1
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Smart R, Powell D, Pacula RL, Peet E, Abouk R, Davis CS. Investigating the complexity of naloxone distribution: Which policies matter for pharmacies and potential recipients. JOURNAL OF HEALTH ECONOMICS 2024; 97:102917. [PMID: 39043099 DOI: 10.1016/j.jhealeco.2024.102917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 04/13/2024] [Accepted: 07/05/2024] [Indexed: 07/25/2024]
Abstract
Despite efforts to expand naloxone access, opioid-related overdoses remain a significant contributor to mortality. We study state efforts to expand naloxone distribution through pharmacies by reducing the non-monetary costs to prescribers, dispensers, and/or potential recipients of naloxone. We find that laws that only address liability costs have small and insignificant effects on the volume of naloxone dispensed through pharmacies. In contrast, we estimate large effects of laws removing the need for patients to obtain prescriptions from traditional prescribers (e.g., primary care physicians): laws authorizing non-patient-specific prescription distribution and laws granting pharmacists prescriptive authority. We test whether areas designated as primary care shortage areas-where it would be costlier to obtain a prescription-were disproportionately impacted. Shortage areas experienced sharper growth in pharmacy naloxone dispensing in states adopting prescriptive authority policies. These gains were primarily due to those facing low out-of-pocket costs, suggesting that price barriers also must be addressed to increase naloxone purchases.
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Affiliation(s)
| | | | | | | | - Rahi Abouk
- William Paterson University, United States
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2
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Calcaterra SL, Martin M, Bottner R, Englander H, Weinstein Z, Weimer MB, Lambert E, Herzig SJ. Management of opioid use disorder and associated conditions among hospitalized adults: A Consensus Statement from the Society of Hospital Medicine. J Hosp Med 2022; 17:744-756. [PMID: 35880813 PMCID: PMC9474708 DOI: 10.1002/jhm.12893] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Revised: 05/25/2022] [Accepted: 05/29/2022] [Indexed: 01/14/2023]
Abstract
Hospital-based clinicians frequently care for patients with opioid withdrawal or opioid use disorder (OUD) and are well-positioned to identify and initiate treatment for these patients. With rising numbers of hospitalizations related to opioid use and opioid-related overdose, the Society of Hospital Medicine convened a working group to develop a Consensus Statement on the management of OUD and associated conditions among hospitalized adults. The guidance statement is intended for clinicians practicing medicine in the inpatient setting (e.g., hospitalists, primary care physicians, family physicians, advanced practice nurses, and physician assistants) and is intended to apply to hospitalized adults at risk for, or diagnosed with, OUD. To develop the Consensus Statement, the working group conducted a systematic review of relevant guidelines and composed a draft statement based on extracted recommendations. Next, the working group obtained feedback on the draft statement from external experts in addiction medicine, SHM members, professional societies, harm reduction organizations and advocacy groups, and peer reviewers. The iterative development process resulted in a final Consensus Statement consisting of 18 recommendations covering the following topics: (1) identification and treatment of OUD and opioid withdrawal, (2) perioperative and acute pain management in patients with OUD, and (3) methods to optimize care transitions at hospital discharge for patients with OUD. Most recommendations in the Consensus Statement were derived from guidelines based on observational studies and expert consensus. Due to the lack of rigorous evidence supporting key aspects of OUD-related care, the working group identified important issues necessitating future research and exploration.
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Affiliation(s)
- Susan L. Calcaterra
- Department of Medicine, Division of General Internal Medicine and Division of Hospital Medicine, University of Colorado, Aurora, CO, USA
| | - Marlene Martin
- Department of Medicine, Division of Hospital Medicine, University of California San Francisco and San Francisco General Hospital, San Francisco, CA, USA
| | - Richard Bottner
- Department of Internal Medicine, Dell Medical School at The University of Texas at Austin, Austin, TX, USA
| | - Honora Englander
- Department of Medicine, Section of Addiction Medicine and Division of Hospital Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Zoe Weinstein
- Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
| | | | - Eugene Lambert
- Harvard Medical School and Massachusetts General Hospital, Department of Medicine, Division of General Internal Medicine, Boston, MA, USA
| | - Shoshana J. Herzig
- Harvard Medical School and Massachusetts General Hospital, Department of Medicine, Division of General Internal Medicine, Boston, MA, USA
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
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3
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van Draanen J, Satti S, Morgan J, Gaudette L, Knight R, Ti L. Using passive surveillance technology for overdose prevention: Key ethical and implementation issues. Drug Alcohol Rev 2021; 41:406-409. [PMID: 34355446 DOI: 10.1111/dar.13373] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 05/21/2021] [Accepted: 07/17/2021] [Indexed: 11/29/2022]
Abstract
Passive surveillance technology has the potential to increase safety through monitoring spaces where people are at risk of overdose. One key opportunity for the use of passive surveillance technology to prevent overdose fatality is in bathrooms where people may be using drugs. However, uncertainty remains with regards to how to attain informed consent, implications for data storage and privacy and potential negative socio-legal ramifications for people who use drugs. In addition, there are issues regarding responsibility and liability for the devices. Transparency with regards to data privacy and security may also be needed before bathroom users will feel comfortable with such solutions. In this article, we discuss these issues and offer recommendations to provide a foundation for future research and policy development.
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Affiliation(s)
- Jenna van Draanen
- British Columbia Centre on Substance Use, Vancouver, Canada.,Child, Family, and Population Health Nursing, University of Washington, Seattle, USA
| | | | - Jeffrey Morgan
- British Columbia Centre on Substance Use, Vancouver, Canada
| | - Laural Gaudette
- Overdose Prevention Society, Overdose Prevention Participatory Research Assistant Program, Vancouver, Canada
| | - Rod Knight
- British Columbia Centre on Substance Use, Vancouver, Canada.,Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Lianping Ti
- British Columbia Centre on Substance Use, Vancouver, Canada.,Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, Canada
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4
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Burris S. Research on the Effects of Legal Health Interventions to Prevent Overdose: Too Often Too Little and Too Late. Am J Public Health 2020; 110:768-770. [PMID: 32374702 DOI: 10.2105/ajph.2020.305678] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Scott Burris
- Scott Burris is with the Center for Public Health Law Research, Temple University Beasley School of Law, Philadelphia, PA
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5
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Teklezgi B, Pamreddy A, Ntshangase S, Mdanda S, Singh SD, Gopal ND, Naicker T, Kruger HG, Govender T, Baijnath S. Mass Spectrometric Imaging of the Brain Demonstrates the Regional Displacement of 6-Monoacetylmorphine by Naloxone. ACS OMEGA 2020; 5:12596-12602. [PMID: 32548443 PMCID: PMC7288357 DOI: 10.1021/acsomega.9b03570] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 05/04/2020] [Indexed: 06/11/2023]
Abstract
Overdose is the main cause of mortality among heroin users. Many of these overdose-induced deaths can be prevented through the timely administration of naloxone (NLX), a nonselective mu (μ)-, kappa (κ)-, and delta (δ)-opioid receptor antagonist. NLX competitively inhibits opioid-overdose-induced respiratory depression without eliciting any narcotic effect itself. The aim of this study was to investigate the antagonistic action of NLX by comparing its distribution to that of 6-monacetylmorphine (6-MAM), heroin's major metabolite, in a rodent model using mass spectrometric imaging (MSI) in combination with liquid chromatography-tandem mass spectrometry (LC-MS/MS). Male Sprague-Dawley rats (n = 5) received heroin (10 mg kg-1) intraperitoneally, NLX (10 mg kg-1) intranasally, and NLX injected intranasally 5 min after heroin administration. The animals were sacrificed 15 min after dose and brain tissues were harvested. The MSI image analysis showed a region-specific distribution of 6-MAM in the brain regions including the corpus callosum, hippocampal formation, cerebral cortex, corticospinal tracts, caudate putamen, thalamus, globus pallidus, hypothalamus, and basal forebrain regions of the brain. The antagonist had a similar biodistribution throughout the brain in both groups of animals that received NLX or NLX after heroin administration. The MSI analysis demonstrated that the intensity of 6-MAM in these brain regions was reduced following NLX treatment. The decrease in 6-MAM intensity was caused by its displacement by the antagonist and its binding to these receptors in these specific brain regions, consequently enhancing the opioid elimination. These findings will contribute to the evaluation of other narcotic antagonists that might be considered for use in the treatment of drug overdose via MSI.
