Naloxone--does over-antagonism matter? Evidence of iatrogenic harm after emergency treatment of heroin/opioid overdose

A theoretical explanation of naloxone provision among primary care physicians and community pharmacists in Tennessee

BACKGROUND

Increasing access to naloxone reduces opioid-related morbidity and mortality. Primary care and community pharmacy settings are critical access points, yet limited theoretical research has examined naloxone prescribing and dispensing behaviors.

OBJECTIVES

To determine if the theory of planned behavior (TPB) combined with theoretical constructs from communication science explains intentions to co-prescribe and discuss co-dispensing naloxone among primary care physicians and community pharmacists, respectively.

METHODS

This cross-sectional study surveyed cohorts of licensed primary care physicians and community pharmacists in Tennessee in 2017. Intentions were measured using profession-specific case vignettes, whereby they were asked given 10 similar patients, how many times (0-10) would they co-prescribe or discuss co-dispensing naloxone. Bivariate and multivariable analyses were used.

RESULTS

The analytic sample included 295 physicians (response rate = 15.6 %) and 423 pharmacists (response rate = 19.4 %). Approximately 65 % of physicians reported never intending to co-prescribe naloxone (0 out of 10 patients), while 47 % of pharmacists reported never intending to discuss co-dispensing. All TPB constructs-attitudes (AOR = 1.32, CI = 1.16-1.50), subjective norms (AOR = 1.17, CI = 1.06-1.30), and perceived behavioral control (AOR 1.16, CI = 1.02-1.33)-were associated with an increased likelihood of pharmacists always (versus never) discussing co-dispensing. Similarly, two TPB constructs-attitudes (AOR = 1.41, CI = 1.19-1.68) and subjective norms (AOR = 1.22, CI = 1.08-1.39)-were associated with an increased likelihood of physicians always co-prescribing. Among physicians only, one communication construct-self-perceived communication competence (AOR = 1.19, CI = 1.01-1.41)-was associated with an increased likelihood of always co-prescribing.

CONCLUSION

Findings support the value of theory, particularly TPB, in explaining primary care physician intentions to co-prescribe and community pharmacist intentions to discuss co-dispensing naloxone.

Nalbuphine Potentiates Reversal of Fentanyl Overdose by Naloxone

Developing an effective antidote for fentanyl-induced overdose to achieve timely reversal is an unmet public health need. Previously, we found that naloxone derivative NX90 with mild κ-opioid agonistic properties was three-fold more effective than the parent naloxone in reversing a fentanyl overdose in rats. To investigate whether κ-agonistic properties could indeed augment the robustness of overdose reversal, we evaluated a κ-agonist/µ-antagonist nalbuphine (NB) as well as its combinations with naloxone (NX) in a fentanyl overdose model in rodents. An administration of either NB or NX as single agents at 0.1 mg/kg doses produced a full recovery in 90 ± 9.9 min and 11.4 ± 2.7 min, respectively. A higher dose of NX at 0.2 mg/kg reversed an overdose within 4.8 ± 1.0 min. In contrast to that, the coadministration of NB and NX at 0.1 mg/kg each produced a synergistic effect, with overdose reversal in 3.4 ± 0.2 min. The coadministration of NX and NB at sub-therapeutic doses of 0.05 mg/kg each was also 1.2-fold more effective than NX at 0.2 mg/kg. We further found that co-administration of NB at different doses (0.025, 0.05, 0.1 mg/kg) and ratios (1:4 and 1:1) with NX had differential effects on overdose reversal, cardiorespiratory liabilities, and analgesia.

Clinical Pharmacokinetics and Pharmacodynamics of Naloxone

Naloxone is a World Health Organization (WHO)-listed essential medicine and is the first choice for treating the respiratory depression of opioids, also by lay-people witnessing an opioid overdose. Naloxone acts by competitive displacement of opioid agonists at the μ-opioid receptor (MOR). Its effect depends on pharmacological characteristics of the opioid agonist, such as dissociation rate from the MOR receptor and constitution of the victim. Aim of treatment is a balancing act between restoration of respiration (not consciousness) and avoidance of withdrawal, achieved by titration to response after initial doses of 0.4-2 mg. Naloxone is rapidly eliminated [half-life (t1/2) 60-120 min] due to high clearance. Metabolites are inactive. Major routes for administration are intravenous, intramuscular, and intranasal, the latter primarily for take-home naloxone. Nasal bioavailability is about 50%. Nasal uptake [mean time to maximum concentration (Tmax) 15-30 min] is likely slower than intramuscular, as reversal of respiration lag behind intramuscular naloxone in overdose victims. The intraindividual, interindividual and between-study variability in pharmacokinetics in volunteers are large. Variability in the target population is unknown. The duration of action of 1 mg intravenous (IV) is 2 h, possibly longer by intramuscular and intranasal administration. Initial parenteral doses of 0.4-0.8 mg are usually sufficient to restore breathing after heroin overdose. Fentanyl overdoses likely require higher doses of naloxone. Controlled clinical trials are feasible in opioid overdose but are absent in cohorts with synthetic opioids. Modeling studies provide valuable insight in pharmacotherapy but cannot replace clinical trials. Laypeople should always have access to at least two dose kits for their interim intervention.

Fact vs. fiction: naloxone in the treatment of opioid-induced respiratory depression in the current era of synthetic opioids

Opioid-induced respiratory depression (OIRD) deaths are ~80,000 a year in the US and are a major public health issue. Approximately 90% of fatal opioid-related deaths are due to synthetic opioids such as fentanyl, most of which is illicitly manufactured and distributed either on its own or as an adulterant to other drugs of abuse such as cocaine or methamphetamine. Other potent opioids such as nitazenes are also increasingly present in the illicit drug supply, and xylazine, a veterinary tranquilizer, is a prevalent additive to opioids and other drugs of abuse. Naloxone is the main treatment used to reverse OIRD and is available as nasal sprays, prefilled naloxone injection devices, and generic naloxone for injection. An overdose needs to be treated as soon as possible to avoid death, and synthetic opioids such as fentanyl are up to 50 times more potent than heroin, so the availability of new, higher-dose, 5-mg prefilled injection or 8-mg intranasal spray naloxone preparations are important additions for emergency treatment of OIRDs, especially by lay people in the community. Higher naloxone doses are expected to reverse a synthetic overdose more rapidly and the current formulations are ideal for use by untrained lay people in the community. There are potential concerns about severe withdrawal symptoms, or pulmonary edema from treatment with high-dose naloxone. However, from the perspective of first responders, the balance of risks would point to administration of naloxone at the dose required to combat the overdose where the risk of death is very high. The presence of xylazines as an adulterant complicates the treatment of OIRDs, as naloxone is probably ineffective, although it will reverse the respiratory depression due to the opioid. For these patients, hospitalization is particularly vital. Education about the benefits of naloxone remains important not only in informing people about how to treat emergency OIRDs but also how to obtain naloxone. A call to emergency services is also essential after administering naloxone because, although the patient may revive, they may overdose again later because of the short half-life of naloxone and the long-lasting potency of fentanyl and its analogs.

Stronger, longer, better opioid antagonists? Nalmefene is NOT a naloxone replacement

The fatal overdose crisis claims nearly 200 lives daily in the United States (U.S). Evolutions in the illicit drug supply, such as the addition of sedative adulterants and a shift to synthetic opioids such as fentanyl, have driven increasing rates of both fatal and non-fatal overdose. Specifically, synthetic opioid usage of fentanyl was implicated in 68 % of the U.S. drug overdose deaths in 2022 alone. This has placed tremendous burden on communities, emergency medical services, and healthcare systems, and contributed to tragedy and grief both in the U.S. and worldwide. Despite the availability of effective opioid antagonist medications and standards of care, there has been increased interest in research and development of alternative opioid overdose reversal agents by the National Institutes of Health (NIH) in partnership with pharmaceutical manufacturers over the last decade. The U.S. Food and Drug Administration (FDA) recently approved nalmefene (Opvee) a mu-opioid receptor antagonist that boasts an extended half-life and stronger mu-receptor affinity compared to the standard of care use of naloxone for opioid reversal. In this article, we explore the medical need and ramifications of the introduction of longer-acting opioid antagonists in the current opioid overdose landscape. Existing data highlight the effectiveness of already available naloxone products as a safe and effective standard of care. These data support the notion that stronger, longer-acting agents may be unnecessary, and their existence may cause undue harm, such as more severe and/or prolonged withdrawal symptoms, lead to challenging patient interactions, and complicate the initiation of medications for opioid use disorder. More evidence is needed before healthcare professionals should implement the use of stronger, longer-acting opioid antagonists for reversing opioid overdose over evidence-based, cost-effective naloxone.

