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Russell E, Hawk M, Neale J, Bennett A, Davis C, Hill LG, Winograd R, Kestner L, Lieberman A, Bell A, Santamour T, Murray S, Schneider KE, Walley AY, Jones TS. A call for compassionate opioid overdose response. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 133:104587. [PMID: 39299143 DOI: 10.1016/j.drugpo.2024.104587] [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: 05/15/2024] [Revised: 08/27/2024] [Accepted: 09/03/2024] [Indexed: 09/22/2024]
Abstract
High dose and long-acting opioid overdose reversal drugs can precipitate withdrawal in people who are opioid dependent. Products recently brought to market for community use in the United States (US) have drawn international concern because of their increased risk of withdrawal. At the March 18-19, 2024, Compassionate Overdose Response Summit & Naloxone Dosing Meeting, a panel of harm reduction experts issued the following call to action: 1) people who use drugs should be directly involved in decisions regarding the research, development, selection, and distribution of opioid overdose reversal products; 2) regulatory agencies and pharmaceutical manufacturers should carefully consider and communicate the risk and duration of withdrawal associated with higher dose and longer-acting opioid antagonists; 3) take-home naloxone kits should include at least two doses of an intramuscular (IM) product containing 0.4 mg or an intranasal (IN) product containing ≤4 mg; 4) At this time, high dose and long-acting opioid antagonists have no use in acute opioid overdose response; and, 5) overdose response educational materials, instructions on overdose response, and training should emphasize the restoration of breathing, avoiding withdrawal, and compassionate post-overdose support and care. High dose and long-acting opioid overdose reversal drugs were approved without testing for withdrawal and are often aggressively marketed despite decades of evidence from naloxone distribution programs worldwide that the ideal dose of naloxone is one that restores breathing without inducing withdrawal. Government agencies should direct resources to harm reduction programs to make standard dose take-home naloxone products widely available among people who use drugs. Lay bystanders, people who use drugs, their families, and professional first responders can learn and apply a compassionate approach to opioid overdose response.
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Affiliation(s)
- Erin Russell
- Health Management Associates, 2501 Woodlake Cir Suite 100, Okemos, MI 48864, USA.
| | - Mary Hawk
- University of Pittsburgh School of Public Health, Behavioral and Community Health Sciences, 130 DeSoto Street 6127 Public Health, Pittsburgh, PA 15261, USA.
| | - Joanne Neale
- King's College London, 4 Windsor Walk IoPPN, Denmark Hill, London SE5 8AB, United Kingdom.
| | - Alex Bennett
- New York University, School of Global Public Health, 708 Broadway, NY, NY 10003, USA.
| | - Corey Davis
- Network for Public Health Law, 7101 York Ave S. #270, Edina, MN 55435, USA.
| | - Lucas G Hill
- The University of Texas at Austin, 2409 University Ave, A1910, PHR 2.222, Austin, TX 78712, USA.
| | - Rachel Winograd
- University of Missouri, St. Louis, 43 Benton Ct, St. Louis, MO 63121, USA.
| | - Lauren Kestner
- Center for Prevention Services' Queen City Harm Reduction, 811 Eastway Dr., Charlotte, NC 28205, USA.
| | - Amy Lieberman
- Network for Public Health Law, 7101 York Ave S. #270, Edina, MN 55435, USA.
| | - Alice Bell
- Prevention Point Pittsburgh, 460 Melwood Ave, Suite 100, Pittsburgh, PA 15213, USA.
| | - Tim Santamour
- Florida Harm Reduction Collective, 4601 3rd Ave N., Saint Petersburg, FL 33713, USA.
| | - Stephen Murray
- Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Boston Medical Center, 801 Massachusetts Ave, Boston, MA 02119, USA.
| | - Kristin E Schneider
- Johns Hopkins Bloomberg School of Public Health, 1812 Ashland Ave, Office 333, Baltimore, MD 21030, USA.
| | - Alexander Y Walley
- Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, 801 Massachusetts Ave, Boston, MA, 02119, USA.
| | - T Stephen Jones
- T. Stephen Jones Public Health Consulting, 123 Black Birch Trail, Florence MA 01062, USA.
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Victor G, Hedden-Clayton B, Lenz D, Attaway PR, Ray B. Naloxone vending machines in county jail. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 167:209521. [PMID: 39260806 DOI: 10.1016/j.josat.2024.209521] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 08/30/2024] [Accepted: 09/08/2024] [Indexed: 09/13/2024]
Abstract
INTRODUCTION The overdose epidemic in the United States has intensified following the introduction of illicitly manufactured fentanyl to drug markets with recent estimates indicating 110,000 deaths in 2022 and longer-term trends adversely impacting national life expectancy. A period of incarceration has been identified as a critical touchpoint for overdose prevention given its strong association with risk of overdose. In this paper we describe efforts funded by the Centers for Disease Control and Prevention (CDC) Overdose Data to Action (OD2A) grant to design and implement naloxone vending machines that provide free naloxone within county jails to returning citizens and those visiting county jail facilities. METHODS This study utilized three sources of data. First, we describe the results of a pre-implementation survey administered by technical assistance providers to 18 jails across the state of Michigan. Second, among the 6 jail facilities that accepted a naloxone vending machine we examine administrative data from Michigan Department of Health and Human Services on naloxone orders to look at changes 6-months before and after implementation. Third and lastly, we conducted semi-structured interviews (N = 6) with jail administrators (i.e., County Sheriffs) on the barriers and facilitators to implementing a naloxone vending machine. RESULTS Six facilities indicated they would accept a vending machine to distribute free naloxone. Overall, the total number of naloxone box orders that were distributed across all jail sites increased by 63.5 % from 4104 boxes pre-naloxone vending machine to 6708 boxes post-naloxone vending machine implementation. Qualitative interviews revealed that prior naloxone distribution efforts and foundational knowledge about opioids, overdose, and naloxone emerged as facilitators for vending machine implementation. CONCLUSION This study illustrates the utility of policy-driven funding strategies aimed at mitigating accidental overdose deaths among a high-risk population while building community naloxone saturation efforts.
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Affiliation(s)
- Grant Victor
- School of Social Work, Rutgers, The State University of New Jersey, 390 George St, Suite 710, New Brunswick, NJ 08901, USA; Rutgers Addiction Research Center, The State University of New Jersey, 671 Hoes Lane West, Piscataway, NJ 08854, USA.
| | - Bethany Hedden-Clayton
- Center for Behavioral Health and Justice, School of Social Work, Wayne State University, 5447 Woodward Ave, Detroit, MI 48202, USA
| | - Danielle Lenz
- Center for Behavioral Health and Justice, School of Social Work, Wayne State University, 5447 Woodward Ave, Detroit, MI 48202, USA
| | - Peyton R Attaway
- RTI International, Division for Applied Justice Research, 3040 Cornwallis Road, Research Triangle Park, NC 27709, USA
| | - Bradley Ray
- RTI International, Division for Applied Justice Research, 3040 Cornwallis Road, Research Triangle Park, NC 27709, USA
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Skolnick P, Paavola J, Heidbreder C. Synthetic opioids have disrupted conventional wisdom for treating opioid overdose. DRUG AND ALCOHOL DEPENDENCE REPORTS 2024; 12:100268. [PMID: 39262668 PMCID: PMC11388010 DOI: 10.1016/j.dadr.2024.100268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2024] [Revised: 07/30/2024] [Accepted: 08/01/2024] [Indexed: 09/13/2024]
Abstract
More than 90 % of opioid overdose deaths in North America are now caused by synthetic opioids, and while they are not as prevalent in the European illicit drug market, there are indications that they may become so in the near future. Multiple publications have argued that neither higher doses of naloxone nor more potent opioid receptor antagonists are needed to reverse a synthetic opioid overdose. However, the unique physicochemical properties of synthetic opioids result in a very rapid onset of respiratory depression compared to opium-based molecules, reducing the margin of opportunity to reverse an overdose. While intravenous administration rapidly delivers the high naloxone concentrations needed to reverse a synthetic opioid overdose, this option is often unavailable to first responders. A translational mechanistic model of opioid overdose developed by the FDA's Division of Applied Regulatory Science provides an unbiased approach to evaluate the effectiveness of overdose reversal strategies. Reports using this model demonstrated the naloxone tools (2 mg intramuscular and 4 mg intranasal) used by many first responders can result in an unacceptable loss of life following a synthetic opioid (fentanyl, carfentanil) overdose. Moreover, sequential (2.5 minutes between doses) administration of up to four doses of intranasal naloxone was no more effective at reducing the incidence of cardiac arrest (a surrogate endpoint for lethality) than a single dose, suggesting that attempts at titration may not provide the rapid absorption required to reverse a synthetic opioid overdose. This model was also used to compare the effectiveness of intranasal naloxone to intranasal nalmefene, a recently FDA-approved opioid receptor antagonist with a more rapid absorption and a higher affinity at mu-opioid receptors compared to intranasal naloxone. Intranasal nalmefene resulted in large and clinically meaningful reductions in the incidence of cardiac arrest compared to intranasal naloxone. Furthermore, simultaneous administration of four doses of intranasal naloxone was needed to reduce the incidence of cardiac arrest to levels approaching those produced by a single dose of intranasal nalmefene. These data are consistent with evidence that synthetics have indeed disrupted conventional wisdom in the treatment of opioid overdose.
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Affiliation(s)
- Phil Skolnick
- Indivior, Inc., N, Chesterfield, VA 23235, United States
| | - Jordan Paavola
- Indivior, Inc., N, Chesterfield, VA 23235, United States
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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 PMCID: PMC11392605 DOI: 10.1016/j.jhealeco.2024.102917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [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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5
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Kinoshita AT, Saadat S, Chakravarthy B. Bystanders Saving Lives with Naloxone: A Scoping Review on Methods to Estimate Overdose Reversals. West J Emerg Med 2024; 25:500-506. [PMID: 39028236 PMCID: PMC11254156 DOI: 10.5811/westjem.18037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 01/26/2024] [Accepted: 02/12/2024] [Indexed: 07/20/2024] Open
Abstract
Introduction People who use drugs in community settings are at risk of a fatal overdose, which can be mitigated by naloxone administered via bystanders. In this study we sought to investigate methods of estimating and tracking opioid overdose reversals by community members with take-home naloxone (THN) to coalesce possible ways of characterizing THN reach with a metric that is useful for guiding both distribution of naloxone and advocacy of its benefits. Methods We conducted a scoping review of published literature on PubMed on August 15, 2022, using PRISMA-ScR protocol, for articles discussing methods to estimate THN reversals in the community. The following search terms were used: naloxone AND ("take home" OR kit OR "community distribution" OR "naloxone distribution"). We used backwards citation searching to potentially find additional studies. Overdose education and naloxone distribution program-based studies that analyzed only single programs were excluded. Results The database search captured 614 studies, of which 14 studies were relevant. Backwards citation searching of 765 references did not reveal additional relevant studies. Of the 14 relevant studies, 11 were mathematical models. Ten used Markov models, and one used a system dynamics model. Of the remaining three articles, one was a meta-analysis, and two used spatial analysis. Studies ranged in year of publication from 2013-2022 with mathematical modeling increasing in use over time. Only spatial analysis was used with a focus on characterizing local naloxone use at the level of a specific city. Conclusion Of existing methods to estimate bystander administration of THN, mathematical models are most common, particularly Markov models. System dynamics modeling, meta-analysis, and spatial analysis have also been used. All methods are heavily dependent upon overdose education and naloxone distribution program data published in the literature or available as ongoing surveillance data. Overall, there is a paucity of literature describing methods of estimation and even fewer with methods applied to a local focus that would allow for more targeted distribution of naloxone.
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Affiliation(s)
| | - Soheil Saadat
- University of California Irvine, School of Medicine, Department of Emergency Medicine, Irvine, California
| | - Bharath Chakravarthy
- University of California Irvine, School of Medicine, Department of Emergency Medicine, Irvine, California
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6
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Oleksak P, Nepovimova E, Valko M, Alwasel S, Alomar S, Kuca K. Comprehensive analysis of prohibited substances and methods in sports: Unveiling trends, pharmacokinetics, and WADA evolution. ENVIRONMENTAL TOXICOLOGY AND PHARMACOLOGY 2024; 108:104447. [PMID: 38636744 DOI: 10.1016/j.etap.2024.104447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 03/24/2024] [Accepted: 04/11/2024] [Indexed: 04/20/2024]
Abstract
This review systematically compiles sports-related drugs, substances, and methodologies based on the most frequently detected findings from prohibited lists published annually by the World Anti-Doping Agency (WADA) between 2003 and 2021. Aligned with structure of the 2023 prohibited list, it covers all proscribed items and details the pharmacokinetics and pharmacodynamics of five representatives from each section. Notably, it explores significant metabolites and metabolic pathways associated with these substances. Adverse analytical findings are summarized in tables for clarity, and the prevalence is visually represented through charts. The review includes a concise historical overview of doping and WADA's role, examining modifications in the prohibited list for an understanding of evolving anti-doping measures.
