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Papa C, McClure EA, McCauley J, Haynes L, Matheson T, Jones R, Jennings L, Lawdahl T, Ward R, Brady K, Barth KS. Peer Intervention to Link Overdose Survivors to Treatment (PILOT): Protocol for a Multisite, Randomized Controlled Trial Conducted Within the National Institute on Drug Abuse Clinical Trials Network. JMIR Res Protoc 2024; 13:e60277. [PMID: 39288373 PMCID: PMC11445628 DOI: 10.2196/60277] [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: 05/06/2024] [Revised: 07/03/2024] [Accepted: 07/17/2024] [Indexed: 09/19/2024] Open
Abstract
BACKGROUND The increase in opioid-related overdoses has caused a decrease in average life expectancy, highlighting the need for effective interventions to reduce overdose risk and prevent subsequent overdoses. Peer support specialists (PSSs) offer an appealing strategy to engage overdose survivors and reduce overdose risk, but randomized controlled trials are needed to formalize peer-led interventions and evaluate their effectiveness. OBJECTIVE This National Institute on Drug Abuse Clinical Trials Network (CTN) study is a multisite, prospective, pilot randomized (1:1) controlled trial (CTN protocol 0107) that aims to evaluate the effectiveness of an emergency department (ED)-initiated, peer-delivered intervention tailored for opioid overdose survivors (Peer Intervention to Link Overdose survivors to Treatment [PILOT]), compared with treatment as usual (TAU). METHODS This study evaluates the effectiveness of the 6-month, PSS-led PILOT intervention compared with TAU on the primary outcome of reducing overdose risk behavior 6 months after enrollment. Adults (aged ≥18 years; N=150) with a recent opioid-related overdose were identified and approached in the ED. Participants were screened and enrolled, either in the ED or within 7 days of ED discharge at research offices or in the community and then asked to complete study visits at months 1, 3, 6 (end of intervention), and 7 (follow-up). Participants were enrolled at 3 study sites in the United States: Greenville, South Carolina; Youngstown, Ohio; and Everett, Washington. Participants randomized to the PILOT intervention received a 6-month, PSS-led intervention tailored to each participant's goals to reduce their overdose risk behavior (eg, overdose harm reduction, housing, medical, and substance use treatment or recovery goals). Participants randomized to TAU received standard-of-care overdose materials, education, and services provided through the participating EDs. This paper describes the study protocol and procedures, explains the design and inclusion and exclusion decisions, and provides details of the peer-led PILOT intervention and supervision of PILOT PSSs. RESULTS Study enrollment opened in December 2021 and was closed in July 2023. A total of 150 participants across 3 sites were enrolled in the study, meeting the proposed sample size for the trial. Primary and secondary analyses are underway and expected to be published in early 2025. CONCLUSIONS There is an urgent need to better understand the characteristics of overdose survivors presenting to the ED and for rigorous trials evaluating the effectiveness of PSS-led interventions on engaging overdose survivors and reducing overdose risk. Results from this pilot randomized controlled trial will provide a description of the characteristics of overdose survivors presenting to the ED; outline the implementation of PSS services research in ED settings, including PSS implementation of PSS supervision and activity tracking; and inform ED-initiated PSS-led overdose risk reduction interventions and future research to better understand the implementation and efficacy of these interventions. TRIAL REGISTRATION ClinicalTrials.gov NCT05123027; https://clinicaltrials.gov/study/NCT05123027. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/60277.
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Affiliation(s)
- Carrie Papa
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States
| | - Erin A McClure
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States
- Hollings Cancer Center, Medical University of South Carolina, Charleston, SC, United States
| | - Jenna McCauley
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States
| | - Louise Haynes
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States
| | - Timothy Matheson
- San Francisco Department of Public Health, San Francisco, CA, United States
| | - Richard Jones
- Heritage Health Solutions, Coppell, TX, United States
| | - Lindsey Jennings
- Department of Emergency Medicine, Medical University of South Carolina, Charleston, SC, United States
| | - Tricia Lawdahl
- Faces and Voices of Recovery - Upstate South Carolina, Greenville, SC, United States
| | - Ralph Ward
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, United States
| | - Kathleen Brady
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States
| | - Kelly Stephenson Barth
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, United States
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Akhurst J, Price O, Sutherland R, Gibbs D, Dietze P, Bruno R, Agramunt S, Colledge-Frisby S, Lenton S, Salom C, Thomas N, Peacock A. Naloxone cascade of care among people who regularly inject drugs in Australia, 2020-2022. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2024; 133:104572. [PMID: 39245026 DOI: 10.1016/j.drugpo.2024.104572] [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: 01/14/2024] [Revised: 07/29/2024] [Accepted: 08/23/2024] [Indexed: 09/10/2024]
Abstract
BACKGROUND Examining take-home naloxone (THN) uptake using a 'cascade of care' framework could help identify targets for increasing THN training and carriage among people who may witness or experience opioid overdose. We describe the THN cascade and factors associated with engagement among people who inject drugs. METHODS People aged ≥18 years in Australia who inject drugs were interviewed from 2020 to 2022, reporting lifetime THN awareness and acquisition and past-month carriage. We examined factors associated with engagement using multivariable logistic regression. RESULTS Of 2,149 participants (64 % men, mean age 44.5), 85 % had heard of naloxone, of whom 76 % were aware of THN programs. Of these, 72 % had ever participated in THN training/brief education, 92 % of whom had acquired THN. Of those who had ever acquired THN and reported past-month opioid use, 63 % always/often carried THN when using opioids. Past six-month opioid agonist treatment (OAT) (adjusted odds ratio [AOR] 2.55; 95 %CI 1.91-3.42) and ≥daily injecting (1.32; 1.01-1.73) were associated with awareness. OAT (1.79; 1.38-2.33), past-year opioid overdose (1.68; 1.18-2.42) and older age (1.02; 1.00-1.03) were associated with acquisition. Primarily injecting methamphetamine (versus heroin) in the past month was associated with lower awareness (0.43; 0.31-0.58) and acquisition (0.59; 0.44-0.78). Reporting no accommodation (squatting/sleeping rough) was associated with reduced odds of carriage (0.46; 0.24-0.88). CONCLUSION Participants reported high THN awareness and acquisition, with lower carriage. Future efforts should focus on improving THN access and reducing barriers to carriage, particularly for people experiencing homelessness or who primarily inject non-opioids.
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Affiliation(s)
- Jane Akhurst
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Olivia Price
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Rachel Sutherland
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia
| | - Daisy Gibbs
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia; Burnet Institute, Melbourne, Australia
| | | | - Raimondo Bruno
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia; School of Psychological Sciences, University of Tasmania, Hobart, Australia
| | - Seraina Agramunt
- National Drug Research Institute and enAble Institute, Curtin University, Perth, Australia
| | | | - Simon Lenton
- National Drug Research Institute and enAble Institute, Curtin University, Perth, Australia
| | - Caroline Salom
- Institute for Social Science Research, The University of Queensland, Brisbane Australia
| | - Natalie Thomas
- Institute for Social Science Research, The University of Queensland, Brisbane Australia
| | - Amy Peacock
- National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, Australia; School of Psychological Sciences, University of Tasmania, Hobart, Australia.
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Byrne CJ, Sani F, Flynn T, Malaguti A. 'It was like coming back from the clouds': a qualitative analysis of the lived experience of overdose consequent to drug use among a cohort of people who use drugs in Scotland. Harm Reduct J 2024; 21:112. [PMID: 38849877 PMCID: PMC11157918 DOI: 10.1186/s12954-024-01033-7] [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: 01/08/2024] [Accepted: 06/03/2024] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND Globally, non-fatal overdose (NFOD) rates consequent to drug use, typically opioids, continue increasing at a startling rate. Existing quantitative research has revealed myriad factors and characteristics linked to experiencing NFOD, but it is critically important to explore the lived context underlying these associations. In this qualitative study, we sought to understand the experiences of NFOD among people who use drugs in a Scottish region in order to: enhance public policy responses; inform potential intervention development to mitigate risk; and contribute to the literature documenting the lived experience of NFOD. METHODS From June to July 2021, two peer researchers conducted face-to-face semi-structured interviews with people who use drugs who had experienced recent NFOD attending harm reduction services in Tayside, Scotland. These were transcribed verbatim and evaluated using thematic analysis with an inductive approach which had an experiential and essentialist orientation. RESULTS Twenty people were interviewed across two sites. Of those, 15 (75%) were male and mean age was 38.2 (7.7) years. All had experienced at least one NFOD in the prior six months, and all reported polydrug use. Five themes were identified, within which 12 subthemes were situated. The themes were: social context; personal risk-taking triggers; planned and impulsive consumption; risk perception; and overdose reversal. The results spoke to the environmental, behavioural, cognitive, economic, and marketplace, factors which influence the context of NFOD in the region. CONCLUSIONS A complex interplay of behavioural, psychological, and situational factors were found to impact the likelihood of experiencing NFOD. Structural inequities which policy professionals and civic leaders should seek to remedy were identified, while service providers may seek to reconfigure healthcare provision for people who use drugs to account for the interpersonal, psychological, and social factors identified, which appear to precipitate NFOD. TRIAL REGISTRATION Not applicable.
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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
| | | | - 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
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Schwieger L, Carpenter JE, Moran TP, Erowid F, Cornelison M, Evans D, Morgan B, Murray BP. Access to, Experience with, and Attitudes towards Take Home Naloxone: An Online Survey. J Community Health 2024; 49:526-534. [PMID: 38127295 DOI: 10.1007/s10900-023-01321-6] [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] [Accepted: 12/02/2023] [Indexed: 12/23/2023]
Abstract
The opioid public health crisis continues to burden individuals, communities, and economies. Public health opinion has emphasized the need for increased access to harm reduction services, but there is a dearth of information on the views and experiences of people who use opioids. Our study aimed to investigate the prevalence of naloxone use, attitudes, and experiences with naloxone among an online community of people who use drugs. We performed a cross-sectional survey looking at experiences with and attitudes towards take-home naloxone. Data is presented descriptively, with analysis of the differences between people who do and do not use opioids using the χ2 and Fisher's exact tests. There were 1,143 respondents, of whom 70% were from the United States. Only 38% of participants who use opioids had received naloxone training, but 56% of these individuals said that they felt comfortable using a naloxone kit. Nearly all respondents (95%) said they would be willing to use naloxone on someone who had overdosed and approximately 90% would want naloxone used on them in case of an overdose. Regarding harm reduction, 24% of respondents said they had access to safe use programs, and 33% said they had access to clean needle exchange programs. A majority of the participants who use opioids were in favor of having naloxone with them when using drugs and believed naloxone should be freely available. This study demonstrates the receptiveness of take-home naloxone and highlights the need for better implementation of naloxone within communities that use opioids.
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Affiliation(s)
| | | | - Tim P Moran
- Emory University School of Medicine, Atlanta, GA, USA
| | | | | | - Dabney Evans
- Emory University School of Public Health, Atlanta, GA, USA
| | - Brent Morgan
- Emory University School of Medicine, Atlanta, GA, USA
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Metrebian N, Carter B, Eide D, McDonald R, Neale J, Parkin S, Dascal T, Mackie C, Day E, Guterstam J, Horsburgh K, Kåberg M, Kelleher M, Smith J, Thiesen H, Strang J. A study protocol for a European, mixed methods, prospective, cohort study of the effectiveness of naloxone administration by community members, in reversing opioid overdose: NalPORS. BMC Public Health 2023; 23:1608. [PMID: 37612698 PMCID: PMC10463843 DOI: 10.1186/s12889-023-16445-6] [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: 09/28/2022] [Accepted: 08/02/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND Worldwide, opioid use causes more than 100,000 overdose deaths annually. Naloxone has proven efficacy in reversing opioid overdoses and is approved as an emergency antidote to opioid overdose. Take home naloxone (THN) programmes have been introduced to provide 'community members', who are likely to observe opioid overdoses, with naloxone kits and train them to recognise an overdose and administer naloxone. The acceptability and feasibility of THN programmes has been demonstrated, but the real-life effectiveness of naloxone administration by community members is not known. In recent years, the approval of several concentrated naloxone nasal-spray formulations (in addition to injectable formulations, eg.prenoxad) potentially increases acceptability and scope for wider provision. This study aims to determine the effectiveness of THN (all formulations) in real-world conditions. METHODS A European, multi-country, prospective cohort study, to assess the use of THN by community members to reverse opioid overdoses in a six-month, follow-up period. Participants provided with THN from participating harm reduction and drug treatment sites will be recruited to the study and followed-up for six months. We are particularly interested in the experiences of community members who have been provided with THN and have witnessed an opioid overdose. All participants who witness an opioid overdose during the six-month period (target approx. 600) will be asked to take part in a structured interview about this event. Of these, 60 will be invited to participate in a qualitative interview. A Post Authorisation Efficacy Study (PAES) for the concentrated nasal naloxone, Nyxoid, has been integrated into the study design. DISCUSSION There are many challenges involved in evaluating the real-life effectiveness of THN. It is not possible to use a randomised trial design, recruitment of community members provided with THN will depend upon recruitment sites distributing THN kits, and the type of THN received by participants will depend on regulations and on local clinical and policy decision-makers. Following up this population, some of whom may be itinerant, over the 6-month study period will be challenging, but we plan to maintain contact with participants through regular text message reminders and staff contact. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05072249. Date of Registration: 8.10.2021.
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Affiliation(s)
| | - Ben Carter
- Biostatistics and Health Informatics, King's College London, London, UK
| | - Desiree Eide
- National Addiction Centre, King's College London, London, UK
- Norwegian Centre for Addiction Research, University of Oslo, Oslo, Norway
| | - Rebecca McDonald
- National Addiction Centre, King's College London, London, UK
- Norwegian Centre for Addiction Research, University of Oslo, Oslo, Norway
| | - Joanne Neale
- National Addiction Centre, King's College London, London, UK
| | - Stephen Parkin
- National Addiction Centre, King's College London, London, UK
| | - Teodora Dascal
- National Addiction Centre, King's College London, London, UK
| | - Clare Mackie
- National Addiction Centre, King's College London, London, UK
| | - Ed Day
- Birmingham & Solihull Mental Health NHS Foundation Trust, Birmingham, UK
| | - Joar Guterstam
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet, & Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | | | - Martin Kåberg
- Stockholm Centre for Dependency Disorders, Stockholm, Sweden
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Mike Kelleher
- South London and Maudsley NHS Foundation Trust, London, UK
| | | | | | - John Strang
- National Addiction Centre, King's College London, London, UK.
- South London and Maudsley NHS Foundation Trust, London, UK.
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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.
