naloxone and Drug-Overdose

The United States opioid epidemic is fueled by illicit opioid abuse and prescription opioid misuse and abuse. Consequently, cases of opioid use disorder (OUD, opioid addiction), opioid overdose, and related deaths have increased since the year 2000. Naloxone is an opioid antagonist that rapidly reverses opioid intoxication to prevent death from overdose. It is one of the major risk mitigation strategies recommended in the 2016 Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain. However, despite the exponential increase in dispensing and distribution of naloxone, opioid overdose and related deaths have continued to increase; suggesting that the increased naloxone supply still lags the need. This discordance is attributed at least in part to the negative attitude toward naloxone, which is based on the belief that naloxone is only meant for "addicts" and "abusers" (OUD patients). This negative attitude or so-called naloxone stigma is therefore considered a major barrier for naloxone distribution and consequently, overdose-death prevention efforts. This article presents evidence that challenges common assertions about OUD stigma being the sole and direct driving force behind naloxone stigma, and the purported magnitude of the barrier that naloxone stigma constitutes for naloxone distribution programs among the stakeholders (patients, pharmacists, and prescribers). The case was then made to operationalize and quantify the construct among the stakeholders to determine the extent to which OUD stigma drives naloxone stigma, and the relative impact of naloxone stigma as a barrier for naloxone distribution efforts.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; United States

Pharmacists' provision of naloxone services in community pharmacy settings is well-recognized. Recently, studies describing pharmacists' naloxone services in settings other than community pharmacies have emerged in the literature. There is a need to synthesize evidence from these studies to evaluate the scope and impact of pharmacists' naloxone services beyond community pharmacy settings.. The objectives of this systematic review were to a) identify pharmacists' naloxone services and their outcomes, and b) examine knowledge, attitudes, and barriers (KAB) related to naloxone service provision in non-community pharmacy settings.. Eligible studies were identified using PubMed, Web of Science, and CINAHL. Inclusion criteria were as follows: peer-reviewed empirical research conducted in the U.S. from January 2010 through February 2022; published in English; and addressed a) pharmacists' naloxone services and/or b) KAB related to the implementation of naloxone services. PRISMA guidelines were used to report this study.. Seventy-six studies were identified. The majority were non-randomized and observational; only two used a randomized controlled (RCT) design. Most studies were conducted in veterans affairs (30%) and academic medical centers (21%). Sample sizes ranged from n = 10 to 217,469, and the majority reported sample sizes <100. Pharmacists' naloxone services involved clinical staff education, utilization of screening tools to identify at-risk patients, naloxone prescribing and overdose education and naloxone dispensing (OEND). Outcomes of implementing naloxone services included improved naloxone knowledge, positive attitudes, increased OEND, and overdose reversals. Pharmacists cited inadequate training, time constraints, reimbursement issues, and stigma as barriers that hindered naloxone service implementation.. This systematic review found robust evidence regarding pharmacist-based naloxone services beyond community pharmacy settings. Future programs should use targeted approaches to help pharmacists overcome barriers and enhance naloxone services. Additional research is needed to evaluate pharmacist naloxone services by using rigorous methodologies (e.g., larger sample sizes, RCT designs).

Topics: Community Pharmacy Services; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pharmacies; Pharmacists; Pharmacy

The COVID-19 pandemic impacted healthcare beyond COVID-19 infections. A better understanding of how COVID-19 worsened the opioid crisis has potential to inform future response efforts.. To summarize changes from the COVID-19 pandemic on outcomes regarding opioid use and misuse in the USA and Canada.. We searched MEDLINE via PubMed, EMBASE, and CENTRAL for peer-reviewed articles published between March 2020 and December 2021 that examined outcomes relevant to patients with opioid use, misuse, and opioid use disorder by comparing the period before vs after COVID-19 onset in the USA and Canada. Two reviewers independently screened studies, extracted data, assessed methodological quality and bias via Newcastle-Ottawa Scale, and synthesized results.. Among 20 included studies, 13 (65%) analyzed service utilization, 6 (30%) analyzed urine drug testing results, and 2 (10%) analyzed naloxone dispensation. Opioid-related emergency medicine utilization increased in most studies (85%, 11/13) for both service calls (17% to 61%) and emergency department visits (42% to 122%). Urine drug testing positivity results increased in all studies (100%, 6/6) for fentanyl (34% to 138%), most (80%, 4/5) studies for heroin (-12% to 62%), and most (75%, 3/4) studies for oxycodone (0% to 44%). Naloxone dispensation was unchanged and decreased in one study each.. Significant increases in surrogate measures of the opioid crisis coincided with the onset of COVID-19. These findings serve as a call to action to redouble prevention, treatment, and harm reduction efforts for the opioid crisis as the pandemic evolves.. CRD42021236464.

Topics: Analgesics, Opioid; COVID-19; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Pandemics; United States

More than 20 million people in the United States have a substance use disorder (SUD), increasing their risk for overdose (OD). Patients arriving to emergency departments (EDs) with OD typically require lifesaving interventions, but inconsistencies exist regarding further intervention and discharge instructions. The purpose of the current integrative review was to determine best care practices for patients presenting to EDs with an illicit drug OD. A literature search included the databases PubMed, EBSCO Host, ProQuest Health and Medicine, and Google Scholar. Thirty-five articles outlined interventions for SUD/OD initiated in EDs; most for opioid OD. Best practice intervention components included psychiatric evaluations, SUD screening tools, buprenorphine initiation, naloxone distribution and training, OD prevention education, referrals to medication-assisted treatment, and harm reduction strategies. Barriers to implementation included legislation, insurance/costs, community resource availability, staffing, training, and potential stigma. With myriad approaches, nurses with SUD care experience can advocate for instituting best practices for patients in the ED and upon discharge. [

Topics: Buprenorphine; Drug Overdose; Emergency Service, Hospital; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Substance-Related Disorders; United States

Drug overdose deaths, particularly from opioids, are a major global burden, with 128,000 deaths estimated in 2019. Opioid overdoses can be reversed through the timely administration of naloxone but only if responders are able to administer it. There is an emerging body of research and development in technologies that can detect the early signs of an overdose and facilitate timely responses.. Our aim was to identify and classify overdose-specific digital technologies being developed, implemented, and evaluated.. We conducted a "state-of-the-art review." A systematic search was conducted in MEDLINE, Embase, Web of Science, Scopus, ACM, IEEE Xplore, and SciELO. We also searched references from articles and scanned the gray literature. The search included terms related to telehealth and digital technologies, drugs, and overdose and papers published since 2010. We classified our findings by type of technology and its function, year of publication, country of study, study design, and theme. We performed a thematic analysis to classify the papers according to the main subject.. Included in the selection were 17 original research papers, 2 proof-of-concept studies, 4 reviews, 3 US government grant registries, and 6 commercial devices that had not been named in peer-reviewed literature. All articles were published between 2017 and 2022, with a marked increase since 2019. All were based in or referred to the United States or Canada and concerned opioid overdose. In total, 39% (9/23) of the papers either evaluated or described devices designed to monitor vital signs and prompt an alert once a certain threshold indicating a potential overdose has been reached. A total of 43% (10/23) of the papers focused on technologies to alert potential responders to overdoses and facilitate response. In total, 48% (11/23) of the papers and 67% (4/6) of the commercial devices described combined alert and response devices. Sensors monitor a range of vital signs, such as oxygen saturation level, respiratory rate, or movement. Response devices are mostly smartphone apps enabling responders to arrive earlier to an overdose site. Closed-loop devices that can detect an overdose through a sensor and automatically administer naloxone without any external intervention are still in the experimental or proof-of-concept phase. The studies were grouped into 4 themes: acceptability (7/23, 30%), efficacy or effectiveness (5/23, 22%), device use and decision-making (3/23, 13%), and description of devices (6/23, 26%).. There has been increasing interest in the research and application of these technologies in recent years. Literature suggests willingness to use these devices by people who use drugs and affected communities. More real-life studies are needed to test the effectiveness of these technologies to adapt them to the different settings and populations that might benefit from them.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Technology; Telemedicine; United States

Adolescent and young adult overdoses and overdose fatalities continue to increase despite reductions in self-reported substance use. This review aims to explore factors contributing to this overdose epidemic, highlight signs of overdose and the role of the overdose reversal medication naloxone, and provide recommendations for practice change to support patients and decrease their risk of unintentional overdose.. The potent opioid fentanyl is a common contaminant in nonopioid substances, as well as in heroin and counterfeit pills, heightening risk of fatal overdose. Adolescents and young adults who die of overdose are rarely engaged in substance use disorder treatment. Medications for opioid use disorder are effective at reducing risk of fatal overdose but are underutilized, as is the opioid reversal medication naloxone.. Pediatric clinician engagement in harm reduction with adolescents and young adults, starting with screening through a confidential interview, may enhance pathways to care and reduce the risk of overdose.

Topics: Adolescent; Analgesics, Opioid; Child; Drug Overdose; Fentanyl; Harm Reduction; Humans; Naloxone; Opioid-Related Disorders; Young Adult

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.. 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.. 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.

Topics: Analgesics, Opioid; Artificial Intelligence; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders

Naloxone is an opioid antagonist that reverses the (respiratory-paralyzing) effects of opioids in the body within minutes. Naloxone can therefore reduce opioid overdose deaths. Take-home naloxone (THN) is an intervention recommended by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) and the World Health Organization (WHO). It involves training opioid users and their relatives or friends in the use of naloxone and providing them with the drug in case of emergency.So far, THN has been implemented in Germany mainly by individual addiction support facilities. In order to fully exploit the potential of THN, it is necessary to establish the measure nationwide. In particular, THN can be included in the services offered in (low-threshold) addiction support facilities, in psychiatric facilities, in the context of opioid substitution treatment, and in the correctional system.This discussion article reviews the development of THN in Germany since 1998, highlights the difficulties and obstacles to its widespread implementation, and outlines how THN can succeed as an effective public health intervention in Germany. This is particularly relevant in view of the increasing number of drug-related deaths over the past 10 years.. Das Medikament Naloxon ist ein Opioidantagonist, der innerhalb von Minuten die (atemlähmende) Wirkung von Opioiden im Körper aufhebt. Naloxon kann dadurch zur Reduktion von Todesfällen bei Opioidüberdosierung beitragen. „Take-Home Naloxon“ (THN) ist eine Maßnahme, die vom European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) und der Weltgesundheitsorganisation (WHO) empfohlen wird. Dabei werden Opioidkonsumierende und deren Angehörige, Freunde oder Bekannte im Umgang mit Naloxon geschult und für den Notfall mit dem Medikament ausgestattet.Bisher wird THN in Deutschland überwiegend von einzelnen Einrichtungen der Suchthilfe umgesetzt. Damit das Potenzial von THN voll genutzt werden kann, ist es notwendig, die Maßnahme in Deutschland flächendeckend zu etablieren. Insbesondere in (niedrigschwelligen) Suchthilfeeinrichtungen, psychiatrischen Einrichtungen, im Rahmen von Opioidsubstitutionsbehandlungen und im Justizvollzug kann THN in das Angebot aufgenommen werden.Dieser Diskussionsartikel greift die bisherige Entwicklung von THN in Deutschland seit 1998 auf, zeigt die Schwierigkeiten und Hindernisse einer flächendeckenden Umsetzung und stellt dar, wie THN als wirkungsvolle Public-Health-Maßnahme auch in Deutschland gelingen kann. Besonders relevant ist dies angesichts der seit 10 Jahren steigenden Zahl von Drogentodesfällen.

Topics: Analgesics, Opioid; Drug Overdose; Germany; Humans; Naloxone; Narcotic Antagonists

Opioids are effective analgesics, but they can have harmful adverse effects, such as addiction and potentially fatal respiratory depression. Naloxone is currently the only available treatment for reversing the negative effects of opioids, including respiratory depression. However, the effectiveness of naloxone, particularly after an opioid overdose, varies depending on the pharmacokinetics and the pharmacodynamics of the opioid that was overdosed. Long-acting opioids, and those with a high affinity at the µ-opioid receptor and/or slow receptor dissociation kinetics, are particularly resistant to the effects of naloxone. In this review, the authors examine the pharmacology of naloxone and its safety and limitations in reversing opioid-induced respiratory depression under different circumstances, including its ability to prevent cardiac arrest.

Topics: Analgesics, Opioid; Drug Overdose; Heart Arrest; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Respiratory Insufficiency

New synthetic opioids (NSO) constitute one of the fastest-growing group of New Psychoactive Substances, which emerged on the illicit drug marker in the second half of 2000's. The most popular and the largest NSO subgroup are high potency fentanyl and its analogs. Subsequent to core-structure scheduling of fentanyl-related substances many opioids with different chemical structures are now emerging on the illicit drug market, rendering the landscape highly complex and dynamic.. PubMed, Scopus and Google Scholar were searched for appropriate articles up to December 2022. Moreover, a search for reports was conducted on Institutional websites to identify documentation published by World Health Organization, United Nations Office on Drugs and Crime, United States Drug Enforcement Administration, and European Monitoring Centre for Drugs and Drug Addiction. Only articles or reports written in English were selected.. Non-fentanyl derived synthetic opioids, i.e., 2-benzylbenzimidazoles (nitazenes), brorphine, U-compounds, AH-7921, MT-45 and related compounds are characterized, describing them in terms of available forms, pharmacology, metabolism as well as their toxic effects. Sample procedures and analytical techniques available for detection and quantification of these compounds in biological matrices are also presented. Finally, as overdoses involving highly potent NSO may be difficult to reverse, the effectiveness of naloxone as a rescue agent in NSO overdose is discussed.. Current review presents key information on non-fentanyl derived NSO. Access to upto-date data on substances of abuse is of great importance for clinicians, public health authorities and professionals performing analyses of biological samples.

Topics: Analgesics, Opioid; Drug Overdose; Fentanyl; Humans; Illicit Drugs; Naloxone; Opioid-Related Disorders

Naloxone is an opioid antagonist that is available in numerous formulations and can be easily administered to avert death from opioid overdose. Amid a historic overdose crisis in the United States, naloxone has a crucial role in stemming the loss of life. However, it remains largely inaccessible to the public. Recently, the U.S. Food and Drug Administration announced the approval of the first over-the-counter formulation of naloxone. Although this historic change provides an important opportunity to increase distribution of naloxone, we must take careful steps during this transition so that it does not paradoxically threaten overall access to this life-saving medication. Specifically, we must ensure that a larger supply of naloxone will meet the newly increased demand at a sustainable price for consumers who are most in need. We must also continue to prioritize comprehensive methods of distribution, such as overdose education and naloxone distribution programs, that serve as important tools to reach the most vulnerable populations. In addition, simultaneous investment in harm-reduction strategies, such as supervised consumption spaces, is critical to ensure that naloxone is available in settings where its life-saving potential can be most fully realized.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Nonprescription Drugs; Opioid-Related Disorders; United States

Concerns that take-home naloxone (THN) training may lead to riskier drug use (as a form of overdose risk compensation) remain a substantial barrier to training implementation. However, there was limited good-quality evidence in a systematic review of the association between THN access and subsequent risk compensation behaviors.. To assess whether THN training is associated with changes in overdose risk behaviors, indexed through injecting frequency, in a cohort of people who inject drugs.. This cohort study used prospectively collected self-reported behavioral data before and after THN training of participants in The Melbourne Injecting Drug User Cohort Study (SuperMIX). Annual interviews were conducted in and around Melbourne, Victoria, Australia, from 2008 to 2021. SuperMIX participants were adults who regularly injected heroin or methamphetamine in the 6 months preceding their baseline interview. The current study included only people who inject drugs who reported THN training and had participated in at least 1 interview before THN training.. In 2017, the SuperMIX baseline or follow-up survey began asking participants if and when they had received THN training. The first THN training date that was recorded was included as the exposure variable. Subsequent participant interviews were excluded from analysis.. Injecting frequency was the primary outcome and was used as an indicator of overdose risk. Secondary outcomes were opioid injecting frequency, benzodiazepine use frequency, and the proportion of the time drugs were used alone. Fixed-effects generalized linear (Poisson) multilevel modeling was used to estimate the association between THN training and the primary and secondary outcomes. Time-varying covariates included housing status, income, time in study, recent opioid overdose, recent drug treatment, and needle and syringe coverage. Findings were expressed as incidence rate ratios (IRRs) with 95% CIs.. There were 1328 participants (mean [SD] age, 32.4 [9.0] years; 893 men [67.2%]) who completed a baseline interview in the SuperMIX cohort, and 965 participants completed either a baseline or follow-up interview in or after 2017. Of these 965 participants, 390 (40.4%) reported THN training. A total of 189 people who inject drugs had pretraining participant interviews with data on injecting frequency and were included in the final analysis (mean [SD] number of interviews over the study period, 6.2 [2.2]). In fixed-effects regression analyses adjusted for covariates, there was no change in the frequency of injecting (IRR, 0.91; 95% CI, 0.69-1.20; P = .51), opioid injecting (IRR, 0.95; 95% CI, 0.74-1.23; P = .71), benzodiazepine use (IRR, 0.96; 95% CI, 0.69-1.33; P = .80), or the proportion of reported time of using drugs alone (IRR, 1.04; 95% CI, 0.86-1.26; P = .67) before and after THN training.. This cohort study of people who inject drugs found no evidence of an increase in injecting frequency, along with other markers of overdose risk, after THN training and supply. The findings suggest that THN training should not be withheld because of concerns about risk compensation and that advocacy for availability and uptake of THN is required to address unprecedented opioid-associated mortality.

Topics: Adult; Analgesics, Opioid; Cohort Studies; Drug Overdose; Humans; Male; Naloxone; Narcotic Antagonists; Victoria

The medical community has proposed several clinical recommendations to promote patient safety and health amid the opioid overdose public health crisis. For a frontline practicing physician, distilling the evidence and implementing the latest guidelines may prove challenging. This article aims to highlight pertinent updates and clinical care pearls as they relate to primary care management of chronic pain and opioid use disorder.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pain Management

Fentanyl is a key therapeutic, used in anaesthesia and pain management. It is also increasingly used illicitly and is responsible for a large and growing number of opioid overdose deaths, especially in North America. A number of factors have been suggested to contribute to fentanyl's lethality, including rapid onset of action, in vivo potency, ligand bias, induction of muscle rigidity and reduced sensitivity to reversal by naloxone. Some of these factors can be considered to represent 'anomalous' pharmacological properties of fentanyl when compared with prototypical opioid agonists such as morphine. In this review, we examine the nature of fentanyl's 'anomalous' properties, to determine whether there is really a pharmacological basis to support the existence of such properties, and also discuss whether such properties are likely to contribute to overdose deaths involving fentanyls. LINKED ARTICLES: This article is part of a themed issue on Advances in Opioid Pharmacology at the Time of the Opioid Epidemic. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v180.7/issuetoc.