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Affiliation(s)
- Patrik Oleksak
- Department of Chemistry, Faculty of Science, University of Hradec Kralove, Hradec Kralove 500 03, Czech Republic
| | - Eugenie Nepovimova
- Department of Chemistry, Faculty of Science, University of Hradec Kralove, Hradec Kralove 500 03, Czech Republic
| | - Marian Valko
- Faculty of Chemical and Food Technology, Slovak University of Technology, Bratislava 812 37, Slovakia; Zoology Department, College of Science, King Saud University, Riyadh 11451, Saudi Arabia
| | - Saleh Alwasel
- Zoology Department, College of Science, King Saud University, Riyadh 11451, Saudi Arabia
| | - Suliman Alomar
- Doping Research Chair, Zoology Department, College of Science, King Saud University, Riyadh-11451, Kingdom of Saudi Arabia.
| | - Kamil Kuca
- Department of Chemistry, Faculty of Science, University of Hradec Kralove, Hradec Kralove 500 03, Czech Republic; Biomedical Research Center, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic; Andalusian Research Institute in Data Science and Computational Intelligence (DaSCI), University of Granada, Granada 18071, Spain.
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Irvine MA, Bardwell S, Williams S, Liu L, Ge W, Kinniburgh B, Coombs D, Buxton JA. Estimating the total utilization of take home naloxone during an unregulated drug toxicity crisis: A Bayesian modeling approach. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 128:104454. [PMID: 38788389 DOI: 10.1016/j.drugpo.2024.104454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 05/02/2024] [Accepted: 05/08/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND British Columbia (BC) Canada has a large take-home naloxone (THN) program, implemented as part of the provincial response to the ongoing toxic unregulated drug supply emergency. Ascertaining the rate of use of THN kits is vital to understanding the full impact of the program. However, this is a challenging problem due to under-reporting of kit distribution. This study aims to estimate the total number of THN kits used based on the number of THN kits shipped, the number of THN kits reported as distributed, and the number of THN kits reported as used. METHODS We used BC THN shipment and distribution records (February 2015 to August 2023) to inform a simple Bayesian model of naloxone kit distribution and use. A logistic regression term by health region and distribution site type was incorporated to account for variable under-reporting, and a convolution term was incorporated to account for kit distribution. RESULTS We find the number of THN kits reported as used, and the number of total THN kits distributed, are largely under-reported. An estimated 1,500 (95 % CrI: 1,430 - 1,590) THN kits per 10,000 BC population were used, of which 288 per 10,000 had been reported as used. Of all the THN kits shipped, the model estimated that 43 % (95 % CrI: 41-45 %) of kits were used. We also found variation in both distribution and use by distribution site type, with kits distributed from overdose prevention sites having the highest rate of use (56 %; 95 % CrI: 53-59 %). CONCLUSION Across all sites, kit use is approximately five times higher than has been reported. Our framework can also be applied to other localities where THN programs operate, in order to better estimate the true reach and impact of take home naloxone distribution.
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Affiliation(s)
- Michael A Irvine
- BC Centre for Disease Control, Vancouver, BC, Canada; Department of Statistics, University of British Columbia, Vancouver, BC, Canada.
| | - Samantha Bardwell
- Mathematics Department, University of British Columbia, Vancouver, BC, Canada
| | | | - Lisa Liu
- BC Centre for Disease Control, Vancouver, BC, Canada
| | - Wenxue Ge
- BC Centre for Disease Control, Vancouver, BC, Canada
| | | | - Daniel Coombs
- Mathematics Department, University of British Columbia, Vancouver, BC, Canada
| | - Jane A Buxton
- School of Population and Public Health, University of British Columbia, Vancouver, BC, Canada
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Starbird LE, Onuoha E, Corry G, Hotchkiss J, Benjamin SN, Hunt T, Schackman BR, El-Bassel N. Community-led approaches to making naloxone available in public settings: Implementation experiences in the HEALing communities study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 128:104462. [PMID: 38795466 PMCID: PMC11213655 DOI: 10.1016/j.drugpo.2024.104462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 05/10/2024] [Accepted: 05/15/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND Expanding public naloxone access is a key strategy to reduce opioid overdose fatalities. We describe tailored community-engaged, data-driven approaches to install and maintain naloxone housing units (naloxone boxes) in New York State and estimate the cost of these approaches. METHODS Guided by the Consolidated Framework for Implementation Research, we collected data from administrative records and key informant interviews that documented the unique processes employed by four counties enrolled in the HEALing Communities Study to install and maintain naloxone housing units. We conducted a prospective micro-costing analysis to estimate the cost of each naloxone housing unit strategy from the community perspective. RESULTS While all counties used a coalition to guide action planning for naloxone distribution, we identified unique approaches to implementing naloxone housing units: 1) County-led with technology expansion; 2) County-led grassroots; 3) Small-scale rural opioid overdose prevention program (OOPP) contract and 4) Comprehensive OOPP contract including overdose education and naloxone distribution (OEND) to individuals. The first two county-led approaches had lower cost per naloxone dose disbursed ($28-$38) compared to outsourcing to an OOPP ($183-$266); costs depended on services added to installing and maintaining units, such as OEND. Barriers included competing demands on public health resources (i.e., COVID-19) and stigma toward naloxone and opioid use disorder. Geographic access was a barrier in rural areas whereas existing infrastructure was a facilitator in urban counties. The policy landscape in New York State, which provides free naloxone kits and financial support to OOPPs, facilitated implementation in all counties. CONCLUSIONS If a community has the resources, installing and maintaining naloxone housing units in-house can be less expensive than contracting with an outside partner. However, contracts that include OEND may be more effective at reaching target populations. Financial support from health departments and legislative authorization are important facilitators to making naloxone available in public settings.
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Affiliation(s)
- Laura E Starbird
- Department of Family and Community Health, University of Pennsylvania School of Nursing, 418 Curie Blvd Philadelphia, PA 19104, United States.
| | - Erica Onuoha
- Department of Population Health Sciences, Weill Cornell Medical College, 425 E. 61st St, New York, NY 10065, United States
| | - Grace Corry
- Department of Population Health Sciences, Weill Cornell Medical College, 425 E. 61st St, New York, NY 10065, United States
| | - Juanita Hotchkiss
- Social Intervention Group, Columbia University School of Social Work, 1255 Amsterdam Ave, New York, NY 10027, United States
| | - Shoshana N Benjamin
- Social Intervention Group, Columbia University School of Social Work, 1255 Amsterdam Ave, New York, NY 10027, United States
| | - Timothy Hunt
- Social Intervention Group, Columbia University School of Social Work, 1255 Amsterdam Ave, New York, NY 10027, United States
| | - Bruce R Schackman
- Department of Population Health Sciences, Weill Cornell Medical College, 425 E. 61st St, New York, NY 10065, United States
| | - Nabila El-Bassel
- Social Intervention Group, Columbia University School of Social Work, 1255 Amsterdam Ave, New York, NY 10027, United States
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Scheidell JD, Townsend TN, Zhou Q, Manandhar-Sasaki P, Rodriguez-Santana R, Jenkins M, Buchelli M, Charles DL, Frechette JM, Su JIS, Braithwaite RS. Reducing overdose deaths among persons with opioid use disorder in connecticut. Harm Reduct J 2024; 21:103. [PMID: 38807226 PMCID: PMC11131266 DOI: 10.1186/s12954-024-01026-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 05/20/2024] [Indexed: 05/30/2024] Open
Abstract
BACKGROUND People in Connecticut are now more likely to die of a drug-related overdose than a traffic accident. While Connecticut has had some success in slowing the rise in overdose death rates, substantial additional progress is necessary. METHODS We developed, verified, and calibrated a mechanistic simulation of alternative overdose prevention policy options, including scaling up naloxone (NLX) distribution in the community and medications for opioid use disorder (OUD) among people who are incarcerated (MOUD-INC) and in the community (MOUD-COM) in a simulated cohort of people with OUD in Connecticut. We estimated how maximally scaling up each option individually and in combinations would impact 5-year overdose deaths, life-years, and quality-adjusted life-years. All costs were assessed in 2021 USD, employing a health sector perspective in base-case analyses and a societal perspective in sensitivity analyses, using a 3% discount rate and 5-year and lifetime time horizons. RESULTS Maximally scaling NLX alone reduces overdose deaths 20% in the next 5 years at a favorable incremental cost-effectiveness ratio (ICER); if injectable rather than intranasal NLX was distributed, 240 additional overdose deaths could be prevented. Maximally scaling MOUD-COM and MOUD-INC alone reduce overdose deaths by 14% and 6% respectively at favorable ICERS. Considering all permutations of scaling up policies, scaling NLX and MOUD-COM together is the cost-effective choice, reducing overdose deaths 32% at ICER $19,000/QALY. In sensitivity analyses using a societal perspective, all policy options were cost saving and overdose deaths reduced 33% over 5 years while saving society $338,000 per capita over the simulated cohort lifetime. CONCLUSIONS Maximally scaling access to naloxone and MOUD in the community can reduce 5-year overdose deaths by 32% among people with OUD in Connecticut under realistic budget scenarios. If societal cost savings due to increased productivity and reduced crime costs are considered, one-third of overdose deaths can be reduced by maximally scaling all three policy options, while saving money.
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Affiliation(s)
- Joy D Scheidell
- Department of Health Sciences, University of Central Florida, PO Box 160000, Orlando, FL, 32816, USA.
| | - Tarlise N Townsend
- Department of Population Health, New York University Grossman School of Medicine, 227 E. 30th St, New York, NY, 10016, USA
- Center for Opioid Epidemiology and Policy, New York University Grossman School of Medicine, New York, NY, USA
| | - Qinlian Zhou
- Department of Population Health, New York University Grossman School of Medicine, 227 E. 30th St, New York, NY, 10016, USA
| | - Prima Manandhar-Sasaki
- Department of Population Health, New York University Grossman School of Medicine, 227 E. 30th St, New York, NY, 10016, USA
| | - Ramon Rodriguez-Santana
- HIV Prevention Program, Connecticut Department of Public Health, 410 Capitol Avenue, MS #11APV, Hartford, CT, 06134-0308, USA
| | - Mark Jenkins
- Connecticut Harm Reduction Alliance, 28 Grand St, Hartford, CT, 06106, USA
| | - Marianne Buchelli
- HIV Prevention Program, Connecticut Department of Public Health, 410 Capitol Avenue, MS #11APV, Hartford, CT, 06134-0308, USA
- TB, HIV, STD and Viral Hepatitis Section, Connecticut Department of Public Health, 410 Capitol Avenue, MS #11APV, Hartford, CT, 06134, USA
| | - Dyanna L Charles
- Department of Population Health, New York University Grossman School of Medicine, 227 E. 30th St, New York, NY, 10016, USA
| | - Jillian M Frechette
- Department of Population Health, New York University Grossman School of Medicine, 227 E. 30th St, New York, NY, 10016, USA
| | - Jasmine I-Shin Su
- Department of Population Health, New York University Grossman School of Medicine, 227 E. 30th St, New York, NY, 10016, USA
| | - R Scott Braithwaite
- Department of Population Health, New York University Grossman School of Medicine, 227 E. 30th St, New York, NY, 10016, USA
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Saloner B. The Overdose Crisis in the 2024 Election-Political Fights and Practical Problems. JAMA 2024; 331:1621-1622. [PMID: 38648055 DOI: 10.1001/jama.2024.4997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/25/2024]
Abstract
This Viewpoint discusses the 2024 presidential election in the context of the addiction and overdose crisis in the US, which has been a unifying challenge and a source of major ideological division in US politics.
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Affiliation(s)
- Brendan Saloner
- Department of Health Policy & Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Skinner A, Nolen S, Cerdá M, Rich JD, Marshall BD. A simple heuristic for allocating opioid settlement funding to reduce overdose mortality in the United States. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2024; 50:269-275. [PMID: 38940829 PMCID: PMC11305910 DOI: 10.1080/00952990.2024.2364338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 04/26/2024] [Accepted: 06/01/2024] [Indexed: 06/29/2024]
Abstract
As resolution for opioid-related claims and litigation against pharmaceutical manufacturers and other stakeholders, state and local governments are newly eligible for millions of dollars of settlement funding to address the overdose crisis in the United States. To inform effective use of opioid settlement funds, we propose a simple framework that highlights the principal determinants of overdose mortality: the number of people at risk of overdose each year, the average annual number of overdoses per person at risk, and the average probability of death per overdose event. We assert that the annual number of overdose deaths is a function of these three determinants, all of which can be modified through public health intervention. Our proposed heuristic depicts how each of these drivers of drug-related mortality - and the corresponding interventions designed to address each term - operate both in isolation and in conjunction. We intend for this framework to be used by policymakers as a tool for identifying and evaluating public health interventions and funding priorities that will most effectively address the structural forces shaping the overdose crisis and reduce overdose deaths.
