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Walters SM, Baker R, Frank D, Fadanelli M, Rudolph AE, Zule W, Fredericksen RJ, Bolinski R, Sibley AL, Go VF, Ouellet LJ, Pho MT, Seal DW, Feinberg J, Smith G, Young AM, Stopka TJ. Strategies used to reduce harms associated with fentanyl exposure among rural people who use drugs: multi-site qualitative findings from the rural opioid initiative. Harm Reduct J 2024; 21:154. [PMID: 39182116 PMCID: PMC11344336 DOI: 10.1186/s12954-024-01062-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 07/17/2024] [Indexed: 08/27/2024] Open
Abstract
AIM Illicitly manufactured fentanyl and its analogs are the primary drivers of opioid overdose deaths in the United States (U.S.). People who use drugs may be exposed to fentanyl or its analogs intentionally or unintentionally. This study sought to identify strategies used by rural people who use drugs to reduce harms associated with unintentional fentanyl exposure. METHODS This analysis focused on 349 semi-structured qualitative interviews across 10 states and 58 rural counties in the U.S conducted between 2018 and 2020. Interview guides were collaboratively standardized across sites and included questions about drug use history (including drugs currently used, frequency of use, mode of administration) and questions specific to fentanyl. Deductive coding was used to code all data, then inductive coding of overdose and fentanyl codes was conducted by an interdisciplinary writing team. RESULTS Participants described being concerned that fentanyl had saturated the drug market, in both stimulant and opioid supplies. Participants utilized strategies including: (1) avoiding drugs that were perceived to contain fentanyl, (2) buying drugs from trusted sources, (3) using fentanyl test strips, 4) using small doses and non-injection routes, (5) using with other people, (6) tasting, smelling, and looking at drugs before use, and (7) carrying and using naloxone. Most people who used drugs used a combination of these strategies as there was an overwhelming fear of fatal overdose. CONCLUSION People who use drugs living in rural areas of the U.S. are aware that fentanyl is in their drug supply and use several strategies to prevent associated harms, including fatal overdose. Increasing access to harm reduction tools (e.g., fentanyl test strips, naloxone) and services (e.g., community drug checking, syringe services programs, overdose prevention centers) should be prioritized to address the polysubstance-involved overdose crisis. These efforts should target persons who use opioids and other drugs that may contain fentanyl.
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Affiliation(s)
- Suzan M Walters
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA.
| | - Robin Baker
- Learning Design and Innovation, Dartmouth College, Hanover, NH, USA
| | - David Frank
- Department of Social and Behavioral Health, School of Global Public Health, New York University, New York, NY, USA
| | - Monica Fadanelli
- Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Abby E Rudolph
- Department of Epidemiology and Biostatistics, Temple University College of Public Health, Philadelphia, PA, USA
| | - William Zule
- RTI International, Research Triangle Park, NC, USA
| | | | | | - Adams L Sibley
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | - Vivian F Go
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina-Chapel Hill, Chapel Hill, NC, USA
| | - Lawrence J Ouellet
- Division of Epidemiology and Biostatistics, School of Public Health, University of Illinois Chicago, Chicago, IL, USA
| | - Mai T Pho
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - David W Seal
- Social, Behavioral, and Population Sciences, Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
| | - Judith Feinberg
- Departments of Behavioral Medicine and Psychiatry and Medicine/Infectious Diseases, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Gordon Smith
- Department of Epidemiology and Biostatistics, School of Public Health, West Virginia University, Morgantown, WV, USA
| | - April M Young
- Department of Epidemiology and Environmental Health, University of Kentucky College of Public Health, Lexington, KY, USA
| | - Thomas J Stopka
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA
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Agley J, Henderson C, Seo DC, Parker M, Golzarri-Arroyo L, Dickinson S, Tidd D. The Feasibility of Using the National PulsePoint Cardiopulmonary Resuscitation Responder Network to Facilitate Overdose Education and Naloxone Distribution: Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2024; 13:e57280. [PMID: 38551636 PMCID: PMC11015366 DOI: 10.2196/57280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Revised: 02/27/2024] [Accepted: 03/04/2024] [Indexed: 04/15/2024] Open
Abstract
