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van Draanen J, Adwell A, Wettemann C, Fockele CE, Goh B, Perlmutter DL, Williams GW, Holland N, Frohe T. "You might be nice, but where you take me, they're not gonna be": Preferences for field-based post-overdose interventions. Drug Alcohol Rev 2024. [PMID: 39205432 DOI: 10.1111/dar.13926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 07/17/2024] [Accepted: 07/18/2024] [Indexed: 09/04/2024]
Abstract
INTRODUCTION Emergency medical services (EMS) systems are piloting interventions to respond to overdoses with additional services such as leave-behind naloxone and medication for opioid use disorder, but little is known about the perspectives of people who use drugs (PWUD) on these interventions being delivered by EMS during an overdose response. METHODS The Consolidated Framework for Implementation Research guided the development of data collection tools, the analytic strategy and the organisation of results. A community engaged method was used which included both academically trained researchers and community trained researchers who are also PWUD. This study used semi-structured interviews to gather data from 13 PWUD in King County, Washington in June 2022. Data were analysed using thematic analysis. RESULTS The people interviewed for this study viewed EMS distribution of leave-behind naloxone and field-based buprenorphine favourably. They viewed EMS facilitation of hepatitis C virus and HIV testing in the field less favourably and were concerned about stigmas associated with those results. Additional themes emerged regarding: the need for different approaches to post-overdose care; the need for new services, including post-overdose trauma counselling and an alternative destination to the emergency department; and the harms of law enforcement presence at overdose responses. DISCUSSION AND CONCLUSIONS This study found strong support for leave-behind naloxone and field-initiated buprenorphine. Further training for EMS should include trauma-informed care and strategies to address burnout and increase compassion. Alternatives to the emergency department as a post-overdose destination are needed. These strategies should be considered by jurisdictions revising overdose response protocols.
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Affiliation(s)
- Jenna van Draanen
- Department of Child, Family, and Population Health Nursing, University of Washington, Seattle, USA
- Department of Health Systems and Population Health, University of Washington, Seattle, USA
| | - Addy Adwell
- Department of Child, Family, and Population Health Nursing, University of Washington, Seattle, USA
| | - Courteney Wettemann
- Department of Child, Family, and Population Health Nursing, University of Washington, Seattle, USA
- Research with Expert Advisors on Drug Use, Seattle, USA
| | | | - Brenda Goh
- Department of Health Systems and Population Health, University of Washington, Seattle, USA
| | - David L Perlmutter
- Department of Health Systems and Population Health, University of Washington, Seattle, USA
| | | | | | - Tessa Frohe
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, USA
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Belden C, Kopak A, Coules C, Friesen T, Hall J, Shukla S. Building bridges to outpatient treatment services for post-overdose care via paramedic buprenorphine field initiation. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2024; 162:209364. [PMID: 38626851 DOI: 10.1016/j.josat.2024.209364] [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: 09/15/2023] [Revised: 03/19/2024] [Accepted: 04/07/2024] [Indexed: 05/13/2024]
Abstract
INTRODUCTION Despite sustained efforts to reduce opioid-related overdose fatalities, rates have continued to rise. In many areas, overdose response involves emergency medical service (EMS) personnel administering naloxone and transporting patients to the emergency department (ED). However, a substantial number of patients decline transport, and many EDs do not provide medication for opioid use disorder (MOUD). One approach to filling this gap involves delivering MOUD to overdose patients in the field with trained post-overdose EMS teams who can initiate buprenorphine. In this MOUD field initiation pilot program, a trained EMS Community Paramedicine team initiates buprenorphine in the field and links patients to care. The program includes three pathways to treatment with the first designed for EMS to initiate buprenorphine after overdose reversal when the patient is in withdrawal from naloxone; a second pathway initiates buprenorphine after overdose when the patient is not in withdrawal; and a third enables self-referral via a connection to the community EMS team not necessarily related to a recent overdose. METHODS We conducted a retrospective cohort study of the MOUD field initiation pilot program. Data are from 28 patients who entered care immediately post-overdose initiation of buprenorphine, 21 patients who initiated on buprenorphine while not in naloxone withdrawal, and 37 patients who self-referred to treatment following outreach efforts by paramedicine and peer support professionals. RESULTS A total of 118 patients initiated buprenorphine during the 12-month study period and 104 (83 %) visited the clinic for their first appointment. Over two thirds (68 %, n = 80) remained engaged in care after 30 days. Retained patients tended to be male, white, uninsured, food insecure, have unstable housing, lack reliable transportation, and report prior involvement with the criminal legal system. CONCLUSION The initial 12-month period of the pilot program demonstrated the feasibility of initiating buprenorphine at the site of overdose without requiring transport to the ED and offer self-referral pathways for people experiencing barriers to treatment. Specialized EMS can play a critical role in expanding access to MOUD treatment by bridging the gap between overdose and comprehensive community-based care.