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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
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Wilkerson AH, Sharma M, Davis RE, Stephens PM, Kim RW, Bhati D, Nahar VK. Predisposing, enabling and reinforcing factors associated with opioid addiction helping behaviour in tri-state Appalachian counties: application of the PRECEDE-PROCEED model-cross-sectional analysis. BMJ Open 2023; 13:e066147. [PMID: 37192792 DOI: 10.1136/bmjopen-2022-066147] [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] [Indexed: 05/18/2023] Open
Abstract
OBJECTIVES The overdose epidemic was designated a 'Public Health Emergency' in the USA on 26 October 2017, bringing attention to the severity of this public health problem. The Appalachian region remains substantially impacted by the effects from years of overprescription of opioids, and subsequently opioid non-medical use and addiction. This study aims to examine the utility of the PRECEDE-PROCEED model constructs (ie, predisposing, reinforcing and enabling factors) to explain opioid addiction helping behaviour (ie, helping someone who has an opioid addiction) among members of the public living in tri-state Appalachian counties. DESIGN Cross-sectional study. SETTING Rural county in the Appalachian region of the USA. PARTICIPANTS A total of 213 participants from a retail mall in a rural Appalachian Kentucky county completed the survey. Most participants were between the ages of 18 and 30 years (n=68; 31.9%) and identified as men (n=139; 65.3%). PRIMARY OUTCOME MEASURE Opioid addiction helping behaviour. RESULTS The regression model was significant (F (6, 180)=26.191, p<0.001) and explained 44.8% of the variance in opioid addiction helping behaviour (R2=0.448). Attitude towards helping someone with opioid addiction (B=0.335; p<0.001), behavioural skills (B=0.208; p=0.003), reinforcing factors (B=0.190; p=0.015) and enabling factors (B=0.195; p=0.009) were all significantly associated with opioid addiction helping behaviour. CONCLUSIONS PRECEDE-PROCEED model constructs have utility to explain opioid addiction helping behaviour among individuals in a region greatly impacted by the overdose epidemic. This study provides an empirically tested framework for future programmes addressing helping behaviour related to opioid non-medical use.
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Affiliation(s)
- Amanda H Wilkerson
- Department of Health Science, The University of Alabama, Tuscaloosa, Alabama, USA
| | - Manoj Sharma
- Department of Social and Behavioral Health, Department of Internal Medicine, University of Nevada Las Vegas, Las Vegas, Nevada, USA
| | - Robert E Davis
- Substance Use and Mental Health Laboratory, Department of Health, Human Performance, and Recreation, University of Arkansas, Fayetteville, Arkansas, USA
| | - Philip M Stephens
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Center for Animal and Human Health in Appalachia, College of Veterinary Medicine, Lincoln Memorial University, Harrogate, Tennessee, USA
| | - Richard W Kim
- Center for Animal and Human Health in Appalachia, College of Veterinary Medicine, Lincoln Memorial University, Harrogate, Tennessee, USA
- Department of Physical Medicine and Rehabilitation, New York-Presbyterian Hospital, Columbia University Medical Center and Weill Cornell Medical Center, New York City, New York, USA
| | - Deepak Bhati
- Casualty Section, All India Institute of Ayurveda, New Delhi, India
| | - Vinayak K Nahar
- Department of Dermatology, School of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
- Department of Preventive Medicine, School of Medicine/John D. Bower School of Population Health, University of Mississippi Medical Center, Jackson, Mississippi, USA
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Olding M, Boyd J, Kerr T, Fowler A, McNeil R. (Re)situating expertise in community-based overdose response: Insights from an ethnographic study of overdose prevention sites (OPS) in Vancouver, Canada. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2023; 111:103929. [PMID: 36529032 PMCID: PMC10184134 DOI: 10.1016/j.drugpo.2022.103929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 10/20/2022] [Accepted: 12/02/2022] [Indexed: 12/23/2022]
Abstract
Overdose Prevention Sites (OPS) are low-barrier services where people may use illicit drugs under the monitoring of staff trained to provide life-saving care in the event of an overdose. In British Columbia (BC), Canada, OPS have been rapidly scaled-up as a community-based response to the overdose crisis and are staffed primarily by community members who are also people who use drugs (PWUD). While it is known that PWUD perform vital roles in OPS and other community-based overdose interventions, the expertise and expert knowledge of PWUD in this work remains under-theorised. This study draws on 20 months of ethnographic fieldwork in Vancouver, BC (July 2018 to March 2020), to explore how OPS responders who are PWUD developed and enacted expertise in overdose response. Ethnographic fieldwork focused on four OPS located in Vancouver's Downtown Eastside (DTES) and Downtown South neighbourhoods. Methods included 100 hours of observation in the sites and surrounding areas, three site-specific focus groups with OPS responders (n=20), and semi-structured interviews with OPS responders (n=14) and service users (n=23). Data was analysed with the aim of characterizing the knowledge underpinning responders' expertise, and the arrangements which allow for the formation and enactment of expertise. We found that OPS responders' expertise was grounded in experiential knowledge acquired through their positionality as PWUD and members of a broader community of activists engaged in mutual aid. Responders became skilled in overdose response through frequent practice and drew on their experiential and embodied knowledge of overdose to provide care that was both technically proficient and responsive to the broader needs of PWUD (e.g. protection from criminalization and stigmatizing treatment). Responders emphasized that the spatial arrangements of OPS supported the development of expertise by facilitating more specialized and comprehensive overdose care. OPS became sites of collective expertise around overdose management as responder teams developed shared understandings of overdose management, including processes for managing uncertainty, delegating team responsibilities, and sharing decision-making. This research re-situates theoretical understandings of expertise in community-based overdose response with implications for overdose prevention interventions. Findings underscore the experiential and embodied expertise of PWUD as community-based responders; the importance of supportive environments and team-based approaches for overdose response; and the benefits of community-driven training that extends beyond technical skills of overdose identification and naloxone administration.
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Affiliation(s)
- Michelle Olding
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 1Y6, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Jade Boyd
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 1Y6, Canada; Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Thomas Kerr
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 1Y6, Canada; Faculty of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Al Fowler
- East Vancouver Activist, Vancouver, BC, Canada
| | - Ryan McNeil
- British Columbia Centre on Substance Use, 1045 Howe Street, Vancouver, BC, V6Z 1Y6, Canada; Yale School of Medicine, New Haven, CT, United States.
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Wagner KD, Marks C, Felsher M, Latkin C, Pearson JL, Falade-Nwulia OO. Individual and social network correlates of responding to multiple overdoses among a cohort of people who use drugs. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 5:100107. [PMID: 36688935 PMCID: PMC9854250 DOI: 10.1016/j.dadr.2022.100107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background The purpose of this study was to identify characteristics of people who respond to two or more overdoses (i.e., multiple overdose responders; MOR) compared to those who respond to zero or one, and the association between MOR status and changes in network size. Methods Secondary analysis of data from a randomized trial among 199 PWUD in Baltimore, MD (2016-2019). We used cross-tabulation, 𝜒 2 , and ANOVA models to identify cross-sectional associations between overdose response and demographic, drug use, and network size; and ANCOVA models to examine the relationship between baseline MOR status and change in network size. Results From the cohort of 199, 185 people provided data on overdose response at baseline; 197 provided data at 6-month follow-up. At baseline, 27.6% of participants were classified as MORs (ever). Correlates of MOR status included homelessness; age; injecting drug use; quality of interactions with police (respectful vs. not); and use of powder cocaine, prescription opioids, and heroin. MORs had larger networks and their network size decreased more over time, but the association was not statistically significant. At follow-up, 16% were classified as MORs (past 6 months); correlates of follow-up MOR status were similar to those at baseline. Conclusions Overdose prevention interventions rely on PWUD to respond to overdoses. Identifying factors associated with MOR status could increase intervention efficiency and providing MORs with support could increase sustainability. Our findings suggest that PWUD experiencing homelessness, using cocaine and heroin, and demonstrating increased salience of overdose in their lives would benefit from targeted programs.
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Affiliation(s)
- Karla D. Wagner
- School of Public Health, University of Nevada, Reno; Reno, Nevada, USA,Corresponding Author: 1664 N. Virginia St. MC 0274; Reno, NV 89557, (K.D. Wagner)
| | - Charles Marks
- School of Public Health, University of Nevada, Reno; Reno, Nevada, USA
| | - Marisa Felsher
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins School of Medicine; Baltimore, MD, USA
| | - Carl Latkin
- Department of Health, Behavior and Society, Johns Hopkins School of Medicine; Baltimore, MD, USA
| | | | - Oluwaseun O Falade-Nwulia
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins School of Medicine; Baltimore, MD, USA
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Ericson ØB, Eide D, Lobmaier P, Clausen T. Risks and overdose responses: Participant characteristics from the first seven years of a national take-home naloxone program. Drug Alcohol Depend 2022; 240:109645. [PMID: 36191532 DOI: 10.1016/j.drugalcdep.2022.109645] [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: 06/30/2022] [Revised: 09/19/2022] [Accepted: 09/22/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND In 2014, the Norwegian government funded a large-scale take-home naloxone (THN) program to address high overdose mortality rates. The aims of this study are to describe characteristics among persons trained to receive THN, describe actions taken following THN use at an overdose event and to explore factors associated with naloxone use. METHODS This was a prospective cohort study of individuals who received THN from 2014 to 2021. Descriptive characteristics were collected at initial training. When returning for refill, participants reported on their previous naloxone use. In a multivariable logistic regression model exploring associations with naloxone use: gender, age, opioid use history, concomitant drug use, injecting, history of experienced or witnessed overdose were included. RESULTS In total, 3527 individuals were included in this study. There were 958 individuals who returned for refills 2303 times. Most participants were male (63.6%), with a history of opioid use (77.5%). Those who reported naloxone use were more likely to have a history of opioid use (aOR= 4.1; 95% CI=2.77,6.1), were younger (aOR=0.98; 95% CI=0.97,0.99) and had witnessed overdoses (aOR=3.3; 95% CI=1.98,5.34). Among current opioid users, the odds were higher for injectors (aOR=1.57; 95% CI=1.18,2.1). Naloxone use was reported 1282 times. Additional actions such as waking the person and calling the ambulance were frequently reported. Survival was reported in almost all cases (94%). CONCLUSION People who use drugs are a suitable target group for THN-programs, as they seem to be willing and capable to reverse overdoses effectively. Given their personal risk factors for overdosing, recipients will likely also benefit from overdose prevention education.
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Affiliation(s)
- Øystein Bruun Ericson
- The Norwegian Centre for Addiction Research, Building 45, Ullevål Hospital, Kirkeveien 166, 0450 Oslo, Norway.
| | - Desiree Eide
- The Norwegian Centre for Addiction Research, Building 45, Ullevål Hospital, Kirkeveien 166, 0450 Oslo, Norway
| | - Philipp Lobmaier
- The Norwegian Centre for Addiction Research, Building 45, Ullevål Hospital, Kirkeveien 166, 0450 Oslo, Norway; Diakonhjemmet Hospital, Division of Mental Health and Substance Abuse, PB 23 Vinderen, 0319 Oslo, Norway
| | - Thomas Clausen
- The Norwegian Centre for Addiction Research, Building 45, Ullevål Hospital, Kirkeveien 166, 0450 Oslo, Norway
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11
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Sajwani HS, Williams AV. A systematic review of the distribution of take-home naloxone in low- and middle-income countries and barriers to the implementation of take-home naloxone programs. Harm Reduct J 2022; 19:117. [PMID: 36266701 PMCID: PMC9585764 DOI: 10.1186/s12954-022-00700-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 10/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Opioid overdose epidemic is hitting record highs worldwide, accounting for 76% of mortality related to substance use. Take-home naloxone (THN) strategies are being implemented in many developed countries that suffer from high opioid overdose death rates. They aim to provide overdose identification and naloxone administration training, along with THN delivery to opioid users and others likely to witness an overdose incident such as family members and peers. However, little is known about such measures in low- and middle-income countries (LMIC), where opioid use and opioid-related deaths are reportedly high. This systematic literature review aims to examine the distribution of THN in LMIC, review studies identifying barriers to the implementation of THN programs worldwide, and assess their applicability to LMIC. METHODS The literature was searched and analyzed for eligible studies with quality assessment. RESULTS Two studies were found from LMIC on THN programs with promising results, and 13 studies were found on the barriers identified in implementing THN programs worldwide. The main barriers to THN strategies were the lack of training of healthcare providers, lack of privileges, time constraints, cost, legislative/policy restrictions, stigma, fear of litigation, and some misperceptions around THN. CONCLUSIONS The barriers outlined in this paper are probably applicable to LMIC, but more difficult to overcome considering the differences in their response to opioid overdose, their cultural attitudes and norms, the high cost, the waivers required, the legislative differences and the severe penalties for drug-related offenses in some of these countries. The solutions suggested to counter-act these obstacles can also be more difficult to achieve in LMIC. Further research is required in this area with larger sample sizes to provide a better understanding of the obstacles to the implementation, feasibility, accessibility, and utilization of THN programs in LMIC.
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Affiliation(s)
- Hawraa Sameer Sajwani
- Department of Addictions, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
- University of Adelaide, Adelaide, Australia
- Virginia Commonwealth University, Richmond, VA US
- University of California, Los Angeles, Los Angeles, CA US
- Sheikh Khalifa Medical City, Abu Dhabi, UAE
| | - Anna V Williams
- Department of Addictions, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
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12
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Jones JD, Campbell AN, Brandt L, Metz VE, Martinez S, Wall M, Corbeil T, Andrews H, Castillo F, Neale J, Strang J, Ross S, Comer SD. A randomized clinical trial of the effects of brief versus extended opioid overdose education on naloxone utilization outcomes by individuals with opioid use disorder. Drug Alcohol Depend 2022; 237:109505. [PMID: 35709575 PMCID: PMC9472254 DOI: 10.1016/j.drugalcdep.2022.109505] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 05/16/2022] [Accepted: 05/17/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Overdose education and naloxone distribution (OEND) trains people who use opioids (PWUO) in how to intervene in cases of opioid overdose but best practices have not been assessed empirically. METHODS PWUO along with a significant other (SO) were randomized to one of three training conditions. In the Treatment-as-Usual (TAU) condition, participants were randomized to receive minimal overdose-related education. In the extended training (ET) condition, PWUO received an extended training, while their SO received no overdose training. In the final condition, both the participant and SO received the extended overdose training (ETwSO). Outcome measures were naloxone use and overdose knowledge and competency assessed immediately before and after training, and at 1-, 3-, 6-, and 12-month timepoints following training. RESULTS Three hundred and twenty-one PWUO (w/ a SO) were randomized. All intensities of OD training were associated with sustained increases in OD knowledge/ competency (versus pre-training baseline p's < 0.01). PWUO intervened in 166 ODs. The 12-month incidence of naloxone use did not significantly differ between groups. Extended training (ET + ETwSO) compared to TAU resulted in significantly greater naloxone utilization by: 30 days (10.1% vs 4.1%, p = 0.041), 60 days (16.4% vs 5.2%, p<0.001) and 90 days (17.9% vs 9.5%, p = 0.039). CONCLUSIONS All intensities of OD training were associated with sustained increases in OD knowledge and competency, and equivalent rates of successful naloxone use. More extensive training increased naloxone utilization during the first 3 months. However, the benefits of more comprehensive training should be balanced against feasibility.
