Statewide efforts to address the opioid epidemic: Results from a national survey of single state agencies

BACKGROUND

Single State Agencies (SSAs) are at the forefront of efforts to address the nation's opioid epidemic, responsible for allocating billions of dollars in federal, state, and local funds to ensure service quality, promote best practices, and expand access to care. Federal expenditures to SSAs have more than tripled since the early years of the epidemic, yet, it is unclear what initiatives SSAs have undertaken to address the crisis and how they are financing these efforts.

METHODS

This study used data from an internet-based survey of SSAs, conducted by the University of Chicago Survey Lab from January to December 2021 (response rate of 94 %). The survey included a set of 14 items identifying statewide efforts to address the opioid epidemic and six funding sources. We calculated the percentage of SSAs that supported each statewide effort and the percentage of SSAs reporting use of each source of funding across the 14 statewide efforts.

RESULTS

Treatment of opioid-related overdose figured most prominently among statewide efforts, with all SSAs providing funding for naloxone distribution and all but one SSA supporting naloxone training. Recovery support services, Project ECHO, and Hub and Spoke models were supported by the vast majority of SSAs. Statewide efforts related to expanding access to medications for opioid use disorder (MOUD) received somewhat less support, with 45 % of SSAs supporting mobile methadone/MOUD clinics/programs and 70 % supporting buprenorphine in emergency departments. A relatively low proportion of SSAs (54 %) provided support for syringe services programs. State Opioid Response (SOR) funds were the most common funding source reported by SSAs (57 % of SSAs), followed by block grant funds (19 %) and other state funding (15 %).

CONCLUSION

Results highlight a range of SSA efforts to address the nation's opioid epidemic. Limited adoption of efforts to expand access to MOUD and harm reduction services may represent missed opportunities. The uncertainty over reauthorization of the SOR grant post-2025 also raises concerns over sustainability of funding for many of these statewide initiatives.

Racial/ethnic differences in receipt of naloxone distributed by opioid overdose prevention programs in New York City

INTRODUCTION

We evaluated racial/ethnic differences in the receipt of naloxone distributed by opioid overdose prevention programs (OOPPs) in New York City (NYC).

METHODS

We used naloxone recipient racial/ethnic data collected by OOPPs from April 2018 to March 2019. We aggregated quarterly neighborhood-specific rates of naloxone receipt and other covariates to 42 NYC neighborhoods. We used a multilevel negative binomial regression model to assess the relationship between neighborhood-specific naloxone receipt rates and race/ethnicity. Race/ethnicity was stratified into four mutually exclusive groups: Latino, non-Latino Black, non-Latino White, and non-Latino Other. We also conducted racial/ethnic-specific geospatial analyses to assess whether there was within-group geographic variation in naloxone receipt rates for each racial/ethnic group.

RESULTS

Non-Latino Black residents had the highest median quarterly naloxone receipt rate of 41.8 per 100,000 residents, followed by Latino residents (22.0 per 100,000), non-Latino White (13.6 per 100,000) and non-Latino Other residents (13.3 per 100,000). In our multivariable analysis, compared with non-Latino White residents, non-Latino Black residents had a significantly higher receipt rate, and non-Latino Other residents had a significantly lower receipt rate. In the geospatial analyses, both Latino and non-Latino Black residents had the most within-group geographic variation in naloxone receipt rates compared to non-Latino White and Other residents.

CONCLUSIONS

This study found significant racial/ethnic differences in naloxone receipt from NYC OOPPs. We observed substantial variation in naloxone receipt for non-Latino Black and Latino residents across neighborhoods, indicating relatively poorer access in some neighborhoods and opportunities for new approaches to address geographic and structural barriers in these locations.

Projected Estimates of Opioid Mortality After Community-Level Interventions

Importance

The United States is experiencing a crisis of opioid overdose. In response, the US Department of Health and Human Services has defined a goal to reduce overdose mortality by 40% by 2022.

Objective

To identify specific combinations of 3 interventions (initiating more people to medications for opioid use disorder [MOUD], increasing 6-month retention with MOUD, and increasing naloxone distribution) associated with at least a 40% reduction in opioid overdose in simulated populations.

Design, Setting, and Participants

This decision analytical model used a dynamic population-level state-transition model to project outcomes over a 2-year horizon. Each intervention scenario was compared with the counterfactual of no intervention in simulated urban and rural communities in Massachusetts. Simulation modeling was used to determine the associations of community-level interventions with opioid overdose rates. The 3 examined interventions were initiation of more people to MOUD, increasing individuals' retention with MOUD, and increasing distribution of naloxone. Data were analyzed from July to November 2020.

Main Outcomes and Measures

Reduction in overdose mortality, medication treatment capacity needs, and naloxone needs.

Results

No single intervention was associated with a 40% reduction in overdose mortality in the simulated communities. Reaching this goal required use of MOUD and naloxone. Achieving a 40% reduction required that 10% to 15% of the estimated OUD population not already receiving MOUD initiate MOUD every month, with 45% to 60%% retention for at least 6 months, and increased naloxone distribution. In all feasible settings and scenarios, attaining a 40% reduction in overdose mortality required that in every month, at least 10% of the population with OUD who were not currently receiving treatment initiate an MOUD.

Conclusions and Relevance

In this modeling study, only communities with increased capacity for treating with MOUD and increased MOUD retention experienced a 40% decrease in overdose mortality. These findings could provide a framework for developing community-level interventions to reduce opioid overdose death.