BACKGROUND The use of naloxone, an opioid antagonist, is a critical component of the US response to fatal opioid-involved overdoses. The importance and utility of naloxone in preventing fatal overdoses have been widely declaimed by medical associations and government officials and are supported by strong research evidence. Still, there are gaps in the current US national strategy because many opioid-involved overdose fatalities have no evidence of naloxone administration. Improving the likelihood that naloxone will be used to prevent fatal overdoses is predicated on facilitating an environment wherein naloxone is available near each overdose and can be accessed by someone who is willing and able to use it. How to accomplish this on a national scale has been unclear. However, there exists a national network of >1 million cardiopulmonary resuscitation (CPR) layperson responders and 4800 emergency responder agencies linked through a mobile phone app called PulsePoint Respond. PulsePoint responders certify that they are trained to administer CPR and are willing to respond to possible cardiac events in public. When such an event occurs near their mobile phone's location, they receive an alert to respond. These motivated citizens are ideally positioned to carry naloxone and reverse overdoses that occur in public. OBJECTIVE This randomized controlled trial will examine the feasibility of recruiting first responder agencies and layperson CPR responders who already use PulsePoint to obtain overdose education and carry naloxone. METHODS This will be a 3-arm parallel-group randomized controlled trial. We will randomly select 180 first responder agencies from the population of agencies contracting with the PulsePoint Foundation. The 3 study arms will include a standard recruitment arm, a misperception-correction recruitment arm, and a control arm (1:1:1 allocation, with random allocation stratified by zip code designation [rural or nonrural]). We will study agency recruitment and, among the agencies we successfully recruit, responder certification of receiving overdose and naloxone education, carrying naloxone, or both. Hypothesis 1 contrasts agency recruitment success between arms 1 and 2, and hypothesis 2 contrasts the ratios of layperson certification across all 3 arms. The primary analyses will be a logistic regression comparing the recruitment rates among the arms, adjusting for rural or nonrural zip code designation. RESULTS This study was reviewed by the Indiana University Institutional Review Board (20218 and 20219). This project was funded beginning September 14, 2023, by the National Institute on Drug Abuse. CONCLUSIONS The hypotheses in this study will test whether a specific type of messaging is particularly effective in recruiting agencies and layperson responders. Although we hypothesize that arm 2 will outperform the other arms, our intention is to use the best-performing approach in the next phase of this study if any of our approaches demonstrates feasibility. TRIAL REGISTRATION OSF Registries osf.io/egn3z; https://osf.io/egn3z. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) PRR1-10.2196/57280.
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Affiliation(s)
- Jon Agley
- Prevention Insights, Department of Applied Health Science, School of Public Health Bloomington, Indiana University Bloomington, Bloomington, IN, United States
| | - Cris Henderson
- Prevention Insights, Department of Applied Health Science, School of Public Health Bloomington, Indiana University Bloomington, Bloomington, IN, United States
| | - Dong-Chul Seo
- Department of Applied Health Science, School of Public Health Bloomington, Indiana University Bloomington, Bloomington, IN, United States
| | - Maria Parker
- Department of Epidemiology and Biostatistics, School of Public Health Bloomington, Indiana University Bloomington, Bloomington, IN, United States
| | - Lilian Golzarri-Arroyo
- Biostatistics Consulting Center, School of Public Health Bloomington, Indiana University Bloomington, Bloomington, IN, United States
| | - Stephanie Dickinson
- Biostatistics Consulting Center, School of Public Health Bloomington, Indiana University Bloomington, Bloomington, IN, United States
| | - David Tidd
- Prevention Insights, Department of Applied Health Science, School of Public Health Bloomington, Indiana University Bloomington, Bloomington, IN, United States
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Walters SM, Felsher M, Frank D, Jaiswal J, Townsend T, Muncan B, Bennett AS, Friedman SR, Jenkins W, Pho MT, Fletcher S, Ompad DC. I Don't Believe a Person Has to Die When Trying to Get High: Overdose Prevention and Response Strategies in Rural Illinois. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1648. [PMID: 36674402 PMCID: PMC9864395 DOI: 10.3390/ijerph20021648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/10/2023] [Accepted: 01/13/2023] [Indexed: 06/17/2023]
Abstract
BACKGROUND Overdose is a leading cause of morbidity and mortality among people who inject drugs. Illicitly manufactured fentanyl is now a major driver of opioid overdose deaths. METHODS Semi-structured interviews were conducted with 23 participants (19 persons who inject drugs and 4 service providers) from rural southern Illinois. Data were analyzed using constant comparison and theoretical sampling methods. RESULTS Participants were concerned about the growing presence of fentanyl in both opioids and stimulants, and many disclosed overdose experiences. Strategies participants reported using to lower overdose risk included purchasing drugs from trusted sellers and modifying drug use practices by partially injecting and/or changing the route of transmission. Approximately half of persons who inject drugs sampled had heard of fentanyl test strips, however fentanyl test strip use was low. To reverse overdoses, participants reported using cold water baths. Use of naloxone to reverse overdose was low. Barriers to naloxone access and use included fear of arrest and opioid withdrawal. CONCLUSIONS People who inject drugs understood fentanyl to be a potential contaminant in their drug supply and actively engaged in harm reduction techniques to try to prevent overdose. Interventions to increase harm reduction education and information about and access to fentanyl test strips and naloxone would be beneficial.