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Affiliation(s)
- Belin
G. Teklezgi
- Catalysis
and Peptide Research Unit, University of
KwaZulu-Natal, Westville Campus, Durban 3629, South Africa
| | - Annapurna Pamreddy
- Catalysis
and Peptide Research Unit, University of
KwaZulu-Natal, Westville Campus, Durban 3629, South Africa
| | - Sphamandla Ntshangase
- Catalysis
and Peptide Research Unit, University of
KwaZulu-Natal, Westville Campus, Durban 3629, South Africa
| | - Sipho Mdanda
- Catalysis
and Peptide Research Unit, University of
KwaZulu-Natal, Westville Campus, Durban 3629, South Africa
| | - Sanil D. Singh
- Department
of Pharmaceutical Science, University of
KwaZulu-Natal, Westville
Campus, Durban 3629, South Africa
| | - Nirmala D. Gopal
- Department
of Criminology, University of KwaZulu-Natal, Durban 4041, South Africa
| | - Tricia Naicker
- Catalysis
and Peptide Research Unit, University of
KwaZulu-Natal, Westville Campus, Durban 3629, South Africa
| | - Hendrik G. Kruger
- Catalysis
and Peptide Research Unit, University of
KwaZulu-Natal, Westville Campus, Durban 3629, South Africa
| | - Thavendran Govender
- Department
of Chemistry, University of Zululand, Richards Bay 3900, South Africa
| | - Sooraj Baijnath
- Catalysis
and Peptide Research Unit, University of
KwaZulu-Natal, Westville Campus, Durban 3629, South Africa
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6
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Martino JG, Smith SR, Rafie S, Rafie S, Marienfeld C. Physician and Pharmacist: Attitudes, Facilitators, and Barriers to Prescribing Naloxone for Home Rescue. Am J Addict 2019; 29:65-72. [DOI: 10.1111/ajad.12982] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Revised: 09/18/2019] [Accepted: 11/09/2019] [Indexed: 11/28/2022] Open
Affiliation(s)
- Janine G. Martino
- Department of PharmacyUniversity of California San Diego HealthSan Diego California
| | - Shawn R. Smith
- Department of Pharmacy Practice and AdministrationWestern University of Health Sciences College of PharmacyPomona California
| | - Sally Rafie
- Department of PharmacyUniversity of California San Diego HealthSan Diego California
| | - Samantha Rafie
- Department of PsychiatryUniversity of California San Diego HealthSan Diego California
- Department of Mental HealthVA San Diego Healthcare SystemSan Diego California
| | - Carla Marienfeld
- Department of PsychiatryUniversity of California San Diego HealthSan Diego California
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7
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A Survey on the Adjuvant Role of Naloxone Alone or Combined with Alum in Vaccination Against Fasciolosis in BALB/c Mice. Acta Parasitol 2019; 64:236-245. [PMID: 30788648 DOI: 10.2478/s11686-019-00030-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Accepted: 12/20/2018] [Indexed: 11/21/2022]
Abstract
BACKGROUND Fasciolosis is a zoonotic parasitic disease imposing a heavy load of livestock losses worldwide. PURPOSE We aimed to evaluate immune-stimulatory effects of naloxone (NLX), an opioid receptor antagonist, in combination with alum in mice vaccinated with excretory-secretory antigens (E/S) of Fasciola hepatica. METHODS 8-week-old female BALB/c mice were subcutaneously vaccinated using E/S antigens of F. hepatica. Experimental groups (14 mice per group) included: vaccine (E/S antigen), alum vaccine (E/S antigen plus alum), NLX vaccine (E/S antigen plus NLX), and alum-NLX vaccine (E/S antigen plus a mixture of alum-NLX). The control group was infused with PBS. Lymphocyte proliferation and the levels of IFN-γ, IL-4, IgG2a, IgG1, and total IgG were measured. RESULTS Mice vaccinated with NLX or alum-NLX adjuvants showed significantly higher rates of lymphocyte proliferation, IFN-γ, total IgG, and IgG2a levels. The mice that were injected with alum showed a significantly higher concentration of IL-4. Ratios of IFN-γ/Il-4 and IgG2a/IgG1 were significantly higher in the NLX and alum-NLX groups in comparison with the groups vaccinated either with alum or without any adjuvant. A significantly higher protection rate (62.5%) was seen in mice vaccinated with the alum-NLX adjuvant compared to the other groups. CONCLUSION NLX can be effective in conferring cellular immunity and protection against F. hepatica. It is recommended to consider this agent as a potential adjuvant in vaccines against fasciolosis.
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8
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Kilwein TM, Wimbish LA, Gilbert L, Wambeam RA. Practices and concerns related to naloxone use among emergency medical service providers in a rural state: A mixed-method examination. Prev Med Rep 2019; 14:100872. [PMID: 31061782 PMCID: PMC6487279 DOI: 10.1016/j.pmedr.2019.100872] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 04/06/2019] [Accepted: 04/07/2019] [Indexed: 12/15/2022] Open
Abstract
The rate of opioid misuse and overdose continues to increase in rural areas of the U.S. In response, access to naloxone hydrochloride ("naloxone"), an opioid antagonist used to reverse opioid overdose, has increased among both first responders and laypeople. While plenty of research has examined naloxone use among laypeople, little remains known about practices and concerns related to naloxone among emergency medical services (EMS) providers. This is particularly true among those serving rural areas that are disproportionately affected by opioid overdoses and the underutilization of naloxone. Accordingly, a mixed-method approach consisting of a quantitative Internet survey (N = 854) and qualitative focus groups (N = 20) was utilized to examine practices and concerns related to naloxone among EMS providers in a rural state. Participants represented a range of EMS licensure levels and years of experience. Findings from the focus groups can be summarized under two major themes: 1) variance in naloxone use and 2) concerns about naloxone use. In addition, meaningful information on practices of and concerns related to naloxone use, including rates of naloxone administration, knowledge about naloxone use/overdose, confidence in administering naloxone and providing follow-up care, and perceptions of rural impact, were obtained from rural EMS. Information obtained from this study can help inform policy and prevention efforts specific to EMS providers serving rural areas, including providing further evidence for permitting all EMS providers, regardless of licensure level, to administer naloxone and ensuring that education about naloxone use is effectively disseminated to these providers.