The University of Miami Infectious Disease Elimination Act Syringe Services Program: A Blueprint for Student Advocacy, Education, and Innovation

After the closure of pill mills and implementation of Florida's Prescription Drug Monitoring Program in 2010, high demand for opioids was met with counterfeit pills, heroin, and fentanyl. In response, medical students at the University of Miami Miller School of Medicine embarked on a journey to bring syringe services programs (SSPs) to Florida through an innovative grassroots approach. Working with the Florida Medical Association, students learned patient advocacy, legislation writing, and negotiation within a complex political climate. Advocacy over 4 legislative sessions (2013-2016) included committee testimony and legislative visit days, resulting in the authorization of a 5-year SSP pilot. The University of Miami's Infectious Disease Elimination Act (IDEA) SSP opened on December 1, 2016. Students identified an urgent need for expanded health care for program participants and founded a weekly free clinic at the SSP. Students who rotate through the clinic learn medicine and harm reduction through the lens of social justice, with exposure to people who use drugs, sex workers, individuals experiencing homelessness, and other vulnerable populations. The earliest success of the IDEA SSP was the distribution of over 2,000 boxes of nasal naloxone, which the authors believe positively contributed to a decrease in the number of opioid-related deaths in Miami-Dade County for the first time since 2013. The second was the early identification of a cluster of acute human immunodeficiency virus infections among program participants. Inspired by these successes, students from across the state joined University of Miami students and met with legislators in their home districts, wrote op-eds, participated in media interviews, and traveled to the State Capitol to advocate for decisive action to mitigate the opioid crisis. The 2019 legislature passed legislation authorizing SSPs statewide. In states late to adopt SSPs, medical schools have a unique opportunity to address the opioid crisis using this evidence-based approach.

Overdose Education and Naloxone Distribution Within Syringe Service Programs - United States, 2019

Syringe service programs (SSPs), which provide access to sterile syringes and other injection equipment and their safe disposal after use,* represent a highly successful human immunodeficiency virus (HIV) prevention intervention. SSPs are associated with a 58% reduction in the incidence of HIV infection among persons who inject drugs (1). In addition, SSPs have led efforts to prevent opioid overdose deaths by integrating evidence-based opioid overdose education and naloxone distribution (OEND) programs (2-4). OEND programs train laypersons to respond during overdose events and provide access to naloxone and directions for drug delivery (2-4). SSPs are ideal places for OEND because they provide culturally relevant services designed to reach persons at high risk for experiencing or observing an opioid overdose. A 2013 survey found that only 55% of SSPs in the United States had implemented OEND (5). To characterize current implementation of OEND among SSPs, and to describe the current reach (i.e., the ratio of persons who received naloxone per opioid overdose death and the ratio of naloxone doses distributed per opioid overdose death) of SSP-based OEND programs by U.S. Census division,^† a survey of known U.S. SSPs was conducted in 2019, which found that 94% of SSPs had implemented OEND. In addition, the reach of SSP-based OEND programs varied by U.S. Census division. Scaling up of SSP-based OEND delivery programs could be a critical component for areas of the country with high opioid overdose death rates and low reach.

Economic Evaluation of Interventions to Address Opioid Misuse: A Systematic Review of Methods Used in Simulation Modeling Studies

OBJECTIVES

Several evidence-based interventions exist for people who misuse opioids, but there is limited guidance on optimal intervention selection. Economic evaluations using simulation modeling can guide the allocation of resources and help tackle the opioid crisis. This study reviews methods employed by economic evaluations using computer simulations to investigate the health and economic effects of interventions meant to address opioid misuse.

METHODS

We conducted a systematic mapping review of studies that used simulation modeling to support the economic evaluation of interventions targeting prevention, treatment, or management of opioid misuse or its direct consequences (ie, overdose). We searched 6 databases and extracted information on study population, interventions, costs, outcomes, and economic analysis and modeling approaches.

RESULTS

Eighteen studies met the inclusion criteria. All of the studies considered only one segment of the continuum of care. Of the studies, 13 evaluated medications for opioid use disorder, and 5 evaluated naloxone distribution programs to reduce overdose deaths. Most studies estimated incremental cost per quality-adjusted life-years and used health system and/or societal perspectives. Models were decision trees (n = 4), Markov (n = 10) or semi-Markov models (n = 3), and microsimulations (n = 1). All of the studies assessed parameter uncertainty though deterministic and/or probabilistic sensitivity analysis, 4 conducted formal calibration, only 2 assessed structural uncertainty, and only 1 conducted expected value of information analyses. Only 10 studies conducted validation.

CONCLUSIONS

Future economic evaluations should consider synergies between interventions and examine combinations of interventions to inform optimal policy response. They should also more consistently conduct model validation and assess the value of further research.

Empowering Students and Influencing Policy Change Through Experiential Public Health Advocacy Education

BACKGROUND

Public health advocacy is central to the work of many health professionals, including nurses. Although deemed to be a core competency for public health practitioners, courses described in the literature often lack a focus on experiential learning, which is an essential component to acquiring public health advocacy skills.

METHOD

This article describes an innovative, 12-week graduate course that provides students with a combination of theory and experiential learning through an opportunity to engage in political advocacy, community mobilization, and media engagement on a current public health issue.

RESULTS

An advocacy campaign undertaken by students to increase community access to the overdose reversal medication naloxone is described in light of the current North American overdose epidemic. Key considerations for teaching public health advocacy to facilitate development of nursing courses elsewhere are highlighted.

CONCLUSION

Public health advocacy education is important and needs to be expanded both within the nursing profession and across all disciplines. [J Nurs Educ. 2019;58(12):698-703.].

