1
|
Aquizerate A, Rousselet M, Cochard A, Guerlais M, Gerardin M, Lefebvre E, Duval M, Laforgue EJ, Victorri-Vigneau C. "Naloxone? Not for me!" First cross-assessment by patients and healthcare professionals of the risk of opioid overdose. Harm Reduct J 2024; 21:20. [PMID: 38263159 PMCID: PMC10804588 DOI: 10.1186/s12954-024-00941-y] [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] [Received: 12/04/2023] [Accepted: 01/17/2024] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND Opioid-related mortality is a rising public health concern in France, where opioids were in 2021 implicated in 75% of overdose deaths. Opioid substitution treatment (OST) was implicated in almost half of deaths related to substance and drug abuse. Although naloxone could prevent 80% of these deaths, there are a number of barriers to the distribution of take-home naloxone (THN) among opioid users in France. This study is the first one which compares patients' self-assessment of the risk of future opioid overdose with the hetero-assessment provided by healthcare professionals in a population of individuals eligible for naloxone. METHODS This was a multicenter descriptive observational study carried out in pharmacies across the Pays de la Loire region (France) during April and May 2022. All adult patients who visited a participating pharmacy for a prescription of OST and provided oral informed consent were enrolled in the study. Retrospective data were collected through cross-sectional interviews conducted by the pharmacist with the patient, utilizing an ad hoc questionnaire. The patient's self-assessment of overdose risk was evaluated using a Likert scale from 0 to 10. The pharmacist relied on the presence or absence of overdose risk situations defined by the French Health Authority (HAS). The need to hold THN was assessed using a composite criterion. RESULTS A total of 34 patients were interviewed; near one third were aware of the existence of THN and a minority had THN in their possession. Out of the 34 participants, 29 assessed their own risk of future opioid overdose: 65.5% reported having zero risk, while 6.9% believed they had a high risk. Nevertheless, at least one risk situation of opioid overdose was identified according to HAS criteria in 73.5% of the participants (n = 25). Consequently, 55% of the participants underestimated their risk of experiencing a future opioid overdose. Yet, dispensing THN has been judged necessary for 88.2% of the participants. CONCLUSION This study underscored the imperative need to inform not only healthcare professionals but also the patients and users themselves on the availability of THN and the risk situations of opioid overdose.
Collapse
Affiliation(s)
- Aurélie Aquizerate
- Nantes Université, CHU Nantes, Centre d'Evaluation et d'Information sur la Pharmacodépendance-Addictovigilance (CEIP-A), Service de Pharmacologie Clinique, 44000, Nantes, France
| | - Morgane Rousselet
- Nantes Université, CHU Nantes, Centre d'Evaluation et d'Information sur la Pharmacodépendance-Addictovigilance (CEIP-A), Service de Pharmacologie Clinique, 44000, Nantes, France
- Nantes Université, Univ Tours, CHU Nantes, CHU Tours, INSERM, MethodS in Patients-Centered Outcomes and HEalth Research, SPHERE, 44000, Nantes, France
| | - Axel Cochard
- Nantes Université, CHU Nantes, Centre d'Evaluation et d'Information sur la Pharmacodépendance-Addictovigilance (CEIP-A), Service de Pharmacologie Clinique, 44000, Nantes, France
| | - Marylène Guerlais
- Nantes Université, CHU Nantes, Centre d'Evaluation et d'Information sur la Pharmacodépendance-Addictovigilance (CEIP-A), Service de Pharmacologie Clinique, 44000, Nantes, France
| | - Marie Gerardin
- Nantes Université, CHU Nantes, Centre d'Evaluation et d'Information sur la Pharmacodépendance-Addictovigilance (CEIP-A), Service de Pharmacologie Clinique, 44000, Nantes, France
| | - Emilie Lefebvre
- Nantes Université, CHU Nantes, Centre d'Evaluation et d'Information sur la Pharmacodépendance-Addictovigilance (CEIP-A), Service de Pharmacologie Clinique, 44000, Nantes, France
| | - Mélanie Duval
- Nantes Université, CHU Nantes, Centre d'Evaluation et d'Information sur la Pharmacodépendance-Addictovigilance (CEIP-A), Service de Pharmacologie Clinique, 44000, Nantes, France
| | - Edouard-Jules Laforgue
- Nantes Université, CHU Nantes, Centre d'Evaluation et d'Information sur la Pharmacodépendance-Addictovigilance (CEIP-A), Service de Pharmacologie Clinique, 44000, Nantes, France
- Nantes Université, Univ Tours, CHU Nantes, CHU Tours, INSERM, MethodS in Patients-Centered Outcomes and HEalth Research, SPHERE, 44000, Nantes, France
| | - Caroline Victorri-Vigneau
- Nantes Université, CHU Nantes, Centre d'Evaluation et d'Information sur la Pharmacodépendance-Addictovigilance (CEIP-A), Service de Pharmacologie Clinique, 44000, Nantes, France.
- Nantes Université, Univ Tours, CHU Nantes, CHU Tours, INSERM, MethodS in Patients-Centered Outcomes and HEalth Research, SPHERE, 44000, Nantes, France.
| |
Collapse
|
2
|
Urmanche AA, Harocopos A. Experiences Administering Naloxone Among People in Different Social Roles: People Who Use Opioids and Family Members and Friends. JOURNAL OF DRUG ISSUES 2023; 53:475-489. [PMID: 37829614 PMCID: PMC10569559 DOI: 10.1177/00220426221133024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
Unintentional drug overdose deaths continue to be a critical public health issue. Naloxone, a nonscheduled, safe, and effective drug that reverses opioid-involved overdoses is available to non-medically trained individuals ("lay people"), but there is scant information about how people in different social roles experience naloxone administration. We conducted 24 in-depth interviews with people who use opioids (PWUO; n = 15) and family members and friends of people who use opioids (FF; n = 9) who had administered naloxone in response to an opioid overdose. Compared with PWUO, members of the FF group were less reticent to administer naloxone in response to an overdose. PWUO and FF had different perspectives of law enforcement and demonstrated varied knowledge of the Good Samaritan Law. While PWUO found that having and administering naloxone was empowering, FF took a more pragmatic approach, reporting the need for naloxone as an unfortunate reality of their loved one's drug use.
Collapse
Affiliation(s)
- Adelya A Urmanche
- New York City Department of Health and Mental Hygiene, Bureau of Alcohol and Drug Use Prevention, Care and Treatment, NY, USA
| | - Alex Harocopos
- New York City Department of Health and Mental Hygiene, Bureau of Alcohol and Drug Use Prevention, Care and Treatment, NY, USA
| |
Collapse
|
3
|
Lindenfeld Z, Kim S, Chang JE. Assessing the effectiveness of problem-solving courts on the reduction of overdose deaths in the United States: A difference-in-difference study. DRUG AND ALCOHOL DEPENDENCE REPORTS 2022; 4:100088. [PMID: 36846580 PMCID: PMC9948897 DOI: 10.1016/j.dadr.2022.100088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 07/08/2022] [Accepted: 08/02/2022] [Indexed: 06/18/2023]
Abstract
BACKGROUND Criminal justice-involved populations are disproportionately more likely to have an active substance use disorder (SUD) and experience a fatal overdose. One way the criminal justice system connects individuals with SUDs to treatment is through problem-solving drug courts designed to divert offenders into treatment. The aim of this study is to assess the effect of drug court implementation on drug overdoses in U.S counties. METHODS A difference-in-difference analysis of publicly available data on problem-solving courts and monthly, county-level overdose death data, was completed to understand the difference in number of overdose deaths per county per year for counties with a drug court and those without. The time frame was 2000-2012, which included 630 courts serving 221 counties. RESULTS There was a significant effect of drug courts in reducing county overdose mortality by 2.924 (95% CI: -3.478 - -2.370), after controlling for annual trends. Additionally, having a higher number of outpatient SUD providers in the county (coefficient 0.092, 95% CI: 0.032 - 0.152), a higher proportion of uninsured population (coefficient 0.062, 95% CI: 0.052-0.072), and being in the Northeast region (coefficient 0.51, 95% CI: 0.313 - 0.707), was associated with higher county overdose mortality. CONCLUSIONS When considering responses to SUDs, our findings point towards drug courts as a useful component of a compendium of strategies to address opioid fatalities. Policymakers and local leaders who wish to engage the criminal justice system in efforts to address the opioid epidemic should be aware of this relationship.
Collapse
Affiliation(s)
- Zoe Lindenfeld
- Department of Public Health Policy and Management, School of Global Public Health, New York University, 726 Broadway, New York, NY 10012, United States of America
| | - Sooyoung Kim
- Department of Public Health Policy and Management, School of Global Public Health, New York University, 726 Broadway, New York, NY 10012, United States of America
| | - Ji Eun Chang
- Department of Public Health Policy and Management, School of Global Public Health, New York University, 726 Broadway, New York, NY 10012, United States of America
| |
Collapse
|
4
|
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.
