1
|
O'Brien C, Klipp S, Jawa R, Wilson JD. Community pharmacists' attitudes toward and practice of pharmacy-based harm reduction services in Pittsburgh, PA: a descriptive survey. Harm Reduct J 2024; 21:137. [PMID: 39030563 DOI: 10.1186/s12954-024-01018-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 05/09/2024] [Indexed: 07/21/2024] Open
Abstract
BACKGROUND In Pittsburgh, PA, legal changes in recent decades have set the stage for an expanded role for community pharmacists to provide harm reduction services, including distributing naloxone and non-prescription syringes (NPS). In the wake of the syndemics of the COVID-19 pandemic and worsening overdose deaths from synthetic opioids, we examine knowledge, attitudes, and practices of harm reduction services among community pharmacists in Pittsburgh and identify potential barriers of expanded pharmacy-based harm reduction services. METHODS We provided flyers to 83 community pharmacies within a 5-mile radius of the University of Pittsburgh Medical Center to recruit practicing community pharmacists to participate in an anonymous electronic survey. We used a 53-question Qualtrics survey consisting of multiple-choice, 5 or 6 point-Likert scale, and open-ended questions adapted from 5 existing survey instruments. Survey measures included demographics, knowledge, attitudes, and practices of harm reduction services (specifically naloxone and NPS provision), and explored self-reported barriers to future implementation. Data was collected July-August 2022. We conducted descriptive analysis using frequencies and proportions reported for categorical variables as well as means and standard deviations (SD) for continuous variables. We analyzed open-ended responses using inductive content analysis. RESULTS Eighty-eight community pharmacists responded to the survey. 90% of participants agreed pharmacists had a role in overdose prevention efforts, and 92% of participants had previously distributed naloxone. Although no pharmacists reported ever refusing to distribute naloxone, only 29% always provided overdose prevention counseling with each naloxone distributed. In contrast, while 87% of participants had positive attitudes toward the usefulness of NPS for reducing disease, only 73% of participants ever distributed NPS, and 54% had refused NPS to a customer. Participants endorsed a lack of time and concerns over clientele who used drugs as the most significant barriers to offering more comprehensive harm reduction services. CONCLUSIONS Our findings highlight that while most community pharmacists have embraced naloxone provision, pharmacy policies and individual pharmacists continue to limit accessibility of NPS. Future expansion efforts for pharmacy-based harm reduction services should not only address the time and labor constraints identified by community pharmacists, but also fear-based policy and stigma toward people who inject drugs and harm reduction more broadly.
Collapse
Affiliation(s)
- Caitlin O'Brien
- School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA.
| | | | - Raagini Jawa
- Division of General Internal Medicine, Center for Research in Healthcare, University of Pittsburgh, Pittsburgh, PA, USA
| | - J Deanna Wilson
- Department of Family Medicine and Community Health, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
2
|
Elswick Fockele C, Frohe T, McBride O, Perlmutter DL, Goh B, Williams G, Wettemann C, Holland N, Finegood B, Oliphant-Wells T, Williams EC, van Draanen J. Harm Reduction in the Field: First Responders' Perceptions of Opioid Overdose Interventions. West J Emerg Med 2024; 25:490-499. [PMID: 39028235 PMCID: PMC11254139 DOI: 10.5811/westjem.18033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 10/24/2023] [Accepted: 02/09/2024] [Indexed: 07/20/2024] Open
Abstract
Introduction Recent policy changes in Washington State presented a unique opportunity to pair evidence-based interventions with first responder services to combat increasing opioid overdoses. However, little is known about how these interventions should be implemented. In partnership with the Research with Expert Advisors on Drug Use team, a group of academically trained and community-trained researchers with lived and living experience of substance use, we examined facilitators and barriers to adopting leave-behind naloxone, field-based buprenorphine initiation, and HIV and hepatitis C virus (HCV) testing for first responder programs. Methods Our team completed semi-structured, qualitative interviews with 32 first responders, mobile integrated health staff, and emergency medical services (EMS) leaders in King County, Washington, from February-May 2022. Semi-structured interviews were recorded, transcribed, and coded using an integrated deductive and inductive thematic analysis approach grounded in community-engaged research principles. We collected data until saturation was achieved. Data collection and analysis were informed by the Consolidated Framework for Implementation Research. Two investigators coded independently until 100% consensus was reached. Results Our thematic analysis revealed several perceived facilitators (ie, tension for change, relative advantage, and compatibility) and barriers (ie, limited adaptability, lack of evidence strength and quality, and prohibitive cost) to the adoption of these evidence-based clinical interventions for first responder systems. There was widespread support for the distribution of leave-behind naloxone, although funding was identified as a barrier. Many believed field-based initiation of buprenorphine treatment could provide a more effective response to overdose management, but there were significant concerns that this intervention could run counter to the rapid care model. Lastly, participants worried that HIV and HCV testing was inappropriate for first responders to conduct but recommended that this service be provided by mobile integrated health staff. Conclusion These results have informed local EMS strategic planning, which will inform roll out of process improvements in King County, Washington. Future work should evaluate the impact of these interventions on the health of overdose survivors.
Collapse
Affiliation(s)
| | - Tessa Frohe
- University of Washington, Department of Psychiatry and Behavioral Sciences, Seattle, Washington
| | - Owen McBride
- University of Washington, Department of Emergency Medicine, Seattle, Washington
| | - David L. Perlmutter
- University of Washington, Department of Health Systems and Population Health, Seattle, Washington
| | - Brenda Goh
- University of Washington, Department of Health Systems and Population Health, Seattle, Washington
| | - Grover Williams
- Research with Expert Advisors on Drug Use, Seattle, Washington
| | | | - Nathan Holland
- Research with Expert Advisors on Drug Use, Seattle, Washington
| | - Brad Finegood
- Public Health – Seattle & King County, Seattle, Washington
| | | | - Emily C. Williams
- University of Washington, Department of Health Systems and Population Health, Seattle, Washington
- Health Services Research & Development Center of Innovation for Veteran-Centered and Value-Driven Care, Veterans Affairs Puget Sound Health Care System, Seattle, Washington
| | - Jenna van Draanen
- University of Washington, Department of Health Systems and Population Health, Seattle, Washington
- University of Washington, Department of Child, Family, and Population Health Nursing, Seattle, Washington
| |
Collapse
|
3
|
Starbird LE, Onuoha E, Corry G, Hotchkiss J, Benjamin SN, Hunt T, Schackman BR, El-Bassel N. Community-led approaches to making naloxone available in public settings: Implementation experiences in the HEALing communities study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 128:104462. [PMID: 38795466 PMCID: PMC11213655 DOI: 10.1016/j.drugpo.2024.104462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 05/10/2024] [Accepted: 05/15/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND Expanding public naloxone access is a key strategy to reduce opioid overdose fatalities. We describe tailored community-engaged, data-driven approaches to install and maintain naloxone housing units (naloxone boxes) in New York State and estimate the cost of these approaches. METHODS Guided by the Consolidated Framework for Implementation Research, we collected data from administrative records and key informant interviews that documented the unique processes employed by four counties enrolled in the HEALing Communities Study to install and maintain naloxone housing units. We conducted a prospective micro-costing analysis to estimate the cost of each naloxone housing unit strategy from the community perspective. RESULTS While all counties used a coalition to guide action planning for naloxone distribution, we identified unique approaches to implementing naloxone housing units: 1) County-led with technology expansion; 2) County-led grassroots; 3) Small-scale rural opioid overdose prevention program (OOPP) contract and 4) Comprehensive OOPP contract including overdose education and naloxone distribution (OEND) to individuals. The first two county-led approaches had lower cost per naloxone dose disbursed ($28-$38) compared to outsourcing to an OOPP ($183-$266); costs depended on services added to installing and maintaining units, such as OEND. Barriers included competing demands on public health resources (i.e., COVID-19) and stigma toward naloxone and opioid use disorder. Geographic access was a barrier in rural areas whereas existing infrastructure was a facilitator in urban counties. The policy landscape in New York State, which provides free naloxone kits and financial support to OOPPs, facilitated implementation in all counties. CONCLUSIONS If a community has the resources, installing and maintaining naloxone housing units in-house can be less expensive than contracting with an outside partner. However, contracts that include OEND may be more effective at reaching target populations. Financial support from health departments and legislative authorization are important facilitators to making naloxone available in public settings.
Collapse
Affiliation(s)
- Laura E Starbird
- Department of Family and Community Health, University of Pennsylvania School of Nursing, 418 Curie Blvd Philadelphia, PA 19104, United States.
| | - Erica Onuoha
- Department of Population Health Sciences, Weill Cornell Medical College, 425 E. 61st St, New York, NY 10065, United States
| | - Grace Corry
- Department of Population Health Sciences, Weill Cornell Medical College, 425 E. 61st St, New York, NY 10065, United States
| | - Juanita Hotchkiss
- Social Intervention Group, Columbia University School of Social Work, 1255 Amsterdam Ave, New York, NY 10027, United States
| | - Shoshana N Benjamin
- Social Intervention Group, Columbia University School of Social Work, 1255 Amsterdam Ave, New York, NY 10027, United States
| | - Timothy Hunt
- Social Intervention Group, Columbia University School of Social Work, 1255 Amsterdam Ave, New York, NY 10027, United States
| | - Bruce R Schackman
- Department of Population Health Sciences, Weill Cornell Medical College, 425 E. 61st St, New York, NY 10065, United States
| | - Nabila El-Bassel
- Social Intervention Group, Columbia University School of Social Work, 1255 Amsterdam Ave, New York, NY 10027, United States
| |
Collapse
|
4
|
Marley G, Annis IE, Ostrach B, Egan K, Delamater PL, Bell R, Dasgupta N, Carpenter DM. Naloxone Accessibility by Standing Order in North Carolina Community Pharmacies. J Am Pharm Assoc (2003) 2024; 64:102021. [PMID: 38307248 PMCID: PMC11081860 DOI: 10.1016/j.japh.2024.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/22/2024] [Accepted: 01/23/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND According to a standing order in North Carolina (NC), naloxone can be purchased without a provider prescription. OBJECTIVE The objective of this study is to examine whether same-day naloxone accessibility and cost vary by pharmacy type and rurality in NC. METHODS A cross-sectional telephone audit of 202 NC community pharmacies stratified by pharmacy type and county of origin was conducted in March and April 2023. Trained "secret shoppers" enacted a standardized script and recorded whether naloxone was available and its cost. We examined the relationship between out-of-pocket naloxone cost, pharmacy type, and rurality. RESULTS Naloxone could be purchased in 53% of the pharmacies contacted; 26% incorrectly noting that naloxone could be filled only with a provider prescription and 21% did not sell naloxone. Naloxone availability by standing order was statistically different by pharmacy type (chain/independent) (χ2 = 20.58, df = 4, P value < 0.001), with a higher frequency of willingness to dispense according to the standing order by chain pharmacies in comparison to independent pharmacies. The average quoted cost for naloxone nasal spray at chain pharmacies was $84.69; the cost was significantly more ($113.54; P < 0.001) at independent pharmacies. Naloxone cost did not significantly differ by pharmacy rurality (F2,136 = 2.38, P = 0.10). CONCLUSION Approximately half of NC community pharmacies audited dispense naloxone according to the statewide standing order, limiting same-day access to this life-saving medication. Costs were higher at independent pharmacies, which could be due to store-level policies. Future studies should further investigate these cost differences, especially as intranasal naloxone transitions from a prescription only to over-the-counter product.
Collapse
Affiliation(s)
- Grace Marley
- Grace T. Marley, PharmD, UNC Eshelman School of Pharmacy 201 Pharmacy Lane, CB 7355, Chapel Hill, NC 27599-7355, USA
| | - Izabela E Annis
- Izabela E Annis, MS, Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, NC 27599
| | - Bayla Ostrach
- Bayla Ostrach PhD, MA CIP, Medical Anthropology & Family Medicine, Boston University School of Medicine; Fruit of Labor Action Research & Technical Assistance, LLC, 608 Emmas Grove Rd., Fletcher, NC 28732
| | - Kathleen Egan
- Kathleen L Egan PhD, MS, Department of Implementation Science, Division of Public Health Sciences, Wake Forest University School of Medicine
| | - Paul L. Delamater
- Paul Delamater PhD, Department of Geography and Environment, University of North Carolina at Chapel Hill
| | - Ronny Bell
- Ronny Bell, PhD, Division of Pharmaceutical Outcomes and Policy, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, 27599
| | - Nabarun Dasgupta
- Nabarun Dasgupta, MPH, PhD, Injury Prevention Research Center, 725 MLK Jr. Blvd, CB 7505, Chapel Hill, NC 27599
| | - Delesha M. Carpenter
- Delesha M. Carpenter MSPH, PhD, UNC Eshelman School of Pharmacy 220 Campus Drive CPO 2125 Asheville, NC 28804
| |
Collapse
|
5
|
Hansgen JP, Robertson ML, Verzino EM, Manning LM. Increasing Naloxone Access and Prescribing for Patients on High-Dose Opioids From a Managed Care Pharmacy Health Plan Perspective. J Pharm Pract 2024:8971900241247598. [PMID: 38685768 DOI: 10.1177/08971900241247598] [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: 05/02/2024]
Abstract
Background: Opioid overdoses decrease when communities have access to naloxone. Clinicians play a key role in offering naloxone to high-risk chronic opioid patients. Managed care pharmacists within our health plan noted disproportionate processing for claims of opioid utilizers compared to claims of naloxone prescriptions. Objective: To increase naloxone access and prescribing to members who classify at a dosage with a higher risk for opioid overdose, defined as over 90 morphine milligram equivalents (MME). Methods: Multiple system-wide initiatives were implemented to improve naloxone access. A claims file was pulled monthly to identify members on opioids meeting MME criteria >90 MME per day excluding members with cancer, sickle cell disease, or on hospice. A separate report was then matched to naloxone claims and prescribing percentages calculated. Results: 12 444 utilizing members on opioids were identified from June 2019 prescription claims data. Of these, 131 were on opioids exceeding 90 MME per day, or 1.05% of utilizers, and the percentage of members exceeding 90 MME per day prescribed naloxone was 6.87%. By May 2023, the percentage of opioid utilizers exceeding 90 MME per day decreased to 0.58%. Naloxone prescribing increased to 41.18%. Conclusion: A multi-pronged approach to improve access to naloxone and continued educational efforts by our health plan increased naloxone prescribing in members on opioids exceeding 90 MME per day.
