The synthetic opioid epidemic and the need for mental health support for first responders who intervene in overdose cases

Opioid overdose prevention training needs: Findings from emergency medical services providers in Baltimore County, Maryland

Emergency Medical Services (EMS) providers are on the frontlines of the opioid response. This study explored the EMS training needs in Baltimore County, Maryland. An online survey conducted between January-June 2021 assessed knowledge, attitudes, awareness, and self-efficacy to use opioid overdose prevention strategies; burnout, compassion fatigue, stress, and wellness; and training needs among EMS providers (N = 256). Participants reported positive attitudes toward the use of opioid treatment guidelines and confidence in their ability to use the guidelines. They indicated positive attitudes toward harm reduction, but less favorable attitudes toward opioid use disorder (OUD). Although the participants understood the role of a peer recovery specialist moderately well, they were not fully comfortable with making a referral. They reported relatively low levels of burnout and compassion fatigue and good wellness practices, but indicated a moderate level of stress associated with COVID-19. Perceived training needs included: lifetime fitness and wellness, trauma-informed care, stigma awareness, stages of change, and harm reduction. Offering these trainings and enhancing EMS providers' comfort to make referrals to peer recovery support services may strengthen the referral systems and connect overdose survivors to a continuum of care.

Ensuring Optimal Mental Health Programs and Policies for First Responders: Opportunities and Challenges in One U.S. State

This study examined opportunities and challenges faced by individuals working to advance mental health policy and programming for first responders. We utilized qualitative content analysis and interviews with 16 firefighters, emergency medical services professionals, law enforcement officers, and others involved in programming or policy in the U.S. state of Ohio. Six themes characterized opportunities and challenges encountered: (1) variations in programming and policy exist across jurisdictions; (2) opportunities exist to enhance mental health awareness and self-care training for first responders; (3) need exists for specialized mental health clinicians accustomed to and capable of effectively working with first responders; (4) confidentiality protections are lacking for peer supporters not trained in critical incident stress management; (5) having an internal champion and broader support is key to program and policy advancement; and (6) interdepartmental collaboration provides opportunities for sharing resources and best practices. Results illustrate continued need for strategic policymaking, program development, and coordination.

Synthetic opioids: a review and clinical update

The term 'opioids' refers to both the natural compounds ('opiates') which are extracted from the opium poppy plant (Papaver somniferum) and their semi-synthetic and synthetic derivatives. They all possess relatively similar biochemical profiles and interact with the opioid receptors within the human body to produce a wide range of physiological effects. They have historically been used for medicinal purposes, their analgesic and sedative effects, and in the management of chronic and severe pain. They have also been used for non-medicinal and recreational purposes to produce feelings of relaxation, euphoria and well-being. Over the last decade, the emergence of an illegal market in new synthetic opioids has become a major global public health issue, associated with a substantial increase in unintentional overdoses and drug-related deaths. Synthetic opioids include fentanyl, its analogues and emerging non-fentanyl opioids. Their popularity relates to changes in criminal markets, pricing, potency, availability compared to classic opioids, ease of transport and use, rapid effect and lack of detection by conventional testing technologies. This article expands on our previous review on new psychoactive substances. We now provide a more in-depth review on synthetic opioids and explore the current challenges faced by people who use drugs, healthcare professionals, and global public health systems.

Emotional reactions of trained overdose responders who use opioids following intervention in an overdose event

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.

Conceptualizing overdose trauma: The relationships between experiencing and witnessing overdoses with PTSD symptoms among street-recruited female sex workers in Baltimore, Maryland

BACKGROUND

The opioid crisis has rendered witnessing and experiencing overdoses a common occurrence, especially among marginalized and drug using populations, including female sex workers (FSW). Such exposures may confer psychological trauma that has gone unrecognized. We explored relationships between experiencing and witnessing overdoses and PTSD symptomology to understand the traumatic nature of these experiences.

METHODS

Data were from FSW (N = 380) in Baltimore City, Maryland, who reported whether they had witnessed/experienced any overdoses in the past 6 months ("overdose traumas") and PTSD symptoms (PCL-5). We tested for associations between overdose traumas and PTSD diagnoses/symptomology in bivariate logistic regression models and multivariate models, adjusting for sociodemographic, experiences of violence, and drug use characteristics.

