A Comparison of Efficacy of Treatment and Time to Administration of Naloxone by BLS and ALS Providers

Evaluation of a large-scale health department naloxone distribution program: Per capita naloxone distribution and overdose morality

OBJECTIVES

To report per-capita distribution of take-home naloxone to lay bystanders and evaluate changes in opioid overdose mortality in the county over time.

METHODS

Hamilton County Public Health in southwestern Ohio led the program from Oct 2017-Dec 2019. Analyses included all cartons distributed within Hamilton County or in surrounding counties to people who reported a home address within Hamilton County. Per capita distribution was estimated using publicly available census data. Opioid overdose mortality was compared between the period before (Oct 2015-Sep 2017) and during (Oct 2017-Sep 2019) the program.

RESULTS

A total of 10,416 cartons were included for analyses, with a total per capita distribution of 1,275 cartons per 100,000 county residents (average annual rate of 588/100,000). Median monthly opioid overdose mortality in the two years before (28 persons, 95% CI 25-31) and during (26, 95% CI 23-28) the program did not differ significantly.

CONCLUSIONS

Massive and rapid naloxone distribution to lay bystanders is feasible. Even large-scale take-home naloxone distribution may not substantially reduce opioid overdose mortality rates.

Prehospital Naloxone Administration Patterns during the Era of Synthetic Opioids

Background: The opioid epidemic is an ongoing public health emergency, exacerbated in recent years by the introduction and rising prevalence of synthetic opioids. The National EMS Scope of Practice Model was changed in 2017 to recommend allowing basic life support (BLS) clinicians to administer intranasal (IN) naloxone. This study examines local IN naloxone administration rates for 4 years after the new recommendation, and Glasgow Coma Scale (GCS) scores and respiratory rates before and after naloxone administration.Methods: This retrospective cohort study evaluated naloxone administrations between April 1st 2017 and March 31st 2021 in a mixed urban-suburban EMS system. Naloxone dosages, routes of administration, and frequency of administrations were captured along with demographic information. Analysis of change in the ratio of IN to intravenous (IV) naloxone administrations per patient was performed, with the intention of capturing administration patterns in the area. Analyses were performed for change over time of IN naloxone rates of administration, change in respiratory rates, and change in GCS scores after antidote administration. ALS and BLS clinician certification levels were also identified. Bootstrapping procedures were used to estimate 95% confidence intervals for correlation coefficients.Results: Two thousand and ninety patients were analyzed. There was no statistically significant change in the IN/parenteral ratio over time (p = 0.79). Repeat dosing increased over time from 1.2 ± 0.4 administrations per patient to 1.3 ± 0.5 administrations per patient (r = 0.078, 95% CI: 0.036 - 0.120; p = 0.036). Mean respiratory rates before (mean = 12.6 - 12.6, r = -0.04, 95% CI: -0.09 - 0.01; p = 0.1) and after (mean = 15.2 - 14.9, r = -0.03, 95% CI: -0.08 - 0.01; p = 0.172) naloxone administration have not changed. While initial GCS scores have become significantly lower, GCS scores after administration of naloxone have not changed (initial median GCS 10 - 6, p < 0.001; final median GCS 15 - 15, p = 0.23).Conclusions: Current dosing protocols of naloxone appear effective in the era of synthetic opioids in our region, although patients may be marginally more likely to require repeat naloxone doses.

It's what the community demands: Results of community-based emergency opioid overdose trainings

OBJECTIVES

In response to a surge of drug overdoses involving polysubstance use among Atlanta service industry workers that resulted in the deaths of five people in the Atlanta area in the summer of 2021, a local community of harm reductionists and nurses organized opioid education and naloxone distribution (OEND) training sessions specifically customized for service industry workers in Atlanta. After the sessions, the nurses and harm reductionists asked attendants to participate in a study concerning their response to overdoses. The reason nurses and harm reductionists conducted the study was to determine the efficacy of OEND training adapted for those working in the service industries as well as to evaluate and possibly modify the training sessions for future use. This pre-post study examined if and how participants' knowledge and attitudes toward an opioid-involved overdose changed after engaging with the OEND training. If the study determined that the sessions were successful in teaching service industry workers how to mitigate the immediate and devastating effects of overdose, we recommend expanding and implementing both adaptable training sessions like the OEND training referenced, as well as accompanying studies to improve the training sessions' effectiveness.

DESIGN

The pre-post study used convenience sampling to recruit participants in emergent OEND training. Participants completed an abbreviated version the Opioid Overdose Attitudes Scale (OOAS) which measured how, and to what degree, they changed their attitudes towards overdoses and their responses to them. Participants also completed an abbreviated version of the Opioid Overdose Knowledge Scale (OOKS) which measured how effectively the OEND increased their knowledge when it came to properly responding to an overdose, which included implementing naloxone as part of immediate rehabilitation treatment. Paired nonparametric tests assessed changes in participants' OOAS/OOKS scores.

RESULTS

A total of 161 individuals attended, and 72 consented to be in the study. The sample predominately consisted of white (76.4%) and female (66.7%) adults whose age averaged 34.3 years. Attitude and knowledge score improvements were statistically significant: approximately 11 points (p < .001) and 3 points (p < .001), respectively.

CONCLUSIONS

This rapidly implemented training was associated with improving attitudes and knowledge about responding to an opioid-involved overdose. We recommend expanding the scope of studies like these in order to develop and examine effective, dynamic, and targeted OEND training tailored towards specific community groups and situations, such as polysubstance overdose among service industry workers. As the opioid epidemic worsens, it is critical to equip community members themselves with the skills and tools to recognize and respond to opioid overdoses as a frontline prevention to overdose deaths.

Evaluation of Basic Life Support First Responder Naloxone Administration Protocol Adherence

Objectives: Opioid overdoses have become a significant problem across the United States resulting in respiratory depression and risk of death. Basic Life Support (BLS) first responders have had the option to treat respiratory depression using a bag-valve-mask device, however naloxone, an opioid antagonist, has been shown to quickly restore normal respiration. Since the introduction of naloxone and recent mandates across many states for BLS personnel to carry and administer naloxone, investigation into the adherence of naloxone use standing protocols is warranted.

Methods: This preliminary study examined 100 initial cases of BLS first responder administration of naloxone for appropriate indications and protocol adherence.

Results: This study found that n=22/100 naloxone administrations were inappropriate, often given to patients who were not suffering from respiratory depression (n=11/22). Positive pressure ventilation (PPV) was not administered prior to naloxone in n=56/100 cases, of which n=42/100 had an inadequate respiratory effort documented. For patients with a known history of substance use disorder, there was a significant increase in administration of naloxone prior to PPV (60%; n=33/55) compared to patients without a known history (30%; n=9/30).

Conclusion: Overall these preliminary data suggest that during BLS naloxone administration, the majority of cases did not follow at least one component of the standard protocol for patients with respiratory depression. This study suggests that further education and more research are needed to better understand the decision-making processes of prehospital providers to ensure adherence to standard protocols.