Topics: Analgesics, Opioid; Drug Overdose; Fentanyl; Humans; Naloxone; Narcotic Antagonists

Overdose deaths are often viewed as the leading edge of the opioid epidemic which has gripped the United States over the past two decades (Skolnick, 2018a). This emphasis is perhaps unsurprising because opioid overdose is both the number-one cause of death for individuals between 25 and 64 years old (Dezfulian et al., 2021) and a significant contributor to the decline in average lifespan (Dowell et al., 2017). Exacerbated by the COVID 19 pandemic, it was estimated there were 93,400 drug overdose deaths in the United States during the 12 months ending December 2020, with more than 69,000 (that is, >74%) of these fatalities attributed to opioid overdose (Ahmad et al., 2021). However, the focus on mortality statistics (Ahmad et al., 2021; Shover et al., 2020) tends to obscure the broader medical impact of nonfatal opioid overdose. Analyses of multiple databases indicate that for each opioid-induced fatality, there are between 6.4 and 8.4 non-fatal overdoses, exacting a significant burden on both the individual and society. Over the past 7-8 years, there has been an alarming increase in the misuse of synthetic opioids ("synthetics"), primarily fentanyl and related piperidine-based analogs. Within the past 2-3 years, a structurally unrelated class of high potency synthetics, benzimidazoles exemplified by etonitazene and isotonitazene ("iso"), have also appeared in illicit drug markets (Thompson, 2020; Ujvary et al. 2021). In 2020, it was estimated that over 80% of fatal opioid overdoses in the United States now involve synthetics (Ahmad et al., 2021). The unique physicochemical and pharmacological properties of synthetics described in this review are responsible for both the morbidity and mortality associated with their misuse as well as their widespread availability. This dramatic increase in the misuse of synthetics is often referred to as the "3rd wave" (Pardo et al., 2019; Volkow and Blanco, 2020) of the opioid epidemic. Among the consequences resulting from misuse of these potent opioids is the need for higher doses of the competitive antagonist, naloxone, to reverse an overdose. The development of more effective reversal agents such as those described in this review is an essential component of a tripartite strategy (Volkow and Collins, 2017) to reduce the biopsychosocial impact of opioid misuse in the "synthetic era".

Topics: Adult; Analgesics, Opioid; COVID-19 Drug Treatment; Drug Overdose; Humans; Middle Aged; Naloxone; Opiate Overdose; United States

Take home naloxone (THN) programs have been rapidly upscaled in response to increasing opioid-related mortality. One often cited concern is that naloxone provision could be associated with increased opioid use, due to the availability of naloxone to reverse opioid overdose. We conducted a systematic review to determine whether THN provision is associated with changes in substance use by participants enrolled in THN programs.. We conducted a systematic review of the literature to assess changes in heroin or other substance use by people who use opioids following THN provision.. Seven studies with 2578 participants were included. Of the seven studies, there were two quasi-experimental studies and five cohort studies. Based on the Joanna Briggs Institute quality assessment, four studies were of moderate quality and three studies were of high quality. Of the five studies that reported on the primary outcome of heroin use, no study found evidence of increased heroin use across the study population. Five studies reported on other substance use (benzodiazepines, alcohol, cocaine, amphetamine, cannabis, prescription opioids), none of which found evidence of an increase in other substance use associated with THN provision. Four studies reported on changes in overdose frequency following THN provision: three studies reporting no change, and one study of people prescribed opioids finding a reduction in opioid-related emergency department attendances for participants who received naloxone.. We found no evidence that THN provision was associated with increased opioid use or overdose. Concerns that THN supply may lead to increased substance use were not supported by data from reviewed studies.

Topics: Analgesics, Opioid; Drug Overdose; Heroin; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

Harm reduction is an approach to reduce the risk of harms to an individual using substances without requiring abstinence. This review discusses substance-specific interventions for opioids, alcohol, and stimulants that can minimize harms for individuals who use these substances. Topics discussed include overdose prevention, infection prevention, and low-barrier substance use disorder treatment.

Topics: Alcohol Drinking; Analgesics, Opioid; Behavior, Addictive; Central Nervous System Stimulants; Counseling; Delivery of Health Care; Drug Overdose; Fentanyl; Harm Reduction; Humans; Infection Control; Male; Naloxone; Narcotic Antagonists; Narcotics; Opioid-Related Disorders; Pre-Exposure Prophylaxis; Substance-Related Disorders

Realization of the life-saving potential of "take-home naloxone" has been a personal journey, but it has also been a collective journey. It has been a story of individual exploration and growth, and also a story of changes at a societal level. "Take-home naloxone" has matured since its first conceptualization a quarter of a century ago. It required recognition of the enormous burden of deaths from drug overdose (particularly heroin and other opioids), and also realization of critical clusterings (such as post-release from prison). It also required realization that, since many overdose deaths are witnessed, we can potentially prevent many deaths by mobilizing drug users themselves, their families, and the wider caring community to act as intervention workforce to give life-saving interim emergency care. Summary of Scope: This article explores 5 areas (many illustrations UK-based where the author works): firstly, the need for strong science; secondly, our improved understanding of opioid overdose and deaths; thirdly, the search for greater impact from our policies and interventions; fourthly, developing better forms of naloxone; and fifthly, examining the challenges still to be addressed.. "Take-home naloxone" is an exemplar of harm reduction with potential global impact - drug policy and practice for the public good. However, "having the potential" is not good enough - there needs to be actual implementation. This will be easier once the component parts of "take-home naloxone" are improved (better naloxone products, better training aids, revised legislation, and explicit funding support). Many improvements are already possible, but we hesitate about implementation. It is our responsibility to drive progress faster. With "take-home naloxone," we can be proud of what we have achieved, but we must also be humble about how much more we still need to do.

Topics: Analgesics, Opioid; Drug Overdose; Heroin; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders

The US overdose crisis is driven by fentanyl, heroin, and prescription opioids. One evidence-based policy response has been to broaden naloxone distribution, but how much naloxone a community would need to reduce the incidence of fatal overdose is unclear. We aimed to estimate state-level US naloxone need in 2017 across three main naloxone access points (community-based programmes, provider prescription, and pharmacy-initiated distribution) and by dominant opioid epidemic type (fentanyl, heroin, and prescription opioid).. In this modelling study, we developed, parameterised, and applied a mechanistic model of risk of opioid overdose and used it to estimate the expected reduction in opioid overdose mortality after deployment of a given number of two-dose naloxone kits. We performed a literature review and used a modified-Delphi panel to inform parameter definitions. We refined an established model of the population at risk of overdose by incorporating changes in the toxicity of the illicit drug supply and in the naloxone access point, then calibrated the model to 2017 using data obtained from proprietary data sources, state health departments, and national surveys for 12 US states that were representative of each epidemic type. We used counterfactual modelling to project the effect of increased naloxone distribution on the estimated number of opioid overdose deaths averted with naloxone and the number of naloxone kits needed to be available for at least 80% of witnessed opioid overdoses, by US state and access point.. Need for naloxone differed by epidemic type, with fentanyl epidemics having the consistently highest probability of naloxone use during witnessed overdose events (range 58-76% across the three modelled states in this category) and prescription opioid-dominated epidemics having the lowest (range 0-20%). Overall, in 2017, community-based and pharmacy-initiated naloxone access points had higher probability of naloxone use in witnessed overdose and higher numbers of deaths averted per 100 000 people in state-specific results with these two access points than with provider-prescribed access only. To achieve a target of naloxone use in 80% of witnessed overdoses, need varied from no additional kits (estimated as sufficient) to 1270 kits needed per 100 000 population across the 12 modelled states annually. In 2017, only Arizona had sufficient kits to meet this target.. Opioid epidemic type and how naloxone is accessed have large effects on the number of naloxone kits that need to be distributed, the probability of naloxone use, and the number of deaths due to overdose averted. The extent of naloxone distribution, especially through community-based programmes and pharmacy-initiated access points, warrants substantial expansion in nearly every US state.. National Institute of Health, National Institute on Drug Abuse.

Topics: Analgesics, Opioid; Drug Overdose; Fentanyl; Heroin; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid Epidemic; Prescriptions; United States

Naloxone-based interventions as part of health systems can reverse an opioid overdose. Previous systematic reviews have identified the effectiveness of naloxone; however, the role of context and mechanisms for its use has not been explored. This realist systematic review aims to identify a theory of how naloxone works based on the contexts and mechanisms that contribute to the success of the intervention for improved outcomes.. Pre-registered at PROSPERO, this realist review followed RAMESES standards of reporting. Keywords included 'naloxone' and ' opioid overdose'. All study designs were included. Data extraction using 55 relevant outputs based on realist logic produced evidence of two middle-range theories: Naloxone Bystander Intervention Theory and Skills Transfer Theory.. Harm reduction and/or low threshold contexts provide a non-judgemental approach which support in-group norms of helping and empower the social identity of the trained and untrained bystander. This context also creates the conditions necessary for skills transfer and diffusion of the intervention into social networks. Stigma and negative attitudes held by first responders and stakeholders involved in the implementation process, such as police or GPs, can prohibit the bystander response by inducing fear in responding. This interferes with skills transfer, naloxone use and carriage of naloxone kits.. The findings provide theoretically informed guidance regarding the harm reduction contexts that are essential for the successful implementation of naloxone-based interventions. Peer-to-peer models of training are helpful as it reinforces social identity and successful skills transfer between bystanders. Health systems may want to assess the prevalence of, and take steps to reduce opioid-related stigma with key stakeholders in contexts using a low threshold training approach to build an environment  to support positive naloxone outcomes.. PROSPERO 2019 CRD42019141003.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders

The USA has recently entered the third decade of the opioid epidemic. Opioid overdose deaths reached a new record of over 74,000 in a 12-month period ending April 2021. Naloxone is the primary opioid overdose reversal agent, but concern has been raised that naloxone is not efficacious against the pervasive illicit high potency opioids (i.e., fentanyl and fentanyl analogs).. This narrative review provides a brief overview of naloxone, including its history and pharmacology, and the evidence regarding naloxone efficacy against fentanyl and fentanyl analogs. We also highlight current advances in overdose treatments and technologies that have been tested in humans.. The argument that naloxone is not efficacious against fentanyl and fentanyl analogs rests on case studies, retrospective analyses of community outbreaks, pharmacokinetics, and pharmacodynamics. No well-controlled studies have been conducted to test this argument, and the current literature provides limited evidence to suggest that naloxone is ineffective against fentanyl or fentanyl analog overdose. Rather a central concern for treating fentanyl/fentanyl analog overdose is the rapidity of overdose onset and the narrow window for treatment. It is also difficult to determine if other non-opioid substances are contributing to a drug overdose, for which naloxone is not an effective treatment. Alternative pharmacological approaches that are currently being studied in humans include other opioid receptor antagonists (e.g., nalmefene), respiratory stimulants, and buprenorphine. None of these approaches target polysubstance overdose and only one novel approach (a wearable naloxone delivery device) would address the narrow treatment window.

Topics: Analgesics, Opioid; Drug Overdose; Drug-Related Side Effects and Adverse Reactions; Fentanyl; Humans; Illicit Drugs; Naloxone; Narcotic Antagonists; Opiate Overdose; Retrospective Studies

Topics: Analgesics, Opioid; Drug Overdose; Harm Reduction; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Physicians

The administration of the opioid antagonist naloxone in the community is a measure to prevent death from opioid overdose. Approved nasal naloxone sprays deliver initial doses of 0.9 to 8 mg. The level of the initial community dose is controversial, as the scientific base is weak.In this review knowledge of the pharmacokinetics of nasal, both approved and improvised nasal sprays, and intramuscular naloxone will be utilized to evaluate dose-effect relationships in previous studies of opioid overdose outcomes.. The aim was to present scientifically based considerations on the initial nasal naloxone doses currently available, which reasonably balances the effect and adverse outcomes, given that at least two doses are at hand. Also included in these considerations is the challenge by illicitly manufactured fentanyl and analogs.This paper is based on both peer-reviewed and grey literature identified by several searches, of such as naloxone pharmacokinetics/formulations/outcomes/emergency medical services, in PubMed and Embase.. There is little scientific evidence that supports the use of initial systemic dosing that exceeds 0.8 mg in the community. Higher doses increase the risk of withdrawal symptoms feared in people who use opioids. Many obstacles may reduce the potential of community-administered naloxone.

Topics: Adult; Analgesics, Opioid; Drug Overdose; Fentanyl; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose

U.S. military veterans have been heavily impacted by the opioid overdose crisis, with drug overdose mortality rates increasing by 53% from 2010-2019. Risk for overdose among veterans is complex and influenced by ongoing interaction among physiological/biological, psychological, and socio-structural factors. A thorough understanding of opioid-related overdose among veterans, one that goes beyond simple pharmacological determinism, must examine the interplay of pain, pain treatment, and stress, as well as psychological and social experiences-before, during, and after military service. Comprehensive efforts to tackle the overdose crisis among veterans require interventions that address each of these dimensions. Promising interventions include widespread naloxone distribution and increased provision of low-threshold wrap-around services, including medications for opioid use disorder (MOUD) and holistic/complementary approaches. Interventions that are delivered by peers - individuals who share key experiential or sociodemographic characteristics with the population being served - may be ideally suited to address many of the barriers to opioid-related risk mitigation common among veterans. Community care models could be beneficial for the large proportion of veterans who are not connected to the Veterans Health Administration and for veterans who, for various reasons including mental health problems and the avoidance of stigma, are socially isolated or reluctant to use traditional substance use services. Interventions need to be tailored in such a way that they reach those more socially isolated veterans who may not have access to naloxone or the social support to help them in overdose situations. It is important to incorporate the perspectives and voices of veterans with lived experience of substance use into the design and implementation of new overdose prevention resources and strategies to meet the needs of this population. Key messagesU.S. military veterans have been heavily impacted by the opioid overdose crisis, with drug overdose mortality rates increasing by 53% from 2010-2019.The risks for overdose that veterans face need to be understood as resulting from an ongoing interaction among biological/physiological, psychological, and social/structural factors.Addressing drug overdose in the veteran population requires accessible and non-judgemental, low threshold, wraparound, and holistic solutions that recognise the complex aetiology of overdose risk for

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Opiate Overdose; Opioid-Related Disorders; Pain; Risk Factors; Veterans

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Police

Opioid overdose continues to affect thousands each year in the United States, with nearly 850,000 lives lost within the last 20 years. It will take a comprehensive and coordinated approach from all members of the health care team and health care institutions, in addition to governmental officials, public safety, and community organizations to mitigate this crisis. Nurses can be instrumental in educating patients, families, and community members about ways to combat this epidemic, instrumental in advocating for their patients, advocating for reform, as well as continuing to bring awareness to this health crisis and provoke dialogue about ongoing solutions to end it.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Nurse's Role; Opiate Overdose; Opioid-Related Disorders; Patient Education as Topic; United States

The COVID-19 pandemic has amplified the need for wide deployment of effective harm reduction strategies in preventing opioid overdose mortality. Placing naloxone in the hands of key responders, including law enforcement officers who are often first on the scene of a suspected overdose, is one such strategy. New York State (NYS) was one of the first states to implement a statewide law enforcement naloxone administration program. This article provides an overview of the law enforcement administration of naloxone in NYS between 2015 and 2020 and highlights key characteristics of over 9000 opioid overdose reversal events.. Data in naloxone usage report forms completed by police officers were compiled and analyzed. Data included 9133 naloxone administration reports by 5835 unique officers located in 60 counties across NYS. Descriptive statistics were used to examine attributes of the aided individuals, including differences between fatal and non-fatal incidents. Additional descriptive analyses were conducted for incidents in which law enforcement officers arrived first at the scene of suspected overdose. Comparisons were made to examine year-over-year trends in administration as naloxone formulations were changed. Quantitative analysis was supplemented by content analysis of officers' notes (n = 2192).. In 85.9% of cases, law enforcement officers arrived at the scene of a suspected overdose prior to emergency medical services (EMS) personnel. These officers assessed the likelihood of an opioid overdose having occurred based on the aided person's breathing status and other information obtained on the scene. They administered an average of 2 doses of naloxone to aided individuals. In 36.8% of cases, they reported additional administration of naloxone by other responders including EMS, fire departments, and laypersons. Data indicated the aided survived the suspected overdose in 87.4% of cases.. With appropriate training, law enforcement personnel were able to recognize opioid overdoses and prevent fatalities by administering naloxone and carrying out time-sensitive medical interventions. These officers provided life-saving services to aided individuals alongside other responders including EMS, fire departments, and bystanders. Further expansion of law enforcement naloxone administration nationally and internationally could help decrease opioid overdose mortality.

Topics: COVID-19; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; New York; Opiate Overdose; Pandemics; Police

Opioid overdose epidemic is hitting record highs worldwide, accounting for 76% of mortality related to substance use. Take-home naloxone (THN) strategies are being implemented in many developed countries that suffer from high opioid overdose death rates. They aim to provide overdose identification and naloxone administration training, along with THN delivery to opioid users and others likely to witness an overdose incident such as family members and peers. However, little is known about such measures in low- and middle-income countries (LMIC), where opioid use and opioid-related deaths are reportedly high. This systematic literature review aims to examine the distribution of THN in LMIC, review studies identifying barriers to the implementation of THN programs worldwide, and assess their applicability to LMIC.. The literature was searched and analyzed for eligible studies with quality assessment.. Two studies were found from LMIC on THN programs with promising results, and 13 studies were found on the barriers identified in implementing THN programs worldwide. The main barriers to THN strategies were the lack of training of healthcare providers, lack of privileges, time constraints, cost, legislative/policy restrictions, stigma, fear of litigation, and some misperceptions around THN.. The barriers outlined in this paper are probably applicable to LMIC, but more difficult to overcome considering the differences in their response to opioid overdose, their cultural attitudes and norms, the high cost, the waivers required, the legislative differences and the severe penalties for drug-related offenses in some of these countries. The solutions suggested to counter-act these obstacles can also be more difficult to achieve in LMIC. Further research is required in this area with larger sample sizes to provide a better understanding of the obstacles to the implementation, feasibility, accessibility, and utilization of THN programs in LMIC.