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Affiliation(s)
- Jermaine D Jones
- Division on Substance Use Disorders, New York State Psychiatric Institute and Department of Psychiatry, Columbia University Irving Medical Center, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA.
| | - Aimee N Campbell
- Division on Substance Use Disorders, New York State Psychiatric Institute and Department of Psychiatry, Columbia University Irving Medical Center, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA
| | - Laura Brandt
- Division on Substance Use Disorders, New York State Psychiatric Institute and Department of Psychiatry, Columbia University Irving Medical Center, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA
| | - Verena E Metz
- Kaiser Permanente Division of Research, Center for Addiction and Mental Health Research, 2000 Broadway, Oakland, CA 94612, USA
| | - Suky Martinez
- Division on Substance Use Disorders, New York State Psychiatric Institute and Department of Psychiatry, Columbia University Irving Medical Center, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA
| | - Melanie Wall
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY 10032, USA
| | - Thomas Corbeil
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY 10032, USA
| | - Howard Andrews
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, NY 10032, USA
| | - Felipe Castillo
- Division on Substance Use Disorders, New York State Psychiatric Institute and Department of Psychiatry, Columbia University Irving Medical Center, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA
| | - Joanne Neale
- National Addiction Centre, King's College London, 4 Windsor Walk, Denmark Hill, London SE5 8BB, United Kingdom
| | - John Strang
- National Addiction Centre, King's College London, 4 Windsor Walk, Denmark Hill, London SE5 8BB, United Kingdom
| | - Stephen Ross
- Addictive Disorders and Experimental Therapeutics Research Laboratory, New York University Langone Health, New York, NY 10016, USA
| | - Sandra D Comer
- Division on Substance Use Disorders, New York State Psychiatric Institute and Department of Psychiatry, Columbia University Irving Medical Center, 1051 Riverside Drive, Unit 120, New York, NY 10032, USA
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13
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Modeling of overdose and naloxone distribution in the setting of fentanyl compared to heroin. Drug Alcohol Depend 2022; 236:109478. [PMID: 35588609 PMCID: PMC9235402 DOI: 10.1016/j.drugalcdep.2022.109478] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/22/2022] [Accepted: 04/25/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Fentanyl has replaced most other non-prescribed opioids in much of North America. There is controversy over whether a hypothetical reduced efficacy of naloxone in reversing fentanyl is a major contributor to the coincident rising overdose mortality. METHODS We modified an existing Markov decision analytic model of heroin overdose and naloxone distribution to account for known risks of fentanyl by adjusting overdose risk, the likelihood of death in the event of overdose, and the proportion of cases in which available naloxone was administered in time to prevent death. We assumed near-universal survival when naloxone was administered promptly for heroin or fentanyl overdose, but allowed that to decline in sensitivity analyses for fentanyl. We varied the proportion of use that was fentanyl and adjusted the modified parameters accordingly to estimate mortality as the dominant opioid shifted. RESULTS Absent naloxone, the annual overdose death rate was 1.0% and 4.1% for heroin and fentanyl, respectively. With naloxone reaching 80% of those at risk, the overdose death rate was 0.7% and 3.6% for heroin and fentanyl, respectively, representing reductions of 26.4% and 12.0%. Monte Carlo simulations resulted in overdose mortality with fentanyl of 3.3-5.2% without naloxone and 2.6-4.9% with naloxone, with 95% certainty. Positing reduced efficacy for naloxone in reversing fentanyl resulted in 3.6% of fentanyl overdose deaths being prevented by naloxone. CONCLUSIONS Heightened risk for overdose and subsequent death, alongside the time-sensitive need for naloxone administration, fully account for increased mortality when fentanyl replaces heroin, assuming optimal pharmacologic efficacy of naloxone.
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14
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Miller NM, Waterhouse-Bradley B, Campbell C, Shorter GW. How do naloxone-based interventions work to reduce overdose deaths: a realist review. Harm Reduct J 2022; 19:18. [PMID: 35197057 PMCID: PMC8867850 DOI: 10.1186/s12954-022-00599-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 02/01/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Naloxone-based interventions as part of health systems can reverse an opioid overdose. Previous systematic reviews have identified the effectiveness of naloxone; however, the role of context and mechanisms for its use has not been explored. This realist systematic review aims to identify a theory of how naloxone works based on the contexts and mechanisms that contribute to the success of the intervention for improved outcomes. METHODS Pre-registered at PROSPERO, this realist review followed RAMESES standards of reporting. Keywords included 'naloxone' and ' opioid overdose'. All study designs were included. Data extraction using 55 relevant outputs based on realist logic produced evidence of two middle-range theories: Naloxone Bystander Intervention Theory and Skills Transfer Theory. RESULTS Harm reduction and/or low threshold contexts provide a non-judgemental approach which support in-group norms of helping and empower the social identity of the trained and untrained bystander. This context also creates the conditions necessary for skills transfer and diffusion of the intervention into social networks. Stigma and negative attitudes held by first responders and stakeholders involved in the implementation process, such as police or GPs, can prohibit the bystander response by inducing fear in responding. This interferes with skills transfer, naloxone use and carriage of naloxone kits. CONCLUSIONS The findings provide theoretically informed guidance regarding the harm reduction contexts that are essential for the successful implementation of naloxone-based interventions. Peer-to-peer models of training are helpful as it reinforces social identity and successful skills transfer between bystanders. Health systems may want to assess the prevalence of, and take steps to reduce opioid-related stigma with key stakeholders in contexts using a low threshold training approach to build an environment to support positive naloxone outcomes. TRIAL REGISTRATION PROSPERO 2019 CRD42019141003.
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Affiliation(s)
- Nicole M Miller
- Institute of Mental Health Sciences, School of Psychology, Ulster University, Coleraine, UK
| | | | | | - Gillian W Shorter
- Drug and Alcohol Research Network & Centre for Improving Health Related Quality of Life, School of Psychology, Queen's University Belfast, Belfast, UK.
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15
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Rangachari P, Govindarajan A, Mehta R, Seehusen D, Rethemeyer RK. The relationship between Social Determinants of Health (SDoH) and death from cardiovascular disease or opioid use in counties across the United States (2009-2018). BMC Public Health 2022; 22:236. [PMID: 35120479 PMCID: PMC8817535 DOI: 10.1186/s12889-022-12653-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Accepted: 01/27/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Death from cardiovascular disease (CVD) has been a longstanding public health challenge in the US, whereas death from opioid use is a recent, growing public health crisis. While population-level approaches to reducing CVD risk are known to be effective in preventing CVD deaths, more targeted approaches in high-risk communities are known to work better for reducing risk of opioid overdose. For communities to plan effectively in addressing both public health challenges, they need information on significant community-level (vs individual-level) predictors of death from CVD or opioid use. This study addresses this need by examining the relationship between 1) county-level social determinants of health (SDoH) and CVD deaths and 2) county-level SDoH and opioid-use deaths in the US, over a ten-year period (2009-2018). METHODS A single national county-level ten-year 'SDoH Database' is analyzed, to address study objectives. Fixed-effects panel-data regression analysis, including county, year, and state-by-year fixed effects, is used to examine the relationship between 1) SDoH and CVD death-rate and 2) SDoH and opioid-use death-rate. Eighteen independent (SDoH) variables are included, spanning three contexts: socio-economic (e.g., race/ethnicity, income); healthcare (e.g., system-characteristics); and physical-infrastructure (e.g., housing). RESULTS After adjusting for county, year, and state-by-year fixed effects, the significant county-level positive SDoH predictors for CVD death rate were, median age and percentage of civilian population in armed forces. The only significant negative predictor was percentage of population reporting White race. On the other hand, the four significant negative predictors of opioid use death rate were median age, median household income, percent of population reporting Hispanic ethnicity and percentage of civilian population consisting of veterans. Notably, a dollar increase in median household income, was estimated to decrease sample mean opioid death rate by 0.0015% based on coefficient value, and by 20.05% based on effect size. CONCLUSIONS The study provides several practice and policy implications for addressing SDoH barriers at the county level, including population-based approaches to reduce CVD mortality risk among people in military service, and policy-based interventions to increase household income (e.g., by raising county minimum wage), to reduce mortality risk from opioid overdoses.
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Affiliation(s)
- Pavani Rangachari
- Department of Interdisciplinary Health Sciences, Augusta University, 987 St. Sebastian Way, Augusta, GA, 30912, USA. .,Department of Family Medicine, Augusta University, 987 St. Sebastian Way, Augusta, GA, 30912, USA.
| | | | - Renuka Mehta
- Department of Pediatrics, Augusta University, Augusta, GA, 30912, USA
| | - Dean Seehusen
- Department of Family Medicine, Augusta University, Augusta, GA, 30912, USA
| | - R Karl Rethemeyer
- College of Social and Behavioral Sciences, University of Massachusetts, Amherst, MA, 01003, USA
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16
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Bascou NA, Haslund-Gourley B, Amber-Monta K, Samson K, Goss N, Meredith D, Friedman A, Needleman A, Kumar VK, Fischer BD. Reducing the stigma surrounding opioid use disorder: evaluating an opioid overdose prevention training program applied to a diverse population. Harm Reduct J 2022; 19:5. [PMID: 35034649 PMCID: PMC8761384 DOI: 10.1186/s12954-022-00589-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 01/10/2022] [Indexed: 11/20/2022] Open
Abstract
Background The opioid epidemic is a rapidly growing public health concern in the USA, as the number of overdose deaths continues to increase each year. One strategy for combating the rising number of overdoses is through opioid overdose prevention programs (OOPPs).
Objective To evaluate the effectiveness of an innovative OOPP, with changes in knowledge and attitudes serving as the primary outcome measures.
Methods The OOPP was developed by a group of medical students under guidance from faculty advisors. Training sessions focused on understanding stigmatizing factors of opioid use disorder (OUD), as well as protocols for opioid overdose reversal through naloxone administration. Pre- and post-surveys were partially adapted from the opioid overdose attitudes and knowledge scales and administered to all participants. Paired t-tests were conducted to assess differences between pre- and post-surveys. Results A total of 440 individuals participated in the training; 381 completed all or the majority of the survey. Participants came from a diverse set of backgrounds, ages, and experiences. All three knowledge questions showed significant improvements. For attitude questions, significant improvements were found in all three questions evaluating confidence, two of three questions assessing attitudes towards overdose reversal, and four of five questions evaluating stigma and attitudes towards individuals with OUD. Conclusions Our innovative OOPP was effective not only in increasing knowledge but also in improving attitudes towards overdose reversal and reducing stigma towards individuals with OUD. Given the strong improvements in attitudes towards those with OUD, efforts should be made to incorporate the unique focus on biopsychosocial and sociohistorical components into future OOPPs. Supplementary Information The online version contains supplementary material available at 10.1186/s12954-022-00589-6.
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Affiliation(s)
| | | | | | - Kyle Samson
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Nathaniel Goss
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Dakota Meredith
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Andrew Friedman
- Drexel University College of Medicine, Philadelphia, PA, USA
| | | | - Vishnu K Kumar
- Drexel University College of Medicine, Philadelphia, PA, USA
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17
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Brandt L, Yanagida T, Campbell ANC, Jones JD, Schultes MT, Martinez S, Comer SD. Multi-informant Implementation and Intervention Outcomes of Opioid Overdose Education and Naloxone Distribution in New York City. GLOBAL IMPLEMENTATION RESEARCH AND APPLICATIONS 2021; 1:209-222. [PMID: 34622215 PMCID: PMC8450721 DOI: 10.1007/s43477-021-00021-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 07/23/2021] [Indexed: 11/28/2022]
Abstract
Overdose Education and Naloxone Distribution (OEND) is an effective public health intervention to reduce opioid overdose fatalities (McDonald and Strang, Addiction 111:1177-1187, 2016). However, we know little about OEND implementation outcomes (i.e., indicators of implementation success), specifically the fidelity of training delivery, and how these may relate to intervention outcomes (i.e., indicators of the success or effectiveness of an intervention), such as overdose knowledge and attitudes. This study evaluated 16 OEND trainings conducted at different Opioid Overdose Prevention Programs in New York City. Trainees (N = 75) completed the Opioid Overdose Knowledge and Attitude Scales before and after training (intervention outcomes). Implementation outcomes were fidelity (competence and adherence of the trainer, N = 10; modified Fidelity Checklist) and acceptability of OEND (Acceptability of Intervention Measure), assessed from multiple perspectives (trainees, trainers, and an independent observer). Trainees' overdose knowledge, t(71) = - 8.12, p < 0.001, 95% CI [- 6.54, - 3.96], and attitudes, t(65) = - 6.85, p < 0.001, 95% CI [- 0.59, - 0.33], improved significantly from pre- to post-training. Stepwise multiple regression models indicated that adherence of the trainer rated from the observer perspective added significantly to the prediction of changes in overdose knowledge, F(1, 67) = 9.81, p = 0.003, and explained 13% of the variance in outcome. However, fidelity measures from the perspective of trainees or trainers and acceptability of OEND were not associated with changes in trainees' overdose knowledge or attitudes. OEND implementation outcomes and their relationship with intervention outcomes differed depending on the role of the fidelity rater in relation to the intervention. Specifically, our findings indicate that fidelity should be measured from an independent perspective (i.e., an individual who is experienced with fidelity rating but not directly involved in the intervention). SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s43477-021-00021-4.
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Affiliation(s)
- Laura Brandt
- Division on Substance Use Disorders, Department of Psychiatry & New York State Psychiatric Institute, Columbia University Irving Medical Center, 1051 Riverside Drive, Unit #120, New York, NY 10032 USA
| | - Takuya Yanagida
- Department of Developmental and Educational Psychology, University of Vienna, Universitaetsstrasse 7 (NIG), 1010 Vienna, Austria
| | - Aimee N. C. Campbell
- Division on Substance Use Disorders, Department of Psychiatry & New York State Psychiatric Institute, Columbia University Irving Medical Center, 1051 Riverside Drive, Unit #120, New York, NY 10032 USA
| | - Jermaine D. Jones
- Division on Substance Use Disorders, Department of Psychiatry & New York State Psychiatric Institute, Columbia University Irving Medical Center, 1051 Riverside Drive, Unit #120, New York, NY 10032 USA
| | - Marie-Therese Schultes
- Department of Developmental and Educational Psychology, University of Vienna, Universitaetsstrasse 7 (NIG), 1010 Vienna, Austria
- Institute for Implementation Science in Healthcare, University of Zurich, Universitaetstrasse 84, 8006 Zurich, Switzerland
| | - Suky Martinez
- Division on Substance Use Disorders, Department of Psychiatry & New York State Psychiatric Institute, Columbia University Irving Medical Center, 1051 Riverside Drive, Unit #120, New York, NY 10032 USA
| | - Sandra D. Comer
- Division on Substance Use Disorders, Department of Psychiatry & New York State Psychiatric Institute, Columbia University Irving Medical Center, 1051 Riverside Drive, Unit #120, New York, NY 10032 USA
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18
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Brandt L, Campbell ANC, Jones JD, Martinez S, Neale J, Parkin S, Brown C, Strang J, Comer SD. Emotional reactions of trained overdose responders who use opioids following intervention in an overdose event. Subst Abus 2021; 43:581-591. [PMID: 34520679 PMCID: PMC8810579 DOI: 10.1080/08897077.2021.1975870] [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] [Indexed: 10/20/2022]
Abstract
Background: Our aim was to explore emotional reactions to intervening in an overdose event from the perspective of individuals who use opioids (peer responders). In addition, we were interested in the impact this experience may have on peer responders' feelings about helping in an overdose situation in the future. Methods: For this qualitative sub-study of a randomized controlled trial (RCT), data from 61 interviews were analyzed thematically using an inductive approach. Results: Peer responders had diverse emotional reactions to the overdose event. These ranged from a sense of pride and other positive feelings associated with their ability to help to ambivalence about being involved in situations perceived as challenging and burdensome. There were few reports of the overdose event as an exclusively negative experience. Many peer responders perceived it as their duty to use naloxone again if required. However, some had ambivalent feelings toward this responsibility, which may be related to negative experiences with previous intervention efforts. Conclusions: The capacity of people who use opioids to help reduce the harms associated with opioid overdose is experienced as empowering by some. Nonetheless, engaging peer responders in strategies to reduce opioid-related mortality should be coupled with appropriate resources to process their experiences and emotional responses.