Collapse
Affiliation(s)
- Jodi P Hansgen
- Pharmacy Services, Baylor Scott & White Health Plan, Temple, TX, USA
| | - Megan L Robertson
- Pharmacy Services, Baylor Scott & White Health Plan, Temple, TX, USA
| | - Ellen M Verzino
- Pharmacy Services, Baylor Scott & White Health Plan, Temple, TX, USA
| | - Lindsay M Manning
- Pharmacy Services, Baylor Scott & White Health Plan, Temple, TX, USA
| |
Collapse
|
6
|
Byrne CJ, Sani F, Thain D, Fletcher EH, Malaguti A. Psychosocial factors associated with overdose subsequent to Illicit Drug use: a systematic review and narrative synthesis. Harm Reduct J 2024; 21:81. [PMID: 38622647 PMCID: PMC11017611 DOI: 10.1186/s12954-024-00999-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 04/03/2024] [Indexed: 04/17/2024] Open
Abstract
BACKGROUND AND AIMS Psychological and social status, and environmental context, may mediate the likelihood of experiencing overdose subsequent to illicit drug use. The aim of this systematic review was to identify and synthesise psychosocial factors associated with overdose among people who use drugs. METHODS This review was registered on Prospero (CRD42021242495). Systematic record searches were undertaken in databases of peer-reviewed literature (Medline, Embase, PsycINFO, and Cinahl) and grey literature sources (Google Scholar) for work published up to and including 14 February 2023. Reference lists of selected full-text papers were searched for additional records. Studies were eligible if they included people who use drugs with a focus on relationships between psychosocial factors and overdose subsequent to illicit drug use. Results were tabulated and narratively synthesised. RESULTS Twenty-six studies were included in the review, with 150,625 participants: of those 3,383-4072 (3%) experienced overdose. Twenty-one (81%) studies were conducted in North America and 23 (89%) reported polydrug use. Psychosocial factors associated with risk of overdose (n = 103) were identified and thematically organised into ten groups. These were: income; housing instability; incarceration; traumatic experiences; overdose risk perception and past experience; healthcare experiences; perception of own drug use and injecting skills; injecting setting; conditions with physical environment; and social network traits. CONCLUSIONS Global rates of overdose continue to increase, and many guidelines recommend psychosocial interventions for dependent drug use. The factors identified here provide useful targets for practitioners to focus on at the individual level, but many identified will require wider policy changes to affect positive change. Future research should seek to develop and trial interventions targeting factors identified, whilst advocacy for key policy reforms to reduce harm must continue.
Collapse
Affiliation(s)
- Christopher J Byrne
- Division of Molecular and Clinical Medicine, School of Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK.
- Directorate of Public Health, NHS Tayside, Kings Cross Hospital, Dundee, UK.
| | - Fabio Sani
- Division of Psychology, School of Humanities, Social Sciences and Law, University of Dundee, Scrymgeour Building, Dundee, UK
| | - Donna Thain
- Directorate of Public Health, NHS Tayside, Kings Cross Hospital, Dundee, UK
| | - Emma H Fletcher
- Directorate of Public Health, NHS Tayside, Kings Cross Hospital, Dundee, UK
| | - Amy Malaguti
- Division of Psychology, School of Humanities, Social Sciences and Law, University of Dundee, Scrymgeour Building, Dundee, UK
- Tayside Drug and Alcohol Recovery Psychology Service, NHS Tayside, Dundee, UK
| |
Collapse
|
7
|
Cid A, Mahajan N, Wong WWL, Beazely M, Grindrod KA. An economic evaluation of community pharmacy-dispensed naloxone in Canada. Can Pharm J (Ott) 2024; 157:84-94. [PMID: 38463179 PMCID: PMC10924576 DOI: 10.1177/17151635241228241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Revised: 11/27/2023] [Accepted: 12/04/2023] [Indexed: 03/12/2024]
Abstract
Aims To determine the cost-effectiveness of pharmacy-based intranasal (IN) and intramuscular (IM) naloxone distribution in Canada. Methods We developed a state-transition model for pharmacy-based naloxone distribution, every 3 years, to illicit, prescription, opioid-agonist therapy and nonopioid use populations compared to no naloxone distribution. We used a monthly cycle length, lifetime horizon and a Canadian provincial Ministry of Health perspective. Transition probabilities, cost and utility data were retrieved from the literature. Costs (2020) and quality-adjusted life years (QALY) were discounted 1.5% annually. Microsimulation, 1-way and probabilistic sensitivity analyses were conducted. Results Distribution of naloxone to all Canadians compared to no distribution prevented 151 additional overdose deaths per 10,000 persons, with an incremental cost-effectiveness ratio (ICER) of $50,984 per QALY for IM naloxone and an ICER of $126,060 per QALY for IN naloxone. Distribution of any naloxone to only illicit opioid users was the most cost-effective. One-way sensitivity analysis showed that survival rates for illicit opioid users were most influenced by the availability of either emergency medical services or naloxone. Conclusion Distribution of IM and IN naloxone to all Canadians every 3 years is likely cost-effective at a willingness-to-pay threshold of $140,000 Canadian dollars/QALY (~3 × gross domestic product from the World Health Organization). Distribution to people who use illicit opioids was most cost-effective and prevented the most deaths. This is important, as more overdose deaths could be prevented through nationwide public funding of IN naloxone kits through pharmacies, since individuals report a preference for IN naloxone and these formulations are easier to use, save lives and are cost-effective. Can Pharm J (Ott) 2024;157:xx-xx.
Collapse
Affiliation(s)
- Ashley Cid
- From the School of Pharmacy, University of Waterloo, Kitchener, Ontario
| | - Nikita Mahajan
- From the School of Pharmacy, University of Waterloo, Kitchener, Ontario
| | - William W L Wong
- From the School of Pharmacy, University of Waterloo, Kitchener, Ontario
| | - Michael Beazely
- From the School of Pharmacy, University of Waterloo, Kitchener, Ontario
| | - Kelly A Grindrod
- From the School of Pharmacy, University of Waterloo, Kitchener, Ontario
| |
Collapse
|
8
|
Lambdin BH, Bluthenthal RN, Garner BR, Wenger LD, Browne EN, Morris T, Ongais L, Megerian CE, Kral AH. Organize and mobilize for implementation effectiveness to improve overdose education and naloxone distribution from syringe services programs: a randomized controlled trial. Implement Sci 2024; 19:22. [PMID: 38419058 PMCID: PMC10900734 DOI: 10.1186/s13012-024-01354-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/14/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND The United States (US) continues to face decades-long increases in opioid overdose fatalities. As an opioid overdose reversal medication, naloxone can dramatically reduce opioid overdose mortality rates when distributed to people likely to experience or witness an opioid overdose and packaged with education on its use, known as overdose education and naloxone distribution (OEND). Syringe services programs (SSPs) are ideal venues for OEND with staff who are culturally competent in providing services for people who are at risk of experiencing or observing an opioid overdose. We carried out a randomized controlled trial of SSPs to understand the effectiveness of the organize and mobilize for implementation effectiveness (OMIE) approach at improving OEND implementation effectiveness within SSPs. METHODS Using simple randomization, 105 SSPs were enrolled into the trial and assigned to one of two study arms - (1) dissemination of OEND best practice recommendations (Control SSPs) or the OMIE approach along with dissemination of the OEND best practice recommendations (i.e., OMIE SSPs). OMIE SSPs could participate in 60-min OMIE sessions once a month for up to 12 months. At 12-month post-baseline, 102 of 105 SSPs (97%) responded to the follow-up survey. RESULTS The median number of sessions completed by OMIE SSPs was 10. Comparing OMIE SSPs to control SSPs, we observed significant increases in the number of participants receiving naloxone (incidence rate ratio: 2.15; 95% CI: 1.42, 3.25; p < 0.01) and the rate of naloxone doses distributed per SSP participant (adjusted incidence rate ratio: 1.97; 95% CI: 1.18, 3.30; p = 0.01). We observed no statistically significant difference in the number of adopted best practices between conditions (difference in means 0.2, 95% CI: - 0.7, 1.0; p = 0.68). We also observed a threshold effect where SSPs receiving a higher OMIE dose had greater effect sizes with regard to the number of people given naloxone and the number of naloxone doses distributed. CONCLUSIONS In conclusion, the multifaceted OMIE approach was effective at increasing naloxone distribution from SSPs, despite substantial external shocks during the trial. These findings have major implications for addressing the overdose crisis, which has continued unabated for decades. TRIAL REGISTRATION ClinicalTrials.gov, NCT03924505 . Registered 19 April 2019.
Collapse
Affiliation(s)
- Barrot H Lambdin
- RTI International, 2150 Shattuck Avenue, 8Th Floor, Berkeley, CA, 94704, USA.
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA.
- Department of Global Health, University of Washington, Seattle, WA, USA.
| | - Ricky N Bluthenthal
- Keck Medicine, Department of Population and Public Health Sciences, University of Southern California, 1975 Zonal Ave, Los Angeles, CA, 90033, USA
| | - Bryan R Garner
- Department of Internal Medicine, College of Medicine, The Ohio State University, 370 W. 9Th Avenue, Columbus, OH, 43210, USA
| | - Lynn D Wenger
- RTI International, 2150 Shattuck Avenue, 8Th Floor, Berkeley, CA, 94704, USA
| | - Erica N Browne
- RTI International, 2150 Shattuck Avenue, 8Th Floor, Berkeley, CA, 94704, USA
| | - Terry Morris
- RTI International, 2150 Shattuck Avenue, 8Th Floor, Berkeley, CA, 94704, USA
| | - Lee Ongais
- San Francisco AIDS Foundation, 1035 Market Street, 4Th Floor, San Francisco, CA, 94103, USA
| | - Cariné E Megerian
- RTI International, 2150 Shattuck Avenue, 8Th Floor, Berkeley, CA, 94704, USA
| | - Alex H Kral
- RTI International, 2150 Shattuck Avenue, 8Th Floor, Berkeley, CA, 94704, USA
| |
Collapse
|
9
|
Tonin FS, Alves da Costa F, Fernandez-Llimos F. Impact of harm minimization interventions on reducing blood-borne infection transmission and some injecting behaviors among people who inject drugs: an overview and evidence gap mapping. Addict Sci Clin Pract 2024; 19:9. [PMID: 38310293 PMCID: PMC10838443 DOI: 10.1186/s13722-024-00439-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 01/18/2024] [Indexed: 02/05/2024] Open
Abstract
BACKGROUND This study aimed to synthetize the evidence on the effectiveness of harm minimization interventions on reducing blood-borne infection transmission and injecting behaviors among people who inject drugs (PWID) through a comprehensive overview of systematic reviews and evidence gap mapping. METHODS A systematic review was conducted with searches in PubMed and Scopus to identify systematic reviews assessing the impact of interventions aimed at reducing the harms associated with injectable drug use. The overall characteristics of the studies were extracted and their methodological quality was assessed using AMSTAR-2. An evidence gap map was constructed, highlighting the most frequently reported outcomes by intervention (CRD42023387713). RESULTS Thirty-three systematic reviews were included. Of these, 14 (42.2%) assessed the impact of needle/syringe exchange programs (NSEP) and 11 (33.3%) examined opioid agonist therapy (OAT). These interventions are likely to be associated with reductions of HIV/HCV incidence (10-40% risk reduction for NSEP; 50-60% for OAT) and sharing injecting paraphernalia (50% for NSEP, 25-85% for OAT), particularly when combined (moderate evidence). Behavioral/educational interventions were assessed in 12 reviews (36.4%) with most authors in favor/partially in favor of the use of these approaches (moderate evidence). Take-home naloxone programs and supervised-injection facilities were each assessed in two studies (6.1%), which reported inconclusive results (limited/inconsistent evidence). Most authors reported high levels of heterogeneity and risk of bias. Other interventions and outcomes were inadequately reported. Most systematic reviews presented low or critically low quality. CONCLUSION The evidence is sufficient to support the effectiveness of OAT, NSEP and their combination in reducing blood-borne infection transmission and certain injecting behaviors among PWID. However, evidence of other harm minimizations interventions in different settings and for some outcomes remain insufficient.
Collapse
Affiliation(s)
- Fernanda S Tonin
- H&TRC - Health & Technology Research Center, ESTeSL - Escola Superior de Tecnologia da Saúde, Instituto Politécnico de Lisboa, Lisbon, Portugal
| | - Filipa Alves da Costa
- Research Institute for Medicines (iMED.ULisboa), Faculty of Pharmacy, University of Lisbon, Av. Prof. Gama Pinto, Lisbon, Portugal.
| | - Fernando Fernandez-Llimos
- Applied Molecular Biosciences Unit, (UCIBIO-i4HB) Laboratory of Pharmacology, Faculty of Pharmacy, University of Porto, Porto, Portugal
| |
Collapse
|
10
|
Håkansson A, Alanko Blomé M, Isendahl P, Landgren M, Malmqvist U, Troberg K. Distribution of intranasal naloxone to potential opioid overdose bystanders in Sweden: effects on overdose mortality in a full region-wide study. BMJ Open 2024; 14:e074152. [PMID: 38171623 PMCID: PMC10773398 DOI: 10.1136/bmjopen-2023-074152] [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: 04/04/2023] [Accepted: 11/20/2023] [Indexed: 01/05/2024] Open
Abstract
OBJECTIVES Distribution of take-home naloxone is suggested to reduce opioid-related fatalities, but few studies have examined the effects on overdose deaths in the general population of an entire community. This study aimed to assess the effects on overdose deaths of a large-scale take-home naloxone programme starting in June 2018, using an observational design with a historic control period. DESIGN From the national causes of death register, deaths diagnosed as X42 or Y12 (International Classification of Diseases, 10th revision, ICD-10) were registered as overdoses. Numbers of overdoses were calculated per 100 000 inhabitants in the general population, and controlled for data including only individuals with a prior substance use disorder in national patient registers, to focus on effects within the primary target population of the programme. The full intervention period (2019-2021) was compared with a historic control period (2013-2017). SETTING Skåne county, Sweden. PARTICIPANTS General population. INTERVENTIONS Large-scale take-home naloxone distribution to individuals at risk of overdose. PRIMARY AND SECONDARY OUTCOME MEASURES Decrease in overdose deaths per 100 000 inhabitants, in total and within the population with substance use disorder diagnosis. RESULTS Annual average number of overdose deaths decreased significantly from 3.9 to 2.8 per 100 000 inhabitants from the control period to the intervention period (a significant decrease in men, from 6.7 to 4.3, but not in women, from 1.2 to 1.3). Significant changes remained when examining only prior substance use disorder patients, and decreases in overdose deaths could not be attributed to a change in treatment needs for opioid use disorders in healthcare and social services. CONCLUSIONS The present study, involving 3 years of take-home naloxone distribution, demonstrated a decreased overdose mortality in the population, however, only in men. The findings call for further implementation of naloxone programmes, and for further studies of potential effects and barriers in women. TRIAL REGISTRATION NUMBER NCT03570099.