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Affiliation(s)
- Alexandra Skinner
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Shayla Nolen
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
| | - Magdalena Cerdá
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, US
| | - Josiah D. Rich
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
- The Center for Health and Justice Transformation, The Miriam Hospital, Providence, RI, USA
- Department of Medicine, Rhode Island Hospital, Providence, RI, USA
| | - Brandon D.L. Marshall
- Department of Epidemiology, Brown University School of Public Health, Providence, RI, USA
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Zang X, Skinner A, Krieger MS, Behrends CN, Park JN, Green TC, Walley AY, Morgan JR, Linas BP, Yedinak JL, Schackman BR, Marshall BDL. Evaluation of Strategies to Enhance Community-Based Naloxone Distribution Supported by an Opioid Settlement. JAMA Netw Open 2024; 7:e2413861. [PMID: 38814644 PMCID: PMC11140538 DOI: 10.1001/jamanetworkopen.2024.13861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 03/28/2024] [Indexed: 05/31/2024] Open
Abstract
Importance Many US states are substantially increasing community-based naloxone distribution, supported in part through settlements from opioid manufacturers and distributors. Objectives To evaluate the potential impact of increased naloxone availability on opioid overdose deaths (OODs) and explore strategies to enhance this impact by integrating interventions to address solitary drug use. Design, Setting, and Participants This decision analytical modeling study used PROFOUND (Prevention and Rescue of Fentanyl and Other Opioid Overdoses Using Optimized Naloxone Distribution Strategies), a previously published simulation model, to forecast annual OODs between January 2023 and December 2025. The simulated study population included individuals from Rhode Island who misused opioids and stimulants and were at risk for opioid overdose. Exposures The study modeled expanded naloxone distribution supported by the state's opioid settlement (50 000 naloxone nasal spray kits each year). Two approaches to expanding naloxone distribution were evaluated: one based on historical spatial patterns of naloxone distribution (supply-based approach) and one based on the spatial distribution of individuals at risk (demand-based approach). In addition, hypothetical interventions to enhance the likelihood of witnessed overdoses in private or semiprivate settings were considered. Main Outcomes and Measures Annual number of OODs and ratio of fatal to nonfatal opioid overdoses. Results Modeling results indicated that distributing more naloxone supported by the state's opioid settlement could reduce OODs by 6.3% (95% simulation interval [SI], 0.3%-13.7%) and 8.8% (95% SI, 1.8%-17.5%) in 2025 with the supply-based and demand-based approaches, respectively. However, increasing witnessed overdoses by 20% to 60% demonstrated greater potential for reducing OODs, ranging from 8.5% (95% SI, 0.0%-20.3%) to 24.1% (95% SI, 8.6%-39.3%). Notably, synergistic associations were observed when combining both interventions: increased naloxone distribution with the 2 approaches and a 60% increase in witnessed overdoses could reduce OODs in 2025 by 33.5% (95% SI, 17.1%-50.4%) and 37.4% (95% SI, 19.6%-56.3%), respectively. Conclusions and Relevance These findings suggest that interventions to address solitary drug use are needed to maximize the impact of continued efforts to increase community-based naloxone distribution, which may be particularly important for jurisdictions that have strong community-based naloxone distribution programs.
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Affiliation(s)
- Xiao Zang
- Division of Health Policy and Management, School of Public Health, University of Minnesota, Minneapolis
| | - Alexandra Skinner
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island
| | - Maxwell S. Krieger
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island
| | - Czarina N. Behrends
- Department of Population Health Sciences, Weill Cornell Medical College, New York City, New York
| | - Ju N. Park
- Department of Medicine, Brown University, Providence, Rhode Island
| | - Traci C. Green
- The Heller School for Social Policy and Management, Brandeis University, Waltham, Massachusetts
| | - Alexander Y. Walley
- Department of Medicine, Section of General Internal Medicine, Boston Medical Center and Boston University School of Medicine, Boston, Massachusetts
| | - Jake R. Morgan
- Department of Health Law, Policy & Management, Boston University School of Public Health, Boston, Massachusetts
| | - Benjamin P. Linas
- Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Jesse L. Yedinak
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island
| | - Bruce R. Schackman
- Department of Population Health Sciences, Weill Cornell Medical College, New York City, New York
| | - Brandon D. L. Marshall
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island
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Manko CD, Ahmed MS, Harrison LR, Kodavatiganti SA, Lugo N, Konadu JO, Khan F, Massari CA, Sealey TK, Addison ME, Mbah CN, McCall KL, Fraiman JB, Piper BJ. Retrospective study investigating naloxone prescribing and cost in US Medicaid and Medicare patients. BMJ Open 2024; 14:e078592. [PMID: 38692729 PMCID: PMC11086430 DOI: 10.1136/bmjopen-2023-078592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2023] [Accepted: 03/25/2024] [Indexed: 05/03/2024] Open
Abstract
BACKGROUND Opioid overdoses in the USA have increased to unprecedented levels. Administration of the opioid antagonist naloxone can prevent overdoses. OBJECTIVE This study was conducted to reveal the pharmacoepidemiologic patterns in naloxone prescribing to Medicaid patients from 2018 to 2021 as well as Medicare in 2019. DESIGN Observational pharmacoepidemiologic study SETTING: US Medicare and Medicaid naloxone claims INTERVENTION: The Medicaid State Drug Utilisation Data File was utilised to extract information on the number of prescriptions and the amount prescribed of naloxone at a national and state level. The Medicare Provider Utilisation and Payment was also utilised to analyse prescription data from 2019. OUTCOME MEASURES States with naloxone prescription rates that were outliers of quartile analysis were noted. RESULTS The number of generic naloxone prescriptions per 100 000 Medicaid enrollees decreased by 5.3%, whereas brand naloxone prescriptions increased by 245.1% from 2018 to 2021. There was a 33.1-fold difference in prescriptions between the highest (New Mexico=1809.5) and lowest (South Dakota=54.6) states in 2019. Medicare saw a 30.4-fold difference in prescriptions between the highest (New Mexico) and lowest states (also South Dakota) after correcting per 100 000 enrollees. CONCLUSIONS This pronounced increase in the number of naloxone prescriptions to Medicaid patients from 2018 to 2021 indicates a national response to this widespread public health emergency. Further research into the origins of the pronounced state-level disparities is warranted.
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Affiliation(s)
| | - Mohamed S Ahmed
- Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Lavinia R Harrison
- Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
- Holy Family University, Philadelphia, Pennsylvania, USA
| | | | - Noelia Lugo
- Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Jason Osei Konadu
- Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
- Temple University College of Liberal Arts, Philadelphia, Pennsylvania, USA
| | - Farrin Khan
- Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Carrie A Massari
- Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Tenisha K Sealey
- Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Maame Efua Addison
- Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
- University of Scranton, Scranton, Pennsylvania, USA
| | - Celine N Mbah
- Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Kenneth L McCall
- Department of Pharmacy Practice, Binghamton University, Binghamton, New York, USA
- Department of Pharmacy Practice, University of New England, Portland, Maine, USA
| | - Joseph B Fraiman
- Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Brian J Piper
- Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
- Center for Pharmacy Innovation and Outcomes, Geisinger, Danville, Pennsylvania, USA
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Cerdá M, Hamilton AD, Hyder A, Rutherford C, Bobashev G, Epstein JM, Hatna E, Krawczyk N, El-Bassel N, Feaster DJ, Keyes KM. Simulating the Simultaneous Impact of Medication for Opioid Use Disorder and Naloxone on Opioid Overdose Death in Eight New York Counties. Epidemiology 2024; 35:418-429. [PMID: 38372618 DOI: 10.1097/ede.0000000000001703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/20/2024]
Abstract
BACKGROUND The United States is in the midst of an opioid overdose epidemic; 28.3 per 100,000 people died of opioid overdose in 2020. Simulation models can help understand and address this complex, dynamic, and nonlinear social phenomenon. Using the HEALing Communities Study, aimed at reducing opioid overdoses, and an agent-based model, Simulation of Community-Level Overdose Prevention Strategy, we simulated increases in buprenorphine initiation and retention and naloxone distribution aimed at reducing overdose deaths by 40% in New York Counties. METHODS Our simulations covered 2020-2022. The eight counties contrasted urban or rural and high and low baseline rates of opioid use disorder treatment. The model calibrated agent characteristics for opioid use and use disorder, treatments and treatment access, and fatal and nonfatal overdose. Modeled interventions included increased buprenorphine initiation and retention, and naloxone distribution. We predicted a decrease in the rate of fatal opioid overdose 1 year after intervention, given various modeled intervention scenarios. RESULTS Counties required unique combinations of modeled interventions to achieve a 40% reduction in overdose deaths. Assuming a 200% increase in naloxone from current levels, high baseline treatment counties achieved a 40% reduction in overdose deaths with a simultaneous 150% increase in buprenorphine initiation. In comparison, low baseline treatment counties required 250-300% increases in buprenorphine initiation coupled with 200-1000% increases in naloxone, depending on the county. CONCLUSIONS Results demonstrate the need for tailored county-level interventions to increase service utilization and reduce overdose deaths, as the modeled impact of interventions depended on the county's experience with past and current interventions.
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Affiliation(s)
- Magdalena Cerdá
- From the Department of Population Health, New York University School of Medicine, New York, NY
| | - Ava D Hamilton
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Ayaz Hyder
- Division of Environmental Health Sciences, College of Public Health, Ohio State University, Columbus, OH
| | - Caroline Rutherford
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Georgiy Bobashev
- Center for Data Science, RTI International, Research Triangle Park, NC
| | - Joshua M Epstein
- Department of Epidemiology, New York University School of Global Public Health, New York, NY
| | - Erez Hatna
- Department of Epidemiology, New York University School of Global Public Health, New York, NY
| | - Noa Krawczyk
- From the Department of Population Health, New York University School of Medicine, New York, NY
| | | | - Daniel J Feaster
- Department of Public Health Sciences, University of Miami Miller School of Medicine, Miami, FL
| | - Katherine M Keyes
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
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Nataraj N, Rikard SM, Zhang K, Jiang X, Guy GP, Rice K, Mattson CL, Gladden RM, Mustaquim DM, Illg ZN, Seth P, Noonan RK, Losby JL. Public Health Interventions and Overdose-Related Outcomes Among Persons With Opioid Use Disorder. JAMA Netw Open 2024; 7:e244617. [PMID: 38568691 PMCID: PMC10993074 DOI: 10.1001/jamanetworkopen.2024.4617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 02/05/2024] [Indexed: 04/05/2024] Open
Abstract
Importance Given the high number of opioid overdose deaths in the US and the complex epidemiology of opioid use disorder (OUD), systems models can serve as a tool to identify opportunities for public health interventions. Objective To estimate the projected 3-year association between public health interventions and opioid overdose-related outcomes among persons with OUD. Design, Setting, and Participants This decision analytical model used a simulation model of the estimated US population aged 12 years and older with OUD that was developed and analyzed between January 2019 and December 2023. The model was parameterized and calibrated using 2019 to 2020 data and used to estimate the relative change in outcomes associated with simulated public health interventions implemented between 2021 and 2023. Main Outcomes and Measures Projected OUD and medications for OUD (MOUD) prevalence in 2023 and number of nonfatal and fatal opioid-involved overdoses among persons with OUD between 2021 and 2023. Results In a baseline scenario assuming parameters calibrated using 2019 to 2020 data remained constant, the model projected more than 16 million persons with OUD not receiving MOUD treatment and nearly 1.7 million persons receiving MOUD treatment in 2023. Additionally, the model projected over 5 million nonfatal and over 145 000 fatal opioid-involved overdoses among persons with OUD between 2021 and 2023. When simulating combinations of interventions that involved reducing overdose rates by 50%, the model projected decreases of up to 35.2% in nonfatal and 36.6% in fatal opioid-involved overdoses among persons with OUD. Interventions specific to persons with OUD not currently receiving MOUD treatment demonstrated the greatest reduction in numbers of nonfatal and fatal overdoses. Combinations of interventions that increased MOUD initiation and decreased OUD recurrence were projected to reduce OUD prevalence by up to 23.4%, increase MOUD prevalence by up to 137.1%, and reduce nonfatal and fatal opioid-involved overdoses among persons with OUD by 6.7% and 3.5%, respectively. Conclusions and Relevance In this decision analytical model study of persons with OUD, findings suggested that expansion of evidence-based interventions that directly reduce the risk of overdose fatality among persons with OUD, such as through harm reduction efforts, could engender the highest reductions in fatal overdoses in the short-term. Interventions aimed at increasing MOUD initiation and retention of persons in treatment projected considerable improvement in MOUD and OUD prevalence but could require a longer time horizon for substantial reductions in opioid-involved overdoses.