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Affiliation(s)
- Tess M. Kilwein
- University of Wyoming, 1000 E. University Ave., Laramie, WY 82071, United States of America
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9
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Khezri P, Shahabi S, Abasi E, Hajipirloo HM. Comparison of immunogenical potency of Leishmania major (MRHO/IR/75/ER) antigens prepared by 3 different methods in conjunction with Alum-Naltrexone adjuvant in BALB/c mice. ALEXANDRIA JOURNAL OF MEDICINE 2019. [DOI: 10.1016/j.ajme.2018.10.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Peyman Khezri
- Cellular and Molecular Research Center, Department of Parasitology and Mycology, School of Medicine, Urmia University of Medical Sciences, Urmia, Iran
| | - Shahram Shahabi
- Cellular and Molecular Research Center, Department of Immunology, School of Medicine, Urmia University of Medical Sciences, Urmia, Iran
| | - Esmaeil Abasi
- Cellular and Molecular Research Center, Department of Parasitology and Mycology, School of Medicine, Urmia University of Medical Sciences, Urmia, Iran
| | - Habib Mohammadzadeh Hajipirloo
- Cellular and Molecular Research Center, Department of Parasitology and Mycology, School of Medicine, Urmia University of Medical Sciences, Urmia, Iran
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10
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Zschoche JH, Nesbit S, Murtaza U, Sowell A, Waldfogel JM, Arwood N, Rush J, McNamara L, Swarthout M, Nesbit T, Ortmann M. Development and implementation of procedures for outpatient naloxone prescribing at a large academic medical center. Am J Health Syst Pharm 2018; 75:1812-1820. [DOI: 10.2146/ajhp170759] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
| | - Suzanne Nesbit
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD
| | - Umbreen Murtaza
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD
| | - Amanda Sowell
- Department of Pharmacy, Palmetto Health Richland Hospital, Columbia, SC
| | | | - Nicole Arwood
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD
| | - Jordan Rush
- Department of Pharmacy, University of North Carolina Hospitals, Chapel Hill, NC
| | - LeAnn McNamara
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD
| | | | - Todd Nesbit
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD
| | - Melinda Ortmann
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD
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11
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Davis CS, Carr DH. The Law and Policy of Opioids for Pain Management, Addiction Treatment, and Overdose Reversal. ACTA ACUST UNITED AC 2017. [DOI: 10.18060/3911.0027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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12
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McDonald R, Campbell ND, Strang J. Twenty years of take-home naloxone for the prevention of overdose deaths from heroin and other opioids-Conception and maturation. Drug Alcohol Depend 2017; 178:176-187. [PMID: 28654870 DOI: 10.1016/j.drugalcdep.2017.05.001] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 05/02/2017] [Accepted: 05/02/2017] [Indexed: 10/25/2022]
Abstract
BACKGROUND Opioid overdose is a major cause of mortality, but injury and fatal outcomes can be prevented by timely administration of the opioid antagonist naloxone. Pre-provision of naloxone to opioid users and family members (take-home naloxone, THN) was first proposed in 1996, and WHO Guidelines were issued in 2014. While widespread in some countries, THN is minimally available or absent elsewhere. This review traces the development of THN over twenty years, from speculative harm reduction proposal to public health strategy. METHOD Medline and PsycINFO were searched for peer-reviewed literature (1990-2016) using Boolean queries: 1) "naloxone OR Narcan"; 2) "(opioid OR opiate) AND overdose AND prevention". Grey literature and specialist websites were also searched. Data were extracted and synthesized as narrative review, with key events presented as chronological timeline. RESULTS Results are presented in 5-year intervals, starting with the original proposal and THN pilots from 1996 to 2001. Lack of familiarity with THN challenged early distribution schemes (2001-2006), leading to further testing, evaluation, and assessment of challenges and perceived medicolegal barriers. From 2006-2011, response to social and legal concerns led to the expansion of THN programs; followed by high-impact research and efforts to widen THN availability from 2011 to 2016. CONCLUSIONS Framed as a public health tool for harm reduction, THN has overcome social, clinical, and legal barriers in many jurisdictions. Nonetheless, the rising death toll of opioid overdose illustrates that current THN coverage is insufficient, and greater public investment in overdose prevention will be required if THN is to achieve its full potential impact.
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Affiliation(s)
- Rebecca McDonald
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, Addictions Sciences Building, 4 Windsor Walk, Denmark Hill, London, SE5 8BB, United Kingdom
| | - Nancy D Campbell
- Department of Science and Technology Studies, Sage Labs 5202, Rensselaer Polytechnic Institute, 110 Eighth Street Troy, NY, 12180, United States
| | - John Strang
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, Addictions Sciences Building, 4 Windsor Walk, Denmark Hill, London, SE5 8BB, United Kingdom.
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13
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Olsen A, McDonald D, Lenton S, Dietze PM. Assessing causality in drug policy analyses: How useful are the Bradford Hill criteria in analysing take-home naloxone programs? Drug Alcohol Rev 2017; 37:499-501. [DOI: 10.1111/dar.12523] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Revised: 10/19/2016] [Accepted: 11/29/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Anna Olsen
- National Centre of Epidemiology and Population Health; Australian National University; Canberra Australia
| | - David McDonald
- National Centre of Epidemiology and Population Health; Australian National University; Canberra Australia
- Social Research & Evaluation Pty Ltd; Canberra Australia
| | - Simon Lenton
- National Drug Research Institute; Curtin University; Perth Australia
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14
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Davis C, Carr D. State legal innovations to encourage naloxone dispensing. J Am Pharm Assoc (2003) 2017; 57:S180-S184. [DOI: 10.1016/j.japh.2016.11.007] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 11/18/2016] [Accepted: 11/18/2016] [Indexed: 10/20/2022]
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15
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English and American Drug Clients' Views of the Acceptability, Advantages, and Disadvantages of Treatment and Harm Reduction Interventions. JOURNAL OF DRUG ISSUES 2016. [DOI: 10.1177/002204260703700208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Although drug abusers present to clinics and drop-in centers requesting various treatments and harm reduction interventions, clinicians and administrators have little direct empirical evidence of the degree to which clients find various therapies acceptable or the perceived advantages and disadvantages of specific interventions. A structured interview was administered to 48 male and female outpatient or detoxification ward clients in Nottingham, England, and 40 female residential treatment program clients in Northwest Ohio, to assess the acceptability of and related attitudes regarding a broad range of interventions. Large proportions of respondents in both samples, and especially in the English sample, reported somewhat or complete acceptance of various abstinence-oriented treatments and harm reduction interventions for those still taking drugs. Respondents also discriminated among these interventions, as evidenced by differing levels of acceptance of many and outright rejection of other interventions. Although there were differences in acceptance and experience of the specific interventions between the two samples, respondents in both countries provided balanced appraisals of the advantages and disadvantages of each intervention.
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16
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What is known about community pharmacy supply of naloxone? A scoping review. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2016; 32:24-33. [DOI: 10.1016/j.drugpo.2016.02.006] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 02/03/2016] [Accepted: 02/06/2016] [Indexed: 11/21/2022]
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17
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Sivilotti MLA. Flumazenil, naloxone and the 'coma cocktail'. Br J Clin Pharmacol 2016; 81:428-36. [PMID: 26469689 PMCID: PMC4767210 DOI: 10.1111/bcp.12731] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Revised: 07/29/2015] [Accepted: 07/31/2015] [Indexed: 01/14/2023] Open
Abstract
Flumazenil and naloxone are considered to be pharmacologically ideal antidotes. By competitive binding at the molecular target receptors, they are highly specific antagonists of two important drug classes, the benzodiazepines and opioids, respectively. Both antidotes enjoy rapid onset and short duration after parenteral administration, are easily titrated and are essentially devoid of agonist effects. Yet only naloxone is widely used as a component of the 'coma cocktail', a sequence of empirical treatments to correct altered mental status, while experts discourage the use of flumazenil for such patients. This review contrasts the history, indications, published evidence and novel applications for each antidote in order to explain this disparity in the clinical use of these 'ideal' antidotes.
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Affiliation(s)
- Marco L A Sivilotti
- Emergency Medicine and Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario
- Ontario Poison Centre, Hospital for Sick Children, Toronto, Ontario, Canada
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18
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Brodrick JE, Brodrick CK, Adinoff B. Legal regimes surrounding naloxone access: considerations for prescribers. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2016; 42:117-28. [DOI: 10.3109/00952990.2015.1109648] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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19
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McAuley A, Aucott L, Matheson C. Exploring the life-saving potential of naloxone: A systematic review and descriptive meta-analysis of take home naloxone (THN) programmes for opioid users. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2015; 26:1183-8. [DOI: 10.1016/j.drugpo.2015.09.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 09/22/2015] [Accepted: 09/23/2015] [Indexed: 10/23/2022]
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20
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Coe MA, Walsh SL. Distribution of naloxone for overdose prevention to chronic pain patients. Prev Med 2015; 80:41-3. [PMID: 26024850 PMCID: PMC4592383 DOI: 10.1016/j.ypmed.2015.05.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Revised: 04/11/2015] [Accepted: 05/19/2015] [Indexed: 11/28/2022]
Abstract
In this commentary, we reflect on the growing opioid overdose epidemic and propose that chronic pain patients prescribed opioids are contributing to growing mortality rates. We advocate for expanding naloxone access and overdose prevention training, which has historically been directed when available to injection drug users, to chronic pain patients who may be at high risk for accidental opioid overdose.
