose survivors received MOUD. Buprenorphine and MMT were associated with reduced all-cause and opioid-related mortality.

Primary Funding Source

National Center for Advancing Translational Sciences of the National Institutes of Health.

2017 HIVMA of IDSA Clinical Practice Guideline for the Management of Chronic Pain in Patients Living With HIV

Pain has always been an important part of human immunodeficiency virus (HIV) disease and its experience for patients. In this guideline, we review the types of chronic pain commonly seen among persons living with HIV (PLWH) and review the limited evidence base for treatment of chronic noncancer pain in this population. We also review the management of chronic pain in special populations of PLWH, including persons with substance use and mental health disorders. Finally, a general review of possible pharmacokinetic interactions is included to assist the HIV clinician in the treatment of chronic pain in this population.It is important to realize that guidelines cannot always account for individual variation among patients. They are not intended to supplant physician judgment with respect to particular patients or special clinical situations. The Infectious Diseases Society of American considers adherence to these guidelines to be voluntary, with the ultimate determination regarding their application to be made by the physician in the light of each patient's individual circumstances.

Toots, tastes and tester shots: user accounts of drug sampling methods for gauging heroin potency

BACKGROUND

Internationally, overdose is the primary cause of death among people injecting drugs. However, since 2001, heroin-related overdose deaths in the United States (US) have risen sixfold, paralleled by a rise in the death rate attributed to synthetic opioids, particularly the fentanyls. This paper considers the adaptations some US heroin injectors are making to protect themselves from these risks.

METHODS

Between 2015 and 2016, a team of ethnographers collected data through semi-structured interviews and observation captured in field notes and video recording of heroin preparation/consumption. Ninety-one current heroin injectors were interviewed (Baltimore, n = 22; Chicago, n = 24; Massachusetts and New Hampshire, n = 36; San Francisco, n = 9). Experience injecting heroin ranged from < 1-47 years. Eight participants, who were exclusively heroin snorters, were also interviewed. Data were analyzed thematically.

RESULTS

Across the study sites, multiple methods of sampling "heroin" were identified, sometimes used in combination, ranging from non-injecting routes (snorting, smoking or tasting a small amount prior to injection) to injecting a partial dose and waiting. Partial injection took different forms: a "slow shot" where the user injected a portion of the solution in the syringe, keeping the needle in the injection site, and continuing or withdrawing the syringe or a "tester shot" where the solution was divided into separate injections. Other techniques included getting feedback from others using heroin of the same batch or observing those with higher tolerance injecting heroin from the same batch before judging how much to inject themselves. Although a minority of those interviewed described using these drug sampling techniques, there is clearly receptivity among some users to protecting themselves by using a variety of methods.

CONCLUSIONS

The use of drug sampling as a means of preventing an overdose from injection drug use reduces the quantity absorbed at any one time allowing users to monitor drug strength and titrate their dose accordingly. Given the highly unpredictable potency of the drugs currently being sold as heroin in the US, universal precautions should be adopted more widely. Further research is needed into facilitators and barriers to the uptake of these drug sampling methods.

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.

Mitigating the heroin crisis in Baltimore, MD, USA: a cost-benefit analysis of a hypothetical supervised injection facility

Background

In Baltimore, MD, as in many cities throughout the USA, overdose rates are on the rise due to both the increase of prescription opioid abuse and that of fentanyl and other synthetic opioids in the drug market. Supervised injection facilities (SIFs) are a widely implemented public health intervention throughout the world, with 97 existing in 11 countries worldwide. Research has documented the public health, social, and economic benefits of SIFs, yet none exist in the USA. The purpose of this study is to model the health and financial costs and benefits of a hypothetical SIF in Baltimore.

Methods

We estimate the benefits by utilizing local health data and data on the impact of existing SIFs in models for six outcomes: prevented human immunodeficiency virus transmission, Hepatitis C virus transmission, skin and soft-tissue infection, overdose mortality, and overdose-related medical care and increased medication-assisted treatment for opioid dependence.