Regional variation in states' naloxone accessibility laws in association with opioid overdose death rates-Observational study (STROBE compliant)

Though overall death from opioid overdose are increasing in the United States, the death rate in some states and population groups is stabilizing or even decreasing. Several states have enacted a Naloxone Accessibility Laws to increase naloxone availability as an opioid antidote. The extent to which these laws permit layperson distribution and possession varies. The aim of this study is to investigate differences in provisions of Naloxone Accessibility Laws by states mainly in the Northeast and West regions, and the impact of naloxone availability on the rates of drug overdose deaths.This cross-sectional study was based on the National Vital Statistics System multiple cause-of-death mortality files. The average changes in drug overdose death rates between 2013 and 2017 in relevant states of the Northeast and West regions were compared according to availability of naloxone to laypersons.Seven states in the Northeast region and 10 states in the Western region allowed layperson distribution of naloxone. Layperson possession of naloxone was allowed in 3 states each in the Northeast and the Western regions. The average drug overdose death rates increased in many states in the both regions regardless of legalization of layperson naloxone distribution. The average death rates of 3 states that legalized layperson possession in the West region decreased (-0.33 per 100,000 person); however, in states in the West region that did not allow layperson possession and states in the Northeast region regardless of layperson possession increased between 2013 and 2017.The provision to legalize layperson possession of naloxone was associated with decreased average opioid overdose death rates in 3 states of the West region.

Availability and Cost of Naloxone Nasal Spray at Pharmacies in Philadelphia, Pennsylvania, 2017

IMPORTANCE

Despite the increasingly important role of pharmacies in the implementation of naloxone access laws, there is limited information on the impact of such laws at the local level.

OBJECTIVE

To evaluate the availability (with or without a prescription) and cost of naloxone nasal spray at pharmacies in Philadelphia, Pennsylvania, following a statewide standing order enacted in Pennsylvania in August 2015 to allow pharmacies to dispense naloxone without a prescription.

DESIGN, SETTING, AND PARTICIPANTS

A survey study was conducted by telephone of all pharmacies in Philadelphia between February and August 2017. Pharmacies were geocoded and linked with the American Community Survey (2011-2015) to obtain information on the demographic characteristics of census tracts and the Medical Examiner's Office of the Philadelphia Department of Public Health to derive information on the number of opioid overdose deaths per 100 000 people for each planning district. Data were analyzed from March 2018 to February 2019.

MAIN OUTCOMES AND MEASURES

Availability and out-of-pocket cost of naloxone nasal spray (with or without a prescription) at Philadelphia pharmacies overall and by pharmacy and neighborhood characteristics.

RESULTS

Of 454 eligible pharmacies, 418 were surveyed (92.1% response rate). One in 3 pharmacies (34.2%) had naloxone nasal spray in stock; of these, 61.5% indicated it was available without a prescription. There were significant differences in the availability of naloxone by pharmacy type and neighborhood characteristics. Naloxone was both more likely to be in stock (45.9% vs 27.8%; difference, 18.0%; 95% CI, 8.3%-27.8%; P < .001) and available without a prescription (80.6% vs 42.2%; difference, 38.4%; 95% CI, 23.0%-53.8%; P < .001) in chain stores than in independent stores. Naloxone was also less likely to be available in planning districts with very elevated rates of opioid overdose death (≥50 per 100 000 people) compared with those with lower rates (31.1% vs 38.5%). The median (interquartile range) out-of-pocket cost among pharmacies offering naloxone without a prescription was $145 ($119-$150); costs were greatest in independent pharmacies and planning districts with elevated rates of opioid overdose death.

CONCLUSIONS AND RELEVANCE

Despite the implementation of a statewide standing order in Pennsylvania more than 3 years prior to this study, only one-third of Philadelphia pharmacies carried naloxone nasal spray and many also required a physician's prescription. Efforts to strengthen the implementation of naloxone access laws and better ensure naloxone supply at local pharmacies are warranted, especially in localities with the highest rates of overdose death.

Naloxone Accessibility Without a Prescriber Encounter Under Standing Orders at Community Pharmacy Chains in Texas

This study evaluated naloxone accessibility from chain pharmacies in Texas 32 months after state legislation allowing pharmacists to dispense naloxone under standing orders from authorizing prescribers.

Provision of Naloxone Without a Prescription by California Pharmacists 2 Years After Legislation Implementation

This study assesses the availability of pharmacist-furnished naloxone 2 years after implementation of legislation in California allowing provision of the drug without a physician’s prescription.

Trends and economic drivers for United States naloxone pricing, January 2006 to February 2017

Anecdotal evidence indicates that naloxone prices have risen in recent years, but limited research has examined the magnitude of these increases and potential causes. We contribute nationally representative evidence to help answer each of these questions, including wholesale pricing data from a proprietary drug sales database spanning January 2006 to February 2017. We find that all formulations of naloxone increased in price since 2006 except for Narcan Nasal Spray. These cumulative increases totaled 2281% for the 0.4 MG single-dose products, 244% for the 2 MG single-dose products, 3797% for the 4 MG multi-dose products, and 469% for the 0.4 MG Evzio auto-injector. We believe that increased demand for naloxone from the opioid epidemic may explain the more gradual price increases for the 0.4 MG single-dose and 4 MG multi-dose products prior to 2012. On the other hand, we believe that the sudden, sustained prices increases occurring for all of the products since 2012 may be the result of a drug shortage for the 0.4 MG single-dose products and the fact that each naloxone product has historically been sold by only a single competitor.