Remaking the 'angry Narcanned subject': Affording new subject positions through take-home naloxone training

Naloxone is a medication used to reverse opioid overdose. Alongside its lifesaving effects, it also has a reputation for producing distress, aggression and occasionally violence upon administration. This article analyses how take-home naloxone (THN) training initiatives address naloxone's reputation for producing aggression and conflict, and how new subject positions emerge in the context of this training. While the role of naloxone in producing aggression has been discussed in a range of research, this work emphasises that such conflict is neither inevitable nor even likely because it is contingent on several other issues such as administration practices. Building on this scholarship, we work with Bruno Latour's theorisation of technological 'affordances' to analyse THN as a socially co-produced technology that, rather than either determining or neutrally communicating actions and effects, 'affords' possibilities, capacities and subjects. Analysing data drawn from observations of THN training in Victoria, Australia, and in-depth interviews with training participants, we argue that the issue of conflict upon revival affords a subject position we term the 'angry Narcanned subject'. This subject, we note, has come to hold a powerful position in understandings of naloxone, not least because it tends to accord with stereotypes of antisocial drug users. From here, we argue that a much of THN training is focused on challenging and reframing naloxone's reputation for conflict and questioning related subject positions, especially that of the angry Narcanned subject. We argue that this process of challenging and reframing affords two new subject positions for consumers: the 'capable administrator' and the 'calmer revivee'. We conclude that while THN training affords multiple, potentially positive, subject positions, unless these initiatives are accompanied by broader interventions such as decriminalisation campaigns, they may inadvertently responsibilise people who consume opioids for addressing overdose and erase the role of prohibition, criminalisation and stigmatisation in producing overdose events.

Systematic Review of Naloxone Dosing and Adverse Events in the Emergency Department

BACKGROUND

Experts recommend using the lowest effective dose of naloxone to balance the reversal of opioid-induced respiratory depression and avoid precipitated opioid withdrawal, however, there is no established dosing standards within the emergency department (ED).

OBJECTIVES

The aim of this review was to determine current naloxone dosing practice in the ED and their association with adverse events.

METHODS

We conducted a systematic review by searching PubMed, Cochrane, Embase, and EBSCO from 2000-2021. Articles containing patient-level data for initial ED dose and patient outcome had data abstracted by two independent reviewers. Patients were divided into subgroups depending on the initial dose of i.v. naloxone: low dose ([LD], < 0.4 mg), standard dose ([SD], 0.4-2 mg), or high dose ([HD], > 2 mg). Our outcomes were the dose range administered and adverse events per dose. We compared groups using chi-squared difference of proportions or Fisher's exact test.

RESULTS

The review included 13 articles with 209 patients in the results analysis: 111 patients in LD (0.04-0.1 mg), 95 in SD (0.4-2 mg), and 3 in HD (4-12 mg). At least one adverse event was reported in 37 SD patients (38.9%), compared with 14 in LD (12.6%, p < 0.0001) and 2 in HD (100.0%, p = 0.16). At least one additional dose was administered to 53 SD patients (55.8%), compared with 55 in LD (49.5%, p < 0.0001), and 3 in HD (100.0%, p = 0.48).

CONCLUSIONS

Lower doses of naloxone in the ED may help reduce related adverse events without increasing the need for additional doses. Future studies should evaluate the effectiveness of lower doses of naloxone to reverse opioid-induced respiratory depression without causing precipitated opioid withdrawal.

Sweden's first Take-Home Naloxone program: participant characteristics, dose endpoints and predictors for overdose reversals

BACKGROUND

Opioid overdoses are a growing concern, particularly among people who inject drugs. Sweden, with a comparatively high proportion of drug-related mortality, introduced its first Take-Home Naloxone (THN) program in 2018, at the Stockholm needle and syringe program (NSP). In this study we compare THN participant characteristics regarding refills and overdose reversals as well as investigate predictors associated with number of reversals. We also investigate interventions performed in overdose situations and endpoints for naloxone doses.

METHODS

This was a prospective open inclusion cohort study conducted between January 24^th 2018 and March 31^st 2022 at the Stockholm NSP. Participants received THN, free of charge, after a training session and provided data regarding drug use and overdose experiences. During refill visits, participants reported if the naloxone was used for overdose reversal and, if so, responded to a ten-item questionnaire which included stating whether the naloxone recipient was the participant themselves or somebody else. Questionnaire data was combined with NSP database demographic data. Zero-inflated Poisson regression was applied to analyse predictors for number of reported overdose reversals.

RESULTS

Among study participants (n = 1,295), 66.5% stated opioids as their primary drug, and 61.4% and 81.0% had previous experience of a personal or witnessed overdose, respectively. Overall, 44.0% of participants reported a total of 1,625 overdose reversals and the victim was known to have survived in 95.6% of cases. Stimulant use (aIRR 1.26; 95% CI 1.01, 1.58), benzodiazepine use (aIRR 1.75; 95% CI 1.1, 2.78) and homelessness (aIRR 1.35; 95% CI 1.06, 1.73) were predictors associated with an increased number of reported overdose reversals. Mortality was higher among those who reported at least one overdose reversal (HR 3.4; 95% CI 2.2, 5.2).

CONCLUSIONS

An NSP's existent framework can be utilised to effectively implement a THN program, provide basic training and reach numerous high-risk individuals. During the four-year study, THN participants reversed a sizeable number of potentially fatal overdoses, of which many were reported by participants whose primary drug was not opioids. Naloxone refill rate was high, indicating that participants were motivated to maintain a supply of naloxone in case of future overdose events.

Take-Home Naloxone and risk management from the perspective of people who survived an opioid overdose in Stockholm - An analysis informed by drug, set and setting

BACKGROUND

Take-Home Naloxone (THN) programs were introduced in Sweden in 2018 - a country with one of the highest rates of overdose mortality in the EU and a severe stigmatisation of people who inject drugs. This qualitative study builds on the international research that has expanded a previously narrow and medical focus on overdose deaths. It uses Zinberg's framework to look beyond the role of the "drug" to include the attitudes and personality of the person ("set") and contextual factors ("setting"). This study explores the impacts of THN from the perspective of overdose survivors.

METHODS

Between November 2021 and May 2022 semi-structured interviews were conducted with 22 opioid overdose survivors, recruited among clients of the Stockholm needle and syringe program. All the participants had been treated with naloxone in an overdose situation. The interviews were processed through thematic analysis using deductive and inductive coding in accordance with the theoretical framework.

RESULTS

Interviewees included men and women who used different types of drugs. THN has impacted on "drug" in terms of naloxone-induced withdrawal symptoms and peers having to deal with survivors' emotions. Exploring "set" revealed feelings of shame following naloxone revival for the person who overdosed. Despite such reactions, participants retained an overwhelmingly positive attitude towards THN. Participants integrated THN into their risk management practices ("setting") and some acknowledged that THN provided a new way to treat overdoses without necessarily needing to interact with authorities, especially the police.

CONCLUSION

The THN program has influenced "drug, set and setting" for participants, providing increased safety at drug-intake and transferring overdose management and the burden of care to the community. The lived experience of participants also exposes the limitations of THN indicating that there are additional unmet needs beyond THN programs, particularly in terms of "setting".

A scoping review of mHealth technologies for opioid overdose prevention, detection and response

ISSUES

Opioid overdose kills over 100,000 people each year globally. Mobile health (mHealth) technologies and devices, including wearables, with the capacity to prevent, detect or respond to opioid overdose exist in early form, or could be re-purposed or designed. These technologies may particularly help those who use alone. For technologies to be successful, they must be effective and acceptable to the at-risk population. The aim of this scoping review is to identify published studies on mHealth technologies that attempt to prevent, detect or respond to opioid overdose.