Collapse
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.
| |
Collapse
|
5
|
Neale J, Farrugia A, Campbell AN, Dietze P, Dwyer R, Fomiatti R, Jones JD, Comer SD, Fraser S, Strang J. UNDERSTANDING PREFERENCES FOR TYPE OF TAKE-HOME NALOXONE DEVICE: INTERNATIONAL QUALITATIVE ANALYSIS OF THE VIEWS OF PEOPLE WHO USE OPIOIDS. DRUGS (ABINGDON, ENGLAND) 2022; 29:109-120. [PMID: 35813841 PMCID: PMC9268211 DOI: 10.1080/09687637.2021.1872499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background Take-home naloxone (THN) is provided to non-medically trained people to reverse potential opioid overdoses. There is an increasing range of effective intramuscular (IM) and intranasal (IN) naloxone devices and this paper explores the types preferred by people who use opioids, using consumer behaviour literature to interpret the findings. Methods Data derive from two unconnected qualitative studies involving audio-recorded semi-structured interviews. Study 1 was conducted in the United States (n=21 users of non-medical/illicit opioids). Study 2 was conducted in Australia (n=42 users of non-medical/illicit or prescribed opioids). Findings Most participants preferred IN naloxone. Preferences were based on the ease, speed, safety and comfort of each device and underpinned by accounts of overdose revivals as being very rushed and frightening situations. Preferences related to complex interactions between the naloxone device ('product'); the knowledge, skills, experience and attitudes of the lay responder ('consumer'), and when, where and how naloxone was to be used ('usage situation'). Conclusions THN programs should offer choice of device when possible and nasal naloxone if resources permit. Asking people which devices they prefer and why and treating them as valued consumers of naloxone products can generate insights that improve future naloxone technology and increase THN uptake and usage.
Collapse
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
| | | | - Aimee N. Campbell
- Division on Substance Use Disorders, Department of Psychiatry, New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, USA
| | - Paul Dietze
- Program on Behaviours and Health Risks, Burnet Institute, Melbourne, Australia.,National Drug Research Institute, Curtin University, Melbourne, Australia
| | - Robyn Dwyer
- Centre for Alcohol Policy Research, School of Psychology and Public Health, La Trobe University, Melbourne, Australia
| | - Renae Fomiatti
- Australian Research Centre in Sex, Health and Society, La Trobe University, Melbourne, Australia
| | - Jermaine D. Jones
- Division on Substance Use Disorders, Department of Psychiatry, New York State Psychiatric Institute and Columbia University Irving Medical Center, New York, USA
| | | | | | | |
Collapse
|
6
|
Hatteberg SJ, Kollath-Cattano C, Weller DS, Scully AE. Encountering Overdose: Examining the Contexts and Correlates of US College Students' Overdose Experiences. Subst Use Misuse 2022; 57:1599-1607. [PMID: 35877471 DOI: 10.1080/10826084.2022.2102188] [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: 10/16/2022]
Abstract
BACKGROUND As overdose rates increase, it is critical to better understand the causes and contexts of overdose, particularly for college students who exhibit high rates of alcohol and drug use. The purpose of this study was to examine the social contexts of U.S. college students' overdose experiences (their own, witnessed, and family'/friends'), and to assess the correlates of personal overdose. METHODS A cross-sectional survey containing open- and closed-ended questions about overdose encounters was completed by undergraduate students at a southeastern American university (n = 1,236). Descriptive frequencies assessed prevalence, substance involvement, and fatalities associated with different encounter types. A content analysis of open-ended responses examined the social contexts of encounters. Multivariate logistic regression was used to assess the correlates of personal overdose. RESULTS Forty-one percent of respondents reported at least one type of overdose encounter and witnessed overdose was most common. Substances involved varied across encounter type and 20-40% of respondents reported overdose-related fatalities. Students who encountered overdose often reported multiple experiences and many attributed overdoses to mixing substances. Respondents commonly encountered overdose as intervening bystanders and overdose events were often perceived to be intentional or the result of using substances to cope with stress/mental health concerns. Personal overdose was significantly associated with having ever mixed alcohol with prescription drugs, been diagnosed with a mental disorder, witnessed an overdose, and had a family member/friend overdose. CONCLUSION Findings suggest a need for future research into the contexts and consequences of students' overdose encounters to more effectively tailor overdose prevention/response initiatives within college communities.
Collapse
Affiliation(s)
- Sarah J Hatteberg
- Department of Sociology & Anthropology, College of Charleston, Charleston, South Carolina, USA
| | - Christy Kollath-Cattano
- Department of Health and Human Performance, College of Charleston, Charleston, South Carolina, USA
| | - Donald S Weller
- Department of Health and Human Performance, College of Charleston, Charleston, South Carolina, USA
| | - Anne E Scully
- Department of Health and Human Performance, College of Charleston, Charleston, South Carolina, USA
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
McDonald R, Parkin S, Eide D, Neale J, Clausen T, Metrebian N, Carter B, Strang J. Rethinking 'carriage' of take-home naloxone. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 95:103253. [PMID: 33848942 DOI: 10.1016/j.drugpo.2021.103253] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 03/22/2021] [Accepted: 03/24/2021] [Indexed: 10/21/2022]
Abstract
Take-home naloxone (THN) provision to people who use drugs, their family/friends, and non-medical personnel is considered a public health strategy to improve community-based naloxone access and reduce the time to antidote treatment for opioid overdose in order to prevent fatal outcome. THN programs typically report up to three performance indicators: the volume of THN kits distributed, the rate of requests for re-supply of THN kits (e.g., following naloxone use for overdose reversal), and - increasingly - THN "carriage". In this Research Methods piece, we discuss the current shortcomings in the latter measurement of THN carriage from a mixed-methods perspective and describe possible implications for public health related research and improved data analyses. We present an argument for the need to improve research methods in the case of THN "carriage" and propose a multidimensional measurement structure that takes into account: 1) the location of the THN kit relative to its owner, 2) the owner's immediate access to the kit in an emergency, 3) the type of THN device, and 4) the purpose of THN ownership (i.e., for use in self or known/unknown other/s).
Collapse
Affiliation(s)
- Rebecca McDonald
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Stephen Parkin
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Desiree Eide
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; Norwegian Centre for Addiction Research, Institute of Clinical Medicine, University of Oslo, Norway
| | - Joanne Neale
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Thomas Clausen
- Norwegian Centre for Addiction Research, Institute of Clinical Medicine, University of Oslo, Norway
| | - Nicola Metrebian
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ben Carter
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - John Strang
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK; South London and Maudsley NHS Foundation Trust, London, UK.
| |
Collapse
|
9
|
Parkin S, Neale J, Brown C, Jones JD, Brandt L, Castillo F, Campbell ANC, Strang J, Comer SD. A qualitative study of repeat naloxone administrations during opioid overdose intervention by people who use opioids in New York City. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2021; 87:102968. [PMID: 33096365 PMCID: PMC7940548 DOI: 10.1016/j.drugpo.2020.102968] [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: 07/13/2020] [Revised: 09/15/2020] [Accepted: 09/17/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Take-home naloxone (THN) kits have been designed to provide community members (including people who use drugs, their families and/or significant others) with the necessary resources to address out-of-hospital opioid overdose events. Kits typically include two doses of naloxone. This 'twin-pack' format means that lay responders need information on how to use each dose. Advice given tends to be based on dosage algorithms used by medical personnel. However, little is currently known about how and why people who use drugs, acting as lay responders, decide to administer the second dose contained within single THN kits. The aim of this article is to explore this issue. METHODS Data were generated from a qualitative semi-structured interview study that was embedded within a randomised controlled trial examining the risks and benefits of Overdose Education and Naloxone Distribution (OEND) training in New York City (NYC). Analysis for this article focuses upon the experiences of 22 people who use(d) opioids and who provided repeat naloxone administrations (RNA) during 24 separate overdose events. The framework method of analysis was used to compare the time participants believed had passed between each naloxone dose administered ('subjective response interval') with the 'recommended response interval' (2-4 minutes) given during OEND training. Framework analysis also charted the various reasons and rationale for providing RNA during overdose interventions. RESULTS When participants' subjective response intervals were compared with the recommended response interval for naloxone dosing, three different time periods were reported for the 24 overdose events: i. 'two doses administered in under 2 minutes' (n = 10); ii. 'two doses administered within 2-4 minutes' (n = 7), and iii. 'two doses administered more than 4 minutes apart' (n = 7). A variety of reasons were identified for providing RNA within each of the three categories of response interval. Collectively, reasons for RNA included panic, recognition of urgency, delays in retrieving naloxone kit, perceptions of recipients' responsiveness/non-responsiveness to naloxone, and avoidance of Emergency Response Teams (ERT). CONCLUSION Findings suggest that decision-making processes by people who use opioids regarding how and when to provide RNA are influenced by factors that relate to the emergency event. In addition, the majority of RNA (17/24) occurred outside of the recommended response interval taught during OEND training. These findings are discussed in terms of evidence-based intervention and 'evidence-making intervention' with suggestions for how RNA guidance may be developed and included within future/existing models of OEND training.
