Overdose Detection Technologies to Reduce Solitary Overdose Deaths: A Literature Review

An Autonomous Implantable Device for the Prevention of Death from Opioid Overdose

Opioid overdose accounts for nearly 75,000 deaths per year in the United States, representing a leading cause of mortality amongst the prime working age population (25-54 years). At overdose levels, opioid-induced respiratory depression becomes fatal without timely administration of the rescue drug naloxone. Currently, overdose survival relies entirely on bystander intervention, requiring a nearby person to discover and identify the overdosed individual, and have immediate access to naloxone to administer. Government efforts have focused on providing naloxone in abundance but do not address the equally critical component for overdose rescue: a willing and informed bystander. To address this unmet need, we developed the Naloximeter: a class of life-saving implantable devices that autonomously detect and treat overdose, with the ability to simultaneously contact first-responders. We present three Naloximeter platforms, for both fundamental research and clinical translation, all equipped with optical sensors, drug delivery mechanisms, and a supporting ecosystem of technology to counteract opioid-induced respiratory depression. In small and large animal studies, the Naloximeter rescues from otherwise fatal opioid overdose within minutes. This work introduces life-changing, clinically translatable technologies that broadly benefit a susceptible population recovering from opioid use disorder.

Implementing Canada's first national virtual phone based overdose prevention service: lessons learned from creating the National Overdose Response Service (NORS)

The opioid epidemic remains one of the largest public health crises in North America to date. While there have been many diverse strategies developed to reduce the harms associated with substance use, these are primarily concentrated within a few large urban centers. As a result, there have been increased calls for equitable access to harm reduction services for those who cannot or choose not to access in-person harm reduction services. In December 2020, Canada's National Overdose Response Service (NORS) a telephone based overdose response hotline and virtual supervised consumption service, was established in collaboration with various agencies and people with lived and living experience of substance use (PWLLE) across Canada to expand access to harm reduction services using novel Opioid Response Technology. In this manuscript we explore the lessons learned from the establishment and continued operation of the service exploring topics related to the initial establishment of the service, securing a phone line, routing technology, EMS dispatch solutions, peer and volunteer recruitment, legal and ethical support, policy and procedure development, securing funding, and marketing. Furthermore, we detail how this service has grown and changed in response to the various needs of service users.

Using alone at home: What's missing in housing-based responses to the overdose crisis?

BACKGROUND

Against the backdrop of North America's overdose crisis, most overdose deaths are occurring in housing environments, largely due to individuals using drugs alone. Overdose deaths in cities remain concentrated in marginal housing environments (e.g., single-room occupancy housing, shelters), which are often the only forms of housing available to urban poor and drug-using communities. This commentary aims to highlight current housing-based overdose prevention interventions and to situate them within the broader environmental contexts of marginal housing. In doing so, we call attention to the need to better understand marginal housing as sites of overdose vulnerability and public health intervention to optimize responses to the overdose crisis.

HARM REDUCTION AND OVERDOSE PREVENTION IN HOUSING

In response to high overdose rates in marginal housing environments several interventions (e.g., housing-based supervised consumption rooms, peer-witnessed injection) have recently been implemented in select jurisdictions. However, even with the growing recognition of marginal housing as a key intervention site, housing-based interventions have yet to be scaled up in a meaningful way. Further, there have been persistent challenges to tailoring these approaches to address dynamics within housing environments. Thus, while it is critical to expand coverage of housing-based interventions across marginal housing environments, these interventions must also attend to the contextual drivers of risks in these settings to best foster enabling environments for harm reduction and maximize impacts.

CONCLUSION

Emerging housing-focused interventions are designed to address key drivers of overdose risk (e.g., using alone, toxic drug supply). Yet, broader contextual factors (e.g., drug criminalization, housing quality, gender) are equally critical factors that shape how structurally vulnerable people who use drugs navigate and engage with harm reduction interventions. A more comprehensive understanding of these contextual factors within housing environments is needed to inform policy and programmatic interventions that are responsive to the needs of people who use drugs in these settings.