APPROACH

A systematic scoping review of literature was conducted up to October 2022. APA PsychInfo, Embase, Web of Science and Medline databases were searched.

INCLUSION CRITERIA

articles had to report on (i) mHealth technologies that deal with (ii) opioid (iii) overdose.

KEY FINDINGS

A total of 348 records were identified, with 14 studies eligible for this review across four domains: (i) technologies that require intervention/response from others (four); (ii) devices that use biometric data to detect overdose (five); (iii) devices that automatically respond to an overdose with administration of an antidote (three); (iv) acceptability/willingness to use overdose-related technologies/devices (five).

IMPLICATIONS

There are multiple routes in which these technologies may be deployed, but several factors impact acceptability (e.g., discretion or size) and accuracy of detection (e.g., sensitive parameter/threshold with low false positive rate).

CONCLUSION

mHealth technologies for opioid overdose may play a crucial role in responding to the ongoing global opioid crises. This scoping review identifies vital research that will determine the future success of these technologies.

Comparison of intranasal and intramuscular naloxone in opioid overdoses managed by ambulance staff: a double-dummy, randomised, controlled trial

AIMS

To measure and evaluate clinical response to nasal naloxone in opioid overdoses in the pre-hospital environment.

DESIGN

Randomised, controlled, double-dummy, blinded, non-inferiority trial, and conducted at two centres.

SETTING

Participants were included by ambulance staff in Oslo and Trondheim, Norway, and treated at the place where the overdose occurred.

PARTICIPANTS

Men and women age above 18 years with miosis, rate of respiration ≤8/min, and Glasgow Coma Score <12/15 were included. Informed consent was obtained through a deferred-consent procedure.

INTERVENTION AND COMPARATOR

A commercially available 1.4 mg/0.1 mL intranasal naloxone was compared with 0.8 mg/2 mL naloxone administered intramuscularly.

MEASUREMENTS

The primary end-point was restoration of spontaneous respiration of ≥10 breaths/min within 10 minutes. Secondary outcomes included time to restoration of spontaneous respiration, recurrence of overdose within 12 hours and adverse events.

FINDINGS

In total, 201 participants were analysed in the per-protocol population. Heroin was suspected in 196 cases. With 82% of the participants being men, 105 (97.2%) in the intramuscular group and 74 (79.6%) in the intranasal group returned to adequate spontaneous respiration within 10 minutes after one dose. The estimated risk difference was 17.5% (95% CI, 8.9%-26.1%) in favour of the intramuscular group. The risk of receiving additional naloxone was 19.4% (95% CI, 9.0%-29.7%) higher in the intranasal group. Adverse reactions were evenly distributed, except for drug withdrawal reactions, where the estimated risk difference was 6.8% (95% CI, 0.2%-13%) in favour of the intranasal group in a post hoc analysis.

CONCLUSION

Intranasal naloxone (1.4 mg/0.1 mL) was less efficient than 0.8 mg intramuscular naloxone for return to spontaneous breathing within 10 minutes in overdose patients in the pre-hospital environment when compared head-to-head. Intranasal naloxone at 1.4 mg/0.1 mL restored breathing in 80% of participants after one dose and had few mild adverse reactions.

Pharmacokinetic considerations for community-based dosing of nasal naloxone in opioid overdose in adults

INTRODUCTION

The administration of the opioid antagonist naloxone in the community is a measure to prevent death from opioid overdose. Approved nasal naloxone sprays deliver initial doses of 0.9 to 8 mg. The level of the initial community dose is controversial, as the scientific base is weak.In this review knowledge of the pharmacokinetics of nasal, both approved and improvised nasal sprays, and intramuscular naloxone will be utilized to evaluate dose-effect relationships in previous studies of opioid overdose outcomes.

AREAS COVERED

The aim was to present scientifically based considerations on the initial nasal naloxone doses currently available, which reasonably balances the effect and adverse outcomes, given that at least two doses are at hand. Also included in these considerations is the challenge by illicitly manufactured fentanyl and analogs.This paper is based on both peer-reviewed and grey literature identified by several searches, of such as naloxone pharmacokinetics/formulations/outcomes/emergency medical services, in PubMed and Embase.

EXPERT OPINION

There is little scientific evidence that supports the use of initial systemic dosing that exceeds 0.8 mg in the community. Higher doses increase the risk of withdrawal symptoms feared in people who use opioids. Many obstacles may reduce the potential of community-administered naloxone.

Modifying naloxone to reverse fentanyl-induced overdose

Developing an effective antidote for fentanyl-induced overdose (OD) is an unmet medical need that requires both lipophilicity comparable to fentanyl and fast onset of overdose reversal. We synthesized and evaluated a bioreversible derivative of naloxone (NX-90) in silico, in vitro and in vivo to yield a robust reversal of fentanyl-induced OD in rats. All monitored reflexes along with the heart rate (HR) and respiratory rate (RR) were fully restored faster in the NX-90 groups than in naloxone groups on equimolar bases when given intranasally. In NX-90 treated rats RR over the time of observation (RR AUC) was significantly higher at all respective doses with no re-narcotization observed. Apart from the enhanced pharmacodynamics profile, NX-90 was found to have lower circulating levels of naloxone, clean profile in in vitro selectivity panels, as well as Ames and CYP450 counter screens. Finally, we demonstrated a robust release of the parent naloxone in brain matrix, as well as lower peripheral naloxone levels after NX-90 iv administration. With the demonstrated pharmacological profile superior yet congruent to naloxone we nominated NX-90 for preclinical development as an effective intranasal fentanyl antidote.

Take-Home Naloxone and the Prevention of Deaths from Heroin Overdose: Pursuing Strong Science, Fuller Understanding, Greater Impact

BACKGROUND AND CONTEXT

Realization of the life-saving potential of "take-home naloxone" has been a personal journey, but it has also been a collective journey. It has been a story of individual exploration and growth, and also a story of changes at a societal level. "Take-home naloxone" has matured since its first conceptualization a quarter of a century ago. It required recognition of the enormous burden of deaths from drug overdose (particularly heroin and other opioids), and also realization of critical clusterings (such as post-release from prison). It also required realization that, since many overdose deaths are witnessed, we can potentially prevent many deaths by mobilizing drug users themselves, their families, and the wider caring community to act as intervention workforce to give life-saving interim emergency care. Summary of Scope: This article explores 5 areas (many illustrations UK-based where the author works): firstly, the need for strong science; secondly, our improved understanding of opioid overdose and deaths; thirdly, the search for greater impact from our policies and interventions; fourthly, developing better forms of naloxone; and fifthly, examining the challenges still to be addressed.

KEY MESSAGES

"Take-home naloxone" is an exemplar of harm reduction with potential global impact - drug policy and practice for the public good. However, "having the potential" is not good enough - there needs to be actual implementation. This will be easier once the component parts of "take-home naloxone" are improved (better naloxone products, better training aids, revised legislation, and explicit funding support). Many improvements are already possible, but we hesitate about implementation. It is our responsibility to drive progress faster. With "take-home naloxone," we can be proud of what we have achieved, but we must also be humble about how much more we still need to do.

UNDERSTANDING PREFERENCES FOR TYPE OF TAKE-HOME NALOXONE DEVICE: INTERNATIONAL QUALITATIVE ANALYSIS OF THE VIEWS OF PEOPLE WHO USE OPIOIDS

Background

Take-home naloxone (THN) is provided to non-medically trained people to reverse potential opioid overdoses. There is an increasing range of effective intramuscular (IM) and intranasal (IN) naloxone devices and this paper explores the types preferred by people who use opioids, using consumer behaviour literature to interpret the findings.

Methods

Data derive from two unconnected qualitative studies involving audio-recorded semi-structured interviews. Study 1 was conducted in the United States (n=21 users of non-medical/illicit opioids). Study 2 was conducted in Australia (n=42 users of non-medical/illicit or prescribed opioids).

Findings

Most participants preferred IN naloxone. Preferences were based on the ease, speed, safety and comfort of each device and underpinned by accounts of overdose revivals as being very rushed and frightening situations. Preferences related to complex interactions between the naloxone device ('product'); the knowledge, skills, experience and attitudes of the lay responder ('consumer'), and when, where and how naloxone was to be used ('usage situation').