Collapse
Affiliation(s)
- Stephen Parkin
- National Addiction Centre, King's College London, 4 Windsor Walk, Denmark Hill, SE5 8BB, United Kingdom.
| | - Joanne Neale
- National Addiction Centre, King's College London, 4 Windsor Walk, Denmark Hill, SE5 8BB, United Kingdom; South London and Maudsley NHS Foundation Trust, Maudsley Hospital, Denmark Hill, London; Centre for Social Research in Health, University of New South Wales, Sydney, NSW 2052, Australia
| | - Caral Brown
- National Addiction Centre, King's College London, 4 Windsor Walk, Denmark Hill, SE5 8BB, United Kingdom
| | - Jermaine D Jones
- Division on Substance Use Disorders, Columbia University Irving Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 120, New York, NY 10032, United States
| | - Laura Brandt
- Division on Substance Use Disorders, Columbia University Irving Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 120, New York, NY 10032, United States
| | - Felipe Castillo
- Division on Substance Use Disorders, Columbia University Irving Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 120, New York, NY 10032, United States
| | - Aimee N C Campbell
- Division on Substance Use Disorders, Columbia University Irving Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 120, New York, NY 10032, United States
| | - John Strang
- National Addiction Centre, King's College London, 4 Windsor Walk, Denmark Hill, SE5 8BB, United Kingdom; South London and Maudsley NHS Foundation Trust, Maudsley Hospital, Denmark Hill, London
| | - Sandra D Comer
- Division on Substance Use Disorders, Columbia University Irving Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 120, New York, NY 10032, United States
| |
Collapse
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
Neale J, Kalk NJ, Parkin S, Brown C, Brandt L, Campbell ANC, Castillo F, Jones JD, Strang J, Comer SD. Factors associated with withdrawal symptoms and anger among people resuscitated from an opioid overdose by take-home naloxone: Exploratory mixed methods analysis. J Subst Abuse Treat 2020; 117:108099. [PMID: 32811629 PMCID: PMC7491601 DOI: 10.1016/j.jsat.2020.108099] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 07/06/2020] [Accepted: 07/25/2020] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Take-home naloxone (THN) is a clinically effective and cost-effective means of reducing opioid overdose fatality. Nonetheless, naloxone administration that successfully saves a person's life can still produce undesirable and harmful effects. AIM To better understand factors associated with two widely reported adverse outcomes following naloxone administration; namely the person resuscitated displays: i. withdrawal symptoms and ii. anger. METHODS A mixed methods study combining a randomized controlled trial of overdose education and naloxone prescribing to people with opioid use disorder and semi-structured qualitative interviews with trial participants who had responded to an overdose whilst in the trial. All data were collected in New York City (2014-2019). A dataset (comprising demographic, pharmacological, situational, interpersonal, and overdose training related variables) was generated by transforming qualitative interview data from 47 overdose events into dichotomous variables and then combining these with quantitative demographic and overdose training related data from the main trial. Associations between variables within the dataset and reports of: i. withdrawal symptoms and ii. anger were explored using chi-squared tests, t-tests, and logistic regressions. RESULTS A multivariate logistic regression found that people who had overdosed were significantly more likely to display anger if the person resuscitating them criticized, berated or chastised them during resuscitation (adjusted OR = 27 [95% CI = 4.0-295]). In contrast, they were significantly less likely to display anger if the person resuscitating them communicated positively with them (OR = 0.10 [95% CI = 0.01-0.78]). Both positive and negative communication styles were independently associated with anger, and communication was associated with 59% of the variance in anger. There was no evidence that people who displayed withdrawal symptoms were more likely to display anger than those not displaying withdrawal symptoms, and neither displaying withdrawal symptoms nor displaying anger were associated with using more drugs after resuscitation. CONCLUSIONS Contrary to common assumptions, withdrawal symptoms and anger following naloxone administration may be unrelated phenomena. Findings are consistent with previous research that has suggested that a lay responder's positive or reassuring communication style may lessen anger post overdose. Implications for improving THN programmes and naloxone administration are discussed.
Collapse
Affiliation(s)
- Joanne Neale
- National Addiction Centre, King's College London, 4 Windsor Walk, Denmark Hill, London, SE5 8BB, United Kingdom; Centre for Social Research in Health, University of New South Wales, Sydney, NSW 2052, Australia; South London and Maudsley NHS Foundation Trust, Camberwell, London, SE5 8AZ, United Kingdom.
| | - Nicola J Kalk
- National Addiction Centre, King's College London, 4 Windsor Walk, Denmark Hill, London, SE5 8BB, United Kingdom; South London and Maudsley NHS Foundation Trust, Camberwell, London, SE5 8AZ, United Kingdom.
| | - Stephen Parkin
- National Addiction Centre, King's College London, 4 Windsor Walk, Denmark Hill, London, SE5 8BB, United Kingdom.
| | - Caral Brown
- National Addiction Centre, King's College London, 4 Windsor Walk, Denmark Hill, London, SE5 8BB, United Kingdom.
| | - Laura Brandt
- Division on Substance Use Disorders, Columbia University Irving Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 120, New York, NY 10032, United States.
| | - Aimee N C Campbell
- Division on Substance Use Disorders, Columbia University Irving Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 120, New York, NY 10032, United States.
| | - Felipe Castillo
- Division on Substance Use Disorders, Columbia University Irving Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 120, New York, NY 10032, United States.
| | - Jermaine D Jones
- Division on Substance Use Disorders, Columbia University Irving Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 120, New York, NY 10032, United States.
| | - John Strang
- National Addiction Centre, King's College London, 4 Windsor Walk, Denmark Hill, London, SE5 8BB, United Kingdom; South London and Maudsley NHS Foundation Trust, Camberwell, London, SE5 8AZ, United Kingdom.
| | - Sandra D Comer
- Division on Substance Use Disorders, Columbia University Irving Medical Center and New York State Psychiatric Institute, 1051 Riverside Drive, Unit 120, New York, NY 10032, United States.
| |
Collapse
|
12
|
Salvador JG, Sussman AL, Takeda MY, Katzman WG, Moya Balasch M, Katzman JG. Barriers to and recommendations for take-home naloxone distribution: perspectives from opioid treatment programs in New Mexico. Harm Reduct J 2020; 17:31. [PMID: 32404109 PMCID: PMC7222293 DOI: 10.1186/s12954-020-00375-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 04/28/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Naloxone is a safe and effective medication to help reverse opioid overdose. Providing take-home naloxone to patients in opioid treatment settings is a critical step to reducing opioid overdose deaths. In New Mexico, a US state with one of the highest rates of opioid overdose deaths, legislation was passed in 2017 (House Bill 370) to support take-home naloxone, and followed by naloxone training of Opioid Treatment Program staff to increase distribution. METHODS Naloxone training was offered to all New Mexico Opioid Treatment Programs along with a baseline survey to assess current practices and barriers to take-home naloxone distribution. Focus groups were conducted approximately 1 year post-training with staff at a subset of the trained Opioid Treatment Programs to assess the impact of the legislation and training provided. RESULTS Baseline survey results show most Opioid Treatment Program staff were unfamiliar with House Bill 370, reported conflicting understandings of their agency's current take-home naloxone practices, and reported a number of barriers at the patient, agency, and policy level. Follow-up focus groups revealed support for House Bill 370 but persistent barriers to its implementation at the patient, agency, and policy level including patient receptivity, cost of naloxone, staff time, and prohibitive pharmacy board regulations. CONCLUSIONS In spite of targeted legislation and training, provision of take-home naloxone at remained low. This is alarming given the need for this lifesaving medication among the Opioid Treatment Program patient population, and high opioid death rate in New Mexico. Locally, important next steps include clarifying regulatory guidelines and supporting policy/billing changes to offset costs to Opioid Treatment Programs. Globally, additional research is needed to identify the prevalence of take-home naloxone distribution in similar settings, common barriers, and best practices that can be shared to increase access to this vital lifesaving medication in this critical context.
Collapse
Affiliation(s)
- Julie G Salvador
- Department of Psychiatry and Behavioral Sciences, University of New Mexico School of Medicine, MSC09 5030 1UNM, Albuquerque, NM, 87131-0001, USA.
| | - Andrew L Sussman
- Department of Family and Community Medicine, University of New Mexico School of Medicine, Albuquerque, USA
| | - Mikiko Y Takeda
- Department of Pharmacy Practice and Administrative Sciences, College of Pharmacy, University of New Mexico, Albuquerque, USA
| | | | - Monica Moya Balasch
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, USA
| | - Joanna G Katzman
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, USA
| |
Collapse
|
13
|
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).
Collapse
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
| |
Collapse
|
14
|
McAuley A, Munro A, Taylor A. "Once I'd done it once it was like writing your name": Lived experience of take-home naloxone administration by people who inject drugs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2018; 58:46-54. [PMID: 29803097 DOI: 10.1016/j.drugpo.2018.05.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Revised: 03/23/2018] [Accepted: 05/08/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND The supply of naloxone, the opioid antagonist, for peer administration ('take-home naloxone' (THN)) has been promoted as a means of preventing opioid-related deaths for over 20 years. Despite this, little is known about PWID experiences of take-home naloxone administration. The aim of this study was to advance the evidence base on THN by producing one of the first examinations of the lived-experience of THN use among PWID. METHODS Qualitative, face to face, semi-structured interviews were undertaken at a harm reduction service with individuals known to have used take-home naloxone in an overdose situation in a large urban area in Scotland. Interpretative Phenomenological Analysis (IPA) was then applied to the data from these in-depth accounts. RESULTS The primary analysis involved a total of 8 PWID (seven male, one female) known to have used take-home naloxone. This paper focuses on the two main themes concerning naloxone administration: psychological impacts of peer administration and role perceptions. In the former, the feelings participants encounter at different stages of their naloxone experience, including before, during and after use, are explored. In the latter, the concepts of role legitimacy, role adequacy, role responsibility and role support are considered. CONCLUSION This study demonstrates that responding to an overdose using take-home naloxone is complex, both practically and emotionally, for those involved. Although protocols exist, a multitude of individual, social and environmental factors shape responses in the short and longer terms. Despite these challenges, participants generally conveyed a strong sense of therapeutic commitment to using take-home naloxone in their communities.
