Heroin and pharmaceutical opioid overdose events: Emergency medical response characteristics

Developing medical simulations for opioid overdose response training: A qualitative analysis of narratives from responders to overdoses

Medical simulation offers a controlled environment for studying challenging clinical care situations that are difficult to observe directly. Overdose education and naloxone distribution (OEND) programs aim to train potential rescuers in responding to opioid overdoses, but assessing rescuer performance in real-life situations before emergency medical services arrive is exceedingly complex. There is an opportunity to incorporate individuals with firsthand experience in treating out-of-hospital overdoses into the development of simulation scenarios. Realistic overdose simulations could provide OEND programs with valuable tools to effectively teach hands-on skills and support context-sensitive training regimens. In this research, semi-structured interviews were conducted with 17 individuals experienced in responding to opioid overdoses including emergency department physicians, first responders, OEND program instructors, and peer recovery specialists. Two coders conducted qualitative content analysis using open and axial thematic coding to identify nuances associated with illicit and prescription opioid overdoses. The results are presented as narrative findings complemented by summaries of the frequency of themes across the interviews. Over 20 hours of audio recording were transcribed verbatim and then coded. During the open and axial thematic coding process several primary themes, along with subthemes, were identified, highlighting the distinctions between illicit and prescription opioid overdoses. Distinct contextual details, such as locations, clinical presentations, the environment surrounding the patient, and bystanders' behavior, were used to create four example simulations of out-of-hospital overdoses. The narrative findings in this qualitative study offer context-sensitive information for developing out-of-hospital overdose scenarios applicable to simulation training. These insights can serve as a valuable resource, aiding instructors and researchers in systematically creating evidence-based scenarios for both training and research purposes.

The changing epidemiology of opioid overdose in Baltimore, Maryland, 2012-2017: insights from emergency medical services

INTRODUCTION

An estimated 100,306 people died from an overdose from May 2020 to April 2021. Emergency Medical Services (EMS) are often the first responder to opioid overdose, and EMS encounter records can provide granular epidemiologic data on opioid overdose. This study describes the demographic, temporal, and geographic epidemiology of suspected opioid overdose in Baltimore City using data from Baltimore City Fire Department EMS encounters with the administration of the opioid antagonist naloxone.

METHOD

The present analyses used patient encounter data from 2012 to 2017 from the Baltimore City Fire Department, the city's primary provider of EMS services. The analytic sample included patient encounters within the city that involved naloxone administration to patients 15 years of age or older (n = 20,592). Negative binomial regression was used to calculate the incidence rates based on demographic characteristics, year, and census tract. Choropleth maps were used to show the geographic distribution of overdose incidence across census tracts in 2013, 2015, and 2017.

RESULTS

From 2012 to 2017, the annual number of EMS encounters with naloxone administrations approximately doubled every 2 years, and the temporal pattern of naloxone administration was similar to the pattern of fatal opioid-related overdoses. For most census tracts, incidence rates significantly increased over time. Population-based incidence of naloxone administration varied significantly by socio-demographic characteristics. Males, non-whites, and those 25-69 years of age had the highest incidence rates.

CONCLUSION

The incidence of naloxone administration increased dramatically over the study period. Despite significant cross-sectional variation in incidence across demographically and geographically defined groups, there were significant proportional increases in incidence rates, consistent with fatal overdose rates over the period. This study demonstrated the value of EMS data for understanding the local epidemiology of opioid-related overdose. Key MessagesPatterns of EMS encounters with naloxone administration appear to be an excellent proxy for patterns of opioid-related overdoses based on the consistency of fatal overdose rates over time.EMS plays a central role in preventing fatal opioid-related overdoses through the administration of naloxone, provision of other emergency services, and transportation to medical facilities.EMS encounters with naloxone administration could also be used to evaluate the impact of overdose prevention interventions and public health services.

How do people who use drugs receiving Opioid Medication Therapy perceive their treatment ? A multicentre study

Background

The resurgence of heroin use and the misuse of pharmaceutical opioids are some of the reasons for a worldwide increase in opioid dependence. Opioid Medication Therapies (OMT) have amply demonstrated their efficacy. From a medical point of view, the main objectives of OMT concern medical and social outcomes, centred on risk reduction and the cessation of opioid use. But patient points of view can differ and few studies have explored opioid-dependent patient viewpoints on their OMT. This variable seems important to consider in a patient-centred approach. The aim of our study was to explore points of view of people who use drugs (PWUD) treated with OMT, in a large multicentre sample.

