Naloxone administration by law enforcement officers in New York State (2015-2020)

Using RE-AIM Framework to Evaluate Recovery Opioid Overdose Team Plus: A Peer-Led Post-overdose Quick Response Team

Peer recovery coaches utilize their lived experiences to support overdose survivors, a role gaining prominence across communities. A convergent mixed methods design, informed by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework, was used to evaluate the Recovery Opioid Overdose Team Plus (ROOT +), through an iterative evaluation using web-based surveys and qualitative interviews. Reach: Over 27 months, ROOT + responded to 83% of suspected overdose referrals (n = 607) and engaged with 41% of survivors (n = 217) and 7% of survivors' family/friends (n = 38). Effectiveness: Among those initially engaged with ROOT +, 36% of survivors remained engaged, entered treatment, or were in recovery at 90 days post-overdose (n = 77). Adoption: First responders completed 77% of ROOT + referrals (n = 468). Implementation: Barriers included lack of awareness of ROOT + , working phones, and access to treatment from community partner interviews (n = 15). Maintenance: Adaptations to ROOT + were made to facilitate implementation. Peer-led teams are promising models to engage with overdose survivors.

Disparities in the accuracy of reporting opioid overdoses to 9-1-1 by race and sex of overdose victim, Marion County, Indiana, 2011-2020

OBJECTIVES

To assess the prevalence of emergency medical incidents wherein naloxone was administered but overdose was not described as the chief complaint during the 9-1-1 call, including differences by overdose victim race/ethnicity and sex.

METHODS

We computed the percentage of 9-1-1 calls in Marion County, Indiana, from 2011 to 2020, wherein naloxone was administered but the caller did not describe overdose as the chief complaint. We estimated a logistic regression to examine the associations between reporting of overdose as the chief complaint and race and sex of the overdose victim.

RESULTS

Almost one-fifth of 9-1-1 calls preceding naloxone administration did not describe overdose as the chief complaint. 9-1-1 callers were more likely to describe a non-overdose as the chief complaint when the overdose victim was Black or female.

CONCLUSION

9-1-1 callers are less likely to use terminology describing overdose when the overdose victim is female or Black, than when the victim is male or White. Inaccurate terminology when calling 9-1-1 could delay naloxone administration, thereby increasing risk of overdose death and hypoxic brain injury. Some 9-1-1 callers may be avoiding overdose terminology to prevent a police response, or due to lack of knowledge about overdose identification, but further research is needed to determine the mechanisms underlying these findings.

High-dose naloxone formulations are not as essential as we thought

Naloxone is an effective FDA-approved opioid antagonist for reversing opioid overdoses. Naloxone is available to the public and can be administered through intramuscular (IM), intravenous (IV), and intranasal spray (IN) routes. Our literature review investigates the adequacy of two doses of standard IM or IN naloxone in reversing fentanyl overdoses compared to newer high-dose naloxone formulations. Moreover, our initiative incorporates the experiences of people who use drugs, enabling a more practical and contextually-grounded analysis. The evidence indicates that the vast majority of fentanyl overdoses can be successfully reversed using two standard IM or IN dosages. Exceptions include cases of carfentanil overdose, which necessitates ≥ 3 doses for reversal. Multiple studies documented the risk of precipitated withdrawal using ≥ 2 doses of naloxone, notably including the possibility of recurring overdose symptoms after resuscitation, contingent upon the half-life of the specific opioid involved. We recommend distributing multiple doses of standard IM or IN naloxone to bystanders and educating individuals on the adequacy of two doses in reversing fentanyl overdoses. Individuals should continue administration until the recipient is revived, ensuring appropriate intervals between each dose along with rescue breaths, and calling emergency medical services if the individual is unresponsive after two doses. We do not recommend high-dose naloxone formulations as a substitute for four doses of IM or IN naloxone due to the higher cost, risk of precipitated withdrawal, and limited evidence compared to standard doses. Future research must take into consideration lived and living experience, scientific evidence, conflicts of interest, and the bodily autonomy of people who use drugs.