Collapse
Affiliation(s)
- Andrew McAuley
- School of Media, Culture and Society, University of the West of Scotland, Paisley, UK; School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK; Health Protection Scotland, Meridian Court, Cadogan St, Glasgow, UK.
| | - Alison Munro
- Scottish Improvement Science Collaborating Centre, University of Dundee, Dundee, UK
| | - Avril Taylor
- Health Protection Scotland, Meridian Court, Cadogan St, Glasgow, UK
| |
Collapse
|
15
|
Abstract
Aims and methodA cross-sectional survey was conducted to assess patient knowledge and information provision about opioid substitution treatment among individuals with opiate dependence receiving treatment at four treatment centres in South London.ResultsIn total 118 people were recruited to the study. Participants answered a mean of 14 out of 34 questions assessing a range of factors such as medication, blood-borne viruses and overdose correctly. Participants overestimated their performance on average by almost 40%. Individuals with a history of previous treatments scored significantly higher than those in their first treatment episode. The majority reported having been given written information on most of the topics assessed.Clinical implicationsThe results of this study highlight the need to improve education about opioid dependence and its treatment. Poorly informed patients are unlikely to make optimal treatment choices. Improving patients' knowledge and understanding about treatment may lead to better engagement, retention, treatment adherence and, ultimately, better health outcomes.
Collapse
|
16
|
Goldman-Hasbun J, DeBeck K, Buxton JA, Nosova E, Wood E, Kerr T. Knowledge and possession of take-home naloxone kits among street-involved youth in a Canadian setting: a cohort study. Harm Reduct J 2017; 14:79. [PMID: 29273031 PMCID: PMC5741899 DOI: 10.1186/s12954-017-0206-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 12/13/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The distribution of take-home naloxone (THN) kits has been an important strategy in reducing overdose fatalities among people who use drugs. However, little is known about the use of THN among youth who are street-involved. The present study explores knowledge and possession of THN among street-involved youth in a Canadian setting. METHODS Data were derived from the At-Risk Youth Study (ARYS), a prospective cohort of street-involved youth age 14-28 at enrollment in Vancouver, Canada. Participants completed a standardized questionnaire, which included items related to knowledge and possession of THN, sociodemographic characteristics, and substance use-related factors. Multivariable logistic regression models were used to identify factors independently associated with knowledge and possession of THN. RESULTS Between December 2014 and November 2016, 177 youth were interviewed, including 68 females (38.4%). While 126 (71.2%) participants reported knowledge of THN, only 40 (22.6%) possessed a THN kit. Caucasian/white ethnicity was found to be positively associated with both knowledge and possession of THN (both p < 0.05). Public injection drug use in the last 6 months was found to be positively associated with knowledge of THN, while daily heroin use and daily methamphetamine use were associated with possession of THN (all p < 0.05). Male gender was negatively associated with possession of THN (p < 0.05). CONCLUSIONS These findings highlight important gaps between knowledge and possession of THN among youth and the need to increase participation in THN programs among specific populations including non-white and male youth. Further research is needed to gain a better understanding of the barriers that may prevent certain youth from acquiring THN kits.
Collapse
Affiliation(s)
- Julia Goldman-Hasbun
- British Columbia Centre on Substance Use, 608-1081 Burrard Street, Vancouver, V6Z 1Y6, BC, Canada
| | - Kora DeBeck
- British Columbia Centre on Substance Use, 608-1081 Burrard Street, Vancouver, V6Z 1Y6, BC, Canada.,School of Public Policy, Simon Fraser University, 515 West Hastings Street, Vancouver, V6B 5K3, BC, Canada
| | - Jane A Buxton
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, V6T 1Z3, BC, Canada.,British Columbia Centre for Disease Control, 655 West 12th Avenue, Vancouver, V5Z 4R4, BC, Canada
| | - Ekaterina Nosova
- British Columbia Centre on Substance Use, 608-1081 Burrard Street, Vancouver, V6Z 1Y6, BC, Canada
| | - Evan Wood
- British Columbia Centre on Substance Use, 608-1081 Burrard Street, Vancouver, V6Z 1Y6, BC, Canada.,Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, V6Z 1Y6, BC, Canada
| | - Thomas Kerr
- British Columbia Centre on Substance Use, 608-1081 Burrard Street, Vancouver, V6Z 1Y6, BC, Canada. .,Department of Medicine, University of British Columbia, St. Paul's Hospital, 608-1081 Burrard Street, Vancouver, V6Z 1Y6, BC, Canada.
| |
Collapse
|
17
|
Zadoretzky C, McKnight C, Bramson H, Des Jarlais D, Phillips M, Hammer M, Cala ME. The New York 911 Good Samaritan Law and Opioid Overdose Prevention Among People Who Inject Drugs. WORLD MEDICAL & HEALTH POLICY 2017. [DOI: 10.1002/wmh3.234] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
18
|
McDonald R, Campbell ND, Strang J. Twenty years of take-home naloxone for the prevention of overdose deaths from heroin and other opioids-Conception and maturation. Drug Alcohol Depend 2017; 178:176-187. [PMID: 28654870 DOI: 10.1016/j.drugalcdep.2017.05.001] [Citation(s) in RCA: 94] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 05/02/2017] [Accepted: 05/02/2017] [Indexed: 10/25/2022]
Abstract
BACKGROUND Opioid overdose is a major cause of mortality, but injury and fatal outcomes can be prevented by timely administration of the opioid antagonist naloxone. Pre-provision of naloxone to opioid users and family members (take-home naloxone, THN) was first proposed in 1996, and WHO Guidelines were issued in 2014. While widespread in some countries, THN is minimally available or absent elsewhere. This review traces the development of THN over twenty years, from speculative harm reduction proposal to public health strategy. METHOD Medline and PsycINFO were searched for peer-reviewed literature (1990-2016) using Boolean queries: 1) "naloxone OR Narcan"; 2) "(opioid OR opiate) AND overdose AND prevention". Grey literature and specialist websites were also searched. Data were extracted and synthesized as narrative review, with key events presented as chronological timeline. RESULTS Results are presented in 5-year intervals, starting with the original proposal and THN pilots from 1996 to 2001. Lack of familiarity with THN challenged early distribution schemes (2001-2006), leading to further testing, evaluation, and assessment of challenges and perceived medicolegal barriers. From 2006-2011, response to social and legal concerns led to the expansion of THN programs; followed by high-impact research and efforts to widen THN availability from 2011 to 2016. CONCLUSIONS Framed as a public health tool for harm reduction, THN has overcome social, clinical, and legal barriers in many jurisdictions. Nonetheless, the rising death toll of opioid overdose illustrates that current THN coverage is insufficient, and greater public investment in overdose prevention will be required if THN is to achieve its full potential impact.
Collapse
Affiliation(s)
- Rebecca McDonald
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, Addictions Sciences Building, 4 Windsor Walk, Denmark Hill, London, SE5 8BB, United Kingdom
| | - Nancy D Campbell
- Department of Science and Technology Studies, Sage Labs 5202, Rensselaer Polytechnic Institute, 110 Eighth Street Troy, NY, 12180, United States
| | - John Strang
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, Addictions Sciences Building, 4 Windsor Walk, Denmark Hill, London, SE5 8BB, United Kingdom.
| |
Collapse
|
19
|
Nolan S, Buxton J, Dobrer S, Dong H, Hayashi K, Milloy MJ, Kerr T, Montaner J, Wood E. Awareness, Possession, and Use of Take-Home Naloxone Among Illicit Drug Users, Vancouver, British Columbia, 2014-2015. Public Health Rep 2017; 132:563-569. [PMID: 28750193 DOI: 10.1177/0033354917717230] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Although take-home naloxone (THN) programs are integral in strategies to prevent overdose deaths among opioid users, the uptake of THN among people who use drugs (PWUD) (including non-opioid users) is unknown. The objectives of this study were to determine awareness, possession, and use of THN among PWUD in Vancouver, Canada, and identify barriers to adopting this strategy. METHODS From December 1, 2014, to May 29, 2015, participants in 2 prospective cohort studies of PWUD in Vancouver completed a standardized questionnaire, which asked about awareness, possession, and use of THN; sociodemographic characteristics; and drug use patterns. We conducted multivariable logistic regression analyses to determine factors independently associated with awareness and possession of THN. RESULTS Of 1137 PWUD, 727 (64%) reported at least 1 previous overdose ever, and 220 (19%) had witnessed an overdose in the previous 6 months. Although 769 (68%) participants overall reported awareness of THN, only 88 of 392 (22%) opioid users had a THN kit, 18 (20%) of whom had previously administered naloxone. Factors that were positively associated with awareness of THN included witnessing an overdose in the previous 6 months (adjusted odds ratio [aOR] = 2.23; 95% confidence interval [CI], 1.49-3.34; P < .001), possession of THN (aOR = 1.85; 95% CI, 1.11-3.06; P = .02), younger age (aOR = 1.02; 95% CI, 1.01-1.04; P = .003), white race (aOR = 1.67; 95% CI, 1.27-2.19; P < .001), hepatitis C infection (aOR = 1.63; 95% CI, 1.13-2.36; P = .01), residing in Vancouver's Downtown Eastside neighborhood (aOR = 1.93; 95% CI, 1.47-2.53; P < .001), and at least daily heroin injection (aOR = 1.69; 95% CI, 1.09-2.62; P < .02). CONCLUSION Efforts to improve knowledge of and participation in the THN program may contribute to reduced opioid overdose mortality in Vancouver.