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Affiliation(s)
- Laura Brandt
- Division on Substance Use Disorders, New York State Psychiatric Institute & Department of Psychiatry, Columbia University Irving Medical Center, New York, New York, USA
| | - Aimee N. C. Campbell
- Division on Substance Use Disorders, New York State Psychiatric Institute & Department of Psychiatry, Columbia University Irving Medical Center, New York, New York, USA
| | - Jermaine D. Jones
- Division on Substance Use Disorders, New York State Psychiatric Institute & Department of Psychiatry, Columbia University Irving Medical Center, New York, New York, USA
| | - Suky Martinez
- Division on Substance Use Disorders, New York State Psychiatric Institute & Department of Psychiatry, Columbia University Irving Medical Center, New York, New York, USA
| | - Joanne Neale
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
- Centre for Social Research in Health, University of New South Wales, Sydney, Australia
- South London and Maudsley NHS Foundation Trust, Camberwell, London, UK
| | - Stephen Parkin
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Caral Brown
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - John Strang
- National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
- South London and Maudsley NHS Foundation Trust, Camberwell, London, UK
| | - Sandra D. Comer
- Division on Substance Use Disorders, New York State Psychiatric Institute & Department of Psychiatry, Columbia University Irving Medical Center, New York, New York, USA
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19
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Razaghizad A, Windle SB, Filion KB, Gore G, Kudrina I, Paraskevopoulos E, Kimmelman J, Martel MO, Eisenberg MJ. The Effect of Overdose Education and Naloxone Distribution: An Umbrella Review of Systematic Reviews. Am J Public Health 2021; 111:e1-e12. [PMID: 34214412 PMCID: PMC8489614 DOI: 10.2105/ajph.2021.306306] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2021] [Indexed: 11/04/2022]
Abstract
Background. Opioids contribute to more than 60 000 deaths annually in North America. While the expansion of overdose education and naloxone distribution (OEND) programs has been recommended in response to the opioid crisis, their effectiveness remains unclear. Objectives. To conduct an umbrella review of systematic reviews to provide a broad-based conceptual scheme of the effect and feasibility of OEND and to identify areas for possible optimization. Search Methods. We conducted the umbrella review of systematic reviews by searching PubMed, Embase, PsycINFO, Epistemonikos, the Cochrane Database of Systematic Reviews, and the reference lists of relevant articles. Briefly, an academic librarian used a 2-concept search, which included opioid subject headings and relevant keywords with a modified PubMed systematic review filter. Selection Criteria. Eligible systematic reviews described comprehensive search strategies and inclusion and exclusion criteria, evaluated the quality or risk of bias of included studies, were published in English or French, and reported data relevant to either the safety or effectiveness of OEND programs, or optimal strategies for the management of opioid overdose with naloxone in out-of-hospital settings. Data Collection and Analysis. Two reviewers independently extracted study characteristics and the quality of included reviews was assessed in duplicate with AMSTAR-2, a critical appraisal tool for systematic reviews. Review quality was rated critically low, low, moderate, or high based on 7 domains: protocol registration, literature search adequacy, exclusion criteria, risk of bias assessment, meta-analytical methods, result interpretation, and presence of publication bias. Summary tables were constructed, and confidence ratings were provided for each outcome by using a previously modified version of the Royal College of General Practitioners' clinical guidelines. Main Results. Six systematic reviews containing 87 unique studies were included. We found that OEND programs produce long-term knowledge improvement regarding opioid overdose, improve participants' attitudes toward naloxone, provide sufficient training for participants to safely and effectively manage overdoses, and effectively reduce opioid-related mortality. High-concentration intranasal naloxone (> 2 mg/mL) was as effective as intramuscular naloxone at the same dose, whereas lower-concentration intranasal naloxone was less effective. Evidence was limited for other naloxone formulations, as well as the need for hospital transport after overdose reversal. The preponderance of evidence pertained persons who use heroin. Author's Conclusions. Evidence suggests that OEND programs are effective for reducing opioid-related mortality; however, additional high-quality research is required to optimize program delivery. Public Health Implications. Community-based OEND programs should be implemented widely in high-risk populations.
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Affiliation(s)
- Amir Razaghizad
- Amir Razaghizad, Sarah B. Windle, Kristian B. Filion, and Mark J. Eisenberg are with the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada. Genevieve Gore is with the Schulich Library of Physical Sciences, Life Sciences, and Engineering, McGill University, Montreal. Irina Kudrina is with the Department of Family Medicine, Faculty of Medicine, McGill University. Elena Paraskevopoulos is with the Department of Anesthesia, Faculty of Medicine, McGill University. Jonathan Kimmelman is with the Studies of Translation, Ethics, and Medicine Biomedical Ethics Unit, McGill University. Marc O. Martel is with the Faculty of Dentistry, McGill University
| | - Sarah B Windle
- Amir Razaghizad, Sarah B. Windle, Kristian B. Filion, and Mark J. Eisenberg are with the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada. Genevieve Gore is with the Schulich Library of Physical Sciences, Life Sciences, and Engineering, McGill University, Montreal. Irina Kudrina is with the Department of Family Medicine, Faculty of Medicine, McGill University. Elena Paraskevopoulos is with the Department of Anesthesia, Faculty of Medicine, McGill University. Jonathan Kimmelman is with the Studies of Translation, Ethics, and Medicine Biomedical Ethics Unit, McGill University. Marc O. Martel is with the Faculty of Dentistry, McGill University
| | - Kristian B Filion
- Amir Razaghizad, Sarah B. Windle, Kristian B. Filion, and Mark J. Eisenberg are with the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada. Genevieve Gore is with the Schulich Library of Physical Sciences, Life Sciences, and Engineering, McGill University, Montreal. Irina Kudrina is with the Department of Family Medicine, Faculty of Medicine, McGill University. Elena Paraskevopoulos is with the Department of Anesthesia, Faculty of Medicine, McGill University. Jonathan Kimmelman is with the Studies of Translation, Ethics, and Medicine Biomedical Ethics Unit, McGill University. Marc O. Martel is with the Faculty of Dentistry, McGill University
| | - Genevieve Gore
- Amir Razaghizad, Sarah B. Windle, Kristian B. Filion, and Mark J. Eisenberg are with the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada. Genevieve Gore is with the Schulich Library of Physical Sciences, Life Sciences, and Engineering, McGill University, Montreal. Irina Kudrina is with the Department of Family Medicine, Faculty of Medicine, McGill University. Elena Paraskevopoulos is with the Department of Anesthesia, Faculty of Medicine, McGill University. Jonathan Kimmelman is with the Studies of Translation, Ethics, and Medicine Biomedical Ethics Unit, McGill University. Marc O. Martel is with the Faculty of Dentistry, McGill University
| | - Irina Kudrina
- Amir Razaghizad, Sarah B. Windle, Kristian B. Filion, and Mark J. Eisenberg are with the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada. Genevieve Gore is with the Schulich Library of Physical Sciences, Life Sciences, and Engineering, McGill University, Montreal. Irina Kudrina is with the Department of Family Medicine, Faculty of Medicine, McGill University. Elena Paraskevopoulos is with the Department of Anesthesia, Faculty of Medicine, McGill University. Jonathan Kimmelman is with the Studies of Translation, Ethics, and Medicine Biomedical Ethics Unit, McGill University. Marc O. Martel is with the Faculty of Dentistry, McGill University
| | - Elena Paraskevopoulos
- Amir Razaghizad, Sarah B. Windle, Kristian B. Filion, and Mark J. Eisenberg are with the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada. Genevieve Gore is with the Schulich Library of Physical Sciences, Life Sciences, and Engineering, McGill University, Montreal. Irina Kudrina is with the Department of Family Medicine, Faculty of Medicine, McGill University. Elena Paraskevopoulos is with the Department of Anesthesia, Faculty of Medicine, McGill University. Jonathan Kimmelman is with the Studies of Translation, Ethics, and Medicine Biomedical Ethics Unit, McGill University. Marc O. Martel is with the Faculty of Dentistry, McGill University
| | - Jonathan Kimmelman
- Amir Razaghizad, Sarah B. Windle, Kristian B. Filion, and Mark J. Eisenberg are with the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada. Genevieve Gore is with the Schulich Library of Physical Sciences, Life Sciences, and Engineering, McGill University, Montreal. Irina Kudrina is with the Department of Family Medicine, Faculty of Medicine, McGill University. Elena Paraskevopoulos is with the Department of Anesthesia, Faculty of Medicine, McGill University. Jonathan Kimmelman is with the Studies of Translation, Ethics, and Medicine Biomedical Ethics Unit, McGill University. Marc O. Martel is with the Faculty of Dentistry, McGill University
| | - Marc O Martel
- Amir Razaghizad, Sarah B. Windle, Kristian B. Filion, and Mark J. Eisenberg are with the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada. Genevieve Gore is with the Schulich Library of Physical Sciences, Life Sciences, and Engineering, McGill University, Montreal. Irina Kudrina is with the Department of Family Medicine, Faculty of Medicine, McGill University. Elena Paraskevopoulos is with the Department of Anesthesia, Faculty of Medicine, McGill University. Jonathan Kimmelman is with the Studies of Translation, Ethics, and Medicine Biomedical Ethics Unit, McGill University. Marc O. Martel is with the Faculty of Dentistry, McGill University
| | - Mark J Eisenberg
- Amir Razaghizad, Sarah B. Windle, Kristian B. Filion, and Mark J. Eisenberg are with the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada. Genevieve Gore is with the Schulich Library of Physical Sciences, Life Sciences, and Engineering, McGill University, Montreal. Irina Kudrina is with the Department of Family Medicine, Faculty of Medicine, McGill University. Elena Paraskevopoulos is with the Department of Anesthesia, Faculty of Medicine, McGill University. Jonathan Kimmelman is with the Studies of Translation, Ethics, and Medicine Biomedical Ethics Unit, McGill University. Marc O. Martel is with the Faculty of Dentistry, McGill University
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Bowles JM, Smith LR, Mittal ML, Harding RW, Copulsky E, Hennessey G, Dunkle A, Davidson PJ, Wagner KD. "I wanted to close the chapter completely … and I feel like that [carrying naloxone] would keep it open a little bit": Refusal to carry naloxone among newly-abstinent opioid users and 12-step identity. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 94:103200. [PMID: 33765517 PMCID: PMC10155624 DOI: 10.1016/j.drugpo.2021.103200] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Revised: 03/01/2021] [Accepted: 03/02/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND 12-step programs aim to address drug-related harms, like opioid overdose, via abstinence. However, abstaining from opioids can diminish tolerance, which increases risk for overdose death upon resumption. A recent study found that desire to abstain from drugs inhibited willingness to participate in take-home naloxone programming, which was linked to perceptions of harm reduction strategies being tied to drug use. In the present study, we uncovered a similar phenomenon occurring among newly-abstinent participants who were refusing to carry naloxone. METHODS This study is an analysis of broader qualitative data collected throughout Southern California among persons who use opioids, including those recently abstinent. Preliminary analysis revealed that those newly abstinent refused to accept naloxone at the end of interviews, and so we began probing about this (N=44). We used thematic analysis and author positionality to explicate the emergent phenomenon and applied social identity theory to conceptualize findings. RESULTS Mechanisms underlying naloxone refusal included its tie to a drug-using identity that newly-abstinent participants were attempting to retire. Carrying naloxone was also viewed as pointless due to doubt of witnessing an overdose again. Furthermore, the thought of being equipped with naloxone was not believed to be congruent with an abstinent identity, e.g. "me carrying it [naloxone] is making me feel like I'm going to be hanging out with people that are doing it [using drugs]." CONCLUSION Recent detoxification heightens vulnerability to overdose, which other newly-abstinent peers might be positioned to respond to as bonds are formed through 12-step identity formation. However, naloxone is often refused by this group due to perceived 12-step identity clash. While some treatment spaces distribute naloxone, 12-step identity associated behavioral expectations appear to conflict with this strategy. Reframing these disconnects is essential for expanding the lifesaving naloxone community safety net.
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Affiliation(s)
- J. M. Bowles
- University of California San Diego, Division of Infectious Diseases and Global Public Health, La Jolla, CA, United States
- Centre on Drug Policy Evaluation, Li Ka Shing Knowledge Institute, St. Michael’s Hospital: Toronto, ON, Canada
- Correspondence: Corresponding author for refereeing submission process, | 215-260-8510
| | - L. R. Smith
- University of California San Diego, Division of Infectious Diseases and Global Public Health, La Jolla, CA, United States
| | - M. L. Mittal
- University of California San Diego, Division of Infectious Diseases and Global Public Health, La Jolla, CA, United States
| | - R. W. Harding
- School of Community Health Sciences, University of Nevada, Reno, United States
| | - E. Copulsky
- University of California San Diego, Division of Infectious Diseases and Global Public Health, La Jolla, CA, United States
| | - G. Hennessey
- University of California San Diego, Division of Infectious Diseases and Global Public Health, La Jolla, CA, United States
| | - A. Dunkle
- Solace Foundation, California, United States
| | - P. J. Davidson
- University of California San Diego, Division of Infectious Diseases and Global Public Health, La Jolla, CA, United States
- Joint last and corresponding authors if published: |
| | - K. D. Wagner
- School of Community Health Sciences, University of Nevada, Reno, United States
- Joint last and corresponding authors if published: |
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Samuels EA, Wentz A, McCormick M, McDonald JV, Marshall BDL, Friedman C, Koziol J, Alexander-Scott NE. Rhode Island's Opioid Overdose Hospital Standards and Emergency Department Naloxone Distribution, Behavioral Counseling, and Referral to Treatment. Ann Emerg Med 2021; 78:68-79. [PMID: 33865617 PMCID: PMC9119858 DOI: 10.1016/j.annemergmed.2021.02.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Revised: 12/13/2020] [Accepted: 02/01/2021] [Indexed: 10/21/2022]
Abstract
STUDY OBJECTIVE We sought to determine the influence of the Levels of Care for Rhode Island Emergency Departments and Hospitals for Treating Overdose and Opioid Use Disorder (Levels of Care) on emergency department (ED) provision of take-home naloxone, behavioral counseling, and referral to treatment. METHODS A retrospective analysis of Rhode Island ED visits for opioid overdose from 2017 to 2018 was performed using data from a statewide opioid overdose surveillance system. Changes in provision of take-home naloxone, behavioral counseling, and referral to treatment before and after Levels of Care implementation were assessed using interrupted time series analysis. We compared outcomes by hospital type using multivariable modified Poisson regression models with generalized estimating equation estimation to account for hospital-level variation. RESULTS We analyzed 245 overdose visits prior to Levels of Care implementation (January to March 2017) and 1340 overdose visits after implementation (hospital certification to December 2018). After implementation, the proportion of patients offered naloxone increased on average by 13% (95% confidence interval [CI] 5.6% to 20.4%). Prior to implementation, the proportion of patients receiving behavioral counseling and treatment referral was declining. After implementation, this decline slowed and stabilized, and on average 18.6% more patients received behavioral counseling (95% CI 1.3% to 35.9%) and 23.1% more patients received referral to treatment (95% CI 2.7% to 43.5%). Multivariable analysis showed that after implementation, there was a significant increase in the likelihood of being offered naloxone at Level 1 (adjusted relative risk [aRR] 1.31 [95% CI 1.06 to 1.61]) and Level 3 (aRR 3.13 [95% CI 1.08 to 9.06]) hospitals and an increase in referrals for medication for opioid use disorder (from 2.5% to 17.8%) at Level 1 hospitals (RR 7.73 [95% CI 3.22 to 18.55]). Despite these increases, less than half of the patients treated for an opioid overdose received behavioral counseling or referral to treatment CONCLUSION: The establishment of ED policies for treatment and services after opioid overdose improved naloxone distribution, behavioral counseling, and referral to treatment at hospitals without previously established opioid overdose services. Future investigations are needed to better characterize implementation barriers and evaluate policy influence on patient outcomes.