Topics: Analgesics, Opioid; Developing Countries; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders

911 Good Samaritan Laws (GSLs) confer limited legal immunity to bystanders in possession of controlled substances who report emergency overdoses. While these laws may decrease opioid overdose mortality, current literature reduces GSLs to a small number of variables, overlooking substantial differences in implementation and statutory context which dramatically alter their applicability.. We identified all state GSLs and their legislative history, characterizing features into four categories using a novel framework: breadth of protected activities, burden placed on Good Samaritans, strength of protection, and exemption in coverage. When protections depended on the nature of the controlled substance, heroin served as a common point of comparison.. GSLs vary substantially across states and time. Protections depend on the quantity of substances involved and may extend to the person experiencing the overdose or persons reporting their own overdose. Protected offenses range from possession of controlled substances to drug-induced homicide. In some states, Good Samaritans must complete substance use treatment or administer naloxone to retain protections. Immunity ranges from protection from arrest to merely procedural protections at trial, and may even exclude persons in possession of opioids. Exemptions target persons engaging in chronic substance use, such as persons invoking protection multiple times or previously reporting an overdose.. States offer Good Samaritans substantially different protections even when the statutes confer nominally comparable immunities. Accommodating this heterogeneity will enhance the validity of future studies into these laws and their efficacy.

Topics: Analgesics, Opioid; Controlled Substances; Drug Overdose; Humans; Law Enforcement; Naloxone; Narcotic Antagonists; United States

The only medication available currently to prevent and treat opioid overdose (naloxone) was approved by the US Food and Drug Administration (FDA) nearly 50 years ago. Because of its pharmacokinetic and pharmacodynamic properties, naloxone has limited utility under some conditions and would not be effective to counteract mass casualties involving large-scale deployment of weaponized synthetic opioids. To address shortcomings of current medical countermeasures for opioid toxicity, a trans-agency scientific meeting was convened by the US National Institute of Allergy and Infectious Diseases/National Institutes of Health (NIAID/NIH) on August 6 and 7, 2019, to explore emerging alternative approaches for treating opioid overdose in the event of weaponization of synthetic opioids. The meeting was initiated by the Chemical Countermeasures Research Program (CCRP), was organized by NIAID, and was a collaboration with the National Institute on Drug Abuse/NIH (NIDA/NIH), the FDA, the Defense Threat Reduction Agency (DTRA), and the Biomedical Advanced Research and Development Authority (BARDA). This paper provides an overview of several presentations at that meeting that discussed emerging new approaches for treating opioid overdose, including the following: (1) intranasal nalmefene, a competitive, reversible opioid receptor antagonist with a longer duration of action than naloxone; (2) methocinnamox, a novel opioid receptor antagonist; (3) covalent naloxone nanoparticles; (4) serotonin (5-HT)

Topics: Analgesics, Opioid; Animals; Congresses as Topic; Drug Overdose; Humans; Medical Countermeasures; Naloxone; Narcotic Antagonists; Opioid Epidemic; Opioid-Related Disorders; Prognosis; Risk Assessment; Risk Factors

The use of novel synthetic opioids as recreational drugs has become a public health concern as they are implicated in numerous fatal intoxications across the world. Synthetic opioids have played a major role in the United States opioid crisis and may contribute to a similar opioid epidemic in Europe. The most prominent group of designer opioids consists of fentanyl and its analogues. At present, carfentanil is the most dangerous fentanyl derivative. It was recently detected as an adulterant to other illicit drugs and counterfeit pharmaceuticals, contributing to life-threatening hospital admissions and fatalities. Toxic exposure to carfentanil typically occurs through injection, insufflation or inhalation. Carfentanil produces similar pharmacotoxicological effects to other opioids. However, due to its extraordinary potency, reversing carfentanil-induced severe and recurring respiratory depression requires administration of multiple or higher than standard doses of naloxone. Toxicological reports indicate that carfentanil use is strongly connected to polydrug use. Detection of carfentanil requires specific and sensitive analytical methods that are not commonly available in hospitals. Since abuse of carfentanil is an emerging problem, particularly in the United States, there is an urgent need to develop new techniques for rapid determination of intoxication evoked by this drug as well as new treatment regimens for effective overdose maintenance. This review presents current knowledge on pharmacological activity of carfentanil, prevalence and patterns of use, and analytical methods of its detection. Special emphasis is given to carfentanil-related non-fatal and lethal overdose cases.

Topics: Analgesics, Opioid; Chromatography, Liquid; Drug Contamination; Drug Overdose; Fentanyl; Forensic Toxicology; Humans; Mass Spectrometry; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Respiratory Insufficiency

There is a high risk of death from opioid overdose following release from prison. Efforts to develop and implement overdose prevention programs for justice-involved populations have increased in recent years. An understanding of the gaps in knowledge on prevention interventions is needed to accelerate development, implementation, and dissemination of effective strategies.. A systematic search process identified 43 published papers addressing opioid overdose prevention in criminal justice settings or among justice-involved populations from 2010 to February 2020. Cross-cutting themes were identified, coded and qualitatively analyzed.. Papers were coded into five categories: acceptability (n = 8), accessibility (n = 4), effectiveness (n = 5), feasibility (n = 7), and participant overdose risk (n = 19). Common themes were: (1) Acceptability of naloxone is associated with injection drug use, overdose history, and perceived risk within the situational context; (2) Accessibility of naloxone is a function of the interface between corrections and community; (3) Evaluations of overdose prevention interventions are few, but generally show increases in knowledge or reductions in opioid overdose; (4) Coordinated efforts are needed to implement prevention interventions, address logistical challenges, and develop linkages between corrections and community providers; (5) Overdose is highest immediately following release from prison or jail, often preceded by service-system interactions, and associated with drug-use severity, injection use, and mental health disorders, as well as risks in the post-release environment.. Study findings can inform the development of overdose prevention interventions that target justice-involved individuals and policies to support their implementation across criminal justice and community-based service systems.

Topics: Analgesics, Opioid; Criminal Law; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders

Opioid related overdoses and overdose deaths continue to constitute an urgent public health crisis. The implementation of naloxone programs, such as 'take-home naloxone' (THN), has emerged as a key intervention in reducing opioid overdose deaths. These programs aim to train individuals at risk of witnessing or experiencing an opioid overdose to recognize an opioid overdose and respond with naloxone. Naloxone effectively reverses opioid overdoses on a physiological level; however, there are outstanding questions on community THN program effectiveness (adverse events, dosing requirements, dose-response between routes of administration) and implementation (accessibility, availability, and affordability). The objective of this scoping review is to identify existing systematic reviews and best practice guidelines relevant to clinical and operational guidance on the distribution of THN.. Using the Arksey & O'Malley framework for scoping reviews, we searched both academic literature and grey literature databases using keywords (Naloxone) AND (Overdose) AND (Guideline OR Review OR Recommendation OR Toolkit). Only documents which had a structured review of evidence and/or provided summaries or recommendations based on evidence were included (systematic reviews, meta-analyses, scoping reviews, short-cut or rapid reviews, practice/clinical guidelines, and reports). Data were extracted from selected evidence in two key areas: (1) study identifiers; and (2) methodological characteristics.. A total of 47 articles met inclusion criteria: 20 systematic reviews; 10 grey literature articles; 8 short-cut or rapid reviews; 4 scoping reviews; and 5 other review types (e.g. mapping review and comprehensive reviews). The most common subject themes were: naloxone effectiveness, safety, provision feasibility/acceptability of naloxone distribution, dosing and routes of administration, overdose response after naloxone administration, cost-effectiveness, naloxone training and education, and recommendations for policy, practice and gaps in knowledge.. Several recent systematic reviews address the effectiveness of take-home naloxone programs, naloxone dosing/route of administration, and naloxone provision models. Gaps remain in the evidence around evaluating cost-effectiveness, training parameters and strategies, and adverse events following naloxone administration. As THN programs continue to expand in response to opioid overdose deaths, this review will contribute to understanding the evidence base for policy and THN program development and expansion.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders

Drug-related deaths globally are increasing year on year, with the largest proportion of these being opioid-related. The opioid antagonist naloxone distributed for take-home use ('Take-Home Naloxone (THN)') has been championed as one method of tackling this public health crisis, however to be effective it must be available at an opioid overdose. Ownership and carriage are therefore fundamental to THN success. This study aimed to assess the prevalence of ownership and carriage of THN internationally among people who use drugs (PWUD).. NHS Scotland Journals, AMED, EMBASE, HMIC, MEDLINE, PsycINFO, CINAHL Complete, PubMed, Cochrane Library, PROSPERO and grey literature were searched for articles which measured prevalence of THN ownership or carriage between 1996 and 2020. Ownership was defined as report of a personal supply of THN. Carriage was defined as the participant carrying THN on their person at time of data collection or reporting a frequency of how often they carry THN. Risk of bias was evaluated using the Joanna Briggs Checklist for Prevalence Studies.. Systematic search yielded 6363 papers, with ten eligible papers identified. Eight articles were included in ownership prevalence and five articles included for carriage prevalence, with an overlap of three studies between both measures. Pooled prevalence indicated moderate ownership levels (57%, CI 47-67%) but lower carriage levels (20%, CI 12-31%). Analysis was complicated by the limited number of available studies and lack of standardised terminology and measurement.. Understanding naloxone ownership and carriage globally is hampered by limited evidence and heterogeneity across studies. From the available data, prevalence of THN carriage overall appears low, despite moderate ownership. Given the variation across studies, future research should seek to utilise more standardised terminology and methods of measurement. Furthermore, services distributing THN must ensure the importance of regular carriage of naloxone is consistently emphasised.

Topics: Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Ownership; Prevalence

In recent years, there has been an emergence of numerous novel drugs. Such toxicity may occur in both adolescents and adults. This article discusses the opioid epidemic and several emerging opioids, including buprenorphine, loperamide, fentanyl, fentanyl derivatives, and others. Kratom, a plant occasionally used for opiate detoxification, along with the sedatives etizolam and phenibut, will be discussed. Lastly, this article discusses the phenethylamines and marijuana.

Topics: Analgesics, Opioid; Buprenorphine; Cannabinoids; Designer Drugs; Drug Overdose; Fentanyl; Humans; Hypnotics and Sedatives; Illicit Drugs; Loperamide; Mitragyna; Naloxone; Narcotic Antagonists; Phenethylamines; Substance-Related Disorders

Evaluate the relationship between naloxone dose (initial and cumulative) and opioid toxicity reversal and adverse events in undifferentiated and presumed fentanyl/ultra-potent opioid overdoses.. We searched Embase, MEDLINE, Cochrane Central Register of Controlled Trials, DARE, CINAHL, Science Citation Index, reference lists, toxicology websites, and conference proceedings (1972 to 2018). We included interventional, observational, and case studies/series reporting on naloxone dose and opioid toxicity reversal or adverse events in people >12 years old.. A total of 174 studies (110 case reports/series, 57 observational, 7 interventional) with 26,660 subjects (median age 35 years; 74% male). Heterogeneity precluded meta-analysis. Where reported, we abstracted naloxone dose and proportion of patients with toxicity reversal. Among patients with presumed exposure to fentanyl/ultra-potent opioids, 56.9% (617/1,085) responded to an initial naloxone dose ≤0.4 mg compared with 80.2% (170/212) of heroin users, and 30.4% (7/23) responded to an initial naloxone dose >0.4 mg compared with 59.1% (1,434/2,428) of heroin users. Among patients who responded, median cumulative naloxone doses were higher for presumed fentanyl/ultra-potent opioids than heroin overdoses in North America, both before 2015 (fentanyl/ultra-potent opioids: 1.8 mg [interquartile interval {IQI}, 1.0, 4.0]; heroin: 0.8 mg [IQI, 0.4, 0.8]) and after 2015 (fentanyl/ultra-potent opioids: 3.4 mg [IQI, 3.0, 4.1]); heroin: 2 mg [IQI, 1.4, 2.0]). Where adverse events were reported, 11% (490/4,414) of subjects experienced withdrawal. Variable reporting, heterogeneity and poor-quality studies limit conclusions.. Practitioners have used higher initial doses, and in some cases higher cumulative naloxone doses to reverse toxicity due to presumed fentanyl/ultra-potent opioid exposure compared with other opioids. High-quality comparative naloxone dosing studies assessing effectiveness and safety are needed.

Topics: Adult; Analgesics, Opioid; Child; Drug Overdose; Female; Fentanyl; Humans; Male; Naloxone; Narcotic Antagonists; Opiate Overdose

Topics: Behavior Therapy; Drug Overdose; Harm Reduction; Humans; Illicit Drugs; Medical History Taking; Naloxone; Narcotic Antagonists; Narcotics; Opioid-Related Disorders; Patient Care Planning; Social Support

In recent years the prescription opioid overdose epidemic has decreased, but has been more than offset by increases in overdose caused by fentanyl and fentanyl analogues. Opioid overdose patients should receive naloxone if they have significant respiratory depression and/or loss of protective airway reflexes. Patients who receive naloxone should be observed for recurrent opioid effects. Patients with opioid overdose may be admitted to the intensive care unit for naloxone infusions, treatment of noncardiogenic pulmonary edema, autonomic instability, or sequelae of hypoxia-ischemia or cardiac arrest. Primary and secondary prevention are important to reduce the number of people with life-threatening opioid overdose.

Topics: Analgesics, Opioid; Drug Overdose; Fentanyl; Humans; Naloxone; Opioid Epidemic

Nonfatal opioid overdose is a significant risk factor for subsequent fatal overdose. The time after a nonfatal overdose may provide a critical engagement opportunity to both reduce subsequent overdose risk and link individuals to treatment. Post-overdose interventions have emerged in affected communities throughout the United States (US). The objective of this scoping review is to identify US-based post-overdose intervention models (1) described in peer-reviewed literature and (2) implemented in public health and community settings.. Using the adapted PRISMA Checklist for Scoping Reviews, we searched PubMed, PsychInfo, Academic OneFile, and federal and state databases for peer-reviewed and gray literature descriptions of post-overdose programs. We developed search strings with a reference librarian. We included studies or programs with at least the following information available: name of program, description of key components, intervention team, and intervention timing.. We identified a total of 27 programs, 3 from the peer-reviewed literature and 24 from the gray literature. 9 programs operated out of the ED, while 18 programs provided post-overdose support in other ways: through home or overdose location visits, mobile means, or as law enforcement diversion. Commonly, they include partnerships among public safety and community service providers.. Programs are emerging throughout the US to care for individuals after a nonfatal opioid overdose. There is variability in the timing, components, and follow-up in these programs and little is known about their effectiveness. Future work should focus on evaluation and testing of post-overdose programs so that best practices for care can be implemented.

Topics: Adult; Analgesics, Opioid; Drug Overdose; Female; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Practice Guidelines as Topic; Preventive Health Services; United States; Young Adult

The global rise in opioid-related harms has impacted the United States severely. Current efforts to manage the opioid crisis have prompted a re-evaluation of many of the existing roles in the healthcare system, in order to maximize their individual effects on reducing opioid-associated morbidity and preventing overdose deaths. As one of the most accessible healthcare professionals in the US, pharmacists are well-positioned to participate in such activities. Historically, US pharmacists have had a limited role in the surveillance and treatment of substance use disorders. This narrative review explores the literature describing novel programs designed to capitalize on the role of the community pharmacist in helping to reduce opioid-related harms, as well as evaluations of existing practices already in place in the US and elsewhere around the world. Specific approaches examined include strategies to facilitate pharmacist monitoring for problematic opioid use, to increase pharmacy-based harm reduction efforts (including naloxone distribution and needle exchange programs), and to involve community pharmacists in the dispensation of opioid agonist therapy (OAT). Each of these activities present a potential means to further engage pharmacists in the identification and treatment of opioid use disorders (OUDs). Through a careful examination of these approaches, we hope that new strategies can be adopted to leverage the unique role of the community pharmacist to help reduce opioid-related harms in the US.

Topics: Analgesics, Opioid; Attitude of Health Personnel; Community Pharmacy Services; Drug Overdose; Harm Reduction; Health Services Accessibility; Medication Therapy Management; Naloxone; Needle-Exchange Programs; Opiate Substitution Treatment; Opioid-Related Disorders; Patient Education as Topic; Pharmacists; Prescriptions; Professional Role; United States

Topics: Adrenergic Neurons; Analgesics, Opioid; Drug Overdose; Fentanyl; Humans; Muscle Rigidity; Naloxone; Narcotic Antagonists; Opioid Epidemic; Respiratory Insufficiency; Time-to-Treatment

We sought to understand the implementation of multifaceted community plans to address opioid-related harms.. Our scoping review examined the extent of the literature on community plans to prevent and reduce opioid-related harms, characterise the key components, and identify gaps.. We searched MEDLINE, Embase, PsycINFO, CINHAL, SocINDEX and Academic Search Primer, and three search engines for English language peer-reviewed and grey literature from the past 10 years.. Eligible records addressed opioid-related harms or overdose, used two or more intervention approaches (eg, prevention, treatment, harm reduction, enforcement and justice), involved two or more partners and occurred in an Organisation for Economic Co-operation and Development country.. Qualitative thematic and quantitative analysis was conducted on the charted data. Stakeholders were engaged through fourteen interviews, three focus groups and one workshop.. We identified 108 records that described 100 community plans in Canada and the USA; four had been evaluated. Most plans were provincially or state funded, led by public health and involved an average of seven partners. Commonly, plans used individual training to implement interventions. Actions focused on treatment and harm reduction, largely to increase access to addiction services and naloxone. Among specific groups, people in conflict with the law were addressed most frequently. Community plans typically engaged the public through in-person forums. Stakeholders identified three key implications to our findings: addressing equity and stigma-related barriers towards people with lived experience of substance use; improving data collection to facilitate evaluation; and enhancing community partnerships by involving people with lived experience of substance use.. Current understanding of the implementation and context of community opioid-related plans demonstrates a need for evaluation to advance the evidence base. Partnership with people who have lived experience of substance use is underdeveloped and may strengthen responsive public health decision making.

Topics: Community Health Services; Drug Overdose; Harm Reduction; Humans; Naloxone; Narcotic Antagonists; Substance-Related Disorders

Women are being disproportionately affected by the opioid crisis, including during pregnancy. Pain and other vulnerabilities to addiction differ between men and women. Management of opioid use disorder should be gender informed and accessible across the lifespan. During pregnancy, care teams should be multidisciplinary to include obstetrics, addiction, social work, anesthesia, pediatrics, and behavioral health. Pain management for women with opioid use disorder requires tailored approaches, including integration of trauma-informed care and addressing psychosocial needs. Thus, coordinated continued care by obstetric and addiction providers through pregnancy into postpartum is key to supporting women in recovery.