The Need to Rethink Harm Reduction for People Using Drugs Alone to Reduce Overdose Fatalities

Background: During the ongoing opioid epidemic, Cuyahoga County (second largest in Ohio) reported overdose mortality rates (54/per 100,000) higher than the national average. Prior research demonstrates that people who use drugs often use alone but there is minimal research on people who died of overdose while using alone. The objective of this study is to examine sociodemographic, toxicologic, and injury characteristics, and emergency medical response to overdose decedents who died using drugs alone. Method: Data from the Cuyahoga County Medical Examiner's Office (2016-2020, N = 2944) on unintentional overdose deaths in adults was tabulated including socio-demographic, toxicologic, and injury-related information. Decedents using drugs alone were identified and compared to those not using alone via Chi-square and Fisher's exact tests. We further fit a multivariate logistic regression model to evaluate socio-demographic, toxicologic, and injury-related factors associated with increased odds of using alone. All results are reported with 95% confidence intervals. Result: Among decedents, 75% (n = 2205) were using drugs alone. Decedents using alone were more likely to be using drugs at home (p = 0.001) or be found dead at the scene (p < 0.001) and less likely to receive naloxone (p < 0.001) have other person/bystander, not using, present (p = 0.002). Using drugs at home (aOR = 1.61[1.19-2.20]) was associated with higher odds of using alone; and being married (aOR = 0.57[0.38-0.86]), having history of illicit drug use (aOR = 0.25[0.08-0.81]) and other person present, who was not using (aOR = 0.58[0.42-0.79]) were associated with lower odds of using alone. Conclusion: New harm reduction approaches targeting people using drugs alone are needed to reduce overdose deaths.

Perspectives of healthcare workers on the integration of overdose detection technologies in acute care settings

BACKGROUND

People who use drugs (PWUD) face disproportionately high rates of hospitalizations and patient-initiated discharge (leaving against medical advice), explained by a combination of stigma, withdrawal, judgment, blame, and improper pain management. In addition, evidence has shown that despite abstinence-based policies within healthcare settings, PWUD continue to use their substances in healthcare environments often hidden away from hospital staff, resulting in fatalities. Various novel overdose detection technologies (ODTs) have been developed with early adoption in a few settings to reduce the morbidity and mortality from risky substance use patterns within healthcare environments. Our study aimed to gain the perspectives of healthcare workers across Canada on implementing ODTs within these settings.

METHOD

We used purposive and snowball sampling to recruit 16 healthcare professionals to participate in semi-structured interviews completed by two evaluators. Interview transcripts were analyzed using thematic analysis to identify key themes and subthemes.

RESULTS

Participants recognized ODTs as a potentially feasible solution for increasing the safety of PWUD in healthcare settings. Our results suggest the mixed ability of these services to decrease stigma and build rapport with PWUD. Participants further highlighted barriers to implementing these services, including pre-established policies, legal recourse, and coordination of emergency responses to suspected overdoses. Lastly, participants highlight that ODTs should only be one part of a multifaceted approach to reducing harm in healthcare settings and could currently be integrated into discharge planning.

CONCLUSION

Healthcare professionals from across Canada found ODTs to be an acceptable intervention, but only as part of a larger suite of harm reduction interventions to reduce the harms associated with illicit drug use in healthcare settings. In contrast, participants noted institutional policies, stigma on behalf of healthcare workers and leadership would present significant challenges to their uptake and dissemination.

What impacts the acceptability of wearable devices that detect opioid overdose in people who use opioids? A qualitative study

INTRODUCTION

Drug-related deaths involving an opioid are at all-time highs across the United Kingdom. Current overdose antidotes (naloxone) require events to be witnessed and recognised for reversal. Wearable technologies have potential for remote overdose detection or response but their acceptability among people who use opioids (PWUO) is not well understood. This study explored facilitators and barriers to wearable technology acceptability to PWUO.

METHODS

Twenty-four participants (79% male, average age 46 years) with current (n = 15) and past (n = 9) illicit heroin use and 54% (n = 13) who were engaged in opioid substitution therapy participated in semi-structured interviews (n = 7) and three focus groups (n = 17) in London and Nottingham from March to June 2022. Participants evaluated real devices, discussing characteristics, engagement factors, target populations, implementation strategies and preferences. Conversations were recorded, transcribed and thematically analysed.

RESULTS

Three themes emerged: device-, person- and environment-specific factors impacting acceptability. Facilitators included inconspicuousness under the device theme and targeting subpopulations of PWUO at the individual theme. Barriers included affordability of devices and limited technology access within the environment theme. Trust in device accuracy for high and overdose differentiation was a crucial facilitator, while trust between technology and PWUO was a significant environmental barrier.