Collapse
Affiliation(s)
- Seonaid Nolan
- 1 British Columbia Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, British Columbia, Canada.,2 Department of Medicine, University of British Columbia, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Jane Buxton
- 3 BC Centre for Disease Control, Vancouver, British Columbia, Canada.,4 School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Sabina Dobrer
- 1 British Columbia Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Huiru Dong
- 1 British Columbia Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Kanna Hayashi
- 1 British Columbia Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, British Columbia, Canada.,2 Department of Medicine, University of British Columbia, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - M J Milloy
- 1 British Columbia Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, British Columbia, Canada.,2 Department of Medicine, University of British Columbia, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Thomas Kerr
- 1 British Columbia Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, British Columbia, Canada.,2 Department of Medicine, University of British Columbia, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Julio Montaner
- 1 British Columbia Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, British Columbia, Canada.,2 Department of Medicine, University of British Columbia, St Paul's Hospital, Vancouver, British Columbia, Canada
| | - Evan Wood
- 1 British Columbia Centre for Excellence in HIV/AIDS, St Paul's Hospital, Vancouver, British Columbia, Canada.,2 Department of Medicine, University of British Columbia, St Paul's Hospital, Vancouver, British Columbia, Canada
| |
Collapse
|
20
|
Dunn KE, Barrett FS, Yepez-Laubach C, Meyer AC, Hruska BJ, Sigmon SC, Fingerhood M, Bigelow GE. Brief Opioid Overdose Knowledge (BOOK): A Questionnaire to Assess Overdose Knowledge in Individuals Who Use Illicit or Prescribed Opioids. J Addict Med 2016; 10:314-23. [PMID: 27504923 PMCID: PMC5042823 DOI: 10.1097/adm.0000000000000235] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 05/14/2016] [Indexed: 11/25/2022]
Abstract
BACKGROUND Opioid overdose is a public health crisis. This study describes efforts to develop and validate the Brief Opioid Overdose Knowledge (BOOK) questionnaire to assess patient knowledge gaps related to opioid overdose risks. METHODS Two samples of illicit opioid users and a third sample of patients receiving an opioid for the treatment of chronic pain (total N = 848) completed self-report items pertaining to opioid overdose risks. RESULTS A 3-factor scale was established, representing Opioid Knowledge (4 items), Opioid Overdose Knowledge (4 items), and Opioid Overdose Response Knowledge (4 items). The scale had strong internal and face validity. Patients with chronic pain performed worse than illicit drug users in almost all items assessed, highlighting the need to increase knowledge of opioid overdose risk to this population. CONCLUSIONS This study sought to develop a brief, internally valid method for quickly assessing deficits in opioid overdose risk areas within users of illicit and prescribed opioids, to provide an efficient metric for assessing and comparing educational interventions, facilitate conversations between physicians and patients about overdose risks, and help formally identify knowledge deficits in other patient populations.
Collapse
Affiliation(s)
- Kelly E Dunn
- Behavioral Pharmacology Research Unit, Departments of Psychiatry and Behavioral Sciences (KED, FSB, CYL, GEB), and Medicine (MF), Johns Hopkins University School of Medicine, Baltimore, MD; and Departments of Psychiatry (ACM, BJH, SCS) and Psychology (SCS), University of Vermont, Burlington, VT
| | | | | | | | | | | | | | | |
Collapse
|
21
|
Sondhi A, Ryan G, Day E. Stakeholder perceptions and operational barriers in the training and distribution of take-home naloxone within prisons in England. Harm Reduct J 2016; 13:5. [PMID: 26841876 PMCID: PMC4738801 DOI: 10.1186/s12954-016-0094-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 01/22/2016] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The aim of the study was to assess potential barriers and challenges to the implementation of take-home naloxone (THN) across ten prisons in one region of England. METHODS Qualitative interviews deploying a grounded theory approach were utilised over a 12- to 18-month period that included an on-going structured dialogue with strategic and operational prison staff from the ten prisons and other key stakeholders (n = 17). Prisoner perceptions were addressed through four purposive focus groups belonging to different establishments (n = 26). Document analysis also included report minutes and access to management information and local performance reports. The data were thematically interpreted using visual mapping techniques. RESULTS The distribution and implementation of THN in a prison setting was characterised by significant barriers and challenges. As a result, four main themes were identified: a wide range of negative and confused perceptions of THN amongst prison staff and prisoners; inherent difficulties with the identification and engagement of eligible prisoners; the need to focus on individual prison processes to enhance the effective distribution of THN; and the need for senior prison staff engagement. CONCLUSIONS The distribution of THN within a custodial setting requires consideration of a number of important factors which are discussed.
Collapse
Affiliation(s)
- Arun Sondhi
- Therapeutic Solutions (Addictions) Communications House, 26 York Street, London, W1U 6PZ, UK.
| | - George Ryan
- Public Health England, 2nd Floor Skipton House London Road Elephant & Castle, London, SE1 6LH, UK
| | - Ed Day
- Addiction Psychiatry, Addictions Department, National Addiction Centre, Addiction Sciences Building, 4 Windsor Walk, Denmark Hill, London, SE5 8AF, UK
| |
Collapse
|
22
|
Neale J, Strang J. Naloxone--does over-antagonism matter? Evidence of iatrogenic harm after emergency treatment of heroin/opioid overdose. Addiction 2015; 110:1644-52. [PMID: 26119038 DOI: 10.1111/add.13027] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2015] [Revised: 05/21/2015] [Accepted: 06/22/2015] [Indexed: 11/30/2022]
Abstract
AIM To analyse drug users' views and experiences of naloxone during emergency resuscitation after illicit opiate overdose to identify (i) any evidence of harm caused by excessive naloxone dosing ('over-antagonism'); and (ii) implications for the medical administration of naloxone within contemporary emergency settings. DESIGN Re-analysis of a large qualitative data set comprising 70 face-to-face interviews conducted within a few hours of heroin/opioid overdose occurring, observations from hospital settings and a further 130 interviews with illicit opiate users. Data were generated between 1997 and 1999. SETTING Emergency departments, drug services and pharmacies in two Scottish cities. PARTICIPANTS Two hundred illicit opiate users: 131 males and 69 females. FINDINGS Participants had limited knowledge of naloxone and its pharmacology, yet described it routinely in negative terms and were critical of its medical administration. In particular, they complained that naloxone induced acute withdrawal symptoms, causing patients to refuse treatment, become aggressive, discharge themselves from hospital and take additional street drugs to counter the naloxone effects. Participants believed that hospital staff should administer naloxone selectively and cautiously, and prescribe counter-naloxone medication if dosing precipitated withdrawals. In contrast, observational data indicated that participants did not always know that they had received naloxone and hospital doctors did not necessarily administer it incautiously. CONCLUSIONS Opiate users in urban Scotland repeatedly report harm caused by naloxone over-antagonism, although this is not evident in observational data. The concept of contemporary legend (a form of folklore that can be based on fact and provides a means of communicating and negotiating anxiety) helps to explain why naloxone has such a feared reputation among opiate users.
Collapse
Affiliation(s)
- Joanne Neale
- Reader in Qualitative and Mixed Methods Research, National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - John Strang
- Professor of the Addictions, National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| |
Collapse
|
23
|
Marshall Z, Dechman MK, Minichiello A, Alcock L, Harris GE. Peering into the literature: A systematic review of the roles of people who inject drugs in harm reduction initiatives. Drug Alcohol Depend 2015; 151:1-14. [PMID: 25891234 DOI: 10.1016/j.drugalcdep.2015.03.002] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2014] [Revised: 02/20/2015] [Accepted: 03/01/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND People who inject drugs have been central to the development of harm reduction initiatives. Referred to as peer workers, peer helpers, or natural helpers, people with lived experience of drug use leverage their personal knowledge and skills to deliver harm reduction services. Addressing a gap in the literature, this systematic review focuses on the roles of people who inject drugs in harm reduction initiatives, how programs are organized, and obstacles and facilitators to engaging people with lived experience in harm reduction programs, in order to inform practice and future research. METHODS This systematic review included searches for both peer reviewed and gray literature. All titles and abstracts were screened by two reviewers. A structured data extraction tool was developed and utilized to systematically code information concerning peer roles and participation, program characteristics, obstacles, and facilitators. RESULTS On the basis of specific inclusion criteria 164 documents were selected, with 127 peer-reviewed and 37 gray literature references. Data extraction identified key harm reduction program characteristics and forms of participation including 36 peer roles grouped into five categories, as well as obstacles and facilitators at systemic, organizational, and individual levels. CONCLUSIONS Research on harm reduction programs that involve people with lived experience can help us better understand these approaches and demonstrate their value. Current evidence provides good descriptive content but the field lacks agreed-upon approaches to documenting the ways peer workers contribute to harm reduction initiatives. Implications and ten strategies to better support peer involvement in harm reduction programs are identified.