Topics: Analgesics, Opioid; Chronic Pain; Drug Overdose; Female; Harm Reduction; History, 20th Century; History, 21st Century; Humans; Naloxone; Narcotic Antagonists; Opiate Substitution Treatment; Opioid-Related Disorders; Pain; Pain Management; Patient Care Planning; Patient Participation; Postnatal Care; Pregnancy; Pregnancy Complications; Prenatal Care; Prenatal Diagnosis; Psychological Trauma; Sex Factors

Death due to opioid overdose was declared a public health crisis in Canada in 2015. Traditionally, patients who have overdosed on opioids that are managed by emergency medical services (EMS) are treated with the opioid antagonist naloxone, provided ventilatory support and subsequently transported to hospital. However, certain EMS agencies have permitted patients who have been reversed from opioid overdose to refuse transport, if the patient exhibits capacity to do so. Evidence on the safety of this practice is limited. Therefore, our intent was to examine the available literature to determine mortality and serious adverse events within 48 hours of EMS treat and release due to suspected rebound opioid toxicity after naloxone administration.. A systematic search was performed on 11 May 2017 in PubMed, Cochrane Central, Embase and CINHAL. Studies that reported on the outcome of patients treated with prehospital naloxone and released at the scene were included. Analyses for incidence of mortality and adverse events at the scene were conducted. Risk of bias and assessment of publication bias was also done.. 1401 records were screened after duplicate removal. Eighteen full-text studies were reviewed with seven selected for inclusion. None were found to be high risk of bias. In most studies, heroin was the source of the overdose. Mortality within 48 hours was infrequent with only four deaths among 4912 patients ﴾0.081%﴿ in the seven studies. Only one study reported on adverse events and found no incidence of adverse events from their sample of 71 released patients.. Mortality or serious adverse events due to suspected rebound toxicity in patients released on scene post-EMS treatment with naloxone were rare. However, studies involving longer-acting opioids were rare and no study involved fentanyl.

Topics: Analgesics, Opioid; Drug Overdose; Emergency Medical Services; Humans; Naloxone; Narcotic Antagonists

More than 750,000 persons in the United States inject opioids, methamphetamine, cocaine, or ketamine, and that number is increasing because of the current opioid epidemic. Persons who inject drugs (PWID) are at higher risk of infectious and noninfectious skin, pulmonary, cardiac, neurologic, and other causes of morbidity and mortality. Nonjudgmental inquiries about current drug use can uncover information about readiness for addiction treatment and identify modifiable risk factors for complications of injection drug use. All PWID should be screened for human immunodeficiency virus infection, latent tuberculosis, and hepatitis B and C, and receive vaccinations for hepatitis A and B, tetanus, and pneumonia if indicated. Pre-exposure prophylaxis for human immunodeficiency virus infection should also be offered. Naloxone should be prescribed to those at risk of opioid overdose. Skin and soft tissue infections are the most common medical complication in PWID and the top reason for hospitalization in these patients. Signs of systemic infection require hospitalization, blood cultures, and a comprehensive history and physical examination to determine the source of infection. PWID have a higher incidence of community-acquired pneumonia and are at risk of other pulmonary complications, including opioid-associated pulmonary edema, asthma, and foreign body granulomatosis. Infectious endocarditis is the most common cardiac complication associated with injection drug use and more often involves the right-sided heart valves, which may not present with heart murmurs or peripheral signs and symptoms, in PWID. Injections increase the risk of osteomyelitis, as well as subdural and epidural abscesses.

Topics: Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Needle-Exchange Programs; Physical Examination; Primary Health Care; Substance Abuse, Intravenous; Substance-Related Disorders

There has been an exponential increase in overdose fatalities as illicitly manufactured fentanyl and its analogs (IMF) are becoming more prevalent in the illicit drug supply. In response, overdose education and naloxone distribution (OEND) programs have been implemented throughout the United States as a harm reduction strategy. However, there are increasing reports that higher naloxone doses or repeat administration might be required for overdose victims involving IMF.. In this article, we provide a comprehensive review of the epidemiology, public health impact, and pharmacologic properties of IMF. The pharmacokinetic properties of currently available take-home naloxone (THN) kits, the role of THN as a harm reduction strategy and available data on its clinical use are discussed. Implications of occupational IMF exposure for first responders are also described.. THN administration by a bystander is an effective harm reduction intervention. However, there is growing evidence that higher dose or multiple administrations of naloxone are required to fully reverse IMF related toxicity. Recently, the US Food and Drug Administration approved THN kits with a concentrated naloxone dose that produce high bioavailability. However, limited presence of OEND programs and cost of these new devices impede their accessibility to the general public.

Topics: Analgesics, Opioid; Animals; Drug Overdose; Fentanyl; Harm Reduction; Humans; Illicit Drugs; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; United States

Topics: Analgesics, Opioid; Buprenorphine; Chronic Pain; Drug Overdose; Humans; Methadone; Naloxone; Narcotic Antagonists; Opiate Substitution Treatment; Opioid-Related Disorders; Risk Assessment; Substance Abuse Detection

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Nasal Sprays

People who inject drugs (PWID) are at an elevated risk of fatal overdose in the first year after experiencing a non-fatal event. Such non-fatal events may also result in overdose-related sequelae, ranging from physical injury to paralysis. Given variation in drug markets and treatment availability across countries and regions, we may see similar variations in non-fatal overdose prevalence. Monitoring non-fatal overdose prevalence among PWID is essential for informing treatment intervention efforts, and thus our review aims to estimate the global, regional, and national prevalence of non-fatal overdose, and determine characteristics associated with experiencing such an event.. We conducted a systematic review and meta-analyses to estimate country, regional, and global estimates of recent and lifetime non-fatal overdose prevalence among PWID. Using meta-regression analyses we also determined associations between sample characteristics and non-fatal overdose prevalence.. An estimated 3.2 (1.8-5.2) million PWID have experienced at least one overdose in the previous year. Among PWID, 20.5% (15.0-26.1%) and 41.5% (34.6-48.4%) had experienced a non-fatal event in the previous 12 months and lifetime respectively. Frequent injecting was strongly associated with PWID reporting recent and lifetime non-fatal overdose. Estimates of recent non-fatal overdose were particularly high in Asia and North America.. Around one in five PWID are at an elevated risk of fatally overdosing every year, however there is substantial geographical variation. In countries with higher rates of non-fatal overdose there is need to introduce or mainstream overdose prevention strategies such as opioid agonist treatment and naloxone administration training programs.

Topics: Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Prevalence; Risk Factors; Substance Abuse, Intravenous

Naloxone is a well-established essential medicine for the treatment of life-threatening heroin/opioid overdose in emergency medicine. Over two decades, the concept of 'take-home naloxone' has evolved, comprising pre-provision of an emergency supply to laypersons likely to witness an opioid overdose (e.g. peers and family members of people who use opioids as well as non-medical personnel), with the recommendation to administer the naloxone to the overdose victim as interim care while awaiting an ambulance. There is an urgent need for more widespread naloxone access considering the growing problem of opioid overdose deaths, accounting for more than 100,000 deaths worldwide annually. Rises in mortality are particularly sharp in North America, where the ongoing prescription opioid problem is now overlaid with a rapid growth in overdose deaths from heroin and illicit fentanyl. Using opioids alone is dangerous, and the mortality risk is clustered at certain times and contexts, including on prison release and discharge from hospital and residential care. The provision of take-home naloxone has required the introduction of new legislation and new naloxone products. These include pre-filled syringes and auto-injectors and, crucially, new concentrated nasal sprays (four formulations recently approved in different countries) with speed of onset comparable to intramuscular naloxone and relative bioavailability of approximately 40-50%. Choosing the right naloxone dose in the fentanyl era is a matter of ongoing debate, but the safety margin of the approved nasal sprays is superior to improvised nasal kits. New legislation in different countries permits over-the-counter sales or other prescription-free methods of provision. However, access remains uneven with take-home naloxone still not provided in many countries and communities, and with ongoing barriers contributing to implementation inertia. Take-home naloxone is an important component of the response to the global overdose problem, but greater commitment to implementation will be essential, alongside improved affordable products, if a greater impact is to be achieved.

Topics: Analgesics, Opioid; Animals; Drug Overdose; Emergency Medicine; Humans; Naloxone; Opioid-Related Disorders; Public Health

Fatalities from opioid overdose have risen by 117% over the past 10 years. Increasing access to the opioid antagonist, naloxone can combat this trend and saves lives. This study investigates the various routes of naloxone administration for opioid reversal in the prehospital setting.. PubMed, Ovid, and Google Scholar were searched for references that included the words naloxone and prehospital. Inclusion criteria were peer reviewed publications after 1995, English language, studies conducted in an outpatient setting, and intramuscular, intranasal, intravenous, or subcutaneous formulations; exclusion criteria were review articles or editorials.. 8 articles met the inclusion criteria: intramuscular, intranasal, intravenous, and subcutaneous dosage forms of naloxone were analyzed to compare their time to administration, time to efficacy, financial impact, administrator safety, and administrator preference.. There is little consensus on the optimal route of naloxone administration in the prehospital setting. Little training is required for proper administration of the intramuscular auto-injector; however, the high price of this device is a barrier to access. Intranasal naloxone appears to be the optimal dosage form when considering cost, effectiveness, and administrator safety. Pharmacists must be aware of trends in naloxone use, dosage forms, and administration when caring for patients and their communities.

Topics: Analgesics, Opioid; Drug Administration Routes; Drug Overdose; Emergency Medical Services; Humans; Naloxone; Narcotic Antagonists; Pharmacists; Professional Role

Non-injectable naloxone formulations are being developed for opioid overdose reversal, but only limited data have been published in the peer-reviewed domain. Through examination of a hitherto-unsearched database, we expand public knowledge of non-injectable formulations, tracing their development and novelty, with the aim to describe and compare their pharmacokinetic properties.. (i) The PatentScope database of the World Intellectual Property Organization was searched for relevant English-language patent applications; (ii) Pharmacokinetic data were extracted, collated and analysed; (iii) PubMed was searched using Boolean search query '(nasal OR intranasal OR nose OR buccal OR sublingual) AND naloxone AND pharmacokinetics'.. Five hundred and twenty-two PatentScope and 56 PubMed records were identified: three published international patent applications and five peer-reviewed papers were eligible. Pharmacokinetic data were available for intranasal, sublingual, and reference routes. Highly concentrated formulations (10-40 mg mL. Exploratory analysis identified intranasal bioavailability as associated positively with dose and negatively with volume.. We find consistent direction of development of intranasal sprays to high-concentration, low-volume formulations with bioavailability in the 20-60% range. These have potential to deliver a therapeutic dose in 0.1 mL volume. [McDonald R, Danielsson Glende Ø, Dale O, Strang J. International patent applications for non-injectable naloxone for opioid overdose reversal: Exploratory search and retrieve analysis of the PatentScope database. Drug Alcohol Rev 2017;00:000-000].

Topics: Administration, Intranasal; Administration, Sublingual; Databases, Factual; Drug Overdose; Humans; Naloxone; Narcotic Antagonists

To provide an update on prescription of naloxone as a harm-reduction strategy, PubMed was searched to identify publications relevant to naloxone prescribing for reversal of opioid overdose. Opportunities now exist to expand naloxone use, although evidence suggests these are often missed or underexploited. The US FDA has approved an intranasal naloxone spray and an autoinjector naloxone formulation for community use. Effective use of naloxone in community settings requires screening to identify patients at risk of opioid overdose, discussing naloxone use with patients and their relatives, and providing appropriate training. The tools exist to expand the use of naloxone more widely into the community, thereby creating an opportunity to reduce opioid overdose fatalities.

Topics: Administration, Intranasal; Analgesics, Opioid; Drug Overdose; Drug Prescriptions; Humans; Naloxone; Opiate Alkaloids

To assess the pharmacokinetic properties of community-use formulations of naloxone for emergency treatment of opioid overdose.. Systematic literature review based on searches of established databases and congress archives.. Seven studies met inclusion criteria: two of US FDA-approved intramuscular (im.)/subcutaneous (sc.) auto-injectors, one of an FDA-approved intranasal spray, two of unapproved intranasal kits (syringe with atomizer attachment) and two of intranasal products in development.. The pharmacokinetics of im./sc. auto-injector 2 mg and approved intranasal spray (2 and 4 mg) demonstrated rapid uptake and naloxone exposure exceeding that of the historic benchmark (0.4 mg im.), indicating that naloxone exposure was adequate for reversal of opioid overdose.

Topics: Administration, Intranasal; Analgesics, Opioid; Drug Overdose; Humans; Injections, Intramuscular; Injections, Subcutaneous; Naloxone; Pharmacokinetics; United States; United States Food and Drug Administration

The rapid rise in the opioid epidemic has had a deleterious impact across the United States. This increase has drawn the attention of the critical care community not only because of the surge in acute opioid overdose-related admissions, but also due to the increase in the number of opioid-dependent and opioid-tolerant patients being treated in the intensive care unit (ICU). Opioid-related issues relevant to the critical care physician include direct care of patients with opioid overdoses, the provision of sufficient analgesia to patients with opioid dependence and tolerance, and the task of preventing long-term opioid dependence in patients who survive ICU care. This review identifies the challenges facing the ICU physician working with patients presenting with opioid-related complications, discusses current solutions, and suggests future areas of research and heightened ICU clinician attention.

Topics: Analgesics, Non-Narcotic; Analgesics, Opioid; Anesthesia, Conduction; Comorbidity; Complementary Therapies; Critical Care; Critical Illness; Drug Overdose; Drug Tolerance; Humans; Intensive Care Units; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pain Management

Fentanyl is a potent synthetic opioid used as a narcotic analgesic supplement in general and regional anesthesia as well as in management of persistent, severe chronic pain. Alarming epidemiological and forensic medicine reports, accumulated mainly during the last two decades, point to a growing increase in illicit use of fentanyl, mainly in North America and Europe. Toxicological data indicates that fentanyl use is inextricably linked with polydrug use. There are two main sources of fentanyl on the "recreational" drug market. First, the most common, combines illicitly manufactured fentanyl from clandestine sources. The drug is often mixed up with heroin ("fake heroin") to increase its potency at a little cost, or included in cocaine products. It can also be mixed into and sold as oxycodone-, hydrocodone- or alprazolam-containing tablets. The other way to gain fentanyl is through the diversion of fentanyl-containing medicines, especially transdermal patches (FTPs). Fentanyl extracted from FTP can be administered intravenously, insufflated or inhaled after volatilization. The drug can also be delivered by oral or transmucosal application of the whole patch, or by rectal insertion. The most common overdose symptoms are coma, lethargy, respiratory depression and arrest. Although naloxone, an opioid receptor antagonist, is the standard drug for fentanyl overdose rescue, attempts to revive patients with naloxone could be unsuccessful, due to the rapid onset of fentanyl's action. As the fentanyl problem is constantly growing, there is an urgent need for new, effective harm-reduction strategies and technologies, as well as overdose maintenance.

Topics: Analgesics, Opioid; Dosage Forms; Drug Contamination; Drug Overdose; Drug Trafficking; Fentanyl; Humans; Illicit Drugs; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Transdermal Patch

Naloxone access through established healthcare settings is critical to responding to the opioid crisis. We conducted a systematic review to assess the acceptability and feasibility of prescribing naloxone to patients in primary care. We queried PubMed, EmBase and CINAHL for US-based, peer-reviewed, full-length, original articles relating to acceptability or feasibility of prescribing naloxone in primary care. Searches yielded 270 unduplicated articles; one analyst reviewed all titles and abstracts. Two analysts independently reviewed eligible articles for study design, study outcome, and acceptability and/or feasibility. Analyses were compared and a third reviewer consulted if discrepancies emerged. Seventeen articles were included. Providers' willingness to prescribe naloxone appeared to increase over time. Most studies provided prescribers in-person naloxone trainings, including how to write a prescription and indications for prescribing. Most studies implemented universal prescribing, whereby anyone prescribed long-term opioids or otherwise at risk for overdose was eligible for naloxone. Patient education was largely provided by prescribers and most studies provided take-home educational materials. Providers reported concerns around naloxone prescribing including lack of knowledge around prescribing and educating patients. Providers also reported benefits such as improving difficult conversations around opioids and resetting the culture around opioids and overdose. Current literature supports the acceptability and feasibility of naloxone prescribing in primary care. Provision of naloxone through primary care may help normalize such medication safety interventions, support larger opioid stewardship efforts, and expand access to patients not served by a community distribution program.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Patient Education as Topic; Primary Health Care

This review provides a national summary of what is currently known about the Canadian opioid crisis with respect to opioid-related deaths and harms and potential risk factors as of December 2017.. We reviewed all public-facing opioid-related surveillance or epidemiological reports published by provincial and territorial ministries of health and chief coroners' or medical examiners' offices. In addition, we reviewed publications from federal partners and reports and articles published prior to December 2017. We synthesized the evidence by comparing provincial and territorial opioid-related mortality and morbidity rates with the national rates to look for regional trends.. The opioid crisis has affected every region of the country, although some jurisdictions have been impacted more than others. As of 2016, apparent opioid-related deaths and hospitalization rates were highest in the western provinces of British Columbia and Alberta and in both Yukon and the Northwest Territories. Nationally, most apparent opioid-related deaths occurred among males; individuals between 30 and 39 years of age accounted for the greatest proportion. Current evidence suggests regional age and sex differences with respect to health outcomes, especially when synthetic opioids are involved. However, differences between data collection methods and reporting requirements may impact the interpretation and comparability of reported data.. This report identifies gaps in evidence and areas for further investigation to improve our understanding of the national opioid crisis. The Public Health Agency of Canada will continue to work closely with the provinces, territories and national partners to further refine and standardize national data collection, conduct special studies and expand information-sharing to improve the evidence needed to inform public health action and prevent opioid-related deaths and harms.. Cette recension offre un panorama à l'échelle nationale de ce que l’on savait, en décembre 2017, au sujet de la crise des opioïdes au Canada, en matière de décès et de méfaits liés à la consommation d’opioïdes et en matière de facteurs de risque potentiels.. Nous avons examiné tous les rapports de surveillance et les rapports épidémiologiques sur les opioïdes destinés au public ayant été publiés par les ministères de la Santé des provinces et des territoires et les bureaux des coroners en chef ou des médecins légistes. Nous avons également examiné les publications de nos partenaires fédéraux ainsi que les rapports et les articles sur le sujet publiés jusqu'à décembre 2017. Nous avons synthétisé les données en comparant les taux de mortalité et de morbidité liés à la consommation d’opioïdes dans les provinces et les territoires aux taux observés à l’échelle nationale afin de déceler d’éventuelles tendances à l’échelle régionale.. La crise des opioïdes touche toutes les régions du pays, mais certaines sont plus durement atteintes que d’autres. En effet, depuis 2016, les taux de décès et d’hospitalisations apparemment liés à la consommation d’opioïdes sont plus élevés dans les provinces de l’Ouest que sont la Colombie‑Britannique et l’Alberta, ainsi qu’au Yukon et dans les Territoires du Nord‑Ouest. À l’échelle nationale, la plupart des décès apparemment liés à la consommation d’opioïdes sont survenus chez des hommes et ils ont touché en plus grande proportion les 30 à 39 ans. Les données disponibles laissent penser qu'il existe des différences régionales en matière de résultats de santé en fonction de l'âge et du sexe, en particulier lorsque des opioïdes synthétiques sont en cause. Toutefois, des différences relevant des méthodes de collecte et des exigences relatives à la déclaration des données peuvent jouer sur l’interprétation et la comparabilité des résultats.. Ce rapport relève des lacunes en ce qui concerne certaines données et certains domaines, auxquelles il faudra remédier en menant des études plus approfondies pour mieux comprendre la crise nationale des opioïdes. L’Agence de la santé publique du Canada va continuer de travailler en étroite collaboration avec les provinces, les territoires et ses partenaires nationaux pour affiner et normaliser les processus de collecte de données à l’échelle nationale, mener des études spécifiques et améliorer l’échange d’information, afin que l’on dispose de meilleures données sur lesquelles se fonder pour élaborer des mesures de santé publique et prévenir les décès et les méfaits liés aux opioïdes.