RESULTS

In our sample, 35.3% witnessed a fatal overdose, 51.9% witnessed a non-fatal overdose, and 28.3% experienced an overdose in the past 6 months. More than half (52.4%) met criteria for PTSD. Most endorsed symptoms within each PTSD domain: 63.2% for intrusive, 58.4% for avoidance, 66.1% for cognition/mood, and 64.7% for arousal/reactivity symptoms. Experiencing an overdose was associated with meeting PTSD criteria and symptoms in all domains in bivariate models. Witnessing an overdose was associated with PTSD diagnoses and intrusive and arousal/reactivity symptoms in bivariate models. Adjusting for sociodemographic characteristics and drug use, experiencing an overdose was associated with intrusive and cognition/mood symptoms, while neither trauma remained associated with PTSD diagnoses.

CONCLUSIONS

Traumas related to overdose, coined "overdose traumas" appear to be extremely psychologically traumatic, though the relationships vary by type and symptom. Programs should be cognizant of psychological trauma to address the full spectrum of overdose harms. Existing measures of PTSD do not accurately represent the effects of overdose traumas in populations like FSW due to the structural barriers to avoiding locations/situations where overdoses may occur and the overlap between symptoms, drug effects, and adaptive responses to homelessness.

One opioid user saving another: the first study of an opioid overdose-reversal and naloxone distribution program addressing hard-to-reach drug scenes in Denmark

BACKGROUND

Overdose education and naloxone distribution programs decrease opioid overdose deaths. However, no studies of such programs have been carried out in Denmark. The aim of this study was to evaluate the feasibility and the effect of a broader "training-the-trainers" model in low-threshold settings after participation in the "Danish Save Lives" [SL] program.

METHODS

Between May 2013 and November 2015, 552 participants from four municipalities took part in the SL program. The program is built on the train-the-trainers model where a central trainer trains others (trainers), who in turn train others (helpers). Participants were 30 police officers (5%), 188 people who use opioids (34%), 23 significant others (4%), and 217 social workers (39%). Ninety-four participants could not be classified (17%). At follow-up, participants were interviewed to determine the number and outcomes of opioid overdoses. Logistic regression was used to assess predictors of treating an overdose.

RESULTS

In all, 37 (7%) participants had intervened in 45 opioid overdose events (two trainers and 35 helpers). Detailed descriptions of the overdose event were available from 32 follow-up interviews (70%). In 16 cases, the person who intervened was already present at the site when the overdose occurred, and in 17 cases, the overdose victim recovered without complications. All overdose victims survived except one. People who used opioids were more likely to have treated an overdose than other participants (adjusted odds ratio [AOR] = 8.50, p = 0.001), and the likelihood of treating and overdose declined over time AOR = 0.37 (0.13, 0.93), p = 0.034).

CONCLUSIONS

Prevention programs that target people who use opioids are more likely to be effective than programs that target professionals, especially in high-risk settings that can be hard for paramedics to reach. A future goal is to explore how prevention programs can be adapted to new user groups.

TRIAL REGISTRATION

The Danish Data Protection Agency, 2015-57-0002, Aarhus University, 2016-051-000001, 184, retrospectively registered.

"You can see those concentric rings going out": Emergency personnel's experiences treating overdose and perspectives on policy-level responses to the opioid crisis in New Hampshire

BACKGROUND

In parallel to a substantial increase in opioid overdose deaths in New Hampshire (NH), emergency personnel experienced an increase in opioid-related encounters. To inform public health responses to this crisis, insights into the experiences and perspectives of those emergency personnel who treat opioid-related overdoses are warranted.

AIMS

Systematically examine emergency personnel's experiences treating opioid overdoses and obtain their perspectives on policy-level responses to the opioid crisis in NH.

METHODS

Semi-structured qualitative interviews were conducted with 18 first responders [firefighters (n = 6), police officers (n = 6), emergency medical service providers (n = 6)] and 18 emergency department personnel employed in six NH counties. Interviews focused on emergency personnel's perspectives on fentanyl/heroin formulations, experiences treating overdoses, harm reduction strategies, and experiences with treatment referral. Interviews were audio recorded, transcribed verbatim, and analyzed using content analysis.

RESULTS

Emergency personnel cited the potency and inconsistency of fentanyl-laced heroin as primary drivers of opioid overdose. Increases in overdose-related encounters took a substantial emotional toll on emergency personnel, who described a range of responses including feelings of burnout, exhaustion, and helplessness. While some emergency personnel felt conflicted about the implementation of harm reduction strategies like syringe services programs, others emphasized the necessity of these services. Emergency personnel expressed frustration with barriers to treatment referral in the state and recommended immediate treatment access after overdose events.

CONCLUSIONS

Findings suggest that interventions addressing trauma and burnout are necessary to support emergency personnel, while expanded harm reduction and treatment access are critical to support those who experience opioid overdose in NH.