Modeling Health Benefits and Harms of Public Policy Responses to the US Opioid Epidemic

OBJECTIVES

To estimate health outcomes of policies to mitigate the opioid epidemic.

METHODS

We used dynamic compartmental modeling of US adults, in various pain, opioid use, and opioid addiction health states, to project addiction-related deaths, life years, and quality-adjusted life years from 2016 to 2025 for 11 policy responses to the opioid epidemic.

RESULTS

Over 5 years, increasing naloxone availability, promoting needle exchange, expanding medication-assisted addiction treatment, and increasing psychosocial treatment increased life years and quality-adjusted life years and reduced deaths. Other policies reduced opioid prescription supply and related deaths but led some addicted prescription users to switch to heroin use, which increased heroin-related deaths. Over a longer horizon, some such policies may avert enough new addiction to outweigh the harms. No single policy is likely to substantially reduce deaths over 5 to 10 years.

CONCLUSIONS

Policies focused on services for addicted people improve population health without harming any groups. Policies that reduce the prescription opioid supply may increase heroin use and reduce quality of life in the short term, but in the long term could generate positive health benefits. A portfolio of interventions will be needed for eventual mitigation.

Government Patent Use to Address the Rising Cost of Naloxone: 28 U.S.C. § 1498 and Evzio

The rising cost of the opioid antagonist and overdose reversal agent naloxone is an urgent public health problem. The recent and dramatic price increase of Evzio, a naloxone auto-injector produced by Kaléo, shows how pharmaceutical manufacturers entering the naloxone marketplace rely on market exclusivity guaranteed by the patent system to charge prices at what the market can bear, which can restrict access to life-saving medication. We argue that 28 U.S.C. § 1498, a section of the federal code that allows the government to use patent-protected products for its own purposes in exchange for reasonable compensation, could be used to procure generic naloxone auto-injectors, or at least bring Kaléo to the negotiating table. Precedent exists for the use of § 1498 to procure pharmaceuticals, and it could give meaning to the federal government's recent declaration of a public health emergency around the opioid epidemic, discourage new market entrants from charging exorbitant prices, and yield important public health benefits.

The Opioid Epidemic in Indian Country

The national opioid epidemic is severely impacting Indian Country. In this article, we draw upon data from the Centers for Disease Control and Prevention to describe the contours of this crisis among Native Americans. While these data are subject to significant limitations, we show that Native American opioid overdose mortality rates have grown substantially over the last seventeen years. We further find that this increase appears to at least parallel increases seen among non-Hispanic whites, who are often thought to be uniquely affected by this crisis. We then profile tribal medical and legal responses to the opioid epidemic, ranging from tribally-operated medication-assisted therapy to drug diversion courts rooted in traditional tribal cultures.

State Responses to the Opioid Crisis

This paper focuses on the most common state policy responses to the opioid crisis, dividing them into six broad categories. Within each category we highlight the rationale behind the group of policies within it, discuss the details and support for individual policies, and explore the research base behind them. The objective is to better understand the most prevalent state responses to the opioid crisis.

Cost-Effectiveness of Take-Home Naloxone for the Prevention of Overdose Fatalities among Heroin Users in the United Kingdom

BACKGROUND

Heroin overdose is a major cause of premature death. Naloxone is an opioid antagonist that is effective for the reversal of heroin overdose in emergency situations and can be used by nonmedical responders.

OBJECTIVE

Our aim was to assess the cost-effectiveness of distributing naloxone to adults at risk of heroin overdose for use by nonmedical responders compared with no naloxone distribution in a European healthcare setting (United Kingdom).

METHODS

A Markov model with an integrated decision tree was developed based on an existing model, using UK data where available. We evaluated an intramuscular naloxone distribution reaching 30% of heroin users. Costs and effects were evaluated over a lifetime and discounted at 3.5%. The results were assessed using deterministic and probabilistic sensitivity analyses.

RESULTS

The model estimated that distribution of intramuscular naloxone, would decrease overdose deaths by around 6.6%. In a population of 200,000 heroin users this equates to the prevention of 2,500 premature deaths at an incremental cost per quality-adjusted life year (QALY) gained of £899. The sensitivity analyses confirmed the robustness of the results.

CONCLUSIONS

Our evaluation suggests that the distribution of take-home naloxone decreased overdose deaths by around 6.6% and was cost-effective with an incremental cost per QALY gained well below a £20,000 willingness-to-pay threshold set by UK decision-makers. The model code has been made available to aid future research. Further study is warranted on the impact of different formulations of naloxone on cost-effectiveness and the impact take-home naloxone has on the wider society.

Pharmacy-based statewide naloxone distribution: A novel "top-down, bottom-up" approach

OBJECTIVE

To highlight New Mexico's multifaceted approach to widespread pharmacy naloxone distribution and to share the interventions as a tool for improving pharmacy-based naloxone practices in other states.

SETTING

New Mexico had the second highest drug overdose death rate in 2014 of which 53% were related to prescription opioids. Opioid overdose death is preventable through the use of naloxone, a safe and effective medication that reverses the effects of prescription opioids and heroin. Pharmacists can play an important role in providing naloxone to individuals who use prescription opioids.

PRACTICE DESCRIPTION

Not applicable.

PRACTICE INNOVATIONS

Not applicable.

INTERVENTIONS

A multifaceted approach was utilized in New Mexico from the top down with legislative passage of provisions for a statewide standing order and New Mexico Department of Health support for pharmacy-based naloxone delivery. A bottom up approach was also initiated with the development and implementation of a training program for pharmacists and pharmacy technicians.