Topics: Age Factors; Canada; Drug Overdose; Emergency Medical Services; Fentanyl; Hospitalization; Humans; Illicit Drugs; Naloxone; Narcotic Antagonists; Narcotics; Opioid-Related Disorders; Prescription Drugs; Risk Factors; Sex Factors; Vulnerable Populations

Drawing from existing opioid prescribing guidelines, this article describes how medical providers can reduce the risk of overdose. Through primary prevention, providers can prevent initial exposure and associated risks by educating patients, using risk stratification, minimizing opioid dose and duration, and avoiding coprescribing with sedatives. Secondary prevention efforts include monitoring patients with urine toxicology and prescription monitoring programs, and screening for opioid use disorders. Tertiary prevention includes treating opioid use disorders and providing naloxone to prevent overdose death. Specific preventive strategies may be required for those with psychiatric disorders or substance use disorders, adolescents, the elderly, and pregnant women.

Topics: Analgesics, Opioid; Drug Overdose; Health Knowledge, Attitudes, Practice; Humans; Medical History Taking; Mental Disorders; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pain Management; Risk Assessment; Substance Abuse Detection; Substance-Related Disorders

Testing the efficacy of academic detailing in improving the practice of prescribing naloxone for patients on high-dose opioids.. Academic detailing has been identified as an effective method for improving health care practices through focused community education. We found that academic detailing is an effective method in improving health care providers' knowledge about the importance of prescribing naloxone for patients on high-dose opioids. We also found that prescribers prescribed more naloxone after our education program. This study reflects the importance of education and academic detailing in resolving health problems. Academic detailing can provide effective preventive tools that can reduce the incidence of health problems we encounter.

Topics: Analgesics, Opioid; Community Health Services; Drug Overdose; Drug Prescriptions; Drug Utilization; Health Education; Health Personnel; Humans; Inappropriate Prescribing; Naloxone; Narcotic Antagonists; Surveys and Questionnaires; Wisconsin

Substance use disorders, including opioid use disorders, are a major public health concern in the United States. Between 2005 and 2014, the rate of opioid-related emergency department (ED) visits nearly doubled, from 89.1 per 100,000 persons in 2005 to 177.7 per 100,000 persons in 2014. Thus, the ED presents a distinctive opportunity for harm-reduction strategies such as distribution of naloxone to patients who are at risk for an opioid overdose.. We conducted a systematic review of all existing literature related to naloxone distribution from the ED. We included only those articles published in peer-reviewed journals that described results relating to naloxone distribution from the ED.. Of the 2,286 articles we identified from the search, five met the inclusion criteria and had direct relevance to naloxone distribution from the ED setting. Across the studies, we found variation in the methods of implementation and evaluation of take-home naloxone programs in the ED. In the three studies that attempted patient follow-up, success was low, limiting the evidence for the programs' effectiveness. Overall, in the included studies there is evidence that distributing take-home naloxone from the ED has the potential for harm reduction; however, the uptake of the practice remained low. Barriers to implementation included time allocated for training hospital staff and the burden on workflow.. This systematic review of the best evidence available supports the ED as a potential setting for naloxone distribution for overdose reversal in the community. The variability of the implementation methods across the studies highlights the need for future research to determine the most effective practices.

Topics: Drug Overdose; Emergency Service, Hospital; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Program Evaluation; United States

The intranasal route for medication administration is increasingly popular in the emergency department and out-of-hospital setting because such administration is simple and fast, and can be used for patients without intravenous access and in situations in which obtaining an intravenous line is difficult or time intensive (eg, for patients who are seizing or combative). Several small studies (mostly pediatric) have shown midazolam to be effective for procedural sedation, anxiolysis, and seizures. Intranasal fentanyl demonstrates both safety and efficacy for the management of acute pain. The intranasal route appears to be an effective alternative for naloxone in opioid overdose. The literature is less clear on roles for intranasal ketamine and dexmedetomidine.

Topics: Administration, Intranasal; Analgesics, Opioid; Conscious Sedation; Dexmedetomidine; Drug Overdose; Emergency Service, Hospital; Fentanyl; Humans; Hypnotics and Sedatives; Ketamine; Midazolam; Naloxone; Patient Safety; Practice Guidelines as Topic; Randomized Controlled Trials as Topic; Treatment Outcome; Wounds and Injuries

People released from correctional settings are at an elevated risk of opioid overdose death in the weeks immediately following release. However, it is not well understood how this population, as a particularly high-risk group, is included in, and benefits from take-home naloxone (THN) programs. The objective of this review is to map research into THN for people released from correctional settings in order to identify further research needs.. We searched electronic databases, grey literature, and conference abstracts for reports on THN for people in or released from correctional settings. Studies were categorised into themes defined by the study's aims and focus. Results from each study were summarised by theme.. We identified 19 studies reporting on THN programs for people released from correctional settings. Studies have examined attitudes towards naloxone among people in custody or recently released from custody (theme 1), and among non-prisoner stakeholders such as prison staff (theme 2). Evaluations and interventional studies (theme 3) have examined process indicators and approaches to naloxone training, including for contacts of prisoners, but there are challenges in assessing health outcomes of THN in the correctional context. Case reports suggest that training in correctional settings translates to action post-release (theme 4).. The feasibility of THN in the context of release from a correctional setting has been established, but there is a need for rigorous research into health outcomes and program implementation. This is an emerging field of study and ongoing assessment of the state of the literature and research needs is recommended.

Topics: Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Prisoners; Prisons

Opioid overdose is a major cause of mortality, but injury and fatal outcomes can be prevented by timely administration of the opioid antagonist naloxone. Pre-provision of naloxone to opioid users and family members (take-home naloxone, THN) was first proposed in 1996, and WHO Guidelines were issued in 2014. While widespread in some countries, THN is minimally available or absent elsewhere. This review traces the development of THN over twenty years, from speculative harm reduction proposal to public health strategy.. Medline and PsycINFO were searched for peer-reviewed literature (1990-2016) using Boolean queries: 1) "naloxone OR Narcan"; 2) "(opioid OR opiate) AND overdose AND prevention". Grey literature and specialist websites were also searched. Data were extracted and synthesized as narrative review, with key events presented as chronological timeline.. Results are presented in 5-year intervals, starting with the original proposal and THN pilots from 1996 to 2001. Lack of familiarity with THN challenged early distribution schemes (2001-2006), leading to further testing, evaluation, and assessment of challenges and perceived medicolegal barriers. From 2006-2011, response to social and legal concerns led to the expansion of THN programs; followed by high-impact research and efforts to widen THN availability from 2011 to 2016.. Framed as a public health tool for harm reduction, THN has overcome social, clinical, and legal barriers in many jurisdictions. Nonetheless, the rising death toll of opioid overdose illustrates that current THN coverage is insufficient, and greater public investment in overdose prevention will be required if THN is to achieve its full potential impact.

Topics: Analgesics, Opioid; Drug Overdose; Family; Heroin; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Peer Group; Time Factors

Drug abuse and its consequences remain a significant public health issue. An increasing number of individuals are present in the emergency room with life-threatening drug intoxication. It is imperative that emergency room physicians are cognizant of the signs, symptoms, and treatment to improve the chances of early recognition and treatment. As a result, the proportion of lives saved will increase significantly. In this article, we present some of the most prevalent life-threatening drugs that lead to emergency room admission. The signs, symptoms, and treatment modalities are discussed.

Topics: Analgesics, Opioid; Cocaine; Designer Drugs; Drug Overdose; Humans; Marijuana Smoking; Naloxone; Substance-Related Disorders

U-47700 is a synthetic opioid developed by The Upjohn Company in the 1970s, which has recently appeared in the news and medical literature due to its toxicity. Currently, there are no clinical trial data assessing the safety of U-47700.. To describe the signs and symptoms of ingestion, laboratory testing, and treatment modalities for U-47700 intoxication.. We searched PubMed, Embase, Web of Science, and EBSCO for articles using the term "U-47700" and "47700." The following inclusion criteria were used: had to be in English; full text; must involve humans; must be either a randomized control trial, prospective trial, retrospective analysis, case series, or case report; and must include clinical findings at presentation. We identified and extracted data from relevant articles. Ten relevant articles were included with 16 patients. Patients that died after overdose with U-47700 typically presented to the hospital with pulmonary edema. Patients who survived an overdose presented with decreased mental status and decreased respiratory rate suggestive of an opioid toxidrome. Patients also commonly had tachycardia. Immunoassays failed to identify U-47700, and the identification of U-47700 required the use of chromatographic and spectral techniques.. We report the first clinical review of U-47700 intoxication.

Topics: Analgesics, Opioid; Benzamides; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; United States

Topics: Drug Overdose; Humans; Naloxone; Narcotic Antagonists

Naloxone is effective for reversing opioid overdose, but optimal strategies for out-of-hospital use are uncertain.. To synthesize evidence on 1) the effects of naloxone route of administration and dosing for suspected opioid overdose in out-of-hospital settings on mortality, reversal of overdose, and harms, and 2) the need for transport to a health care facility after reversal of overdose with naloxone.. Ovid MEDLINE (1946 through September 2017), PsycINFO, Cochrane Central Register of Controlled Trials, CINAHL, U.S. Food and Drug Administration (FDA) materials, and reference lists.. English-language cohort studies and randomized trials that compared different doses of naloxone, administration routes, or transport versus nontransport after reversal of overdose with naloxone. Main outcomes were mortality, reversal of overdose, recurrence of overdose, and harms.. Dual extraction and quality assessment of individual studies; consensus assessment of overall strength of evidence (SOE).. Of 13 eligible studies, 3 randomized controlled trials and 4 cohort studies compared different administration routes. At the same dose (2 mg), 1 trial found similar efficacy between higher-concentration intranasal naloxone (2 mg/mL) and intramuscular naloxone, and 1 trial found that lower-concentration intranasal naloxone (2 mg/5 mL) was less effective than intramuscular naloxone but was associated with decreased risk for agitation (low SOE). Evidence was insufficient to evaluate other comparisons of route of administration. Six uncontrolled studies reported low rates of death and serious adverse events (0% to 1.25%) in nontransported patients after successful naloxone treatment.. There were few studies, all had methodological limitations, and none evaluated FDA-approved autoinjectors or highly concentrated intranasal formulations.. Higher-concentration intranasal naloxone (2 mg/mL) seems to have efficacy similar to that of intramuscular naloxone for reversal of opioid overdose, with no difference in adverse events. Nontransport after reversal of overdose with naloxone seems to be associated with a low rate of serious harms, but no study evaluated risks of transport versus nontransport.. Agency for Healthcare Research and Quality. (PROSPERO: CRD42016053891).

Topics: Administration, Intranasal; Analgesics, Opioid; Drug Overdose; Emergency Medical Services; Humans; Injections, Intramuscular; Naloxone; Narcotic Antagonists

Naloxone reversal of opioid-induced respiratory depression outside of medical facilities has become more prevalent because of the escalating opioid epidemic in the USA. Take-home naloxone for treatment of opioid emergencies is now being recommended by numerous federal, state, and professional organizations. Areas covered: The scope of the opioid overdose epidemic is reviewed along with practical, clinical, regulatory, and usability considerations for take-home naloxone routes of administration currently available and associated delivery systems. Specific opioid-related factors are discussed in detail with emphasis placed on life-threatening respiratory depression and naloxone antagonism. A clinical overview, including pharmacokinetic and FDA approval information for each take-home naloxone product is discussed in detail as well as the impact of take-home naloxone in the community. Finally, given these products are to be used in a panic-stricken, life-threatening opioid emergency, an analysis of available usability data is provided with proposed directions for further study. Expert opinion: Based on the available clinical evidence, auto-injectable naloxone should be the preferred administration route for take-home naloxone treatment until additional safety, efficacy, and comparative outcomes data are available for unconventional routes of administration that unequivocally provide equal or superior results.

Topics: Analgesics, Opioid; Drug Administration Routes; Drug Approval; Drug Delivery Systems; Drug Overdose; Emergencies; Humans; Naloxone; Narcotic Antagonists; Respiratory Insufficiency; United States; United States Food and Drug Administration

The current standards for domestic emergency medical services suggest that all patients suspected of opioid overdose be transported to the emergency department for evaluation and treatment. This includes patients who improve after naloxone administration in the field because of concerns for rebound toxicity. However, various emergency medical services systems release such patients at the scene after a 15- to 20-min observation period as long as they return to their baseline.. We sought to determine if a "treat and release" clinical pathway is safe in prehospital patients with suspected opioid overdose.. Five studies were identified and critically appraised. From a pooled total of 3875 patients who refused transport to the emergency department after an opioid overdose, three patient deaths were attributed to rebound toxicity. These results imply that a "treat and release" policy might be safe with rare complications. A close review of these studies reveals several confounding factors that make extrapolation to our population limited.. The existing literature suggests a "treat and release" policy for suspected prehospital opioid overdose might be safe, but additional research should be conducted in a prospective design.

Topics: Analgesics; Analgesics, Opioid; Drug Overdose; Emergency Service, Hospital; Guidelines as Topic; Heroin; Humans; Naloxone; Patient Safety

Heroin use in the US has exploded in recent years, and heroin overdoses requiring naloxone are very common. After awakening, some heroin users refuse further treatment or transport to the hospital. These patients may be at risk for recurrent respiratory depression or pulmonary edema. In those transported to the emergency department, the duration of the observation period is controversial. Additionally, non-medical first responders and lay bystanders can administer naloxone for heroin and opioid overdoses. There are concerns about the outcomes and safety of this practice as well.. To search the medical literature related to the following questions: (1) What are the medical risks to a heroin user who refuses ambulance transport after naloxone? (2) If the heroin user is treated in the emergency department with naloxone, how long must they be observed prior to discharge? (3) How effective in heroin users is naloxone administered by first responders and bystanders? Are there risks associated with naloxone distribution programs?. We searched PubMed and GoogleScholar with search terms related to each of the questions listed above. The search was limited to English language and excluded patents and citations. The search was last updated on September 31, 2016. The articles found were reviewed for relevance to our objective questions. Eight out of 1020 citations were relevant to the first 2 questions, 5 of 707 were relevant to the third question and 15 of 287 were relevant to the fourth question. In the prehospital environment, does a heroin user revived with naloxone always require ambulance transport and what are the medical risks if ambulance transport is refused after naloxone? The eight articles were all observational studies done either prospectively or retrospectively. Two studies focused on heroin overdoses and included 1069 patients not transported to the hospital. No deaths occurred in this group. In counting the patients from all eight studies, some of which included non-heroin opioid overdoses, there were 5443 patients treated without transport and four deaths from rebound opioid toxicity. The number needed to transport to save one life (NNT) is 1361. Adverse effects were mostly related to opioid withdrawal. If a heroin user is treated in the ED, how long must the patient stay under observation before being safe for discharge? Five articles addressing the duration of ED observation required for patients treated with naloxone for opioid overdoses. Although a wide range of observation durations were reported, one study supported observing patients for one hour. If after this period the patient mobilizes as usual, has normal vital signs, and a Glasgow Coma Scale of 15, they can be discharged safely. What are the likely risks in heroin users following naloxone use by lay bystanders or first responders? Of the 15 relevant papers, a systematic review reported a 100% survival rate in eleven studies and a range of 96-99% survival in the remaining four. Two other studies suffered from poor follow-up and had lower success rates of 83% and 89%. Few if any risks were associated with opioid overdose prevention programs in which lay people were trained to administer naloxone.. Patients revived with naloxone after heroin overdose may be safely released without transport to the hospital if they have normal mentation and vital signs. In the absence of co-intoxicants and further opioid use there is very low risk of death from rebound opioid toxicity. For those patients treated in the ED for opioid overdose, an observation period of one hour is sufficient if they ambulate as usual, have normal vital signs and a Glasgow Coma Scale of 15. Patients suffering opioid toxicity can be administered naloxone safely by first responders and trained lay people. Programs that train these individuals are likely safe and beneficial, however further research is necessary.

Topics: Drug Overdose; Emergency Service, Hospital; Emergency Treatment; Heroin; Humans; Naloxone; Narcotic Antagonists; Narcotics; Time Factors; Transportation of Patients

The opioid use and overdose crisis is persistent and dynamic. Opioid overdoses were initially driven in the 1990s and 2000s by the increasing availability and misuse of prescription opioids. More recently, opioid overdoses are increasing at alarming rates due to wider use of heroin, which in some places is mixed with fentanyl or fentanyl derivatives. Naloxone access for opioid overdose rescue is one of the US Department of Health and Human Services' three priority areas for responding to the opioid crisis. This article summarizes the known benefits of naloxone access and details unanswered questions about overdose education and naloxone rescue kits. Hopefully future research will address these knowledge gaps, improve the effectiveness of opioid overdose education and naloxone distribution programs, and unlock the full promise of naloxone rescue kits.

Topics: Drug Overdose; Drug Users; Emergency Service, Hospital; Female; Humans; Male; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; United States

Flumazenil and naloxone are considered to be pharmacologically ideal antidotes. By competitive binding at the molecular target receptors, they are highly specific antagonists of two important drug classes, the benzodiazepines and opioids, respectively. Both antidotes enjoy rapid onset and short duration after parenteral administration, are easily titrated and are essentially devoid of agonist effects. Yet only naloxone is widely used as a component of the 'coma cocktail', a sequence of empirical treatments to correct altered mental status, while experts discourage the use of flumazenil for such patients. This review contrasts the history, indications, published evidence and novel applications for each antidote in order to explain this disparity in the clinical use of these 'ideal' antidotes.

