Utilizing a train-the-trainer model for multi-site naloxone distribution programs

Scaling up overdose education and naloxone distribution in Kentucky: adoption and reach achieved through a "hub with many spokes" model

BACKGROUND

Scaling up overdose education and naloxone distribution (OEND), an evidence-based practice for reducing opioid overdose mortality, in communities remains a challenge. Novel models and intentional implementation strategies are needed. Drawing upon the EPIS model's phases of Exploration, Preparation, Implementation, and Sustainment (Aarons et al. in Adm Policy Ment Health 38:4-23, 2011), this paper describes the development of the University of Kentucky's unique centralized "Naloxone Hub with Many Spokes" approach to implementing OEND as part of the HEALing Communities Study (HCS-KY).

METHODS

To scale up OEND in eight Kentucky counties, implementation strategies were utilized at two levels: a centralized university-based naloxone dispensing unit ("Naloxone Hub") and adopting organizations ("Many Spokes"). Implementation strategies varied across the EPIS phases, but heavily emphasized implementation facilitation. The Naloxone Hub provided technical assistance, overdose education resources, and no-cost naloxone to partner organizations. Implementation outcomes across the EPIS phases were measured using data from internal study management trackers and naloxone distribution data submitted by partner organizations.

RESULTS

Of 209 organizations identified as potential partners, 84.7% (n = 177) engaged in the Exploration/Preparation phase by participating in an initial meeting with an Implementation Facilitator about the HCS-KY OEND program. Adoption of the HCS-KY OEND program, defined as receipt of at least one shipment of naloxone, was achieved with 69.4% (n = 145) of all organizations contacted. During the Implementation phase, partner organizations distributed 40,822 units of naloxone, with partner organizations distributing a mean of 281.5 units of naloxone (SD = 806.2). The mean number of units distributed per county was 5102.8 (SD = 3653.3; range = 1057 - 11,053) and the mean county level distribution rate was 8396.5 units per 100,000 residents (SD = 8103.1; range = 1709.5-25,296.3). Of the partner organizations that adopted the HCS-KY OEND program, 87.6% (n = 127) attended a sustainability meeting with an Implementation Facilitator and agreed to transition to the state-funded naloxone program.

CONCLUSIONS

These data demonstrate the feasibility of this "Hub with Many Spokes" model for scaling up OEND in communities highly affected by the opioid epidemic. Trial registration ClinicalTrials.gov, NCT04111939. Registered 30 September 2019, https://clinicaltrials.gov/ct2/show/NCT04111939 .

Risks and overdose responses: Participant characteristics from the first seven years of a national take-home naloxone program

BACKGROUND

In 2014, the Norwegian government funded a large-scale take-home naloxone (THN) program to address high overdose mortality rates. The aims of this study are to describe characteristics among persons trained to receive THN, describe actions taken following THN use at an overdose event and to explore factors associated with naloxone use.

METHODS

This was a prospective cohort study of individuals who received THN from 2014 to 2021. Descriptive characteristics were collected at initial training. When returning for refill, participants reported on their previous naloxone use. In a multivariable logistic regression model exploring associations with naloxone use: gender, age, opioid use history, concomitant drug use, injecting, history of experienced or witnessed overdose were included.

RESULTS

In total, 3527 individuals were included in this study. There were 958 individuals who returned for refills 2303 times. Most participants were male (63.6%), with a history of opioid use (77.5%). Those who reported naloxone use were more likely to have a history of opioid use (aOR= 4.1; 95% CI=2.77,6.1), were younger (aOR=0.98; 95% CI=0.97,0.99) and had witnessed overdoses (aOR=3.3; 95% CI=1.98,5.34). Among current opioid users, the odds were higher for injectors (aOR=1.57; 95% CI=1.18,2.1). Naloxone use was reported 1282 times. Additional actions such as waking the person and calling the ambulance were frequently reported. Survival was reported in almost all cases (94%).

CONCLUSION

People who use drugs are a suitable target group for THN-programs, as they seem to be willing and capable to reverse overdoses effectively. Given their personal risk factors for overdosing, recipients will likely also benefit from overdose prevention education.

Who is using take-home naloxone? An examination of supersavers

Background

As the opioid overdose crisis persists and take-home naloxone (THN) programmes expand, it is important that the intervention is targeted towards those most likely to use it. We examined THN program participants to 1) describe those that return for refills, specifically those that reported multiple use (supersavers), and 2) to examine what rescuer characteristics were associated with higher rates of THN use.