Collapse
Affiliation(s)
- Anders Håkansson
- Psychiatry, Lund University, Lund, Sweden
- Malmö Addiction Center, Region Skåne, Malmo, Sweden
| | - Marianne Alanko Blomé
- Clinical Infection Medicine, Lund University, Lund, Sweden
- Region Skåne, Malmö, Sweden
| | | | | | | | - Katja Troberg
- Malmö Addiction Center, Region Skåne, Malmo, Sweden
- Clinical Infection Medicine, Lund University, Lund, Sweden
| |
Collapse
|
11
|
Bird SM. Opioid-related deaths and their counterpart by occurrence era, age group and coimplicated drugs: Scotland vs. England and Wales. Br J Clin Pharmacol 2023. [PMID: 38009544 DOI: 10.1111/bcp.15976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 11/07/2023] [Accepted: 11/10/2023] [Indexed: 11/29/2023] Open
Abstract
AIMS Compare by occurrence era and age group how opioid-related deaths (ORDs) and their counterpart evolved in Scotland vs. England and Wales during 2006-2020. For Scotland, compare coimplication rates between ORDs and non-ORDs for any benzodiazepine, cocaine or gabapentin/pregabalin, and consider whether coimplication in ORDs depended on opioid-specificity. METHODS Cross-tabulations of drug misuse deaths (DMDs) obtained by 3 yearly occurrence era (2006-2008 to 2018-2020) and age group (under 25, 25-34, 35-44, 45-54, 55+ years) for England and Wales and subdivided by whether at least 1 opiate was mentioned on death certificate (DMD-Os or not); and of Scotland's opioid-related deaths (ORDs vs. non-ORDs) together with (i) coimplication by any benzodiazepine, cocaine or gabapentin/pregabalin; and (ii) opioid-specificity of ORDs. ORD is defined by heroin/morphine, methadone or buprenorphine being implicated in DMD. RESULTS Per era between 2012-2014 and 2018-2020, Scotland's ORDs increased by 54% and non-ORDs by 34%. Increase in DMD-Os in England and Wales was more modest. Cocaine was implicated in 83% of Scotland's 2690 non-ORDs during 2006-2020; and any benzodiazepine in 53% of 8409 ORDs. However, in 2018-2020, coimplication rates in 2926 ORDs (880 non-ORDs) were 81% (33%) for any benzodiazepine, 30% (74%) for cocaine and 38% (22%) for gabapentin/pregabalin. Coimplication rate in 2018-2020 for any benzodiazepine was lowest at 70% (616/877) for heroin/morphine ORDs; and, by age group, at 66% (160/241) for ORDs aged 55+ years. CONCLUSIONS Drug testing to inform users, shared intelligence between police and public health for earlier detection of changes in supply and monitoring of prescribed daily-dose of methadone are urgent.
Collapse
|
12
|
Pless V, McClure J, Davis M, Farfalla J, Onufrey Y, Humm K, Ranade R, Terzian M. Reducing Overdose Through Policy Interventions: ASTHO's Recommendations for State and Territorial Health Officials and Agencies. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2023; 29:748-752. [PMID: 37478096 DOI: 10.1097/phh.0000000000001799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2023]
Affiliation(s)
- Victoria Pless
- Association of State and Territorial Health Officials, Arlington, Virginia
| | | | | | | | | | | | | | | |
Collapse
|
13
|
Fleißner S, Stöver H, Schäffer D. [Take-home naloxone: a building block of drug emergency prophylaxis in Germany]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2023; 66:1035-1041. [PMID: 37233811 PMCID: PMC10465660 DOI: 10.1007/s00103-023-03705-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 04/19/2023] [Indexed: 05/27/2023]
Abstract
Naloxone is an opioid antagonist that reverses the (respiratory-paralyzing) effects of opioids in the body within minutes. Naloxone can therefore reduce opioid overdose deaths. Take-home naloxone (THN) is an intervention recommended by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) and the World Health Organization (WHO). It involves training opioid users and their relatives or friends in the use of naloxone and providing them with the drug in case of emergency.So far, THN has been implemented in Germany mainly by individual addiction support facilities. In order to fully exploit the potential of THN, it is necessary to establish the measure nationwide. In particular, THN can be included in the services offered in (low-threshold) addiction support facilities, in psychiatric facilities, in the context of opioid substitution treatment, and in the correctional system.This discussion article reviews the development of THN in Germany since 1998, highlights the difficulties and obstacles to its widespread implementation, and outlines how THN can succeed as an effective public health intervention in Germany. This is particularly relevant in view of the increasing number of drug-related deaths over the past 10 years.
Collapse
Affiliation(s)
- Simon Fleißner
- Institut für Suchtforschung Frankfurt (ISFF), University of Applied Sciences Frankfurt, Nibelungenplatz 1, 60318, Frankfurt am Main, Deutschland.
| | - Heino Stöver
- Institut für Suchtforschung Frankfurt (ISFF), University of Applied Sciences Frankfurt, Nibelungenplatz 1, 60318, Frankfurt am Main, Deutschland
| | | |
Collapse
|
14
|
Trayner K, Yeung A, Sumnall HR, Anderson M, Glancy ME, Atkinson A, Smith M, McAuley A. National increase in the community supply of take-home naloxone associated with a mass media campaign in Scotland: a segmented time series analysis. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023:104106. [PMID: 37563038 DOI: 10.1016/j.drugpo.2023.104106] [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: 02/23/2023] [Revised: 06/15/2023] [Accepted: 06/18/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Take-home naloxone (THN) programmes have been associated with reductions in opioid-related mortality. In response to high rates of drug-related deaths in Scotland, the Scottish Government commissioned the 'How to save a life' (HTSAL) mass media campaign to: (1) increase awareness of drug-related deaths and how to respond to an overdose, and (2) increase the supply of THN. The aim of this study was to assess the effect of the campaign on the supply of THN. METHODS We used an interrupted time series design to assess the effect of the HTSAL mass media campaign on the national community supply of THN. The study time period was August 2020-December 2021. We modelled two key dates: the start of the campaign (week beginning (w/b) 30th of August 2021) and after the end of the main campaign (w/b 25th of October 2021). RESULTS The total number of THN kits distributed in the community in Scotland during the study period was 27,064. The mean number of THN kits distributed per week (relative to the pre-campaign period), increased by 126% during the campaign and 57% post-campaign. In segmented regression analyses, the pre-campaign trend in the number of THN kits supplied was increasing by an average of 1% each week (RR=1.01, 95% CI 1.01 to 1.01, p<0.001). Once the campaign started, a significant change in level was observed, and the number of kits increased by 75% (RR=1.75, 95% CI 1.29 to 2.40, p<0.001). The trend during the campaign was stable (i.e. not increasing or decreasing) but a significant change in level was observed when the campaign ended, and the number of THN kits supplied decreased by 32% (RR=0.68, 95% CI 0.46 to 0.98, p = 0.042). The trend during the post-campaign period was stable. CONCLUSIONS The HTSAL campaign had a short term, but large and significant impact, on the community supply of THN in Scotland. Mass media campaigns could be combined with other interventions and strategies to maintain the increased uptake of THN outside of campaign periods.
Collapse
Affiliation(s)
- Kma Trayner
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK; Public Health Scotland, Glasgow, UK.
| | - A Yeung
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK; Public Health Scotland, Glasgow, UK
| | - H R Sumnall
- Liverpool John Moores University, Liverpool, UK
| | | | - M E Glancy
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK; Public Health Scotland, Glasgow, UK
| | - A Atkinson
- Liverpool John Moores University, Liverpool, UK
| | - M Smith
- Public Health Scotland, Glasgow, UK
| | - A McAuley
- School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK; Public Health Scotland, Glasgow, UK
| |
Collapse
|
15
|
Urmanche AA, Harocopos A. Experiences Administering Naloxone Among People in Different Social Roles: People Who Use Opioids and Family Members and Friends. JOURNAL OF DRUG ISSUES 2023; 53:475-489. [PMID: 37829614 PMCID: PMC10569559 DOI: 10.1177/00220426221133024] [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] [Indexed: 10/14/2023]
Abstract
Unintentional drug overdose deaths continue to be a critical public health issue. Naloxone, a nonscheduled, safe, and effective drug that reverses opioid-involved overdoses is available to non-medically trained individuals ("lay people"), but there is scant information about how people in different social roles experience naloxone administration. We conducted 24 in-depth interviews with people who use opioids (PWUO; n = 15) and family members and friends of people who use opioids (FF; n = 9) who had administered naloxone in response to an opioid overdose. Compared with PWUO, members of the FF group were less reticent to administer naloxone in response to an overdose. PWUO and FF had different perspectives of law enforcement and demonstrated varied knowledge of the Good Samaritan Law. While PWUO found that having and administering naloxone was empowering, FF took a more pragmatic approach, reporting the need for naloxone as an unfortunate reality of their loved one's drug use.
Collapse
Affiliation(s)
- Adelya A Urmanche
- New York City Department of Health and Mental Hygiene, Bureau of Alcohol and Drug Use Prevention, Care and Treatment, NY, USA
| | - Alex Harocopos
- New York City Department of Health and Mental Hygiene, Bureau of Alcohol and Drug Use Prevention, Care and Treatment, NY, USA
| |
Collapse
|
16
|
Bejarano Romero R, Arredondo Sánchez-Lira J, Slim Pasaran S, Chávez Rivera A, Angulo Corral L, Salimian A, Romero Vadilllo JJ, Goodman-Meza D. Implementing a decentralized opioid overdose prevention strategy in Mexico, a pending public policy issue. LANCET REGIONAL HEALTH. AMERICAS 2023; 23:100535. [PMID: 37351156 PMCID: PMC10282171 DOI: 10.1016/j.lana.2023.100535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/13/2023] [Accepted: 06/01/2023] [Indexed: 06/24/2023]
Abstract
The public health crisis due to opioid overdose is worsening in Mexico's northern region due to the introduction of illicitly manufactured fentanyl into the local drug supply. Though there is an increase in overdose deaths, there is no accurate report of overdoses by Mexican government agencies and no comprehensive opioid overdose prevention strategy. There is currently only an anti-drug marketing strategy which is likely insufficient to mitigate the growing epidemic. In order to address the growing opioid overdose crisis in the country, it is necessary to create and implement a decentralized prevention strategy, that includes naloxone distribution, expanded treatment services in regions most in need, and create active dialogue with community organisations already implementing harm reduction actions. Decisive action must be taken by the Mexican government to ensure the health and wellbeing of the Mexican citizens, especially those at high risk for opioid overdose.
Collapse
Affiliation(s)
- Raúl Bejarano Romero
- SDSU-UCSD Joint Doctoral Program in Interdisciplinary Research on Substance Use, 5500 Campanile Drive, San Diego, CA 92123-4119, USA
| | - Jaime Arredondo Sánchez-Lira
- School of Public Health and Social Policy, University of Victoria, British Columbia, HSD University of Victoria, Victoria, BC, Canada
| | - Said Slim Pasaran
- Integración Social Verter A.C., C. José Azueta 230, Primera, Mexicali, BC 21100, Mexico
| | | | - Lourdes Angulo Corral
- Integración Social Verter A.C., C. José Azueta 230, Primera, Mexicali, BC 21100, Mexico
| | - Anabel Salimian
- Department of Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, Los Angeles, CA 90095, USA
| | - Jorge J. Romero Vadilllo
- Universidad Autónoma Metropolitana – Campus Xochimilco, Calz. del Hueso 1100, Coapa, Villa Quietud, Coyoacán, Ciudad de México, CDMX 04960, Mexico
| | - David Goodman-Meza
- Department of Medicine, David Geffen School of Medicine at UCLA, 10833 Le Conte Ave, Los Angeles, CA 90095, USA
| |
Collapse
|
17
|
Sisson ML, Azuero A, Chichester KR, Carpenter MJ, Businelle MS, Shelton RC, Cropsey KL. Preliminary effectiveness of online opioid overdose and naloxone administration training and impact of naloxone possession on opioid use. Drug Alcohol Depend 2023; 249:110815. [PMID: 37336007 DOI: 10.1016/j.drugalcdep.2023.110815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 05/29/2023] [Accepted: 05/31/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Despite the demonstrated value of opioid overdose education and naloxone distribution (OEND) programs, uptake and utilization remains low. Accessibility to OEND is limited and traditional programs may not reach many high-risk individuals. This study evaluated the effectiveness of online opioid overdose and naloxone administration education and the impact of naloxone possession. METHODS Individuals with self-reported illicit use of opioids were recruited via Craigslist advertisements and completed all assessments and education online via REDCap. Participants watched a 20-minute video outlining signs of opioid overdose and how to administer naloxone. They were then randomized to either receive a naloxone kit or be given instructions on where to obtain a kit. Effectiveness of training was measured with pre- and post-training knowledge questionnaires. Naloxone kit possession, overdoses, opioid use frequency, and treatment interest were self-reported on monthly follow-up assessments. RESULTS Mean knowledge scores significantly increased from 6.82/9.00 to 8.22 after training (t(194)=6.85, p <0.001, 95% CI[1.00, 1.81], Cohen's d=0.85). Difference in naloxone possession between randomized groups was significant with a large effect size (p <0.001, diff=0.60, 95% CI[0.47, 0.73]). A bidirectional relationship was found between naloxone possession and frequency of opioid use. Overdoses and treatment interest were similar across possession status. CONCLUSIONS Overdose education is effective in online video format. Disparity in naloxone possession across groups indicates barriers to obtaining naloxone from pharmacies. Naloxone possession did not influence risky opioid use or treatment interest and its impact on frequency of use warrants further investigation. TRIAL REGISTRATION Clinitaltrials.gov-NCT04303000.
Collapse
Affiliation(s)
- Michelle L Sisson
- Department of Psychiatry and Behavioral Neurobiology, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
| | - Andres Azuero
- Department of Nursing, Family, Community & Health Systems, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Keith R Chichester
- Department of Psychiatry and Behavioral Neurobiology, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Matthew J Carpenter
- Medical University of South Carolina, Hollings Cancer Center & Department of Psychiatry and Behavioral Sciences, Charleston, SC, USA
| | - Michael S Businelle
- TSET Health Promotion Research Center, Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104, USA
| | - Richard C Shelton
- Department of Psychiatry and Behavioral Neurobiology, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Karen L Cropsey
- Department of Psychiatry and Behavioral Neurobiology, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| |
Collapse
|
18
|
Chhatwal J, Mueller PP, Chen Q, Kulkarni N, Adee M, Zarkin G, LaRochelle MR, Knudsen AB, Barbosa C. Estimated Reductions in Opioid Overdose Deaths With Sustainment of Public Health Interventions in 4 US States. JAMA Netw Open 2023; 6:e2314925. [PMID: 37294571 PMCID: PMC10257094 DOI: 10.1001/jamanetworkopen.2023.14925] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 04/08/2023] [Indexed: 06/10/2023] Open
Abstract
Importance In 2021, more than 80 000 US residents died from an opioid overdose. Public health intervention initiatives, such as the Helping to End Addiction Long-term (HEALing) Communities Study (HCS), are being launched with the goal of reducing opioid-related overdose deaths (OODs). Objective To estimate the change in the projected number of OODs under different scenarios of the duration of sustainment of interventions, compared with the status quo. Design, Setting, and Participants This decision analytical model simulated the opioid epidemic in the 4 states participating in the HCS (ie, Kentucky, Massachusetts, New York, and Ohio) from 2020 to 2026. Participants were a simulated population transitioning from opioid misuse to opioid use disorder (OUD), overdose, treatment, and relapse. The model was calibrated using 2015 to 2020 data from the National Survey on Drug Use and Health, the US Centers for Disease Control and Prevention, and other sources for each state. The model accounts for reduced initiation of medications for OUD (MOUDs) and increased OODs during the COVID-19 pandemic. Exposure Increasing MOUD initiation by 2- or 5-fold, improving MOUD retention to the rates achieved in clinical trial settings, increasing naloxone distribution efforts, and furthering safe opioid prescribing. An initial 2-year duration of interventions was simulated, with potential sustainment for up to 3 additional years. Main Outcomes and Measures Projected reduction in number of OODs under different combinations and durations of sustainment of interventions. Results Compared with the status quo, the estimated annual reduction in OODs at the end of the second year of interventions was 13% to 17% in Kentucky, 17% to 27% in Massachusetts, 15% to 22% in New York, and 15% to 22% in Ohio. Sustaining all interventions for an additional 3 years was estimated to reduce the annual number of OODs at the end of the fifth year by 18% to 27% in Kentucky, 28% to 46% in Massachusetts, 22% to 34% in New York, and 25% to 41% in Ohio. The longer the interventions were sustained, the better the outcomes; however, these positive gains would be washed out if interventions were not sustained. Conclusions and Relevance In this decision analytical model study of the opioid epidemic in 4 US states, sustained implementation of interventions, including increased delivery of MOUDs and naloxone supply, was found to be needed to reduce OODs and prevent deaths from increasing again.