Method

A cross-sectional multicentre study explored the points of view of PWUD with Opioid Use Disorder following OMT. Data regarding the patients’ points of view were collected using a self-administered questionnaire developed by the scientific committee of the study. A descriptive analysis and an exploratory factor analysis were performed to explore the structure of items exploring patient viewpoints.

Results

263 opioid dependent PWUD were included, a majority were men consuming heroin prior to being prescribed OMT. 68% were on methadone, 32% were on buprenorphine. Most PWUD identified a positive impact on their lives, with 92.8% agreeing or strongly agreeing that OMT had changed a lot of things in their lives. The exploratory factor analysis identified three factors: (F1) items related to points of views concerning the objectives and efficacy of OMT; (F2) items related to the legitimacy of OMT as a treatment compared to a drug, (F3) items related to experiences and relationships with OMT.

Conclusion

Patient viewpoints on efficacy were correlated with the pharmacological benefits of OMT and with the associated psychosocial measures. The implications of OMT in relationships, such as the feeling of being judged, concerned a majority. Points of view were ambivalent concerning the role of OMT as a treatment or as a drug. Involving patient points of view in therapeutic strategies decisions could help enhance positive views among PWUD on OMT and help PWUD towards their recovery.

Trial registration: OPAL study was registered: (NCT01847729).

Emergency Medical Services and Syndromic Surveillance: A Comparison With Traditional Surveillance and Effects on Timeliness

OBJECTIVE

Traditional public health surveillance of nonfatal opioid overdose relies on emergency department (ED) billing data, which can be delayed substantially. We compared the timeliness of 2 new data sources for rapid drug overdose surveillance-emergency medical services (EMS) and syndromic surveillance-with ED billing data.

METHODS

We used data on nonfatal opioid overdoses in Kentucky captured in EMS, syndromic surveillance, and ED billing systems during 2018-2019. We evaluated the time-series relationships between EMS and ED billing data and syndromic surveillance and ED billing data by calculating cross-correlation functions, controlling for influences of autocorrelations. A case example demonstrates the usefulness of EMS and syndromic surveillance data to monitor rapid changes in opioid overdose encounters in Kentucky during the COVID-19 epidemic.

RESULTS

EMS and syndromic surveillance data showed moderate-to-strong correlation with ED billing data on a lag of 0 (r = 0.694; 95% CI, 0.579-0.782; t = 9.73; df = 101; P < .001; and r = 0.656; 95% CI, 0.530-0.754; t = 8.73; df = 101; P < .001; respectively) at the week-aggregated level. After the COVID-19 emergency declaration, EMS and syndromic surveillance time series had steep increases in April and May 2020, followed by declines from June through September 2020. The ED billing data were available for analysis 3 months after the end of a calendar quarter but closely followed the trends identified by the EMS and syndromic surveillance data.

CONCLUSION

Data from EMS and syndromic surveillance systems can be reliably used to monitor nonfatal opioid overdose trends in Kentucky in near-real time to inform timely public health response.

Predictors of having naloxone in urban and rural Oregon findings from NHBS and the OR-HOPE study

PURPOSE

Naloxone is an opioid antagonist that can be effectively administered by bystanders to prevent overdose. We determined the proportion of people who had naloxone and identified predictors of naloxone ownership among two samples of people who inject drugs (PWID) who use opioids in Portland and rural Western Oregon.

BASIC PROCEDURES

We used data from participants in Portland's National HIV Behavioral Surveillance (NHBS, N = 477) and the Oregon HIV/Hepatitis and Opioid Prevention and Engagement Study (OR-HOPE, N = 133). For each sample, we determined the proportion of participants who had naloxone and estimated unadjusted and adjusted relative risk of having naloxone associated with participant characteristics.

MAIN FINDINGS

Sixty one percent of NHBS and 30 % of OR-HOPE participants had naloxone. In adjusted analysis, having naloxone was associated with female gender, injecting goofballs (compared to heroin alone), housing stability, and overdose training in the urban NHBS sample, and having naloxone was associated with drug of choice, frequency of injection, and race in the rural OR-HOPE sample. In both samples, having naloxone was crudely associated with SSP use, but this was attenuated after adjustment.

PRINCIPAL CONCLUSIONS

Naloxone ownership was insufficient and highly variable among two samples of PWID who use opioids in Oregon. People who use methamphetamine, males, and people experiencing homelessness may be at increased risk for not having naloxone and SSP may play a key role in improving access.