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Affiliation(s)
- Marion A Coe
- Department of Pharmacology, College of Medicine, University of Kentucky, 845 Angliana Avenue, Lexington, KY 40508, United States; Center on Drug and Alcohol Research, College of Medicine, University of Kentucky, 845 Angliana Avenue, Lexington, KY 40508, United States
| | - Sharon L Walsh
- Department of Pharmacology, College of Medicine, University of Kentucky, 845 Angliana Avenue, Lexington, KY 40508, United States; Center on Drug and Alcohol Research, College of Medicine, University of Kentucky, 845 Angliana Avenue, Lexington, KY 40508, United States; Department of Behavioral Science, College of Medicine, University of Kentucky, 845 Angliana Avenue, Lexington, KY 40508, United States.
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Someabozorg MA, Mirkazemi S, Mehrizi AA, Shokri F, Djadid ND, Zakeri S. Administration of naloxone in combination with recombinant Plasmodium vivax AMA-1 in BALB/c mice induces mixed Th1/Th2 immune responses. Parasite Immunol 2015; 37:521-532. [PMID: 26234932 DOI: 10.1111/pim.12220] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2015] [Accepted: 07/28/2015] [Indexed: 11/30/2022]
Abstract
Naloxone (NLX) has the ability to shift the immune response to a Th1 profile. Therefore, the adjuvant efficacy of NLX with recombinant P. vivax apical membrane antigen-1(rPvAMA-1) in BALB/c mice was evaluated. Mice were immunized subcutaneously with purified rPvAMA-1 formulated with NLX (doses of 5 mg/kg body weight) alone or in combination with IFA. A significant increase in anti-PvAMA-1 IgG antibody after the second boost (mean OD490 = 2·08 and 2·17, in groups received, rPvAMA-1/NLX and rPvAMA-1/NLX/IFA, respectively) was detected. IgG1 and IgG2b were the predominant isotypes in all immunized mouse groups. In immunized mice with rPvAMA-1/NLX (mean: 1036 pg/mL) and with rPvAMA-1/NLX/IFA (mean: 1024 pg/mL), IFN-γ was elicited in response to rPvAMA-1 after the second boost. No detectable IL-4 secretion was determined in all tested groups. In conclusion, the administration of NLX alone or NLX/IFA with rPvAMA-1 in BALB/c mice, which induced mixed Th1/Th2 immune responses, was comparable with that of the same recombinant antigen with CFA/IFA adjuvant. The results indicate that NLX alone may possibly not be considered as a potent Th1 adjuvant in PvAMA-1-based vaccine. However, in order to modulate immune responses from mixed Th1/Th2 to strong and protective Th1 response, further study is warranted on combination of NLX with other adjuvants such as CpG motifs or MPL in proper vaccine formulation. Additionally, dose-response study is necessary to determine the effect of different doses of antigen combined with NLX (at various doses) in Balb/c mice.
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Affiliation(s)
- M A Someabozorg
- Malaria and Vector Research Group (MVRG), Biotechnology Research Center (BRC), Pasteur Institute of Iran, Tehran, Iran.,Department of Immunology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - S Mirkazemi
- Malaria and Vector Research Group (MVRG), Biotechnology Research Center (BRC), Pasteur Institute of Iran, Tehran, Iran
| | - A A Mehrizi
- Malaria and Vector Research Group (MVRG), Biotechnology Research Center (BRC), Pasteur Institute of Iran, Tehran, Iran
| | - F Shokri
- Department of Immunology, School of Public Health, Tehran University of Medical Sciences, Tehran, Iran
| | - N D Djadid
- Malaria and Vector Research Group (MVRG), Biotechnology Research Center (BRC), Pasteur Institute of Iran, Tehran, Iran
| | - S Zakeri
- Malaria and Vector Research Group (MVRG), Biotechnology Research Center (BRC), Pasteur Institute of Iran, Tehran, Iran
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Wagner KD, Liu L, Davidson PJ, Cuevas-Mota J, Armenta RF, Garfein RS. Association between non-fatal opioid overdose and encounters with healthcare and criminal justice systems: Identifying opportunities for intervention. Drug Alcohol Depend 2015; 153:215-20. [PMID: 26091751 PMCID: PMC4512661 DOI: 10.1016/j.drugalcdep.2015.05.026] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Revised: 05/11/2015] [Accepted: 05/12/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Accidental overdose, driven largely by opioids, is a leading cause of death among people who inject drugs (PWIDs). We conducted secondary analysis of data from a cohort of PWIDs to identify venues where high-risk PWID could be targeted by overdose education/naloxone distribution (OEND) programs. METHODS 573 PWIDs completed a quantitative survey between June, 2012 and January, 2014, which was analyzed using multivariable logistic regression. The dependent variable was a dichotomous indicator of experiencing a heroin/opioid-related overdose in the past six months. Independent variables included: demographics, drug use behavior, and encounters with two venues - the health care and criminal justice systems - that could serve as potential venues for OEND programs. RESULTS Almost half (41.5%) reported ever experiencing a heroin/opioid overdose, and 45 (7.9%) reported experiencing at least one heroin/opioid overdose in the past six months. In the final multivariable model, receiving care in a hospital in the past six months (Adjusted Odds Ratio [AdjOR] 4.08, 95% Confidence Interval [C.I.] 2.07, 8.04, p<0.001) and being arrested for drug possession in the past six months (AdjOR 5.17, 95% C.I. 2.37, 11.24, p<0.001) were associated with experiencing an opioid overdose in the past six months. CONCLUSIONS Identifying venues outside of those that traditionally target services to PWIDs (i.e., syringe exchange programs) will be critical to implementing OEND interventions at a scale sufficient to address the growing epidemic of heroin/opioid related deaths. Clinical settings, such as hospitals, and drug-related encounters with law enforcement officers are promising venues for the expansion of OEND programs.
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Affiliation(s)
- Karla D. Wagner
- School of Community Health Sciences, University of Nevada, Reno; 1664 N. Virginia St. MC 0274; Reno, NV 89557
| | - Lin Liu
- Division of Biostatistics & Bioinformatics, Department of Family Medicine and Public Health, University of California School of Medicine; 9500 Gilman Drive MC 0717; La Jolla, CA 92093
| | - Peter J. Davidson
- Division of Global Public Health, Department of Medicine, University of California San Diego School of Medicine; 9500 Gilman Drive MC 0507; La Jolla, CA 92093
| | - Jazmine Cuevas-Mota
- Division of Global Public Health, Department of Medicine, University of California San Diego School of Medicine; 9500 Gilman Drive MC 0507; La Jolla, CA 92093
| | - Richard F. Armenta
- Division of Global Public Health, Department of Medicine, University of California San Diego School of Medicine; 9500 Gilman Drive MC 0507; La Jolla, CA 92093
| | - Richard S. Garfein
- Division of Global Public Health, Department of Medicine, University of California San Diego School of Medicine; 9500 Gilman Drive MC 0507; La Jolla, CA 92093
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Davis CS, Carr D, Southwell JK, Beletsky L. Engaging Law Enforcement in Overdose Reversal Initiatives: Authorization and Liability for Naloxone Administration. Am J Public Health 2015; 105:1530-7. [PMID: 26066921 DOI: 10.2105/ajph.2015.302638] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Opioid overdose is reversible through the timely administration of naloxone, which has been used by emergency medical services for decades. Law enforcement officers (LEOs) are often the first emergency responders to arrive at an overdose, but they are not typically equipped with naloxone. This is rapidly changing; more than 220 law enforcement agencies in 24 states now carry naloxone. However, rollout in some departments has been hampered by concerns regarding officer and agency liability. We systematically examined the legal risk associated with LEO naloxone administration. LEOs can be authorized to administer naloxone through a variety of mechanisms, and liability risks related to naloxone administration are similar to or lower than those of other activities in which LEOs commonly engage.