Collapse
Affiliation(s)
- Jagpreet Chhatwal
- Institute for Technology Assessment, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | - Peter P. Mueller
- Institute for Technology Assessment, Massachusetts General Hospital, Boston
| | - Qiushi Chen
- Institute for Technology Assessment, Massachusetts General Hospital, Boston
- Harold and Inge Marcus Department of Industrial and Manufacturing Engineering, The Pennsylvania State University, University Park
| | - Neeti Kulkarni
- Institute for Technology Assessment, Massachusetts General Hospital, Boston
| | - Madeline Adee
- Institute for Technology Assessment, Massachusetts General Hospital, Boston
| | - Gary Zarkin
- RTI International, Research Triangle Park, North Carolina
| | - Marc R. LaRochelle
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
- Boston Medical Center, Boston, Massachusetts
| | - Amy B. Knudsen
- Institute for Technology Assessment, Massachusetts General Hospital, Boston
- Harvard Medical School, Boston, Massachusetts
| | | |
Collapse
|
19
|
Cooper JA, Onyeka I, Cardwell C, Paterson E, Kirk R, O'Reilly D, Donnelly M. Record linkage studies of drug-related deaths among adults who were released from prison to the community: a scoping review. BMC Public Health 2023; 23:826. [PMID: 37147595 PMCID: PMC10161544 DOI: 10.1186/s12889-023-15673-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 04/13/2023] [Indexed: 05/07/2023] Open
Abstract
BACKGROUND There are public health concerns about an increased risk of mortality after release from prison. The objectives of this scoping review were to investigate, map and summarise evidence from record linkage studies about drug-related deaths among former adult prisoners. METHODS MEDLINE, EMBASE, PsychINFO and Web of Science were searched for studies (January 2011- September 2021) using keywords/index headings. Two authors independently screened all titles and abstracts using inclusion and exclusion criteria and subsequently screened full publications. Discrepancies were discussed with a third author. One author extracted data from all included publications using a data charting form. A second author independently extracted data from approximately one-third of the publications. Data were entered into Microsoft Excel sheets and cleaned for analysis. Standardised mortality ratios (SMRs) were pooled (where possible) using a random-effects DerSimonian-Laird model in STATA. RESULTS A total of 3680 publications were screened by title and abstract, and 109 publications were fully screened; 45 publications were included. The pooled drug-related SMR was 27.07 (95%CI 13.32- 55.02; I 2 = 93.99%) for the first two weeks (4 studies), 10.17 (95%CI 3.74-27.66; I 2 = 83.83%) for the first 3-4 weeks (3 studies) and 15.58 (95%CI 7.05-34.40; I 2 = 97.99%) for the first 1 year after release (3 studies) and 6.99 (95%CI 4.13-11.83; I 2 = 99.14%) for any time after release (5 studies). However, the estimates varied markedly between studies. There was considerable heterogeneity in terms of study design, study size, location, methodology and findings. Only four studies reported the use of a quality assessment checklist/technique. CONCLUSIONS This scoping review found an increased risk of drug-related death after release from prison, particularly during the first two weeks after release, though drug-related mortality risk remained elevated for the first year among former prisoners. Evidence synthesis was limited as only a small number of studies were suitable for pooled analyses for SMRs due to inconsistencies in study design and methodology.
Collapse
Affiliation(s)
- Janine A Cooper
- Centre for Public Health, Queen's University Belfast, Royal Hospitals Site, Grosvenor Road, Belfast, UK.
- Administrative Data Research Centre Northern Ireland (ADRC NI), Centre for Public Health, Queen's University Belfast, Royal Hospitals Site, Grosvenor Road, Belfast, UK.
| | - Ifeoma Onyeka
- Centre for Public Health, Queen's University Belfast, Royal Hospitals Site, Grosvenor Road, Belfast, UK
- Administrative Data Research Centre Northern Ireland (ADRC NI), Centre for Public Health, Queen's University Belfast, Royal Hospitals Site, Grosvenor Road, Belfast, UK
- Present address: Department of Psychology, Sociology and Politics, Sheffield Hallam University, Sheffield, UK
| | - Christopher Cardwell
- Centre for Public Health, Queen's University Belfast, Royal Hospitals Site, Grosvenor Road, Belfast, UK
| | - Euan Paterson
- Centre for Public Health, Queen's University Belfast, Royal Hospitals Site, Grosvenor Road, Belfast, UK
- Administrative Data Research Centre Northern Ireland (ADRC NI), Centre for Public Health, Queen's University Belfast, Royal Hospitals Site, Grosvenor Road, Belfast, UK
| | - Richard Kirk
- Healthcare in Prison, South Eastern Health and Social Care Trust, Dundonald, UK
| | - Dermot O'Reilly
- Centre for Public Health, Queen's University Belfast, Royal Hospitals Site, Grosvenor Road, Belfast, UK
- Administrative Data Research Centre Northern Ireland (ADRC NI), Centre for Public Health, Queen's University Belfast, Royal Hospitals Site, Grosvenor Road, Belfast, UK
| | - Michael Donnelly
- Centre for Public Health, Queen's University Belfast, Royal Hospitals Site, Grosvenor Road, Belfast, UK
- Administrative Data Research Centre Northern Ireland (ADRC NI), Centre for Public Health, Queen's University Belfast, Royal Hospitals Site, Grosvenor Road, Belfast, UK
| |
Collapse
|
20
|
Yeung MEM, Lee CH, Hartmann R, Lang E. Opioid-related emergency department visits and deaths after a harm-reduction intervention: a retrospective observational cohort time series analysis. CMAJ Open 2023; 11:E537-E545. [PMID: 37339791 DOI: 10.9778/cmajo.20220104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/22/2023] Open
Abstract
BACKGROUND To date, there has been little research on the effect of safe consumption site and community-based naloxone programs on regional opioid-related emergency department visits and deaths. We sought to determine the impact of these interventions on regional opioid-related emergency department visit and death rates in the province of Alberta. METHODS We used a retrospective observational design, via interrupted time series analysis, to assess municipal opioid-related emergency department visit volume and opioid-related deaths (defined by poisoning and opioid use disorder). We compared rates before and after program implementation in individual Alberta municipalities and province-wide after safe consumption site (March 2018 to October 2018) and community-based naloxone (January 2016) program implementation. RESULTS A total of 24 107 emergency department visits and 2413 deaths were included in the study. After safe consumption site opening, we saw decreased opioid-related emergency department visits in Calgary (level change -22.7 [-20%] visits per month, 95% confidence interval [CI] -29.7 to -15.8) and Lethbridge (level change -8.8 [-50%] visits per month, 95% CI -11.7 to -5.9), and decreased deaths in Edmonton (level change -5.9 [-55%] deaths per month, 95% CI -8.9 to -2.9). We observed increased emergency department visits after community-based naloxone program implementation in urban Alberta (level change 38.9 [46%] visits, 95% CI 33.3 to 44.4). We also observed an increase in urban opioid-related deaths (level change 9.1 [40%] deaths, 95% CI 6.7 to 11.5). INTERPRETATION The results of this study suggest differences exist between municipalities employing similar interventions. Our results also suggest contextual variation; for example, illicit drug supply toxicity may modify the ability of a community-based naloxone program to prevent opioid overdose without a thorough public health response.
Collapse
Affiliation(s)
- Matthew E M Yeung
- Departments of Emergency Medicine (Yeung, Lang) and Critical Care Medicine (Lee), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Hartmann), University of Saskatchewan, Saskatoon, Sask.
| | - Chel Hee Lee
- Departments of Emergency Medicine (Yeung, Lang) and Critical Care Medicine (Lee), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Hartmann), University of Saskatchewan, Saskatoon, Sask
| | - Riley Hartmann
- Departments of Emergency Medicine (Yeung, Lang) and Critical Care Medicine (Lee), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Hartmann), University of Saskatchewan, Saskatoon, Sask
| | - Eddy Lang
- Departments of Emergency Medicine (Yeung, Lang) and Critical Care Medicine (Lee), University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Hartmann), University of Saskatchewan, Saskatoon, Sask
| |
Collapse
|
21
|
Sohn M, Delcher C, Talbert JC, Cheng Y, Xu Y, Jadhav ED, Freeman PR. The Impact of Naloxone Coprescribing Mandates on Opioid-Involved Overdose Deaths. Am J Prev Med 2023; 64:483-491. [PMID: 36496279 DOI: 10.1016/j.amepre.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 09/21/2022] [Accepted: 10/13/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Since 2017, a total of 10 states have mandated naloxone coprescribing intended to prevent fatal opioid overdoses. This study aims to assess the association between naloxone coprescribing/offering mandates and opioid-involved overdose deaths on the basis of the opioid type. METHODS Data on overdose deaths from 1999 to 2020 came from the National Center for Health Statistics CDC WONDER Online Database. This study examined deaths stratified by illicit/synthetic opioids and prescription/treatment opioids. Difference-in-difference negative binomial regression models estimated average marginal effects and 95% CIs. Covariates included opioid dispensing rate, Good Samaritan law, pharmacy-based naloxone access law, mandatory use of prescription drug monitoring program, and recreational cannabis dispensaries. Data collection and analysis were conducted in 2022. RESULTS Ten states implemented naloxone coprescribing/offering mandates during the period. Coprescribing/offering mandates significantly reduced the number of prescription/treatment overdose deaths by 8.61 per state per quarter (95% CI= -15.13, -2.09), a 16% reduction from the counterfactual estimates. Coprescribing/offering mandates did not significantly impact illicit/synthetic overdose deaths (average marginal effect=0.32; 95% CI= -18.27, 18.91). CONCLUSIONS Coprescribing/offering mandates prevent overdose deaths for its target population, individuals using prescription/treatment opioids. These mandates do not appear to impact populations using illicit/synthetic opioids; thus, expanded efforts are needed to reach these individuals.
Collapse
Affiliation(s)
- Minji Sohn
- College of Pharmacy, Ferris State University, Big Rapids, Michigan.
| | - Chris Delcher
- Institute for Pharmaceutical Outcomes and Policy (IPOP), Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, Kentucky
| | - Jeffery C Talbert
- Institute for Biomedical Informatics, College of Medicine, University of Kentucky, Lexington, Kentucky
| | - Yue Cheng
- Institute for Pharmaceutical Outcomes and Policy (IPOP), Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, Kentucky
| | - Yong Xu
- Marketing Department, College of Business, Ferris State University, Big Rapids, Michigan
| | - Emmanuel D Jadhav
- College of Health Professions, Ferris State University, Big Rapids, Michigan
| | - Patricia R Freeman
- Institute for Pharmaceutical Outcomes and Policy (IPOP), Department of Pharmacy Practice and Science, College of Pharmacy, University of Kentucky, Lexington, Kentucky
| |
Collapse
|
22
|
Hartung DM, McCracken CM, Nguyen T, Kempany K, Waddell EN. Fatal and nonfatal opioid overdose risk following release from prison: A retrospective cohort study using linked administrative data. JOURNAL OF SUBSTANCE USE AND ADDICTION TREATMENT 2023; 147:208971. [PMID: 36821990 DOI: 10.1016/j.josat.2023.208971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 11/08/2022] [Accepted: 01/31/2023] [Indexed: 02/12/2023]
Abstract
INTRODUCTION Among individuals who are released from prison, opioid overdose is a leading cause of death with a risk more than ten-fold the general population. Although the epidemiology of opioid-related fatalities has been described, few studies have characterized both fatal and nonfatal opioid-related poisonings. The objective of this study was to estimate risk of fatal and nonfatal opioid overdose among adults released from prison. METHODS The study estimated fatal and nonfatal opioid overdose rates using linked corrections, Medicaid, hospital discharge, and vital statistics from the state of Oregon from 2014 to 2018. Multivariable proportional hazards models identified demographic and prison-related factors associated with overdose. RESULTS Between 2014 and 2017, 18,258 individuals were released from prison. A majority of individuals were male (87 %) and ages 26 to 64 (83 %). Two-thirds had a documented substance use disorder treatment need and 20 % demonstrated mental health treatment need. Following prison release, 579 opioid overdose events occurred; 65 (11 %) were fatal. The rate of opioid overdose was 1085.7 per 100,000 person-years (PY). Rates were highest in the first two weeks (2286.7 per 100,000 PY), among women (1582.9 per 100,000 PY), and those with mental health (1624.3 per 100,000 PY) or substance use disorder treatment needs (1382.6 per 100,100 PY). Only mental health (adjusted hazard ratio [aHR] 1.54, 95 % CI 1.24 to 1.90) and substance use need (aHR 2.59; 95 % CI 2.01 to 3.34) remained significant in multivariable models. CONCLUSIONS The rate of opioid overdose is markedly elevated after prison release, particularly in the first two weeks. In women, the higher rate of opioid overdose is mediated by a greater mental health burden.