Conclusions

THN programs should offer choice of device when possible and nasal naloxone if resources permit. Asking people which devices they prefer and why and treating them as valued consumers of naloxone products can generate insights that improve future naloxone technology and increase THN uptake and usage.

Treatment of overdose in the synthetic opioid era

Overdose deaths are often viewed as the leading edge of the opioid epidemic which has gripped the United States over the past two decades (Skolnick, 2018a). This emphasis is perhaps unsurprising because opioid overdose is both the number-one cause of death for individuals between 25 and 64 years old (Dezfulian et al., 2021) and a significant contributor to the decline in average lifespan (Dowell et al., 2017). Exacerbated by the COVID 19 pandemic, it was estimated there were 93,400 drug overdose deaths in the United States during the 12 months ending December 2020, with more than 69,000 (that is, >74%) of these fatalities attributed to opioid overdose (Ahmad et al., 2021). However, the focus on mortality statistics (Ahmad et al., 2021; Shover et al., 2020) tends to obscure the broader medical impact of nonfatal opioid overdose. Analyses of multiple databases indicate that for each opioid-induced fatality, there are between 6.4 and 8.4 non-fatal overdoses, exacting a significant burden on both the individual and society. Over the past 7-8 years, there has been an alarming increase in the misuse of synthetic opioids ("synthetics"), primarily fentanyl and related piperidine-based analogs. Within the past 2-3 years, a structurally unrelated class of high potency synthetics, benzimidazoles exemplified by etonitazene and isotonitazene ("iso"), have also appeared in illicit drug markets (Thompson, 2020; Ujvary et al. 2021). In 2020, it was estimated that over 80% of fatal opioid overdoses in the United States now involve synthetics (Ahmad et al., 2021). The unique physicochemical and pharmacological properties of synthetics described in this review are responsible for both the morbidity and mortality associated with their misuse as well as their widespread availability. This dramatic increase in the misuse of synthetics is often referred to as the "3rd wave" (Pardo et al., 2019; Volkow and Blanco, 2020) of the opioid epidemic. Among the consequences resulting from misuse of these potent opioids is the need for higher doses of the competitive antagonist, naloxone, to reverse an overdose. The development of more effective reversal agents such as those described in this review is an essential component of a tripartite strategy (Volkow and Collins, 2017) to reduce the biopsychosocial impact of opioid misuse in the "synthetic era".

Emotional reactions of trained overdose responders who use opioids following intervention in an overdose event

Background: Our aim was to explore emotional reactions to intervening in an overdose event from the perspective of individuals who use opioids (peer responders). In addition, we were interested in the impact this experience may have on peer responders' feelings about helping in an overdose situation in the future. Methods: For this qualitative sub-study of a randomized controlled trial (RCT), data from 61 interviews were analyzed thematically using an inductive approach. Results: Peer responders had diverse emotional reactions to the overdose event. These ranged from a sense of pride and other positive feelings associated with their ability to help to ambivalence about being involved in situations perceived as challenging and burdensome. There were few reports of the overdose event as an exclusively negative experience. Many peer responders perceived it as their duty to use naloxone again if required. However, some had ambivalent feelings toward this responsibility, which may be related to negative experiences with previous intervention efforts. Conclusions: The capacity of people who use opioids to help reduce the harms associated with opioid overdose is experienced as empowering by some. Nonetheless, engaging peer responders in strategies to reduce opioid-related mortality should be coupled with appropriate resources to process their experiences and emotional responses.

Impact of the Opioid Epidemic

In recent years the prescription opioid overdose epidemic has decreased, but has been more than offset by increases in overdose caused by fentanyl and fentanyl analogues. Opioid overdose patients should receive naloxone if they have significant respiratory depression and/or loss of protective airway reflexes. Patients who receive naloxone should be observed for recurrent opioid effects. Patients with opioid overdose may be admitted to the intensive care unit for naloxone infusions, treatment of noncardiogenic pulmonary edema, autonomic instability, or sequelae of hypoxia-ischemia or cardiac arrest. Primary and secondary prevention are important to reduce the number of people with life-threatening opioid overdose.

Feasibility of Safe Opioid Prescribing in Outpatient Palliative Care: A Quality Improvement Project

BACKGROUND

No guidelines for safe opioid prescribing in palliative care exist, which contributes to limited monitoring of opioid misuse in palliative care.

MEASURES

Feasibility of a safe opioid prescribing standard operating protocol (SOP) was determined by assessing the percentage of patients in an outpatient cancer center who completed each component of a five-component SOP.

INTERVENTION

A five-component SOP included: risk stratification for misuse, consent form, prescription drug monitoring program review, urine drug testing, and Naloxone for high-risk individuals.

OUTCOMES

After one year, compliance rates on four of the of the five-component SOP were greater or equal to 93%. Naloxone co-prescription for high-risk patients never reached over 78%, largely due to clinical decision not to co-prescribe if transition to hospice was imminent.

CONCLUSIONS/LESSONS LEARNED

Safe opioid prescribing measures are feasible in outpatient palliative care and can facilitate identification of individuals at risk for opioid misuse and prompt early interventions for misuse.

New and Emerging Opioid Overdose Risk Factors

Purpose of Review

The purpose of this review is to provide a review of the current literature surrounding opioid overdose risk factors, focusing on relatively new factors in the opioid crisis.

Recent Findings

Both a market supply driving force and a subpopulation of people who use opioids actively seeking out fentanyl are contributing to its recent proliferation in the opioid market. Harm reduction techniques such as fentanyl testing strips, naloxone education and distribution, drug sampling behaviors, and supervised injection facilities are all seeing expanded use with increasing amounts of research being published regarding their effectiveness. Availability and use of interventions such as medication for opioid use disorder and peer recovery coaching programs are also on the rise to prevent opioid overdose.

Summary

The opioid epidemic is an evolving crisis, necessitating continuing research to identify novel overdose risk factors and the development of new interventions targeting at-risk populations.

Rethinking 'carriage' of take-home naloxone

Take-home naloxone (THN) provision to people who use drugs, their family/friends, and non-medical personnel is considered a public health strategy to improve community-based naloxone access and reduce the time to antidote treatment for opioid overdose in order to prevent fatal outcome. THN programs typically report up to three performance indicators: the volume of THN kits distributed, the rate of requests for re-supply of THN kits (e.g., following naloxone use for overdose reversal), and - increasingly - THN "carriage". In this Research Methods piece, we discuss the current shortcomings in the latter measurement of THN carriage from a mixed-methods perspective and describe possible implications for public health related research and improved data analyses. We present an argument for the need to improve research methods in the case of THN "carriage" and propose a multidimensional measurement structure that takes into account: 1) the location of the THN kit relative to its owner, 2) the owner's immediate access to the kit in an emergency, 3) the type of THN device, and 4) the purpose of THN ownership (i.e., for use in self or known/unknown other/s).

Opioid-Associated Out-of-Hospital Cardiac Arrest: Distinctive Clinical Features and Implications for Health Care and Public Responses: A Scientific Statement From the American Heart Association

Opioid overdose is the leading cause of death for Americans 25 to 64 years of age, and opioid use disorder affects >2 million Americans. The epidemiology of opioid-associated out-of-hospital cardiac arrest in the United States is changing rapidly, with exponential increases in death resulting from synthetic opioids and linear increases in heroin deaths more than offsetting modest reductions in deaths from prescription opioids. The pathophysiology of polysubstance toxidromes involving opioids, asphyxial death, and prolonged hypoxemia leading to global ischemia (cardiac arrest) differs from that of sudden cardiac arrest. People who use opioids may also develop bacteremia, central nervous system vasculitis and leukoencephalopathy, torsades de pointes, pulmonary vasculopathy, and pulmonary edema. Emergency management of opioid poisoning requires recognition by the lay public or emergency dispatchers, prompt emergency response, and effective ventilation coupled to compressions in the setting of opioid-associated out-of-hospital cardiac arrest. Effective ventilation is challenging to teach, whereas naloxone, an opioid antagonist, can be administered by emergency medical personnel, trained laypeople, and the general public with dispatcher instruction to prevent cardiac arrest. Opioid education and naloxone distributions programs have been developed to teach people who are likely to encounter a person with opioid poisoning how to administer naloxone, deliver high-quality compressions, and perform rescue breathing. Current American Heart Association recommendations call for laypeople and others who cannot reliably establish the presence of a pulse to initiate cardiopulmonary resuscitation in any individual who is unconscious and not breathing normally; if opioid overdose is suspected, naloxone should also be administered. Secondary prevention, including counseling, opioid overdose education with take-home naloxone, and medication for opioid use disorder, is important to prevent recurrent opioid overdose.