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Affiliation(s)
- Nisha Nataraj
- Division of Overdose Prevention, National Center for Injury Prevention and Control, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - S. Michaela Rikard
- Division of Overdose Prevention, National Center for Injury Prevention and Control, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Kun Zhang
- Division of Overdose Prevention, National Center for Injury Prevention and Control, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Xinyi Jiang
- Division of Overdose Prevention, National Center for Injury Prevention and Control, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Gery P. Guy
- Division of Overdose Prevention, National Center for Injury Prevention and Control, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Ketra Rice
- Division of Injury Prevention, National Center for Injury Prevention and Control, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Christine L. Mattson
- Division of Overdose Prevention, National Center for Injury Prevention and Control, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - R. Matthew Gladden
- Division of Overdose Prevention, National Center for Injury Prevention and Control, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Desiree M. Mustaquim
- Division of Overdose Prevention, National Center for Injury Prevention and Control, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Zachary N. Illg
- Division of Overdose Prevention, National Center for Injury Prevention and Control, US Centers for Disease Control and Prevention, Atlanta, Georgia
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Puja Seth
- Division of Overdose Prevention, National Center for Injury Prevention and Control, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Rita K. Noonan
- Division of Overdose Prevention, National Center for Injury Prevention and Control, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Jan L. Losby
- Division of Overdose Prevention, National Center for Injury Prevention and Control, US Centers for Disease Control and Prevention, Atlanta, Georgia
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16
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Skolnick P. Comment on: Can Intranasal Nalmefene Reduce the Number of Opioid Overdose Deaths? Clin Pharmacol Drug Dev 2024; 13:317-318. [PMID: 38289195 DOI: 10.1002/cpdd.1382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 01/01/2024] [Indexed: 03/02/2024]
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17
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Han B, Compton WM, Einstein EB, Elder E, Volkow ND. Pregnancy and Postpartum Drug Overdose Deaths in the US Before and During the COVID-19 Pandemic. JAMA Psychiatry 2024; 81:270-283. [PMID: 37991773 PMCID: PMC10918496 DOI: 10.1001/jamapsychiatry.2023.4523] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 09/25/2023] [Indexed: 11/23/2023]
Abstract
Importance Knowledge about characteristics of US pregnancy-associated decedents is needed to guide responses. Objective To examine individual sociodemographic characteristics and residing county's health care resources and socioeconomic factors among pregnancy-associated overdose decedents in comparison with obstetric decedents and overdose decedents who were not pregnant in the past year. Design, Setting, and Participants This cross-sectional, exploratory study included 1457 pregnant and postpartum overdose decedents, 4796 obstetric decedents, and 11 205 nonpregnant overdose decedents aged 10 to 44 years from 2018 to 2021. Data were analyzed August 2023. Exposures Decedents from the 2018-2021 Multiple Cause of Death Files linked to the 2021 Area Health Resources Files and the 2018-2021 County Health Rankings data at the county level. Main Outcomes and Measures Pregnancy-associated deaths were defined as deaths during pregnancy or within 1 year of pregnancy termination. This study focused on unintentional drug overdoses or drug overdoses with undetermined intent involving the most common psychotropic drugs of misuse. Results From 2018 to 2021, across the pregnancy-postpartum continuum, pregnancy-associated overdose mortality ratios consistently increased among women aged 10 to 44 years. Mortality ratio more than tripled among pregnant and postpartum women aged 35 to 44 years from 4.9 (95% CI, 3.0-8.0) per 100 000 mothers aged 35 to 44 years with a live birth in January to June 2018 to 15.8 (95% CI, 12.3-20.4) in July to December 2021 (average semiannual percentage changes, 15.9; 95% CI, 8.7-23.6; P < .001). Compared with pregnant obstetric decedents, pregnant overdose decedents had increased odds of being aged 10 to 34 years (75.4% vs 59.5%; range of odds ratios [ORs], 1.8 [95% CI, 1.3-2.5] for ages 10 to 24 years to 2.2 [95% CI, 1.7-2.8] for ages 25 to 34 years), being non-college graduates (72.1% vs 59.4%; range of ORs, 2.7 [95% CI, 1.7-4.3] for those with some college education to 3.9 [95% CI, 2.4-6.1] for those with less than high school education), being unmarried (88.0% vs 62.1%; OR, 4.5; 95% CI, 3.7-6.0), and dying in nonhome, non-health care settings (25.9% vs 4.5%; OR, 2.5; 95% CI, 1.8-3.6) and were associated with decreased odds of dying in health care settings (34.7% vs 77.6%; range of ORs, 0.1 [95% CI, 0.1-0.1] for those who died in hospital inpatient settings to 0.4 [95% CI, 0.3-0.6] for those who died in hospital outpatient/emergency room settings). Conclusions and Relevance From 2018 to 2021, the mortality ratio more than tripled among pregnant and postpartum women aged 35 to 44 years, consistent with increases in overdose mortality across US populations. Most pregnancy-associated overdose deaths occurred outside health care settings, indicating the need for strengthening community outreach and maternal medical support. To reduce pregnancy-associated overdose mortality, evidence-based interventions are urgently needed at individual, health care, local, and national levels, along with nonpunitive approaches incentivizing pregnant and postpartum women to seek substance use disorder treatments.
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Affiliation(s)
- Beth Han
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| | - Wilson M. Compton
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| | - Emily B. Einstein
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| | - Emerald Elder
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
| | - Nora D. Volkow
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, Maryland
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18
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Knudsen HK, Freeman PR, Oyler DR, Oser CB, Walsh SL. Scaling up overdose education and naloxone distribution in Kentucky: adoption and reach achieved through a "hub with many spokes" model. Addict Sci Clin Pract 2023; 18:72. [PMID: 38031180 PMCID: PMC10688494 DOI: 10.1186/s13722-023-00426-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 11/17/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Scaling up overdose education and naloxone distribution (OEND), an evidence-based practice for reducing opioid overdose mortality, in communities remains a challenge. Novel models and intentional implementation strategies are needed. Drawing upon the EPIS model's phases of Exploration, Preparation, Implementation, and Sustainment (Aarons et al. in Adm Policy Ment Health 38:4-23, 2011), this paper describes the development of the University of Kentucky's unique centralized "Naloxone Hub with Many Spokes" approach to implementing OEND as part of the HEALing Communities Study (HCS-KY). METHODS To scale up OEND in eight Kentucky counties, implementation strategies were utilized at two levels: a centralized university-based naloxone dispensing unit ("Naloxone Hub") and adopting organizations ("Many Spokes"). Implementation strategies varied across the EPIS phases, but heavily emphasized implementation facilitation. The Naloxone Hub provided technical assistance, overdose education resources, and no-cost naloxone to partner organizations. Implementation outcomes across the EPIS phases were measured using data from internal study management trackers and naloxone distribution data submitted by partner organizations. RESULTS Of 209 organizations identified as potential partners, 84.7% (n = 177) engaged in the Exploration/Preparation phase by participating in an initial meeting with an Implementation Facilitator about the HCS-KY OEND program. Adoption of the HCS-KY OEND program, defined as receipt of at least one shipment of naloxone, was achieved with 69.4% (n = 145) of all organizations contacted. During the Implementation phase, partner organizations distributed 40,822 units of naloxone, with partner organizations distributing a mean of 281.5 units of naloxone (SD = 806.2). The mean number of units distributed per county was 5102.8 (SD = 3653.3; range = 1057 - 11,053) and the mean county level distribution rate was 8396.5 units per 100,000 residents (SD = 8103.1; range = 1709.5-25,296.3). Of the partner organizations that adopted the HCS-KY OEND program, 87.6% (n = 127) attended a sustainability meeting with an Implementation Facilitator and agreed to transition to the state-funded naloxone program. CONCLUSIONS These data demonstrate the feasibility of this "Hub with Many Spokes" model for scaling up OEND in communities highly affected by the opioid epidemic. Trial registration ClinicalTrials.gov, NCT04111939. Registered 30 September 2019, https://clinicaltrials.gov/ct2/show/NCT04111939 .
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Affiliation(s)
- Hannah K Knudsen
- Department of Behavioral Science and Center on Drug & Alcohol Research, University of Kentucky, 845 Angliana Avenue, Room 204, Lexington, KY, 40508, USA.
| | - Patricia R Freeman
- Department of Pharmacy Practice and Science and Center for the Advancement of Pharmacy Practice, College of Pharmacy, University of Kentucky, Lexington, KY, 40536, USA
| | - Douglas R Oyler
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, 40536, USA
| | - Carrie B Oser
- Department of Sociology, Center on Drug & Alcohol Research, and Center for Health Equity Transformation, University of Kentucky, Lexington, KY, 40536, USA
| | - Sharon L Walsh
- Department of Behavioral Science and Center on Drug & Alcohol Research, University of Kentucky, 845 Angliana Avenue, Room 204, Lexington, KY, 40508, USA
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Marks KR, Oyler DR, Strickland JC, Jaggers J, Roberts MF, Miracle DK, Barnes C, Lei F, Smith A, Mackin E, Martin MC, Freeman PR. Bystander preference for naloxone products: a field experiment. Harm Reduct J 2023; 20:171. [PMID: 38017424 PMCID: PMC10685501 DOI: 10.1186/s12954-023-00904-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Accepted: 11/17/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Bystander administration of naloxone is a critical strategy to mitigate opioid overdose mortality. To ensure bystanders' willingness to carry and administer naloxone in response to a suspected overdose, it is critical to select products for community distribution with the highest likelihood of being utilized. This study examines bystanders' preference for and willingness to administer three naloxone products approved by the FDA for bystander use and identify product features driving preference. METHODS The population was a convenience sample of individuals who attended the Kentucky State Fair, August 18-28, 2022, in Louisville, Kentucky. Participants (n = 503) watched a standardized overdose education and naloxone training video, rated their willingness to administer each of three products (i.e., higher-dose nasal spray, lower-dose nasal spray, intramuscular injection), selected a product to take home, and rated factors affecting choice. RESULTS After training, 44.4% chose the higher-dose nasal spray, 30.1% chose the intramuscular injection, and 25.5% chose the lower-dose nasal spray. Factors most influencing choice on a 10-point Likert scale were ease of use (9 [7-10]), naloxone dose (8 [5-10]), and product familiarity (5 [5-9]). CONCLUSIONS Bystanders expressed high willingness to administer all studied formulations of naloxone products. Product choice preference varied as a function of product features. As the number and variety of available products continue to increase, continuous evaluation of formulation acceptability, in addition to including individuals with lived experience who are receiving and administering overdose reversal agents, is critical to support adoption and save lives.
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Affiliation(s)
- Katherine R Marks
- Department of Behavioral Science, College of Medicine, University of Kentucky, Lexington, KY, USA.
- Department for Behavioral Health, Developmental and Intellectual Disabilities, Cabinet for Health and Family Services, 275 E. Main Street, Frankfort, KY, 40621, USA.
| | - Douglas R Oyler
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Justin C Strickland
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jody Jaggers
- Kentucky Pharmacy Education and Research Foundation, Frankfort, KY, USA
| | - Monica F Roberts
- Substance Use Priority Research Area, University of Kentucky, Lexington, KY, USA
| | - Dustin K Miracle
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Chase Barnes
- Kentucky Department for Public, Health Division of Public Health Protection & Safety, Frankfort, KY, USA
| | - Feitong Lei
- Department of Biostatistics, College of Public Health, University of Kentucky, Lexington, KY, USA
| | - Amanda Smith
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Eric Mackin
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
| | - Martika C Martin
- Kentucky Pharmacy Education and Research Foundation, Frankfort, KY, USA
| | - Patricia R Freeman
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, KY, USA
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Dahlem CH, Patil R, Khadr L, Ploutz-Snyder RJ, Boyd CJ, Shuman CJ. Effectiveness of take ACTION online naloxone training for law enforcement officers. HEALTH & JUSTICE 2023; 11:47. [PMID: 37979100 PMCID: PMC10656891 DOI: 10.1186/s40352-023-00250-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Accepted: 11/09/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Training law enforcement officers (LEOs) to administer naloxone is a recommended strategy to reduce overdose deaths in the United States. To achieve this, an evidence-based and scalable naloxone training curriculum that is easy to use and readily scalable is needed. Convenient web-based training is a flexible method for delivering educational interventions particularly for LEOs who have irregular or shifting schedules. This study examined the effectiveness of a comprehensive web-based naloxone training that was created in partnership with LEOs on their knowledge, confidence, and attitudes regarding naloxone. METHODS From May 2019 to September 2020, five law enforcement departments from Michigan participated in web-based naloxone training. A total of 182 LEOs (77% male) were in the final sample based on matching pre-and post-test surveys. LEOs were assessed on knowledge, confidence, and attitudes towards naloxone. Negative binomial and Poisson regression was conducted to assess associations between knowledge, confidence, and attitudes towards naloxone before and after training. RESULTS Significant improvements in overdose knowledge and confidence were revealed across all departments with median (IQR) total composite scores for knowledge increasing from 35 (32, 37) to 40 (39, 42) (p < 0.01) and confidence increasing from 18.5 (15, 20) to 20 (20, 25) (p < 0.01). Median (IQR) attitude scores did not change. CONCLUSION Our web-based naloxone training was effective in improving knowledge and confidence for LEOs but did not significantly improve LEOs attitudes towards naloxone across most departments. The web-based format is readily scalable and quickly disseminated and meets the immediate need for LEO overdose training. Additional intervention is needed to address the negative attitudes of LEOs regarding naloxone.