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Affiliation(s)
- Corey S Davis
- Derek Carr and Corey S. Davis are with the Network for Public Health Law-Southeastern Region, Carrboro, NC. Jessica K. Southwell is with the North Carolina Institute for Public Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill. Leo Beletsky is with the Northeastern University School of Law and Bouvé College of Health Sciences, Boston, MA
| | - Derek Carr
- Derek Carr and Corey S. Davis are with the Network for Public Health Law-Southeastern Region, Carrboro, NC. Jessica K. Southwell is with the North Carolina Institute for Public Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill. Leo Beletsky is with the Northeastern University School of Law and Bouvé College of Health Sciences, Boston, MA
| | - Jessica K Southwell
- Derek Carr and Corey S. Davis are with the Network for Public Health Law-Southeastern Region, Carrboro, NC. Jessica K. Southwell is with the North Carolina Institute for Public Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill. Leo Beletsky is with the Northeastern University School of Law and Bouvé College of Health Sciences, Boston, MA
| | - Leo Beletsky
- Derek Carr and Corey S. Davis are with the Network for Public Health Law-Southeastern Region, Carrboro, NC. Jessica K. Southwell is with the North Carolina Institute for Public Health, Gillings School of Global Public Health, University of North Carolina at Chapel Hill. Leo Beletsky is with the Northeastern University School of Law and Bouvé College of Health Sciences, Boston, MA
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Doe-Simkins M, Quinn E, Xuan Z, Sorensen-Alawad A, Hackman H, Ozonoff A, Walley AY. Overdose rescues by trained and untrained participants and change in opioid use among substance-using participants in overdose education and naloxone distribution programs: a retrospective cohort study. BMC Public Health 2014; 14:297. [PMID: 24684801 PMCID: PMC4004504 DOI: 10.1186/1471-2458-14-297] [Citation(s) in RCA: 124] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Accepted: 03/17/2014] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND One approach to preventing opioid overdose, a leading cause of premature, preventable mortality, is to provide overdose education and naloxone distribution (OEND). Two outstanding issues for OEND implementation include 1) the dissemination of OEND training from trained to untrained community members; and 2) the concern that OEND provides active substance users with a false sense of security resulting in increased opioid use. METHODS To compare overdose rescue behaviors between trained and untrained rescuers among people reporting naloxone rescue kit use; and determine whether heroin use changed after OEND, we conducted a retrospective cohort study among substance users in the Massachusetts OEND program from 2006 to 2010. We used chi square and t-test statistics to compare the differences in overdose management characteristics among overdoses managed by trained versus untrained participants. We employed Wilcoxon signed rank test to compare median difference among two repeated measures of substance use among participants with drug use information collected more than once. RESULTS Among 4,926 substance-using participants, 295 trained and 78 untrained participants reported one or more rescues, resulting in 599 rescue reports. We found no statistically significant differences in help-seeking (p = 0.41), rescue breathing (p = 0.54), staying with the victim (p = 0.84) or in the success of naloxone administration (p = 0.69) by trained versus untrained rescuers. We identified 325 OEND participants who had drug use information collected more than once. We found no significant overall change in the number of days using heroin in past 30 days (decreased 38%, increased 35%, did not change 27%, p = 0.52). CONCLUSION Among 4926 substance users who participated in OEND, 373(7.6%) reported administering naloxone during an overdose rescue. We found few differences in behavior between trained and untrained overdose rescuers. Prospective studies will be needed to determine the optimal level of training and whether naloxone rescue kits can meet an over-the-counter standard. With no clear evidence of increased heroin use, this concern should not impede expansion of OEND programs or policies that support them.
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Affiliation(s)
- Maya Doe-Simkins
- Clinical Addiction Research Education Unit, Section of General Internal Medicine, Boston University School of Medicine, 801 Massachusetts Avenue, Second Floor, Boston, MA 02118, USA
| | - Emily Quinn
- Data Coordinating Center, Boston University School of Public Health, 801 Massachusetts Avenue, Third Floor, Boston, MA 02118, USA
| | - Ziming Xuan
- Department of Community Health Sciences, Boston University School of Public Health, 801 Massachusetts Avenue, Fourth Floor, Boston, MA 02118, USA
| | - Amy Sorensen-Alawad
- Clinical Addiction Research Education Unit, Section of General Internal Medicine, Boston University School of Medicine, 801 Massachusetts Avenue, Second Floor, Boston, MA 02118, USA
| | - Holly Hackman
- Massachusetts Department of Public Health, 250 Washington Street, Boston, MA 02108, USA
| | - Al Ozonoff
- Boston Children’s Hospital, Center for Patient Safety and Quality Research, 300 Longwood Avenue, Boston, MA 02115, USA
- Harvard Medical School, Department of Pediatrics, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Alexander Y Walley
- Clinical Addiction Research Education Unit, Section of General Internal Medicine, Boston University School of Medicine, 801 Massachusetts Avenue, Second Floor, Boston, MA 02118, USA
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Walley AY, Doe-Simkins M, Quinn E, Pierce C, Xuan Z, Ozonoff A. Opioid overdose prevention with intranasal naloxone among people who take methadone. J Subst Abuse Treat 2013; 44:241-7. [DOI: 10.1016/j.jsat.2012.07.004] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Revised: 06/13/2012] [Accepted: 07/02/2012] [Indexed: 10/27/2022]
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McAuley A, Best D, Taylor A, Hunter C, Robertson R. From evidence to policy: The Scottish national naloxone programme. DRUGS-EDUCATION PREVENTION AND POLICY 2012. [DOI: 10.3109/09687637.2012.682232] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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27
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Effects of concurrent intravenous morphine sulfate and naltrexone hydrochloride on end-tidal carbon dioxide. Harm Reduct J 2012; 9:13. [PMID: 22420453 PMCID: PMC3341179 DOI: 10.1186/1477-7517-9-13] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2011] [Accepted: 03/15/2012] [Indexed: 11/10/2022] Open
Abstract
Background Respiratory depression, a potentially fatal side-effect of opioid-overdose, may be reversed by timely administration of an opioid antagonist, such as naloxone or naltrexone. Tampering with a formulation of morphine sulfate and sequestered naltrexone hydrochloride extended release capsules (MS-sNT) releases both the opioid morphine and the antagonist naltrexone. A study in recreational opioid-users indicated that morphine and naltrexone injected in the 25:1 ratio (duplicating the ratio of the formulation) found MS-sNT reduced morphine-induced euphoric effects vs intravenous (IV) morphine alone. In the same study, the effects of morphine + naltrexone on end-tidal carbon dioxide (EtCO2), a measure of respiratory-depression, were evaluated and these data are reported here. Methods Single-center, placebo-controlled, double-blind crossover study. Non-dependent male opioid users were randomized to receive single IV doses of placebo, 30 mg morphine alone, and 30 mg morphine + 1.2 mg naltrexone. EtCO2 was measured by noninvasive capnography. Results Significant differences in EtCO2 least-squares means across all treatments for maximal effect (Emax) and area under the effect curve (AUE0-2, AUE0-8, AUE0-24) were detected (all p ≤ 0.0011). EtCO2 Emax values for morphine + naltrexone were significantly reduced vs morphine alone (42.9 mm Hg vs 47.1 mm Hg, p < 0.0001) and were not significantly different vs placebo (41.9 mm Hg). Median time to reach maximal effect (TEmax) was delayed for morphine + naltrexone vs morphine alone (5.0 h vs 1.0 h). Conclusions Results provide preliminary evidence that the naltrexone:morphine ratio within MS-sNT is sufficient to significantly reduce EtCO2 when administered intravenously to non-dependent male recreational opioid-users. Further studies with multiple measures of respiratory-function are warranted to determine if risk of respiratory depression is also reduced by naltrexone in the tampered formulation.