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Affiliation(s)
- Charles Belden
- Mountain Area Health Education Center, 121 Hendersonville Rd, Asheville, NC 28803, USA.
| | - Albert Kopak
- Mountain Area Health Education Center, 121 Hendersonville Rd, Asheville, NC 28803, USA.
| | - Courtney Coules
- Mountain Area Health Education Center, 121 Hendersonville Rd, Asheville, NC 28803, USA.
| | - Tessa Friesen
- Mountain Area Health Education Center, 121 Hendersonville Rd, Asheville, NC 28803, USA.
| | - Justin Hall
- Buncombe County Emergency Medical Services, 164 Erwin Hills Rd, Asheville, NC 28806, USA.
| | - Shuchin Shukla
- Mountain Area Health Education Center, 121 Hendersonville Rd, Asheville, NC 28803, USA
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Senthilkumar R, Bailey A, Moner E, Parduhn T, Evans EA. Lessons Learned from Implementation of a Post-opioid Overdose Outreach Program in a Rural Massachusetts Community. Community Ment Health J 2024; 60:482-493. [PMID: 37902945 DOI: 10.1007/s10597-023-01198-8] [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: 05/17/2023] [Accepted: 10/03/2023] [Indexed: 11/01/2023]
Abstract
Post-overdose outreach programs can play a key role in reducing opioid overdose deaths and increasing access to healthcare services. The design and implementation of these programs, especially in rural communities, remains a gap in knowledge. We aimed to understand the lessons learned from the implementation experiences of the Community, Opportunity, Network, Navigation, Exploration, and Connection Team (CONNECT), a post-overdose outreach program based in a rural community in Massachusetts. We conducted semi-structured focus groups and interviews with 21 community partners after the first year of implementation in 2022. Participants included behavioral health, medical, public health, and public safety personnel involved in the design and implementation of CONNECT. Using a combination of thematic and rapid qualitative analysis methods, we inductively coded transcripts for salient themes. Themes were mapped onto the Health Equity Implementation Framework to better understand implementation and health-equity factors. Facilitators to implementation of this innovation included efficient inter-partner data sharing and coordination, and ability to offer numerous health services to clients to meet their needs. Key partners identified that CONNECT serves clients who use opioids, have previous involvement with the legal system, and reside in low-income areas within this rural region. Unhoused individuals and individuals who do not call 9-11 after an overdose were identified as populations of need that CONNECT was missing due to structural barriers. Partners shared how the context of this rural community came with challenges related to limited access to health services and pervasive stigma towards substance use, while it was also perceived to foster a culture of collaboration and unity among multidisciplinary key partners. Post overdose outreach programs serve clients with complex health needs. The ability to access services for these health needs is shaped by the post overdose outreach program and its key partners, and by the broader community context. As post-overdose outreach programs continue to expand as a promising strategy to address the opioid overdose crisis, there exists a need to contextualize implementation strategies to inform adaptations and develop best-practices.
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Affiliation(s)
- Rithika Senthilkumar
- Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, MA, 01003, USA
| | - Amelia Bailey
- Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, MA, 01003, USA.
- Department of Behavioral and Social Sciences, School of Public Health, Brown University, Box G-S121-3, Providence, RI, 02912, USA.