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Affiliation(s)
- Chin Hwa Dahlem
- Center for the Study of Drugs, Alcohol, Smoking and Health, Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, 400 N. Ingalls Rd Rm 3174, Ann Arbor, MI, 48109, USA.
| | - Rohan Patil
- Center for the Study of Drugs, Alcohol, Smoking and Health, Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, 400 N. Ingalls Rd Rm 3174, Ann Arbor, MI, 48109, USA
| | - Lara Khadr
- Applied Biostatistics Laboratory, Ann Arbor, USA
| | | | - Carol J Boyd
- Center for the Study of Drugs, Alcohol, Smoking and Health, Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, 400 N. Ingalls Rd Rm 3174, Ann Arbor, MI, 48109, USA
| | - Clayton J Shuman
- Center for the Study of Drugs, Alcohol, Smoking and Health, Department of Health Behavior and Biological Sciences, School of Nursing, University of Michigan, 400 N. Ingalls Rd Rm 3174, Ann Arbor, MI, 48109, USA
- Department of System Populations and Leadership, Ann Arbor, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, USA
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Diaz JE, Preciado E, Chiasson MA, Hirshfield S. Association Between Age of Anal Sex Debut and Adult Health Behaviors Among Sexual Minoritized Men Living with HIV. ARCHIVES OF SEXUAL BEHAVIOR 2023; 52:3565-3575. [PMID: 37378702 PMCID: PMC11034742 DOI: 10.1007/s10508-023-02642-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 06/01/2023] [Accepted: 06/02/2023] [Indexed: 06/29/2023]
Abstract
Earlier age of anal sex debut (ASD) has been linked with contemporary and long-term health outcomes, including vulnerability to HIV acquisition. The goal of this study was to utilize a life course approach to examine associations between earlier ASD and recent health behaviors among sexual minoritized men (SMM) living with HIV. A total of 1156 U.S. SMM living with HIV recruited from social and sexual networking apps and websites completed online surveys as part of a longitudinal eHealth intervention. Data from baseline surveys were analyzed to determine associations between age of ASD and adult health outcomes, including mental health, HIV viral load, and substance use. The median age of ASD among these participants was 17 years old, consistent with other work. Earlier ASD was significantly associated with a greater likelihood of past 2-week anxiety (AOR = 1.45, 95% CI 1.07-1.97) and past 3-month opioid use (AOR = 1.60, 95% CI 1.13-2.26); no significant associations were found for recent depression, HIV viral load, or stimulant use. Earlier ASD may function as an important proxy measure for deleterious health outcomes in adulthood, particularly recent anxiety and opioid use. Expansion of comprehensive and affirming sexual health education is critical to early engagement of individuals with a higher risk of HIV acquisition, with plausible downstream health benefits lasting into adulthood among SMM living with HIV.
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Affiliation(s)
- José E Diaz
- Department of Medicine, STAR Program, SUNY Downstate Health Sciences University, 450 Clarkson Avenue, Brooklyn, NY, 11203, USA
| | | | - Mary Ann Chiasson
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY, USA
- Division of Infectious Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Sabina Hirshfield
- Department of Medicine, STAR Program, SUNY Downstate Health Sciences University, 450 Clarkson Avenue, Brooklyn, NY, 11203, USA.
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22
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Sugarman OK, Hulsey EG, Heller D. Achieving the Potential of Naloxone Saturation by Measuring Distribution. JAMA HEALTH FORUM 2023; 4:e233338. [PMID: 37889482 DOI: 10.1001/jamahealthforum.2023.3338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2023] Open
Abstract
This Viewpoint advocates for improved strategies to measure naloxone distribution and evaluate how effectively naloxone reaches people most likely to experience or witness an opioid overdose.
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Affiliation(s)
- Olivia K Sugarman
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Rioux W, Marshall T, Ghosh SM. Virtual overdose monitoring services and overdose prevention technologies: Opportunities, limitations, and future directions. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 119:104121. [PMID: 37453373 DOI: 10.1016/j.drugpo.2023.104121] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 06/29/2023] [Accepted: 07/03/2023] [Indexed: 07/18/2023]
Abstract
Overdose mortality has continued to rise in North America and across the globe in people who use drugs. Current harm reduction strategies such as supervised consumption sites and naloxone kit distribution have been important public health strategies implemented to decrease the harms associated with illicit drug use however have key limitations which prevent their scalability. This is represented in statistics which indicate that the vast majority of overdose mortality occur in individuals who use drugs by themselves. To address this, virtual overdose monitoring services and overdose detection technologies have emerged as an adjunct solution that may help improve access to harm reduction services for those that cannot or choose not to access current in-person services. This article outlines the current limitations of harm reduction services, the opportunities, challenges, and controversies of these technologies and services, and suggests avenues for additional research and policy development.
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Affiliation(s)
- William Rioux
- Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Tyler Marshall
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - S Monty Ghosh
- Department of Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada; Department of General Internal Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada.
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Rosenberg M. Updated Estimates of Annual U.S. Health System Spending from a Hypothetical National Naloxone Co-Prescribing Mandate. Subst Use Misuse 2023; 58:1707-1713. [PMID: 37614062 PMCID: PMC10544767 DOI: 10.1080/10826084.2023.2244065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/25/2023]
Abstract
Background: Naloxone-prescription opioid co-prescribing mandates have increasingly been proposed and adopted in the U.S., at both the national and state levels, as a public health intervention for mitigating the impacts of opioid overdoses. In this study, we assess whether a hypothetical national, naloxone co-prescribing mandate has become less costly for the U.S. health system since 2018. Methods: We expand and update an existing economic model of naloxone co-prescribing to estimate annual health system spending. We refresh the model inputs through 2021 to reflect changes to the opioid and naloxone landscapes, expand the model to account for more types of market responses, and develop additional scenarios around alternate implementation strategies such as bulk purchasing. Results: We estimate annual spending increases across all retail opioid patients of $1.4-$4.0 billion with naloxone nasal sprays and auto-injectors, and $0.6-$0.9 billion with traditional injectable naloxone formulations. We also find that bulk purchasing could lead to higher spending increases in some patient populations absent volume discounts. Conclusions: Our estimates are substantially lower than prior research. Key drivers include lower prices for naloxone, higher current naloxone distribution, a longer approved shelf life for naloxone, and lower estimated sizes for some patient populations. Additional research is needed to estimate the potential benefits of naloxone co-prescribing for mitigating opioid overdoses, and whether they could outweigh spending increases. Steps that could make this policy more beneficial or less costly include targeting higher risk patient populations and promoting large-scale purchasing agreements with volume discounts to help offset potential price increases.
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Affiliation(s)
- Matthew Rosenberg
- Economics Staff, Center for Drug Evaluation and Research, US Food and Drug Administration. 10903 New Hampshire Avenue, Silver Spring, MD 20993, USA
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25
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Lowenstein M, Abrams MP, Crowe M, Shimamoto K, Mazzella S, Botcheos D, Bertocchi J, Westfahl S, Chertok J, Garcia KP, Truchil R, Holliday-Davis M, Aronowitz S. "Come try it out. Get your foot in the door:" Exploring patient perspectives on low-barrier treatment for opioid use disorder. Drug Alcohol Depend 2023; 248:109915. [PMID: 37207615 PMCID: PMC10330675 DOI: 10.1016/j.drugalcdep.2023.109915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 04/15/2023] [Accepted: 05/05/2023] [Indexed: 05/21/2023]
Abstract
PURPOSE Low-barrier treatment is an emerging strategy for opioid use disorder (OUD) care that prioritizes access to evidence-based medication while minimizing requirements that may limit treatment access in more traditional delivery models, particularly for marginalized patients. Our objective was to explore patient perspectives about low-barrier approaches, with a focus on understanding barriers to and facilitators of engagement from the patient point of view. METHODS We conducted semi-structured interviews with patients accessing buprenorphine treatment from a multi-site, low-barrier mobile treatment program in Philadelphia, PA from July-December 2021. We analyzed interview data using thematic content analysis and identified key themes. RESULTS The 36 participants were 58% male, 64% Black, 28% White, and 31% Latinx. 89% were enrolled in Medicaid, and 47% were unstably housed. Our analysis revealed three main facilitators of treatment in the low-barrier model. These included 1) program structure that met participant needs, such as flexibility, rapid medication access and robust case management services; 2) harm reduction approach that included acceptance of patient goals other than abstinence and provision of harm reduction services on-site; and 3) strong interpersonal connections with team members, including those with lived experience. Participants contrasted these experiences with other care they had received in the past. Barriers related to lack of structure, limitations of street-based care, and limited support for co-occurring needs, particularly mental health. CONCLUSIONS This study provides key patient perspectives on low-barrier approaches for OUD treatment. Our findings can inform future program design to increase treatment access and engagement for individuals poorly served by traditional delivery models.
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Affiliation(s)
- Margaret Lowenstein
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia, PA, United States; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States.
| | - Matthew P Abrams
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Molly Crowe
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | | | | | - Denise Botcheos
- Prevention Point Philadelphia, Philadelphia, PA, United States
| | | | - Shawn Westfahl
- Prevention Point Philadelphia, Philadelphia, PA, United States
| | - Judy Chertok
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Kristine Pamela Garcia
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Rachael Truchil
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - M Holliday-Davis
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - Shoshana Aronowitz
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, United States; University of Pennsylvania School of Nursing, Philadelphia, PA, United States
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Gray M, Shin SS, Silcox J, Flores D, Bolivar D, Irwin AN, Floyd AS, Bratberg J, Boggis JS, Hartung DM, Green TC. "Like it was just everyday business": A qualitative study of pharmacy-based naloxone and syringe customer experience. J Am Pharm Assoc (2003) 2023; 63:838-846. [PMID: 36872182 PMCID: PMC10198806 DOI: 10.1016/j.japh.2023.01.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 12/16/2022] [Accepted: 01/20/2023] [Indexed: 01/28/2023]
Abstract
BACKGROUND As rates of overdoses involving opioids continue to rise in the United States, community pharmacies are uniquely positioned as a central access point of care for individuals to access harm reduction supplies, such as naloxone and nonprescription syringes (NPS). OBJECTIVES This study aimed to identify the facilitators and barriers of obtaining naloxone and NPS at community pharmacies that participated in Respond to Prevent (R2P), a multicomponent intervention to increase dispensing rates of naloxone, buprenorphine, and NPS. METHODS Pharmacy customers were recruited to participate in semistructured qualitative interviews conducted immediately after they obtained, or attempted to obtain, naloxone and NPS (when applicable) from R2P-participating pharmacies. Thematic analysis was conducted on the transcribed interviews, and content coding was applied to ethnographic notes and text messages from participants. RESULTS Of the 32 participants, most (n = 28, 88%) successfully obtained naloxone and most of those seeking NPS successfully (n = 14, 82%) purchased them as well. Participants reported positive overall experiences at the community pharmacies. Participants described using the intervention advertising materials, as designed, to facilitate the request for naloxone. Many participants shared that they felt respected by pharmacists and that they valued naloxone counseling sessions that were tailored to meet their needs and allowed space for them to ask questions. Barriers included experiences where the intervention did not address structural challenges that prohibited the purchase of naloxone and where certain types of staff lacked knowledge, treated participants poorly, or did not adequately provide expected naloxone counseling. CONCLUSION Pharmacy customer experiences obtaining naloxone and NPS in R2P-participating pharmacies identify facilitators and barriers to access that may be used to reform implementation and future interventions. Barriers identified can help enhance strategies or inform policies to improve pharmacy-based harm reduction supply distribution not addressed through existing interventions.