Longitudinal Assessment of Emergency Responders' Attitudes Toward People Who Overdose and Naloxone Following an Overdose Education Training

BACKGROUND

In addition to teaching overdose recognition and response, overdose education and naloxone distribution (OEND) trainings for emergency responders aim to improve trainee attitudes toward people who use drugs and toward naloxone. This study examines the training effectiveness long term, as well as the extent to which improvements are dependent on profession type or recent experience administering naloxone.

METHODS

A total of 774 emergency responders, consisting of law enforcement officers (LEOs) (n = 624, 81%) and emergency medical service (EMS) personnel (n = 150, 19%), attended OEND trainings and completed surveys immediately prior to ("pre") and following ("post") the training, as well as 6 months later ("follow-up"). Survey items assessed attitudes toward people who have overdosed, naloxone-related risk compensation (ie, "enabling") beliefs, and whether participants had administered naloxone since attending the training. Multiple regression and estimated marginal means were used to evaluate changes in scores.

RESULTS

Emergency responders showed improved attitudes (pre = 2.60, follow-up = 2.45, P < .001) and risk compensation beliefs (pre = 2.97, follow-up = 2.67, P < .001) 6 months following the training. Follow-up scores differed by profession, with LEOs endorsing worse attitudes (difference = 0.55, P = .013) and more risk compensation beliefs (difference = 0.67, P = .014) than EMS. In addition, having recently administered naloxone predicted more negative attitudes (EMS: difference = 0.55, P = .01; LEO: difference = 0.54, P = .004) and risk compensation beliefs (EMS = 0.73, P = .006; LEO = 0.69, P = .002) at follow-up.

CONCLUSION

Six months after an OEND training, emergency responders' attitudes toward people who overdose, and their risk compensation beliefs remained improved. However, LEOs had more negative follow-up attitudes and beliefs compared to EMS. Emergency responders who had administered naloxone had worse attitudes and beliefs at follow-up than those who had not. Of note, our sample evidenced sizable attrition between pre and follow-up assessments, leaving room for selection bias. Future studies should investigate how to mitigate negative effects of administering naloxone on attitudes toward those who overdose, and belief that naloxone is "enabling."

Comparison of Administration of 8-Milligram and 4-Milligram Intranasal Naloxone by Law Enforcement During Response to Suspected Opioid Overdose - New York, March 2022-August 2023

In 2021, an 8-mg intranasal naloxone product was approved by the Food and Drug Administration; however, no studies have examined outcomes among persons who receive the 8-mg naloxone product and those who receive the usual 4-mg product. During March 2022-August 2023, New York State Department of Health (NYSDOH) supplied some New York State Police (NYSP) troops with 8-mg intranasal naloxone; other troops continued to receive 4-mg intranasal naloxone to treat suspected opioid overdose. NYSP submitted detailed reports to NYSDOH when naloxone was administered. No significant differences were observed in survival, mean number of naloxone doses administered, prevalence of most postnaloxone signs and symptoms, postnaloxone anger or combativeness, or hospital transport refusal among 4-mg and 8-mg intranasal naloxone recipients; however, persons who received the 8-mg intranasal naloxone product had 2.51 times the risk for opioid withdrawal signs and symptoms, including vomiting, than did those who received the 4-mg intranasal naloxone product (95% CI = 1.51-4.18). This initial study suggests no benefits to law enforcement administration of higher-dose naloxone were identified; more research is needed to guide public health agencies in considering whether 8-mg intranasal naloxone confers additional benefits for community organizations.

Effectiveness of take ACTION online naloxone training for law enforcement officers

BACKGROUND

Training law enforcement officers (LEOs) to administer naloxone is a recommended strategy to reduce overdose deaths in the United States. To achieve this, an evidence-based and scalable naloxone training curriculum that is easy to use and readily scalable is needed. Convenient web-based training is a flexible method for delivering educational interventions particularly for LEOs who have irregular or shifting schedules. This study examined the effectiveness of a comprehensive web-based naloxone training that was created in partnership with LEOs on their knowledge, confidence, and attitudes regarding naloxone.

METHODS

From May 2019 to September 2020, five law enforcement departments from Michigan participated in web-based naloxone training. A total of 182 LEOs (77% male) were in the final sample based on matching pre-and post-test surveys. LEOs were assessed on knowledge, confidence, and attitudes towards naloxone. Negative binomial and Poisson regression was conducted to assess associations between knowledge, confidence, and attitudes towards naloxone before and after training.