| | - Emily Moner
- Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, MA, 01003, USA
| | - Taylor Parduhn
- Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, MA, 01003, USA
| | - Elizabeth A Evans
- Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, MA, 01003, USA
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Joyce VR, Oliva EM, Garcia CC, Trafton J, Asch SM, Wagner TH, Humphreys K, Owens DK, Bounthavong M. Healthcare costs and use before and after opioid overdose in Veterans Health Administration patients with opioid use disorder. Addiction 2023; 118:2203-2214. [PMID: 37465971 DOI: 10.1111/add.16289] [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: 10/06/2022] [Accepted: 06/09/2023] [Indexed: 07/20/2023]
Abstract
AIMS To compare healthcare costs and use between United States (US) Veterans Health Administration (VHA) patients with opioid use disorder (OUD) who experienced an opioid overdose (OD cohort) and patients with OUD who did not experience an opioid overdose (non-OD cohort). DESIGN This is a retrospective cohort study of administrative and clinical data. SETTING The largest integrated national health-care system is the US Veterans Health Administration's healthcare systems. PARTICIPANTS We included VHA patients diagnosed with OUD from October 1, 2017 through September 30, 2018. We identified the index date of overdose for patients who had an overdose. Our control group, which included patients with OUD who did not have an overdose, was randomly assigned an index date. A total of 66 513 patients with OUD were included for analysis (OD cohort: n = 1413; non-OD cohort: n = 65 100). MEASUREMENTS Monthly adjusted healthcare-related costs and use in the year before and after the index date. We used generalized estimating equation models to compare patients with an opioid overdose and controls in a difference-in-differences framework. FINDINGS Compared with the non-OD cohort, an opioid overdose was associated with an increase of $16 890 [95% confidence interval (CI) = $15 611-18 169; P < 0.001] in healthcare costs for an estimated $23.9 million in direct costs to VHA (95% CI = $22.1 million, $25.7 million) within the 30 days following overdose after adjusting for baseline characteristics. Inpatient costs ($13 515; 95% CI = $12 378-14 652; P < 0.001) reflected most of this increase. Inpatient days (+6.15 days; 95% CI, = 5.33-6.97; P < 0.001), inpatient admissions (+1.01 admissions; 95% CI = 0.93-1.10; P < 0.001) and outpatient visits (+1.59 visits; 95% CI = 1.34-1.84; P < 0.001) also increased in the month after opioid overdose. Within the overdose cohort, healthcare costs and use remained higher in the year after overdose compared with pre-overdose trends. CONCLUSIONS The US Veterans Health Administration patients with opioid use disorder (OUD) who have experienced an opioid overdose have increased healthcare costs and use that remain significantly higher in the month and continuing through the year after overdose than OUD patients who have not experienced an overdose.
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Affiliation(s)
- Vilija R Joyce
- VA Health Economics Resource Center, US Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Elizabeth M Oliva
- VA Center for Innovation to Implementation, US Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Carla C Garcia
- VA Health Economics Resource Center, US Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Jodie Trafton
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
- VA Program Evaluation and Resource Center, Office of Mental Health and Suicide Prevention, VA Central Office, US Department of Veterans Affairs, Palo Alto, CA, USA
| | - Steven M Asch
- VA Center for Innovation to Implementation, US Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Medicine, Stanford University, Stanford, CA, USA
| | - Todd H Wagner
- VA Health Economics Resource Center, US Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Keith Humphreys
- VA Center for Innovation to Implementation, US Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, CA, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, CA, USA
| | - Douglas K Owens
- Stanford Health Policy, Department of Health Policy, Stanford University, Stanford, CA, USA
| | - Mark Bounthavong
- VA Health Economics Resource Center, US Department of Veterans Affairs, VA Palo Alto Health Care System, Palo Alto, CA, USA
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Bailey A, Harrington C, Evans EA. A scoping review of community-based post-opioid overdose intervention programs: implications of program structure and outcomes. HEALTH & JUSTICE 2023; 11:3. [PMID: 36707446 PMCID: PMC9883127 DOI: 10.1186/s40352-022-00201-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 12/14/2022] [Indexed: 06/18/2023]
Abstract
BACKGROUND An emergent intervention to address the opioid epidemic is the use of multidisciplinary outreach teams which connect an individual in the community to healthcare resources after the experience of an opioid overdose. While these interventions are receiving federal funding, less is known empirically to inform future interventions. Understanding the process and outcomes of these interventions is advisable due to the novel partnerships of public health and law enforcement agencies who sometimes hold divergent goals. The objective of the present review was to describe program structure and evaluated outcomes of community-based post-overdose interventions. RESULTS A search of PubMed, PsycInfo, and Web of Science yielded 5 peer-reviewed articles that detail the implementation and outcomes of interventions delivered in the United States published from 2001 to July 2021. Most interventions used a multidisciplinary outreach team and referenced first responder data to contact individuals who recently experienced an overdose at their residence. Services offered often included referral to substance use treatment, recovery coaches, and social services. Method of outreach, evaluation measures, and outcomes varied. From the available literature, facilitators of program engagement included communication, information sharing, and leadership buy-in among multidisciplinary partners. CONCLUSIONS Future studies could benefit from exploration of service provision in rural areas, for family affected by overdose, and for minoritized populations. Community-based post-overdose interventions utilizing a law enforcement partnership are emergent with promising yet limited examples in empirical literature.