Collapse
Affiliation(s)
- Daniel M Hartung
- College of Pharmacy, Oregon State University, Portland, OR, United States of America.
| | - Caitlin M McCracken
- College of Pharmacy, Oregon State University, Portland, OR, United States of America
| | - Thuan Nguyen
- OHSU-Portland State University School Public Health, Oregon Health & Science University, Portland, OR, United States of America
| | - Katherine Kempany
- Oregon Department of Corrections, Salem, OR, United States of America
| | - Elizabeth Needham Waddell
- OHSU-Portland State University School Public Health, Oregon Health & Science University, Portland, OR, United States of America
| |
Collapse
|
23
|
Tracy BM, Bergus KC, Hoover EJ, Young AJ, Sims CA, Wahl WL, Valdez CL. Fatal opioid overdoses geospatially cluster with level 1 trauma centers in Ohio. Surgery 2023; 173:788-793. [PMID: 36253312 DOI: 10.1016/j.surg.2022.08.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 08/01/2022] [Accepted: 08/05/2022] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Ohio is consistently ranked as one of the worst states for opioid overdose deaths. Traumatic injury has been linked to opioid overdose deaths, yet the location of trauma centers has not been explored. We examined whether geospatial clustering occurred between county-level opioid overdose deaths (OODs) and trauma center levels. METHODS We obtained 2019 county-level data from the Ohio Department of Health for fatal overdoses from prescription opioids. We obtained the total number of opioid doses prescribed in 2019 per county from the Ohio Automated Rx Reporting System and American College of Surgeons designated trauma center locations within Ohio from their website. We used geospatial analysis to assess if clustering occurred between trauma center level and prescription opioid overdose deaths at a county level. RESULTS There were 42 trauma centers located within 21 counties: 7 counties had level 1, and 14 counties had only level 2/level 3. There was no difference in rates of opioid doses prescribed per 100,000 people between counties with level 1 trauma centers and only level 2/level 3. However, prescription OODs rates were significantly higher in counties with level 1 trauma centers (37.6 vs 20, P = .02). Geospatial clustering was observed between level 1 trauma centers and prescription opioid overdose deaths at the county level (P < .01). CONCLUSION Geospatial clustering exists between prescription OODs and level 1 trauma center locations in Ohio. Improved at-risk patient identification and targeted community outreach represent opportunities for trauma providers to tackle the opioid epidemic.
Collapse
Affiliation(s)
- Brett M Tracy
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio.
| | - Katherine C Bergus
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Erin J Hoover
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Andrew J Young
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Carrie A Sims
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Wendy L Wahl
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Carrie L Valdez
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| |
Collapse
|
24
|
Lambdin BH, Wenger L, Bluthenthal R, Bartholomew TS, Tookes HE, LaKosky P, O'Neill S, Kral AH. How do contextual factors influence naloxone distribution from syringe service programs in the USA: a cross-sectional study. Harm Reduct J 2023; 20:26. [PMID: 36855181 PMCID: PMC9972698 DOI: 10.1186/s12954-023-00755-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 02/09/2023] [Indexed: 03/02/2023] Open
Abstract
BACKGROUND Naloxone is a medication that can quickly reverse an opioid overdose. Syringe service programs (SSPs) are community-based prevention programs that provide a range of evidence-based interventions in the USA, including naloxone distribution. Attributes of SSPs make them ideal settings for naloxone distribution-they have staff and delivery models that are designed to reach people who use drugs where they are. We assessed which outer and inner setting factors of SSPs were associated with naloxone distribution in the USA. METHODS We surveyed SSPs in the USA known to the North American Syringe Exchange Network in 2019. Using the exploration, preparation, implementation and maintenance framework, we assessed inner and outer contextual factors associated with naloxone distribution among SSPs (n = 263 or 77% of SSPs). We utilized negative binomial regression to assess which factors were associated with the number of naloxone doses distributed and people receiving naloxone. RESULTS SSPs reported distributing 710,232 naloxone doses to 230,506 people in the prior year. Regarding outer setting, SSPs located in areas with high levels of community support had a higher level of naloxone distribution (aIRR = 3.07; 95% confidence interval (CI): 2.09-4.51; p < 0.001) and 110% (p = 0.022) higher rate of people receiving naloxone (aIRR = 2.10; 95% CI 1.46-3.02; p < 0.001) in the past 12 months. The legal status of SSPs and the level of need was not significantly associated with naloxone distribution. Regarding inner setting, SSPs with proactive refill systems (aIRR = 2.08; 95% CI 1.27-3.41; p = 0.004), greater number of distribution days (aIRR = 1.09 per day; 95% CI 1.06-1.11; p < 0.001) and older programs (aIRR = 1.06 per year; 95% CI 1.02-1.11; p = 0.004) were associated with higher levels of naloxone distribution. Also, SSPs with proactive refill systems (aIRR = 2.23; 95% CI 1.38-3.58; p = 0.001); greater number of distribution days (aIRR = 1.04; 95% CI 1.02-1.07; p < 0.001) and older programs (aIRR = 1.11; 95% CI 1.05-1.17; p < 0.001) were associated with a higher number of people receiving naloxone. CONCLUSION We identified outer and inner setting factors of SSPs that were associated with greater naloxone distribution. It is critical to ensure SSPs are adequately resourced to build community support for services and develop service delivery models that maximize naloxone distribution to address the nation's opioid overdose crisis.
Collapse
Affiliation(s)
- Barrot H Lambdin
- RTI International, Berkeley, CA, USA.
- University of California San Francisco, San Francisco, CA, USA.
- University of Washington, Seattle, WA, USA.
| | | | | | | | | | - Paul LaKosky
- North American Syringe Exchange Network, Tacoma, WA, USA
| | | | | |
Collapse
|
25
|
Speakman EM, Hillen P, Heyman I, Murray J, Dougall N, Aston EV, McAuley A. 'I'm not going to leave someone to die': carriage of naloxone by police in Scotland within a public health framework: a qualitative study of acceptability and experiences. Harm Reduct J 2023; 20:20. [PMID: 36805681 PMCID: PMC9938955 DOI: 10.1186/s12954-023-00750-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 02/03/2023] [Indexed: 02/21/2023] Open
Abstract
BACKGROUND Scotland has one of the highest rates of drug-related deaths (DRDs) per capita in Europe, the majority of which involve opioids. Naloxone is a medication used to reverse opioid-related overdoses. In efforts to tackle escalating DRDs in many countries, naloxone is increasingly being provided to people who are likely first responders in overdose situations. This includes non-healthcare professionals, such as police officers. A pilot exercise to test the carriage and administration of naloxone by police officers was conducted in selected areas of Scotland between March and October 2021. The aim of the study was to explore the acceptability and experiences of naloxone carriage and administration by police in Scotland. METHODS The study comprised of two stages. Stage 1 involved in-depth one-to-one qualitative interviews with 19 community stakeholders (people with lived experience, family members, support workers). Stage 2 involved a mixture of in-depth one-to-one interviews and focus groups with 41 police officers. Data were analysed thematically, and the findings from the two stages were triangulated to develop overarching themes and subthemes. RESULTS By the end of the pilot, 808 police officers had been trained in the use of intranasal naloxone. Voluntary uptake of naloxone kits among police officers who completed training was 81%. There were 51 naloxone administration incidents recorded by police officers at suspected opioid-related overdose incidents during the pilot. Most officers shared positive experiences of naloxone administration. Naloxone as a first aid tool suited their role as first responders and their duty and desire to preserve life. Perceived barriers included concerns about police undertaking health-related work, potential legal liabilities and stigmatising attitudes. The majority of participants (and all community stakeholders) were supportive of the pilot and for it to be expanded across Scotland. CONCLUSIONS Police carriage of naloxone is an acceptable and potentially valuable harm reduction tool to help tackle the DRDs crisis in Scotland. However, it requires appropriate integration with existing health and social care systems. The intervention lies at the intersection between public health and policing and implies a more explicit public health approach to policing.
Collapse
Affiliation(s)
| | - Peter Hillen
- grid.20409.3f000000012348339XSchool of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Inga Heyman
- grid.20409.3f000000012348339XSchool of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Jennifer Murray
- grid.20409.3f000000012348339XSchool of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Nadine Dougall
- grid.20409.3f000000012348339XSchool of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Elizabeth V. Aston
- grid.20409.3f000000012348339XSchool of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Andrew McAuley
- grid.5214.20000 0001 0669 8188School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK
| |
Collapse
|
26
|
Curtis M, Wilkinson AL, Dietze P, Stewart AC, Kinner SA, Cossar RD, Nehme E, Aitken C, Walker S, Butler T, Winter RJ, Smith K, Stoove M. Prospective study of retention in opioid agonist treatment and contact with emergency healthcare following release from prisons in Victoria, Australia. Emerg Med J 2023; 40:347-354. [PMID: 36759173 PMCID: PMC10176422 DOI: 10.1136/emermed-2022-212755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 01/28/2023] [Indexed: 02/11/2023]
Abstract
BACKGROUND People recently released from prison engage with emergency healthcare at greater rates than the general population. While retention in opioid agonist treatment (OAT) is associated with substantial reductions in the risk of opioid-related mortality postrelease, it is unknown how OAT affects contact with emergency healthcare. In a cohort of men who injected drugs regularly prior to imprisonment, we described rates of contact with ambulance services and EDs, and their associations with use of OAT, in the 3 months after release from prison. METHODS Self-report data from a prospective observational cohort of men who regularly injected drugs before a period of sentenced imprisonment, recruited between September 2014 and May 2016, were linked to state-wide ambulance and ED records over a 3-month postrelease period in Victoria, Australia. We used generalised linear models to estimate associations between OAT use (none/interrupted/retained) and contact with ambulance and EDs postrelease, adjusted for other covariates. RESULTS Among 265 participants, we observed 77 ambulance contacts and 123 ED contacts over a median of 98 days of observation (IQR 87-125 days). Participants who were retained in OAT between prison release and scheduled 3-month postrelease follow-up interviews had lower rates of contact with ambulance (adjusted incidence rate ratio (AIRR) 0.33, 95% CI 0.14 to 0.76) and ED (AIRR 0.43, 95% CI 0.22 to 0.83), compared with participants with no OAT use postrelease. Participants with interrupted OAT use did not differ from those with no OAT use in rates of contact with ambulance or ED. CONCLUSION We found lower rates of contact with emergency healthcare after release among people retained in OAT, but not among people reporting interrupted OAT use, underscoring the benefits of postrelease OAT retention. Strategies to improve accessibility and support OAT retention after leaving prison are important for men who inject drugs.
Collapse
Affiliation(s)
- Michael Curtis
- Disease Elimination, Burnet Institute, Melbourne, Victoria, Australia .,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Monash Addiction Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Anna L Wilkinson
- Disease Elimination, Burnet Institute, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Paul Dietze
- Disease Elimination, Burnet Institute, Melbourne, Victoria, Australia.,National Drug Research Institute, Curtin University, Melbourne, Victoria, Australia
| | - Ashleigh Cara Stewart
- Disease Elimination, Burnet Institute, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Victorian Institute of Forensic Medicine, Southbank, Victoria, Australia.,Department of Forensic Medicine, Monash University, Melbourne, Victoria, Australia
| | - Stuart A Kinner
- School of Population Health, Curtin University, Perth, Western Australia, Australia.,School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia.,Centre for Adolescent Health, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Griffith Criminology Institute, Griffith University, Brisbane, Queensland, Australia
| | | | - Emily Nehme
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Research & Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Campbell Aitken
- Disease Elimination, Burnet Institute, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Shelley Walker
- Disease Elimination, Burnet Institute, Melbourne, Victoria, Australia.,National Drug Research Institute, Curtin University, Melbourne, Victoria, Australia
| | - Tony Butler
- Justice Health Research Program, School of Population Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Rebecca J Winter
- Disease Elimination, Burnet Institute, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Gastroenterology, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Karen Smith
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Research & Evaluation, Ambulance Victoria, Doncaster, Victoria, Australia
| | - Mark Stoove
- Disease Elimination, Burnet Institute, Melbourne, Victoria, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,School of Psychology and Public Health, La Trobe University, Melbourne, Victoria, Australia
| |
Collapse
|
27
|
Curtis M, Dietze P, Winter RJ, Rathnayake K, Smith K, Stoove M. Non-fatal opioid overdose after release from prison among men who injected drugs prior to their imprisonment: a prospective data linkage study. Med J Aust 2023; 218:94-95. [PMID: 36344250 PMCID: PMC10952488 DOI: 10.5694/mja2.51774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 09/09/2022] [Accepted: 09/23/2022] [Indexed: 11/09/2022]
Affiliation(s)
- Michael Curtis
- Burnet InstituteMelbourneVIC
- Monash UniversityMelbourneVIC
| | - Paul Dietze
- Burnet InstituteMelbourneVIC
- Monash UniversityMelbourneVIC
| | | | | | - Karen Smith
- Monash UniversityMelbourneVIC
- Ambulance VictoriaMelbourneVIC
| | - Mark Stoove
- Burnet InstituteMelbourneVIC
- Monash UniversityMelbourneVIC
| |
Collapse
|
28
|
Won NY, Palamar JJ, Mike SA, Fitzgerald ND, Cottler LB. A Qualitative Analysis of Emergency Medical Services (EMS) Personnel Experiences and Perceptions Responding to Drug Overdoses in the United States (US) During the COVID-19 Pandemic. JOURNAL OF HEALTH RESEARCH 2023; 37:270-279. [PMID: 38148880 PMCID: PMC10751031 DOI: 10.56808/2586-940x.1045] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023] Open
Abstract
Summary Background The purpose of this work was to describe the experiences of EMS personnel in responding to drug overdose-related calls and the impact the pandemic has had to help better inform current response and treatment efforts. Methods Semi-structured interviews were conducted with 99 EMS personnel across 18 areas throughout the United States that were designated as Early Warning Network sentinel sites by the National Institute on Drug Abuse-funded National Drug Early Warning System. Participants were asked about topics including the potential burdens from the pandemic and the opioid crisis. We coded the interview responses and identified themes through qualitative analysis. Multiple cycles of descriptive coding, recoding, subcoding, pattern-coding, and thematic coding of responses were conducted. Results Responses were categorized into the following themes: 1) being over-worked from increased call volume; 2) increased risk for personal harm when responding to patients; 3) compassion fatigue due to long hours and repeat calls for the same people; 4) conflicting perceptions of the utility of naloxone; 5) the need for better treatment options to respond to opioid crisis on top of COVID-19. Conclusions The burden of the substance use disorder (SUD) crisis on EMS personnel has been compounded by the COVID-19 pandemic. These reports from EMS personnel throughout the US can help inform policy and procedures to better protect the mental health of EMS personnel and to ensure better care for patients with SUD. These experiences and recommendations may be of use for other countries as substance use and COVID-19 are global health issues.