Opioid-related incident severity and emergency medical service naloxone administration by sex in Massachusetts, 2013-2019

BACKGROUND

A Cross-sectional study of all emergency ambulance runs reported by licensed Emergency Medical Services (EMS) providers between 2013 and 2019 was undertaken to determine if the sex of a patient experiencing opioid-related symptoms had an impact on their odds of receiving naloxone from EMS. Methods: All runs within Massachusetts for individuals 11 years and older with a reported sex between 2013 and 2019 (n = 5,533,704 runs) were included. Covariates modeled were patient age, year of the incident, and county of the incident. Runs were separated into those that were opioid-related versus not; opioid-related runs were further subdivided into five severity categories including dead on arrival, acute opioid overdose, opioid intoxicated, opioid withdrawal, and other opioid-related incident. Results: Among opioid-related runs, women had 24% lower odds (95% CI 0.68-0.86) of appearing in the dead on arrival category and 20% lower odds (95% CI 0.78-0.82) of appearing in the acute opioid overdose category than men. Among acute opioid overdoses, runs where patient symptoms met Massachusetts EMS guidelines for naloxone administration, women had 18% lower odds (95% CI 0.76-0.89) of receiving naloxone than men. Conclusions: Sex-related differences persist in the odds of naloxone administration by EMS providers when controlling for symptom presentation.

Rural Emergency Medical Service Providers Perceptions on the Causes of and Solutions to the Opioid Crisis: A Qualitative Assessment

Introduction:

The continuing opioid crisis poses unique challenges to remote and often under-resourced rural communities. Emergency medical service (EMS) providers serve a critical role in responding to opioid overdose for individuals living in rural or remote areas who experience opioid overdoses. They are often first at the scene of an overdose and are sometimes the only health care provider in contact with an overdose patient who either did not survive or refused additional care. As such, EMS providers have valuable perspectives to share on the causes and consequences of the opioid crisis in rural communities.

Methods:

EMS providers attending a statewide EMS conference serving those from greater Minnesota and surrounding states were invited to take a 2-question survey asking them to reflect upon what they believed to be the causes of the opioid crisis and what they saw as the solutions to the opioid crisis. Results were coded and categorized using a Consensual Qualitative Research approach.

Results:

EMS providers’ perceptions on causes of the opioid crisis were categorized into 5 main domains: overprescribing, ease of access, socioeconomic vulnerability, mental health concerns, and lack of resources and education. Responses focused on solutions to address the opioid crisis were categorized into 5 main domains: need for increased education, enhanced opioid oversight, increased access to treatment programs, alternative therapies for pain management, and addressing socioeconomic vulnerabilities.

Conclusion:

Along with the recognition that the opioid crisis was at least partially caused by overprescribing, rural EMS providers who participated in this study recognized the critical role of social determinants of health in perpetuating opioid-related harm. Participants in this study reported that education and increased access to treatment facilities and appropriate pain management, along with recognition of the role of social determinants of health in opioid dependency, were necessary steps to address the opioid crisis.

Opioid-Associated Out-of-Hospital Cardiac Arrest: Distinctive Clinical Features and Implications for Health Care and Public Responses: A Scientific Statement From the American Heart Association

Opioid overdose is the leading cause of death for Americans 25 to 64 years of age, and opioid use disorder affects >2 million Americans. The epidemiology of opioid-associated out-of-hospital cardiac arrest in the United States is changing rapidly, with exponential increases in death resulting from synthetic opioids and linear increases in heroin deaths more than offsetting modest reductions in deaths from prescription opioids. The pathophysiology of polysubstance toxidromes involving opioids, asphyxial death, and prolonged hypoxemia leading to global ischemia (cardiac arrest) differs from that of sudden cardiac arrest. People who use opioids may also develop bacteremia, central nervous system vasculitis and leukoencephalopathy, torsades de pointes, pulmonary vasculopathy, and pulmonary edema. Emergency management of opioid poisoning requires recognition by the lay public or emergency dispatchers, prompt emergency response, and effective ventilation coupled to compressions in the setting of opioid-associated out-of-hospital cardiac arrest. Effective ventilation is challenging to teach, whereas naloxone, an opioid antagonist, can be administered by emergency medical personnel, trained laypeople, and the general public with dispatcher instruction to prevent cardiac arrest. Opioid education and naloxone distributions programs have been developed to teach people who are likely to encounter a person with opioid poisoning how to administer naloxone, deliver high-quality compressions, and perform rescue breathing. Current American Heart Association recommendations call for laypeople and others who cannot reliably establish the presence of a pulse to initiate cardiopulmonary resuscitation in any individual who is unconscious and not breathing normally; if opioid overdose is suspected, naloxone should also be administered. Secondary prevention, including counseling, opioid overdose education with take-home naloxone, and medication for opioid use disorder, is important to prevent recurrent opioid overdose.