Iterative categorisation (IC) (part 2): interpreting qualitative data

Iterative categorisation (IC) is a systematic and transparent technique for analysing qualitative textual data, first presented in Addiction in 2016. IC breaks the analytical process down into stages, separating basic 'description' from more advanced 'interpretation'. This paper focuses on the interpretive analytical stage that is shown to comprise three core processes: (i) conceptualising (undertaken inductively, deductively or abductively); (ii) differentiating; and (iii) externalising. Each process is described, followed by published examples to support what has been explained. As qualitative analyses tend to be recursive rather than linear, the three processes often need to be repeated to account for all the data. Following the stages of IC will ensure that qualitative research generates improved understanding of the phenomena being studied, study findings contribute to and enhance the existing literature, the audience for any qualitative output is broad and international, and any practical implications or study recommendations are relevant to other contexts and settings.

A qualitative study of repeat naloxone administrations during opioid overdose intervention by people who use opioids in New York City

BACKGROUND

Take-home naloxone (THN) kits have been designed to provide community members (including people who use drugs, their families and/or significant others) with the necessary resources to address out-of-hospital opioid overdose events. Kits typically include two doses of naloxone. This 'twin-pack' format means that lay responders need information on how to use each dose. Advice given tends to be based on dosage algorithms used by medical personnel. However, little is currently known about how and why people who use drugs, acting as lay responders, decide to administer the second dose contained within single THN kits. The aim of this article is to explore this issue.

METHODS

Data were generated from a qualitative semi-structured interview study that was embedded within a randomised controlled trial examining the risks and benefits of Overdose Education and Naloxone Distribution (OEND) training in New York City (NYC). Analysis for this article focuses upon the experiences of 22 people who use(d) opioids and who provided repeat naloxone administrations (RNA) during 24 separate overdose events. The framework method of analysis was used to compare the time participants believed had passed between each naloxone dose administered ('subjective response interval') with the 'recommended response interval' (2-4 minutes) given during OEND training. Framework analysis also charted the various reasons and rationale for providing RNA during overdose interventions.

RESULTS

When participants' subjective response intervals were compared with the recommended response interval for naloxone dosing, three different time periods were reported for the 24 overdose events: i. 'two doses administered in under 2 minutes' (n = 10); ii. 'two doses administered within 2-4 minutes' (n = 7), and iii. 'two doses administered more than 4 minutes apart' (n = 7). A variety of reasons were identified for providing RNA within each of the three categories of response interval. Collectively, reasons for RNA included panic, recognition of urgency, delays in retrieving naloxone kit, perceptions of recipients' responsiveness/non-responsiveness to naloxone, and avoidance of Emergency Response Teams (ERT).

CONCLUSION

Findings suggest that decision-making processes by people who use opioids regarding how and when to provide RNA are influenced by factors that relate to the emergency event. In addition, the majority of RNA (17/24) occurred outside of the recommended response interval taught during OEND training. These findings are discussed in terms of evidence-based intervention and 'evidence-making intervention' with suggestions for how RNA guidance may be developed and included within future/existing models of OEND training.

Cannabinoid CB2 Receptor Activation Attenuates Fentanyl-Induced Respiratory Depression

Introduction: Overdose fatalities associated with the opioid epidemic are predictably attributable to drug-induced respiratory depression. In terms of illicit opioid abuse, fentanyl is the synthetic opioid responsible for the largest number of overdose deaths. There is, therefore, an urgent need to identify safe and effective therapeutics that can attenuate fentanyl-induced respiratory depression. Identification of effective alternate analgesic strategies that lessen the respiratory depression associated with narcotics would also help improve current strategies for pain management. Our laboratory recently reported that the G protein-biased CB₂ cannabinoid receptor agonist LY2828360 suppressed chemotherapy-induced neuropathic nociception and attenuated both morphine tolerance and physical dependence in paclitaxel-treated mice. However, the impact of LY2828360 on other undesirable side effects of opioids, such as opioid-induced respiratory depression, remains unknown. Materials and Methods: We used whole-body plethysmography to assess the impact of the CB₂ cannabinoid agonist LY2828360 on fentanyl-induced respiratory depression using wild-type (WT) and CB₂ knockout (CB₂KO) mice. Results: Fentanyl reduced minute ventilation and respiratory frequency without altering tidal volume in both WT and CB₂KO mice. In WT mice, the high dose of fentanyl (0.2 mg/kg intraperitoneal [i.p.]) produced a greater suppression of respiratory parameters compared with the low dose of fentanyl (0.1 mg/kg i.p.). Coadministration of a behaviorally active dose of LY2828360 (3 mg/kg i.p.) with fentanyl (0.2 mg/kg i.p.) attenuated fentanyl-induced respiratory depression in WT mice. Notably, LY2828360 (3 mg/kg i.p.) did not attenuate fentanyl-induced respiratory depression in CB₂KO mice, consistent with mediation by CB₂ receptors. Moreover, LY2828360 (3 mg/kg i.p.) alone lacked intrinsic effects on respiratory parameters in either WT or CB₂KO mice. Conclusion: The combination of a CB₂ agonist with fentanyl may represent a safer adjunctive therapeutic strategy compared with a narcotic analgesic alone by attenuating the development of opioid-induced respiratory depression. Moreover, the CB₂ agonist, administered alone, did not alter respiration. Our findings suggest that the CB₂ cannabinoid agonist LY2828360 may provide CB₂-mediated protection against fentanyl-induced respiratory depression, a detrimental and unwanted side effect of opioid use and abuse.

Factors associated with withdrawal symptoms and anger among people resuscitated from an opioid overdose by take-home naloxone: Exploratory mixed methods analysis

INTRODUCTION

Take-home naloxone (THN) is a clinically effective and cost-effective means of reducing opioid overdose fatality. Nonetheless, naloxone administration that successfully saves a person's life can still produce undesirable and harmful effects.

AIM

To better understand factors associated with two widely reported adverse outcomes following naloxone administration; namely the person resuscitated displays: i. withdrawal symptoms and ii. anger.

METHODS

A mixed methods study combining a randomized controlled trial of overdose education and naloxone prescribing to people with opioid use disorder and semi-structured qualitative interviews with trial participants who had responded to an overdose whilst in the trial. All data were collected in New York City (2014-2019). A dataset (comprising demographic, pharmacological, situational, interpersonal, and overdose training related variables) was generated by transforming qualitative interview data from 47 overdose events into dichotomous variables and then combining these with quantitative demographic and overdose training related data from the main trial. Associations between variables within the dataset and reports of: i. withdrawal symptoms and ii. anger were explored using chi-squared tests, t-tests, and logistic regressions.

RESULTS

A multivariate logistic regression found that people who had overdosed were significantly more likely to display anger if the person resuscitating them criticized, berated or chastised them during resuscitation (adjusted OR = 27 [95% CI = 4.0-295]). In contrast, they were significantly less likely to display anger if the person resuscitating them communicated positively with them (OR = 0.10 [95% CI = 0.01-0.78]). Both positive and negative communication styles were independently associated with anger, and communication was associated with 59% of the variance in anger. There was no evidence that people who displayed withdrawal symptoms were more likely to display anger than those not displaying withdrawal symptoms, and neither displaying withdrawal symptoms nor displaying anger were associated with using more drugs after resuscitation.

CONCLUSIONS

Contrary to common assumptions, withdrawal symptoms and anger following naloxone administration may be unrelated phenomena. Findings are consistent with previous research that has suggested that a lay responder's positive or reassuring communication style may lessen anger post overdose. Implications for improving THN programmes and naloxone administration are discussed.

Prehospital naloxone administration - what influences choice of dose and route of administration?