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28
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Hill D, Mcauley A. A comparative study of stakeholder views on take-home naloxone services. JOURNAL OF SUBSTANCE USE 2011. [DOI: 10.3109/14659891.2011.595275] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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29
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Jazani NH, Sohrabpour M, Mazloomi E, Shahabi S. A novel adjuvant, a mixture of alum and the general opioid antagonist naloxone, elicits both humoral and cellular immune responses for heat-killed Salmonella typhimurium vaccine. ACTA ACUST UNITED AC 2010; 61:54-62. [PMID: 21054579 DOI: 10.1111/j.1574-695x.2010.00747.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
In the current study, we tested the efficacy of the mixture of naloxone, an opioid receptor antagonist, and alum, as a new adjuvant, in the induction of humoral and cellular immunity in response to heat-killed Salmonella typhimurium (HKST) as a model vaccine. BALB/c mice were divided into five groups. Mice in the experimental groups received either the HKST vaccine alone or in combination with the adjuvant alum, naloxone or the alum-naloxone mixture. Mice in the negative control group received phosphate-buffered saline. All mice were immunized two times on days 0 and 14. Two weeks after the last immunization, immune responses to S. typhimurium were assessed. Our results indicated that the administration of the alum-naloxone mixture as an adjuvant increased the ability of the HKST vaccine to enhance lymphocyte proliferation, shifted the immune response towards a T-helper 1 (Th1) pattern and increased S. typhimurium-specific immunoglobulin G (IgG), IgG2a, IgG1 and the ratio of IgG2a to IgG1. This resulted in improved protective immunity against S. typhimurium. In conclusion, the administration of the alum-naloxone mixture as an adjuvant, in combination with the HKST vaccine, can enhance both humoral and cellular immunity and shift the immune responses to a Th1 pattern.
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Affiliation(s)
- Nima Hosseini Jazani
- Department of Microbiology, Immunology and Genetics, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran
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30
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Naloxone and alum synergistically augment adjuvant activities of each other in a mouse vaccine model of Salmonella typhimurium infection. Immunobiology 2010; 216:744-51. [PMID: 21093956 DOI: 10.1016/j.imbio.2010.10.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2010] [Revised: 10/18/2010] [Accepted: 10/18/2010] [Indexed: 11/23/2022]
Abstract
Alum is the most commonly used adjuvant for human vaccination but is a poor inducer of cell mediated immunity and T helper 1 (Th1) responses. We have previously shown that naloxone (NLX), which is a general opioid antagonist, acts as an effective adjuvant in enhancing vaccine-induced cellular immunity and Th1 immune responses. Here, we tested the efficacy of an alum-NLX mixture, as a new adjuvant, in the induction of humoral and cellular immunity in response to endotoxin-removed lysate (ERL) of Salmonella typhimurium (S. typhimurium) as a model vaccine. BALB/c mice were divided into five vaccination groups. Mice in the experimental groups received either the ERL vaccine alone or in combination with the adjuvant alum, NLX or the alum-NLX mixture. Mice in the negative control group received phosphate-buffered saline. All mice were immunized on days 0 and 7. Two weeks after the last immunization, immune responses to S. typhimurium were assessed. Our results indicate that including the alum-NLX mixture as an adjuvant during vaccination increased the ability of the ERL vaccine to enhance lymphocyte proliferation, shifted the immune response toward a Th1 profile and increased S. typhimurium-specific IgG, IgG2a and the ratio of IgG2a to IgG1. This resulted in improved protective immunity against S. typhimurium. In conclusion, administering an alum-NLX mixture adjuvant in combination with the ERL vaccine enhances both humoral and cellular immunity, and shifts the immune response to a Th1 pattern.
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Wagner KD, Valente TW, Casanova M, Partovi SM, Mendenhall BM, Hundley JH, Gonzalez M, Unger JB. Evaluation of an overdose prevention and response training programme for injection drug users in the Skid Row area of Los Angeles, CA. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2010; 21:186-93. [PMID: 19268564 PMCID: PMC4291458 DOI: 10.1016/j.drugpo.2009.01.003] [Citation(s) in RCA: 140] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2008] [Revised: 09/24/2008] [Accepted: 01/19/2009] [Indexed: 10/21/2022]
Abstract
BACKGROUND Fatal opioid overdose is a significant cause of mortality among injection drug users (IDUs). METHODS We evaluated an overdose prevention and response training programme for IDUs run by a community-based organisation in Los Angeles, CA. During a 1-h training session participants learned skills to prevent, recognise, and respond to opioid overdoses, including: calling for emergency services, performing rescue breathing, and administering an intramuscular injection of naloxone (an opioid antagonist). Between September 2006 and January 2008, 93 IDUs were trained. Of those, 66 (71%) enrolled in the evaluation study and 47 participants (71%) completed an interview at baseline and 3-month follow-up. RESULTS Twenty-one percent of participants were female, 42% were white, 29% African American, and 18% Latino. Most were homeless or lived in temporary accommodation (73%). We found significant increases in knowledge about overdose, in particular about the use of naloxone. Twenty-two participants responded to 35 overdoses during the follow-up period. Twenty-six overdose victims recovered, four died, and the outcome of five cases was unknown. Response techniques included: staying with the victim (85%), administering naloxone (80%), providing rescue breathing (66%), and calling emergency services (60%). The average number of appropriate response techniques used by participants increased significantly from baseline to follow-up (p<0.05). Half (53%) of programme participants reported decreased drug use at follow-up. CONCLUSION Overdose prevention and response training programmes may be associated with improved overdose response behaviour, with few adverse consequences and some unforeseen benefits, such as reductions in personal drug use.
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Affiliation(s)
- Karla D Wagner
- Institute for Health Promotion and Disease Prevention Research, Keck School of Medicine, University of Southern California, Alhambra, CA 91803, USA.
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Jazani NH, Karimzad M, Mazloomi E, Sohrabpour M, Hassan ZM, Ghasemnejad H, Roshan-Milani S, Shahabi S. Evaluation of the adjuvant activity of naloxone, an opioid receptor antagonist, in combination with heat-killed Listeria monocytogenes vaccine. Microbes Infect 2010; 12:382-8. [PMID: 20152926 DOI: 10.1016/j.micinf.2010.02.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2010] [Revised: 01/30/2010] [Accepted: 02/01/2010] [Indexed: 10/19/2022]
Abstract
We have previously demonstrated the adjuvant activity of naloxone (NLX), a general opioid antagonist, using a DNA vaccine for herpes simplex virus type 1. Here, the adjuvant activity of NLX has been evaluated using a heat-killed Listeria monocytogenes (HKLM) vaccine as a model for general immunization against intracellular bacteria. BALB/c mice were divided into three groups: the Vac group received the HKLM vaccine alone; the NLX-Vac group received the HKLM vaccine in combination with the adjuvant NLX; and the control group received phosphate buffered saline (PBS). Our results indicate that the administration of NLX as an adjuvant enhances the ability of the HKLM vaccine to increase lymphocyte proliferation, delayed type hypersensitivity, and skewing of the immune response toward a T-helper 1 (Th1) pattern. Additionally, combination of NLX with the HKLM vaccine improves protective immunity against L. monocytogenes. In conclusion, administration of NLX as an adjuvant for the HKLM vaccine can enhance cell-mediated immunity and shift the immune response to Th1.