Collapse
Affiliation(s)
- Nae Y. Won
- Department of Epidemiology, College of Public Health and Health Professions, College of Medicine, University of Florida, USA
| | - Joseph J. Palamar
- New York University Grossman School of Medicine, Department of Population Health, USA
| | - Stephen A. Mike
- Department of Epidemiology, College of Public Health and Health Professions, College of Medicine, University of Florida, USA
| | - Nicole D. Fitzgerald
- Department of Epidemiology, College of Public Health and Health Professions, College of Medicine, University of Florida, USA
| | - Linda B. Cottler
- Department of Epidemiology, College of Public Health and Health Professions, College of Medicine, University of Florida, USA
| |
Collapse
|
29
|
Tabatabai M, Cooper RL, Wilus DM, Edgerton RD, Ramesh A, MacMaster SA, Patel PN, Singh KP. The Effect of Naloxone Access Laws on Fatal Synthetic Opioid Overdose Fatality Rates. J Prim Care Community Health 2023; 14:21501319221147246. [PMID: 36625264 PMCID: PMC9834937 DOI: 10.1177/21501319221147246] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 12/05/2022] [Accepted: 12/07/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Increases in fatal synthetic opioid overdoses over the past 8 years have left states scrambling for effective means to curtail these deaths. Many states have implemented policies and increased service capacity to address this rise. To better understand the effectiveness of policy level interventions we estimated the impact of the presence of naloxone access laws (NALs) on synthetic opioid fatalities at the state level. METHODS A multivariable longitudinal linear mixed model with a random intercept was used to determine the relationship between the presence of NALs and synthetic opioid overdose death rates, while controlling for, Good Samaritan laws, opioid prescription rate, and capacity for medication for opioid use disorder (MOUD), utilizing a quadratic time trajectory. Data for the study was collected from the National Vital Statistics System using multiple cause-of-death mortality files linked to drug overdose deaths. RESULTS The presence of an NAL had a significant (univariate P-value = .013; multivariable p-value = .010) negative relationship to fentanyl overdose death rates. Other significant controlling variables were quadratic time (univariate and multivariable P-value < .001), MOUD (univariate P-value < .001; multivariable P-value = .009), and Good Samaritan Law (univariate P-value = .033; multivariable P-value = .018). CONCLUSION Naloxone standing orders are strongly related to fatal synthetic opioid overdose reduction. The effect of NALs, MOUD treatment capacity, and Good Samaritan laws all significantly influenced the synthetic opioid overdose death rate. The use of naloxone should be a central part of any state strategy to reduce overdose death rate.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | - Karan P. Singh
- University of Texas at Tyler School of
Medicine, Tyler, TX, USA
| |
Collapse
|
30
|
AL-Tabbaa MM, Bdiwi E, Endress K, Altarras K. The Significant Impact of Narcan Reversals on Overdose Mortality in Peoria County, IL. Cureus 2022; 14:e29918. [PMID: 36348887 PMCID: PMC9633100 DOI: 10.7759/cureus.29918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2022] [Indexed: 11/06/2022] Open
Abstract
Objectives: Determine the impact of Narcan administrations in Peoria County, IL on the number of overdose deaths by testing the statistical significance of the association between monthly Narcan reversals and overdose mortality. As well as re-shedding the light on the opioid pandemic post-COVID. Methods: We collected data on Narcan reversals from hospital emergency departments, Emergency Medical Services (EMS), the County Sheriff’s Office, local police departments, and other agencies that distributed and/or administered Narcan in Peoria County from January through December 2018. Data for the 2018 overdose mortality was collected through vital records at the Peoria City/County Health Department. Results: Results from simple linear regression suggest that a significant proportion of the total variation in overdose mortality over 2018 was predicted by the Narcan reversals, F(1, 11) = 5.872, p< 0.05. Multiple R2 indicates that approximately 30.7% of the variation in overdose mortality was predicted by the Narcan reversals. If there were 0 Narcan reversals, there would be 8.362 overdose deaths per month. Conclusions: Narcan is known to save lives in cases of opioid overdose, and the need for increased administration campaigns is warranted to further battle the opioid epidemic. As this study has proven, Narcan administration has the potential to significantly decrease overdose mortality.
Collapse
|
31
|
Proportion and conditions of use of intranasal take-home naloxone kits: A retrospective study in two French outpatient addiction centers, 2016–2020. Therapie 2022; 77:581-584. [DOI: 10.1016/j.therap.2022.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 01/11/2022] [Indexed: 11/23/2022]
|
32
|
Bird SM. Study-design in pandemics: From surveillance and performance-evaluation to licensing and pharmacovigilance. Pharm Stat 2022; 21:764-777. [PMID: 35819118 PMCID: PMC9544724 DOI: 10.1002/pst.2217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Revised: 03/06/2022] [Accepted: 03/07/2022] [Indexed: 11/10/2022]
Abstract
Andy Grieve, the first pharmaceutical statistician to be President of the Royal Statistical Society, practiced in the regulated world of drug development. With reduction in drug development costs as his motivation, Grieve advanced Bayesian methods for developing predictive methods for efficacy and toxicity - to be used as early as possible in the drug development process; and his presidential address exhorted statisticians to weigh-in wherever data are used to make decisions. Diagnostic tests for infectious diseases are less regulated than drugs and vaccines unless the blood supply is at risk. Unlike in the HIV and HCV pandemics of the late 20th century, even well-designed surveys linked to a volunteered biological sample (to be tested for SARS-CoV-2 antigen or antibodies) have had modest or low consent rates. Record-linkage, statistical design and reporting standards have seen triumph and tragedy. Among the triumphs are: Liverpool's insistence on dual testing (lateral flow device; polymerase chain reaction [PCR]) of some 6000 asymptomatic citizens who attended for SARS-CoV-2-screening; two tricky randomized controlled public-policy trials on daily contact testing for close contacts of index cases of SARS-CoV-2 infection versus self-isolation (with or without initial PCR); and among already-consented participants in surveillance, over 80% secondary consent for linkage to their health records, including the Immunization Management Service. Before the next pandemic we need to entrench better regulation of diagnostic tests, better informed consent (not via weblinks), better feedback to participants, and transparency about basic safety data.
Collapse
Affiliation(s)
- Sheila M Bird
- MRC Biostatistics Unit, Cambridge, UK.,College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| |
Collapse
|
33
|
Antoniou T, Men S, Tadrous M, Leece P, Munro C, Gomes T. Impact of a publicly funded pharmacy-dispensed naloxone program on fatal opioid overdose rates: A population-based study. Drug Alcohol Depend 2022; 236:109473. [PMID: 35523113 DOI: 10.1016/j.drugalcdep.2022.109473] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 04/21/2022] [Accepted: 04/21/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Studies examining the impact of pharmacy-dispensed naloxone programs on fatal opioid overdose rates are lacking. We examined the impact of the publicly funded Ontario Naloxone Program for Pharmacies (ONPP), implemented in June 2016, on provincial rates of opioid overdose deaths. METHODS We conducted a population-based interrupted time-series study between July 1, 2012 and December 31, 2018. We considered a parsimonious model with terms for time, ONPP implementation, and time following the ONPP implementation. Models were adjusted for population characteristics, number of pharmacies and rate of naloxone distributed through non-pharmacy sites within provincial public health units. RESULTS In the parsimonious model, the ONPP was associated with a non-significant 9% reduction in the level of fatal opioid overdoses (rate ratio [RR] 0.91; 95% confidence interval [CI] 0.79-1.06), a finding that was most pronounced in regions in the lowest tertile of implementation (RR 0.75; 95% CI 0.62-0.91). Following multivariable adjustment, there was an increase in the level (RR 1.06; 95% CI 0.94-1.19) and slope change (RR 1.06; 95% CI 1.02-1.10) of fatal overdose rates. CONCLUSION The ONPP is insufficient as a single intervention to meaningfully reduce rates of fatal opioid overdoses during a period in which the cause of these deaths shifted from prescription opioids to highly potent fentanyl analogs. Access to additional harm reduction, treatment, and other interventions is necessary to prevent deaths and optimize the health of people who use drugs.
Collapse
Affiliation(s)
- Tony Antoniou
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada; Department of Family and Community Medicine, Unity Health, Toronto, Ontario, Canada; Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Ontario Drug Policy Research Network, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada.
| | | | - Mina Tadrous
- ICES, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada; Women's College Research Institute, Toronto, Ontario, Canada
| | - Pamela Leece
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; Public Health Ontario, Toronto, Ontario, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Charlotte Munro
- Ontario Drug Policy Research Network, Toronto, Ontario, Canada
| | - Tara Gomes
- Li Ka Shing Knowledge Institute, Unity Health, Toronto, Ontario, Canada; Ontario Drug Policy Research Network, Toronto, Ontario, Canada; ICES, Toronto, Ontario, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada; Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| |
Collapse
|
34
|
Cherrier N, Kearon J, Tetreault R, Garasia S, Guindon E. Community Distribution of Naloxone: A Systematic Review of Economic Evaluations. PHARMACOECONOMICS - OPEN 2022; 6:329-342. [PMID: 34762276 PMCID: PMC8581604 DOI: 10.1007/s41669-021-00309-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/06/2021] [Indexed: 05/05/2023]
Abstract
BACKGROUND As a core component of harm-reduction strategies to address the opioid crisis, several countries have instituted publicly funded programs to distribute naloxone for lay administration in the community. The effectiveness in reducing mortality from opioid overdose has been demonstrated in multiple systematic reviews. However, the economic impact of community naloxone distribution programs is not fully understood. OBJECTIVES Our objective was to conduct a review of economic evaluations of community distribution of naloxone, assessing for quality and applicability to diverse contexts and settings. DATA SOURCES The search strategy was performed on MEDLINE, Embase, and EconLit databases. STUDY ELIGIBILITY CRITERIA AND INTERVENTIONS Search criteria were developed based on two themes: (1) papers involving naloxone or narcan and (2) any form of economic evaluation. A focused search of the grey literature was also conducted. Studies exploring the intervention of community distribution of naloxone were selected. STUDY APPRAISAL AND SYNTHESIS METHODS Data extraction was done using the British Medical Journal guidelines for economic submissions, assigning quality levels based on the impact of the missing or unclear components on the strength of the conclusions. RESULTS A total of nine articles matched our inclusion criteria: one cost-effectiveness analysis, eight cost-utility analyses, and one cost-benefit analysis. Overall, the quality of the studies was good (six of high quality, two of moderate quality, and one of low quality). All studies concluded that community distribution of naloxone was cost effective, with an incremental cost-utility ratio range of $US111-58,738 (year 2020 values) per quality-adjusted life-year gained. LIMITATIONS Our search strategy was developed iteratively, rather than following an a priori design. Additionally, our search was limited to English terms. CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS Based on this review, community distribution of naloxone is a worthwhile investment and should be considered by other countries dealing with the opioid epidemic.
Collapse
Affiliation(s)
- Nelda Cherrier
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Joanne Kearon
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
| | - Robin Tetreault
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Sophiya Garasia
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada
| | - Emmanuel Guindon
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada
| |
Collapse
|
35
|
Monds LA, Bravo M, Mills L, Malcolm A, Gilliver R, Wood W, Harrod ME, Read P, Nielsen S, Dietze PM, Lenton S, Bleeker AM, Lintzeris N. The Overdose Response with Take Home Naloxone (ORTHN) project: Evaluation of health worker training, attitudes and perceptions. Drug Alcohol Rev 2022; 41:1085-1094. [PMID: 35442514 DOI: 10.1111/dar.13474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 03/27/2022] [Accepted: 03/28/2022] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Naloxone is a life-saving medication that reverses opioid overdose; naloxone can be provided on a 'take-home' basis so naloxone can be administered outside of the health-care setting. The Overdose Response and Take Home Naloxone (ORTHN) project established a model of care for take-home naloxone (THN) interventions across alcohol and other drug and harm reduction services in NSW, Australia. This paper evaluates the staff training and credentialing program, and examines staff attitudes and perspectives regarding the provision of THN interventions in these settings. METHODS Staff across seven services were trained through a 'train-the-trainer' credentialing model to deliver ORTHN, including naloxone supply. Staff were surveyed regarding their experience, attitudes and knowledge on THN prior to and after training, and after 6 months. At the 6 months follow up, staff were asked about the interventions they provided, barriers and enablers to uptake, and opinions regarding future rollout. RESULTS A total of 204 staff were trained and credentialed to provide the ORTHN intervention. Most (60%) were nurses, followed by needle syringe program workers and allied health/counsellors (32%). Linear and logistic regression analyses indicated that the training program was associated with significant improvements in staff knowledge and attitudes towards overdose and THN; however, only attitudinal improvements were maintained over time. There were high rates of staff satisfaction with the ORTHN intervention and training. DISCUSSION/CONCLUSIONS The ORTHN program is 'fit for purpose' for broad implementation in these settings. A number of potential barriers (e.g. time, medication and staffing costs) and enablers (e.g. peer engagement, regulatory framework for naloxone supply) in implementing THN interventions were identified.
Collapse
Affiliation(s)
- Lauren A Monds
- Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, Australia.,Discipline of Addiction Medicine, Central Clinical School, The University of Sydney, Sydney, Australia.,NSW Drug and Alcohol Clinical Research and Improvement Network, Sydney, Australia
| | - Maria Bravo
- Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, Australia.,Discipline of Addiction Medicine, Central Clinical School, The University of Sydney, Sydney, Australia.,NSW Drug and Alcohol Clinical Research and Improvement Network, Sydney, Australia
| | - Llewellyn Mills
- Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, Australia.,Discipline of Addiction Medicine, Central Clinical School, The University of Sydney, Sydney, Australia.,NSW Drug and Alcohol Clinical Research and Improvement Network, Sydney, Australia
| | - Annie Malcolm
- Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, Australia.,NSW Drug and Alcohol Clinical Research and Improvement Network, Sydney, Australia
| | - Rosie Gilliver
- Kirketon Road Centre, South Eastern Sydney Local Health District, Sydney, Australia
| | - William Wood
- Medically Supervised Injecting Centre, Sydney, Australia
| | | | - Phillip Read
- Kirketon Road Centre, South Eastern Sydney Local Health District, Sydney, Australia.,The Kirby Institute, UNSW Sydney, Sydney, Australia
| | - Suzanne Nielsen
- Monash Addiction Research Centre, Monash University, Melbourne, Australia
| | - Paul M Dietze
- National Drug Research Institute, Melbourne, Australia.,Behaviours and Health Risks Program, Burnet Institute, Melbourne, Australia
| | - Simon Lenton
- National Drug Research Institute, Faculty of Health Sciences, Curtin University, Perth, Australia
| | - Anne M Bleeker
- Alcohol, Tobacco and Other Drug Association, Canberra, Australia
| | - Nicholas Lintzeris
- Drug and Alcohol Services, South Eastern Sydney Local Health District, Sydney, Australia.,Discipline of Addiction Medicine, Central Clinical School, The University of Sydney, Sydney, Australia.,NSW Drug and Alcohol Clinical Research and Improvement Network, Sydney, Australia
| |
Collapse
|
36
|
Troberg K, Isendahl P, Blomé MA, Dahlman D, Håkansson A. Characteristics of and Experience Among People Who Use Take-Home Naloxone in Skåne County, Sweden. Front Public Health 2022; 10:811001. [PMID: 35359781 PMCID: PMC8960176 DOI: 10.3389/fpubh.2022.811001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 02/01/2022] [Indexed: 01/10/2023] Open
Abstract
BackgroundOpioid overdose related injury or death can be prevented by bystander naloxone administration. For naloxone to be present when and where overdoses occur, opioid prevention education and naloxone distribution (OPEND) must be established on a broad level. This is the 30-month follow-up of the first multi-site naloxone project in Sweden, implemented at 31 sites in the County of Skåne 2018.AimTo address participant characteristics and factors associated with returning for naloxone refill and with having used naloxone for overdose reversal. An additional aim was to describe self-reported reasons for naloxone refill and overdose experiences.MethodsData were collected during June 2018—December 2020 through questionnaires at baseline and upon naloxone refill of the initial and subsequent naloxone kit. Descriptive statistics was used to address participant characteristics, those returning for naloxone refill and reporting overdose reversal. Chi-2 test was used for variable comparison between groups. Factors associated with overdose reversals were examined by logistic regression analysis. Reasons for naloxone refill, overdose situation and management were presented descriptively.ResultsAmong 1,079 study participants, 22% (n = 235) returned for naloxone refill, of which 60% (n = 140) reported a total of 229 overdose reversals. Reversals were more likely to be reported by participants trained at needle exchange programs (NEPs) [adjusted odds ratio (AOR) = 5.18, 95% Confidence interval (CI) = 3.38–7.95)], with previous experience of own (AOR = 1.63, 95% CI = 1.03–2.58) or witnessed (AOR = 2.12, 95% CI = 1.05–4.29) overdose, or who had used sedatives during the last 30 days before initial training (AOR = 1.56, 95% CI = 1.04–2.33). A majority of overdoses reportedly occurred in private settings (62%), where the victim was a friend (35%) or acquaintance (31%) of the rescuer.ConclusionParticipants with own risk factors associated with overdose (e.g., injection use, concomitant use of benzodiazepines and previous experience of own overdose) were more likely to report administering naloxone for overdose reversal. Overdose management knowledge was high. The findings indicate that implementation of multi-site OPEND reaches individuals at particularly high risk of own overdose in settings with limited previous harm reduction strategies and favors a further scaling up of naloxone programs in similar settings.