Methods

This study included a cohort of consenting THN recipients from June 2014–June 2021 who completed initial and refill questionnaires from a widespread program in Norway. Age, gender, number of witnessed and experienced overdoses were assessed for associations with higher reported rates of THN use. ‘Supersavers’ reported 3 or more THN uses.

Results

A total of 1054 participants returned for a THN refill during the study period. Of these, 558 reported their last THN to have been used on an overdose. Supersavers (those that reported 3 or more THN uses) were younger, primarily reported current opioid use, and had witnessed higher rates of overdoses at the time of initial training when compared to non-supersavers (those that reported 0–2 THN uses).

Conclusions

THN programs should continue to emphasize and prioritize THN for people actively using drugs, particularly those who have witnessed overdoses previously.

The Overdose Response with Take Home Naloxone (ORTHN) project: Evaluation of health worker training, attitudes and perceptions

INTRODUCTION

Naloxone is a life-saving medication that reverses opioid overdose; naloxone can be provided on a 'take-home' basis so naloxone can be administered outside of the health-care setting. The Overdose Response and Take Home Naloxone (ORTHN) project established a model of care for take-home naloxone (THN) interventions across alcohol and other drug and harm reduction services in NSW, Australia. This paper evaluates the staff training and credentialing program, and examines staff attitudes and perspectives regarding the provision of THN interventions in these settings.

METHODS

Staff across seven services were trained through a 'train-the-trainer' credentialing model to deliver ORTHN, including naloxone supply. Staff were surveyed regarding their experience, attitudes and knowledge on THN prior to and after training, and after 6 months. At the 6 months follow up, staff were asked about the interventions they provided, barriers and enablers to uptake, and opinions regarding future rollout.

RESULTS

A total of 204 staff were trained and credentialed to provide the ORTHN intervention. Most (60%) were nurses, followed by needle syringe program workers and allied health/counsellors (32%). Linear and logistic regression analyses indicated that the training program was associated with significant improvements in staff knowledge and attitudes towards overdose and THN; however, only attitudinal improvements were maintained over time. There were high rates of staff satisfaction with the ORTHN intervention and training.

DISCUSSION/CONCLUSIONS

The ORTHN program is 'fit for purpose' for broad implementation in these settings. A number of potential barriers (e.g. time, medication and staffing costs) and enablers (e.g. peer engagement, regulatory framework for naloxone supply) in implementing THN interventions were identified.

Implementation and Outcomes of a Train-the-Trainer Program at Behavioral Health Treatment Centers as a Mechanism to Maintain Organizational Capacity to Address Tobacco Use Disorder

Despite prior successful implementation of Taking Texas Tobacco Free (TTTF), an evidence-based tobacco-free workplace program, in local mental health authorities (LMHAs), post-implementation employee attrition necessitated continuing education on tobacco-free policies and tobacco treatment practices. Here, we report on the outcomes of a train-the-trainer program which trained "champions" to deliver tobacco cessation education at their LMHAs. Three LMHAs participated in program implementation via 10 champions, iteratively trained and coached by TTTF. Measures administered evaluated four goals: (1) increase champions' self-efficacy in delivering trainings, (2) achieve program fidelity via TTTF staff evaluation of trainer effectiveness and knowledge increases among attending employees, (3) achieve stakeholder program acceptability, and (4) achieve program adoption via an increase in follow-up trainings. Champions' self-efficacy increased throughout TTTF training. TTTF staff ratings of champion-led trainings met the targeted range for trainer effectiveness; employees had a 28.71% knowledge increase over baseline post-training (p < 0.001). Employees rated champions' training delivery "very good" to "excellent", on average; both champions and employees were, on average, "satisfied" to "extremely satisfied" with the curriculum and training received. There was an increase over baseline in trainings delivered during follow-up, and trainings increased in length and topic coverage. Ultimately, the train-the-trainer program achieved the intended goals, although not all changes were statistically significant, likely at least partially attributable to small sample sizes. Overall, these results suggest that TTTF's train-the-trainer program was successful in its delivery and intention to build capacity for the provision of in-house tobacco education trainings to behavioral health employees/providers. However, further evaluation in additional settings, with more champions, et cetera, is necessary to validate these findings, ensure their replicability, link program implementation with reduced patient tobacco use rates, and assess long-term sustainability.

Impact of a Multilevel Quality Improvement Intervention Using National Partnerships on Human Papillomavirus Vaccination Rates

OBJECTIVE

To evaluate the effectiveness of a multilevel intervention using national partnerships on human papillomavirus (HPV) vaccination rates.