EVALUATION

Naloxone Medicaid claims were used to illustrate statewide distribution and utilization of the pharmacist statewide standing order for naloxone. Percent of pharmacies dispensing naloxone in each county were calculated. Trained pharmacy staff completed a program evaluation form. Questions about quality of instruction and ability of trainer to meet stated objectives were rated on a Likert scale.

RESULTS

There were 808 naloxone Medicaid claims from 100 outpatient pharmacies during the first half of 2016, a 9-fold increase over 2014. The "A Dose of R_xeality" training program evaluation indicated that participants felt the training was free from bias and met all stated objectives (4 out of 4 on Likert scale).

CONCLUSIONS

A multi-pronged approach coupling state and community collaboration was successful in overcoming barriers and challenges associated with pharmacy naloxone distribution and ensured its success as an effective avenue for naloxone acquisition in urban and rural communities.

Opioid overdose education and naloxone distribution: Development of the Veterans Health Administration's national program

OBJECTIVES

To prevent opioid-related mortality, the Veterans Health Administration (VHA) developed a national Opioid Overdose Education and Naloxone Distribution (OEND) program.

SETTING

VHA's OEND program sought national implementation of OEND across all medical facilities (n = 142).

PRACTICE DESCRIPTION

This paper describes VHA's efforts to facilitate nationwide health care system-based OEND implementation, including the critical roles of VHA's national pharmacy services and academic detailing services.

PRACTICE INNOVATION

VHA is the first large health care system in the United States to implement OEND nationwide. Launching the national program required VHA to translate a primarily community-based public health approach to OEND into a health care system-based approach that distributed naloxone to patients with opioid use disorders as well as to patients prescribed opioid analgesics. Key innovations included developing steps to implement OEND, pharmacy developing standard naloxone rescue kits, adding those kits to the VHA National Formulary, centralizing kit distribution, developing clinical guidance for issuing naloxone kits, and supporting OEND as a focal campaign of academic detailing. Other innovations included the development of patient and provider education resources (e.g., brochures, videos, accredited training) and implementation and evaluation resources (e.g., technical assistance, clinical decision support tools).

EVALUATION

Clinical decision support tools that leverage VHA national data are available to clinical staff with appropriate permissions. These tools allow staff and leaders to evaluate OEND implementation and provide actionable next steps to help them identify patients who could benefit from OEND.

RESULTS

Through fiscal year 2016, VHA dispensed 45,178 naloxone prescriptions written by 5693 prescribers to 39,328 patients who were primarily prescribed opioids or had opioid use disorder. As of February 2, 2016, there were 172 spontaneously reported opioid overdose reversals with the use of VHA naloxone prescriptions.

CONCLUSION

VHA has successfully translated community-based OEND into health care system-based OEND targeting 2 patient populations. There is a tremendous amount that can be learned from VHA's experience implementing this novel health care innovation nationwide.

Opiate addiction and overdose: experiences, attitudes, and appetite for community naloxone provision

BACKGROUND

More than 200 opiate overdose deaths occur annually in Ireland. Overdose prevention and management, including naloxone prescription, should be a priority for healthcare services. Naloxone is an effective overdose treatment and is now being considered for wider lay use.

AIM

To establish GPs' views and experiences of opiate addiction, overdose care, and naloxone provision.

DESIGN AND SETTING

An anonymous postal survey to GPs affiliated with the Department of Academic General Practice, University College Dublin, Ireland.

METHOD

A total of 714 GPs were invited to complete an anonymous postal survey. Results were compared with a parallel GP trainee survey.

RESULTS

A total of 448/714 (62.7%) GPs responded. Approximately one-third of GPs were based in urban, rural, and mixed areas. Over 75% of GPs who responded had patients who used illicit opiates, and 25% prescribed methadone. Two-thirds of GPs were in favour of increased naloxone availability in the community; almost one-third would take part in such a scheme. A higher proportion of GP trainees had used naloxone to treat opiate overdose than qualified GPs. In addition, a higher proportion of GP trainees were willing to be involved in naloxone distribution than qualified GPs. Intranasal naloxone was much preferred to single (P<0.001) or multiple dose (P<0.001) intramuscular naloxone. Few GPs objected to wider naloxone availability, with 66.1% (n = 292) being in favour.

CONCLUSION

GPs report extensive contact with people who have opiate use disorders but provide limited opiate agonist treatment. They support wider availability of naloxone and would participate in its expansion. Development and evaluation of an implementation strategy to support GP-based distribution is urgently needed.

Strategies and policies to address the opioid epidemic: A case study of Ohio

OBJECTIVE

To describe the strategies and policies implemented in Ohio to improve opioid safety and to discuss the role that pharmacists can play in implementing, promoting, and enhancing the effectiveness of these policies.

SETTING

Ohio has the fifth highest rate of drug overdose deaths (24.6 deaths per 100,000) in the United States. Unintentional drug overdose has become the leading cause of injury-related death in Ohio. In 2015, there were 3050 overdose deaths in Ohio, and in 2014 there were an estimated 12,847 overdose events reversed by emergency medical services with naloxone.

PRACTICE DESCRIPTION

Not applicable.

PRACTICE POLICY INNOVATION

In 2011, the Governor's Cabinet Opiate Action Team was created to implement a multifaceted strategy, in part (1) to promote the responsible use of opioids, (2) to reduce the supply of opioids, and (3) to support overdose prevention and expand access to naloxone. Innovations to assist these goals include the development of Ohio guidelines on the responsible use of opioids, mandatory use of Ohio's prescription drug monitoring program, closing pill mills, promotion of drug take-back programs and increased access to naloxone and public health campaigns.