DISCUSSION AND CONCLUSIONS

Determinants of acceptability can be categorised into device, person and environmental factors. PWUO, on the whole, require devices that are inconspicuous, comfortable, accessible, easy to use, controlled by trustworthy organisations and highly accurate. Device developers must consider how the type of end-user and their environment moderate acceptability of the device.

Addressing overdose risks and fatalities in public bathrooms: insights from the development of a Safer Bathroom Toolkit in British Columbia, Canada

SETTING

In British Columbia (BC), over 11,000 people have died of an overdose since 2016. Recently, an all-party standing committee on health tabled a report identifying several gaps in BC's overdose response. Chief among these is the inequitable distribution of supervised consumption and overdose prevention services across BC and barriers to accessing services that are currently available. In this context, public bathrooms continue to act as consumption spaces and contribute to overdose-related risks and fatalities.

INTERVENTION

The Safer Bathroom project sought to address long-standing policy and practice gaps by developing a toolkit to improve bathroom overdose prevention and response. Activities included a literature review and cross-sectoral, province-wide consultation (Fall 2021), the creation and launch of the Safer Bathroom Toolkit (Fall 2022), and knowledge transfer activities (ongoing).

OUTCOMES

The toolkit meets four objectives. First, it provides a bathroom safety checklist that helps identify and, most importantly, mitigate safety risks. Second, it offers organizational guidance on developing a bathroom safety policy and procedure. Third, it includes practical resources such as staff training material and signs that communicate bathroom safety messages in a non-stigmatizing manner. Finally, it identifies bathroom architecture and design features that can increase or decrease overdose-related risks.

IMPLICATIONS

The Safer Bathroom Toolkit is a highly comprehensive resource developed in response to the overdose crisis. However, significant reporting, research, policy, and practice gaps remain. This paper concludes with an overview of recommendations for advancing overdose prevention and response efforts within and beyond the bathroom context.

Virtual overdose monitoring services/mobile overdose response services: estimated number of potentially averted drug poisoning fatality events by various telephone and digital-based overdose prevention/harm reduction services in North America

Background

Virtual overdose monitoring services or Mobile Overdose Response Services (MORS) are novel virtual harm reduction tools which have gained popularity as an adjunct public health intervention especially for those who cannot access harm reduction resources through traditional means. At this time, relatively little is known about their ability to reach their goals of reducing overdose mortality. Our study aims to summarize the potential effectiveness of various MORS collectively to avoid potential mortality from a drug poisoning event/drug overdose.

Methods

Utilizing publicly available data from various MORS alongside some usage data provided by these services for this study, we model the impact of these services on fatal drug poisoning/overdose. In order to calculate the number of deaths averted, a Monte Carlo simulation was used to calculate point estimates with 95% confidence for fatal drug poisonings/drug overdose potentially averted through the utilization of various MORS.

Results

From the earliest mention of MORS in current literature (2019), a total of 299 drug poisoning/overdose events occurred across these services. Noting the broad range of mortality statistics available in current literature, these technologies have potentially prevented between 33 to 243 deaths. Our Monte Carlo estimates 135 potentially fatal drug poisonings/overdose were overall averted by the various MORS.

Conclusions

While there is yet to be a robust data set proving the effectiveness of these services, conservative estimates show that MORS can reduce mortality associated with substance use and therefore should be considered as a viable harm-reduction strategy but as an adjunct to more established harm reduction services such as supervised consumption sites and supervised injection facilities. While more research is needed, clinicians and practitioners should consider the suggestion of these tools for patients who use drugs.

Evaluating the Impact of Brave Technology Co-op's Novel Drug Overdose Detection and Response Devices in North America: a Retrospective Study

Assess the preliminary impact of Brave Technology Co-op's overdose detection devices that have been implemented in housing, medical, social service facilities, and several private settings in North America. Administrative data was collected by Brave on their Buttons and Sensors during several proof-of-concept projects and full installations in Canada and United States (US) between December 2018 and July 2022. Data analyzed provided insights on the number of overdoses detected and reversed (averted overdose deaths) using Brave Sensors and Buttons, along with other programmatic and session-specific indicators. Implementation of 486 Brave Buttons and 148 Brave Sensors in Canada has detected and prevented 108 overdose deaths (100 using Buttons and 8 using Sensors) whereas implementation of 170 Buttons in the US has averted 2 overdose deaths to date, with the potential to save many more lives. Brave's devices hold promise for increasing rates of overdose detection and preventing overdose deaths.