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Affiliation(s)
- Amelia Bailey
- Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, MA 01003 USA
- Department of Behavioral and Social Sciences, School of Public Health, Brown University, Providence, RI 02912 USA
| | - Calla Harrington
- Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, MA 01003 USA
| | - Elizabeth A. Evans
- Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, MA 01003 USA
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Loera LJ, Hill LG, Zagorski CM, Jermain ML, Tirado CF. Description and Evaluation of a Pilot Advanced Pharmacy Practice Experience in Addiction Medicine. AMERICAN JOURNAL OF PHARMACEUTICAL EDUCATION 2023; 87:ajpe8926. [PMID: 35131764 PMCID: PMC10159605 DOI: 10.5688/ajpe8926] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 02/01/2022] [Indexed: 05/06/2023]
Abstract
Objective. To assess the impact of a pilot advanced pharmacy practice experience (APPE) on fourth-year (P4) Doctor of Pharmacy (PharmD) students' knowledge and confidence related to substance use disorder, harm reduction, and co-occurring psychiatric conditions.Methods. Beginning in 2020, a 62-item assessment was developed and administered to P4 students at the beginning and end of the six-week APPE. The assessment tested knowledge in 10 content areas related to substance use disorder, harm reduction, and co-occurring disorders. Students also ranked their confidence in providing care related to each content area. The post-assessment included a free-text (open-ended) item to provide feedback on the APPE experience. Descriptive statistics and paired t tests were used to analyze the data.Results. Complete pre- and post-assessments were obtained from all participating students (N=7). The mean cumulative knowledge score increased from 55.2% to 81.5%, and the mean cumulative confidence score improved from 34.2% to 81.8%. Free-text responses garnered positive feedback from students, who indicated that the APPE allowed them to immerse themselves in all stages of the recovery process, gain confidence in presentation skills with patients, and solidify their passion for addiction medicine.Conclusion. A novel APPE in addiction medicine addressed a current gap in pharmacy education, earned positive evaluations from student pharmacists, increased student knowledge and confidence related to substance use disorder, harm reduction, and co-occurring disorders, and supported the development of new interprofessional collaborations. United States colleges of pharmacy that do not yet offer APPEs in this clinical domain should consider this model.
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Affiliation(s)
- Lindsey J Loera
- The University of Texas at Austin, College of Pharmacy, Austin, Texas
| | - Lucas G Hill
- The University of Texas at Austin, College of Pharmacy, Austin, Texas
| | - Claire M Zagorski
- The University of Texas at Austin, College of Pharmacy, Austin, Texas
| | - Mandy L Jermain
- Pharmacyclics, An AbbVie Company, Silicon Valley, California
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First Responder Assertive Linkage Programs: A Scoping Review of Interventions to Improve Linkage to Care for People Who Use Drugs. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2022; 28:S302-S310. [PMID: 36194798 PMCID: PMC9531971 DOI: 10.1097/phh.0000000000001611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
CONTEXT In response to the drug overdose crisis, first responders, in partnership with public health, provide new pathways to substance use disorder (SUD) treatment and other services for individuals they encounter in their day-to-day work. OBJECTIVE This scoping review synthesizes available evidence on first responder programs that take an assertive approach to making linkages to care. RESULTS Seven databases were searched for studies published in English in peer-reviewed journals between January 2000 and December 2019. Additional articles were identified through reference-checking and subject matter experts. Studies were selected for inclusion if they sufficiently described interventions that (1) focus on adults who use drugs; (2) are in the United States; (3) involve police, fire, or emergency medical services; and (4) assertively link individuals to SUD treatment. Twenty-two studies met inclusion criteria and described 34 unique programs, implementation barriers and facilitators, assertive linkage strategies, and linkage outcomes, including unintended consequences. CONCLUSIONS Findings highlight the range of linkage strategies concurrently implemented and areas for improving practice and research, such as the need for more linkages to evidence-based strategies, namely, medications for opioid use disorder, harm reduction, and wraparound services.