METHODS

The American Cancer Society's Vaccinate Adolescents against Cancer program is a multilevel intervention focusing on systems and providers. The 2017 cohort introduced national partnerships to deliver intervention elements and Maintenance of Certification and continuing medical education credits for physicians. Eleven federally qualified health center (FQHC) systems completed interventions in 2017. Interventions included provider training and ≥1 other evidence-based systems improvement. We compared adolescent vaccination rates in the preintervention period (2016) and intervention period (2017) among adolescents who turned 13 during the calendar year. Intervention effectiveness was assessed using repeated measures paired t tests and Cohen's d effect size for vaccination rate change.

RESULTS

All FQHC systems implemented provider training plus an average of 2.3 additional systems improvements. Series initiation increased by an average of 23.6 percentage points (47.2%-70.8%). HPV completion rates increased by an average of 22.7 percentage points (24.6%-46.3%). Meningococcal and Tdap vaccination rates increased by 23.3 and 25.9 percentage points respectively (47.9%-71.2% and 48.8%-74.7%). All changes were statistically significant (all P < .05) and indicated large effect sizes (Cohen's d³ 1.15). Among clinicians completing postintervention surveys, 90% reported making changes to their health care system or direct patient care based on what they had learned.

CONCLUSIONS

Multilevel interventions focusing on provider training and systems changes can substantially improve on-time adolescent vaccination coverage and can be successfully performed using national partnerships and a train-the-trainer model.

A sustainable model for raising colposcopy expertise in low-to-middle-income countries

OBJECTIVE

The objective of the study was to assess the effectiveness of training low-to-middle-income countries' local healthcare providers using the Train-the-trainers model in basic colposcopy for cervical cancer prevention.

METHOD

This project was designed based on a philosophy known as Train-the-trainers which train proficient colposcopists and a cadre of local trainers who can continue to train and maintain their expertise in a self-sustaining system. The Train-the-trainers workshop is a 1-day program that focuses on three domains; knowledge, communication, and practical skills. Trainer candidates were given pre-course reading assignments and presentation decks. The expert trainers provided feedback on their presentations and tips on communication skills. The practical aspects of the training are supported by proficiency at the Loop Electro-excision procedure simulator and their responses to frequently asked questions.

RESULTS

Sixteen physicians from Vietnam attended the Colposcopy Workshop in 2018 and are used as controls. Eleven attended a workshop conducted by trainer candidates who went through the training program outlined above in 2019. A Wilcoxon Signed-ranks test indicated that differences between pre- and post-quizzes' scores were statistically significant in both the 2018 (Z=4.21, P=0.003, r=1.26) and 2019 cohorts (Z=3.558, P<0.001, r=0.89) while Mann-Whitney U test did not detect the difference between the 2018 and 2019 cohorts, U=70.0, P=0.359, r=0.176. The subjective feedback scores from Year 2019 were similar to scores to Year 2018.

CONCLUSION

Our preliminary data did not highlight any differences between lectures delivered by expert trainers and lectures delivered by trainer candidates trained in the program. Train-the- trainers might be a more sustainable model for organically raising expertise to effectively provide cervical cancer screening and prevention in low-to-middle-income countries.

Endogenous opiates and behavior: 2017

This paper is the fortieth consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2017 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

One opioid user saving another: the first study of an opioid overdose-reversal and naloxone distribution program addressing hard-to-reach drug scenes in Denmark

BACKGROUND

Overdose education and naloxone distribution programs decrease opioid overdose deaths. However, no studies of such programs have been carried out in Denmark. The aim of this study was to evaluate the feasibility and the effect of a broader "training-the-trainers" model in low-threshold settings after participation in the "Danish Save Lives" [SL] program.

METHODS

Between May 2013 and November 2015, 552 participants from four municipalities took part in the SL program. The program is built on the train-the-trainers model where a central trainer trains others (trainers), who in turn train others (helpers). Participants were 30 police officers (5%), 188 people who use opioids (34%), 23 significant others (4%), and 217 social workers (39%). Ninety-four participants could not be classified (17%). At follow-up, participants were interviewed to determine the number and outcomes of opioid overdoses. Logistic regression was used to assess predictors of treating an overdose.