Collapse
Affiliation(s)
- Katja Troberg
- Division of Psychiatry, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Malmö Addiction Centre, Region Skåne, Malmö, Sweden
- *Correspondence: Katja Troberg
| | - Pernilla Isendahl
- Department of Infectious Disease, University Hospital Skåne, Malmö, Sweden
| | - Marianne Alanko Blomé
- Department of Infectious Disease, University Hospital Skåne, Malmö, Sweden
- Regional Office for Communicable Disease Control, Malmö, Sweden
| | - Disa Dahlman
- Division of Psychiatry, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Center for Primary Health Care Research, Department of Clinical Sciences, Lund University, Region Skåne, Malmö, Sweden
| | - Anders Håkansson
- Division of Psychiatry, Department of Clinical Sciences Lund, Lund University, Lund, Sweden
- Malmö Addiction Centre, Region Skåne, Malmö, Sweden
| |
Collapse
|
37
|
Kelly BC, Vuolo M. Do naloxone access laws affect perceived risk of heroin use? Evidence from national US data. Addiction 2022; 117:666-676. [PMID: 34617356 PMCID: PMC8844056 DOI: 10.1111/add.15682] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 08/18/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIMS Whether expanded access to naloxone reduces perceptions of risk about opioid use has been subject to debate. Our aim was to assess how implementation of naloxone access laws shapes perceived risk of heroin use. DESIGN Using data from the restricted-access National Survey on Drug Use and Health, Prescription Drug Abuse Policy System and the US Census, we applied two-way fixed-effects models to determine whether naloxone access laws decreased perceived risk of any heroin use or regular heroin use. We used Bayes factors (BFs) to confirm evidence for null findings. SETTING United States. PARTICIPANTS A total of 884 800 respondents aged 12 and older from 2004 to 2016. MEASUREMENTS A binary indicator of whether a state implemented naloxone access laws was regressed on respondent-perceived risk of (1) any heroin use and (2) regular heroin use. Ratings of perceived risk were assessed on a scale of 1 (none) to 4 (great risk). FINDINGS In all instances, the BFs support evidence for the null hypothesis. Across models with three distinct specifications of naloxone access laws, we found no evidence of decreased risk perceptions, as confirmed by BFs ranging from 0.009 to 0.057. Across models of specific vulnerable subgroups, such as people who use opioids (BFs = 0.039-0.225) or young people (BFs = 0.009-0.158), we found no evidence of decreased risk perceptions. Across diverse subpopulations by gender (BFs = 0.011-0.083), socio-economic status (BFs = 0.015-0.168) or race/ethnicity (BFs = 0.016-0.094), we found no evidence of decreased risk perceptions. CONCLUSIONS There appears to be no empirical evidence that implementation of naloxone access laws has adversely affected perceptions of risk of heroin in the broader US population or within vulnerable subgroups or diverse subpopulations.
Collapse
Affiliation(s)
| | - Mike Vuolo
- The Ohio State University; Dept. of Sociology
| |
Collapse
|
38
|
Humphreys K, Shover CL, Andrews CM, Bohnert ASB, Brandeau ML, Caulkins JP, Chen JH, Cuéllar MF, Hurd YL, Juurlink DN, Koh HK, Krebs EE, Lembke A, Mackey SC, Larrimore Ouellette L, Suffoletto B, Timko C. Responding to the opioid crisis in North America and beyond: recommendations of the Stanford-Lancet Commission. Lancet 2022; 399:555-604. [PMID: 35122753 PMCID: PMC9261968 DOI: 10.1016/s0140-6736(21)02252-2] [Citation(s) in RCA: 178] [Impact Index Per Article: 89.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 08/01/2021] [Accepted: 10/06/2021] [Indexed: 02/07/2023]
Affiliation(s)
- Keith Humphreys
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA.
| | - Chelsea L Shover
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - Christina M Andrews
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA
| | - Amy S B Bohnert
- Department of Psychiatry and Department of Anesthesiology, University of Michigan Health System, Ann Arbor, MI, USA; Veterans Affairs Center for Clinical Management Research, Veterans Affairs Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Margaret L Brandeau
- Department of Management Science and Engineering, Huang Engineering Center, Stanford University, Stanford, CA USA
| | | | - Jonathan H Chen
- Stanford Center for Biomedical Informatics Research, Stanford University School of Medicine, Stanford, CA, USA; Division of Hospital Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Yasmin L Hurd
- Addiction Institute, Icahn School of Medicine, New York, NY, USA
| | - David N Juurlink
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Howard K Koh
- Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA, USA
| | - Erin E Krebs
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA; Center for Care Delivery and Outcomes Research, Veterans Affairs Minneapolis Health Care System, Minneapolis, MN, USA
| | - Anna Lembke
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Sean C Mackey
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
| | | | - Brian Suffoletto
- Department of Emergency Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Christine Timko
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA, USA; Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
| |
Collapse
|
39
|
Pollini RA, Ozga JE, Joyce R, Xuan Z, Walley AY. Limited access to pharmacy-based naloxone in West Virginia: Results from a statewide purchase trial. Drug Alcohol Depend 2022; 231:109259. [PMID: 34998246 PMCID: PMC8810724 DOI: 10.1016/j.drugalcdep.2021.109259] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 12/07/2021] [Accepted: 12/09/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND West Virginia (WV) has the highest overdose mortality rate in the United States and expanding naloxone access is crucial for reducing opioid overdose deaths. We conducted a purchase trial to establish an objective measure of naloxone access under WV's naloxone standing order (NSO) program. METHODS A stratified random sample of 200 chain and independent retail pharmacies across WV were included. Each pharmacy underwent two purchase attempts-one by a person who used illicit opioids (PWUIO) and one by a potential bystander who did not use illicit opioids but had a relationship with a PWUIO. We used matched-pairs analysis to identify differences in outcomes by purchaser type (PWUIO vs bystander). Chi-square and independent-samples t-tests were used to compare outcomes by pharmacy type (chain vs independent). RESULTS Overall, 29% of purchase attempts were successful, with no significant difference between PWUIO and bystanders (p = 0.798). Fewer than half (44%) of successful purchases included verbal counseling, and bystanders were more likely to receive counseling than PWUIO (33% vs 4%, p = 0.018). Common reasons for failed purchases were naloxone not being in stock (41%), requiring a naloxone prescription (35%), and/or requiring formal identification (23%). Chain pharmacies were more likely to sell naloxone than independents (35% vs 19%, p = 0.001). CONCLUSIONS We documented limited naloxone access under the WV NSO. These findings indicate that simply establishing an NSO program is insufficient to expand access. Implementation efforts should ensure adequate naloxone stocks, pro-active delivery of NSO-related information and pharmacist training, and avoidance of recordkeeping requirements that may impede access.
Collapse
Affiliation(s)
- Robin A. Pollini
- Department of Behavioral Medicine & Psychiatry, School of Medicine, West Virginia University, 3602 Collins Ferry Road, Morgantown WV, 26505, United States,Department of Epidemiology, School of Public Health, West Virginia University, 3602 Collins Ferry Road, Morgantown WV, 26505, United States
| | - Jenny E. Ozga
- Department of Behavioral Medicine & Psychiatry, School of Medicine, West Virginia University, 3602 Collins Ferry Road, Morgantown WV, 26505, United States
| | - Rebecca Joyce
- Department of Behavioral Medicine & Psychiatry, School of Medicine, West Virginia University, 3602 Collins Ferry Road, Morgantown WV, 26505, United States
| | - Ziming Xuan
- Department of Community Health Sciences, School of Public Health, Boston University, Crosstown Building - CT 454, 801 Massachusetts Ave, 4th Floor, Boston, MA 02118, United States
| | - Alexander Y. Walley
- Boston Medical Center and Boston University School of Medicine, Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, 801 Massachusetts Ave, 2nd Floor, Boston, MA 02118, United States
| |
Collapse
|
40
|
Marks C, Wagner KD. Supporting people responding to overdoses. Lancet Public Health 2022; 7:e198-e199. [DOI: 10.1016/s2468-2667(22)00011-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 01/13/2022] [Indexed: 10/19/2022]
|
41
|
Chatterjee A, Yan S, Xuan Z, Waye KM, Lambert AM, Green TC, Stopka TJ, Pollini RA, Morgan JR, Walley AY. Broadening access to naloxone: Community predictors of standing order naloxone distribution in Massachusetts. Drug Alcohol Depend 2022; 230:109190. [PMID: 34864356 PMCID: PMC8714703 DOI: 10.1016/j.drugalcdep.2021.109190] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 11/16/2021] [Accepted: 11/16/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND Naloxone is a prescription medication that reverses opioid overdoses. Allowing naloxone to be dispensed directly by a pharmacist without an individual prescription under a naloxone standing order (NSO) can expand access. The community-level factors associated with naloxone dispensed under NSO are unknown. METHODS Using a dataset comprised of pharmacy reports of naloxone dispensed under NSO from 70% of Massachusetts retail pharmacies, we examined relationships between community-level demographics, rurality, measures of treatment for opioid use disorder, and overdose deaths with naloxone dispensed under NSO per ZIP Code-quarter from 2014 until 2018. We used a multi-variable zero-inflated negative binomial model, assessing odds of any naloxone dispensed under NSO, as well as a multi-variable negative binomial model assessing quantities of naloxone dispensed under NSO. RESULTS From 2014-2018, quantities of naloxone dispensed under NSO and the number of pharmacies dispensing any naloxone under NSO increased over time. However, communities with greater percentages of people with Hispanic ethnicity (aOR 0.91, 95% CI 0.86-0.96 per 5% increase), and rural communities compared to urban communities (aOR 0.81, 95% CI 0.73-0.90) were less likely to dispense any naloxone by NSO. Communities with more individuals treated with buprenorphine dispensed more naloxone under NSO, as did communities with more opioid-related overdose deaths. CONCLUSION Naloxone dispensing has substantially increased, in part driven by standing orders. A lower likelihood of naloxone being dispensed under NSO in communities with larger Hispanic populations and in more rural communities suggests the need for more equitable access to, and uptake of, lifesaving medications like naloxone.
Collapse
Affiliation(s)
- Avik Chatterjee
- Boston Medical Center and Boston University School of Medicine, Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, 801 Massachusetts Ave, 2nd Floor, Boston, MA 02118, USA.
| | - Shapei Yan
- Boston Medical Center and Boston University School of Medicine, Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, 801 Massachusetts Ave, 2nd Floor, Boston, MA 02118, USA
| | - Ziming Xuan
- Boston University School of Public Health, Department of Community Health Sciences, 801 Massachusetts Ave, Crosstown Building 4th Floor, Boston, MA 02118, USA
| | - Katherine M Waye
- Boston Medical Center and Boston University School of Medicine, Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, 801 Massachusetts Ave, 2nd Floor, Boston, MA 02118, USA
| | - Audrey M Lambert
- Boston Medical Center and Boston University School of Medicine, Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, 801 Massachusetts Ave, 2nd Floor, Boston, MA 02118, USA
| | - Traci C Green
- The Heller School for Social Policy and Management at Brandeis University, Institute for Behavioral Health, 415 South St, MS 035, Waltham, MA 02453, USA
| | - Thomas J Stopka
- Tufts University School of Medicine, Department of Public Health and Community Medicine, Tufts University School of Medicine, 136 Harrison Ave, Boston, MA 02111, USA
| | - Robin A Pollini
- West Virginia University School of Medicine, Department of Behavioral Medicine and Psychiatry and West Virginia University School of Public Health, Department of Epidemiology and Biostatistics, 1 Medical Center Dr, Morgantown, WV 26506, USA
| | - Jake R Morgan
- Boston University School of Public Health, Department of Health Law, Policy and Management, 715 Albany St, Talbot Building Floor 2 West, Boston, MA 02118, USA
| | - Alexander Y Walley
- Boston Medical Center and Boston University School of Medicine, Grayken Center for Addiction, Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, 801 Massachusetts Ave, 2nd Floor, Boston, MA 02118, USA
| |
Collapse
|
42
|
Strang J. Take-Home Naloxone and the Prevention of Deaths from Heroin Overdose: Pursuing Strong Science, Fuller Understanding, Greater Impact. Eur Addict Res 2022; 28:161-175. [PMID: 34963112 DOI: 10.1159/000519939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 09/07/2021] [Indexed: 11/19/2022]
Abstract
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.
Collapse
Affiliation(s)
- John Strang
- National Addiction Centre, Kings College London, London, United Kingdom
| |
Collapse
|
43
|
Behrends CN, Gutkind S, Winkelstein E, Wright M, Dolatshahi J, Welch A, Paone D, Kunins HV, Schackman BR. Costs of opioid overdose education and naloxone distribution in New York City. Subst Abus 2022; 43:692-698. [PMID: 34666633 PMCID: PMC9048167 DOI: 10.1080/08897077.2021.1986877] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background: Naloxone is an opioid antagonist medication that can be administered by lay people or medical professionals to reverse opioid overdoses and reduce overdose mortality. Cost was identified as a potential barrier to providing expanded overdose education and naloxone distribution (OEND) in New York City (NYC) in 2017. We estimated the cost of delivering OEND for different types of opioid overdose prevention programs (OOPPs) in NYC. Methods: We interviewed naloxone coordinators at 11 syringe service programs (SSPs) and 10 purposively sampled non-SSPs in NYC from December 2017 to September 2019. The samples included diverse non-SSP program types, program sizes, and OEND funding sources. We calculated one-time start up costs and ongoing operating costs using micro-costing methods to estimate the cost of personnel time and materials for OEND activities from the program perspective, but excluding naloxone kit costs. Results: Implementing an OEND program required a one-time median startup cost of $874 for SSPs and $2,548 for other programs excluding overhead, with 80% of those costs attributed to time and travel for training staff. SSPs spent a median of $90 per staff member trained and non-SSPs spent $150 per staff member. The median monthly cost of OEND program activities excluding overhead was $1,579 for SSPs and $2,529 for non-SSPs. The costs for non-SSPs varied by size, with larger, multi-site programs having higher median costs compared to single-site programs. The estimated median cost per kit dispensed excluding and including overhead was $19 versus $25 per kit for SSPs, and $36 versus $43 per kit for non-SSPs, respectively. Conclusions: OEND operating costs vary by program type and number of sites. Funders should consider that providing free naloxone to OEND programs does not cover full operating costs. Further exploration of cost-effectiveness and program efficiency should be considered across different types of OEND settings.