EVALUATION

Not applicable.

RESULTS

Since the development of the Governor's Cabinet Opiate Action Team, there were 81 million fewer doses of opioids dispensed to Ohio patients in 2015 compared with 782 million doses dispensed in 2011. As such, the proportion of unintentional drug overdose deaths involving prescription opioids has reduced from 45% in 2011 to 22% in 2015.

CONCLUSION

Strong political support was crucial in Ohio to facilitate the rapid implementation opioid overdose prevention programs and the promotion of public awareness campaigns. However, the misuse and abuse of prescription opioids are complex problems requiring a comprehensive and multifaceted approach. Pharmacists are identified as a crucial component of the state strategy to addressing opioid abuse by promoting responsible prescribing and adopting prevention practices.

Why is it so hard to implement change? A qualitative examination of barriers and facilitators to distribution of naloxone for overdose prevention in a safety net environment

BACKGROUND

The increase in opioid overdose deaths has become a national public health crisis. Naloxone is an important tool in opioid overdose prevention. Distribution of nasal naloxone has been found to be a feasible, and effective intervention in community settings and may have potential high applicability in the emergency department, which is often the initial point of care for persons at high risk of overdose. One safety net hospital introduced an innovative policy to offer take-home nasal naloxone via a standing order to ensure distribution to patients at risk for overdose. The aims of this study were to examine acceptance and uptake of the policy and assess facilitators and barriers to implementation.

METHODS

After obtaining pre-post data on naloxone distribution, we conducted a qualitative study. The PARiHS framework steered development of the qualitative guide. We used theoretical sampling in order to include the range of types of emergency department staff (50 total). The constant comparative method was initially used to code the transcripts and identify themes; the themes that emerged from the coding were then mapped back to the evidence, context and facilitation constructs of the PARiHS framework.

RESULTS

Acceptance of the policy was good but uptake was low. Primary themes related to facilitators included: real-world driven intervention with philosophical, clinician and leadership support; basic education and training efforts; availability of resources; and ability to leave the ED with the naloxone kit in hand. Barriers fell into five general categories: protocol and policy; workflow and logistical; patient-related; staff roles and responsibilities; and education and training.

CONCLUSIONS

The actual implementation of a new innovation in healthcare delivery is largely driven by factors beyond acceptance. Despite support and resources, implementation was challenging, with low uptake. While the potential of this innovation is unknown, understanding the experience is important to improve uptake in this setting and offer possible solutions for other facilities to address the opioid overdose crisis. Use of the PARiHS framework allowed us to recognize and understand key evidence, contextual and facilitation barriers to the successful implementation of the policy and to identify areas for improvement.

Identifying Patients for Overdose Prevention With ICD-9 Classification in the Emergency Department, Massachusetts, 2013-2014

The national rise in opioid overdose deaths signifies a need to integrate overdose prevention within healthcare delivery settings. The emergency department (ED) is an opportune location for such interventions. To effectively integrate prevention services, the target population must be clearly defined. We used ICD-9 discharge codes to establish and apply overdose risk categories to ED patients seen from January 1, 2013 to December 31, 2014 at an urban safety-net hospital in Massachusetts with the goal of informing ED-based naloxone rescue kit distribution programs. Of 96,419 patients, 4,468 (4.6%) were at increased risk of opioid overdose, defined by prior opioid overdose, misuse, or polysubstance misuse. A small proportion of those at risk were prescribed opioids on a separate occasion. Use of risk categories defined by ICD-9 codes identified a notable proportion of ED patients at risk for overdose, and provides a systematic means to prioritize and direct clinical overdose prevention efforts.

Messaging to Increase Public Support for Naloxone Distribution Policies in the United States: Results from a Randomized Survey Experiment

Background

Barriers to public support for naloxone distribution include lack of knowledge, concerns about potential unintended consequences, and lack of sympathy for people at risk of overdose.

Methods

A randomized survey experiment was conducted with a nationally-representative web-based survey research panel (GfK KnowledgePanel). Participants were randomly assigned to read different messages alone or in combination: 1) factual information about naloxone; 2) pre-emptive refutation of potential concerns about naloxone distribution; and 3) a sympathetic narrative about a mother whose daughter died of an opioid overdose. Participants were then asked if they support or oppose policies related to naloxone distribution. For each policy item, logistic regression models were used to test the effect of each message exposure compared with the no-exposure control group.

Results

The final sample consisted of 1,598 participants (completion rate: 72.6%). Factual information and the sympathetic narrative alone each led to higher support for training first responders to use naloxone, providing naloxone to friends and family members of people using opioids, and passing laws to protect people who administer naloxone. Participants receiving the combination of the sympathetic narrative and factual information, compared to factual information alone, were more likely to support all policies: providing naloxone to friends and family members (OR: 2.0 [95% CI: 1.4 to 2.9]), training first responders to use naloxone (OR: 2.0 [95% CI: 1.2 to 3.4]), passing laws to protect people if they administer naloxone (OR: 1.5 [95% CI: 1.04 to 2.2]), and passing laws to protect people if they call for medical help for an overdose (OR: 1.7 [95% CI: 1.2 to 2.5]).

Conclusions

All messages increased public support, but combining factual information and the sympathetic narrative was most effective. Public support for naloxone distribution can be improved through education and sympathetic portrayals of the population who stands to benefit from these policies.