RESULTS

In all, 37 (7%) participants had intervened in 45 opioid overdose events (two trainers and 35 helpers). Detailed descriptions of the overdose event were available from 32 follow-up interviews (70%). In 16 cases, the person who intervened was already present at the site when the overdose occurred, and in 17 cases, the overdose victim recovered without complications. All overdose victims survived except one. People who used opioids were more likely to have treated an overdose than other participants (adjusted odds ratio [AOR] = 8.50, p = 0.001), and the likelihood of treating and overdose declined over time AOR = 0.37 (0.13, 0.93), p = 0.034).

CONCLUSIONS

Prevention programs that target people who use opioids are more likely to be effective than programs that target professionals, especially in high-risk settings that can be hard for paramedics to reach. A future goal is to explore how prevention programs can be adapted to new user groups.

TRIAL REGISTRATION

The Danish Data Protection Agency, 2015-57-0002, Aarhus University, 2016-051-000001, 184, retrospectively registered.

Lessons learned from ramping up a Canadian Take Home Naloxone programme during a public health emergency: a mixed-methods study

OBJECTIVES

This study describes the 2016 expansion of the British Columbia Take Home Naloxone (BCTHN) programme quantitatively and explores the challenges, facilitators and successes during the ramp up from the perspectives of programme stakeholders.

DESIGN

Mixed-methods study.

SETTING

The BCTHN programme was implemented in 2012 to reduce opioid overdose deaths by providing naloxone kits and overdose recognition and response training in BC, Canada. An increase in the number of overdose deaths in 2016 in BC led to the declaration of a public health emergency and a rapid ramp up of naloxone kit production and distribution. BCTHN distributes naloxone to the five regional health authorities of BC.

PARTICIPANTS

Focus groups and key informant interviews were conducted with 18 stakeholders, including BC Centre for Disease Control staff, urban and rural site coordinators, and harm reduction coordinators from the five regional health authorities across BC.

PRIMARY AND SECONDARY OUTCOME MEASURES

Take Home Naloxone (THN) programme activity, qualitative themes and lessons learnt were identified.

RESULTS

In 2016, BCTHN responded to a 20-fold increase in demand of naloxone kits and added over 300 distribution sites. Weekly numbers of overdose events and overdose deaths were correlated with increases in THN kits ordered the following week, during 2013-2017. Challenges elicited include forecasting demand, operational logistics, financial, manpower and policy constraints. Facilitators included outsourcing kit production, implementing standing orders and policy changes in naloxone scheduling, which allowed for easier hiring of staff, reduced paperwork and expanded client access.

CONCLUSION

For THN programmes preparing for potential increases in naloxone demand, we recommend creating an online database, implementing standing orders and developing online training resources for standardised knowledge translation to site staff and clients.

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

BACKGROUND

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

Naloxone distribution and possession following a large-scale naloxone programme

AIMS

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

DESIGN

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

SETTING

Seven Norwegian cities.

PARTICIPANTS

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

MEASUREMENTS

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

FINDINGS

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

CONCLUSIONS

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

Ambulance-attended opioid overdoses: An examination into overdose locations and the role of a safe injection facility

Background: Although the United States and numerous other countries are amidst an opioid overdose crisis, access to safe injection facilities remains limited. Methods: We used prospective data from ambulance journals in Oslo, Norway, to describe the patterns, severity, and outcomes of opioid overdoses and compared these characteristics among various overdose locations. We also examined what role a safe injection facility may have had on these overdoses. Results: Based on 48,825 ambulance calls, 1054 were for opioid overdoses from 465 individuals during 2014 and 2015. The rate of calls for overdoses was 1 out of 48 of the total ambulance calls. Males made up the majority of the sample (n = 368, 79%), and the median age was 35 (range: 18-96). Overdoses occurred in public locations (n = 530, 50.3%), the safe injection facility (n = 353, 33.5%), in private homes (n = 83, 7.9%), and other locations (n = 88, 8.3%). Patients from the safe injection facility and private homes had similarly severe initial clinical symptoms (Glasgow Coma Scale median =3 and respiratory frequency median =4 breaths per minute) when compared with other locations, yet the majority from the safe injection facility did not require further ambulance transport to the hospital (n = 302, 85.6%). Those overdosed in public locations (odds ratio [OR] = 1.66, 95% confidence interval [CI] = 1.17-2.35), and when the safe injection facility was closed (OR =1.4, 95% CI =1.04-1.89), were more likely to receive transport for further treatment. Conclusions: Our findings suggest that the opening hours at the safe injection facility and the overdose location may impact the likelihood of ambulance transport for further treatment.