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Affiliation(s)
| | | | - Joseph Silcox
- Opioid Policy Research Collaborative, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA
| | | | - Derek Bolivar
- Opioid Policy Research Collaborative, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA
| | | | - Anthony S. Floyd
- University of Washington, School of Medicine, Addictions, Drug, & Alcohol Institute, Seattle, WA
| | | | - Jesse S. Boggis
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine, Dartmouth College, Lebanon, NH
| | | | - Traci C. Green
- Opioid Policy Research Collaborative, The Heller School for Social Policy and Management, Brandeis University, Waltham, MA
- COBRE on Opioids and Overdose and the Department of Emergency Medicine, Rhode Island Hospital, Providence, RI
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27
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Tay Wee Teck J, Oteo A, Baldacchino A. Rapid opioid overdose response system technologies. Curr Opin Psychiatry 2023:00001504-990000000-00063. [PMID: 37185583 DOI: 10.1097/yco.0000000000000870] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
PURPOSE OF REVIEW Opioid overdose events are a time sensitive medical emergency, which is often reversible with naloxone administration if detected in time. Many countries are facing rising opioid overdose deaths and have been implementing rapid opioid overdose response Systems (ROORS). We describe how technology is increasingly being used in ROORS design, implementation and delivery. RECENT FINDINGS Technology can contribute in significant ways to ROORS design, implementation, and delivery. Artificial intelligence-based modelling and simulations alongside wastewater-based epidemiology can be used to inform policy decisions around naloxone access laws and effective naloxone distribution strategies. Data linkage and machine learning projects can support service delivery organizations to mobilize and distribute community resources in support of ROORS. Digital phenotyping is an advancement in data linkage and machine learning projects, potentially leading to precision overdose responses. At the coalface, opioid overdose detection devices through fixed location or wearable sensors, improved connectivity, smartphone applications and drone-based emergency naloxone delivery all have a role in improving outcomes from opioid overdose. Data driven technologies also have an important role in empowering community responses to opioid overdose. SUMMARY This review highlights the importance of technology applied to every aspect of ROORS. Key areas of development include the need to protect marginalized groups from algorithmic bias, a better understanding of individual overdose trajectories and new reversal agents and improved drug delivery methods.
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Affiliation(s)
- Joseph Tay Wee Teck
- DigitAS Project, Population and Behavioural Science Division, School of Medicine, University of St Andrews, St Andrews
- Forward Leeds and Humankind Charity, Durham, UK
| | - Alberto Oteo
- DigitAS Project, Population and Behavioural Science Division, School of Medicine, University of St Andrews, St Andrews
| | - Alexander Baldacchino
- DigitAS Project, Population and Behavioural Science Division, School of Medicine, University of St Andrews, St Andrews
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Griffith J, Yorlets RR, Chambers LC, Davis CS, Wentz A, Beaudoin FL, Baird J, Samuels EA. Statewide Policy to Increase Provision of Take-Home Naloxone at Emergency Department Visits for Opioid Overdose, Rhode Island, 2018‒2019. Am J Public Health 2023; 113:372-377. [PMID: 36745856 PMCID: PMC10003491 DOI: 10.2105/ajph.2022.307213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2022] [Indexed: 02/08/2023]
Abstract
In 2017, Rhode Island responded to rising overdose deaths by establishing statewide emergency department (ED) treatment standards for opioid overdose and opioid use disorder. One requirement of the policy is that providers prescribe or provide take-home naloxone to anyone presenting to EDs with opioid overdose. Among adults presenting to EDs with opioid overdose from 2018 to 2019, approximately half received take-home naloxone. Receipt of naloxone was associated with administration of naloxone before ED presentation, ED policy certification level, and regional overdose frequency. (Am J Public Health. 2023;113(4):372-377. https://doi.org/10.2105/AJPH.2022.307213).
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Affiliation(s)
- Jennifer Griffith
- Jennifer Griffith is with Brown University, Providence, RI. Rachel R. Yorlets is with the Department of Epidemiology at the Brown University School of Public Health. Laura C. Chambers is with the Substance Use Epidemiology Program at the Rhode Island Department of Health. Corey S. Davis is with the Network for Public Health Law, Edina, MN. Anna Wentz and Francesca L. Beaudoin are with the Department of Epidemiology at the Brown University School of Public Health. Janette Baird and Elizabeth A. Samuels are with the Department of Emergency Medicine at the Warren Alpert Medical School of Brown University
| | - Rachel R Yorlets
- Jennifer Griffith is with Brown University, Providence, RI. Rachel R. Yorlets is with the Department of Epidemiology at the Brown University School of Public Health. Laura C. Chambers is with the Substance Use Epidemiology Program at the Rhode Island Department of Health. Corey S. Davis is with the Network for Public Health Law, Edina, MN. Anna Wentz and Francesca L. Beaudoin are with the Department of Epidemiology at the Brown University School of Public Health. Janette Baird and Elizabeth A. Samuels are with the Department of Emergency Medicine at the Warren Alpert Medical School of Brown University
| | - Laura C Chambers
- Jennifer Griffith is with Brown University, Providence, RI. Rachel R. Yorlets is with the Department of Epidemiology at the Brown University School of Public Health. Laura C. Chambers is with the Substance Use Epidemiology Program at the Rhode Island Department of Health. Corey S. Davis is with the Network for Public Health Law, Edina, MN. Anna Wentz and Francesca L. Beaudoin are with the Department of Epidemiology at the Brown University School of Public Health. Janette Baird and Elizabeth A. Samuels are with the Department of Emergency Medicine at the Warren Alpert Medical School of Brown University
| | - Corey S Davis
- Jennifer Griffith is with Brown University, Providence, RI. Rachel R. Yorlets is with the Department of Epidemiology at the Brown University School of Public Health. Laura C. Chambers is with the Substance Use Epidemiology Program at the Rhode Island Department of Health. Corey S. Davis is with the Network for Public Health Law, Edina, MN. Anna Wentz and Francesca L. Beaudoin are with the Department of Epidemiology at the Brown University School of Public Health. Janette Baird and Elizabeth A. Samuels are with the Department of Emergency Medicine at the Warren Alpert Medical School of Brown University
| | - Anna Wentz
- Jennifer Griffith is with Brown University, Providence, RI. Rachel R. Yorlets is with the Department of Epidemiology at the Brown University School of Public Health. Laura C. Chambers is with the Substance Use Epidemiology Program at the Rhode Island Department of Health. Corey S. Davis is with the Network for Public Health Law, Edina, MN. Anna Wentz and Francesca L. Beaudoin are with the Department of Epidemiology at the Brown University School of Public Health. Janette Baird and Elizabeth A. Samuels are with the Department of Emergency Medicine at the Warren Alpert Medical School of Brown University
| | - Francesca L Beaudoin
- Jennifer Griffith is with Brown University, Providence, RI. Rachel R. Yorlets is with the Department of Epidemiology at the Brown University School of Public Health. Laura C. Chambers is with the Substance Use Epidemiology Program at the Rhode Island Department of Health. Corey S. Davis is with the Network for Public Health Law, Edina, MN. Anna Wentz and Francesca L. Beaudoin are with the Department of Epidemiology at the Brown University School of Public Health. Janette Baird and Elizabeth A. Samuels are with the Department of Emergency Medicine at the Warren Alpert Medical School of Brown University
| | - Janette Baird
- Jennifer Griffith is with Brown University, Providence, RI. Rachel R. Yorlets is with the Department of Epidemiology at the Brown University School of Public Health. Laura C. Chambers is with the Substance Use Epidemiology Program at the Rhode Island Department of Health. Corey S. Davis is with the Network for Public Health Law, Edina, MN. Anna Wentz and Francesca L. Beaudoin are with the Department of Epidemiology at the Brown University School of Public Health. Janette Baird and Elizabeth A. Samuels are with the Department of Emergency Medicine at the Warren Alpert Medical School of Brown University
| | - Elizabeth A Samuels
- Jennifer Griffith is with Brown University, Providence, RI. Rachel R. Yorlets is with the Department of Epidemiology at the Brown University School of Public Health. Laura C. Chambers is with the Substance Use Epidemiology Program at the Rhode Island Department of Health. Corey S. Davis is with the Network for Public Health Law, Edina, MN. Anna Wentz and Francesca L. Beaudoin are with the Department of Epidemiology at the Brown University School of Public Health. Janette Baird and Elizabeth A. Samuels are with the Department of Emergency Medicine at the Warren Alpert Medical School of Brown University
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Bohler RM, Freeman PR, Villani J, Hunt T, Linas BS, Walley AY, Green TC, Lofwall MR, Bridden C, Frazier LA, Fanucchi LC, Talbert JC, Chandler R. The policy landscape for naloxone distribution in four states highly impacted by fatal opioid overdoses. DRUG AND ALCOHOL DEPENDENCE REPORTS 2023; 6:100126. [PMID: 36643788 PMCID: PMC9838196 DOI: 10.1016/j.dadr.2022.100126] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Expanding access to naloxone is one of the most impactful interventions in decreasing opioid-related mortality. However, state distribution rates of naloxone are insufficient to meet community need. The current study sought to better understand this gap by focusing on state policies that may facilitate or impede naloxone distribution in four states highly impacted by fatal opioid overdoses - Kentucky, Massachusetts, New York, and Ohio. Methods We provide a descriptive analysis of the policy landscape impacting naloxone distribution through pharmacy and community channels in the four states participating in the HEALing Communities Study (HCS). Publicly available data and the expertise of the research team were used to describe each state's naloxone access laws (NALs), Medicaid coverage of naloxone, and community overdose education and naloxone distribution infrastructure. Data presented in this study represent the most current policy landscape through September 2022. Results Variation exists between specific components of the NALs of each state, the structure of Medicaid coverage of naloxone, and the community distribution infrastructure networks. Massachusetts and New York have a statewide standing order, but other states use different strategies short of a statewide standing order to expand access to naloxone. Quantity limits specific to naloxone may limit access to Medicaid beneficiaries in some states. Conclusion States participating in the HCS have developed innovative but different mechanisms to ensure naloxone access. Policies were dynamic and moved towards greater access. Research should consider the policy landscape in the implementation and sustainability of interventions as well as the analysis of outcomes.
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Affiliation(s)
- Robert M. Bohler
- Institute for Behavioral Health, Brandeis University, 415 South Street, Waltham, MA 02453, United States,Corresponding author. (R.M. Bohler)
| | - Patricia R. Freeman
- Department of Pharmacy Practice and Science, University of Kentucky, Lexington, KY, United States
| | - Jennifer Villani
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD, United States
| | - Tim Hunt
- School of Social Work, Social Intervention Group (SIG), Center for Healing of Opioid and Other Substance Use Disorders (CHOSEN), Columbia University, New York, NY, United States
| | - Beth S. Linas
- RTI International, Research Triangle Park, NC, United States
| | - Alexander Y. Walley
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, United States
| | - Traci C. Green
- Institute for Behavioral Health, Brandeis University, 415 South Street, Waltham, MA 02453, United States
| | - Michelle R. Lofwall
- Departments of Behavioral Science and Psychiatry, Center on Drug and Alcohol Research, University of Kentucky College of Medicine, Lexington, KY, United States
| | - Carly Bridden
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, MA, United States
| | - Lisa A. Frazier
- Center for Health Outcomes and Policy Evaluation Studies, College of Public Health, The Ohio State University, Columbus, OH, United States
| | - Laura C. Fanucchi
- Department of Internal Medicine, Division of Infectious Disease, Center on Drug and Alcohol Research, University of Kentucky College of Medicine, Lexington, KY, United States
| | - Jeffery C. Talbert
- Institute for Biomedical Informatics, University of Kentucky College of Medicine, Lexington, KY, United States
| | - Redonna Chandler
- National Institute on Drug Abuse, National Institutes of Health, Bethesda, MD, United States
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Lambdin BH, Wenger L, Bluthenthal R, Bartholomew TS, Tookes HE, LaKosky P, O'Neill S, Kral AH. How do contextual factors influence naloxone distribution from syringe service programs in the USA: a cross-sectional study. Harm Reduct J 2023; 20:26. [PMID: 36855181 PMCID: PMC9972698 DOI: 10.1186/s12954-023-00755-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 02/09/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Naloxone is a medication that can quickly reverse an opioid overdose. Syringe service programs (SSPs) are community-based prevention programs that provide a range of evidence-based interventions in the USA, including naloxone distribution. Attributes of SSPs make them ideal settings for naloxone distribution-they have staff and delivery models that are designed to reach people who use drugs where they are. We assessed which outer and inner setting factors of SSPs were associated with naloxone distribution in the USA. METHODS We surveyed SSPs in the USA known to the North American Syringe Exchange Network in 2019. Using the exploration, preparation, implementation and maintenance framework, we assessed inner and outer contextual factors associated with naloxone distribution among SSPs (n = 263 or 77% of SSPs). We utilized negative binomial regression to assess which factors were associated with the number of naloxone doses distributed and people receiving naloxone. RESULTS SSPs reported distributing 710,232 naloxone doses to 230,506 people in the prior year. Regarding outer setting, SSPs located in areas with high levels of community support had a higher level of naloxone distribution (aIRR = 3.07; 95% confidence interval (CI): 2.09-4.51; p < 0.001) and 110% (p = 0.022) higher rate of people receiving naloxone (aIRR = 2.10; 95% CI 1.46-3.02; p < 0.001) in the past 12 months. The legal status of SSPs and the level of need was not significantly associated with naloxone distribution. Regarding inner setting, SSPs with proactive refill systems (aIRR = 2.08; 95% CI 1.27-3.41; p = 0.004), greater number of distribution days (aIRR = 1.09 per day; 95% CI 1.06-1.11; p < 0.001) and older programs (aIRR = 1.06 per year; 95% CI 1.02-1.11; p = 0.004) were associated with higher levels of naloxone distribution. Also, SSPs with proactive refill systems (aIRR = 2.23; 95% CI 1.38-3.58; p = 0.001); greater number of distribution days (aIRR = 1.04; 95% CI 1.02-1.07; p < 0.001) and older programs (aIRR = 1.11; 95% CI 1.05-1.17; p < 0.001) were associated with a higher number of people receiving naloxone. CONCLUSION We identified outer and inner setting factors of SSPs that were associated with greater naloxone distribution. It is critical to ensure SSPs are adequately resourced to build community support for services and develop service delivery models that maximize naloxone distribution to address the nation's opioid overdose crisis.