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Affiliation(s)
- Elizabeth A Samuels
- Department of Emergency, Alpert Medical School, Brown University, Providence, RI; Rhode Island Department of Health, Providence, RI.
| | - Anna Wentz
- Department of Epidemiology, Brown University School of Public Health, Providence, RI
| | | | | | - Brandon D L Marshall
- Department of Epidemiology, Brown University School of Public Health, Providence, RI
| | - Catherine Friedman
- Department of Psychiatry and Human Behavior, Alpert Medical School, Brown University, Providence, RI
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Dayton L, Mazhnaya A, Schneider KE, Kong X, Winiker A, Davey-Rothwell M, Tobin KE, Latkin CA. Trends in overdose experiences and prevention behaviors among people who use opioids in Baltimore, MD, 2017-2019. Drug Alcohol Depend 2021; 221:108650. [PMID: 33684772 PMCID: PMC8590734 DOI: 10.1016/j.drugalcdep.2021.108650] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 01/09/2021] [Accepted: 02/14/2021] [Indexed: 01/30/2023]
Abstract
BACKGROUND Little is known about trends in overdose behaviors. This study explored non-fatal overdose and engagement in overdose prevention behaviors and compared these trends to city-wide overdose fatality rates from 2017 to 2019 in Baltimore, MD. METHODS The analysis included people who used opioids (PWUO; N = 502) recruited through a community-based study. Enrollment date was used to categorize participants into annual quarters. Logistic regression models examined change in overdose experiences and prevention behaviors with time. Baltimore's fatal overdoses were also mapped over the study period to assess overlaps in trends. RESULTS The majority of the sample were male(68 %), Black(61 %), reported past 6 months homelessness(56 %), and were on average 45 years old. Most had witnessed(61 %), and 28 % had personally experienced an overdose in the past 6 months. Witnessing overdose marginally increased(aβ = 0.182;p = 0.058) while experiencing overdose did not significantly change by enrollment quarter. Most participants had or had been prescribed naloxone(72 %), and one fifth(22 %) regularly carried naloxone, with both access to(aβ = 0,408;p = 0.002) and carrying naloxone(aβ = 0.302;p = 0.006) increasing over time. Overdose communication remained stable, with 63 % of participants reporting discussing overdose sometimes/often. Among participants who injected (n = 376), regularly injecting alone decreased(aβ=-0.207;p = 0.055), and reporting others often/always having naloxone with them when injecting increased over time(aβ = 0.573;p < 0.001). CONCLUSIONS Witnessed overdose marginally increased from 2017 to 2019, aligning with city trends of fatal overdose. Overdose prevention behaviors significantly increased over time. Despite reporting having naloxone or a naloxone prescription, most PWUO did not regularly carry naloxone, and many used alone. Social network diffusion interventions may be a strategy to promote normative overdose prevention behaviors.
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Affiliation(s)
- Lauren Dayton
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA.
| | - Alyona Mazhnaya
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA; School of Public Health, National University of Kyiv-Mohyla Academy, Voloska St, 10, Kyiv, 02000, Ukraine
| | - Kristin E Schneider
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA
| | - Xiangrong Kong
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA; Wilmer Eye Institute, Johns Hopkins School Medicine, 600 N. Wolfe St., Baltimore, MD, 21205, USA; Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA
| | - Abigail Winiker
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA
| | - Melissa Davey-Rothwell
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA
| | - Karin E Tobin
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA
| | - Carl A Latkin
- Department of Health, Behavior and Society, Johns Hopkins Bloomberg School of Public Health, 624 N. Broadway, Baltimore, MD, 21205, USA
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Gjersing L, Helle MK. Injecting Alone is More Common among Men, Frequent Injectors and Polysubstance Users in a Sample of People Who Inject Drugs. Subst Use Misuse 2021; 56:2214-2220. [PMID: 34565289 DOI: 10.1080/10826084.2021.1981388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Injecting alone increases the risk of a fatal overdose. We examined the extent of such behavior in a sample of people who inject drugs (PWID) and the typical characteristics of those injecting alone at least once during the past four weeks. A cross-sectional study. PWID recruited from the street and from low-threshold services in seven Norwegian cities in September 2017 (n = 359). Associations between characteristics and injecting alone were examined using logistic regression analysis. The independent variables were gender (female/male), age, having received overdose-prevention education (no/yes), and, in the past four weeks; homelessness/shelter use (no/yes), in opioid substitution treatment (no/yes), injecting ≥ four days a week (no/yes), and substances injected (opioids only/opioids and other/other only/central stimulants (CS) only/CS and other/CS and opioids/CS, opioids and other). The adjusted odds ratios (aOR) and 95% Confidence Intervals (CI) were reported. Of the 359 PWID, 84.4% reported having injected alone. Males were more likely than females to inject alone (aOR = 1.88 95% CI 1.00-3.54). Furthermore, those injecting frequently (aOR = 1.99 95% CI 1.02-3.86) and those injecting multiple substances (CS, opioids and other) (aOR = 2.94 95% CI 1.01-8.58) were more likely to inject alone compared to those injecting less frequently and opioids only. Although not statistically significant, the effect sizes in the logistic regression models suggest that polysubstance use may be driven by CS use. Injecting alone was common in our sample of PWID, and male gender, frequent injecting and polysubstance injecting were associated with this behavior.
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Affiliation(s)
- Linn Gjersing
- Department of Alcohol, Tobacco and Drugs, Norwegian Institute of Public Health, Oslo, Norway
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Holland TJ, Penm J, Johnson J, Sarantou M, Chaar BB. Stakeholders' Perceptions of Factors Influencing the Use of Take-Home-Naloxone. PHARMACY 2020; 8:pharmacy8040232. [PMID: 33287294 PMCID: PMC7768544 DOI: 10.3390/pharmacy8040232] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 11/24/2020] [Accepted: 11/25/2020] [Indexed: 11/16/2022] Open
Abstract
Background and Aims: Opioid associated death and overdose is a growing burden in societies all over the world. In recent years, legislative changes have increased access to naloxone in the take-home setting for use by patients with a substance use disorder and bystanders, to prevent opioid overdose deaths. However, few studies have explored the factors influencing the uptake by its multiple stakeholders. The aim of this scoping review was to explore the factors influencing the use of take-home naloxone from the perspectives of different stakeholders. Methods: A scoping review methodology was adopted with a systematic search of databases EMBASE, MEDLINE and PubMed. A variation of the search words “naloxone”, “opioid” and “overdose” were used in each database. The articles were screened according to the predetermined inclusion/exclusion criteria and categorized based on their key perspective or target population. Results: The initial database search yielded a total of 1483 articles. After a series of screening processes, 51 articles were included for analysis. Two key stakeholder perspectives emerged: patients and bystanders (n = 36), and healthcare professionals (n = 15). Within the patient and bystander group, a strong consensus arose that there were positive outcomes from increased access to take-home naloxone and relevant training programs. Despite these positive outcomes, some healthcare professionals were concerned that take-home naloxone would encourage high-risk opioid use. Conclusion: Take-home naloxone is slowly being introduced into community practice, with a sense of enthusiasm from patients and bystanders. There are still a number of barriers that need to be addressed from healthcare professionals’ perspective. Future research should be aimed at emergency care professionals outside of the US, who are most experienced with naloxone and its potential impact on the community.
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Affiliation(s)
- Taylor J. Holland
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Camperdown, NSW 2006, Australia; (T.J.H.); (J.P.)
| | - Jonathan Penm
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Camperdown, NSW 2006, Australia; (T.J.H.); (J.P.)
- Department of Pharmacy, Prince of Wales Hospital, Randwick, NSW 2031, Australia
| | - Jacinta Johnson
- UniSA Clinical and Health Sciences, University of South Australia, Adelaide, SA 5000, Australia;
| | - Maria Sarantou
- College of Medicine and Public Health, Flinders University, Bedford Park, SA 5042, Australia;
| | - Betty B. Chaar
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Camperdown, NSW 2006, Australia; (T.J.H.); (J.P.)
- Correspondence: ; Tel.: +61-2-9036-7101 or +61-425-210-547
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Ataiants J, Mazzella S, Roth AM, Sell RL, Robinson LF, Lankenau SE. Overdose response among trained and untrained women with a history of illicit drug use: a mixed-methods examination. DRUGS-EDUCATION PREVENTION AND POLICY 2020; 28:328-339. [PMID: 34321719 DOI: 10.1080/09687637.2020.1818691] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Little is known about differences in bystander behavior among people who use drugs, trained and untrained in opioid overdose prevention. We examined three types of recommended overdose response - a 911 call, rescue breathing/CPR, and naloxone administration-among Philadelphia-based, predominantly street-involved women with a history of illicit drug use. The study utilized a convergent mixed methods approach integrating data from 186 quantitative survey responses and 38 semi-structured qualitative interviews. Quantitative findings revealed that compared to untrained women, trained women were more likely to administer naloxone (32.9% vs. 5.2%) and use two recommended responses (20.0% vs. 9.5%). No significant differences were found between the two groups in calling 911 or using rescue breathing/CPR. Qualitative findings indicated that barriers to enacting recommended overdose response were either structural or situational and included the avoidance of police, inability to carry naloxone or phone due to unstable housing, and perceived lack of safety on the streets and when interacting with strangers. Our study demonstrated that overdose training improved the frequency of naloxone administration among this sample of predominantly street-involved women. Future efforts need to focus on avoiding intrusive policing, scaling-up naloxone refill sites, and providing secondary naloxone distribution via drug user networks.
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Affiliation(s)
- Janna Ataiants
- Department of Community Health and Prevention, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | | | - Alexis M Roth
- Department of Community Health and Prevention, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - Randall L Sell
- Department of Community Health and Prevention, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - Lucy F Robinson
- Department of Epidemiology and Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
| | - Stephen E Lankenau
- Department of Community Health and Prevention, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
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Abstract
BACKGROUND In 2017, approximately 11.4 million Americans used opioids inappropriately. Nearly 47,600 deaths in 2017 were attributable to overdose on opioids. Intranasal naloxone was approved by the Food and Drug Administration in 2015 as a rescue medication for opioid overdose. New York State launched a prescription drug monitoring program in 2012, the Internet System for Tracking Over-Prescribing (I-STOP), that required completion before dispensing any controlled substance. Currently, prescribing naloxone at our institution requires 10 clicks and 2 free text boxes. The goal of this project was to increase the prescribing of intranasal naloxone by utilizing EMR automation and visualization tools. METHODS Our intervention embedded a section within the required I-STOP note, displaying the last date naloxone was prescribed and an option to "prescribe intranasal naloxone." If checked, a prepopulated order dialog box was generated. RESULTS Intranasal naloxone orders for the institution totaled 65 for 2 months before the intervention and 203 for 2 months after the intervention, with 112 (55%) coming directly from the I-STOP note modification. Ease of prescribing improved as total clicks were reduced from 10 to 2, and free text boxes from 2 to 0. CONCLUSIONS Our findings suggest that a clinical decision support system can be an effective way to increase hospital-wide naloxone prescribing rates. We were able to increase prescribing rates by more than three-fold, significantly increasing the availability of a rescue medication to individuals at high-risk for overdose. Intranasal naloxone prescribing increased with the implementation of a visual reminder and a more intuitive ordering experience while preserving provider autonomy.
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Fatal overdose prevention and experience with naloxone: A cross-sectional study from a community-based cohort of people who inject drugs in Baltimore, Maryland. PLoS One 2020; 15:e0230127. [PMID: 32160244 PMCID: PMC7065783 DOI: 10.1371/journal.pone.0230127] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 02/22/2020] [Indexed: 01/13/2023] Open
Abstract
Introduction Overdose is a leading cause of death in the United States, especially among people who inject drugs (PWID). Improving naloxone access and carrying among PWID may offset recent increases in overdose mortality associated with the influx of synthetic opioids in the drug market. This study characterized prevalence and correlates of several naloxone outcomes among PWID. Methods During 2018, a survey to assess experience with naloxone was administered to 915 participants in the AIDS Linked to the IntraVenous Experience (ALIVE) study, an ongoing community-based observational cohort of people who currently inject or formerly injected drugs in Baltimore, Maryland. We examined the associations of naloxone outcomes (training, supply, use, and regular possession) with socio-demographic, substance use and healthcare utilization factors among PWID in order to characterize gaps in naloxone implementation among this high-risk population. Results Median age was 56 years, 34% were female, 85% were African American, and 31% recently injected. In the past six months, 46% (n = 421) reported receiving training in overdose prevention, 38% (n = 346) had received a supply of naloxone, 9% (n = 85) had administered naloxone, and 9% (n = 82) reported usually carrying a supply of naloxone. Recent non-fatal overdose was not associated with any naloxone outcomes in adjusted analysis. Active opioid use (aOR = 2.10, 95% CI: 1.03, 4.28) and recent treatment of alcohol or substance use disorder (aOR = 2.01, 95% CI: 1.13, 3.56) were associated with regularly carrying naloxone. Conclusion Further work is needed to encourage PWID to carry and effectively use naloxone to decrease rates of fatal opioid overdose. While accessing treatment for substance use disorder was positively associated with carrying naloxone, EMS response to 911 calls for overdose, the emergency department, and syringe services programs may be settings in which naloxone access and carrying could be encouraged among PWID.
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Troberg K, Isendahl P, Blomé MA, Dahlman D, Håkansson A. Protocol for a multi-site study of the effects of overdose prevention education with naloxone distribution program in Skåne County, Sweden. BMC Psychiatry 2020; 20:49. [PMID: 32028921 PMCID: PMC7006080 DOI: 10.1186/s12888-020-2470-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 01/30/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Continuously high rates of overdose deaths in Sweden led to the decision by the Skåne County to initiate the first regional take-home naloxone program in Sweden. The project aims to study the effect of overdose prevention education and naloxone distribution on overdose mortality in Skåne County. Secondary outcome measures include non-fatal overdoses and overdose-related harm in the general population, as well as cohort-specific effects in study participants regarding overdoses, mortality and retention in naloxone program. METHODS Implementation of a multi-site train-the-trainer cascade model was launched in June 2018. Twenty four facilities, including opioid substitution treatment units, needle exchange programs and in-patient addiction units were included for the first line of start-up, aspiring to reach a majority of individuals at-risk within the first 6 months. Serving as self-sufficient naloxone hubs, these units provide training, naloxone distribution and study recruitment. During 3 years, questionnaires are obtained from initial training, follow up, every sixth month, and upon refill. Estimated sample size is 2000 subjects. Naloxone distribution rates are reported, by each unit, every 6 months. Medical diagnoses, toxicological raw data and data on mortality and cause of death will be collected from national and regional registers, both for included naloxone recipients and for the general population. Data on vital status and treatment needs will be collected from registers of emergency and prehospital care. DISCUSSION Despite a growing body of literature on naloxone distribution, studies on population effect on mortality are scarce. Most previous studies and reports have been uncontrolled, thus not being able to link naloxone distribution to survival, in relation to a comparison period. As Swedish registers present the opportunity to monitor individuals and entire populations over time, conditions for conducting systematic follow-ups in the Swedish population are good, serving the opportunity to study the impact of large scale overdose prevention education and naloxone distribution and thus fill the knowledge gap. TRIAL REGISTRATION Naloxone Treatment in Skåne County - Effect on Drug-related Mortality and Overdose-related Complications, NCT03570099, registered on 26 June 2018.