Results

We predict that for an annual cost of $1.8 million, a single SIF would generate $7.8 million in savings, preventing 3.7 HIV infections, 21 Hepatitis C infections, 374 days in the hospital for skin and soft-tissue infection, 5.9 overdose deaths, 108 overdose-related ambulance calls, 78 emergency room visits, and 27 hospitalizations, while bringing 121 additional people into treatment.

Conclusions

We conclude that a SIF would be both extremely cost-effective and a significant public health and economic benefit to Baltimore City.

Naloxone Administration for Opioid Overdose Reversal in the Prehospital Setting: Implications for Pharmacists

BACKGROUND

Fatalities from opioid overdose have risen by 117% over the past 10 years. Increasing access to the opioid antagonist, naloxone can combat this trend and saves lives. This study investigates the various routes of naloxone administration for opioid reversal in the prehospital setting.

METHODS

PubMed, Ovid, and Google Scholar were searched for references that included the words naloxone and prehospital. Inclusion criteria were peer reviewed publications after 1995, English language, studies conducted in an outpatient setting, and intramuscular, intranasal, intravenous, or subcutaneous formulations; exclusion criteria were review articles or editorials.

RESULTS

8 articles met the inclusion criteria: intramuscular, intranasal, intravenous, and subcutaneous dosage forms of naloxone were analyzed to compare their time to administration, time to efficacy, financial impact, administrator safety, and administrator preference.

CONCLUSION

There is little consensus on the optimal route of naloxone administration in the prehospital setting. Little training is required for proper administration of the intramuscular auto-injector; however, the high price of this device is a barrier to access. Intranasal naloxone appears to be the optimal dosage form when considering cost, effectiveness, and administrator safety. Pharmacists must be aware of trends in naloxone use, dosage forms, and administration when caring for patients and their communities.

Failure to get into substance abuse treatment

Among substance abusers in the US, the discrepancy in the number who access substance abuse treatment and the number who need treatment is sizable. This results in a major public health problem of access to treatment. The purpose of this study was to examine characteristics of Persons Who Use Drugs (PWUDs) that either hinder or facilitate access to treatment. 2646 participants were administered the Risk Behavior Assessment (RBA) and the Barratt Impulsiveness Scale. The RBA included the dependent variable which was responses to the question "During the last year, have you ever tried, but been unable, to get into a drug treatment or detox program?" In multivariate analysis, factors associated with being unable to access treatment included: Previously been in drug treatment (OR=4.51), number of days taken amphetamines in the last 30days (OR=1.18), traded sex for drugs (OR=1.53), homeless (OR=1.73), Nonplanning subscale of the Barratt Impulsiveness Scale (OR=1.19), age at interview (OR=0.91), and sexual orientation, with bisexual men and women significantly more likely than heterosexuals to have tried but been unable to get into treatment. The answers to the question on "why were you unable to get into treatment" included: No room, waiting list; not enough money, did not qualify, got appointment but no follow through, still using drugs, and went to jail before program start. As expected, findings suggest that limiting organizational and financial obstacles to treatment may go a long way in increasing drug abuse treatment accessibility to individuals in need. Additionally, our study points to the importance of developing approaches for increasing personal planning skills/reducing Nonplanning impulsivity among PWUDs when they are in treatment as a key strategy to ensure access to additional substance abuse treatment in the future.

Hazardous Alcohol Use Associated with Increased Sexual Risk Behaviors Among People Who Inject Drugs

BACKGROUND

Alcohol is associated with a multitude of severe health consequences. While risk behaviors related to illicit drug use are commonly studied among people who inject drugs (PWID), the role of alcohol use has received substantially less attention in this population. We explored whether drug and sexual risk behaviors as well as experiences of violence were associated with hazardous alcohol use in a cohort of PWID.

METHODS

Analyses were conducted using observational data from a prospective cohort of community-recruited HIV-negative PWID in Vancouver, Canada. We used the U.S. National Institute on Alcohol Abuse and Alcoholism definition of hazardous alcohol use (i.e., >14 drinks/wk or >4 drinks on 1 occasion for men, and >7 drinks/wk or >3 drinks on 1 occasion for women). We used multivariable generalized estimating equations (GEE) to identify the factors associated with hazardous alcohol use.