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Affiliation(s)
- Nima Hosseini Jazani
- Food and Beverages Safety Research Center, Urmia University of Medical Sciences, Urmia, Iran
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Lenton SR, Dietze PM, Degenhardt L, Darke S, Butler TG. Now is the time to take steps to allow peer access to naloxone for heroin overdose in Australia. Drug Alcohol Rev 2009; 28:583-5. [DOI: 10.1111/j.1465-3362.2009.00125.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ritter A, Cameron J. A review of the efficacy and effectiveness of harm reduction strategies for alcohol, tobacco and illicit drugs. Drug Alcohol Rev 2009; 25:611-24. [PMID: 17132577 DOI: 10.1080/09595230600944529] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Harm reduction is both a policy approach and used to describe a specific set of interventions. These interventions aim to reduce the harms associated with drug use. Employing a strict definition of harm reduction, evidence for the efficacy and effectiveness of alcohol, tobacco and illicit drug harm reduction interventions were reviewed. Systematic searches of the published literature were undertaken. Studies were included if they provided evaluation data (pre-post, or control group comparisons). More than 650 articles were included in the review. The majority of the literature concerned illicit drugs. For alcohol, harm reduction interventions to reduce road trauma are well-founded in evidence. Otherwise, there is limited research to support the efficacy and effectiveness of other alcohol harm reduction interventions. For tobacco, the area is controversial but promising new products that reduce the harms associated with smoking are being developed. In the area of illicit drugs there is solid efficacy, effectiveness and economic data to support needle syringe programmes and outreach programmes. There is limited published evidence to date for other harm reduction interventions such as non-injecting routes of administration, brief interventions and emerging positive evidence for supervised injecting facilities. There is sufficient evidence to support the wide-spread adoption of harm reduction interventions and to use harm reduction as an overarching policy approach in relation to illicit drugs. The same cannot be concluded for alcohol or tobacco. Research at a broad policy level is required, especially in light of the failure by many policy makers to adopt cost-effective harm reduction interventions.
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Affiliation(s)
- Alison Ritter
- Australian National University, Canberra, Australian Capital Territory, Australia.
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Doe-Simkins M, Walley AY, Epstein A, Moyer P. Saved by the nose: bystander-administered intranasal naloxone hydrochloride for opioid overdose. Am J Public Health 2009; 99:788-91. [PMID: 19363214 DOI: 10.2105/ajph.2008.146647] [Citation(s) in RCA: 189] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Administering naloxone hydrochloride (naloxone) during an opioid overdose reverses the overdose and can prevent death. Although typically delivered via intramuscular or intravenous injection, naloxone may be delivered via intranasal spray device. In August 2006, the Boston Public Health Commission passed a public health regulation that authorized an opioid overdose prevention program that included intranasal naloxone education and distribution of the spray to potential bystanders. Participants were taught by trained nonmedical needle exchange staff. After 15 months, the program provided training and intranasal naloxone to 385 participants who reported 74 successful overdose reversals. Problems with intranasal naloxone were uncommon. Overdose prevention education with distribution of intranasal naloxone is a feasible public health intervention to address opioid overdose.
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Affiliation(s)
- Maya Doe-Simkins
- Boston Public Health Commission AHOPE Needle Exchange program, Boston, MA, USA
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Jamali A, Mahdavi M, Hassan ZM, Sabahi F, Farsani MJ, Bamdad T, Soleimanjahi H, Motazakker M, Shahabi S. A novel adjuvant, the general opioid antagonist naloxone, elicits a robust cellular immune response for a DNA vaccine. Int Immunol 2009; 21:217-25. [PMID: 19174474 DOI: 10.1093/intimm/dxn139] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
While many adjuvants have been discovered and used in research, only a few adjuvants have been permitted for use with human vaccination. We have previously shown that the administration of naloxone (NLX), a general opioid antagonist, during infection with a non-virulent strain of herpes simplex virus type 1 (HSV-1) could enhance protection against HSV-1 challenge. Here, the adjuvant activity of NLX has been evaluated using a DNA vaccine for HSV-1 as a model. BALB/c mice were divided into four groups; for experimental groups, mice received the glycoprotein D1 (gD1) DNA vaccine alone or in combination with the adjuvant NLX. A positive control group received the KOS strain of HSV-1, and a negative control group received PBS. All mice were immunized three times on days 0, 21 and 42. Three weeks after the last immunization, immune responses against HSV-1 were assessed. Our results indicate that the administration of NLX as an adjuvant increased the ability of the gD1 DNA vaccine to enhance cytolytic T lymphocyte activity, lymphocyte proliferation, delayed-type hypersensitivity and shifting the immune response toward a T helper (Th)1 pattern and improved protective immunity against HSV-1. NLX also increased the IgG2a/IgG1 ratio, though it did not affect the production of HSV-1 antiserum. In conclusion, administration of NLX as an adjuvant in combination with the gD1 DNA vaccine can enhance cell-mediated immunity and shift the immune responses to Th1.
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Affiliation(s)
- Abbas Jamali
- Department of Microbiology, Immunology and Genetics, Faculty of Medicine, Urmia University of Medical Sciences, Urmia, Iran
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Kim D, Irwin KS, Khoshnood K. Expanded access to naloxone: options for critical response to the epidemic of opioid overdose mortality. Am J Public Health 2009; 99:402-7. [PMID: 19150908 DOI: 10.2105/ajph.2008.136937] [Citation(s) in RCA: 127] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The United States is in the midst of a prolonged and growing epidemic of accidental and preventable deaths associated with overdoses of licit and illicit opioids. For more than 3 decades, naloxone has been used by emergency medical personnel to pharmacologically reverse overdoses. The peers or family members of overdose victims, however, are most often the actual first responders and are best positioned to intervene within an hour of the onset of overdose symptoms. Data from recent pilot programs demonstrate that lay persons are consistently successful in safely administering naloxone and reversing opioid overdose. Current evidence supports the extensive scaleup of access to naloxone. We present advantages and limitations associated with a range of possible policy and program responses.
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Affiliation(s)
- Daniel Kim
- American Medical Association, Chicago, IL, USA
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Maxwell S, Bigg D, Stanczykiewicz K, Carlberg-Racich S. Prescribing naloxone to actively injecting heroin users: a program to reduce heroin overdose deaths. J Addict Dis 2007; 25:89-96. [PMID: 16956873 DOI: 10.1300/j069v25n03_11] [Citation(s) in RCA: 184] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Heroin overdose deaths have increased alarmingly in Chicago over the past decade. Naloxone, an opioid antagonist with no abuse potential, has been used to reverse opiate overdose in emergency medical settings for decades. We describe here a program to educate opiate users in the prevention of opiate overdose and its reversal with intramuscular naloxone. Participant education and naloxone prescription are accomplished within a large comprehensive harm reduction program network. Since institution of the program in January 2001, more than 3,500 10 ml (0.4 mg/ml) vials of naloxone have been prescribed and 319 reports of peer reversals received. The Medical Examiner of Cook County reported a steady increase in heroin overdose deaths since 1991, with a four-fold increase between 1996 and 2000. This trend reversed in 2001, with a 20% decrease in 2001 and 10% decreases in 2002 and 2003.
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Beletsky L, Ruthazer R, Macalino GE, Rich JD, Tan L, Burris S. Physicians' knowledge of and willingness to prescribe naloxone to reverse accidental opiate overdose: challenges and opportunities. J Urban Health 2007; 84:126-36. [PMID: 17146712 PMCID: PMC2078257 DOI: 10.1007/s11524-006-9120-z] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Naloxone, the standard treatment for heroin overdose, is a safe and effective prescription drug commonly administered by emergency room physicians or first responders acting under standing orders of physicians. High rates of overdose deaths and widely accepted evidence that witnesses of heroin overdose are often unwilling or unable to call 9-1-1 has led to interventions in several US cities and abroad in which drug users are instructed in overdose rescue techniques and provided a "take-home" dose of naloxone. Under current Food and Drug Administration (FDA) regulations, such interventions require physician involvement. As part of a larger study to evaluate the knowledge and attitudes of doctors towards providing drug treatment and harm reduction services to injection drug users (IDUs), we investigated physician knowledge and willingness to prescribe naloxone. Less than one in four of the respondents in our sample reported having heard of naloxone prescription as an intervention to prevent opiate overdose, and the majority reported that they would never consider prescribing the agent and explaining its application to a patient. Factors predicting a favorable attitude towards prescribing naloxone included fewer negative perceptions of IDUs, assigning less importance to peer and community pressure not to treat IDUs, and increased confidence in ability to provide meaningful treatment to IDUs. Our data suggest that steps to promote naloxone distribution programs should include physician education about evidence-based harm minimization schemes, broader support for such initiatives by professional organizations, and policy reform to alleviate medicolegal concerns associated with naloxone prescription. FDA re-classification of naloxone for over-the-counter sales and promotion of nasal-delivery mechanism for this agent should be explored.