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Affiliation(s)
- Katja Troberg
- Department of Clinical Sciences, Psychiatry, Faculty of Medicine, Lund University, Lund, Sweden. .,Division of Psychiatry, Addiction Center Malmö, Region Skåne, Malmö, Sweden. .,Malmö Addiction Centre, Clinical Research Unit, Södra Förstadsg. 35, Plan 4, S-205 02, Malmö, Sweden.
| | - Pernilla Isendahl
- grid.411843.b0000 0004 0623 9987Department of Infectious Disease, University Hospital Skåne, Malmö, Sweden
| | - Marianne Alanko Blomé
- grid.411843.b0000 0004 0623 9987Department of Infectious Disease, University Hospital Skåne, Malmö, Sweden ,Regional Office for Communicable Disease Control, Malmö, Sweden
| | - Disa Dahlman
- grid.4514.40000 0001 0930 2361Department of Clinical Sciences, Psychiatry, Faculty of Medicine, Lund University, Lund, Sweden ,grid.4514.40000 0001 0930 2361Department of Clinical Sciences, Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden
| | - Anders Håkansson
- grid.4514.40000 0001 0930 2361Department of Clinical Sciences, Psychiatry, Faculty of Medicine, Lund University, Lund, Sweden ,grid.426217.40000 0004 0624 3273Division of Psychiatry, Addiction Center Malmö, Region Skåne, Malmö, Sweden
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Katzman JG, Takeda MY, Greenberg N, Moya Balasch M, Alchbli A, Katzman WG, Salvador JG, Bhatt SR. Association of Take-Home Naloxone and Opioid Overdose Reversals Performed by Patients in an Opioid Treatment Program. JAMA Netw Open 2020; 3:e200117. [PMID: 32101312 PMCID: PMC7137685 DOI: 10.1001/jamanetworkopen.2020.0117] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Accepted: 12/29/2019] [Indexed: 01/09/2023] Open
Abstract
Importance The US opioid crisis was deemed a public health emergency in 2017. More than 130 individuals in the US die daily as a result of unintentional opioid overdose deaths. Objective To measure use of take-home naloxone for overdose reversals performed by study participants with opioid use disorder receiving treatment at an opioid treatment program. Design, Setting, and Participants In a year-long cohort study, between April 4, 2016, and May 16, 2017, 395 study participants enrolled at the University of New Mexico Addiction and Substance Abuse Opioid Treatment Program, an outpatient clinic treating substance use disorders. Inclusion criteria included all patients enrolled at University of New Mexico Addiction and Substance Abuse Opioid Treatment Program during the study enrollment period; positive history of opioid use disorder treated with methadone, buprenorphine, or naltrexone; and age 18 years or older. Exclusion criteria included allergy to naloxone and age younger than 18 years. The study closed 1 year after enrollment, on May 17, 2018. Data analysis was performed from May 2018 to July 2019. Exposure Two doses of take-home naloxone combined with opioid overdose education were provided to study participants. Main Outcomes and Measures The primary outcome was to measure the association of take-home naloxone with overdose reversals performed by patients with opioid use disorder enrolled in an opioid treatment program. Results We enrolled 395 study participants (270 female [68.4%]; mean [SD] age, 35.4 [12.6] years; 260 [65.8%] with Hispanic white race/ethnicity) in the 1-year prospective trial. Sixty-eight female participants (25.2% of all female participants) were pregnant at the time of enrollment. Seventy-three of the 395 study participants (18.0%) performed 114 overdose reversals in the community. All community reversals were heroin related. Most study participants (86.8%) stated that the person on whom they performed an overdose reversal was a friend, relative, acquaintance, or significant other. In the year before enrollment, only 18 study participants (4.5%) had been prescribed naloxone. Conclusions and Relevance Take-home naloxone as part of overdose education and naloxone distribution provided to patients in an opioid treatment program may be associated with a strategic targeted harm reduction response for reversing opioid overdose-related deaths. Policy makers may consider regulations to mandate overdose education and naloxone distribution in opioid treatment programs.
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Affiliation(s)
- Joanna G. Katzman
- Department of Neurosurgery, University of New Mexico, Albuquerque
- Project ECHO, ECHO Institute, Albuquerque, New Mexico
| | | | - Nina Greenberg
- Department of Mathematics and Statistics, University of New Mexico, Albuquerque
| | | | - Amal Alchbli
- Department of Neurosurgery, University of New Mexico, Albuquerque
| | | | - Julie G. Salvador
- Department of Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque
| | - Snehal R. Bhatt
- UNM Addiction and Substance Use Program, Department of Psychiatry and Behavioral Sciences, University of New Mexico, Albuquerque
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The impact of a pharmacist-led naloxone education and community distribution project on local use of naloxone. J Am Pharm Assoc (2003) 2020; 60:S56-S60. [PMID: 31953118 DOI: 10.1016/j.japh.2019.11.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 11/14/2019] [Accepted: 11/25/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To assess the use and public perception of naloxone through distribution and education by pharmacists at local health screenings in low-income communities in Western Pennsylvania. METHODS A prospective study was conducted, offering education on opioid use disorder and naloxone to individuals attending community outreach events in Allegheny County, PA. Participants with interest and willingness to use naloxone in the event of an opioid overdose were offered naloxone nasal spray and additional training. These individuals were asked to complete a survey at the time of naloxone provision and were recontacted by telephone at a later date to collect follow-up data. The primary objective of the study was to ascertain naloxone use at follow-up. Secondary objectives of the study were to measure the difficulty of obtaining naloxone, identify any change in knowledge of naloxone before and after pharmacist intervention, and assess public perception of stigma associated with naloxone initiatives. Data were analyzed using descriptive and univariate comparative statistics. RESULTS A total of 265 people received naloxone, and 132 (49.8%) completed the initial survey. Fifty-seven participants subsequently completed both surveys (43.2% follow-up). Naloxone was utilized by 3.5% of respondents over an average of 3 months. Participants' perception of obtaining naloxone before the study was evenly distributed (35.8% never tried, 32.1% difficult, and 30.2% not difficult). A total of 52.6% of respondents believed that naloxone initiatives decreased the stigma of illicit opioid use. CONCLUSION Naloxone provided in the community setting was utilized by a small percentage of the general public in the 2- to 4-month follow-up. Pharmacists can provide naloxone education and training within communities affected by high opioid overdose rates.
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Carpenter J, Murray BP, Atti S, Moran TP, Yancey A, Morgan B. Naloxone Dosing After Opioid Overdose in the Era of Illicitly Manufactured Fentanyl. J Med Toxicol 2020; 16:41-48. [PMID: 31471760 PMCID: PMC6942078 DOI: 10.1007/s13181-019-00735-w] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 08/01/2019] [Accepted: 08/21/2019] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Illicitly manufactured fentanyl (IMF) is responsible for a growing number of deaths. Some case series have suggested that IMF overdoses require significantly higher naloxone doses than heroin overdoses. Our objective was to determine if the naloxone dose required to treat an opioid overdose is associated with the finding of fentanyl, opiates, or both on urine drug screen (UDS). METHODS A retrospective chart review was conducted at a single emergency department and its affiliated emergency medical services (EMS) agency. The charts of all patients who received naloxone through this EMS from 1/1/2017 to 6/15/2018 were reviewed. The study included patients diagnosed with a non-suicidal opioid overdose whose UDS was positive for opiates, fentanyl, or both. Data collected included demographics, vital signs, initial GCS, EMS and ED naloxone administrations, response to treatment, laboratory findings, and ED disposition. The fentanyl-only and fentanyl + opiate groups were compared to the opiate-only group using the stratified (by ED provider) variant of the Mann-Whitney U test. RESULTS Eight hundred and thirty-seven charts were reviewed, and 121 subjects were included in the final analysis. The median age of included subjects was 38 years and 75% were male. In the naloxone dose analysis, neither the fentanyl-only (median 0.8 mg, IQR 0.4-1.6; p = 0.68) nor the fentanyl + opiate (median 0.8 mg, IQR 0.4-1.2; p = 0.56) groups differed from the opiate-only group (median 0.58 mg, IQR 0.4-1.6). CONCLUSION Our findings refute the notion that high potency synthetic opioids like illicitly manufactured fentanyl require increased doses of naloxone to successfully treat an overdose. There were no significant differences in the dose of naloxone required to treat opioid overdose patients with UDS evidence of exposure to fentanyl, opiates, or both. Further evaluation of naloxone stocking and dosing protocols is needed.
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Affiliation(s)
- Joseph Carpenter
- Georgia Poison Center, 50 Hurt Plaza SE, Suite 600, Atlanta, GA, 30303, USA.
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA.
| | | | - Sukhshant Atti
- Georgia Poison Center, 50 Hurt Plaza SE, Suite 600, Atlanta, GA, 30303, USA
| | - Tim P Moran
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Arthur Yancey
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Brent Morgan
- Georgia Poison Center, 50 Hurt Plaza SE, Suite 600, Atlanta, GA, 30303, USA
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
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Saini R, Rao R, Parmar A, Mishra AK, Ambekar A, Agrawal A, Dhingra N. Rates, knowledge and risk factors of non-fatal opioid overdose among people who inject drugs in India: A community-based study. Drug Alcohol Rev 2019; 39:93-97. [PMID: 31769134 DOI: 10.1111/dar.13016] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 11/01/2019] [Accepted: 11/01/2019] [Indexed: 11/28/2022]
Abstract
INTRODUCTION AND AIMS Non-fatal opioid overdose (NFOO) predicts future fatal opioid overdose and is associated with significant morbidity. There is limited literature on the rates and risk factors for NFOO in people who inject drugs (PWID) from India. We aimed to study the rates of NFOO and documented risk factors for NFOO, as well as knowledge-level of NFOO among PWID from India. DESIGN AND METHODS Community-based, cross-sectional and observational study. We interviewed 104 adult male participants receiving HIV prevention services. Drug use patterns, rates of NFOO and opioid overdose risk factors, knowledge about opioid overdose and its management were assessed. RESULTS The mean age of the participants was 27.9 years. The most common opioid used for injecting was heroin followed by buprenorphine. About 45% (n = 47) participants had experienced an opioid overdose at least once in their lifetime. Around 25% (n = 26) participants had overdosed in the past year, while 21% (n = 22) participants had overdosed within the past 3 months. The majority had risk factors that could predispose them to NFOO. No participant was aware of the use of naloxone for opioid overdose. DISCUSSION AND CONCLUSION The rates of NFOO as well as risk factors for overdose among PWID from India are high, with poor knowledge on overdose management. There is urgent need for a program to prevent and manage opioid overdose among PWID in India.
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Affiliation(s)
- Romil Saini
- National Drug Dependence Treatment Centre, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
| | - Ravindra Rao
- National Drug Dependence Treatment Centre, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
| | - Arpit Parmar
- National Drug Dependence Treatment Centre, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
| | - Ashwani K Mishra
- National Drug Dependence Treatment Centre, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
| | - Atul Ambekar
- National Drug Dependence Treatment Centre, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
| | - Alok Agrawal
- National Drug Dependence Treatment Centre, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
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Naumann RB, Durrance CP, Ranapurwala SI, Austin AE, Proescholdbell S, Childs R, Marshall SW, Kansagra S, Shanahan ME. Impact of a community-based naloxone distribution program on opioid overdose death rates. Drug Alcohol Depend 2019; 204:107536. [PMID: 31494440 PMCID: PMC8107918 DOI: 10.1016/j.drugalcdep.2019.06.038] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 06/25/2019] [Accepted: 06/27/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND In August 2013, a naloxone distribution program was implemented in North Carolina (NC). This study evaluated that program by quantifying the association between the program and county-level opioid overdose death (OOD) rates and conducting a cost-benefit analysis. METHODS One-group pre-post design. Data included annual county-level counts of naloxone kits distributed from 2013 to 2016 and mortality data from 2000-2016. We used generalized estimating equations to estimate the association between cumulative rates of naloxone kits distributed and annual OOD rates. Costs included naloxone kit purchases and distribution costs; benefits were quantified as OODs avoided and monetized using a conservative value of a life. RESULTS The rate of OOD in counties with 1-100 cumulative naloxone kits distributed per 100,000 population was 0.90 times (95% CI: 0.78, 1.04) that of counties that had not received kits. In counties that received >100 cumulative kits per 100,000 population, the OOD rate was 0.88 times (95% CI: 0.76, 1.02) that of counties that had not received kits. By December 2016, an estimated 352 NC deaths were avoided by naloxone distribution (95% CI: 189, 580). On average, for every dollar spent on the program, there was $2742 of benefit due to OODs avoided (95% CI: $1,237, $4882). CONCLUSIONS Our estimates suggest that community-based naloxone distribution is associated with lower OOD rates. The program generated substantial societal benefits due to averted OODs. States and communities should continue to support efforts to increase naloxone access, which may include reducing legal, financial, and normative barriers.
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Affiliation(s)
- Rebecca B Naumann
- Department of Epidemiology and Injury Prevention Research Center, University of North Carolina at Chapel Hill, CVS Plaza, Suite 500, 137 East Franklin St., CB #7505, Chapel Hill, NC 27599 USA.
| | - Christine Piette Durrance
- Department of Public Policy, University of North Carolina at Chapel Hill, 203 Abernethy Hall, CB #3435, Chapel Hill, NC 27599 USA.
| | - Shabbar I Ranapurwala
- Department of Epidemiology and Injury Prevention Research Center, University of North Carolina at Chapel Hill, CVS Plaza, Suite 500, 137 East Franklin St., CB #7505, Chapel Hill, NC 27599 USA.
| | - Anna E Austin
- Department of Maternal and Child Health and Injury Prevention Research Center, University of North Carolina at Chapel Hill, CVS Plaza, Suite 500, 137 East Franklin St., CB #7505, Chapel Hill, NC 27599 USA.
| | - Scott Proescholdbell
- Injury and Violence Prevention Branch, Division of Public Health, NC Department of Health and Human Services, 5505 Six Forks Road, Raleigh, NC 27609 USA.
| | - Robert Childs
- Formerly (and at time of this work): Consultant to North Carolina Harm Reduction Coalition, Currently: JBS International, Inc., 5515 Security Lane, Suite 800, North Bethesda, MD 20852 USA.
| | - Stephen W Marshall
- Department of Epidemiology and Injury Prevention Research Center, University of North Carolina at Chapel Hill, CVS Plaza, Suite 500, 137 East Franklin St., CB #7505, Chapel Hill, NC 27599 USA.
| | - Susan Kansagra
- Chronic Disease and Injury Section, Division of Public Health, NC Department of Health and Human Services, 5505 Six Forks Road, Raleigh, NC 27609 USA.
| | - Meghan E Shanahan
- Department of Maternal and Child Health and Injury Prevention Research Center, University of North Carolina at Chapel Hill, CVS Plaza, Suite 500, 137 East Franklin St., CB #7505, Chapel Hill, NC 27599 USA.
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Lim JK, Forman LS, Ruiz S, Xuan Z, Callis BP, Cranston K, Walley AY. Factors associated with help seeking by community responders trained in overdose prevention and naloxone administration in Massachusetts. Drug Alcohol Depend 2019; 204:107531. [PMID: 31526959 DOI: 10.1016/j.drugalcdep.2019.06.033] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2019] [Revised: 06/24/2019] [Accepted: 06/24/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND Community overdose responders do not always seek help from emergency services when administering naloxone. We aimed to identify responder, overdose event, and community characteristics associated with help seeking from emergency services during overdoses reported by Massachusetts Overdose Education and Naloxone Distribution (OEND) enrollees, and to assess trends in help seeking over time. METHODS We analyzed overdose reports submitted between 2007 and 2017 to the Massachusetts Department of Public Health. We used logistic regression, stratified by responder drug use status, to assess associations of characteristics with help seeking during an overdose. RESULTS From January 2007 through December 2017, there were 69,870 OEND enrollees. 5,588 enrollees reported 10,246 overdoses. Help seeking was more likely among responders who did not use drugs. Among responders who did not use drugs, help seeking was more likely when: the responder was older or female, the victim was a stranger or client, and when naloxone did not work. Among responders who used drugs, help seeking was more likely when: the responder was female or had not previously reported responding to an overdose, the victim was a stranger or client or did not use fentanyl, naloxone took a longer time to work, and when the overdose was public or occurred more recently. The percentage of overdoses where help seeking occurred reached a maximum in 2016 at 50%. CONCLUSIONS Help seeking by OEND enrollees was significantly associated with several responder, victim, and event characteristics. Targeted interventions to promote help seeking are warranted, particularly as the lethality of opioid supplies rises.