Trends in deaths following drug use in England before, during, and after the COVID-19 lockdowns

Aim

This research aimed to describe how the characteristics of deaths following drug use changed during the COVID-19 pandemic in England, and how this can inform future strategy to support the health and social care of people who use drugs in future emergency scenarios.

Method

All deaths reported to the National Programme on Substance Abuse Deaths which occurred between January 2018 and December 2021 inclusive were extracted for analysis. Exponential smoothing models were constructed to determine any differences between forecasted vs. actual trends.

Key results

Following the first lockdown period in England there were significant increases in the proportion of people who died at home beyond the 95% confidence bounds of the exponential smoothing model and concurrent decreases in the proportion of people who died in hospital. Whilst the overall proportion of deaths attributable to opioids did not significantly deviate from the forecasted trend, there were significant increases in methadone-related deaths and decreases in heroin/morphine-related death beyond the 95% confidence bounds. The proportion of deaths concluded as suicide increased, as did those implicating antidepressant use. There were no changes in the proportion of deaths following use of other drug classes, alcohol use in combination with psychoactive drugs, or on decedent demographics (gender, age, and drug user status). A small number of deaths due to drug use had COVID-19 infection itself listed as a cause of death (n = 23).

Conclusion

For people who use drugs, the impact of the restrictions due to the COVID-19 pandemic was greater than that of infection from the virus itself. The health and social care strategy for these people needs to be pre-emptively adapted to mitigate against the specific risk factors for fatal drug overdose associated with future emergency scenarios.

Electronic harm reduction interventions for drug overdose monitoring and prevention: A scoping review

BACKGROUND

Novel strategies are required to address rising overdose deaths across the globe. We sought to identify the breadth and depth of the existing evidence around electronic harm reduction (e-harm reduction) interventions that aimed to reduce the harms associated with substance use.

METHODS

We conducted a scoping review according to the PRISMA-ScR and PRISMA for Searching guidelines. A health sciences librarian systematically searched seven health databases from inception until January 20, 2023. Citation chaining and reference lists of included studies were searched to identify additional articles. Two reviewers independently screened, extracted and charted the data. Additionally, we conducted a gray literature search and environmental scan to supplement the findings.

RESULTS

A total of 51 studies met the criteria for inclusion (30 peer-reviewed articles and 21 non-peer reviewed). Most peer-reviewed studies were conducted in Western countries (USA = 23, Canada = 3, Europe = 3, China = 1) and among adult samples (adult = 27, youth/adults =1, unspecified = 2). Study designs were predominantly quantitative (n = 24), with a minority using qualitative (n = 4) or mixed methods (n = 2). Most e-harm reduction interventions were harm reduction (n = 15), followed by education (n = 6), treatment (n = 2), and combined/other approaches (n = 7). Interventions utilized web-based/mobile applications (n = 15), telephone/telehealth (n = 10), and other technology (n = 5).

CONCLUSIONS

While e-harm reduction technology is promising, further research is required to establish the efficacy and effectiveness of these novel interventions.

Virtual overdose monitoring services and overdose prevention technologies: Opportunities, limitations, and future directions

Overdose mortality has continued to rise in North America and across the globe in people who use drugs. Current harm reduction strategies such as supervised consumption sites and naloxone kit distribution have been important public health strategies implemented to decrease the harms associated with illicit drug use however have key limitations which prevent their scalability. This is represented in statistics which indicate that the vast majority of overdose mortality occur in individuals who use drugs by themselves. To address this, virtual overdose monitoring services and overdose detection technologies have emerged as an adjunct solution that may help improve access to harm reduction services for those that cannot or choose not to access current in-person services. This article outlines the current limitations of harm reduction services, the opportunities, challenges, and controversies of these technologies and services, and suggests avenues for additional research and policy development.

Feasibility and acceptability of inserts promoting virtual overdose monitoring services (VOMS) in naloxone kits: a qualitative study

BACKGROUND

In response to the ongoing opioid epidemic, there have been efforts to develop novel harm reduction strategies alongside scaling of currently implemented programs. Virtual overdose monitoring services (VOMS) are a novel intervention which aims to reduce substance-related mortality through technology for those who are out of reach of current supervised consumption sites. Scaling of naloxone programs presents a unique opportunity to promote VOMS to people at risk of substance-related mortality. This study aims to explore the feasibility and acceptability of naloxone kit inserts in promoting awareness of VOMS.