Topics: Analgesics, Opioid; Antidotes; Benzodiazepines; Coma; Drug Overdose; Flumazenil; Humans; Naloxone

Since the late 1980s, opioid-related morbidity and mortality in the United States has dramatically increased. This serious epidemic requires a coordinated medical, public policy, and social response. It is becoming readily apparent that widespread provision of naloxone may help to address this problem. However, because naloxone access laws vary between states, the extent of antidote dissemination may be limited by a given provider's geographic location.. This review targets a physician or prescriber audience, in hopes of providing evidence for the safety and utility of naloxone, education on the baseline legal liability of naloxone provision and protections afforded by access laws, and resources for the proposal of statewide legislation to promote antidote distribution.. Evidence suggests that naloxone administration by laypersons, pursuant to physician prescription or standing order, is safe and effective for reversal of opioid overdose. As of July 2015, 44 states and the District of Columbia have passed naloxone access laws, offering varying degrees of protections for prescribers. Although the likelihood of naloxone-related legal action may parallel that inherent to the usual practice of medicine, providers should be mindful of potential scenarios, exercise methods to mitigate risk, and appreciate the utility of comprehensive naloxone access legislation in orchestrating a coordinated response to the opioid overdose epidemic.

Topics: Drug Overdose; Health Services Accessibility; Humans; Liability, Legal; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; United States

There is growing evidence that expanded supply of take-home naloxone to prevent opioid overdose deaths is needed. Potential routes for expansion of naloxone provision include through community pharmacies. The aim of this scoping review is to establish what is known about community pharmacy supply of naloxone, in light of unique challenges and opportunities present in pharmacy settings. A scoping review methodology was employed using the six stage iterative process advocated by Arksey and O'Malley (2005) and Levac et al. (2010). Searches used key words and terms such as 'naloxone'; 'overdose prevention/drug overdose/opiate overdose'; 'community/retail pharmacy'; 'pharmacist/pharmacy/community pharmacy/pharmaceutical services'; 'professional practice/role'; 'community care'; attitude of health personnel'; 'training/supply/cost'. Appropriate search terms were selected for each database. After initial exploratory searches, comprehensive searches were conducted with Cochrane Database of Systematic Reviews, Medline, Medline in Process, Embase, PsycINFO and CINAHL. Eligibility criteria centered on whether studies broadly described supply of naloxone in community pharmacy or had content relating to community pharmacy supply. The search identified 95 articles, of which 16 were related to pharmacy supply of naloxone. Five themes were presented after initial review of the data and consultation with the project Expert Group, and are; 'Pharmacists Perceptions of Naloxone: Facilitators and Barriers', 'Patient Populations: Identification and Recruitment', 'Supply Systems and Cost', 'Legal Issues', and 'Training of Pharmacists and Community Pharmacy Naloxone Recipients'. Findings from this scoping review suggest that community pharmacy based supply of take-home naloxone warrants the community pharmacy based route for distribution of take home naloxone provision warrants further consideration and development. Existing strengths include a range of established supply models, and training curricula, few direct concerns regarding legal liability of pharmacists in the supply of naloxone (once legal supply systems have been established) and the wide range of potential identifiable patient populations, which include pain patients that may not be in contact with existing naloxone supply programmes.

Topics: Analgesics, Opioid; Community Pharmacy Services; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pharmacists; Professional Role

Deaths from opioid overdose can be prevented through administration of the antagonist naloxone, which has been licensed for injection since the 1970s. To support wider availability of naloxone in community settings, novel non-injectable naloxone formulations are being developed, suitable for emergency use by non-medical personnel.. 1) Identify candidate routes of injection-free naloxone administration potentially suitable for emergency overdose reversal; 2) consider pathways for developing and evaluating novel naloxone formulations.. A three-stage analysis of candidate routes of administration was conducted: 1) assessment of all 112 routes of administration identified by FDA against exclusion criteria. 2) Scrutiny of empirical data for identified candidate routes, searching PubMed and WHO International Clinical Trials Registry Platform using search terms "naloxone AND [route of administration]". 3) Examination of routes for feasibility and against the inclusion criteria.. Only three routes of administration met inclusion criteria: nasal, sublingual and buccal. Products are currently in development and being studied. Pharmacokinetic data exist only for nasal naloxone, for which product development is more advanced, and one concentrated nasal spray was granted licence in the US in 2015. However, buccal naloxone may also be viable and may have different characteristics.. After 40 years of injection-based naloxone treatment, non-injectable routes are finally being developed. Nasal naloxone has recently been approved and will soon be field-tested, buccal naloxone holds promise, and it is unclear what sublingual naloxone will contribute. Development and approval of reliable non-injectable formulations will facilitate wider naloxone provision across the community internationally.

Topics: Administration, Buccal; Administration, Intranasal; Administration, Sublingual; Analgesics, Opioid; Clinical Trials as Topic; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Needles

Fatal outcome of opioid overdose, once detected, is preventable through timely administration of the antidote naloxone. Take-home naloxone provision directly to opioid users for emergency use has been implemented recently in more than 15 countries worldwide, albeit mainly as pilot schemes and without formal evaluation. This systematic review assesses the effectiveness of take-home naloxone, with two specific aims: (1) to study the impact of take-home naloxone distribution on overdose-related mortality; and (2) to assess the safety of take-home naloxone in terms of adverse events.. PubMed, MEDLINE and PsychINFO were searched for English-language peer-reviewed publications (randomized or observational trials) using the Boolean search query: (opioid OR opiate) AND overdose AND prevention. Evidence was evaluated using the nine Bradford Hill criteria for causation, devised to assess a potential causal relationship between public health interventions and clinical outcomes when only observational data are available.. A total of 1397 records (1164 after removal of duplicates) were retrieved, with 22 observational studies meeting eligibility criteria. Due to variability in size and quality of the included studies, meta-analysis was dismissed in favour of narrative synthesis. From eligible studies, we found take-home naloxone met all nine Bradford Hill criteria. The additional five World Health Organization criteria were all either met partially (two) or fully (three). Even with take-home naloxone administration, fatal outcome was reported in one in 123 overdose cases (0.8%; 95% confidence interval = 0.4, 1.2).. Take-home naloxone programmes are found to reduce overdose mortality among programme participants and in the community and have a low rate of adverse events.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

Opioid use and addiction in adolescents and young adults is a health problem of epidemic proportions, with devastating consequences for youth and their families. Opioid overdose is a life-threatening emergency that should be treated with naloxone, and respiratory support if necessary. Overdose should always be an opportunity to initiate addiction treatment. Detoxification is often a necessary, but never sufficient, component of treatment for OUDs. Treatment for OUDs is effective but treatment capacity is alarmingly limited and under-developed. Emerging consensus supports the incorporation of relapse prevention medications such as buprenorphine and extended release naltrexone into comprehensive psychosocial treatment including counseling and family involvement.

Topics: Adolescent; Analgesics, Opioid; Buprenorphine; Drug Overdose; Humans; Naloxone; Naltrexone; Narcotic Antagonists; Opioid-Related Disorders

Topics: Acute Pain; Analgesics, Non-Narcotic; Analgesics, Opioid; Buprenorphine; Buprenorphine, Naloxone Drug Combination; Drug Overdose; Hospitalization; Humans; Methadone; Naloxone; Narcotic Antagonists; Opiate Substitution Treatment; Opioid-Related Disorders; Respiration, Artificial; Substance Withdrawal Syndrome

Topics: Drug Approval; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Narcotics; United States; United States Food and Drug Administration

Drug use can be defined as a kind of self destruction, and it is directly linked to attitudes toward death and suicide occurring in a significant number of users of different narcotics. The aim of the authors was to look for the background of this relationship between drug and death and examine the origin, development, and motives behind heroin overdose based on an analysis of previous studies. It seems clear that pure heroin overdose increased gradually over the years. The fear of the police is the inhibitory factor of the overdose prevention and notification of emergency health care service. Signs of suicide could be the own home as the chosen location for heroin overdose and the presence of partners ("moment of death companion"). Interventions should include simple techniques such as first aid, naloxone administration, resuscitation, prevention of relapse of prisoners and social network extension involving maintenance programs.. A droghasználatot önmagában is öndestrukciónak tekinthetjük, így közvetve kötődik a halállal kapcsolatos attitűdhöz, és jelentős számban fordul elő különböző, a narkotikumok által okozott suicidium a droghasználók körében. A tanulmány célja, hogy feltárja a drog–halál kapcsolat eredetét, hátterét, és azon belül a heroin okozta túladagolások okait a témával foglalkozó tanulmányok elemzésével, eredményeik összefoglalásával. A tiszta heroinos túladagolók életkora az évek folyamán fokozatosan nő. A rendőrségtől való félelem a túladagolás megelőzését és a mentők értesítését gátló tényező. Az öngyilkosság szándékosságára utaló jel lehet a saját otthon mint választott hely, vagy a társak jelenléte, ami a halál pillanatában biztosított társat jelentheti. (Azt, hogy nincsenek egyedül a túladagolás pillanatában.) Ezért a segítségnyújtás egyszerűbb technikáit kell bevezetni: elsősegélynyújtás, naloxonbeadás, újraélesztés, a börtönviseltek visszaesésének megelőzése, a szociális háló kiterjesztése, a fenntartó programokba való bevonás. Orv. Hetil., 2015, 156(9), 352–357.

Topics: Drug Overdose; Emergency Medical Services; Emergency Treatment; Europe; Fear; Friends; Heroin; Heroin Dependence; Humans; Naloxone; Narcotic Antagonists; Narcotics; Police; Prisoners; Resuscitation; Suicide, Attempted; United States

As physicians have increased opioid prescribing, overdose deaths from pharmaceutical opioids have substantially increased in the United States. Naloxone hydrochloride (naloxone), an opioid antagonist, is the standard of care for treatment of opioid induced respiratory depression. Since 1996, community-based programs have offered overdose prevention education and distributed naloxone for bystander administration to people who use opioids, particularly heroin. There is growing interest in translating overdose education and naloxone distribution (OEND) into conventional medical settings for patients who are prescribed pharmaceutical opioids. For this review, we summarized and classified existing publications on overdose education and naloxone distribution to identify evidence of effectiveness and opportunities for translation into conventional medical settings.. For this review, we searched English language PubMed for articles on naloxone based on primary data collection from humans, including feasibility studies, program evaluations, surveys, qualitative studies, and studies comparing the effectiveness of different routes of naloxone administration. We also included cost-effectiveness studies.. We identified 41 articles that represented 5 categories: evaluations of OEND programs, effects of OEND programs on experiences and attitudes of participants, willingness of medical providers to prescribe naloxone, comparisons of different routes of naloxone administration, and the cost-effectiveness of naloxone.. Existing research suggests that people who are at risk for overdose and other bystanders are willing and able to be trained to prevent overdoses and administer naloxone. Counseling patients about the risks of opioid overdose and prescribing naloxone is an emerging clinical practice that may reduce fatalities from overdose while enhancing the safe prescribing of opioids.

Topics: Analgesics, Opioid; Community Health Services; Drug Overdose; General Practice; Health Services Accessibility; Humans; Naloxone; Patient Education as Topic

Opioid overdose fatality has increased threefold since 1999. As a result, prescription drug overdose surpassed motor vehicle collision as the leading cause of unintentional injury-related death in the USA. Naloxone , an opioid antagonist that has been available for decades, can safely reverse opioid overdose if used promptly and correctly. However, clinicians often overestimate the dose of naloxone needed to achieve the desired clinical outcome, precipitating acute opioid withdrawal syndrome (OWS).. This article provides a comprehensive review of naloxone's pharmacologic properties and its clinical application to promote the safe use of naloxone in acute management of opioid intoxication and to mitigate the risk of precipitated OWS. Available clinical data on opioid-receptor kinetics that influence the reversal of opioid agonism by naloxone are discussed. Additionally, the legal and social barriers to take home naloxone programs are addressed.. Naloxone is an intrinsically safe drug, and may be administered in large doses with minimal clinical effect in non-opioid-dependent patients. However, when administered to opioid-dependent patients, naloxone can result in acute opioid withdrawal. Therefore, it is prudent to use low-dose naloxone (0.04 mg) with appropriate titration to reverse ventilatory depression in this population.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Treatment Outcome

The opioid overdose epidemic is a major threat to the public's health, resulting in the development and implementation of a variety of strategies to reduce fatal overdose. Many strategies are focused on primary prevention and increased access to effective treatment, although the past decade has seen an exponential increase in harm reduction initiatives. To maximize identification of opportunities for intervention, initiatives focusing on prevention, access to effective treatment, and harm reduction are examined independently, although considerable overlap exists. Particular attention is given to harm reduction approaches, as increased public and political will have facilitated widespread implementation of several initiatives, including increased distribution of naloxone and policy changes designed to increase bystander assistance during a witnessed overdose.

Topics: Drug Overdose; Evidence-Based Medicine; Harm Reduction; Humans; Incidence; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Risk Factors; Treatment Outcome

The epidemic of drug-related mortality continues to endure. The most common cause of death associated with drugs is overdose and opioids are consistently the substances most prominently involved. As well as efforts to control the availability of illicit drugs and increase engagement in treatment services, the use of naloxone for peer administration has increasingly been championed as a mechanism for addressing the DRD epidemic. Despite increasing adoption and use of take-home naloxone (THN) as a primary response to DRD internationally the evidence base remains limited.. A systematic review and descriptive meta-analysis of the international THN literature was undertaken to determine an effect size for THN programmes. For each study, a proportion of use (PoU) was calculated using the number of 'peer administered uses' and the 'total number of participant/clients' trained and supplied with naloxone with a specific focus on people who use drugs (PWUD). This was constrained to a three month period as the lowest common denominator. As a percentage this gives the three month rate of use (per 100 participants).. From twenty-five identified THN evaluations, nine studies allowed a PoU to be determined. Overall, the model shows a range of 5.2-13.1 (point estimate 9.2) naloxone uses every three months for every 100 PWUD trained.. Our model estimates that around 9% of naloxone kits distributed are likely to be used for peer administration within the first three months of supply for every 100 PWUD trained. Future evaluations should directly compare different training structures to test relative effectiveness and use a series of fixed time periods (3, 6 and 12 months) to determine whether time since training affects rate of naloxone use.

Topics: Drug Overdose; Harm Reduction; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Peer Group; Self Administration

Fatal opioid overdose in the United States is at epidemic levels. Naloxone, an effective opioid antidote, is commonly administered by advanced emergency medical services (EMS) personnel in the prehospital setting. While states are rapidly moving to increase access to naloxone for community bystanders, the EMS system remains the primary source for out-of-hospital naloxone access. Many communities have limited advanced EMS response capability and therefore may not have prehospital access to the medication indicated for opioid overdose reversal. The goal of this research was to determine the authority of different levels of EMS personnel to administer naloxone for the reversal of opioid overdose in the United States, Guam, and Puerto Rico.. The authors systematically reviewed the scope of practice of EMS personnel regarding administration of naloxone for the reversal of opioid overdose. All relevant laws, regulations, and policies from the 50 U. S. states, the District of Columbia, Guam, and Puerto Rico in effect in November 2013 were identified, reviewed, and coded to determine the authority of EMS personnel at four levels (in increasing order of training: emergency medical responders [EMRs], emergency medical technicians [EMTs], intermediate/advanced EMTs, and paramedics) to administer naloxone. Where available, protocols governing route and dose of administration were also identified and analyzed.. All 53 jurisdictions license or certify EMS personnel at the paramedic level, and all permit paramedics to administer naloxone. Of the 48 jurisdictions with intermediate-level EMS personnel, all but one authorized those personnel to administer naloxone as of November 2013. Twelve jurisdictions explicitly permitted EMTs and two permitted EMRs to administer naloxone. At least five jurisdictions modified law or policy to expand EMT access to naloxone in 2013. There is wide variation between states regarding EMS naloxone dosing protocol and route of administration.. Naloxone administration is standard for paramedic and intermediate-level EMS personnel, but most states do not allow basic life support (BLS) personnel to administer this medication. Standards consistent with available medical evidence for naloxone administration, dosing, and route of administration should be implemented at each EMS level of certification.

Topics: Certification; Drug Overdose; Emergency Medical Services; Female; Guam; Humans; Male; Naloxone; Narcotic Antagonists; Puerto Rico; United States

The pharmacology, pharmaco-kinetic properties, and clinical efficacy of naloxone injection administered intranasally for the reversal of opioid overdose are reviewed.. Naloxone is an opioid-receptor antagonist that is used in the treatment of opioid overdose to reverse the respiratory and central nervous system-depressant effects of the opioid. Naloxone injection is traditionally given by intravenous, intramuscular, and subcutaneous routes. Paramedics also administer naloxone injection intranasally in the prehospital setting to treat suspected opioid overdose. The nasal mucosa has a rich blood supply that allows for efficient drug absorption and the avoidance of first-pass hepatic metabolism that would be seen with oral administration. Obtaining vascular access can be difficult in known drug users, prolonging the time required to administer the antidote. Patients awakening from an overdose may be agitated, confused, and even combative, thus increasing the risk of needle-stick injury to first responders. The intranasal route avoids the need for establishing vascular access and can be associated with speedier patient recovery. In two randomized controlled trials, intranasal naloxone alone was shown to be sufficient for reversing opioid-induced respiratory depression in 74% and 72% of the respective study populations of patients experiencing opioid overdose. In addition, the safety profile of intranasal naloxone appears to be no different than that of naloxone injection in the treatment of opioid overdose in the prehospital setting.. Intranasal administration of naloxone appears to be effective in treatment of opioid overdose when i.v. administration is impossible or undesirable.

Topics: Administration, Intranasal; Drug Overdose; Emergency Medical Technicians; Humans; Injections, Intramuscular; Naloxone; Narcotic Antagonists; Narcotics; Needlestick Injuries; Occupational Injuries

Addiction to prescription opioids is prevalent in primary care settings. Increasing prescription opioid use is largely responsible for a parallel increase in overdose nationally. Many patients most at risk for addiction and overdose come into regular contact with primary care providers. Lack of routine addiction screening results in missed treatment opportunities in this setting. We reviewed the literature on screening and brief interventions for addictive disorders in primary care settings, focusing on opioid addiction. Screening and brief interventions can improve health outcomes for chronic illnesses including diabetes, hypertension, and asthma. Similarly, through the use of screening and brief interventions, patients with addiction can achieve improved health outcome. A spectrum of low-threshold care options can reduce the negative health consequences among individuals with opioid addiction. Screening in primary care coupled with short interventions, including motivational interviewing, syringe distribution, naloxone prescription for overdose prevention, and buprenorphine treatment are effective ways to manage addiction and its associated risks and improve health outcomes for individuals with opioid addiction.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Primary Health Care; Substance Abuse Detection

A shortcut review was carried out to establish whether nebulised naloxone is a safe and effective alternative to intravenous naloxone in patients with suspected opioid overdose. 18 papers were found using the reported searches, of which two presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. It is concluded that nebulised naloxone is a safe and effective firstline alternative to parenteral naloxone in spontaneously breathing patients with suspected opioid overdose.