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Affiliation(s)
- Jamie K Lim
- Department of Pediatrics, Boston Medical Center, 1 Boston Medical Center Place, Boston, MA, 02118, USA.
| | - Leah S Forman
- Biostatistics and Epidemiology Data Analytics Center, Boston University School of Public Health, 715 Albany St., Boston, MA, 02118, USA.
| | - Sarah Ruiz
- Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health, 305 South St., Jamaica Plain, MA, 02130, USA; Bureau of Substance Addiction Services, Massachusetts Department of Public Health, 250 Washington Street, Boston, MA, 02108, USA.
| | - Ziming Xuan
- Department of Community Health Sciences, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA, 02118, USA; Grayken Center for Addiction, Section of General Internal Medicine, Department of Medicine, Boston Medical Center and Boston University School of Medicine, 801 Massachusetts Ave., Boston, MA, 02118, USA.
| | - Barry P Callis
- Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health, 305 South St., Jamaica Plain, MA, 02130, USA.
| | - Kevin Cranston
- Bureau of Infectious Disease and Laboratory Sciences, Massachusetts Department of Public Health, 305 South St., Jamaica Plain, MA, 02130, USA.
| | - Alexander Y Walley
- Grayken Center for Addiction, Section of General Internal Medicine, Department of Medicine, Boston Medical Center and Boston University School of Medicine, 801 Massachusetts Ave., Boston, MA, 02118, USA; Bureau of Substance Addiction Services, Massachusetts Department of Public Health, 250 Washington Street, Boston, MA, 02108, USA.
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Pizzicato LN, Johnson CC, Viner KM. Correlates of experiencing and witnessing non-fatal opioid overdoses among individuals accessing harm reduction services in Philadelphia, Pennsylvania. Subst Abus 2019; 41:301-306. [DOI: 10.1080/08897077.2019.1675115] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Lia N. Pizzicato
- Philadelphia Department of Public Health, Office of the Health Commissioner, Philadelphia, PA, USA
- Applied Epidemiology Fellowship, CSTE, Atlanta, Georgia, USA
| | - Caroline C. Johnson
- Philadelphia Department of Public Health, Office of the Health Commissioner, Philadelphia, PA, USA
| | - Kendra M. Viner
- Philadelphia Department of Public Health, Office of the Health Commissioner, Philadelphia, PA, USA
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Abstract
OBJECTIVES Unintentional opioid overdose deaths are a public health crisis, and naloxone is the most effective harm reduction tool to curb many of these deaths. There is growing evidence that take-home naloxone can prevent opioid overdose in targeted populations. The goal of this study is to measure the opioid overdose reversal rate with take-home naloxone among participants with a diagnosis of opioid use disorder (OUD) in an opioid treatment program (OTP) setting. METHODS Patients enrolled in an outpatient OTP program were eligible for this prospective cohort study between April 4, 2016 and July 4, 2016. Two hundred forty-four study participants received overdose education, instruction on how to use naloxone, and were provided with 2 doses of a take-home naloxone auto-injector kit. They were subsequently followed for 3 months. RESULTS Thirty-one study participants reported overdose reversals using naloxone auto-injector kits on 38 community members. All overdose reversals were heroin-related. Eighty-seven per cent of the community members reversed with naloxone were friends or relatives of the study participants. CONCLUSIONS This study validates that naloxone is not commonly used on the index study participant, but is often used on a secondary target among people who inject drugs. The large number of overdose reversals reported in this prospective study suggests that this novel model for naloxone use may be replicated at other OTP settings to reduce opioid overdose deaths.
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Olsen A, Lawton B, Dwyer R, Taing MW, Chun KLJ, Hollingworth S, Nielsen S. Why aren't Australian pharmacists supplying naloxone? Findings from a qualitative study. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 69:46-52. [PMID: 31078908 DOI: 10.1016/j.drugpo.2019.03.020] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 02/28/2019] [Accepted: 03/01/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Opioid overdose is a significant public health issue among people who use pharmaceutical opioids and/or heroin. One response to reducing overdose deaths is to expand public access to naloxone. The Australian Therapeutic Goods Administration down-scheduled naloxone from prescription only (S4) to pharmacist only over-the-counter (OTC, schedule 3) in February 2016. There is little research examining pharmacists' perspectives or experiences of this change. METHODS Thirty-seven semi-structured interviews with Australian community pharmacists were conducted in 2016-2017 to investigate pharmacists' attitudes to and experiences of OTC naloxone. Transcripts were thematically analysed, guided by a broad interest in facilitators and barriers to OTC supply. RESULTS Around half of the pharmacists were aware of the down-scheduling and only two had provided OTC naloxone. Core barriers to pharmacist provision of OTC naloxone included limited understanding of opioid overdose, confusion about the role and responsibilities of pharmacists in providing OTC naloxone, concerns about business, stigma related to people who inject drugs (PWID) and system-level challenges. CONCLUSION Pharmacy provision of OTC naloxone offers an important opportunity to reduce overdose mortality. Our study suggests this opportunity is yet to be realised and highlights several individual- and structural-level impediments hindering the expansion of public access to naloxone via community pharmacies. There is a need to develop strategies to improve pharmacists' knowledge of OTC naloxone and opioid overdose as well as to address other logistical and cultural barriers that limit naloxone provision in pharmacy settings. These need to be addressed at the individual level (training) as well as the system level (information, regulation and supply).
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Affiliation(s)
- Anna Olsen
- National Centre for Epidemiology and Population Health, Australian National University, Acton ACT, 0200, Australia.
| | - Belinda Lawton
- Crawford School of Public Policy, Australian National University, Acton ACT, 0200, Australia
| | - Robyn Dwyer
- Centre for Alcohol Policy Research, LaTrobe University, Bundoora Vic, 3086, Australia
| | - Meng-Wong Taing
- School of Pharmacy, University of Queensland, Brisbane St Lucia, Queensland, 4072, Australia; Centre for Optimising Pharmacy Practice-based Excellence in Research, The University of Queensland, Brisbane, Queensland, Australia
| | - Ka Lai Joyce Chun
- School of Pharmacy, University of Queensland, Brisbane St Lucia, Queensland, 4072, Australia
| | - Samantha Hollingworth
- School of Pharmacy, University of Queensland, Brisbane St Lucia, Queensland, 4072, Australia
| | - Suzanne Nielsen
- National Drug and Alcohol Research Centre, University of New South Wales, Randwick New South Wales, 2031, Australia; Monash Addiction Research Centre, Monash University, Frankston, Victoria, 31699, Australia
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Neale J, Brown C, Campbell ANC, Jones JD, Metz VE, Strang J, Comer SD. How competent are people who use opioids at responding to overdoses? Qualitative analyses of actions and decisions taken during overdose emergencies. Addiction 2019; 114:708-718. [PMID: 30476356 PMCID: PMC6411430 DOI: 10.1111/add.14510] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 10/29/2018] [Accepted: 11/21/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND AIMS Providing take-home naloxone (THN) to people who use opioids is an increasingly common strategy for reversing opioid overdose. However, implementation is hindered by doubts regarding the ability of people who use opioids to administer naloxone and respond appropriately to overdoses. We aimed to increase understanding of the competencies required and demonstrated by opioid users who had recently participated in a THN programme and were subsequently confronted with an overdose emergency. DESIGN Qualitative study designed to supplement findings from a randomized controlled trial of overdose education and naloxone distribution. Interviews were audio-recorded, transcribed, systematically coded and analysed via Iterative Categorization. SETTING New York City, USA. PARTICIPANTS Thirty-nine people who used opioids (32 men, 7 women; aged 22-58 years). INTERVENTION Trial participants received brief or extended overdose training and injectable or nasal naloxone. MEASUREMENTS The systematic coding frame comprised deductive codes based on the topic guide and more inductive codes emerging from the data. FINDINGS In 38 of 39 cases the victim was successfully resuscitated; the outcome of one overdose intervention was unknown. Analyses revealed five core overdose response 'tasks': (1) overdose identification; (2) mobilizing support; (3) following basic first aid instructions; (4) naloxone administration; and (5) post-resuscitation management. These tasks comprised actions and decisions that were themselves affected by diverse cognitive, emotional, experiential, interpersonal and social factors over which lay responders often had little control. Despite this, participants demonstrated high levels of competency. They had acquired new skills and knowledge through training and brought critical 'insider' understanding to overdose events and the resuscitation actions which they applied. CONCLUSIONS People who use opioids can be trained to respond appropriately to opioid overdoses and thus to save their peers' lives. Overdose response requires both practical competency (e.g. skills and knowledge in administering basic first aid and naloxone) and social competency (e.g. willingness to help others, having the confidence to be authoritative and make decisions, communicating effectively and demonstrating compassion and care to victims post-resuscitation).
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Affiliation(s)
- Joanne Neale
- National Addiction Centre, King's College London, London, UK
- Centre for Social Research in Health, University of New South Wales, Sydney, Australia
| | - Caral Brown
- National Addiction Centre, King's College London, London, UK
| | - Aimee N C Campbell
- Division on Substance Use Disorders, Columbia University Medical Center and New York State Psychiatric Institute, New York, USA
| | - Jermaine D Jones
- Division on Substance Use Disorders, Columbia University Medical Center and New York State Psychiatric Institute, New York, USA
| | - Verena E Metz
- Division on Substance Use Disorders, Columbia University Medical Center and New York State Psychiatric Institute, New York, USA
| | - John Strang
- National Addiction Centre, King's College London, London, UK
| | - Sandra D Comer
- Division on Substance Use Disorders, Columbia University Medical Center and New York State Psychiatric Institute, New York, USA
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Bowles JM, Lankenau SE. "I Gotta Go With Modern Technology, So I'm Gonna Give 'em the Narcan": The Diffusion of Innovations and an Opioid Overdose Prevention Program. QUALITATIVE HEALTH RESEARCH 2019; 29:345-356. [PMID: 30311841 DOI: 10.1177/1049732318800289] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Fatal opioid overdoses can be prevented by opioid overdose prevention programs (OOPPs). The present study qualitatively examined the diffusion process of an OOPP among 30 persons who inject drugs (PWIDs) in an opioid-saturated community. Purposive sampling was used to recruit participants into three groups based on familiarity with the OOPP. Findings revealed that participants often adopted the OOPP, which was offered by a local harm reduction organization, if first exposed by staff hosting and implementing it. Barriers to adoption included belief that OOPP training was lengthy or unnecessary, lack of perceived relative advantage, nonengagement with the host organization, and trepidation of administering withdrawal-causing medication to fellow PWIDs. Participants outside of networks diffusing the OOPP were isolated from other PWIDs. Staff from the host organization were influential in encouraging OOPP adoption, which underscores their importance in the effort to reduce fatal overdoses.
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Samuels EA, Baird J, Yang ES, Mello MJ. Adoption and Utilization of an Emergency Department Naloxone Distribution and Peer Recovery Coach Consultation Program. Acad Emerg Med 2019; 26:160-173. [PMID: 30074673 DOI: 10.1111/acem.13545] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 06/29/2018] [Accepted: 07/14/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Rising rates of opioid overdose deaths require innovative programs to prevent and reduce opioid-related morbidity and mortality. This study evaluates adoption, utilization, and maintenance of an emergency department (ED) take-home naloxone and peer recovery coach consultation program for ED patients at risk of opioid overdose. METHODS Using a Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework, we conducted a retrospective provider survey and electronic medical record (EMR) review to evaluate implementation of a naloxone distribution and peer recovery coach consultation program at two EDs. Provider adoption was measured by self-report using a novel survey instrument. EMRs of discharged ED patients at risk for opioid overdose were reviewed in three time periods: preimplementation, postimplementation, and maintenance. Primary study outcomes were take-home naloxone provision and recovery coach consultation. Secondary study outcome was referral to treatment. Chi-square analysis was used for study period comparisons. Logistic regression was conducted to examine utilization moderators. Poisson regression modeled utilization changes over time. RESULTS Most providers reported utilization (72.8%, 83/114): 95.2% (79/83) provided take-home naloxone and 85.5% (71/83) consulted a recovery coach. There were 555 unique patients treated and discharged during the study periods: 131 preimplementation, 376 postimplementation, and 48 maintenance. Postimplementation provision of take-home naloxone increased from none to more than one-third (35.4%, p < 0.001), one-third received consultation with a recovery coach (33.1%, 45/136), and discharge with referral to treatment increased from 9.16% to 20.74% (p = 0.003). Take-home naloxone provision and recovery coach consultation did not depreciate over time. CONCLUSIONS ED naloxone distribution and consultation of a community-based peer recovery coach are feasible and acceptable and can be maintained over time.
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Affiliation(s)
- Elizabeth A. Samuels
- Department of Emergency Medicine Alpert Medical School of Brown University Providence RI
| | - Janette Baird
- Department of Emergency Medicine Alpert Medical School of Brown University Providence RI
| | | | - Michael J. Mello
- Department of Emergency Medicine Alpert Medical School of Brown University Providence RI
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Behar E, Chang JS, Countess K, Matheson T, Santos GM, Coffin P. Perceived Causes of Personal versus Witnessed Overdoses among People who Inject Opioids. Subst Use Misuse 2019; 54:1929-1937. [PMID: 31070106 PMCID: PMC7185847 DOI: 10.1080/10826084.2019.1609988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: Studies show that people who inject drugs (PWID) underestimate their overdose risk. We sought to explore this phenomenon by comparing how PWID perceive causes of personal overdoses compared to witnessed overdoses. Methods: We analyzed 40 interviews from participants enrolled in a randomized-controlled behavioral intervention to reduce overdose among at-risk PWID in San Francisco from 2014 to 2016. Subjects were current illicit opioid injectors with opioid use disorder, had received take-home naloxone, and had overdosed within five years. Interviews were audio-recorded and transcribed verbatim. Using thematic content analysis, three analysts coded the interviews and measured interrater reliability. The analysts developed a codebook of a priori and inductively generated codes, and applied it to all interviews. Coding discrepancies were discussed. Results: We used two theoretical frameworks - actor observer bias (AOB) and intragroup stigma - to analyze participants' descriptions of personal and witnessed overdoses. AOB suggests individuals may assign responsibility of their actions to external factors, while assigning responsibility for others' actions to internal mechanisms. Intragroup stigma describes the process whereby people perpetuate stigma within their own group. Related to these concepts, two principal themes were used to describe personal overdose: (1) drug volatility and (2) ascribing blame to others, and witnessed overdoses: (1) greed and (2) inexperience/foolishness. Conclusion/Importance: The differences in perceived causes of personal versus witnessed overdose align with AOB and intragroup stigma. Understanding how these theories shape overdose experiences may improve behavioral interventions by introducing peer based supports and encouraging PWIDs to employ evidence-based safety precautions when using opioids.