Background

Amidst the ongoing opioid crisis there are debates regarding the optimal route of administration and dosages of naloxone. This applies both for lay people administration and emergency medical services, and in the development of new naloxone products.

We examined the characteristics of naloxone administration, including predictors of dosages and multiple doses during patient treatment by emergency medical service staff in order to enlighten this debate.

Methods

This was a prospective observational study of patients administered naloxone by the Oslo City Center emergency medical service, Norway (2014–2018). Cases were linked to The National Cause of Death Registry. We investigated the route of administration and dosage of naloxone, clinical and demographic variables relating to initial naloxone dose and use of multiple naloxone doses and one-week mortality.

Results

Overall, 2215 cases were included, and the majority (91.9%) were administered intramuscular naloxone. Initial doses were 0.4 or 0.8 mg, and 15% of patients received multiple dosages. Unconscious patients or those in respiratory arrest were more likely to be treated with 0.8 mg naloxone and to receive multiple doses. The one-week mortality from drug-related deaths was 4.1 per 1000 episodes, with no deaths due to rebound opioid toxicity.

Conclusions

Intramuscular naloxone doses of 0.4 and 0.8 mg were effective and safe in the treatment of opioid overdose in the prehospital setting. Emergency medical staff appear to titrate naloxone based on clinical presentation.

Barriers to and recommendations for take-home naloxone distribution: perspectives from opioid treatment programs in New Mexico

BACKGROUND

Naloxone is a safe and effective medication to help reverse opioid overdose. Providing take-home naloxone to patients in opioid treatment settings is a critical step to reducing opioid overdose deaths. In New Mexico, a US state with one of the highest rates of opioid overdose deaths, legislation was passed in 2017 (House Bill 370) to support take-home naloxone, and followed by naloxone training of Opioid Treatment Program staff to increase distribution.

METHODS

Naloxone training was offered to all New Mexico Opioid Treatment Programs along with a baseline survey to assess current practices and barriers to take-home naloxone distribution. Focus groups were conducted approximately 1 year post-training with staff at a subset of the trained Opioid Treatment Programs to assess the impact of the legislation and training provided.

RESULTS

Baseline survey results show most Opioid Treatment Program staff were unfamiliar with House Bill 370, reported conflicting understandings of their agency's current take-home naloxone practices, and reported a number of barriers at the patient, agency, and policy level. Follow-up focus groups revealed support for House Bill 370 but persistent barriers to its implementation at the patient, agency, and policy level including patient receptivity, cost of naloxone, staff time, and prohibitive pharmacy board regulations.

CONCLUSIONS

In spite of targeted legislation and training, provision of take-home naloxone at remained low. This is alarming given the need for this lifesaving medication among the Opioid Treatment Program patient population, and high opioid death rate in New Mexico. Locally, important next steps include clarifying regulatory guidelines and supporting policy/billing changes to offset costs to Opioid Treatment Programs. Globally, additional research is needed to identify the prevalence of take-home naloxone distribution in similar settings, common barriers, and best practices that can be shared to increase access to this vital lifesaving medication in this critical context.

Opioid overdose reversals using naloxone in New York City by people who use opioids: Implications for public health and overdose harm reduction approaches from a qualitative study

BACKGROUND

Adverse reactions to naloxone, such as withdrawal symptoms and aggression, are widely recognised in the literature by pharmaceutical manufacturers and clinical practitioners as standard reactions of individuals who are physically dependent upon opioid drugs following the reversal of potentially fatal opioid overdose. This paper seeks to provide a differentiated view on reactions to naloxone that may have important implications for public health and harm reduction approaches.

METHODS

Analyses from a qualitative investigation embedded within a 5-year Randomised Controlled Trial (RCT) examined the risks and benefits of Overdose Education and Naloxone Distribution (OEND) training models (brief or extended training) in various populations of people who use opioids in New York City. The qualitative experiences (obtained through semi-structured interviews) of 46 people who use opioids and who were each involved in the delivery of naloxone, during 56 separate overdose events that occurred throughout 2016-2018, were studied. Situational analysis and inductive content analysis of interview data focused upon overdose reversals in an attempt to provide understandings of the various adverse effects associated with naloxone from their perspective. These analyses were supplemented by data sessions within the research team during which the findings obtained from situational analysis and inductive content analysis were reviewed and complemented by deductive (clinical) appraisals of the various physical and psychological effects associated with the overdose reversals.

RESULTS

People who use opioids recognise three distinct and interconnected outcomes that may follow a successful opioid overdose reversal after intramuscular or intranasal administration of naloxone. These outcomes are here termed, (i) 'rage' (describing a wide range of angry, hostile and/or aggressive outbursts), (ii) 'withdrawal symptoms,' and (iii) 'not rage, not withdrawal' (i.e., a wide range of short-lived, 'harmless' conditions (such as temporary amnesia, mild emotional outbursts, or physical discomfort) that do not include rage or withdrawal symptoms).

CONCLUSION

Physical and psychological reactions to naloxone should not be understood exclusively as a consequence of acute, opioid-related, withdrawal symptoms. The three distinct and interconnected reversal outcomes identified in this study are considered from a harm reduction policy perspective and are further framed by concepts associated with 'mediated toxicity' (i.e., harm triggered by medicine). The overall conclusion is that harm reduction training programmes that are aligned to the policy and practice of take home naloxone may be strengthened by including awareness and training in how to best respond to 'rage' associated with overdose reversal following naloxone administration by people who use opioids and other laypersons.

Protocol for a multi-site study of the effects of overdose prevention education with naloxone distribution program in Skåne County, Sweden

BACKGROUND

Continuously high rates of overdose deaths in Sweden led to the decision by the Skåne County to initiate the first regional take-home naloxone program in Sweden. The project aims to study the effect of overdose prevention education and naloxone distribution on overdose mortality in Skåne County. Secondary outcome measures include non-fatal overdoses and overdose-related harm in the general population, as well as cohort-specific effects in study participants regarding overdoses, mortality and retention in naloxone program.

METHODS

Implementation of a multi-site train-the-trainer cascade model was launched in June 2018. Twenty four facilities, including opioid substitution treatment units, needle exchange programs and in-patient addiction units were included for the first line of start-up, aspiring to reach a majority of individuals at-risk within the first 6 months. Serving as self-sufficient naloxone hubs, these units provide training, naloxone distribution and study recruitment. During 3 years, questionnaires are obtained from initial training, follow up, every sixth month, and upon refill. Estimated sample size is 2000 subjects. Naloxone distribution rates are reported, by each unit, every 6 months. Medical diagnoses, toxicological raw data and data on mortality and cause of death will be collected from national and regional registers, both for included naloxone recipients and for the general population. Data on vital status and treatment needs will be collected from registers of emergency and prehospital care.

DISCUSSION

Despite a growing body of literature on naloxone distribution, studies on population effect on mortality are scarce. Most previous studies and reports have been uncontrolled, thus not being able to link naloxone distribution to survival, in relation to a comparison period. As Swedish registers present the opportunity to monitor individuals and entire populations over time, conditions for conducting systematic follow-ups in the Swedish population are good, serving the opportunity to study the impact of large scale overdose prevention education and naloxone distribution and thus fill the knowledge gap.

TRIAL REGISTRATION

Naloxone Treatment in Skåne County - Effect on Drug-related Mortality and Overdose-related Complications, NCT03570099, registered on 26 June 2018.