Opioid Overdose Prevention Programs Providing Naloxone to Laypersons - United States, 2014

Drug overdose deaths in the United States have more than doubled since 1999. During 2013, 43,982 drug overdose deaths (unintentional, intentional [suicide or homicide], or undetermined intent) were reported. Among these, 16,235 (37%) were associated with prescription opioid analgesics (e.g., oxycodone and hydrocodone) and 8,257 (19%) with heroin. For many years, community-based programs have offered opioid overdose prevention services to laypersons who might witness an overdose, including persons who use drugs, their families and friends, and service providers. Since 1996, an increasing number of programs provide laypersons with training and kits containing the opioid antagonist naloxone hydrochloride (naloxone) to reverse the potentially fatal respiratory depression caused by heroin and other opioids. In July 2014, the Harm Reduction Coalition (HRC), a national advocacy and capacity-building organization, surveyed 140 managers of organizations in the United States known to provide naloxone kits to laypersons. Managers at 136 organizations completed the survey, reporting on the amount of naloxone distributed, overdose reversals by bystanders, and other program data for 644 sites that were providing naloxone kits to laypersons as of June 2014. From 1996 through June 2014, surveyed organizations provided naloxone kits to 152,283 laypersons and received reports of 26,463 overdose reversals. Providing opioid overdose training and naloxone kits to laypersons who might witness an opioid overdose can help reduce opioid overdose mortality.

Centers for Disease Control and Prevention (CDC). Community-based opioid overdose prevention programs providing naloxone - United States, 2010

Drug overdose death rates have increased steadily in the United States since 1979. In 2008, a total of 36,450 drug overdose deaths (i.e., unintentional, intentional [suicide or homicide], or undetermined intent) were reported, with prescription opioid analgesics (e.g., oxycodone, hydrocodone, and methadone), cocaine, and heroin the drugs most commonly involved . Since the mid-1990s, community-based programs have offered opioid overdose prevention services to persons who use drugs, their families and friends, and service providers. Since 1996, an increasing number of these programs have provided the opioid antagonist naloxone hydrochloride, the treatment of choice to reverse the potentially fatal respiratory depression caused by overdose of heroin and other opioids. Naloxone has no effect on non-opioid overdoses (e.g., cocaine, benzodiazepines, or alcohol) . In October 2010, the Harm Reduction Coalition, a national advocacy and capacity-building organization, surveyed 50 programs known to distribute naloxone in the United States, to collect data on local program locations, naloxone distribution, and overdose reversals. This report summarizes the findings for the 48 programs that completed the survey and the 188 local programs represented by the responses. Since the first opioid overdose prevention program began distributing naloxone in 1996, the respondent programs reported training and distributing naloxone to 53,032 persons and receiving reports of 10,171 overdose reversals. Providing opioid overdose education and naloxone to persons who use drugs and to persons who might be present at an opioid overdose can help reduce opioid overdose mortality, a rapidly growing public health concern.

Distinguishing signs of opioid overdose and indication for naloxone: an evaluation of six overdose training and naloxone distribution programs in the United States

AIMS

This study assessed overdose and naloxone administration knowledge among current or former opioid abusers trained and untrained in overdose-response in the United States.

DESIGN AND PARTICIPANTS

Ten individuals, divided equally between those trained or not trained in overdose recognition and response, were recruited from each of six sites (n = 62).

SETTING

US-based overdose training and naloxone distribution programs in Baltimore, San Francisco, Chicago, New York and New Mexico.

MEASUREMENTS

Participants completed a brief questionnaire on overdose knowledge that included the task of rating 16 putative overdose scenarios for: (i) whether an overdose was occurring and (ii) if naloxone was indicated. Bivariate and multivariable analyses compared results for those trained to untrained. Responses were also compared to those of 11 medical experts using weighted and unweighted kappa statistics.

FINDINGS

Respondents were primarily male (72.6%); 45.8% had experienced an overdose and 72% had ever witnessed an overdose. Trained participants recognized more opioid overdose scenarios accurately (t(60) = 3.76, P < 0.001) and instances where naloxone was indicated (t(59) = 2.2, P < 0.05) than did untrained participants. Receipt of training and higher perceived competency in recognizing signs of an opioid overdose were associated independently with higher overdose recognition scores. Trained respondents were as skilled as medical experts in recognizing opioid overdose situations (weighted kappa = 0.85) and when naloxone was indicated (kappa = 1.0).

CONCLUSIONS

Results suggest that naloxone training programs in the United States improve participants' ability to recognize and respond to opioid overdoses in the community. Drug users with overdose training and confidence in their abilities to respond may effectively prevent overdose mortality.

Attitudes of Australian heroin users to peer distribution of naloxone for heroin overdose: perspectives on intranasal administration

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.

Changes in Canadian heroin supply coinciding with the Australian heroin shortage

AIMS

Previous studies have largely attributed the Australian heroin shortage to increases in local law enforcement efforts. Because western Canada receives heroin from similar source nations, but has not measurably increased enforcement practices or funding levels, we sought to examine trends in Canadian heroin-related indices before and after the Australian heroin shortage, which began in approximately January 2001.

METHODS

During periods before and after January 2001, we examined the number of fatal overdoses and ambulance responses to heroin-related overdoses that required the use of naloxone in British Columbia, Canada. As an overall marker of Canadian supply reduction, we also examined the quantity of heroin seized during this period. Lastly, we examined trends in daily heroin use among injection drug users enrolled in the Vancouver Injection Drug Users Study (VIDUS).