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Affiliation(s)
- Emily Behar
- San Francisco Department of Public Health , San Francisco , California , USA.,University of California , San Francisco , California , USA
| | | | - Kennedy Countess
- San Francisco Department of Public Health , San Francisco , California , USA
| | - Tim Matheson
- San Francisco Department of Public Health , San Francisco , California , USA
| | - Glenn-Milo Santos
- San Francisco Department of Public Health , San Francisco , California , USA.,University of California , San Francisco , California , USA
| | - Phillip Coffin
- San Francisco Department of Public Health , San Francisco , California , USA.,University of California , San Francisco , California , USA
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Huxley-Reicher Z, Maldjian L, Winkelstein E, Siegler A, Paone D, Tuazon E, Nolan ML, Jordan A, MacDonald R, Kunins HV. Witnessed overdoses and naloxone use among visitors to Rikers Island jails trained in overdose rescue. Addict Behav 2018; 86:73-78. [PMID: 29175025 DOI: 10.1016/j.addbeh.2017.11.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 11/06/2017] [Accepted: 11/15/2017] [Indexed: 10/18/2022]
Abstract
With the opioid overdose mortality rates rising nationally, The New York City Department of Health and Mental Hygiene (NYC DOHMH) has worked to expand overdose rescue training (ORT) and naloxone distribution. This study sought to determine rates of overdose witnessing and naloxone use among overdose rescue-trained visitors to the NYC jails on Rikers Island. We conducted a six-month prospective study of visitors to NYC jails on Rikers Island who received ORT. We collected baseline characteristics of study participants, characteristics of overdose events, and responses to witnessed overdose events, including whether the victim was the incarcerated individual the participant was visiting on the day of training. Bivariate analyses compared baseline characteristics of participants who witnessed overdoses to those who did not, and of participants who used naloxone to those who did not. Overall, we enrolled 283 participants visiting NYC's Rikers Island jails into the study. Six months after enrollment, we reached 226 participants for follow-up by phone. 40 participants witnessed 70 overdose events, and 28 participants reported using naloxone. Of the 70 overdose events, three victims were the incarcerated individuals visited on the day of training; nine additional victims were recently released from jail and/or prison. Visitors to persons incarcerated at Rikers Island witness overdose events and are able to perform overdose rescues with naloxone. This intervention reaches a population that includes not only those recently released, but also other people who experienced overdose.
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43
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Peglow SL, Binswanger IA. Preventing Opioid Overdose in the Clinic and Hospital: Analgesia and Opioid Antagonists. Med Clin North Am 2018; 102:621-634. [PMID: 29933819 PMCID: PMC6029888 DOI: 10.1016/j.mcna.2018.02.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Drawing from existing opioid prescribing guidelines, this article describes how medical providers can reduce the risk of overdose. Through primary prevention, providers can prevent initial exposure and associated risks by educating patients, using risk stratification, minimizing opioid dose and duration, and avoiding coprescribing with sedatives. Secondary prevention efforts include monitoring patients with urine toxicology and prescription monitoring programs, and screening for opioid use disorders. Tertiary prevention includes treating opioid use disorders and providing naloxone to prevent overdose death. Specific preventive strategies may be required for those with psychiatric disorders or substance use disorders, adolescents, the elderly, and pregnant women.
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Affiliation(s)
- Stephanie Lee Peglow
- Department of Psychiatry and Behavioral Sciences, Eastern Virginia Medical School, 825 Fairfax Avenue Suite 710, Norfolk, VA 23507, USA.
| | - Ingrid A Binswanger
- Institute for Health Research, Kaiser Permanente Colorado, 2550 South Parker Road, Suite 200, Aurora, CO 80014, USA; Division of General Internal Medicine, Department of Medicine, University of Colorado, 12631 East 17th Avenue, Academic Office One, Campus Box B180, Aurora, CO 80045, USA
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Latkin CA, Edwards C, Davey-Rothwell MA, Yang C, Tobin KE. The relationship between drug use settings, roles in the drug economy, and witnessing a drug overdose in Baltimore, Maryland. Subst Abus 2018; 39:384-389. [PMID: 29432084 DOI: 10.1080/08897077.2018.1439801] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND There has been a dramatic increase in drug overdose deaths in the United States. In the current study, the authors examined factors associated with witnessing a drug overdose. METHODS A sample of 450 substance users in Baltimore, Maryland, were recruited for a behavioral intervention and were administered a survey. Multinomial logistic regression models were used to compare participants who never witnessed a drug overdose with those who witnessed one in the prior 6 months and those who witnessed an overdose over 6 months ago. RESULTS Most (58%) participants were male, 40% experienced homelessness in the prior 6 months, 63% reported a history of heroin injecting, 84% had snorted heroin, 75% reported witnessing a drug overdose, and 38% experienced an overdose. In multinomial logistic regression models, witnessing an overdose in the past 6 months was associated with number of different types of places where drugs were used (adjusted odds ratio [aOR] = 1.34), history of experiencing an overdose (aOR = 1.80), injecting heroin and/or speedball (aOR = 1.78), and snorting heroin (aOR = 1.54). Witnessing an overdose more than 6 months ago was associated with number of different places where drugs were used (aOR = 1.25), history of experiencing an overdose (aOR = 1.61), snorting heroin (aOR = 1.42), and injecting heroin or speedball (aOR = 1.47). CONCLUSIONS These data suggest that people who engage in more public and frequent drug use, and hence are more likely to witness an overdose, should be targeted for interventions to prevent and treat drug overdose.
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Affiliation(s)
- Carl A Latkin
- a Department of Health , Behavior, and Society, Johns Hopkins Bloomberg School of Public Health , Baltimore , Maryland , USA
| | - Catie Edwards
- a Department of Health , Behavior, and Society, Johns Hopkins Bloomberg School of Public Health , Baltimore , Maryland , USA
| | - Melissa A Davey-Rothwell
- a Department of Health , Behavior, and Society, Johns Hopkins Bloomberg School of Public Health , Baltimore , Maryland , USA
| | - Cui Yang
- a Department of Health , Behavior, and Society, Johns Hopkins Bloomberg School of Public Health , Baltimore , Maryland , USA
| | - Karin E Tobin
- a Department of Health , Behavior, and Society, Johns Hopkins Bloomberg School of Public Health , Baltimore , Maryland , USA
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Jacobson AN, Bratberg JP, Monk M, Ferrentino J. Retention of student pharmacists' knowledge and skills regarding overdose management with naloxone. Subst Abus 2018; 39:193-198. [DOI: 10.1080/08897077.2018.1439797] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Affiliation(s)
- Anita N. Jacobson
- College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA
| | - Jeffrey P. Bratberg
- College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA
| | - Miranda Monk
- College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA
| | - John Ferrentino
- College of Pharmacy, University of Rhode Island, Kingston, Rhode Island, USA
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46
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Langham S, Wright A, Kenworthy J, Grieve R, Dunlop WCN. Cost-Effectiveness of Take-Home Naloxone for the Prevention of Overdose Fatalities among Heroin Users in the United Kingdom. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2018; 21:407-415. [PMID: 29680097 DOI: 10.1016/j.jval.2017.07.014] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 07/12/2017] [Accepted: 07/14/2017] [Indexed: 05/22/2023]
Abstract
BACKGROUND Heroin overdose is a major cause of premature death. Naloxone is an opioid antagonist that is effective for the reversal of heroin overdose in emergency situations and can be used by nonmedical responders. OBJECTIVE Our aim was to assess the cost-effectiveness of distributing naloxone to adults at risk of heroin overdose for use by nonmedical responders compared with no naloxone distribution in a European healthcare setting (United Kingdom). METHODS A Markov model with an integrated decision tree was developed based on an existing model, using UK data where available. We evaluated an intramuscular naloxone distribution reaching 30% of heroin users. Costs and effects were evaluated over a lifetime and discounted at 3.5%. The results were assessed using deterministic and probabilistic sensitivity analyses. RESULTS The model estimated that distribution of intramuscular naloxone, would decrease overdose deaths by around 6.6%. In a population of 200,000 heroin users this equates to the prevention of 2,500 premature deaths at an incremental cost per quality-adjusted life year (QALY) gained of £899. The sensitivity analyses confirmed the robustness of the results. CONCLUSIONS Our evaluation suggests that the distribution of take-home naloxone decreased overdose deaths by around 6.6% and was cost-effective with an incremental cost per QALY gained well below a £20,000 willingness-to-pay threshold set by UK decision-makers. The model code has been made available to aid future research. Further study is warranted on the impact of different formulations of naloxone on cost-effectiveness and the impact take-home naloxone has on the wider society.
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Affiliation(s)
| | | | | | - Richard Grieve
- London School of Hygiene and Tropical Medicine, London, UK
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47
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Rzasa Lynn R, Galinkin JL. Naloxone dosage for opioid reversal: current evidence and clinical implications. Ther Adv Drug Saf 2017; 9:63-88. [PMID: 29318006 DOI: 10.1177/2042098617744161] [Citation(s) in RCA: 210] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 11/03/2017] [Indexed: 12/18/2022] Open
Abstract
Opioid-related mortality is a growing problem in the United States, and in 2015 there were over 33,000 opioid-related deaths. To combat this mortality trend, naloxone is increasingly being utilized in a pre-hospital setting by emergency personnel and prescribed to laypersons for out-of-hospital administration. With increased utilization of naloxone there has been a subsequent reduction in mortality following an opioid overdose. Reversal of opioid toxicity may precipitate an opioid-withdrawal syndrome. At the same time, there is a risk of inadequate response or re-narcotization after the administration of a single dose of naloxone in patients who have taken large doses or long-acting opioid formulations, as the duration of effect of naloxone is shorter than that of many opioid agonists. As out-of-hospital use of this medication is growing, so too is concern about effective but safe dosing.
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Affiliation(s)
| | - J L Galinkin
- University of Colorado at Denver, Anschutz Medical Campus, 13123 East 16th Avenue, B090, Aurora, CO 80045-0508, USA
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Petterson AG, Madah-Amiri D. Overdose prevention training with naloxone distribution in a prison in Oslo, Norway: a preliminary study. Harm Reduct J 2017; 14:74. [PMID: 29162122 PMCID: PMC5696738 DOI: 10.1186/s12954-017-0200-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Accepted: 11/14/2017] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND Prison inmates face a ten times increased risk of experiencing a fatal drug overdose during their first 2 weeks upon release than their non-incarcerated counterparts. Naloxone, the antidote to an opioid overdose, has been shown to be feasible and effective when administered by bystanders. Given the particular risk that newly released inmates face, it is vital to assess their knowledge about opioid overdoses, as well as the impact of brief overdose prevention training conducted inside prisons. METHODS Prison inmates nearing release (within 6 months) in Oslo, Norway, voluntarily underwent a brief naloxone training. Using a questionnaire, inmates were assessed immediately prior to and following a naloxone training. Descriptive statistics were performed for main outcome variables, and the Wilcoxon signed-rank test was used to compare the participants' two questionnaire scores from pre-and post-training. RESULTS Participating inmates (n = 31) were found to have a high baseline knowledge of risk factors, symptoms, and care regarding opioid overdoses. Nonetheless, a brief naloxone training session prior to release significantly improved knowledge scores in all areas assessed (p < 0.001). The training appears to be most beneficial in improving knowledge regarding the naloxone, including its use, effect, administration, and aftercare procedures. CONCLUSIONS Given the high risk of overdosing that prison inmates face upon release, the need for prevention programs is critical. Naloxone training in the prison setting may be an effective means of improving opioid overdose response knowledge for this particularly vulnerable group. Naloxone training provided in the prison setting may improve the ability of inmates to recognize and manage opioid overdoses after their release; however, further studies on a larger scale are needed.
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Affiliation(s)
- Aase Grønlien Petterson
- Norwegian Centre for Addiction Research, Institute of Clinical Medicine, University of Oslo, P.O. Box 1039 Blindern, 0315 Oslo, Norway
| | - Desiree Madah-Amiri
- Norwegian Centre for Addiction Research, Institute of Clinical Medicine, University of Oslo, P.O. Box 1039 Blindern, 0315 Oslo, Norway
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Espelt A, Bosque-Prous M, Folch C, Sarasa-Renedo A, Majó X, Casabona J, Brugal MT. Is systematic training in opioid overdose prevention effective? PLoS One 2017; 12:e0186833. [PMID: 29088247 PMCID: PMC5663400 DOI: 10.1371/journal.pone.0186833] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 10/09/2017] [Indexed: 12/03/2022] Open
Abstract
The objectives were to analyze the knowledge about overdose prevention, the use of naloxone, and the number of fatal overdoses after the implementation of Systematic Training in Overdose Prevention (STOOP) program. We conducted a quasi-experimental study, and held face-to-face interviews before (n = 725) and after (n = 722) implementation of systematic training in two different samples of people who injected opioids attending harm reduction centers. We asked participants to list the main causes of overdose and the main actions that should be taken when witnessing an overdose. We created two dependent variables, the number of (a) correct and (b) incorrect answers. The main independent variable was Study Group: Intervention Group (IG), Comparison Group (CG), Pre-Intervention Group With Sporadic Training in Overdose Prevention (PREIGS), or Pre-Intervention Group Without Training in Overdose Prevention (PREIGW). The relationship between the dependent and independent variables was assessed using a multivariate Poisson regression analysis. Finally, we conducted an interrupted time series analysis of monthly fatal overdoses before and after the implementation of systematic program during the period 2006–2015. Knowledge of overdose prevention increased after implementing systematic training program. Compared to the PREIGW, the IG gave more correct answers (IRR = 1.40;95%CI:1.33–1.47), and fewer incorrect answers (IRR = 0.33;95%CI:0.25–0.44). Forty percent of people who injected opioids who received a naloxone kit had used the kit in response to an overdose they witnessed. These courses increase knowledge of overdose prevention in people who use opioids, give them the necessary skills to use naloxone, and slightly diminish the number of fatal opioid overdoses in the city of Barcelona.
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Affiliation(s)
- Albert Espelt
- Agència de Salut Pública de Barcelona, Plaça Lesseps, Barcelona, Spain
- Centros de Investigación Biomédica en Red. Epidemiología y Salud Pública (CIBERESP), Calle Melchor Fernández Almagro, Madrid, Spain
- Facultat de Ciències de la Salut de Manresa, Universitat de Vic Universitat Central de Catalunya (UVicUCC), Av. Universitària, Manresa, Spain
- Departament de Psicobiologia i Metodologia en Ciències de la Salut, Universitat Autònoma de Barcelona, Campus UAB, Bellaterra, Spain
- * E-mail:
| | | | - Cinta Folch
- Centre d'Estudis Epidemiològics sobre les Infeccions de Transmissió Sexual i Sida de Catalunya (CEEISCAT), Agència de Salut Pública de Catalunya (ASPC), Generalitat de Catalunya, Carretera Canyet s/n, Badalona, Spain
| | - Ana Sarasa-Renedo
- Agència de Salut Pública de Barcelona, Plaça Lesseps, Barcelona, Spain
- Programa de Epidemiología Aplicada y de Campo (PEAC), Instituto de Salud Carlos III, Calle Sinesio Delgado, Madrid, Spain
| | - Xavier Majó
- Subdirecció General de Drogodependències, Departament de Salut de la Generalitat de Catalunya, Carrer de Roc Boronat, Barcelona, Spain
| | - Jordi Casabona
- Subdirecció General de Drogodependències, Departament de Salut de la Generalitat de Catalunya, Carrer de Roc Boronat, Barcelona, Spain
| | - M. Teresa Brugal
- Agència de Salut Pública de Barcelona, Plaça Lesseps, Barcelona, Spain
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Abstract
The present clinical case discussion focuses on a patient with comorbid substance use disorder (SUD) and chronic pain, who experienced an overdose of heroin. The case illustrates the complex array of risk factors that contribute to overdose risk, discusses the use of naloxone, and highlights the need for further risk mitigation interventions in patients at risk for overdose.
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