Take-Home Naloxone for the Emergency Interim Management of Opioid Overdose: The Public Health Application of an Emergency Medicine

Naloxone is a well-established essential medicine for the treatment of life-threatening heroin/opioid overdose in emergency medicine. Over two decades, the concept of 'take-home naloxone' has evolved, comprising pre-provision of an emergency supply to laypersons likely to witness an opioid overdose (e.g. peers and family members of people who use opioids as well as non-medical personnel), with the recommendation to administer the naloxone to the overdose victim as interim care while awaiting an ambulance. There is an urgent need for more widespread naloxone access considering the growing problem of opioid overdose deaths, accounting for more than 100,000 deaths worldwide annually. Rises in mortality are particularly sharp in North America, where the ongoing prescription opioid problem is now overlaid with a rapid growth in overdose deaths from heroin and illicit fentanyl. Using opioids alone is dangerous, and the mortality risk is clustered at certain times and contexts, including on prison release and discharge from hospital and residential care. The provision of take-home naloxone has required the introduction of new legislation and new naloxone products. These include pre-filled syringes and auto-injectors and, crucially, new concentrated nasal sprays (four formulations recently approved in different countries) with speed of onset comparable to intramuscular naloxone and relative bioavailability of approximately 40-50%. Choosing the right naloxone dose in the fentanyl era is a matter of ongoing debate, but the safety margin of the approved nasal sprays is superior to improvised nasal kits. New legislation in different countries permits over-the-counter sales or other prescription-free methods of provision. However, access remains uneven with take-home naloxone still not provided in many countries and communities, and with ongoing barriers contributing to implementation inertia. Take-home naloxone is an important component of the response to the global overdose problem, but greater commitment to implementation will be essential, alongside improved affordable products, if a greater impact is to be achieved.

Medication Treatment of Opioid Use Disorder

Opioid use disorder (OUD) is a chronic, relapsing condition, often associated with legal, interpersonal, and employment problems. Medications demonstrated to be effective for OUD are methadone (a full opioid agonist), buprenorphine (a partial agonist), and naltrexone (an opioid antagonist). Methadone and buprenorphine act by suppressing opioid withdrawal symptoms and attenuating the effects of other opioids. Naltrexone blocks the effects of opioid agonists. Oral methadone has the strongest evidence for effectiveness. Longer duration of treatment allows restoration of social connections and is associated with better outcomes. Treatments for OUD may be limited by poor adherence to treatment recommendations and by high rates of relapse and increased risk of overdose after leaving treatment. Treatment with methadone and buprenorphine has the additional risk of diversion and misuse of medication. New depot and implant formulations of buprenorphine and naltrexone have been developed to address issues of safety and problems of poor treatment adherence. For people with OUD who do not respond to these treatments, there is accumulating evidence for supervised injectable opioid treatment (prescribing pharmaceutical heroin). Another medication mode of minimizing risk of overdose is take-home naloxone. Naloxone is an opioid antagonist used to reverse opioid overdose, and take-home naloxone programs aim to prevent fatal overdose. All medication-assisted treatment is limited by lack of access and by stigma. In seeking to stem the rising toll from OUD, expanding access to approved treatment such as methadone, for which there remains the best evidence of efficacy, may be the most useful approach.

"A Blessing and a Curse:" Opioid Users' Perspectives on Naloxone and the Epidemic of Opioid Overdose

Background: To address the alarming rise in opioid overdose deaths, states have increased public access to the overdose reversal medication, naloxone. While some studies suggest that increased naloxone accessibility reduces opioid overdose deaths, others raise concerns about unintended consequences, such as increases in risky drug use and opioid re-use post-overdose to counter naloxone-induced withdrawal symptoms. Few studies have examined the impact of expanded naloxone access on the attitudes and behaviors of opioid users. Methods: In this qualitative study, we conducted in-depth, semi-structured interviews with 36 English-speaking opioid users 18+ years of age. Informants were recruited from an urban methadone clinic, a needle exchange program and a residential treatment program. The approximately hour-long interviews focused on users' attitudes and behaviors surrounding naloxone, opioid use and overdose. Transcribed audio-recordings of interviews were analyzed using NVivo. Results: Informants were ambivalent about naloxone, widely acknowledging its life-saving benefits while reporting such negative effects as severe withdrawal symptoms and the promotion of riskier drug use. Naloxone-induced withdrawal, coupled with misperceptions about naloxone's pharmacological effects, prompted overdose survivors to rapidly re-use opioids and refuse hospitalization following an overdose reversal. About half the sample believed naloxone led to greater risk-taking by others, such as fentanyl use or use in higher quantities, but did not endorse riskier drug use themselves. Conclusions: The results suggest the need for targeted education about the pharmacological effects of naloxone and better strategies for managing naloxone-induced withdrawal. Future research should focus on the extent to which naloxone is associated with greater opioid risk-taking.

More than just availability: Who has access and who administers take-home naloxone in Baltimore, MD

Background

Fatal opioid overdose is a pressing public health concern in the United States. Addressing barriers and augmenting facilitators to take-home naloxone (THN) access and administration could expand program reach in preventing fatal overdoses.

Methods

THN access (i.e., being prescribed or receiving THN) was assessed in a Baltimore, Maryland-based sample of 577 people who use opioids (PWUO) and had a history of injecting drugs. A sub-analysis examined correlates of THN administration among those with THN access and who witnessed an overdose (N = 345). Logistic generalized estimating equations with robust standard errors were used to identify facilitators and barriers to accessing and using THN.

Results

The majority of PWUO (66%) reported THN access. In the multivariable model, decreased THN access was associated with the fear that a person may become aggressive after being revived with THN (aOR: 0.55, 95% CI: 0.35–0.85), police threaten people at an overdose event (aOR: 0.68, 95% CI: 0.36–1.00), and insufficient overdose training (aOR: 0.43, 95% CI: 0.28–0.68). Enrollment in medication-assisted treatment, personally experiencing an overdose, and graduating from high school were associated with higher access. About half (49%) of PWUO with THN access and who had witnessed an overdose reported having administered THN. THN use was positively associated with “often” or “always” carrying THN (aOR: 3.47, 95% CI: 1.99–6.06), witnessing more overdoses (aOR:5.18, 95% CI: 2.22–12.07), experiencing recent homelessness, and injecting in the past year. THN use was reduced among participants who did not feel that they had sufficient overdose training (aOR: 0.56, 95% CI: 0.32–0.96).

Conclusion

THN programs must bolster confidence in administering THN and address barriers to use, such as fear of a THN recipient becoming aggressive. Normative change around carrying THN is an important component in an overdose prevention strategy.

Changes in cardiac vagal tone as measured by heart rate variability during naloxone-induced opioid withdrawal

BACKGROUND

Heart rate variability (HRV) is of interest to researchers due to its potential utility as a marker for both physiological and psychological stress. Sympatholytics are used to treat opioid withdrawal, but little information about the parasympathetic system's role in mediating withdrawal symptoms exists. The goal of the current study was to evaluate changes in HRV during opioid withdrawal to provide a better understanding of the autonomic effects of opioid withdrawal.

METHODS

Ten male participants (mean age = 46.4 years) received intramuscular naloxone (mean dose =0.26 mg) to confirm opioid dependence. The presence and severity of withdrawal symptoms were assessed using subjective and objective measures (Wang et al., 1974). Electrocardiography (ECG) was measured continuously, and HRV was analyzed in 2-minute segments before naloxone injection (at baseline) and after participants were in moderate withdrawal (Wang Test score ≥10). Heart rate, blood pressure, pupil diameter, and respiratory rate were also examined.

RESULTS

Pupil diameter significantly increased after naloxone administration relative to baseline (t(9) = 5.562, p = 0.000). Both high frequency (HF) HRV (Z = -2.803, p = 0.005) and root mean square of successive differences (RMSSD) HRV (Z = -2.090, p = 0.037) were significantly lower during withdrawal relative to baseline. Increases in heart rate (Z = -2.090, p = 0.032) and systolic pressure (t(9) = 8.099, p = 0.0000) from baseline to withdrawal also were significant.

CONCLUSIONS

These preliminary data indicate that a large reduction in cardiac vagal tone occurs during naloxone-induced withdrawal. This finding underscores the need for further research into the role of the parasympathetic nervous system in opioid withdrawal.

A national survey of approaches to manage the ICU patient with opioid use disorder

PURPOSE

Opioid associated admissions to the Intensive Care Unit (ICU) are increasing, but how institutions manage the care of these patients is unknown. We studied the availability of protocols and guidelines in Intensive Care Units (ICUs) for the management of the critically ill patient with opioid use disorder.

MATERIALS AND METHODS

A survey was sent to a random sampling of ICU clinicians at acute care hospitals in the United States.

RESULTS

Of the 300 hospitals contacted, 118 agreed to participate and 58 submitted surveys (49%, 58/118 response rate). While a majority of ICUs has a guideline to titrate sedative analgesics, only 7% reported a guideline that addresses the sedation needs of patients with opioid use disorder. Only one respondent identified a guideline for the continuation of medication-assisted treatment such as methadone. Most respondents did not have, or were unaware of, a guideline to manage opioid withdrawal or to prevent over-reversal with naloxone. Outpatient resources were offered to patients by 36% of institutions, while even fewer reported the use of a dedicated addiction care team.