Lessons learned from the opioid crisis across the pillars of the Canadian drugs and substances strategy

Background

Canada is facing an urgent challenge to reduce the harms associated with opioids: from January 2016 to December of 2018, more than 11,500 individuals lost their lives due to opioid related harms. This review examines responses to the opioid crisis thus far, the lessons learned from these initiatives and the knowledge gaps that still need to be addressed across the four pillar model adopted by the CDSS.

Methods

A search of peer-reviewed literature was conducted in PubMed and PsycNet, and grey literature was retrieved from reputable substance use and health organizations to determine responses to the opioid crisis and related outcomes between 2013 and 2019. Findings related to actions, outcomes and unintended consequences across the categories of prevention, treatment, harm reduction, enforcement and the evidence base were included and synthesized into a narrative review on lessons learned.

Results

The opioid crisis is a result of multiple, complex interrelated factors. Many physicians may not feel competent to appropriately treat pain and/or addiction. Pushes for opioid deprescribing have resulted in some individuals using illicit opioids as treatment. A range of effective and accessible pharmacological and psychological treatments are still required. When regulations are barriers, unsanctioned actions, such as overdose prevention sites, may be enacted by individuals to respond to urgent public health needs. A nimble response with evolving enforcement perspectives can aid individuals experiencing harms from opioid use.

Conclusions

There is no one size fits all response to this crisis, and consideration should be given to the unique needs of different communities and populations, as well as the broader impact of harms on families, communities, and society. A situation so multifaceted requires both immediate and long-term strategies implemented concurrently in order to address the differing and on-going needs of Canadians experiencing opioid harms. The expertise of individuals and families affected by the opioid crisis must be included in consultations and decisions related to different strategies, to ensure responses are not stigmatizing, that they will be effective and acceptable and that unintended consequences are quickly recognized and mitigated.

Early Identification of Locally Emerging Trends in Psychoactive Substance Use - Experience and Best Practice in Four European Localities

Background: Timely information about trends in psychoactive substance use could yield tailored interventions and reduce potential harms. However, conventional epidemiological tools might have limited capacity to detect trends emerging on a local level. Objectives: The aim of this study was to explore best practice in the identification of new drug trends at the local level. Methods: A total of 33 key informants from seven European municipalities/regions were interviewed to describe trends in substance use in their locality and to provide expert insights on how these were identified. Semi-structured interviews were analyzed with open coding method. Results: Four case studies that described local trends and responses were compiled: onset of problematic GHB use in the Dutch municipality of Breda (1); emerging retail shops selling new psychoactive substances (NPS) across the regions of Czech Republic (2) and in the Portuguese Agueda and Coimbra (3); and use of drugs with unknown content in the Italian region of Emilia Romagna, and its city Bologna (4). "Early identifiers" in the four case studies were organizations that work directly with people who use drugs (PWUD), emergency departments, and local police. Efficient methods of horizontal and vertical information sharing, sometimes facilitated by communication platforms, were in place, such that included early warning systems on local, national, and supra-local level. Local-level identification systems appeared as best suited to provide locally relevant information. Conclusions: Best practice in identifying emerging trends should involve all relevant "early identifiers", should consist of supra-local exchange platforms, integrate the qualities of local-level identification, and be facilitated by local-level coordinators.

Activism and scientific research: 20 years of community action by the Vancouver area network of drug users

Background

Over the past several decades, there have been numerous peer-reviewed articles written about people who use drugs (PWUDs) from the Downtown Eastside neighborhood of Vancouver, Canada. While individual researchers have engaged and acknowledged this population as participants and community partners in their work, there has been comparatively little attention given to the role of PWUDs and drug user organizations in directing, influencing, and shaping research agendas.

Methods

In this community-driven research, we examine 20 years of peer-reviewed studies, university theses, books, and reports that have been directed, influenced, and shaped by members of the activist organization the Vancouver Area Network of Drug Users (VANDU). In this paper, we have summarized VANDU’s work based on different themes from each article.

Results

After applying the inclusion criteria to over 400 articles, 59 items containing peer-reviewed studies, books, and reports were included and three themes of topics researched or discussed were identified. Theme 1: ‘health needs’ of marginalized groups was found in 39% of articles, Theme 2: ‘evaluation of projects’ related to harm reduction in 19%, and Theme 3: ‘activism’ related work in 42%. Ninety-four percent of co-authors were from British Columbia and 44% of research was qualitative. Works that have been co-authored by VANDU’s members or acknowledged their participations created 628 citations. Moreover, their work has been accessed more than 149,600 times.

Conclusions

Peer-based, democratic harm reduction organizations are important partners in facilitating groundbreaking health and social research, and through research can advocate for the improved health and wellbeing of PWUDs and other marginalized groups in their community. This article also recommends that PWUDs should be more respectfully engaged and given appropriate credit for their contributions.