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Affiliation(s)
- Barrot H Lambdin
- RTI International, Berkeley, CA, USA.
- University of California San Francisco, San Francisco, CA, USA.
- University of Washington, Seattle, WA, USA.
| | | | | | | | | | - Paul LaKosky
- North American Syringe Exchange Network, Tacoma, WA, USA
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Ardeljan AD, Fiedler B, Fiedler L, Luck GR, Maki DG, Clayton L, Hennekens CH, Ferris A. Naloxone Over the Counter: Increasing Opportunities and Challenges for Health Providers. Am J Med 2023; 136:504-506. [PMID: 36750143 DOI: 10.1016/j.amjmed.2023.01.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 01/17/2023] [Indexed: 02/07/2023]
Affiliation(s)
- Amalia D Ardeljan
- Affiliate Assistant Professor of Medicine, Charles E. Schmidt College of Medicine, Florida Atlantic University
| | - Benjamin Fiedler
- Fourth year medical student, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton
| | - Lawrence Fiedler
- Affiliate Assistant Professor of Medicine, Charles E. Schmidt College of Medicine, Florida Atlantic University
| | - George R Luck
- Department of Anesthesiology, Professional Education, Simulation Center, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton
| | - Dennis G Maki
- Department of Medicine, Infectious Disease and Critical Care Medicine, University of Wisconsin School of Medicine & Public Health, Madison
| | - Lisa Clayton
- Department of Emergency Medicine, Emergency Medicine Residency, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton
| | - Charles H Hennekens
- Department of Medicine and Department of Population Health and Social Medicine, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton
| | - Allison Ferris
- Department of Medicine, Internal Medicine Residency, Charles E. Schmidt College of Medicine, Florida Atlantic University, Boca Raton.
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Heiman E, Lanh S, Moran TP, Steck A, Carpenter J. Electronic Advisories Increase Naloxone Prescribing Across Health Care Settings. J Gen Intern Med 2022; 38:1402-1409. [PMID: 36376626 PMCID: PMC9663180 DOI: 10.1007/s11606-022-07876-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 10/24/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Naloxone is a life-saving, yet underprescribed, medication that is recommended to be provided to patients at high risk of opioid overdose. OBJECTIVE We set out to evaluate the changes in prescriber practices due to the use of an electronic health record (EHR) advisory that prompted opioid prescribers to co-prescribe naloxone when prescribing a high-dose opioid. It also provided prescribers with guidance on decreasing opioid doses for safety. DESIGN This was a retrospective chart abstraction study looking at all opioid prescriptions and all naloxone prescriptions written as emergency department (ED) discharge, inpatient hospital discharge, or outpatient medications, between July 1, 2018, and February 1, 2020. The EHR advisory went live on June 1, 2019. SUBJECTS Included in the analysis were all adult patients seen in the abovementioned settings at a large county hospital and associated outpatient clinics. MAIN MEASURES We performed an interrupted time series analysis looking at naloxone prescriptions and daily opioid dosing in morphine milligram equivalents (MMEs), before and after initiation of the EHR advisory. KEY RESULTS The EHR advisory was associated with changes in prescribers' behavior, leading to increased naloxone prescriptions and decreased prescribed opioid doses. CONCLUSIONS EHR advisories are an effective systems-level intervention to enhance the safety of prescribed opioids and increase rates of naloxone prescribing.
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Affiliation(s)
- Erica Heiman
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.
| | - Sothivin Lanh
- Department of Emergency Medicine, Summa Health System, Akron, OH, USA
| | - Tim P Moran
- Department of Emergency Medicine, Emory School of Medicine, Atlanta, GA, USA
| | - Alaina Steck
- Department of Emergency Medicine, Emory School of Medicine, Atlanta, GA, USA
| | - Joseph Carpenter
- Department of Emergency Medicine, Emory School of Medicine, Atlanta, GA, USA
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Zang X, Bessey SE, Krieger MS, Hallowell BD, Koziol JA, Nolen S, Behrends CN, Murphy SM, Walley AY, Linas BP, Schackman BR, Marshall BDL. Comparing Projected Fatal Overdose Outcomes and Costs of Strategies to Expand Community-Based Distribution of Naloxone in Rhode Island. JAMA Netw Open 2022; 5:e2241174. [PMID: 36350649 PMCID: PMC9647481 DOI: 10.1001/jamanetworkopen.2022.41174] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 09/22/2022] [Indexed: 11/10/2022] Open
Abstract
Importance In 2021, the state of Rhode Island distributed 10 000 additional naloxone kits compared with the prior year through partnerships with community-based organizations. Objective To compare various strategies to increase naloxone distribution through community-based programs in Rhode Island to identify one most effective and efficient strategy in preventing opioid overdose deaths (OODs). Design, Setting, and Participants In this decision analytical model study conducted from January 2016 to December 2022, a spatial microsimulation model with an integrated decision tree was developed and calibrated to compare the outcomes of alternative strategies for distributing 10 000 additional naloxone kits annually among all individuals at risk for opioid overdose in Rhode Island. Interventions Distribution of 10 000 additional naloxone kits annually, focusing on people who inject drugs, people who use illicit opioids and stimulants, individuals at various levels of risk for opioid overdose, or people who misuse prescription opioids vs no additional kits (status quo). Two expanded distribution implementation approaches were considered: one consistent with the current spatial distribution patterns for each distribution program type (supply-based approach) and one consistent with the current spatial distribution of individuals in each of the risk groups, assuming that programs could direct the additional kits to new geographic areas if required (demand-based approach). Main Outcomes and Measures Witnessed OODs, cost per OOD averted (efficiency), geospatial health inequality measured by the Theil index, and between-group variance for OOD rates. Results A total of 63 131 simulated individuals were estimated to be at risk for opioid overdose in Rhode Island based on current population data. With the supply-based approach, prioritizing additional naloxone kits to people who use illicit drugs averted more witnessed OODs by an estimated mean of 18.9% (95% simulation interval [SI], 13.1%-30.7%) annually. Expanded naloxone distribution using the demand-based approach and focusing on people who inject drugs had the best outcomes across all scenarios, averting an estimated mean of 25.3% (95% SI, 13.1%-37.6%) of witnessed OODs annually, at the lowest mean incremental cost of $27 312 per OOD averted. Other strategies were associated with fewer OODs averted at higher costs but showed similar patterns of improved outcomes and lower unit costs if kits could be reallocated to areas with greater need. The demand-based approach reduced geospatial inequality in OOD rates in all scenarios compared with the supply-based approach and status quo. Conclusions and Relevance In this decision analytical model study, variations in the effectiveness, efficiency, and health inequality of the different naloxone distribution expansion strategies and approaches were identified. Future efforts should be prioritized for people at highest risk for overdose (those who inject drugs or use illicit drugs) and redirected toward areas with the greatest need. These findings may inform future naloxone distribution priority settings.
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Affiliation(s)
- Xiao Zang
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island
| | - Sam E. Bessey
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island
| | - Maxwell S. Krieger
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island
| | | | | | - Shayla Nolen
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island
| | - Czarina N. Behrends
- Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Sean M. Murphy
- Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Alexander Y. Walley
- Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Benjamin P. Linas
- Section of Infectious Diseases, Boston Medical Center, Boston, Massachusetts
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Bruce R. Schackman
- Department of Population Health Sciences, Weill Cornell Medical College, New York, New York
| | - Brandon D. L. Marshall
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island
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Implementation and Uptake of the Massachusetts Drug Supply Data Stream: A Statewide Public Health-Public Safety Partnership Drug Checking Program. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2022; 28:S347-S354. [PMID: 36194805 PMCID: PMC9531987 DOI: 10.1097/phh.0000000000001581] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
CONTEXT The illicit drug supply is rapidly evolving. Equally important to gathering drug supply data for monitoring is timely sharing of information with people who use drugs, the providers who care for them, law enforcement partners, and public health stakeholders so that efforts to avoid harmful substances, take preventive actions, and better target interventions can occur. PROGRAM The Massachusetts Drug Supply Data Stream (MADDS) is the country's first statewide community drug checking program. Founded on public health-public safety partnerships, MADDS collects remnant drug packaging and paraphernalia with residue from people who use drugs and noncriminal samples from partnering police departments. MADDS tests samples using simultaneous immunoassay fentanyl test strips, Fourier-transform infrared spectrometry (FTIR), and off-site laboratory testing by gas chromatography-mass spectrometry (GC/MS). Results are accessible to community programs and municipalities, while trend analyses inform public health for cross-site alerts and informational bulletins. IMPLEMENTATION MADDS was launched statewide in 2020 and rapidly expanded to a multisite program. Program staff approached communities and met with municipal police and community partners to secure written agreements to host drug checking. Community partners designed sample collection consistent with their pandemic era workflows. Consultations with stakeholders gathered feedback on design and deliverables. EVALUATION The program tests sample donations on-site from community agencies and police departments, incorporates review by a medical toxicologist for health and safety concerns, crafts stakeholder-specific communications, and disseminates English, Spanish, and Portuguese language materials. For 2020, a total of 427 samples were tested, of which 47.1% were positive for fentanyl. By early 2021, MADDS detected shifts in cocaine purity, alerted communities of a new toxic fentanyl analogue and a synthetic cannabinoid contaminant, and confirmed the increase of xylazine (a veterinary sedative) in Massachusetts. DISCUSSION Community drug checking programs can be collaboratively designed with public health and public safety to generate critical health and safety information for people who use drugs and the communities where they live.
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Pozo BD. Reducing the Iatrogenesis of Police Overdose Response: Time Is of the Essence. Am J Public Health 2022; 112:1236-1238. [PMID: 35862886 PMCID: PMC9382163 DOI: 10.2105/ajph.2022.306987] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Brandon Del Pozo
- Brandon del Pozo is with Rhode Island Hospital and the Warren Alpert Medical School of Brown University, Providence, RI
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Doe-Simkins M, El-Sabawi T, Carroll JJ. Whose Concerns? It's Time to Adjust the Lens of Research on Police-Involved Overdose Response. Am J Public Health 2022; 112:1239-1241. [PMID: 35862884 PMCID: PMC9382179 DOI: 10.2105/ajph.2022.306988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Maya Doe-Simkins
- Maya Doe-Simkins is with the Remedy Alliance, Cedar, MI. Taleed El-Sabawi is with the College of Law, Florida International University, Miami. Jennifer J. Carroll is with the Department of Sociology and Anthropology, North Carolina State University, Raleigh, and Warren Alpert School of Medicine, Brown University, Providence, RI
| | - Taleed El-Sabawi
- Maya Doe-Simkins is with the Remedy Alliance, Cedar, MI. Taleed El-Sabawi is with the College of Law, Florida International University, Miami. Jennifer J. Carroll is with the Department of Sociology and Anthropology, North Carolina State University, Raleigh, and Warren Alpert School of Medicine, Brown University, Providence, RI
| | - Jennifer J Carroll
- Maya Doe-Simkins is with the Remedy Alliance, Cedar, MI. Taleed El-Sabawi is with the College of Law, Florida International University, Miami. Jennifer J. Carroll is with the Department of Sociology and Anthropology, North Carolina State University, Raleigh, and Warren Alpert School of Medicine, Brown University, Providence, RI
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White MD, Watts S, Orosco C, Perrone D, Malm A. Leveraging Body-Worn Camera Footage to Better Understand Opioid Overdoses and the Impact of Police-Administered Naloxone. Am J Public Health 2022; 112:1326-1332. [PMID: 35862885 PMCID: PMC9382158 DOI: 10.2105/ajph.2022.306918] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/20/2022] [Indexed: 11/04/2022]
Abstract
Objectives. To investigate what transpires at opioid overdoses where police administer naloxone and to identify the frequency with which concerns about police-administered naloxone are observed. Methods. We reviewed body-worn camera (BWC) footage of all incidents where a Tempe, Arizona police officer administered naloxone or was present when the Tempe Fire Medical Rescue (TFMR) administered it, from February 3, 2020 to May 7, 2021 (n = 168). We devised a detailed coding instrument and employed univariate and bivariate analysis to examine the frequency of concerns regarding police-administered naloxone. Results. Police arrived on scene before the TFMR in 73.7% of cases. In 88.6% of calls the individual was unconscious when police arrived, but 94.6% survived the overdose. The primary concerns about police-administered naloxone were rarely observed. There were no cases of improper naloxone administration or accidental opioid exposure to an officer. Aggression toward police from an overdose survivor rarely occurred (3.6%), and arrests of survivors (3.6%) and others on scene (1.2%) were infrequent. Conclusions. BWC footage provides a unique window into opioid overdoses. In Tempe, the concerns over police-administered naloxone are overstated. If results are similar elsewhere, those concerns are barriers that must be removed. (Am J Public Health. 2022;112(9):1326-1332. https://doi.org/10.2105/AJPH.2022.306918).