Collapse
Affiliation(s)
- Z Marshall
- Division of Community Health and Humanities, Faculty of Medicine, Memorial University, Health Sciences Centre, 300 Prince Philip Drive, St. John's, NL, Canada A1B 3V6.
| | - M K Dechman
- Department of Anthropology and Sociology, Cape Breton University, PO Box 5300, 1250 Grand Lake Road, Sydney, NS, Canada B1P 6L2.
| | - A Minichiello
- Department of Anthropology and Sociology, Cape Breton University, PO Box 5300, 1250 Grand Lake Road, Sydney, NS, Canada B1P 6L2.
| | - L Alcock
- Health Sciences Library, Memorial University, St John's, NL, Canada A1B 3V6.
| | - G E Harris
- Faculty of Education, G. A. Hickman Building, Memorial University, St. John's, NL, Canada A1B 3X8.
| |
Collapse
|
24
|
Mueller SR, Walley AY, Calcaterra SL, Glanz JM, Binswanger IA. A Review of Opioid Overdose Prevention and Naloxone Prescribing: Implications for Translating Community Programming Into Clinical Practice. Subst Abus 2015; 36:240-53. [PMID: 25774771 DOI: 10.1080/08897077.2015.1010032] [Citation(s) in RCA: 132] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND As physicians have increased opioid prescribing, overdose deaths from pharmaceutical opioids have substantially increased in the United States. Naloxone hydrochloride (naloxone), an opioid antagonist, is the standard of care for treatment of opioid induced respiratory depression. Since 1996, community-based programs have offered overdose prevention education and distributed naloxone for bystander administration to people who use opioids, particularly heroin. There is growing interest in translating overdose education and naloxone distribution (OEND) into conventional medical settings for patients who are prescribed pharmaceutical opioids. For this review, we summarized and classified existing publications on overdose education and naloxone distribution to identify evidence of effectiveness and opportunities for translation into conventional medical settings. METHODS For this review, we searched English language PubMed for articles on naloxone based on primary data collection from humans, including feasibility studies, program evaluations, surveys, qualitative studies, and studies comparing the effectiveness of different routes of naloxone administration. We also included cost-effectiveness studies. RESULTS We identified 41 articles that represented 5 categories: evaluations of OEND programs, effects of OEND programs on experiences and attitudes of participants, willingness of medical providers to prescribe naloxone, comparisons of different routes of naloxone administration, and the cost-effectiveness of naloxone. CONCLUSIONS Existing research suggests that people who are at risk for overdose and other bystanders are willing and able to be trained to prevent overdoses and administer naloxone. Counseling patients about the risks of opioid overdose and prescribing naloxone is an emerging clinical practice that may reduce fatalities from overdose while enhancing the safe prescribing of opioids.
Collapse
Affiliation(s)
- Shane R Mueller
- a Division of General Internal Medicine , University of Colorado School of Medicine , Aurora , Colorado , USA
| | | | | | | | | |
Collapse
|
25
|
A systematic review of community opioid overdose prevention and naloxone distribution programs. J Addict Med 2015; 8:153-63. [PMID: 24874759 DOI: 10.1097/adm.0000000000000034] [Citation(s) in RCA: 315] [Impact Index Per Article: 35.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Community-based opioid overdose prevention programs (OOPPs) that include the distribution of naloxone have increased in response to alarmingly high overdose rates in recent years. This systematic review describes the current state of the literature on OOPPs, with particular focus on the effectiveness of these programs. We used systematic search criteria to identify relevant articles, which we abstracted and assigned a quality assessment score. Nineteen articles evaluating OOPPs met the search criteria for this systematic review. Principal findings included participant demographics, the number of naloxone administrations, percentage of survival in overdose victims receiving naloxone, post-naloxone administration outcome measures, OOPP characteristics, changes in knowledge pertaining to overdose responses, and barriers to naloxone administration during overdose responses. The current evidence from nonrandomized studies suggests that bystanders (mostly opioid users) can and will use naloxone to reverse opioid overdoses when properly trained, and that this training can be done successfully through OOPPs.
Collapse
|
26
|
Development and implementation of an opioid overdose prevention program within a preexisting substance use disorders treatment center. J Addict Med 2014; 8:164-9. [PMID: 24874760 DOI: 10.1097/adm.0000000000000032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This case study of the development and implementation of an opioid overdose prevention program is based on an actual clinic's experience, but information about the clinic, including details of implementation and outcome measures, has been changed. Four experts reflect on the medical, administrative, peer-support, community, and evaluation aspects of this case. This discussion highlights challenges and important considerations in the creation of programs to address the ever-increasing risk for opioid overdose.
Collapse
|
27
|
Abstract
We present a case of failed prehospital treatment of fentanyl induced apnea with intranasal (IN) naloxone. While IN administration of naloxone is becoming more common in both lay and pre-hospital settings, older EMS protocols utilized intravenous (IV) administration. Longer-acting, higher potency opioids, such as fentanyl, may not be as easily reversed as heroin, and studies evaluating IN administration in this population are lacking. In order to contribute to our understanding of the strengths and limitations of IN administration of naloxone, we present a case where it failed to restore ventilation. We also describe peer reviewed literature that supports the use of IV naloxone following heroin overdose and explore possible limitations of generalizing this literature to opioids other than heroin and to IN routes of administration.
Collapse
|
28
|
Eizadi-Mood N, Yaraghi A, Alikhasi M, Jabalameli M, Farsaei S, Sabzghabaee AM. Prediction of endotracheal intubation outcome in opioid-poisoned patients: A clinical approach to bispectral monitoring. CANADIAN JOURNAL OF RESPIRATORY THERAPY : CJRT = REVUE CANADIENNE DE LA THERAPIE RESPIRATOIRE : RCTR 2014; 50:83-6. [PMID: 26078616 PMCID: PMC4456837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Some opioid-poisoned patients do not respond appropriately to naloxone; consequently, intubation is required. Although various measures have been used to evaluate the level of consciousness of poisoned patients, no study has assessed the role of the bispectral index (BIS) to ascertain the depth of anesthesia in opioid-poisoned patients who require endotracheal intubation. OBJECTIVE To compare BIS scores between opioid-poisoned patients with and without intubation, and to determine the BIS cut-off point for endotracheal intubation in these patients. METHODS In the present cross-sectional study, conducted in an Iranian university referral hospital for poisoning emergencies between 2012 and 2013, opioid-poisoned patients (n=41) were divided into two groups according to their requirement for endotracheal intubation. BIS analyses were performed at the time of admission and at the time of intubation for those who required it. In addition, electromyography and signal quality index were evaluated for all patients at the time of admission, and cardiorespiratory monitoring was performed during the hospitalization period. Using ROC curves, and sensitivity and specificity analyses, the optimal BIS cut-off point for prediction of intubation of these patients was determined. RESULTS The optimal cut-off point for prediction of intubation was BIS ≤78, which had a sensitivity of 86.7% (95% CI 66.1 to 98.8) and specificity of 88.5% (95% CI 73.9% to 98.8%); the positive and negative predictive values were 81.2 % and 92%, respectively. CONCLUSIONS BIS may be considered an acceptable index to determine the need for intubation in opioid-poisoned patients whose response to naloxone is inadequate.
Collapse
Affiliation(s)
- Nastaran Eizadi-Mood
- Department of Clinical Toxicology, School of Medicine, Isfahan University of Medical Sciences
| | - Ahmad Yaraghi
- Department of Clinical Toxicology, School of Medicine, Isfahan University of Medical Sciences
| | - Mahsa Alikhasi
- Department of Clinical Toxicology, Noor and Ali Asghar [PBUH] University Hospital
| | - Mitra Jabalameli
- Department of Anesthesiology and Critical Care, School of Medicine
| | - Shadi Farsaei
- Department of Clinical Pharmacy and Pharmacy Practice, School of Pharmacy
| | - Ali Mohammad Sabzghabaee
- Isfahan Clinical Toxicology Research Center, Isfahan University of Medical Sciences, Isfahan, Iran,Correspondence: Dr Ali Mohammad Sabzghabaee, Isfahan Clinical Toxicology Research Center, Isfahan University of Medical Sciences, Hezarjerib Avenue, Isfahan 81746, Iran. Telephone 00983137922500, e-mail
| |
Collapse
|
29
|
Strang J, Bird SM, Parmar MKB. Take-home emergency naloxone to prevent heroin overdose deaths after prison release: rationale and practicalities for the N-ALIVE randomized trial. J Urban Health 2013; 90:983-96. [PMID: 23633090 PMCID: PMC3795186 DOI: 10.1007/s11524-013-9803-1] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The naloxone investigation (N-ALIVE) randomized trial commenced in the UK in May 2012, with the preliminary phase involving 5,600 prisoners on release. The trial is investigating whether heroin overdose deaths post-prison release can be prevented by prior provision of a take-home emergency supply of naloxone. Heroin contributes disproportionately to drug deaths through opiate-induced respiratory depression. Take-home emergency naloxone is a novel preventive measure for which there have been encouraging preliminary reports from community schemes. Overdoses are usually witnessed, and drug users themselves and also family members are a vast intervention workforce who are willing to intervene, but whose responses are currently often inefficient or wrong. Approximately 10% of provided emergency naloxone is thought to be used in subsequent emergency resuscitation but, as yet, there have been no definitive studies. The period following release from prison is a time of extraordinarily high mortality, with heroin overdose deaths increased more than sevenfold in the first fortnight after release. Of prisoners with a previous history of heroin injecting who are released from prison, 1 in 200 will die of a heroin overdose within the first 4 weeks. There are major scientific and logistical challenges to assessing the impact of take-home naloxone. Even in recently released prisoners, heroin overdose death is a relatively rare event: hence, large numbers of prisoners need to enter the trial to assess whether take-home naloxone significantly reduces the overdose death rate. The commencement of pilot phase of the N-ALIVE trial is a significant step forward, with prisoners being randomly assigned either to treatment-as-usual or to treatment-as-usual plus a supply of take-home emergency naloxone. The subsequent full N-ALIVE trial (contingent on a successful pilot) will involve 56,000 prisoners on release, and will give a definitive conclusion on lives saved in real-world application. Advocates call for implementation, while naysayers raise concerns. The issue does not need more public debate; it needs good science.