RESULTS

Between 2006 and 2012, 1,114 HIV-negative individuals were recruited, and 186 (16.7%) reported hazardous alcohol use in the previous 6 months at baseline. In multivariable GEE analyses, having multiple sex partners (adjusted odds ratio [AOR] = 1.25), history of sexually transmitted infection (AOR = 1.50), experiencing violence (AOR = 1.36), and incarceration (AOR = 1.29) were each independently associated with hazardous alcohol use. Caucasian ethnicity (AOR = 0.56), ≥ daily heroin injection (AOR = 0.81), and engagement in addiction treatment (AOR = 0.84) were negatively associated with hazardous alcohol use (all p < 0.05).

CONCLUSIONS

A considerable proportion of PWID reported hazardous alcohol use, which was independently associated with reporting sexual, but not drug-related, HIV risk behaviors and experiencing recent violence. Findings suggest a need to integrate regular screening and evidence-based alcohol interventions into treatment efforts for PWID.

Training law enforcement to respond to opioid overdose with naloxone: Impact on knowledge, attitudes, and interactions with community members

BACKGROUND

Training law enforcement officers (LEOs) to administer naloxone to opioid overdose victims is increasingly part of comprehensive efforts to reduce opioid overdose deaths. Such efforts could yield positive interactions between LEOs and community members and might ultimately help lower overdose death rates.

METHODS

We evaluated a pilot LEO naloxone program by (1) assessing opioid overdose knowledge and attitudes (competency in responding, concerns about naloxone administration, and attitudes towards overdose victims) before and after a 30min training on overdose and naloxone administration, and (2) conducting qualitative interviews with LEOs who used naloxone to respond to overdose emergencies after the training.

RESULTS

Eighty-one LEOs provided pre- and post-training data. Nearly all (89%) had responded to an overdose while serving as an LEO. Statistically significant increases were observed in nearly all items measuring opioid overdose knowledge (p's=0.04 to <0.0001). Opioid overdose competencies (p<0.001) and concerns about naloxone administration (p<0.001) significantly improved after the training, while there was no change in attitudes towards overdose victims (p=0.90). LEOs administered naloxone 11 times; nine victims survived and three of the nine surviving victims made at least one visit to substance abuse treatment as a result of a LEO-provided referral. Qualitative data suggest that LEOs had generally positive experiences when they employed the skills from the training.

CONCLUSIONS

Training LEOs in naloxone administration can increase knowledge and confidence in managing opioid overdose emergencies. Perhaps most importantly, training LEOs to respond to opioid overdose emergencies may have positive effects for LEOs and overdose victims.

Non-fatal overdose as a risk factor for subsequent fatal overdose among people who inject drugs

OBJECTIVES

To examine the relationship between non-fatal overdose and risk of subsequent fatal overdose.

METHODS

We assessed risk factors for overdose death among two prospective cohorts of persons who inject drugs (PWID) in Vancouver, Canada. Extended Cox regression was used to examine if reports of non-fatal overdose were associated with the time to fatal overdose while adjusting for other behavioral, social and structural confounders.

RESULTS

Between May, 1996 and December, 2011, 2317 individuals were followed for a median of 60.8 months. In total, 134 fatal overdose deaths were identified for an incidence density of 8.94 (95% confidence interval [CI]: 7.55-10.59) deaths per 1000 person-years. During the study period there were 1795 reports of non-fatal overdose. In a multivariate model, recent non-fatal overdose was independently associated with the time to overdose mortality (adjusted hazard ratio [AHR]=1.95; 95% CI: 1.17-3.27). As well, there was a dose response effect of increasing cumulative reports of non-fatal overdose on subsequent fatal overdose.

CONCLUSION

Reports of recent non-fatal overdose were independently associated with subsequent overdose mortality in a dose-response relationship. These findings suggest that individuals reporting recent non-fatal overdose should be engaged with intensive overdose prevention interventions.