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Affiliation(s)
- Michael D White
- Michael D. White, Seth Watts, and Carlena Orosco are with the Center for Violence Prevention and Community Safety, Arizona State University, Phoenix. Dina Perrone and Aili Malm are with the School of Criminology, Criminal Justice, and Emergency Management, California State University, Long Beach
| | - Seth Watts
- Michael D. White, Seth Watts, and Carlena Orosco are with the Center for Violence Prevention and Community Safety, Arizona State University, Phoenix. Dina Perrone and Aili Malm are with the School of Criminology, Criminal Justice, and Emergency Management, California State University, Long Beach
| | - Carlena Orosco
- Michael D. White, Seth Watts, and Carlena Orosco are with the Center for Violence Prevention and Community Safety, Arizona State University, Phoenix. Dina Perrone and Aili Malm are with the School of Criminology, Criminal Justice, and Emergency Management, California State University, Long Beach
| | - Dina Perrone
- Michael D. White, Seth Watts, and Carlena Orosco are with the Center for Violence Prevention and Community Safety, Arizona State University, Phoenix. Dina Perrone and Aili Malm are with the School of Criminology, Criminal Justice, and Emergency Management, California State University, Long Beach
| | - Aili Malm
- Michael D. White, Seth Watts, and Carlena Orosco are with the Center for Violence Prevention and Community Safety, Arizona State University, Phoenix. Dina Perrone and Aili Malm are with the School of Criminology, Criminal Justice, and Emergency Management, California State University, Long Beach
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Peet ED, Powell D, Pacula RL. Trends in Out-of-Pocket Costs for Naloxone by Drug Brand and Payer in the US, 2010-2018. JAMA HEALTH FORUM 2022; 3:e222663. [PMID: 36200636 PMCID: PMC9391964 DOI: 10.1001/jamahealthforum.2022.2663] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 06/22/2022] [Indexed: 12/02/2022] Open
Abstract
Importance Improving access to naloxone is a critical component of the nation's strategy to curb fatal overdoses in the opioid crisis. Standing or protocol orders, prescriptive authority laws, and immunity provisions have been passed by states to expand access, but less attention has been given to potential financial barriers to naloxone access. Objective To assess trends in out-of-pocket (OOP) costs for naloxone and examine variation in OOP costs by drug brand and payer. Design, Setting, and Participants This observational study analyzed US naloxone claims data from Symphony Health and associated OOP costs for individuals filling naloxone prescriptions by drug brand and payer between January 1, 2010, to December 31, 2018. The data were analyzed from March 31, 2021, to April 12, 2022. Main Outcomes and Measures The main measures were trends in annual number of naloxone claims (overall, by payer, and by drug brand) and mean annual OOP costs per claim (overall, by payer, and by drug brand). Results Of 719 612 naloxone claims (172 894 generic naloxone, 501 568 Narcan, and 45 150 Evzio) for 2010 through 2018, the number of naloxone claims among insured patients began rapidly increasing after 2014; at the same time, the mean OOP cost of naloxone increased dramatically among the uninsured population. Comparing 2014 with 2018, the mean OOP cost of naloxone decreased by 26% among those with insurance but increased by 506% among uninsured patients. For the uninsured population, the impediment of cost was even larger for certain brands of the drug. In 2016, the mean OOP cost for Evzio among uninsured patients rose to $2136.37 (a 2429% increase relative to 2015) compared with the mean cost of generic naloxone, $72.88, and the cost of Narcan in its first year, $87.95. Throughout the period, the mean OOP costs paid by uninsured patients were higher for Evzio at $1089.17 (95% CI, $884.17-$1294.17) compared with $73.62 (95% CI, $69.24-$78.00) for Narcan and $67.99 (95% CI, $61.42-$74.56) for generic naloxone. Conclusions and Relevance In this observational study, the findings indicated that the OOP cost of naloxone had been an increasingly substantial barrier to naloxone access for uninsured patients, potentially limiting use among this population, which constituted approximately 20% of adults with opioid use disorder.
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Availability of buprenorphine/naloxone films and naloxone nasal spray in community pharmacies in 11 U.S. states. Drug Alcohol Depend 2022; 237:109518. [PMID: 35691255 DOI: 10.1016/j.drugalcdep.2022.109518] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 05/23/2022] [Accepted: 05/28/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Prompt access to prescribed buprenorphine/naloxone films (BUP/NX) and naloxone nasal spray (NNS) is vital for patients with opioid use disorder (OUD), but multiple studies have documented pharmacy-level barriers. METHODS A cross-sectional secret shopper telephone audit was conducted in a sample of 5734 actively licensed pharmacies in 11 U.S. states from May 2020-April 2021. Primary outcomes included availability of 14 generic BUP/NX 8/2 mg and one unit of NNS 4 mg. Outcomes were compared by pharmacy type, county metropolitan status, state Medicaid expansion status, and state drug overdose death rate. RESULTS Data from 4984 pharmacies (3402 chain and 1582 independent) were analyzed. Both medications were available in 41.2 % of pharmacies, BUP/NX was available in 48.3%, and NNS was available in 69.5%. Chain pharmacies were significantly more likely than independent pharmacies to have both medications available, to have each medication available individually, and to be willing to order BUP/NX. Pharmacies in metropolitan counties were more likely to have BUP/NX available than pharmacies in non-metropolitan counties, pharmacies in Medicaid expansion states were more likely to have both medications available and to have NNS available than pharmacies in non-expansion states, and pharmacies in states with high drug overdose death rates were more likely to have NNS available than pharmacies in states with low drug overdose death rates. CONCLUSIONS BUP/NX and NNS are not readily accessible in many U.S. pharmacies. Deficits in access are most pronounced in independent pharmacies, though county- and state-level factors may also influence availability of these essential medications.
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Skoy E, Frenzel O, Eukel H, Lothspeich E, Steig J, Strand M, Werremeyer A. Evaluation of a Program to Screen Patients in Community Pharmacies for Opioid Misuse and Accidental Overdose. Prev Chronic Dis 2022; 19:E41. [PMID: 35834737 PMCID: PMC9336191 DOI: 10.5888/pcd19.220028] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Introduction Community pharmacies nationwide have adopted new strategies to combat the opioid epidemic. One strategy to prevent opioid misuse and accidental overdose is patient screening to identify those at risk. The purpose of our study was to determine whether such screening in community pharmacies led pharmacy personnel to intervene with patients at risk and to describe the proportion of patients they identified as at risk. Methods We implemented the Opioid and Naloxone Education (ONE) program in North Dakota to give community pharmacies and pharmacists training and tools to provide preventive screening for opioid misuse and accidental overdose before dispensing a prescribed opioid. Data were collected and analyzed from September 15, 2018, through May 15, 2021, to evaluate overall patient risk characteristics for opioid misuse and accidental overdose. Results Of 8,217 patients screened, 3.9% were identified as at high risk for opioid misuse, and 18.3% at risk for accidental overdose. Nearly 1 of 3 screenings (31.7%) indicated opioid medication use in the past 60 days. Pharmacists delivered 1 or more risk-factor–dependent interventions to 41.1% of patients in the study. Following screening, naloxone dispensing in pharmacies increased to 6 times the national average. Conclusion Pharmacy-based patient screening for risk of opioid misuse and accidental overdose led to risk-dependent interventions targeted to individual patients. The tools and risk-dependent interventions applied in the ONE program increased patient awareness of opioid risks and ways to reduce risk. Future studies should examine long-term outcomes, including reduction in overdose, treatment of opioid use disorder, and reduced opioid-related acute care.
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Affiliation(s)
- Elizabeth Skoy
- North Dakota State University School of Pharmacy, PO Box 6050, Dept 2660, Fargo, ND 58108.
| | - Oliver Frenzel
- North Dakota State University School of Pharmacy, Fargo, North Dakota.,North Dakota State University School of Public Health, Fargo, North Dakota
| | - Heidi Eukel
- North Dakota State University School of Pharmacy, Fargo, North Dakota
| | - Emily Lothspeich
- North Dakota State University School of Pharmacy, Fargo, North Dakota
| | - Jayme Steig
- North Dakota State University School of Pharmacy, Fargo, North Dakota
| | - Mark Strand
- North Dakota State University School of Pharmacy, Fargo, North Dakota.,North Dakota State University School of Public Health, Fargo, North Dakota
| | - Amy Werremeyer
- North Dakota State University School of Pharmacy, Fargo, North Dakota
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Lai RK, Friedson KE, Reveles KR, Bhakta K, Gonzales G, Hill LG, Evoy KE. Naloxone Accessibility Without an Outside Prescription from U.S. Community Pharmacies: A Systematic Review. J Am Pharm Assoc (2003) 2022; 62:1725-1740. [DOI: 10.1016/j.japh.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 07/19/2022] [Accepted: 07/20/2022] [Indexed: 10/16/2022]
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Stringfellow EJ, Lim TY, Humphreys K, DiGennaro C, Stafford C, Beaulieu E, Homer J, Wakeland W, Bearnot B, McHugh RK, Kelly J, Glos L, Eggers SL, Kazemi R, Jalali MS. Reducing opioid use disorder and overdose deaths in the United States: A dynamic modeling analysis. SCIENCE ADVANCES 2022; 8:eabm8147. [PMID: 35749492 PMCID: PMC9232111 DOI: 10.1126/sciadv.abm8147] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Opioid overdose deaths remain a major public health crisis. We used a system dynamics simulation model of the U.S. opioid-using population age 12 and older to explore the impacts of 11 strategies on the prevalence of opioid use disorder (OUD) and fatal opioid overdoses from 2022 to 2032. These strategies spanned opioid misuse and OUD prevention, buprenorphine capacity, recovery support, and overdose harm reduction. By 2032, three strategies saved the most lives: (i) reducing the risk of opioid overdose involving fentanyl use, which may be achieved through fentanyl-focused harm reduction services; (ii) increasing naloxone distribution to people who use opioids; and (iii) recovery support for people in remission, which reduced deaths by reducing OUD. Increasing buprenorphine providers' capacity to treat more people decreased fatal overdose, but only in the short term. Our analysis provides insight into the kinds of multifaceted approaches needed to save lives.
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Affiliation(s)
| | - Tse Yang Lim
- Sloan School of Management, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Keith Humphreys
- Veterans Affairs and Stanford University Medical Centers, Palo Alto, CA, USA
| | | | | | | | - Jack Homer
- Sloan School of Management, Massachusetts Institute of Technology, Cambridge, MA, USA
- Homer Consulting, Barrytown, NY, USA
| | - Wayne Wakeland
- Systems Science Program, Portland State University, Portland, OR, USA
| | - Benjamin Bearnot
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - R. Kathryn McHugh
- Division of Alcohol, Drugs, and Addiction, McLean Hospital, Harvard Medical School, Boston, MA, USA
| | - John Kelly
- Center for Addiction Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Lukas Glos
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Sara L. Eggers
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Reza Kazemi
- Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, MD, USA
| | - Mohammad S. Jalali
- Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Sloan School of Management, Massachusetts Institute of Technology, Cambridge, MA, USA
- Corresponding author.
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Marks C, Wagner KD. Supporting people responding to overdoses. Lancet Public Health 2022; 7:e198-e199. [DOI: 10.1016/s2468-2667(22)00011-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 01/13/2022] [Indexed: 10/19/2022]
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