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Affiliation(s)
- Suzan M. Walters
- Department of Epidemiology, School of Global Public Health, New York University, New York, NY 10003, USA
- Center for Drug Use and HIV/HCV Research, New York, NY 10003, USA
| | - Marisa Felsher
- College of Population Health, Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - David Frank
- Center for Drug Use and HIV/HCV Research, New York, NY 10003, USA
- Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY 10003, USA
| | - Jessica Jaiswal
- Department of Health Science, University of Alabama, Tuscaloosa, AL 35487, USA
| | - Tarlise Townsend
- Department of Population Health, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Brandon Muncan
- Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA
| | - Alex S. Bennett
- Center for Drug Use and HIV/HCV Research, New York, NY 10003, USA
- Department of Social and Behavioral Sciences, School of Global Public Health, New York University, New York, NY 10003, USA
| | - Samuel R. Friedman
- Center for Drug Use and HIV/HCV Research, New York, NY 10003, USA
- Department of Population Health, New York University Grossman School of Medicine, New York, NY 10016, USA
| | - Wiley Jenkins
- Department of Population Science and Policy, SIU School of Medicine, Springfield, IL 62702, USA
| | - Mai T. Pho
- Department of Medicine, University of Chicago, Chicago, IL 60637, USA
| | | | - Danielle C. Ompad
- Department of Epidemiology, School of Global Public Health, New York University, New York, NY 10003, USA
- Center for Drug Use and HIV/HCV Research, New York, NY 10003, USA
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Etling MA, Vik TA, Janota AD, Liang KL, Kryder‐Reid CL, Robertson M, Scanlon C, Carson A, Agley J, Severance TS. The continuing evolution of a cancer prevention, screening, and survivorship
ECHO
: A second year of implementation. Cancer Med 2022; 12:7398-7405. [PMID: 36504440 PMCID: PMC10067045 DOI: 10.1002/cam4.5441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 10/25/2022] [Accepted: 11/02/2022] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION An estimated 39,010 Indiana residents were diagnosed with cancer in 2021. To address the cancer burden, Project ECHO (Extension Community Healthcare Outcomes) was launched in 2019 in Indiana to build specialty healthcare capacity among non-specialists. Due to positive outcomes from the pilot year, the Cancer Prevention, Screening, and Survivorship ECHO was implemented for a second year. The purpose of this study was to measure the participation and regional impact of this ECHO. METHODS ECHO sessions occurred twice monthly from October 2020 to October 2021. Changes were implemented in response to feedback from the pilot year, including making the curriculum more practical for learners and adding accreditation opportunities. Participant information and feedback was extracted from electronic surveys for review. RESULTS There were 24 ECHO sessions with 213 unique participants, increased from 140 unique participants in the pilot year. An average of 23.5 individuals attended each session, increased from 15.5 individuals per session. Enrolled participants served in a diverse set of roles and represented 247 zip codes, 30 Indiana counties, and 32 states across the United States, each of which increased from the pilot year. DISCUSSION In this second year, this ECHO expanded to reach more participants with increased attendance and a more diverse distribution of roles within healthcare, which may be attributed to feedback-driven curriculum design. Cancer care is multi-disciplinary, with health educators, nurses, and administrators, each acting within the cancer care continuum. As a result, this ECHO has been adapted to serve an increasingly broad distribution of professionals. CONCLUSION The second year of the Cancer Prevention, Screening, and Survivorship ECHO displayed increased overall enrollment and participation, greater diversity among participant roles, and a wider reach across Indiana and the United States.