Collapse
Affiliation(s)
- Czarina N. Behrends
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY
| | - Sarah Gutkind
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY
| | - Emily Winkelstein
- Bureau of Alcohol and Drug Use Prevention, Care and Treatment, New York City Department of Health and Mental Hygiene, Queens, New York
| | - Monique Wright
- Bureau of Alcohol and Drug Use Prevention, Care and Treatment, New York City Department of Health and Mental Hygiene, Queens, New York
| | - Jennifer Dolatshahi
- Bureau of Alcohol and Drug Use Prevention, Care and Treatment, New York City Department of Health and Mental Hygiene, Queens, New York
| | - Alice Welch
- Bureau of Alcohol and Drug Use Prevention, Care and Treatment, New York City Department of Health and Mental Hygiene, Queens, New York
| | - Denise Paone
- Bureau of Alcohol and Drug Use Prevention, Care and Treatment, New York City Department of Health and Mental Hygiene, Queens, New York
| | - Hillary V. Kunins
- Bureau of Alcohol and Drug Use Prevention, Care and Treatment, New York City Department of Health and Mental Hygiene, Queens, New York
| | - Bruce R. Schackman
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY
| |
Collapse
|
44
|
Legal System Involvement and Opioid-Related Overdose Mortality in U.S. Department of Veterans Affairs Patients. Am J Prev Med 2022; 62:e29-e37. [PMID: 34521559 PMCID: PMC8849578 DOI: 10.1016/j.amepre.2021.06.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 05/22/2021] [Accepted: 06/17/2021] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Opioid-related overdose risks are elevated after incarceration. The rates of opioid-related overdose mortality have risen in recent years, including among Veterans Health Administration patients. To inform Veteran overdose prevention, this study evaluates whether opioid-related overdose risks differ for Veterans Health Administration patients with versus those without indicators of legal system involvement. METHODS This retrospective national cohort study, conducted in 2019-2021, used Veterans Health Administration electronic health records and death certificate data from the Department of Veterans Affairs/Department of Defense Mortality Data Repository to examine opioid-related overdose mortality from January 1, 2013 through December 31, 2017. The cohort included 5,390,902 Veterans with Veterans Health Administration inpatient or outpatient encounters in 2012 who were alive as of January 1, 2013, of whom 32,284 (0.60%) patients had legal system involvement in 2012, indicated by Veterans Justice Programs outpatient encounters. Cox proportional hazards regression models assessed the associations between legal involvement and risk of opioid-related overdose mortality. RESULTS There were 4,670 opioid-related overdose deaths, including 295 (6.31%) among legal-involved Veterans. Veterans with legal involvement had a higher opioid-related overdose mortality rate per 100,000 person-years (191.22, 95% CI=169.40, 213.04 vs 17.76, 95% CI=17.23, 18.29, p<0.001) and an elevated risk of opioid-related overdose mortality (adjusted hazard ratio=1.38, 95% CI=1.22, 1.57, p<0.001) compared with those without. CONCLUSIONS Among Veterans receiving Veterans Health Administration care in 2012, documented legal system involvement was associated with an increased risk of opioid-related overdose mortality. Targeting overdose education and naloxone distribution programs and integrating opioid overdose prevention efforts into mental health care may reduce opioid overdose deaths among Veterans with legal involvement.
Collapse
|
45
|
Ramdin C, Guo M, Fabricant S, Santos C, Nelson L. The Impact of a Peer-Navigator Program on Naloxone Distribution and Buprenorphine Utilization in the Emergency Department. Subst Use Misuse 2022; 57:581-587. [PMID: 34970942 DOI: 10.1080/10826084.2021.2023187] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Objectives: In recent years many emergency departments (EDs) have adopted interventions to help patients with opioid use disorder (OUD), particularly buprenorphine initiation and ED-based peer recovery support. There are limited data on the impact of peer navigators on provider naloxone kit distribution and buprenorphine utilization. We aimed to examine the impact of a peer recovery program on naloxone kit distribution and buprenorphine administration. Methods: This was a retrospective study analyzing the change in naloxone kits distributed as well as buprenorphine administrations. Data on naloxone kit and buprenorphine administrations was generated every month between November 2017 and February 2021. Time periods were as follows: implementation of guidelines for buprenorphine and naloxone kits, initiation of the navigator program, and first wave of COVID-19. Numbers of naloxone kits distributed and buprenorphine administrations per month were computed. Results: Between November 2017 and December 2020, there was a significant increase overtime among the 238 naloxone kits distributed (p < 0.0001). Between implementation of guidelines and introduction of peer navigators, there were 49 kits distributed, compared to an increase overtime among 235 kits when the navigator program began (p = 0.0001). There was also a significant increase overtime among 1797 administrations of buprenorphine (p < 0.0001). Administrations increased by 22.4% after implementation of the navigator program-a total of 787 compared to 643 post guideline (p = 0.007). Conclusion: Peer recovery support programs for patients with OUD can have an impact on administration of naloxone kits and buprenorphine. Future studies should determine whether these programs can cause a long-term culture change in the ED.
Collapse
Affiliation(s)
- Christine Ramdin
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Marshall Guo
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Scott Fabricant
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Cynthia Santos
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Lewis Nelson
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| |
Collapse
|
46
|
Belisle LA, Solano-Patricio EDC. Harm reduction: a public health approach to prison drug use. Int J Prison Health 2021; 18:458-472. [PMID: 34962726 DOI: 10.1108/ijph-06-2021-0053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE As prison drug use continues to be a concern worldwide, harm reduction practices serve as an alternative approach to traditional abstinence-only or punishment-oriented methods to address substance use behind bars. The purpose of this study is to present a summary of research surrounding prison-based harm reduction programs. DESIGN/METHODOLOGY/APPROACH This narrative review of the international literature summarizes the harms associated with prison drug use followed by an overview of the literature surrounding three prison-based harm reduction practices: opioid agonist therapy, syringe exchange programs and naloxone distribution. FINDINGS A collection of international research has found that these three harm reduction programs are safe and feasible to implement in carceral settings. Additionally, these services can effectively reduce some of the harms associated with prison drug use (e.g. risky injection practices, needle sharing, fatal overdoses, etc.). However, these practices are underused in correctional settings in comparison to their use in the community. ORIGINALITY/VALUE Various policy recommendations are made based on the available literature, including addressing ethical concerns surrounding prison populations' rights to the same standard of health care and services available in the community. By taking a public health approach to prison drug use, harm reduction practices can provide a marginalized, high-risk population of incarcerated individuals with life-saving services rather than punitive, punishment-oriented measures.
Collapse
Affiliation(s)
- Linsey Ann Belisle
- Department of Criminal Justice and Social Work, University of Houston - Downtown, Houston, Texas, USA
| | | |
Collapse
|
47
|
Naloxone in Correctional Facilities for the Prevention of Opioid Overdose Deaths. JOURNAL OF CORRECTIONAL HEALTH CARE 2021; 28:66-67. [PMID: 34967694 DOI: 10.1089/jchc.2021.29008.ncchc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
|
48
|
Zang X, Macmadu A, Krieger MS, Behrends CN, Green TC, Morgan JR, Murphy SM, Nolen S, Walley AY, Schackman BR, Marshall BDL. Targeting community-based naloxone distribution using opioid overdose death rates: A descriptive analysis of naloxone rescue kits and opioid overdose deaths in Massachusetts and Rhode Island. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 98:103435. [PMID: 34482264 PMCID: PMC8671216 DOI: 10.1016/j.drugpo.2021.103435] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 08/06/2021] [Accepted: 08/20/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Rates of fatal opioid overdose in Massachusetts (MA) and Rhode Island (RI) far exceed the national average. Community-based opioid education and naloxone distribution (OEND) programs are effective public health interventions to prevent overdose deaths. We compared naloxone distribution and opioid overdose death rates in MA and RI to identify priority communities for expanded OEND. METHODS We compared spatial patterns of opioid overdose fatalities and naloxone distribution through OEND programs in MA and RI during 2016 to 2019 using public health department data. The county-level ratio of naloxone kits distributed through OEND programs per opioid overdose death was estimated and mapped to identify potential gaps in naloxone availability across geographic regions and over time. RESULTS From 2016 to 2019, the statewide community-based naloxone distribution to opioid overdose death ratio improved in both states, although more rapidly in RI (from 11.8 in 2016 to 35.6 in 2019) than in MA (from 12.3 to 17.2), driven primarily by elevated and increasing rates of naloxone distribution in RI. We identified some urban/non-urban differences, with higher naloxone distribution relative to opioid overdose deaths in more urban counties, and we observed some counties with high rates of overdose deaths but low rates of naloxone kits distributed through OEND programs. CONCLUSIONS We identified variations in spatial patterns of opioid overdose fatalities and naloxone availability, and these disparities appeared to be widening in some areas over time. Data on the spatial distribution of naloxone distribution and opioid overdose deaths can inform targeted, community-based naloxone distribution strategies that optimize resources to prevent opioid overdose fatalities.
Collapse
Affiliation(s)
- Xiao Zang
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, United States
| | - Alexandria Macmadu
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, United States
| | - Maxwell S Krieger
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, United States
| | - Czarina N Behrends
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York City, New York, United States
| | - Traci C Green
- Institute for Behavioral Health, School for Social Policy and Management, Brandeis University, Waltham, Massachusetts, United States
| | - Jake R Morgan
- Department of Health Law, Policy, and Management, Boston University School of Public Health, Boston, Massachusetts, United States
| | - Sean M Murphy
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York City, New York, United States
| | - Shayla Nolen
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, United States
| | - Alexander Y Walley
- Department of Medicine, Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts, United States
| | - Bruce R Schackman
- Department of Healthcare Policy and Research, Weill Cornell Medical College, New York City, New York, United States
| | - Brandon DL Marshall
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, United States
| |
Collapse
|
49
|
Smart R, Grant S. Effectiveness and implementability of state-level naloxone access policies: Expert consensus from an online modified-Delphi process. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 98:103383. [PMID: 34340167 PMCID: PMC8671224 DOI: 10.1016/j.drugpo.2021.103383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 06/23/2021] [Accepted: 07/08/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Naloxone distribution, a key global strategy to prevent fatal opioid overdose, has been a recent target of legislation in the U.S., but there is insufficient empirical evidence from causal inference methods to identify which components of these policies successfully reduce opioid-related harms. This study aimed to examine expert consensus on the effectiveness and implementability of various state-level naloxone policies. METHODS We used the online ExpertLens platform to conduct a three-round modified-Delphi process with a purposive sample of 46 key stakeholders (advocates, healthcare providers, human/social service practitioners, policymakers, and researchers) with naloxone policy expertise. The Effectiveness Panel (n = 24) rated average effects of 15 types of policies on naloxone pharmacy distribution, opioid use disorder (OUD) prevalence, nonfatal opioid-related overdoses, and opioid-related overdose mortality. The Implementation Panel (n = 22) rated the same policies on acceptability, feasibility, affordability, and equitability. We compared ratings across policies using medians and inter-percentile ranges, with consensus measured using the RAND/UCLA Appropriateness Method Inter-Percentile Range Adjusted for Symmetry technique. RESULTS Experts reached consensus on all items. Except for liability protections and required provision of education or training, experts perceived all policies to generate moderate-to-large increases in naloxone pharmacy distribution. However, only three policies were expected to yield substantive decreases on fatal overdose: statewide standing/protocol order, over-the-counter supply, and statewide "free naloxone." Of these, experts rated only statewide standing/protocol orders as highly affordable and equitable, and unlikely to generate meaningful population-level effects on OUD or nonfatal opioid-related overdose. Across all policies, experts rated naloxone prescribing mandates relatively lower in acceptability, feasibility, affordability, and equitability. CONCLUSION Experts believe statewide standing/protocol orders are an effective, implementable, and equitable policy for addressing opioid-related overdose mortality. While experts believe many other broad policies are effective in reducing opioid-related harms, they also believe these policies face implementation challenges related to cost and reaching vulnerable populations.
Collapse
Affiliation(s)
- Rosanna Smart
- Economics, Sociology, and Statistics Department, RAND Corporation, 1776 Main Street, Santa Monica, CA 90401, USA.
| | - Sean Grant
- Department of Social & Behavioral Sciences, Indiana University Richard M. Fairbanks School of Public Health, 1050 Wishard Blvd, RG 6046, Indianapolis, IN 46202, USA
| |
Collapse
|
50
|
Duke K, Trebilcock J. 'Keeping a lid on it': Exploring 'problematisations' of prescribed medication in prisons in the UK. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 100:103515. [PMID: 34798433 DOI: 10.1016/j.drugpo.2021.103515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 10/13/2021] [Accepted: 10/18/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND The non-medical use of prescription medication and risk of diversion have become policy and practice concerns within prison settings in the UK. These issues have been highlighted by the Advisory Council on the Misuse of Drugs, Her Majesty's Inspectorate of Prisons and Her Majesty's Prison and Probation Service (2019) prison drugs strategy. In 2019, new prescribing guidance was issued by the Royal College of General Practitioners for clinicians working within prison settings. METHODS Informed by Bacchi's (2009) What's the problem represented to be? framework, the ways in which the 'problem' of prescribed medication in prisons have been represented is interrogated through an analysis of the prescribing guidance framework for clinicians working in prisons. RESULTS Restrictive prescribing practices are recommended as a solution to the 'problem' of diversion and misuse of prescribed medication. Prescribers are advised to consider de-prescribing, non-pharmacological treatments and alternative prescriptions with less diversionary potential. They are represented as responsible for the 'problems' that prescribed medication bring to prisons. The guidance is underpinned by the assumption that prescribers lack experience, knowledge and skills in prison settings. People serving prison sentences are assumed to be 'untrustworthy' and their symptoms treated with suspicion. This representation of the 'problem' has a number of effects including the possibility of increasing drug-related harm, damaging the patient-doctor relationship and disengagement from healthcare services. CONCLUSION The representation of prescribed medication as problems of diversion and prescribing practices inhibits alternative representations of the problem which would inform different policy directions including improvements to regime and healthcare provision and would include a range of practitioners in prison settings to address the 'problem' more holistically.
Collapse
Affiliation(s)
- Karen Duke
- Drug and Alcohol Research Centre, Middlesex University, The Burroughs, London, NW4 4BT, United Kingdom.
| | - Julie Trebilcock
- Drug and Alcohol Research Centre, Middlesex University, The Burroughs, London, NW4 4BT, United Kingdom
| |
Collapse
|