Sex Differences in Substance Use and Misuse: A Toxicology Investigators' Consortium (ToxIC) Registry Analysis

Background

Variations between male and female populations are previously reported in classes of harmfully used/misused drugs, severity of substance use disorder and risk of relapse. The aim of this study was to provide a review of bedside medical toxicologist managed, sex-specific poisonings in adults that present with harmful drug use/misuse.

Methods

ToxIC Registry cases ≥19 and ≤65 years old, with harmful drug use or misuse during the timeframe June 2010–December 2016, were studied. Demographics, primary agents of toxic exposure, administration route and complications were analyzed. Descriptive methods were used in the analysis.

Results

The database included 51,440 cases. Of these, 3426 cases were analyzed in which the primary reason for the encounter was harmful substance use/misuse. Females were found to harmfully use/misuse pharmaceutical drugs (N=806, 65.6%) more than nonpharmaceutical drugs (N=423, 34.4%). Males more frequently used nonpharmaceutical drugs (N=1189, 54.1%) than pharmaceutical drugs (1008, 45.9%). Analgesics were used by females (N= 215, 18.2%) and males (N=137, 6.6%). Sedative hypnotics were used by females (N=165, 14%) and males (N=160, 7.8%). Psychoactive agents were used by males (N=325, 15.8%) and females (N=67, 5.7%). Sympathomimetics were used by males (N=381, 18.5%) and females (N=151, 12.8%). The majority of both male and female participants, 1712 (57.9%), utilized an oral route of administration. However, 312 (16.5%) of males utilized inhalation vs 73 (6.8%) of females inhaled their substance.

Conclusion

There were sex-specific differences among patients evaluated for harmful substance use/misuse by toxicologists. Considering these differences in regards to management and preventive approaches may be indicated.

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).

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

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

[Interest of take-home naloxone for opioid overdose]

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

Opioid Abuse as Maladaptive Coping to Life Stressors in U.S. Adults

The Threat Appraisal and Coping Theory suggests that when individuals face life stressors, especially if they have poor self-esteem, they may rely on maladaptive coping behaviors that ease distress but worsen their condition over time. The present study compared five life stressors (health, money, work, family, romance) for their association with opioid use, then examined poor self-esteem as a mediator of these associations. Study participants included 1,047 U.S. adults gathered in a quota sample by SurveyMonkey (54.3% women; 53.3% 45+ years of age; 76.7% White; 60.2% with US$50,000 or higher income; 11.1% using opioids). Participants completed online surveys to report demographics, five life stressors, self-esteem, and indications of opioid use as measured with the PROMIS Questionnaire. Pearson correlation found poor self-esteem associated with high opioid use; multiple regression found health, family, and romance stressors associated with high opioid use ( R2 = .089); and multiple regression found health, money, family, and romance stressors associated with poor self-esteem ( R2 = .283). Then, bootstrapping mediational analyses examined the sequence of HIGH LIFE STRESSORS → POOR SELF-ESTEEM → HIGH OPIOID USE, finding that poor self-esteem was a significant mediator between each life stressor (health, money, family, romance) and increased risk for opioid use. The present sample included mostly individuals with a White ethnic identity and high incomes, so future research should examine these patterns with more diverse samples. In addition, the amount of opioids consumed, present motivations for use, the sequence of events leading to present use, exposure to substance-abuse treatment, and where individuals presently are on the use-recovery process could moderate associations found between life stressors and opioid use.

Opioid recovery initiation: Pilot test of a peer outreach and modified Recovery Management Checkup intervention for out-of-treatment opioid users

The recent surge in opioid-related overdoses and related fatalities underscores the need for assertive mechanisms for linking individuals with opioid use disorders (OUD) to medication-assisted treatment (MAT). This pilot study investigated the feasibility of an intervention that used peer outreach workers to identify out-of-treatment individuals with OUD combined with a modified version of the Recovery Management Checkup to link individuals to methadone treatment. The study was conducted in high-risk communities in Chicago over 8weeks; peer outreach workers identified 88 active opioid/heroin users; 72 were screened as eligible, and 70 showed to the study intake/initial linkage meeting. Most participants were male (73%) and African American (94%), with an average age of 52.0 (sd=7.6). Nearly all (67/70, 96%) were admitted to methadone treatment; median time from initial linkage meeting to treatment admission was 2.6days. Most were still in treatment at 30 and 60days post-intake (69% and 70%, respectively). A high-risk sub-group was identified that had ever received naloxone for an opioid overdose; they had one third of the odds of being in treatment at 30days post-intake compared with others. The intervention model holds promise as an assertive method for identifying and engaging individuals with OUD into treatment.