RESULTS

There was a 35% reduction in overdose deaths, from an annual average of 297 deaths during the years 1998-2000 in comparison to an average of 192 deaths during 2001-03. Similarly, use of naloxone declined 45% in the period coinciding with the Australian heroin shortage. Interestingly, the weight of Canadian heroin seized declined 64% coinciding with the Australian heroin shortage, from an average of 184 kg during 1998-2000 to 67 kg on average during 2001-03. Among 1587 VIDUS participants, the period coinciding with the Australian heroin shortage was associated independently with reduced daily injection of heroin [adjusted odds ratio: 0.55 (95% CI: 0.50-0.61); P < 0.001].

CONCLUSIONS

Massive decreases in three independent markers of heroin use have been observed in western Canada coinciding with the Australian heroin shortage, despite no increases in funding to Canadian enforcement efforts. Markedly reduced Canadian seizure activity also coincided with the Australian heroin shortage. These findings suggest that external global heroin supply forces deserve greater investigation and credence as a potential explanation for the Australian heroin shortage.

Naloxone distribution and cardiopulmonary resuscitation training for injection drug users to prevent heroin overdose death: a pilot intervention study

Fatal heroin overdose has become a leading cause of death among injection drug users (IDUs). Several recent feasibility studies have concluded that naloxone distribution programs for heroin injectors should be implemented to decrease heroin over-dose deaths, but there have been no prospective trials of such programs in North America. This pilot study was undertaken to investigate the safety and feasibility of training injection drug using partners to perform cardiopulmonary resuscitation (CPR) and administer naloxone in the event of heroin overdose. During May and June 2001, 24 IDUs (12 pairs of injection partners) were recruited from street settings in San Francisco. Participants took part in 8-hour training in heroin overdose prevention, CPR, and the use of naloxone. Following the intervention, participants were prospectively followed for 6 months to determine the number and outcomes of witnessed heroin overdoses, outcomes of participant interventions, and changes in participants' knowledge of overdose and drug use behavior. Study participants witnessed 20 heroin overdose events during 6 months follow-up. They performed CPR in 16 (80%) events, administered naloxone in 15 (75%) and did one or the other in 19 (95%). All overdose victims survived. Knowledge about heroin overdose management increased, whereas heroin use decreased. IDUs can be trained to respond to heroin overdose emergencies by performing CPR and administering naloxone. Future research is needed to evaluate the effectiveness of this peer intervention to prevent fatal heroin overdose.

Antidote availability in Quebec hospital pharmacies: impact of N-acetylcysteine and naloxone consumption

OBJECTIVES

To study the availability of 13 specific antidotes in hospitals and correlate the availability of those antidotes to the number of poisonings seen in hospitals using N-acetylcysteine and naloxone consumption as a surrogate.

METHODS

Pharmacy directors of hospitals with an emergency department were surveyed for number of adequately stocked antidotes (N-acetylcysteine, ethanol, cyanide antidote kit or hydroxycobalamine, deferoxamine, digoxin-immune FAB, dimercaprol, flumazenil, glucagon, methylene blue, naloxone, physostigmine, pralidoxime and pyridoxine).

RESULTS

Data were obtained from 96 of 112 (86%) of the pharmacies surveyed. Number of adequately stocked antidotes per hospital ranged from zero to nine of 13. There was a correlation between all hospital characteristics evaluated and the number of adequately stocked antidotes (P<0.05). Correlations between the number of adequately stocked antidotes and the amount of N-acetylcysteine and naloxone consumed were significant (rs=0.58, P<0.001; r(s)=0.53, P<0.001). The amount of N-acetylcysteine consumed, the number of annual visits to the emergency department and the number of hours of pharmacy coverage on weekends independently predicted the presence of adequately stocked antidotes.

CONCLUSIONS

Larger hospitals are more likely to have adequate stocks of antidotes. Adequate stocking of antidotes is significantly correlated with the amount of N-acetyl- cysteine and naloxone consumed. This suggests that hospitals more likely to see serious acetaminophen and opiate poisonings are more likely to maintain adequate stocks of antidotes.

Insufficient stocking of poisoning antidotes in hospital pharmacies

OBJECTIVE

To determine whether antidotes for poisoning and overdose are available in hospitals that provide emergency department care.

DESIGN

Written survey of hospital pharmacy directors, each of whom reported the amount currently in stock of 8 different antidotes: antivenin (Crotalidae) polyvalent, cyanide kit, deferoxamine mesylate, digoxin immune Fab, ethanol, naloxone hydrochloride, pralidoxime chloride, and pyridoxine hydrochloride.

PARTICIPANTS

Pharmacy directors of all hospitals with emergency departments in Colorado, Montana, and Nevada.

MAIN OUTCOME MEASURES

Proportions of hospitals with insufficient stocking of each antidote, defined as complete lack of the antidote or an amount inadequate to initiate treatment of 1 seriously poisoned 70-kg patient.

RESULTS

Questionnaires were mailed to 137 hospital pharmacy directors and 108 (79%) responded. Only 1 (0.9%) of the 108 hospitals stocked all 8 antidotes in adequate amounts. The rate of insufficient stocking for individual antidotes ranged from 2% (for naloxone) to 98% (for digoxin immune Fab). In a multiple regression analysis, smaller hospital size and lack of a formal review of antidote stocking were independent predictors of the number of antidotes stocked insufficiently.

CONCLUSIONS

Insufficient stocking of antidotes is a widespread problem in Colorado, Montana, and Nevada. Although these states are served by a certified regional poison center, potentially lifesaving antidotes are frequently not available when and where they might be needed to treat a single poisoned patient.