METHOD

We used purposive and snowball sampling to recruit 52 key informants, including people who use drugs (PWUD) with experience using VOMS (n = 16), PWUD with no prior experience using VOMS (n = 9), family members of PWUD (n = 5), healthcare and emergency services professionals (n = 10), community-based harm reduction organizations (n = 6), and VOMS administrators/peer support workers (n = 6). Two evaluators completed semi-structured interviews. Interview transcripts were analyzed using thematic analysis informed to identify key themes.

RESULTS

Four key interrelated themes emerged, including the acceptability of naloxone kit inserts to promote VOMS, best practices for implementation, key messaging to include within promotional materials and facilitators to dissemination of harm reduction material. Participants highlighted that messaging should be promoted both inside and outside the kits, should be concise, provide basic information about VOMS and can be facilitated through current distribution streams. Messaging could further be used to draw attention to local harm reduction services and could be promoted on other supplies, including lighters and safer consumption supplies.

CONCLUSION

Findings demonstrate that it is acceptable to promote VOMS within naloxone kits and highlight interviewees preferred ways to do so. Key themes that emerged from interviewees can be used to inform the dissemination of harm reduction information, including VOMS and bolster current strategies for reducing illicit drug overdose.

Rapid opioid overdose response system technologies

PURPOSE OF REVIEW

Opioid overdose events are a time sensitive medical emergency, which is often reversible with naloxone administration if detected in time. Many countries are facing rising opioid overdose deaths and have been implementing rapid opioid overdose response Systems (ROORS). We describe how technology is increasingly being used in ROORS design, implementation and delivery.

RECENT FINDINGS

Technology can contribute in significant ways to ROORS design, implementation, and delivery. Artificial intelligence-based modelling and simulations alongside wastewater-based epidemiology can be used to inform policy decisions around naloxone access laws and effective naloxone distribution strategies. Data linkage and machine learning projects can support service delivery organizations to mobilize and distribute community resources in support of ROORS. Digital phenotyping is an advancement in data linkage and machine learning projects, potentially leading to precision overdose responses. At the coalface, opioid overdose detection devices through fixed location or wearable sensors, improved connectivity, smartphone applications and drone-based emergency naloxone delivery all have a role in improving outcomes from opioid overdose. Data driven technologies also have an important role in empowering community responses to opioid overdose.

SUMMARY

This review highlights the importance of technology applied to every aspect of ROORS. Key areas of development include the need to protect marginalized groups from algorithmic bias, a better understanding of individual overdose trajectories and new reversal agents and improved drug delivery methods.

A scoping review of mHealth technologies for opioid overdose prevention, detection and response

ISSUES

Opioid overdose kills over 100,000 people each year globally. Mobile health (mHealth) technologies and devices, including wearables, with the capacity to prevent, detect or respond to opioid overdose exist in early form, or could be re-purposed or designed. These technologies may particularly help those who use alone. For technologies to be successful, they must be effective and acceptable to the at-risk population. The aim of this scoping review is to identify published studies on mHealth technologies that attempt to prevent, detect or respond to opioid overdose.

APPROACH

A systematic scoping review of literature was conducted up to October 2022. APA PsychInfo, Embase, Web of Science and Medline databases were searched.

INCLUSION CRITERIA

articles had to report on (i) mHealth technologies that deal with (ii) opioid (iii) overdose.

KEY FINDINGS

A total of 348 records were identified, with 14 studies eligible for this review across four domains: (i) technologies that require intervention/response from others (four); (ii) devices that use biometric data to detect overdose (five); (iii) devices that automatically respond to an overdose with administration of an antidote (three); (iv) acceptability/willingness to use overdose-related technologies/devices (five).

IMPLICATIONS

There are multiple routes in which these technologies may be deployed, but several factors impact acceptability (e.g., discretion or size) and accuracy of detection (e.g., sensitive parameter/threshold with low false positive rate).

CONCLUSION

mHealth technologies for opioid overdose may play a crucial role in responding to the ongoing global opioid crises. This scoping review identifies vital research that will determine the future success of these technologies.