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Affiliation(s)
- Leo Beletsky
- Temple University Beasley School of Law, Philadelphia, PA 19122, USA.
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Sporer KA, Kral AH. Prescription naloxone: a novel approach to heroin overdose prevention. Ann Emerg Med 2006; 49:172-7. [PMID: 17141138 DOI: 10.1016/j.annemergmed.2006.05.025] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2006] [Revised: 04/25/2006] [Accepted: 05/23/2006] [Indexed: 11/27/2022]
Abstract
The mortality and morbidity from heroin overdose have increased in the United States and internationally in the last decade. The lipid solubility allows the rapid deposition of heroin and its metabolites into the central nervous system and accounts for the "rush" experienced by users and for the toxicity. Risk factors for fatal and nonfatal heroin overdoses such as recent abstinence, decreased opiate tolerance, and polydrug use have been identified. Opiate substitution treatment such as methadone or buprenorphine is the only proven method of heroin overdose prevention. Death from a heroin overdose most commonly occurs 1 to 3 hours after injection at home in the company of other people. Numerous communities have taken advantage of this opportunity for treatment by implementing overdose prevention education to active heroin users, as well as prescribing naloxone for home use. Naloxone is a specific opiate antagonist without agonist properties or potential for abuse. It is inexpensive and nonscheduled and readily reverses the respiratory depression and sedation caused by heroin, as well as causing transient withdrawal symptoms. Program implementation considerations, legal ramifications, and research needs for prescription naloxone are discussed.
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Affiliation(s)
- Karl A Sporer
- University of California, San Francisco, Department of Medicine, Section of Emergency Medicine, and the Treatment Research Center, USA.
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Worthington N, Markham Piper T, Galea S, Rosenthal D. Opiate users' knowledge about overdose prevention and naloxone in New York City: a focus group study. Harm Reduct J 2006; 3:19. [PMID: 16822302 PMCID: PMC1557479 DOI: 10.1186/1477-7517-3-19] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2005] [Accepted: 07/05/2006] [Indexed: 11/29/2022] Open
Abstract
Background Drug-induced and drug-related deaths have been increasing for the past decade throughout the US. In NYC, drug overdose accounts for nearly 900 deaths per year, a figure that exceeds the number of deaths each year from homicide. Naloxone, a highly effective opiate antagonist, has for decades been used by doctors and paramedics during emergency resuscitation after an opiate overdose. Following the lead of programs in Europe and the US who have successfully distributed take-home naloxone, the Overdose Prevention and Reversal Program at the Lower East Side Harm Reduction Center (LESHRC) has started providing a similar resource for opiate users in NYC. Participants in the program receive a prescription for two doses of naloxone, with refills as needed, and comprehensive training to reduce overdose risk, administer naloxone, perform rescue breathing, and call 911. As of September 2005, 204 participants have received naloxone and been trained, and 40 have revived an overdosing friend or family member. While naloxone accessibility stands as a proven life-saving measure, some opiates users at LESHRC have expressed only minimal interest in naloxone use, due to past experiences and common misconceptions. Methods In order to improve the naloxone distribution program two focus groups were conducted in December 2004 with 13 opiate users at LESHRC to examine knowledge about overdose and overdose prevention. The focus groups assessed participants' (i) experiences with overdose response, specifically naloxone (ii) understanding and perceptions of naloxone, (iii) comfort level with naloxone administration and (iv) feedback about increasing the visibility and desirability of the naloxone distribution program. Results Analyses suggest that there is both support for and resistance to take-home naloxone, marked by enthusiasm for its potential role in reviving an overdosing individual, numerous misconceptions and negative views of its impact and use. Conclusion Focus group results will be used to increase participation in the program and reshape perceptions about naloxone among opiate users, also targeting those already prescribed naloxone to increase their comfort using it. Since NYC is advancing toward a citywide naloxone distribution program, the LESHRC program will play an important role in establishing protocol for effective and wide-reaching naloxone availability.
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Affiliation(s)
| | - Tinka Markham Piper
- Center for Urban Epidemiologic Studies, New York Academy of Medicine, New York, NY 10029, USA
| | - Sandro Galea
- Center for Urban Epidemiologic Studies, New York Academy of Medicine, New York, NY 10029, USA
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI, 48104, USA
| | - David Rosenthal
- Lower East Side Harm Reduction Center, New York, NY 10002, USA
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Burris S, Blankenship KM, Donoghoe M, Sherman S, Vernick JS, Case P, Lazzarini Z, Koester S. Addressing the "risk environment" for injection drug users: the mysterious case of the missing cop. Milbank Q 2004; 82:125-56. [PMID: 15016246 PMCID: PMC2690204 DOI: 10.1111/j.0887-378x.2004.00304.x] [Citation(s) in RCA: 177] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Ecological models of the determinants of health and the consequent importance of structural interventions have been widely accepted, but using these models in research and practice has been challenging. Examining the role of criminal law enforcement in the "risk environment" of injection drug users (IDUs) provides an opportunity to apply structural thinking to the health problems associated with drug use. This article reviews international evidence that laws and law enforcement practices influence IDU risk. It argues that more research is needed at four levels--laws; management of law enforcement agencies; knowledge, attitudes, beliefs, and practices of frontline officers; and attitudes and experiences of IDUs--and that such research can be the basis of interventions within law enforcement to enhance IDU health.
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Affiliation(s)
- Scott Burris
- Temple University, Beasley School of Law, Philadelphia, PA 19122, USA.
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Stozek MA, Taylor LE, LeBreux L, Olson J, Wolf F, Rich JD. Prescribing syringes to injection drug users with HIV: an important clinical and public health tool. J Assoc Nurses AIDS Care 2004; 15:59-63. [PMID: 15090134 DOI: 10.1177/1055329004263755] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Stancliff S, Agins B, Rich JD, Burris S. Syringe access for the prevention of blood borne infections among injection drug users. BMC Public Health 2003; 3:37. [PMID: 14633286 PMCID: PMC317318 DOI: 10.1186/1471-2458-3-37] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2003] [Accepted: 11/21/2003] [Indexed: 11/24/2022] Open
Abstract
Background Approximately one-third of acquired immunodeficiency syndrome cases in the United States are associated with the practice of sharing of injection equipment and are preventable through the once-only use of syringes, needles and other injection equipment. Discussion Sterile syringes may be obtained legally by 4 methods depending on the state. They may be purchased over the counter, prescribed, obtained at syringe exchange programs or furnished by authorized agencies. Each of these avenues has advantages and disadvantages; therefore, legal access through all means is the most likely way to promote the use of sterile syringes. Summary By assisting illicit drug injectors to obtain sterile syringes the primary care provider is able to reduce the incidence of blood borne infections, and educate patients about safe syringe disposal. The provider is also able to initiate discussion about drug use in a nonjudgmental manner and to offer care to patients who are not yet ready to consider drug treatment.
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Affiliation(s)
- Sharon Stancliff
- AIDS Institute, New York State Department of Health, 5 Penn Plaza, 1Floor, New York, New York 10001, USA
| | - Bruce Agins
- AIDS Institute, New York State Department of Health, 5 Penn Plaza, 1Floor, New York, New York 10001, USA
| | - Josiah D Rich
- The Miriam Hospital,164 Summit Avenue, Providence, RI 02906, USA
| | - Scott Burris
- Temple University Beasley School of Law, 1719 N Broad Street Philadelphia, PA 19122, USA
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