CONCLUSIONS

Few institutional guidelines exist to provide clinicians with the tools necessary to prevent harm and promote recovery for this growing and vulnerable ICU population.

Naloxone urban legends and the opioid crisis: what is the role of public health?

As the overdose crisis in North America continues to deepen, public health leaders find themselves responding to sensational media stories, many of which carry forms and themes that mark them as urban legends.

This article analyzes one set of media accounts – stories of misuse of naloxone, an opioid overdose antidote distributed to people who use drugs – through the lens of social science scholarship on urban legends. We suggest that these stories have met a public need to feel a sense of safety in uncertain times, but function to reinforce societal views of people who use drugs as undeserving of support and resources.

Our field has a duty to speak out in favour of evidence-based programs that support the health of people who use drugs, but the optimal communication strategies are not always clear. Drawing attention to the functions and consequences of urban legends can help frame public health communication in a way that responds to needs without reinforcing prejudices, with application beyond naloxone to the other urban legends that continue to emerge in response to this crisis.

Pharmacokinetics of a novel, approved, 1.4-mg intranasal naloxone formulation for reversal of opioid overdose-a randomized controlled trial

BACKGROUND AND AIMS

Intranasal (i.n.) naloxone is an established treatment for opioid overdose. Anyone likely to witness an overdose should have access to the antidote. We aimed to determine whether an i.n. formulation delivering 1.4 mg naloxone hydrochloride would achieve systemic exposure comparable to that of 0.8 mg intramuscular (i.m.) naloxone.

DESIGN

Open, randomized four-way cross-over trial.

SETTING

Clinical Trials Units in St Olav's Hospital, Trondheim and Rikshospitalet, Oslo, Norway.

PARTICIPANTS

Twenty-two healthy human volunteers, 10 women, median age = 25.8 years.

INTERVENTION AND COMPARATOR

One and two doses of i.n. 1.4 mg naloxone compared with i.m. 0.8 mg and intravenous (i.v.) 0.4 mg naloxone.

MEASUREMENTS

Quantification of plasma naloxone was performed by liquid chromatography tandem mass spectrometry. Pharmacokinetic non-compartment analyses were used for the main analyses. A non-parametric pharmacokinetic population model was developed for Monte Carlo simulations of different dosing scenarios.

FINDINGS

Area under the curve from administration to last measured concentration (AUC_0-last ) for i.n. 1.4 mg and i.m. 0.8 mg were 2.62 ± 0.94 and 3.09 ± 0.64 h × ng/ml, respectively (P = 0.33). Maximum concentration (C_max ) was 2.36 ± 0.68 ng/ml for i.n. 1.4 mg and 3.73 ± 3.34 for i.m. 0.8 mg (P = 0.72). Two i.n. doses showed dose linearity and achieved a C_max of 4.18 ± 1.53 ng/ml. T_max was reached after 20.2 ± 9.4 minutes for i.n. 1.4 mg and 13.6 ± 15.4 minutes for i.m. 0.8 mg (P = 0.098). The absolute bioavailability for i.n. 1.4 mg was 0.49 (±0.24), while the relative i.n./i.m. bioavailability was 0.52 (±0.25).

CONCLUSION

Intranasal 1.4 mg naloxone provides adequate systemic concentrations to treat opioid overdose compared with intramuscular 0.8 mg, without statistical difference on maximum plasma concentration, time to maximum plasma concentration or area under the curve. Simulations support its appropriateness both as peer administered antidote and for titration of treatment by professionals.

How competent are people who use opioids at responding to overdoses? Qualitative analyses of actions and decisions taken during overdose emergencies

BACKGROUND AND AIMS

Providing take-home naloxone (THN) to people who use opioids is an increasingly common strategy for reversing opioid overdose. However, implementation is hindered by doubts regarding the ability of people who use opioids to administer naloxone and respond appropriately to overdoses. We aimed to increase understanding of the competencies required and demonstrated by opioid users who had recently participated in a THN programme and were subsequently confronted with an overdose emergency.

DESIGN

Qualitative study designed to supplement findings from a randomized controlled trial of overdose education and naloxone distribution. Interviews were audio-recorded, transcribed, systematically coded and analysed via Iterative Categorization.

SETTING

New York City, USA.

PARTICIPANTS

Thirty-nine people who used opioids (32 men, 7 women; aged 22-58 years).

INTERVENTION

Trial participants received brief or extended overdose training and injectable or nasal naloxone.

MEASUREMENTS

The systematic coding frame comprised deductive codes based on the topic guide and more inductive codes emerging from the data.

FINDINGS

In 38 of 39 cases the victim was successfully resuscitated; the outcome of one overdose intervention was unknown. Analyses revealed five core overdose response 'tasks': (1) overdose identification; (2) mobilizing support; (3) following basic first aid instructions; (4) naloxone administration; and (5) post-resuscitation management. These tasks comprised actions and decisions that were themselves affected by diverse cognitive, emotional, experiential, interpersonal and social factors over which lay responders often had little control. Despite this, participants demonstrated high levels of competency. They had acquired new skills and knowledge through training and brought critical 'insider' understanding to overdose events and the resuscitation actions which they applied.

CONCLUSIONS

People who use opioids can be trained to respond appropriately to opioid overdoses and thus to save their peers' lives. Overdose response requires both practical competency (e.g. skills and knowledge in administering basic first aid and naloxone) and social competency (e.g. willingness to help others, having the confidence to be authoritative and make decisions, communicating effectively and demonstrating compassion and care to victims post-resuscitation).

Take-home naloxone and the politics of care

'Take-home naloxone' refers to a life-saving intervention in which a drug (naloxone) is made available to nonmedically trained people for administration to other people experiencing an opioid overdose. In Australia, it has not been taken up as widely as would be expected, given its life-saving potential. We consider the actions of take-home naloxone, focusing on how care relations shape its uses and effects. Mobilising Science and Technology Studies insights, we suggest that the uses and effects of naloxone are co-produced within social relations and, therefore, this initiative 'affords' multiple outcomes. We argue that these affordances are shaped by a politics of care, and that these politics relate to uptake. We analyse two complementary case studies, drawn from an interview-based project, in which opioid consumers discussed take-home naloxone and its uses. Our analysis maps the ways take-home naloxone can afford (i) a regime of care within an intimate partnership (allowing a terminally ill man to more safely consume opioids) and (ii) a political process of care (in which a consumer takes care of others treated with the medication by administering it 'gently'). We conclude by exploring the political affordances of a politics of care approach for the uptake of take-home naloxone.

"Once I'd done it once it was like writing your name": Lived experience of take-home naloxone administration by people who inject drugs

BACKGROUND

The supply of naloxone, the opioid antagonist, for peer administration ('take-home naloxone' (THN)) has been promoted as a means of preventing opioid-related deaths for over 20 years. Despite this, little is known about PWID experiences of take-home naloxone administration. The aim of this study was to advance the evidence base on THN by producing one of the first examinations of the lived-experience of THN use among PWID.

METHODS

Qualitative, face to face, semi-structured interviews were undertaken at a harm reduction service with individuals known to have used take-home naloxone in an overdose situation in a large urban area in Scotland. Interpretative Phenomenological Analysis (IPA) was then applied to the data from these in-depth accounts.

RESULTS

The primary analysis involved a total of 8 PWID (seven male, one female) known to have used take-home naloxone. This paper focuses on the two main themes concerning naloxone administration: psychological impacts of peer administration and role perceptions. In the former, the feelings participants encounter at different stages of their naloxone experience, including before, during and after use, are explored. In the latter, the concepts of role legitimacy, role adequacy, role responsibility and role support are considered.

CONCLUSION

This study demonstrates that responding to an overdose using take-home naloxone is complex, both practically and emotionally, for those involved. Although protocols exist, a multitude of individual, social and environmental factors shape responses in the short and longer terms. Despite these challenges, participants generally conveyed a strong sense of therapeutic commitment to using take-home naloxone in their communities.