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Davis CS, Carr DH, Glenn MJ, Samuels EA. Legal Authority for Emergency Medical Services to Increase Access to Buprenorphine Treatment for Opioid Use Disorder. Ann Emerg Med 2021; 78:102-108. [PMID: 33781607 DOI: 10.1016/j.annemergmed.2021.01.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 12/29/2020] [Accepted: 01/15/2021] [Indexed: 11/30/2022]
Abstract
Treatment with buprenorphine significantly reduces both all-cause and overdose mortality among individuals with opioid use disorder. Offering buprenorphine treatment to individuals who experience a nonfatal opioid overdose represents an opportunity to reduce opioid overdose fatalities. Although some emergency departments (EDs) initiate buprenorphine treatment, many individuals who experience an overdose either refuse transport to the ED or are transported to an ED that does not offer buprenorphine. Emergency medical services (EMS) professionals can help address this treatment gap. In this Concepts article, we describe the federal legal landscape that governs the ability of EMS professionals to administer buprenorphine treatment, and discuss state and local regulatory considerations relevant to this promising and emerging practice.
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Affiliation(s)
- Corey S Davis
- Harm Reduction Legal Project, Network for Public Health Law, Los Angeles, CA.
| | | | - Melody J Glenn
- Department of Emergency Medicine, University of Arizona, and Banner University Medical Center Tucson, Tucson, AZ
| | - Elizabeth A Samuels
- Department of Emergency Medicine, Alpert Medical School of Brown University, Providence, RI
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Champagne‐Langabeer T, Bakos‐Block C, Yatsco A, Langabeer JR. Emergency medical services targeting opioid user disorder: An exploration of current out-of-hospital post-overdose interventions. J Am Coll Emerg Physicians Open 2020; 1:1230-1239. [PMID: 33392528 PMCID: PMC7771755 DOI: 10.1002/emp2.12208] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/09/2020] [Accepted: 07/13/2020] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE The opioid epidemic continues to escalate, and out-of-hospital emergency medical services (EMS) play a vital role in acute overdose reversal, but could serve a broader role post-incident for follow-up, outreach, and referrals. Our objective is to identify the scope and prevalence of community-based, post-opioid overdose EMS programs across the United States. METHODS We used a narrative review of prior studies in PubMed and Scopus for the last 20 years (1999-2020) to identify relevant medical literature and a web search to identify gray literature of EMS interventions involving opioids. RESULTS Out of nearly 22,000 EMS agencies across the United States, we found evidence of only 27 programs published in medical or gray literature involving post-overdose interventions. They were most commonly found in the north and eastern region of the country. Although most of these programs incorporate harm reduction and education, other more innovative aspects such as linkage to outpatient addiction treatment or peer support services, are much less common. The most comprehensive programs involved combinations of innovative outreach, specialized referrals, integration with police and criminal justice, peer support, and even treatment initiation. CONCLUSIONS Out-of-hospital emergency care has the potential to provide more comprehensive care after drug overdose, but many programs either do not currently have such an intervention in place, or are not disseminating their practices for other agencies to assimilate. EMS protocols and policies that encourage greater adoption of active community paramedicine practices for opioids should be encouraged.
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Affiliation(s)
- Tiffany Champagne‐Langabeer
- Houston Emergency Opioid Engagement SystemSchool of Biomedical InformaticsThe University of Texas Health Science Center at HoustonHoustonTexasUSA
| | - Christine Bakos‐Block
- Houston Emergency Opioid Engagement SystemSchool of Biomedical InformaticsThe University of Texas Health Science Center at HoustonHoustonTexasUSA
| | - Andrea Yatsco
- Houston Emergency Opioid Engagement SystemSchool of Biomedical InformaticsThe University of Texas Health Science Center at HoustonHoustonTexasUSA
| | - James R. Langabeer
- Houston Emergency Opioid Engagement SystemSchool of Biomedical InformaticsThe University of Texas Health Science Center at HoustonHoustonTexasUSA
- Department of Emergency Medicine, McGovern Medical SchoolThe University of Texas Health Science Center at HoustonHoustonTexasUSA
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