Towards evidence-based palliative care in nursing homes in Sweden: a qualitative study informed by the organizational readiness to change theory

BACKGROUND

Sweden has a policy of supporting older people to live a normal life at home for as long as possible. Therefore, it is often the oldest, most frail people who move into nursing homes. Nursing home staff are expected to meet the existential needs of the residents, yet conversations about death and dying tend to cause emotional strain. This study explores organizational readiness to implement palliative care based on evidence-based guidelines in nursing homes in Sweden. The aim was to identify barriers and facilitators to implementing evidence-based palliative care in nursing homes.

METHODS

Interviews were carried out with 20 managers from 20 nursing homes in two municipalities who had participated along with staff members in seminars aimed at conveying knowledge and skills of relevance for providing evidence-based palliative care. Two managers responsible for all elderly care in each municipality were also interviewed. The questions were informed by the theory of Organizational Readiness for Change (ORC). ORC was also used as a framework to analyze the data by means of categorizing barriers and facilitators for implementing evidence-based palliative care.

RESULTS

Analysis of the data yielded ten factors (i.e., sub-categories) acting as facilitators and/or barriers. Four factors constituted barriers: the staff's beliefs in their capabilities to face dying residents, their attitudes to changes at work as well as the resources and time required. Five factors functioned as either facilitators or barriers because there was considerable variation with regard to the staff's competence and confidence, motivation, and attitudes to work in general, as well as the managers' plans and decisional latitude concerning efforts to develop evidence-based palliative care. Leadership was a facilitator to implementing evidence-based palliative care.

CONCLUSIONS

There is a limited organizational readiness to develop evidence-based palliative care as a result of variation in the nursing home staff's change efficacy and change commitment as well as restrictions in many contextual conditions. There are considerable individual- and organizational-level challenges to achieving evidence-based palliative care in this setting. The educational intervention represents one of many steps towards developing a culture conducive to evidence-based nursing home palliative care.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

Rapid widespread distribution of intranasal naloxone for overdose prevention

BACKGROUND

Take home naloxone programs have been successful internationally in training bystanders to reverse an opioid overdose with naloxone, an opioid antagonist. A multi-site naloxone distribution program began in Norway in 2014 as part of a national overdose prevention strategy. The aim of this study was to a) describe the program, and b) present findings from the government-supported intervention.

METHODS

From July 2014 to December 2015, staff from multiple low-threshold facilities trained clients on how to use intranasal naloxone. Distribution occurred without an individual prescription or physician present. Questionnaires from initial and refill trainings were obtained, and distribution rates were monitored.

RESULTS

There were 2056 naloxone sprays distributed from one of the 20 participating facilities, with 277 reports of successful reversals. Participants exhibited known risks for overdosing, with injecting (p=0.02, OR=2.4, 95% CI=1.14, 5.00) and concomitant benzodiazepine use (p=0.01, OR=2.6, 95% CI=1.31, 5.23) being significant predictors for having had high rates of previous overdoses. Suggested target coverage for large-scale programs was met, with an annual naloxone distribution rate of 144 per 100,000 population, as well as 12 times the cities mean annual number of opioid-related deaths.

CONCLUSION

A government-supported multisite naloxone initiative appears to achieve rapid, high volume distribution of naloxone to an at-risk population.

Effects of a health promotion program on medication adherence to antiplatelet therapy among ischemic stroke patients in Hainan Province, China

Survivors of ischemic stroke are still at a significant risk for recurrence. Antiplatelet agents are the treatment of first choice for long-term secondary prevention of vascular events. This study aims to assess a health promotion program on medication adherence to antiplatelet therapy among ischemic stroke patients in Hainan province, China. In five hospitals from the intervention group, four highly experienced physicians trained 62 neurologists, who in turn trained 613 stroke patients to improve their awareness and adherence to antiplatelet therapy. Physicians and patients of the control group received usual stroke management programs. After one-year follow-up, the proportion of patients who took the antiplatelet therapy increased significantly in the intervention group, reaching 73.2%, with a pre-post difference between two arms of 22.9% ( P < 0.01). There was also a significant net increase in the proportion of patients with awareness of antiplatelet therapy (24.4%, P < 0.01). Multivariate analysis illustrated health promotion program, higher education, annual household income, insurance, and medical status affected antiplatelet drug use in stroke patients. In conclusion, the health promotion program, based on a train-the-trainer approach, showed positive effects on awareness of and adherence to antiplatelet therapy, which has the potential to be scaled up to other resource-limited areas.