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Affiliation(s)
- Mary Ann Etling
- Indiana University School of Medicine Indianapolis Indiana USA
- Indiana University Richard M. Fairbanks School of Public Health Indianapolis Indiana USA
| | - Terry A. Vik
- Indiana University School of Medicine Indianapolis Indiana USA
- Riley Hospital for Children Indianapolis Indiana USA
- Riley Hospital Division of Pediatric Hematology Oncology Indianapolis Indiana USA
| | - Andrea D. Janota
- Indiana University Richard M. Fairbanks School of Public Health Indianapolis Indiana USA
| | - Kaley L. Liang
- Indiana University Richard M. Fairbanks School of Public Health Indianapolis Indiana USA
| | | | - Mary Robertson
- Indiana Cancer Consortium Indianapolis Indiana USA
- Indiana University Melvin and Bren Simon Comprehensive Cancer Center Indianapolis Indiana USA
| | | | - Anyé Carson
- Indiana University Richard M. Fairbanks School of Public Health Indianapolis Indiana USA
| | - Jon Agley
- Indiana University School of Public Health Bloomington Indiana USA
- Prevention Insights Bloomington Indiana USA
| | - Tyler S. Severance
- Indiana University School of Medicine Indianapolis Indiana USA
- Riley Hospital for Children Indianapolis Indiana USA
- Riley Hospital Division of Pediatric Hematology Oncology Indianapolis Indiana USA
- Department of Child Health University of Missouri School of Medicine Columbia Missouri USA
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Walters SM, Li WP, Saifi R, Azwa I, Syed Omar SF, Collier ZK, Amir Hassan AB, Haddad MS, Altice FL, Kamarulzaman A, Earnshaw VA. Barriers and Facilitators to Implementing Project ECHO in Malaysia During the COVID-19 Pandemic. J Int Assoc Provid AIDS Care 2022; 21:23259582221128512. [PMID: 36177542 PMCID: PMC9528038 DOI: 10.1177/23259582221128512] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Objective: In Malaysia, HIV is concentrated among key populations who experience barriers to care due to stigma and healthcare discrimination. The COVID-19 pandemic has increased barriers to healthcare. Project ECHO (Extension for Community Healthcare Outcomes) is a transformative tele-education strategy that could improve HIV prevention and treatment. Methods: Practicing physicians who were aged 18 years or older and had internet access participated in asynchronous online focus groups. Results: Barriers to Project ECHO were conflicting priorities, time constraints, and technology. Facilitators included content and format, dedicated time, asynchronized flexible programming, incentives, and ensuring technology was available. Conclusion: Project ECHO is a promising intervention that can increase physicians' knowledge and skill set in specialty medicine during the COVID-19 pandemic. Interventionists in Malaysia in particular, but also in general, should consider these barriers and facilitators when developing Project ECHO as they may aid in developing a more robust program and increase participation.