RESULTS

Significant improvements in overdose knowledge and confidence were revealed across all departments with median (IQR) total composite scores for knowledge increasing from 35 (32, 37) to 40 (39, 42) (p < 0.01) and confidence increasing from 18.5 (15, 20) to 20 (20, 25) (p < 0.01). Median (IQR) attitude scores did not change.

CONCLUSION

Our web-based naloxone training was effective in improving knowledge and confidence for LEOs but did not significantly improve LEOs attitudes towards naloxone across most departments. The web-based format is readily scalable and quickly disseminated and meets the immediate need for LEO overdose training. Additional intervention is needed to address the negative attitudes of LEOs regarding naloxone.

Endogenous opiates and behavior: 2022

This paper is the forty-fifth consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2022 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

High-Dose Naloxone Formulations Are Not as Essential as We Thought

Naloxone is a U.S. Food and Drug Administration (FDA) approved opioid antagonist for reversing opioid overdoses. Naloxone is available to the public, and can be administered through intramuscular (IM), intravenous (IV), and intranasal spray (IN) routes. Our literature review aimed to improve understanding regarding the adequacy of the regularly distributed two doses of low-dose IM or IN naloxone in effectively reversing fentanyl overdoses and whether high-dose naloxone formulations (HDNF) formulations are an optimal solution to this problem. Moreover, our initiative incorporated the perspectives and experiences of people who use drugs (PWUD), enabling a more practical and contextually-grounded analysis. We began by discussing the knowledge and perspectives of Tennessee Harm Reduction, a small peer-led harm reduction organization. A comprehensive literature review was then conducted to gather relevant scholarly works on the subject matter. The evidence indicates that, although higher doses of naloxone have been administered in both clinical and community settings, the vast majority of fentanyl overdoses can be successfully reversed using standard IM dosages with the exception of carfentanil overdoses and other more potent fentanyl analogs, which necessitate three or more doses for effective reversal. Multiple studies documented the risk of precipitated withdrawal using high doses of naloxone. Notably, the possibility of recurring overdose symptoms after resuscitation exists, contingent upon the half-life of the specific opioid. Considering these findings and the current community practice of distributing multiple doses, we recommend providing at least four standard doses of IN or IM naloxone to each potential bystander, and training them to continue administration until the recipient achieves stability, ensuring appropriate intervals between each dose. Based on the evidence, we do not recommend HDNF in the place of providing four doses of standard naloxone due to the higher cost, risk of precipitated withdrawal and limited evidence compared to standard IN and IM. All results must be taken into consideration with the inclusion of the lived experiences, individual requirements, and consent of PWUD as crucial factors. It is imperative to refrain from formulating decisions concerning PWUD in their absence, as their participation and voices should be integral to the decision-making process.

Post-overdose follow-up in the community with peer recovery specialists: the Lake Superior Diversion and Substance Use Response Team

Background

As the overdose epidemic continues to worsen, nonfatal overdose calls for service represent a critical touchpoint for intervention. While most studies have focused on law enforcement led post-overdose follow-up, the current study describes the programmatic characteristics and outcomes of a non-law enforcement post overdose program comprised of peer specialists embedded within a local police department.

Methods

We examined information on 341 follow-up responses occurring over a 16-month study period using administrative data. We assessed programmatic characteristics including demographic information on clients, referral source, engagement type, and goal completion.

Results

The results indicate that over 60% of client referrals ended in the goal of in-person contact. Of those, about 80% went on to complete an engagement goal with the peer specialist. We found no significant variation in client demographics and referral source or follow-up engagement (in-person or not); however, client referrals from law enforcement first responders, the most common source, are significantly less likely to result in an in-person contact, though, if contact is made, similarly likely to complete an engagement goal.

Conclusions

Post overdose response programs that do not involve law enforcement are exceedingly rare. Given that some research has shown that police involvement in post overdose response can have unexpected, associated harms, it is important to assess the effectiveness of post overdose programs that do not involve the police. Findings here suggest that this type of program is successful at locating and engaging community members into recovery support services who have experienced an overdose.