Collapse
Affiliation(s)
- John Strang
- King’s College London, National Addiction Centre (Institute of Psychiatry and The Maudsley), London, SE5 8AF UK
| | | | | |
Collapse
|
30
|
Lankenau SE, Wagner KD, Silva K, Kecojevic A, Iverson E, McNeely M, Kral AH. Injection drug users trained by overdose prevention programs: responses to witnessed overdoses. J Community Health 2013; 38:133-41. [PMID: 22847602 DOI: 10.1007/s10900-012-9591-7] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In response to the growing public health problem of drug overdose, community-based organizations have initiated overdose prevention programs (OPPs), which distribute naloxone, an opioid antagonist, and teach overdose response techniques. Injection drug users (IDUs) have been targeted for this intervention due to their high risk for drug overdose. Limited research attention has focused on factors that may inhibit or prevent IDUs who have been trained by OPPs to undertake recommended response techniques when responding to a drug overdose. IDUs (n = 30) trained by two OPPs in Los Angeles were interviewed in 2010-2011 about responses to their most recently witnessed drug overdose using an instrument containing both open and closed-ended questions. Among the 30 witnessed overdose events, the victim recovered in 29 cases while the outcome was unknown in one case. Participants responded to overdoses using a variety of techniques taught by OPPs. Injecting the victim with naloxone was the most commonly recommended response while other recommended responses included stimulating the victim with knuckles, calling 911, and giving rescue breathing. Barriers preventing participants from employing recommended response techniques in certain circumstances included prior successes using folk remedies to revive a victim, concerns over attracting police to the scene, and issues surrounding access to or use of naloxone. Practical solutions, such as developing booster sessions to augment OPPs, are encouraged to increase the likelihood that trained participants respond to a drug overdose with the full range of recommended techniques.
Collapse
Affiliation(s)
- Stephen E Lankenau
- Department of Community Health and Prevention, School of Public Health, Drexel University, Philadelphia, PA 19102, USA.
| | | | | | | | | | | | | |
Collapse
|
31
|
Attitudes of methadone program staff toward provision of harm-reduction and other services. J Addict Med 2011; 5:289-92. [PMID: 22107879 DOI: 10.1097/adm.0b013e31821dc61a] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The need for expansion of health services provided in drug treatment programs has been widely discussed since the beginning of the HIV epidemic among drug users. Service expansion has focused on various types of services including medical services (eg, primary care) and harm-reduction services (eg, provision of sterile syringes). METHODS A staff survey was conducted in 8 methadone maintenance clinics in the New York/New Jersey area to assess attitudes toward the provision of harm reduction and other services in methadone clinics, and the relationship of these attitudes to other variables. PARTICIPANTS A total of 114 staff members in 8 methadone maintenance clinics completed the survey. RESULTS The majority of staff was supportive of adding services, over 90% supported medical services, and the majority supported harm-reduction services such as syringe access and disposal services. Higher education and HIV knowledge levels were significant correlates of favorable attitudes toward service provision. CONCLUSIONS Support for providing harm-reduction services in methadone maintenance clinics was found. Enhancing knowledge of staff regarding various types of health services, and engaging them in how best to institute new services, should be undertaken when new services are planned.
Collapse
|
32
|
Enteen L, Bauer J, McLean R, Wheeler E, Huriaux E, Kral AH, Bamberger JD. Overdose prevention and naloxone prescription for opioid users in San Francisco. J Urban Health 2010; 87:931-41. [PMID: 20967505 PMCID: PMC3005091 DOI: 10.1007/s11524-010-9495-8] [Citation(s) in RCA: 130] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Opiate overdose is a significant cause of mortality among injection drug users (IDUs) in the United States (US). Opiate overdose can be reversed by administering naloxone, an opiate antagonist. Among IDUs, prevalence of witnessing overdose events is high, and the provision of take-home naloxone to IDUs can be an important intervention to reduce the number of overdose fatalities. The Drug Overdose Prevention and Education (DOPE) Project was the first naloxone prescription program (NPP) established in partnership with a county health department (San Francisco Department of Public Health), and is one of the longest running NPPs in the USA. From September 2003 to December 2009, 1,942 individuals were trained and prescribed naloxone through the DOPE Project, of whom 24% returned to receive a naloxone refill, and 11% reported using naloxone during an overdose event. Of 399 overdose events where naloxone was used, participants reported that 89% were reversed. In addition, 83% of participants who reported overdose reversal attributed the reversal to their administration of naloxone, and fewer than 1% reported serious adverse effects. Findings from the DOPE Project add to a growing body of research that suggests that IDUs at high risk of witnessing overdose events are willing to be trained on overdose response strategies and use take-home naloxone during overdose events to prevent deaths.
Collapse
Affiliation(s)
- Lauren Enteen
- Masters Entry Program in Nursing, University of California, San Francisco, CA, USA
| | | | | | | | | | | | | |
Collapse
|
33
|
McAuley A, Lindsay G, Woods M, Louttit D. Responsible management and use of a personal take-home naloxone supply: A pilot project. DRUGS-EDUCATION PREVENTION AND POLICY 2010. [DOI: 10.3109/09687630802530712] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
34
|
Gaston RL, Best D, Manning V, Day E. Can we prevent drug related deaths by training opioid users to recognise and manage overdoses? Harm Reduct J 2009; 6:26. [PMID: 19781073 PMCID: PMC2762999 DOI: 10.1186/1477-7517-6-26] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2008] [Accepted: 09/25/2009] [Indexed: 11/10/2022] Open
Abstract
Background Naloxone has been evidenced widely as a means of reducing mortality resulting from opiate overdose, yet its distribution to drug users remains limited. However, it is drug users who are most likely to be available to administer naloxone at the scene and who have been shown to be willing and motivated to deliver this intervention. The current study builds on a national training evaluation in England by assessing 6-month outcome data collected primarily in one of the participating centres. Methods Seventy patients with opioid dependence syndrome were trained in the recognition and management of overdoses in Birmingham (n = 66) and London (n = 4), and followed up six months after receiving naloxone. After successful completion of the training, participants received a supply of 400 micrograms of naloxone (in the form of a preloaded syringe) to take home. The study focused on whether participating users still had their naloxone, whether they retained the information, whether they had witnessed an overdose and whether they had naloxone available and were still willing to use it in the event of overdose. Results & Discussion The results were mixed - although the majority of drug users had retained the naloxone prescribed to them, and retention of knowledge was very strong in relation to overdose recognition and intervention, most participants did not carry the naloxone with them consistently and consequently it was generally not available if they witnessed an overdose. The paper discusses the reasons for the reluctance to carry naloxone and potential opportunities for how this might be overcome. Future issues around training and support around peer dissemination are also addressed. Conclusion Our findings confirm that training of drug users constitutes a valuable resource in the management of opiate overdoses and growth of peer interventions that may not otherwise be recognised or addressed. Obstacles have been identified at individual (transportability, stigma) and at a systems level (police involvement, prescription laws). Training individuals does not seem to be sufficient for these programmes to succeed and a coherent implementation model is necessary.
Collapse
Affiliation(s)
- Romina Lopez Gaston
- Department of Psychiatry, University of Birmingham, The Barberry Vincent Drive, Birmingham, UK.
| | | | | | | |
Collapse
|
35
|
Albizu-García CE, Hernández-Viver A, Feal J, Rodríguez-Orengo JF. Characteristics of inmates witnessing overdose events in prison: implications for prevention in the correctional setting. Harm Reduct J 2009; 6:15. [PMID: 19589157 PMCID: PMC2718878 DOI: 10.1186/1477-7517-6-15] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2009] [Accepted: 07/09/2009] [Indexed: 11/17/2022] Open
Abstract
Background Although prevention of opiate overdose has been gaining attention as a harm reduction measure with community drug users, there is scarce information about drug overdose in prison. In correctional institutions without a drug free environment, awareness of overdose events is an important public health concern. This study explores the frequency with which inmates in a state penitentiary system report having witnessed drug overdose events in prison. It also explores whether participants who have witnessed an overdose in prison and know someone who died from an overdose in prison significantly differ from those that do not in selected sociodemographic variables and drug use history to identify a target population for prevention interventions. Methods Data comes from a cross-sectional survey of sentenced inmates in the state prisons of Puerto Rico. A complex probabilistic, multistage sampling design was used. A total of 1,179 individuals participated for an 89% response rate. Results Factors associated with witnessing an overdose event in prison include: male sex, age 25 or older, drug use during current incarceration, and drug injection in prison. Factors associated with knowing someone who died from an overdose in prison include: male sex, age between 25–35, previous incarcerations, and drug use during current incarceration. Conclusion Witnessing a drug overdose is a frequent occurrence within the prison system. The likelihood of witnessing an overdose is greater with being male, polydrug use and drug injection in prison. Findings signal an urgent public health challenge that requires prompt interventions to reduce this drug related harm within the correctional system, including adequate access to medication with opiate agonists.
Collapse
Affiliation(s)
- Carmen E Albizu-García
- Center for Evaluation and Sociomedical Research, University of Puerto Rico Medical Sciences Campus, San Juan, Puerto Rico.
| | | | | | | |
Collapse
|
36
|
Kim D, Irwin KS, Khoshnood K. Expanded access to naloxone: options for critical response to the epidemic of opioid overdose mortality. Am J Public Health 2009; 99:402-7. [PMID: 19150908 DOI: 10.2105/ajph.2008.136937] [Citation(s) in RCA: 127] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
The United States is in the midst of a prolonged and growing epidemic of accidental and preventable deaths associated with overdoses of licit and illicit opioids. For more than 3 decades, naloxone has been used by emergency medical personnel to pharmacologically reverse overdoses. The peers or family members of overdose victims, however, are most often the actual first responders and are best positioned to intervene within an hour of the onset of overdose symptoms. Data from recent pilot programs demonstrate that lay persons are consistently successful in safely administering naloxone and reversing opioid overdose. Current evidence supports the extensive scaleup of access to naloxone. We present advantages and limitations associated with a range of possible policy and program responses.