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Affiliation(s)
- Suzan M Walters
- Department of Epidemiology, 5894New York University School of Global Public Health, New York, NY, USA.,Center for Drug Use and HIV/HCV Research, New York, NY, USA
| | - Wong Pui Li
- Faculty of Medicine, 37447University of Malaya, Kuala Lumpur, Malaysia
| | - Rumana Saifi
- Faculty of Medicine, 37447University of Malaya, Kuala Lumpur, Malaysia.,Centre of Excellence for Research in AIDS, 37447University of Malaya, Kuala Lumpur, Malaysia
| | - Iskandar Azwa
- Faculty of Medicine, 37447University of Malaya, Kuala Lumpur, Malaysia
| | | | | | | | - Marwan S Haddad
- Center for Key Populations, 219813Community Health Center, Inc., New Britain, CT, USA
| | - Frederick L Altice
- Centre of Excellence for Research in AIDS, 37447University of Malaya, Kuala Lumpur, Malaysia.,Department of Internal Medicine, 12228Yale School of Medicine, Yale University, New Haven, CT, USA.,Yale School of Public Health, Yale University, New Haven, CT, USA
| | - Adeeba Kamarulzaman
- Faculty of Medicine, 37447University of Malaya, Kuala Lumpur, Malaysia.,Centre of Excellence for Research in AIDS, 37447University of Malaya, Kuala Lumpur, Malaysia
| | - Valerie A Earnshaw
- Department of Human Development and Family Sciences, 5972University of Delaware, Newark, DE, USA
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6
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Agley J, Delong J, Janota A, Carson A, Roberts J, Maupome G. Reflections on project ECHO: qualitative findings from five different ECHO programs. MEDICAL EDUCATION ONLINE 2021; 26:1936435. [PMID: 34076567 PMCID: PMC8174483 DOI: 10.1080/10872981.2021.1936435] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
Project ECHO (Extension for Community Healthcare Outcomes) was developed in 2003 as an innovative model to facilitate continuing education and professional development. ECHO emphasizes 'moving knowledge, not people.' To accomplish this, ECHO programs use virtual collaboration and case-based learning to allow practitioners, including those in rural and underserved areas, to receive specialist training. The ECHO model has expanded rapidly and is now used in 44 countries. Preliminary research on ECHO's efficacy and effectiveness has shown promising results, but evidence remains limited and appropriate research outcomes have not been clearly defined. To improve the evidence basis for ECHO, this study of 5 ECHO programs (cancer prevention/survivorship, integrated pain management, hepatitis C, HIV, and LGBTQ+ health care elucidated actionable insights about the ECHO programs and directions in which future evaluations and research might progress. This was a qualitative study following COREQ standards. A trained interviewer conducted 10 interviews and 5 focus groups with 25 unique, purposively sampled ECHO attendees (2 interviews and 1 focus group for each of the 5 programs). Data were transcribed verbatim and analyzed using the general inductive approach, then reviewed for reliability. We identified four major categories (reasons to join ECHO, value of participating in ECHO, ways to improve ECHO, and barriers to participation) composed of 23 primary codes. We suggest that thematic saturation was achieved, and a coherent narrative about ECHO emerged for discussion. Participants frequently indicated they received valuable learning experiences and thereby changed their practice; rigorous trials of learning and patient-level outcomes are warranted. This study also found support for the idea that the ECHO model should be studied for its role in convening communities of practice and reducing provider isolation as an outcome in itself. Additional implications, including for interprofessional education and model evolution, were also identified and discussed.
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Affiliation(s)
- Jon Agley
- Prevention Insights, Department of Applied Health Science, School of Public Health Bloomington, Indiana University Bloomington, Bloomington, Indiana, USA
- CONTACT Jon Agley Prevention Insights, Department of Applied Health Science, School of Public Health Bloomington, Indiana University Bloomington, 809 E. 9 St., Bloomington, Indiana, 47405, USA
| | - Janet Delong
- Prevention Insights, Department of Applied Health Science, School of Public Health Bloomington, Indiana University Bloomington, Bloomington, Indiana, USA
| | - Andrea Janota
- IUPUI ECHO Center & Center for Public Health Practice, Richard M. Fairbanks School of Public Health, Indiana University, Purdue University, Indianapolis (IUPUI), Indiana, USA
| | - Anyé Carson
- IUPUI ECHO Center & Center for Public Health Practice, Richard M. Fairbanks School of Public Health, Indiana University, Purdue University, Indianapolis (IUPUI), Indiana, USA
| | - Jeffrey Roberts
- Prevention Insights, Department of Applied Health Science, School of Public Health Bloomington, Indiana University Bloomington, Bloomington, Indiana, USA
| | - Gerardo Maupome
- Richard M. Fairbanks School of Public Health, Indiana University, Purdue University, Indianapolis (IUPUI), Indiana, USA
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