Topics: Administration, Inhalation; Analgesics, Opioid; Drug Overdose; Evidence-Based Emergency Medicine; Humans; Naloxone; Narcotic Antagonists; Nebulizers and Vaporizers

Opiates such as morphine and fentanyl, a major class of analgesics used in the clinical management of pain, exert their effects through the activation of opioid receptors. Opioids are among the most commonly prescribed and frequently abused drugs in the USA; however, the prolonged use of opiates often leads to the development of tolerance and addiction. Although blockade of opioid receptors with antagonists such as naltrexone and naloxone can lessen addictive impulses and facilitate recovery from overdose, systemic disruption of endogenous opioid receptor signalling through the use of these antagonistic drugs can have severe side effects. In the light of these challenges, current efforts have focused on identifying new therapeutic targets that selectively and specifically modulate opioid receptor signalling and function so as to achieve analgesia without the adverse effects associated with chronic opiate use. We have previously reported that opioid receptors interact with each other to form heteromeric complexes and that these interactions affect morphine signalling. Since chronic morphine administration leads to an enhanced level of these heteromers, these opioid receptor heteromeric complexes represent novel therapeutic targets for the treatment of pain and opiate addiction. In this review, we discuss the role of heteromeric opioid receptor complexes with a focus on mu opioid receptor (MOR) and delta opioid receptor (DOR) heteromers. We also highlight the evidence for altered pharmacological properties of opioid ligands and changes in ligand function resulting from the heteromer formation.

Topics: Analgesia; Analgesics; Animals; Drug Antagonism; Drug Overdose; Humans; Morphine Dependence; Naloxone; Naltrexone; Narcotic Antagonists; Pain; Protein Multimerization; Protein Structure, Quaternary; Receptors, Opioid, delta; Receptors, Opioid, mu; Signal Transduction; United States

Topics: Analgesics, Opioid; Drug Overdose; Humans; Intubation, Intratracheal; Naloxone; Narcotic Antagonists

The diversion, misuse, and non-medically supervised use of buprenorphine and buprenorphine/naloxone by opioid users are reviewed. Buprenorphine and buprenorphine/naloxone are used globally as opioid analgesics and in the treatment of opioid dependency. Diversion of buprenorphine and buprenorphine/naloxone represents a complex medical and social issue, and has been widely documented in various geographical regions throughout the world. We first discuss the clinical properties of buprenorphine and its abuse potential. Second, we discuss its diversion and illicit use on an international level, as well as motivations for those activities. Third, we examine the medical risks and benefits of buprenorphine's non-medically supervised use and misuse. These risks and benefits include the effect of buprenorphine's use on HIV risk and the risk of its concomitant use with other medications and drugs of abuse. Finally, we discuss the implications of diversion, misuse, and non-medically supervised use (including potential measures to address issues of diversion); and potential areas for further research.

Topics: Buprenorphine; Drug Overdose; HIV Infections; Humans; Illicit Drugs; Motivation; Naloxone; Narcotic Antagonists; Narcotics; Opioid-Related Disorders; Risk-Taking

Topics: Drug Overdose; Evidence-Based Emergency Medicine; Heroin; Heroin Dependence; Humans; Male; Naloxone; Narcotic Antagonists; Narcotics; Self Administration

This paper reviews available literature regarding the effectiveness, safety and utility of intranasal (i.n.) naloxone for the treatment of heroin overdose.. Scientific literature in the form of published articles during the period January 1984 to August 2007 were identified by searching several databases including Medline, Cinahl and Embase for the following terms: naloxone, narcan, intranasal, nose. The data extracted included study design, patient selection, numbers, outcomes and adverse events.. Reports of the pharmacological investigation and administration of i.n. naloxone for heroin overdose are included in this review. Treatment of heroin overdose by administration of i.n. naloxone has been introduced as first-line treatment in some jurisdictions in North America, and is currently under investigation in Australia.. Currently there is not enough evidence to support i.n. naloxone as first-line intervention by paramedics for treatment of heroin overdose in the pre-hospital setting. Further research is required to confirm its clinical effectiveness, safety and utility. If proved effective, the i.n. route may be useful for drug administration in community settings (including peer-based administration), as it reduces risk of needlestick injury in a population at higher risk of blood-borne viruses. Problematically, naloxone is not manufactured currently in an ideal form for i.n. administration.

Topics: Administration, Intranasal; Drug Overdose; Emergencies; Heroin; Humans; Naloxone; Narcotic Antagonists

Topics: Drug Overdose; Emergency Service, Hospital; Heroin; Humans; Naloxone; Narcotic Antagonists; United Kingdom

Topics: Adult; Demography; Drug Overdose; Heroin; Heroin Dependence; Humans; Naloxone; Narcotic Antagonists; New England; Prevalence; Prisoners; Prisons; Risk Factors

A short cut review was carried out to establish whether intransasal naloxone is effective in suspected opiate overdose. 596 papers were screened, of which eight presented the best evidence to answer the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these best papers are tabulated. The clinical bottom line is that it is likely that intranasal Naloxone is a safe and effective first line prehospital intervention in reversing the effects of an Opioid overdose and helping to reduce the risk of needle stick injury. A large, well conducted trial into it's usage is however required to confirm this.

Topics: Administration, Intranasal; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Narcotics; Treatment Outcome

A short-cut review was carried out to establish whether naloxone may have an awakening effect in patients who have not taken opiates, thereby clouding its use as a diagnostic manoeuvre. The clinical bottom line is that opioid antagonists are able to reverse symptoms such as altered consciousness in patients who have not taken an overdose of opiates. It is unclear in which conditions or circumstances this occurs.

Topics: Adult; Diagnosis, Differential; Drug Overdose; Emergencies; Emergency Service, Hospital; Evidence-Based Medicine; Glasgow Coma Scale; Humans; Male; Naloxone; Narcotic Antagonists; Narcotics

Acute opioid intoxication and overdose are common causes of presentation to emergency departments. Although naloxone, a pure opioid antagonist, has been available for many years, there is still confusion over the appropriate dose and route of administration. This article looks at the reasons for this uncertainty and undertakes a literature review from which a treatment algorithm is presented.

Topics: Algorithms; Dose-Response Relationship, Drug; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Narcotics

This paper reviews the relevant literature related to the distribution of take-home naloxone.. A Medline search was conducted on articles published between January 1990 and June 2004 to identify scientific literature relevant to this subject. Those publications were reviewed, and from them other literature was identified and reviewed.. The prevalence, pathophysiology and circumstances of heroin overdose, and also bystander response are included in this review. Naloxone peer distribution has been instituted to varying degrees in the United States, Italy, Spain, Germany and the United Kingdom.. At this point the evidence supporting naloxone distribution is primarily anecdotal, although promising. Although the distribution of naloxone holds promise for further reducing heroin overdose mortality, problems remain. Naloxone alone may be insufficient in some cases to revive the victim, and cardiopulmonary resuscitation (CPR), especially rescue breathing, may also be needed. A second dose of naloxone might be necessary. Complications following resuscitation from overdose may infrequently need in-hospital care. Mortality from injecting without anyone else present will be unaffected by take-home naloxone. Take-home naloxone should be studied in a rigorous scientific manner.

Topics: Bystander Effect; Drug Overdose; Heroin Dependence; Humans; Naloxone; Narcotic Antagonists

Topics: Adult; Antidotes; Child; Coma; Dose-Response Relationship, Drug; Drug Administration Routes; Drug Overdose; Drug Therapy, Combination; Flumazenil; Glucose; Humans; Naloxone; Narcotic Antagonists; Oxygen; Poisoning; Suicide, Attempted; Thiamine

Topics: Analgesics, Opioid; Drug Overdose; Heroin; Heroin Dependence; Humans; Methadone; Naloxone; Narcotic Antagonists; Patient Education as Topic

The incidence of clonidine overdose is increasing, yet there is a paucity of new information regarding treatment options for clonidine toxicity. Reported treatment approaches vary widely, demonstrating the lack of science on which current treatment is based. Available research needs to be reassessed. Neurotransmitters, receptors, endogenous opioids, and baseline sympathetic tone determine the clinical response to clonidine as well as the potential response to drug therapy following clonidine overdose. This article reviews aspects of clonidine toxicity that need to be further investigated. Multicenter research trials will be required to evaluate new treatment options.

Topics: Adolescent; Adrenergic alpha-Agonists; Adult; Clonidine; Drug Overdose; Female; Humans; Hypertension; Infant; Male; Middle Aged; Naloxone; Narcotic Antagonists

We present a case of a mixed ingestion of valproic acid, gabapentin, mexilitine, and ethanol with central nervous system depression that was reversed by naloxone. This report represents the fourth case demonstrating the antidotal efficacy of naloxone in reversing central nervous system depression associated with acute valproic acid overdose. Increasing clinical experience will more fully elucidate indications for, and optimal dosing of, naloxone in valproic acid toxic states.

Topics: Adult; Anticonvulsants; Drug Overdose; Female; Humans; Naloxone; Narcotic Antagonists; Valproic Acid

Clinicians in the emergency department are often confronted with coma patients due to poisoning. A systematic general approach involving early consultation with a neurologist is of paramount importance. A high index of suspicion, a systematic first assessment already in the prehospital phase and early stabilisation of vital functions are the essential first steps. Specific antidotes like hypertonic glucose and thiamine are part of a "coma cocktail". The opiate antagonist naloxone should be used only when clinically indicated and in a titrated way. Flumazenil should only be used with caution and in restricted cases. Clinical neurological evaluation and technical investigations like CT-scan and laboratory tests should make part of a careful diagnostic plan. Toxicological tests deserve their place in the diagnostic work up of a coma patient with suspected poisoning. Knowledge of the possibilities of the toxicology lab and optimal communication with the clinical toxicologist is important for optimal patient care.

Topics: Accidental Falls; Alcohol-Induced Disorders, Nervous System; Alcoholic Intoxication; Antidotes; Brain Injuries; Coma; Diabetic Coma; Diagnosis, Differential; Diagnostic Tests, Routine; Drug Overdose; Emergencies; Ethanol; First Aid; Flumazenil; Glucagon; Glucose; Humans; Hypoglycemia; Hypoxia, Brain; Monitoring, Physiologic; Naloxone; Neurologic Examination; Stroke; Thiamine

Acute heroin overdose is a common daily experience in the urban and suburban United States and accounts for many preventable deaths. Heroin acts as a pro-drug that allows rapid and complete central nervous system absorption; this accounts for the drug's euphoric and toxic effects. The heroin overdose syndrome (sensitivity for diagnosing heroin overdose, 92%; specificity, 76%) consists of abnormal mental status, substantially decreased respiration, and miotic pupils. The response of naloxone does not improve the sensitivity of this diagnosis. Most overdoses occur at home in the company of others and are more common in the setting of other drugs. Heroin-related deaths are strongly associated with use of alcohol or other drugs. Patients with clinically significant respiratory compromise need treatment, which includes airway management and intravenous or subcutaneous naloxone. Hospital observation for several hours is necessary for recurrence of hypoventilation or other complications. About 3% to 7% of treated patients require hospital admission for pneumonia, noncardiogenic pulmonary edema, or other complications. Methadone maintenance is an effective preventive measure, and others strategies should be studied.

Topics: Drug Overdose; Heroin; Heroin Dependence; Humans; Naloxone; Narcotic Antagonists; United States

Topics: Clinical Trials as Topic; Drug Overdose; Half-Life; Humans; Naloxone; Naltrexone; Narcotic Antagonists; Narcotics

Overdose deaths are a major contributor to excess mortality among heroin users. It has been proposed that opioid overdose morbidity and mortality could be reduced substantially by distributing the opioid antagonist naloxone to heroin users. The ethical issues raised by this proposal are evaluated from a utilitarian perspective. The potential advantages of naloxone distribution include the increased chance of comatose opioid users being quickly resuscitated by others present at the time of an overdose, naloxone's safety and its lack of abuse potential. The main problems raised by the proposal are: the medico-legal complications of medical practitioners prescribing a drug that is most likely to be administered to and by people other than the one for whom it is prescribed; the economic costs of distributing naloxone sufficiently widely to have an impact on overdose morbidity and mortality; and the potentially greater cost-effectiveness of simpler educational interventions. Given the possible benefits of naloxone distribution, it may be worthwhile considering a controlled trial of naloxone distribution to high-risk heroin users.

Topics: Decision Making; Drug Costs; Drug Overdose; Heroin; Heroin Dependence; Humans; Naloxone; Narcotic Antagonists

Opioids and benzodiazepines are two of the most common exposures that cause depressed mental status in children. Establishing a diagnosis of these intoxications may be difficult and is complicated by drugs from these two classes that are not detectable by routine toxicologic screening techniques. Naloxone and flumazenil can be used as diagnostic as well as therapeutic medications in these ingestions. We present a brief review of the mechanism of action, administration recommendations, and adverse effects of naloxone and flumazenil. Although the empiric use of naloxone and flumazenil in the comatose adult patient who presents to the emergency department is being reexamined, many of the concerns do not apply to children. There is still an important role for empiric administration of both naloxone and flumazenil.

Topics: Adolescent; Antidotes; Benzodiazepines; Child; Child, Preschool; Coma; Drug Overdose; Flumazenil; Humans; Infant; Infant, Newborn; Naloxone; Narcotics

Opiate intoxication accounts for the majority of emergencies related to substance abuse. The concomitant intravenous and intramuscular administration of the specific narcotic antagonist naloxone is warranted in such cases. Further threatening complications of opiate abuse include rhabdomyolysis, noncardiogenic pulmonary edema, and both peripheral and central nervous lesions. Opiate abuse is often associated with benzodiazepine abuse. Hence, intravenous administration of the antagonist flumazenil is indicated in patients with suspected acute opiate intoxication resistant to naloxone. Cocaine abuse is not frequent in this country but is usually very severe and clinically heterogeneous. The clinical pattern of cocaine intoxication is initially due to excitatory and later to depressant effects on central nervous, circulatory and respiratory systems. The treatment of acute cocaine intoxication is symptomatic. The internal concealment of cocaine and other drugs in packets (body-packing) may lead to bowel obstruction or to acute intoxication following leaking or breaking of packets.

Topics: Acute Disease; Cocaine; Combined Modality Therapy; Critical Care; Drug Overdose; Flumazenil; Humans; Naloxone; Opioid-Related Disorders

Dextromethorphan, a common ingredient in cough syrups, has rarely been described to cause toxicity. The authors describe an unusual case of a known asthmatic presenting with somnolence, who appeared to be in end-stage respiratory failure. Her partial response to routine naloxone, 1 mg, was surprising. However, additional naloxone was required to completely normalize the patient's mental status. The authors suggest naloxone be administered in doses of 0.4 mg or more intravenously in suspected dextromethorphan overdose.

Topics: Adolescent; Adult; Antidotes; Antitussive Agents; Child, Preschool; Dextromethorphan; Drug Overdose; Female; Humans; Infant; Male; Naloxone; Poisoning

Despite the demonstrated value of opioid overdose education and naloxone distribution (OEND) programs, uptake and utilization remains low. Accessibility to OEND is limited and traditional programs may not reach many high-risk individuals. This study evaluated the effectiveness of online opioid overdose and naloxone administration education and the impact of naloxone possession.. Individuals with self-reported illicit use of opioids were recruited via Craigslist advertisements and completed all assessments and education online via REDCap. Participants watched a 20-minute video outlining signs of opioid overdose and how to administer naloxone. They were then randomized to either receive a naloxone kit or be given instructions on where to obtain a kit. Effectiveness of training was measured with pre- and post-training knowledge questionnaires. Naloxone kit possession, overdoses, opioid use frequency, and treatment interest were self-reported on monthly follow-up assessments.. Mean knowledge scores significantly increased from 6.82/9.00 to 8.22 after training (t(194)=6.85, p <0.001, 95% CI[1.00, 1.81], Cohen's d=0.85). Difference in naloxone possession between randomized groups was significant with a large effect size (p <0.001, diff=0.60, 95% CI[0.47, 0.73]). A bidirectional relationship was found between naloxone possession and frequency of opioid use. Overdoses and treatment interest were similar across possession status.. Overdose education is effective in online video format. Disparity in naloxone possession across groups indicates barriers to obtaining naloxone from pharmacies. Naloxone possession did not influence risky opioid use or treatment interest and its impact on frequency of use warrants further investigation.. Clinitaltrials.gov-NCT04303000.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders

More than half a million Americans died of an opioid-related overdose between 1999 and 2020, the majority occurring between 2015 and 2020. The opioid overdose mortality epidemic disproportionately impacts Black, Indigenous, and people of color (BIPOC): since 2015, overdose mortality rates have increased substantially more among Black (114%) and Latinx (97%) populations compared with White populations (32%). This is in part due to disparities in access to naloxone, an opioid antagonist that can effectively reverse opioid overdose to prevent death. Our recent pilot work determined that many barriers to naloxone access can be identified and addressed by syringe service programs (SSPs) using the Systems Analysis and Improvement Approach to Naloxone distribution (SAIA-Naloxone). This randomized controlled trial will test SAIA-Naloxone's ability to improve naloxone distribution in general and among BIPOC specifically.. We will conduct a trial with 32 SSPs across California, randomly assigning 16 to the SAIA-Naloxone arm and 16 to receive implementation as usual. SAIA-Naloxone is a multifaceted, multilevel implementation strategy through which trained facilitators work closely with SSPs to (1) assess organization-level barriers, (2) prioritize barriers for improvement, and (3) test solutions through iterative change cycles until achieving and sustaining improvements. SSPs receiving SAIA-Naloxone will work with a trained facilitator for a period of 12 months. We will test SAIA-Naloxone's ability to improve SSPs' naloxone distribution using an interrupted time series approach. Data collection will take place during a 3-month lead-in period, the 12-month active period, and for an additional 6 months afterward to determine whether impacts are sustained. We will use a structured approach to specify SAIA-Naloxone to ensure strategy activities are clearly defined and to assess SAIA-Naloxone fidelity to aid in interpreting study results. We will also assess the costs associated with SAIA-Naloxone and its cost-effectiveness.. This trial takes a novel approach to improving equitable distribution of naloxone amid the ongoing epidemic and associated racial disparities. If successful, SAIA-Naloxone represents an important organizational-level solution to the multifaceted and multilevel barriers to equitable naloxone distribution.