Collapse
Affiliation(s)
- Daniel Kim
- American Medical Association, Chicago, IL, USA
| | | | | |
Collapse
|
37
|
Kerr D, Dietze P, Kelly AM, Jolley D. Attitudes of Australian heroin users to peer distribution of naloxone for heroin overdose: perspectives on intranasal administration. J Urban Health 2008; 85:352-60. [PMID: 18347990 PMCID: PMC2329742 DOI: 10.1007/s11524-008-9273-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2007] [Accepted: 02/26/2008] [Indexed: 11/29/2022]
Abstract
Naloxone distribution to injecting drug users (IDUs) for peer administration is a suggested strategy to prevent fatal heroin overdose. The aim of this study was to explore attitudes of IDUs to administration of naloxone to others after heroin overdose, and preferences for method of administration. A sample of 99 IDUs (median age 35 years, 72% male) recruited from needle and syringe programs in Melbourne were administered a questionnaire. Data collected included demographics, attitudes to naloxone distribution, and preferences for method of administration. The primary study outcomes were attitudes of IDUs to use of naloxone for peer administration (categorized on a five-point scale ranging from "very good idea" to "very bad idea") and preferred mode of administration (intravenous, intramuscular, and intranasal). The majority of the sample reported positive attitudes toward naloxone distribution (good to very good idea: 89%) and 92% said they were willing to participate in a related training program. Some participants raised concerns about peer administration including the competence of IDUs to administer naloxone in an emergency, victim response on wakening and legal implications. Most (74%) preferred intranasal administration in comparison to other administration methods (21%). There was no association with age, sex, or heroin practice. There appears to be strong support among Australian IDU for naloxone distribution to peers. Intranasal spray is the preferred route of administration.
Collapse
Affiliation(s)
- Debra Kerr
- Joseph Epstein Centre for Emergency Medicine Research, Sunshine Hospital, 1st Floor, 176 Furlong Rd, St Albans, Victoria, 3021, Australia.
| | | | | | | |
Collapse
|
38
|
Abstract
This paper is the 29th consecutive installment of the annual review of research concerning the endogenous opioid system, now spanning 30 years of research. It summarizes papers published during 2006 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior (Section 2), and the roles of these opioid peptides and receptors in pain and analgesia (Section 3); stress and social status (Section 4); tolerance and dependence (Section 5); learning and memory (Section 6); eating and drinking (Section 7); alcohol and drugs of abuse (Section 8); sexual activity and hormones, pregnancy, development and endocrinology (Section 9); mental illness and mood (Section 10); seizures and neurological disorders (Section 11); electrical-related activity and neurophysiology (Section 12); general activity and locomotion (Section 13); gastrointestinal, renal and hepatic functions (Section 14); cardiovascular responses (Section 15); respiration and thermoregulation (Section 16); and immunological responses (Section 17).
Collapse
Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, CUNY, 65-30 Kissena Blvd., Flushing, NY 11367, United States.
| |
Collapse
|
39
|
|
40
|
Bernstein KT, Bucciarelli A, Piper TM, Gross C, Tardiff K, Galea S. Cocaine- and opiate-related fatal overdose in New York City, 1990-2000. BMC Public Health 2007; 7:31. [PMID: 17349051 PMCID: PMC1839087 DOI: 10.1186/1471-2458-7-31] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2006] [Accepted: 03/09/2007] [Indexed: 11/10/2022] Open
Abstract
Background In New York City (NYC), the annual mortality rate is higher for accidental drug overdoses than for homicides; cocaine and opiates are the drugs most frequently associated with drug overdose deaths. We assessed trends and correlates of cocaine- and opiate-related overdose deaths in NYC during 1990–2000. Methods Data were collected from the NYC Office of the Chief Medical Examiner (OCME) on all fatal drug overdoses involving cocaine and/or opiates that occurred between 1990–2000 (n = 8,774) and classified into three mutually exclusive groups (cocaine only; opiates-only; cocaine and opiates). Risk factors for accidental overdose were examined in the three groups and compared using multinomial logistic regression. Results Overall, among decedents ages 15–64, 2,392 (27.3%) were attributed to cocaine only and 2,825 (32.2%) were attributed to opiates-only. During the interval studied, the percentage of drug overdose deaths attributed to cocaine only fell from 29.2% to 23.6% while the percentage of overdose deaths attributed to opiates-only rose from 30.6% to 40.1%. Compared to New Yorkers who fatally overdosed from opiates-only, fatal overdose attributed to cocaine-only was associated with being male (OR = 0.71, 95% CI 0.62–0.82), Black (OR = 4.73, 95% CI 4.08–5.49) or Hispanic (OR = 1.51, 95% CI 1.29–1.76), an overdose outside of a residence or building (OR = 1.34, 95% CI 1.06–1.68), having alcohol detected at autopsy (OR = 0.50, 95% CI 0.44–0.56) and older age (55–64) (OR = 2.53 95% CI 1.70–3.75)). Conclusion As interventions to prevent fatal overdose become more targeted and drug specific, understanding the different populations at risk for different drug-related overdoses will become more critical.
Collapse
Affiliation(s)
- Kyle T Bernstein
- Department of Emergency Medicine, School of Medicine, New York University. 462 First Ave, 3Floor, Room A345, NY, NY 10003. USA
| | - Angela Bucciarelli
- Center for Urban Epidemiologic Studies, New York Academy of Medicine, 1216 Fifth Ave, NY, NY 10029, USA
| | - Tinka Markham Piper
- Center for Urban Epidemiologic Studies, New York Academy of Medicine, 1216 Fifth Ave, NY, NY 10029, USA
| | - Charles Gross
- Department of Psychiatry, Weill Medical College, Cornell University, 525 E. 68th St, NY, NY 10021 USA
| | - Ken Tardiff
- Department of Psychiatry, Weill Medical College, Cornell University, 525 E. 68th St, NY, NY 10021 USA
| | - Sandro Galea
- Department of Epidemiology, School of Public Health, University of Michigan. 1214 South University, Ann Arbor, Michigan, 48104-2548, USA
- Department of Epidemiology, Columbia University Mailman School of Public Health. 722 168th St, New York, New York 10032, USA
| |
Collapse
|
41
|
Klein SJ, O'Connell DA, Candelas AR, Giglio JG, Birkhead GS. Public health approach to opioid overdose. Am J Public Health 2007; 97:587-8. [PMID: 17329636 PMCID: PMC1829334 DOI: 10.2105/ajph.2006.106120] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
|
42
|
Piper TM, Rudenstine S, Stancliff S, Sherman S, Nandi V, Clear A, Galea S. Overdose prevention for injection drug users: lessons learned from naloxone training and distribution programs in New York City. Harm Reduct J 2007; 4:3. [PMID: 17254345 PMCID: PMC1797013 DOI: 10.1186/1477-7517-4-3] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2006] [Accepted: 01/25/2007] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Fatal heroin overdose is a significant cause of mortality for injection drug users (IDUs). Many of these deaths are preventable because opiate overdoses can be quickly and safely reversed through the injection of Naloxone [brand name Narcan], a prescription drug used to revive persons who have overdosed on heroin or other opioids. Currently, in several cities in the United States, drug users are being trained in naloxone administration and given naloxone for immediate and successful reversals of opiate overdoses. There has been very little formal description of the challenges faced in the development and implementation of large-scale IDU naloxone administration training and distribution programs and the lessons learned during this process. METHODS During a one year period, over 1,000 participants were trained in SKOOP (Skills and Knowledge on Opiate Prevention) and received a prescription for naloxone by a medical doctor on site at a syringe exchange program (SEP) in New York City. Participants in SKOOP were over the age of 18, current participants of SEPs, and current or former drug users. We present details about program design and lessons learned during the development and implementation of SKOOP. Lessons learned described in the manuscript are collectively articulated by the evaluators and implementers of the project. RESULTS There were six primary challenges and lessons learned in developing, implementing, and evaluating SKOOP. These include a) political climate surrounding naloxone distribution; b) extant prescription drug laws; c) initial low levels of recruitment into the program; d) development of participant appropriate training methodology; e) challenges in the design of a suitable formal evaluation; and f) evolution of program response to naloxone. CONCLUSION Other naloxone distribution programs may anticipate similar challenges to SKOOP and we identify mechanisms to address them. Strategies include being flexible in program planning and implementation, developing evaluation instruments for feasibility and simplicity, and responding to and incorporating feedback from participants.
Collapse
Affiliation(s)
- Tinka Markham Piper
- Center for Urban Epidemiologic Studies, New York Academy of Medicine, New York, NY 10029, USA
| | - Sasha Rudenstine
- Center for Urban Epidemiologic Studies, New York Academy of Medicine, New York, NY 10029, USA
| | | | - Susan Sherman
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore MD 21205, USA
| | - Vijay Nandi
- Center for Urban Epidemiologic Studies, New York Academy of Medicine, New York, NY 10029, USA
| | - Allan Clear
- Harm Reduction Coalition, New York, NY 10001, USA
| | - Sandro Galea
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI 48104, USA
| |
Collapse
|