Using ambulance attendances to recruit people who have experienced non-fatal heroin overdose

A descriptive study of racial and ethnic differences of drug overdoses and naloxone administration in Pennsylvania

INTRODUCTION

Drug overdose is a significant public health problem, yet little is known about racial/ethnic differences in drug overdose rates and/or in responses to a drug overdose following naloxone administration. This paper examines differences in rates of survivorship, response, revival and administration of naloxone by race and ethnicity among those who experienced a drug overdose in Pennsylvania between January 1, 2018 and December 31, 2019. Spatio-temporal variations in drug overdose locations were examined to facilitate understanding of service development, planning, and delivery of effective treatment need.

METHODS

Ten thousand two hundred and ninety drug overdose incidents were analyzed from the Pennsylvania Overdose Information Network (ODIN). The ODIN is a centralized repository that contains information on drug overdoses victims including age, gender and race/ethnicity, naloxone administrations and survivorship, drug(s) suspected of causing the overdose, victim outcomes (e.g. hospitalizations and arrests) and average naloxone dosage per victim. Between group differences were tested using χ2 -tests of independence. Multivariate logistic regression was used to estimate the predicted probability of survivorship according to victim characteristics. All statistical analyses and mapping were performed using the R statistical programming environment.

RESULTS

About eighty-seven percent of drug overdose response victims were white, and seventy-one percent were between the ages of 20-39. White females were more likely to receive an overdose response compared to black or Hispanic females. A non-opioid was indicated more frequently in overdoses involving black victims compared to either whites or Latinos. Latinos and blacks were more likely to survive a drug overdose. However, following naloxone administration, no racial or ethnic differences in survivorship were noted. Differences in responsiveness to naloxone and transitions to care following the drug overdose event were also found. Finally, overdoses among Blacks and Latinos demonstrated a stronger spatial patterning across counties compared to whites.

CONCLUSIONS

This study found a significant, disparate impact of race/ethnicity on fatal drug overdoses when naloxone is not administered. Further, individuals who were administered naloxone and subsequently received medical care in a hospital experienced lower drug-related mortality, suggesting that first responders are critical intervention points for individuals in need of medical treatment following a drug overdose. However, while naloxone administration is a necessary first step in the recovery process, longitudinal pathways towards treatment are critical to stem the drug overdose crisis.

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.

EMS runs for suspected opioid overdose: implications for surveillance and prevention

BACKGROUND

Opioid (including prescription opiate) abuse and overdose rates in the United States have surged in the past decade. The dearth and limitations of opioid abuse and overdose surveillance systems impede the development of interventions to address this epidemic. Objective. We explored evidence to support the validity of emergency medical services (EMS) data on naloxone administration as a possible proxy for estimating incidence of opioid overdose.

METHODS

We reviewed data from Baltimore City Fire Department EMS patient records matched with dispatch records over a 13-month time period (2008-2009) based on 2008 Census data. We calculated incidence rates and patient demographic and temporal patterns of naloxone administration, and examined patient evaluation data associated with naloxone administration. Results were compared with the demographic distributions of the EMS patient and city populations and with prior study findings.

RESULTS

Of 116,910 EMS incidents during the study period for patients aged 15 years and older, EMS providers administered naloxone 1,297 times (1.1% of incidents), an average of 100 administrations per month. The overall incidence was 1.87 administrations per 1,000 residents per year. Findings indicated that naloxone administration peaked in the summer months (31% of administrations), on weekends (32%), and in the late afternoon (4:00-5:00 pm [8%]); and there was a trend toward peaking in the first week of the month. The incidence of suspected opioid overdose was highest among male patients, white patients, and those in the 45-54-year age group. Findings on temporal patterns were comparable with findings from prior studies. Demographic patterns of suspected opioid overdose were similar to medical examiner reports of demographic patterns of fatal drug- or alcohol-related overdoses in Baltimore in 2008-2009 (88% of which involved opioids). The findings on patient evaluation data suggest some inconsistencies with previously recommended clinical indications of opioid overdose.

CONCLUSIONS

While our findings suggest limitations of EMS naloxone administration data as a proxy indicator of opioid overdose, the results provide partial support for using these data for estimating opioid overdose incidence and suggest ways to improve such data. The study findings have implications for an EMS role in conducting real-time surveillance and treatment and prevention of opioid abuse and overdose.

Demographic, geographic, and temporal patterns of ambulance runs for suspected opiate overdose in Rhode Island, 1997-20021

We examine ambulance runs for suspected opiate overdose from 1997 to 2002 using a Rhode Island Department of Health database. Of the 8,763 ambulance runs for overdoses, 18.6% were for suspected opiate overdoses. Most cases were males under age 54. Suspected opiate overdoses were more likely to occur in a private residence, were more frequent on Fridays and Saturdays, and peaked in incidence around 9:00 p.m. The incidence rate of suspected opiate overdose by year was similar. The study results may help identify areas for preventive intervention and demonstrate the limitation of using naloxone as a marker of opiate overdose events.

Transient changes in behaviour lead to heroin overdose: results from a case-crossover study of non-fatal overdose

BACKGROUND AND AIMS

Heroin overdose is a serious consequence of heroin use and one of the leading causes of premature death and illness in Australia. Despite considerable research effort little is known about the effects of transient changes in heroin user behaviour and the links to overdose. This research is the first to use a suitable methodology to allow such ephemeral changes and their effects on non-fatal heroin overdose to be examined.

METHODS

A case-crossover design was used in which non-fatal heroin overdose survivors' recall of risk behaviours in the 12 hours prior to overdose (hazard period) was compared to their recall of risk behaviours in the 12 hours prior to a selected non-overdose heroin injection (control period).

RESULTS

A total of 155 participants were able to provide valid details of hazard and control periods. A dose-response relationship was observed between the self-reported amount of heroin used and likelihood of overdose (e.g. > AUD50, OR 12.97, 95% CI 2.54-66.31). The use of benzodiazepines (OR 28, 95% CI 3.81-205.79) or alcohol (OR 2.88, 95% CI 1.29-6.43), during the hazard period was related to overdose risk, but the effect of alcohol was attenuated by the effect of benzodiazepines. Shifting from private to public locations between control and hazard periods was also related to increased risk of overdose (OR 3.63, 95% CI 1.66-7.93).

CONCLUSIONS

We demonstrate the value of a new methodology to explore heroin overdose, as well as discussing its limitations and ways to overcome them in future. In terms of our findings, overdose prevention messages need to highlight the impact of these transient changes in behaviour and to emphasize the risks of using higher doses of heroin as well as continuing to emphasize the risks of combining heroin with other central nervous system (CNS) depressants. Safer environments for heroin use, such as injecting rooms, may also reduce the chances of overdose.

Intentional overdose among heroin overdose survivors

Previous studies have reported varying rates of intentional overdose among heroin overdose survivors. This article reports on the prevalence of intentional heroin overdose among a sample of overdose survivors in Melbourne, Australia. This is part of a larger study examining the risk factors associated with nonfatal overdose. The study involved interviews with 256 heroin overdose survivors successfully resuscitated by Melbourne Ambulance Service paramedics. A substantial minority (17%) of the sample indicated that they had ever had an intentional overdose, and 67% had one within the last 6 months (11% of the total sample). Of those who had ever intentionally overdosed, 21% did so at the overdose for which they were recruited into the study (4% of total sample). Self-reported reasons for intentional heroin overdose fell into two categories: precipitating events and emotional states prior to use. Intentional overdose appears to comprise a relatively low proportion of overall heroin overdoses. However, given the complexity of suicidal thought and behavior, it is possible that some heroin overdose survivors who report their overdose to be unintentional were in fact experiencing some degree of suicidal thinking at the time of the overdose. Future research could address the potentially ambiguous nature of some intentional heroin overdoses.