Topics: Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Randomized Controlled Trials as Topic; Systems Analysis

Worldwide, opioid use causes more than 100,000 overdose deaths annually. Naloxone has proven efficacy in reversing opioid overdoses and is approved as an emergency antidote to opioid overdose. Take home naloxone (THN) programmes have been introduced to provide 'community members', who are likely to observe opioid overdoses, with naloxone kits and train them to recognise an overdose and administer naloxone. The acceptability and feasibility of THN programmes has been demonstrated, but the real-life effectiveness of naloxone administration by community members is not known. In recent years, the approval of several concentrated naloxone nasal-spray formulations (in addition to injectable formulations, eg.prenoxad) potentially increases acceptability and scope for wider provision. This study aims to determine the effectiveness of THN (all formulations) in real-world conditions.. A European, multi-country, prospective cohort study, to assess the use of THN by community members to reverse opioid overdoses in a six-month, follow-up period. Participants provided with THN from participating harm reduction and drug treatment sites will be recruited to the study and followed-up for six months. We are particularly interested in the experiences of community members who have been provided with THN and have witnessed an opioid overdose. All participants who witness an opioid overdose during the six-month period (target approx. 600) will be asked to take part in a structured interview about this event. Of these, 60 will be invited to participate in a qualitative interview. A Post Authorisation Efficacy Study (PAES) for the concentrated nasal naloxone, Nyxoid, has been integrated into the study design.. There are many challenges involved in evaluating the real-life effectiveness of THN. It is not possible to use a randomised trial design, recruitment of community members provided with THN will depend upon recruitment sites distributing THN kits, and the type of THN received by participants will depend on regulations and on local clinical and policy decision-makers. Following up this population, some of whom may be itinerant, over the 6-month study period will be challenging, but we plan to maintain contact with participants through regular text message reminders and staff contact.. ClinicalTrials.gov Identifier: NCT05072249. Date of Registration: 8.10.2021.

Topics: Cohort Studies; Drug Overdose; Humans; Naloxone; Opiate Overdose; Prospective Studies; Randomized Controlled Trials as Topic

Emergency responders face challenges in arriving timely to administer naloxone in opioid overdoses. Therefore, interest in having lay citizens administer naloxone nasal spray has emerged. These citizens, however, must be recruited and trained, and be in proximity to the overdose. This study aimed to develop the Opioid Rapid Response System (ORRS)

Topics: Adolescent; Adult; Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders

Overdoses have surged in rural areas in the U.S. and globally for years, but harm reduction interventions have lagged. Overdose education and naloxone distribution (OEND) programs reduce overdose mortality, but little is known about people who use drugs' (PWUD) experience with these interventions in rural areas. Here, we analyze qualitative data with rural PWUD to learn about participants' experiences with an OEND intervention, and about how participants' perceptions of their rural risk environments influenced the interventions' effects.. Twenty-nine one-on-one, semi-structured qualitative interviews were conducted with rural PWUD engaged in the CARE2HOPE OEND intervention in Appalachian Kentucky. Interviews were conducted via Zoom, audio-recorded, and transcribed verbatim. Thematic analysis was conducted, guided by the Rural Risk Environment Framework.. Participants' naloxone experiences were shaped by all domains of their rural risk environments. The OEND intervention transformed participants' roles locally, so they became an essential component of the local rural healthcare environment. The intervention provided access to naloxone and information, thereby increasing PWUDs' confidence in naloxone administration. Through the intervention, over half of participants gained knowledge on naloxone (access points, administration technique) and on the criminal-legal environment as it pertained to naloxone. Most participants opted to accept and carry naloxone, citing factors related to the social environment (responsibility to their community) and physical/healthcare environments (overdose prevalence, suboptimal emergency response systems). Over half of participants described recent experiences administering intervention-provided naloxone. These experiences were shaped by features of the local rural social environment (anticipated negative reaction from recipients, prior naloxone conversations).. By providing naloxone paired with non-stigmatizing health and policy information, the OEND intervention offered support that allowed participants to become a part of the healthcare environment. Findings highlight need for more OEND interventions; outreach to rural PWUD on local policy that impacts them; tailored strategies to help rural PWUD engage in productive dialogue with peers about naloxone and navigate interpersonal conflict associated with overdose reversal; and opportunities for rural PWUD to formally participate in emergency response systems as peer overdose responders. Trial registration The ClinicalTrials.gov ID for the CARE2HOPE intervention is NCT04134767. The registration date was October 19th, 2019.

Topics: Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Social Environment

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

In light of the accelerating drug overdose epidemic in North America, new strategies are needed to identify communities most at risk to prioritize geographically the existing public health resources (e.g. street outreach, naloxone distribution efforts). We aimed to develop PROVIDENT (Preventing Overdose using Information and Data from the Environment), a machine learning-based forecasting tool to predict future overdose deaths at the census block group (i.e. neighbourhood) level.. Randomized, population-based, community intervention trial.. Rhode Island, USA.. All people who reside in Rhode Island during the study period may contribute data to either the model or the trial outcomes.. Each of the state's 39 municipalities will be randomized to the intervention (PROVIDENT) or comparator condition. An interactive, web-based tool will be developed to visualize the PROVIDENT model predictions. Municipalities assigned to the treatment arm will receive neighbourhood risk predictions from the PROVIDENT model, and state agencies and community-based organizations will direct resources to neighbourhoods identified as high risk. Municipalities assigned to the control arm will continue to receive surveillance information and overdose prevention resources, but they will not receive neighbourhood risk predictions.. The primary outcome is the municipal-level rate of fatal and non-fatal drug overdoses. Fatal overdoses will be defined as unintentional drug-related death; non-fatal overdoses will be defined as an emergency department visit for a suspected overdose reported through the state's syndromic surveillance system. Intervention efficacy will be assessed using Poisson or negative binomial regression to estimate incidence rate ratios comparing fatal and non-fatal overdose rates in treatment vs. control municipalities.. The findings will inform the utility of predictive modelling as a tool to improve public health decision-making and inform resource allocation to communities that should be prioritized for prevention, treatment, recovery and overdose rescue services.

Topics: Analgesics, Opioid; Drug Overdose; Emergency Service, Hospital; Humans; Naloxone; Randomized Controlled Trials as Topic; Rhode Island

To determine whether first responders delivering naloxone by either the IM or intranasal (IN) route were at risk of contamination with inert powder simulating canine opioid exposure.. Prospective, crossover design.. Research study (university setting).. Ten clinically normal working dogs ranging from 9 to 44 months were enrolled based on training to detect odor and ability to be restrained with minimal stress. All enrolled dogs completed both arms of the study without adverse effects.. Dogs were randomly assigned to fentanyl reversal with either IM or IN naloxone and then the alternate treatment after a 7-day washout period. Prior to reversal, dogs' heads were brushed with an inert glow-in-the-dark powder. First responders (the same 2 individuals for all dogs) performing the reversal were photographed under ultraviolet light prior to and 5 min after administering the medication. Digital photographs were scored by body region for presence of glowing powder by observers blinded to timing of photograph (pre- or postreversal) and route of reversal (IM vs IN).. Compared to pretreatment, the inert powder scores were higher after treatment regardless of route of naloxone administration (P < 0.001). IN administration led to higher contamination than IM naloxone, particularly in the chest area (P = 0.012).. Both IN and IM naloxone administration to dogs with clinical signs of opioid exposure result in a risk of first responders becoming contaminated with powder, which could include opioids. Awareness, proper personal protective equipment, and appropriate posttreatment decontamination are important to reduce risk of inadvertent exposure of mucous membranes to these contaminating powders.

Topics: Analgesics, Opioid; Animals; Dog Diseases; Dogs; Drug Overdose; Emergency Responders; Humans; Naloxone; Narcotic Antagonists; Powders; Prospective Studies

Although naloxone prevents opioid overdose deaths, few patients prescribed opioids receive naloxone, limiting its effectiveness in real-world settings. Barriers to naloxone prescribing include concerns that naloxone could increase risk behavior and limited time to provide necessary patient education.. To determine whether pharmacy-based naloxone co-dispensing affected opioid risk behavior. Secondary objectives were to assess if co-dispensing increased naloxone acquisition, increased patient knowledge about naloxone administration, and affected opioid dose and other substance use.. Cluster randomized pragmatic trial of naloxone co-dispensing.. Safety-net health system in Denver, Colorado, between 2017 and 2020.. Seven pharmacies were randomized. Pharmacy patients (N=768) receiving opioids were followed using automated data for 10 months. Pharmacy patients were also invited to complete surveys at baseline, 4 months, and 8 months; 325 survey participants were enrolled from November 15, 2017, to January 8, 2019.. Intervention pharmacies implemented workflows to co-dispense naloxone while usual care pharmacies provided usual services.. Survey instruments assessed opioid risk behavior; hazardous drinking; tobacco, cannabis, and other drug use; and knowledge. Naloxone dispensings and opioid dose were evaluated using pharmacy data among pharmacy patients and survey participants. Intention-to-treat analyses were conducted using generalized linear mixed models accounting for clustering at the pharmacy level.. Opioid risk behavior did not differ by trial group (P=0.52; 8-month vs. baseline adjusted risk ratio [ARR] 1.07; 95% CI 0.78, 1.47). Compared with usual care pharmacies, naloxone dispensings were higher in intervention pharmacies (ARR 3.38; 95% CI 2.21, 5.15) and participant knowledge increased (P=0.02; 8-month vs. baseline adjusted mean difference 1.05; 95% CI 0.06, 2.04). There was no difference in other substance use by the trial group.. Co-dispensing naloxone with opioids effectively increased naloxone receipt and knowledge but did not increase self-reported risk behavior.. Registered at ClinicalTrials.gov ; Identifier: NCT03337100.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pharmacies; Pharmacists

To measure and evaluate clinical response to nasal naloxone in opioid overdoses in the pre-hospital environment.. Randomised, controlled, double-dummy, blinded, non-inferiority trial, and conducted at two centres.. Participants were included by ambulance staff in Oslo and Trondheim, Norway, and treated at the place where the overdose occurred.. Men and women age above 18 years with miosis, rate of respiration ≤8/min, and Glasgow Coma Score <12/15 were included. Informed consent was obtained through a deferred-consent procedure.. A commercially available 1.4 mg/0.1 mL intranasal naloxone was compared with 0.8 mg/2 mL naloxone administered intramuscularly.. The primary end-point was restoration of spontaneous respiration of ≥10 breaths/min within 10 minutes. Secondary outcomes included time to restoration of spontaneous respiration, recurrence of overdose within 12 hours and adverse events.. In total, 201 participants were analysed in the per-protocol population. Heroin was suspected in 196 cases. With 82% of the participants being men, 105 (97.2%) in the intramuscular group and 74 (79.6%) in the intranasal group returned to adequate spontaneous respiration within 10 minutes after one dose. The estimated risk difference was 17.5% (95% CI, 8.9%-26.1%) in favour of the intramuscular group. The risk of receiving additional naloxone was 19.4% (95% CI, 9.0%-29.7%) higher in the intranasal group. Adverse reactions were evenly distributed, except for drug withdrawal reactions, where the estimated risk difference was 6.8% (95% CI, 0.2%-13%) in favour of the intranasal group in a post hoc analysis.. Intranasal naloxone (1.4 mg/0.1 mL) was less efficient than 0.8 mg intramuscular naloxone for return to spontaneous breathing within 10 minutes in overdose patients in the pre-hospital environment when compared head-to-head. Intranasal naloxone at 1.4 mg/0.1 mL restored breathing in 80% of participants after one dose and had few mild adverse reactions.

Topics: Administration, Intranasal; Adolescent; Ambulances; Drug Overdose; Female; Humans; Male; Naloxone; Narcotic Antagonists; Opiate Overdose

Access to the opioid antidote naloxone is a critical component of addressing the opioid crisis. Naloxone is a population-level prevention intervention associated with substantial reductions in overdose mortality and reduction of nonfatal overdose. Pharmacies' pivotal role in dispensing medications like buprenorphine for the treatment of opioid use disorder and selling nonprescription syringes places them at the crossroads of opioid access and risk mitigation methods like naloxone provision. Testing ways to optimize pharmacy-based naloxone provision will be key as the country expands the implementation of naloxone through the medical system. In the Respond to Prevent Study, we conducted a large, practical study of a pharmacy-focused intervention in a sample of Washington, Oregon, Massachusetts and New Hampshire community chain pharmacies to increase naloxone dispensing and improve opioid safety. The intervention integrated two evidence-based educational toolkits and streamlined materials to enhance the focus on naloxone policy, stigma reduction, and patient communications around naloxone, nonprescription syringes and buprenorphine access. The real-world study implemented a stepped wedge, clustered randomized trial design across 175 community chain pharmacies to evaluate the effectiveness of the Respond to Prevent intervention in increasing: (a) pharmacy based naloxone distribution rates, naloxone-related patient engagement, and pharmacist and technicians' attitudes, knowledge, perceived behavioral control and self-efficacy toward naloxone; and (b) pharmacy nonprescription syringe sales, and pharmacist and technicians' attitudes, knowledge, perceived behavioral control and self-efficacy toward dispensing buprenorphine for opioid use disorder (secondary outcomes). This commentary provides a brief narrative about the study and presents insights on the design and adaptations to our study protocol, including those adopted during the unprecedented COVID-19 pandemic further compounded by Western wildfires in 2020.

Topics: Buprenorphine; Buprenorphine, Naloxone Drug Combination; COVID-19; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pandemics; Pharmacies; Pharmacists; Randomized Controlled Trials as Topic; SARS-CoV-2; Syringes

Opioid overdoses require a rapid response, but emergency responders are limited in how quickly they can arrive at the scene for administering naloxone. If laypersons are trained to administer naloxone and are notified of overdoses, more lives can be saved.. This study aimed to examine the feasibility of the Opioid Rapid Response System (ORRS) that recruits, trains, and links citizen responders to overdose events in their community in real-time to administer naloxone. Aim of this paper is to present the protocols for recruiting participants through multiple communication channels; developing and evaluating the online training which has both interactive and asynchronous modules; randomly assigning laypersons to either online naloxone training or waitlist control group; measuring participants' knowledge, skills, and attitudes before and after the training; and distributing intranasal naloxone kits to participants for use in events of overdose in their community.. Sampling: Utilizing a combination of purposive sampling methods, laypersons from across five Indiana counties who did not self-identify as current first responders were invited to participate.. In this two-arm randomized waitlist-controlled study (N = 220), individuals were assigned into either online training or waitlist control that received the training two weeks later.. A linear mixed model will be used for determining the changes in targeted outcomes in the training group and accommodate for fixed and random effects.. While ORRS can become a community-engaged, cost-effective model for technology-based emergency response for opioid overdoses, study protocols can be useful for other emergency response programs that involve laypersons.. gov Registration Number: NCT04589676.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Randomized Controlled Trials as Topic

To examine the pharmacokinetics and safety of FMXIN001, a new intranasal powder-based naloxone formulation, in comparison to Narcan® nasal liquid spray.. FMXIN001, was developed by blending drug microspheres with larger lactose monohydrate particles, that serve as diluent and carrier, as well as a disaggregating agent. Scanning electron microscopy and X-ray were used to characterize the formulation and in vitro deposition was investigated using a nasal cast. We compared the pharmacokinetics and safety of FMXIN001 versus Narcan® in two clinical trials: a pilot study with 14 healthy adults and a pivotal trial in 42 healthy adults (NCT04713709). The studies were open-label, single-dose, randomized, two-period, two-treatment, two-sequence crossover studies to assess the pharmacokinetics and safety of FMXIN001 versus Narcan® nasal spray.. FMXIN001 comprises naloxone microspheres (5-30 μM) and lactose particles (40-240 μM). Upon in vitro testing, naloxone deposits mainly to the middle turbinates region and the upper part of the nasal cavity of a nasal cast. In human subjects, FMXIN001 produced significantly higher exposure at the initial time points of 4, 10, and 30 min, post-administration, compared to Narcan®. Both treatments were safe and well tolerated. FMXIN001, powder-based spray, results in similar overall exposure to Narcan®, but with more rapid absorption in the first 30 min.. FMXIN001 is expected to have a shorter onset of action for a more effective therapeutic intervention to manage opioid overdose. Rapid administration of naloxone in cases of opioid overdose is imperative, given the alarming increase in mortality rates.

Topics: Administration, Intranasal; Adult; Drug Overdose; Humans; Lactose; Naloxone; Narcotic Antagonists; Nasal Sprays; Opiate Overdose; Pilot Projects; Powders

The opioid epidemic in the United States continues to surge, reaching record deaths from opioid and fentanyl overdoses in 2020. This study analyzes spatial and neighborhood correlates of free naloxone distribution sites as well as overdose and naloxone reversal events in Baltimore, Maryland, which has one of the highest overdose rates in the country.. Using data from a randomized clinical trial on HIV prevention among people using substances in Baltimore, Maryland, as well as demographic data from the US Census Bureau, we conducted: (1) exploratory spatial visualizations of census tracts' minimum distance to naloxone distribution sites, (2) univariable Wilcoxon rank-sum tests to compare census tracts on demographic metrics, and (3) bivariable and multivariable negative binomial regression models to assess associations between census tract characteristics and naloxone reversal events.. Valid geographic data were provided for 518 overdose events involving either fentanyl or heroin in this study. Of these, 190 (37%) attempted naloxone reversal events were reported. Exploratory spatial visualization techniques suggest that most distribution sites are appropriately located near populations at high risk of overdose, but study findings also identify areas where drug use and overdoses occur that are located farther from distribution sites. In multivariable analyses, naloxone administration was significantly and inversely associated with distance to the nearest distribution site (incidence rate ratio (IRR)=0.72 per 1000m increase, 95% CI 0.59-0.89, p=0.002).. Study findings emphasize the correlation between proximity to naloxone sites and utilization of resources, highlighting that physical proximity to harm reduction resources may contribute to uptake. Results further underscore that research on service accessibility and utilization must consider the spatial distribution of health services.

Topics: Analgesics, Opioid; Drug Overdose; Fentanyl; Heroin; Humans; Naloxone; Narcotic Antagonists; United States

Overdose education and naloxone distribution (OEND) trains people who use opioids (PWUO) in how to intervene in cases of opioid overdose but best practices have not been assessed empirically.. PWUO along with a significant other (SO) were randomized to one of three training conditions. In the Treatment-as-Usual (TAU) condition, participants were randomized to receive minimal overdose-related education. In the extended training (ET) condition, PWUO received an extended training, while their SO received no overdose training. In the final condition, both the participant and SO received the extended overdose training (ETwSO). Outcome measures were naloxone use and overdose knowledge and competency assessed immediately before and after training, and at 1-, 3-, 6-, and 12-month timepoints following training.. Three hundred and twenty-one PWUO (w/ a SO) were randomized. All intensities of OD training were associated with sustained increases in OD knowledge/ competency (versus pre-training baseline p's < 0.01). PWUO intervened in 166 ODs. The 12-month incidence of naloxone use did not significantly differ between groups. Extended training (ET + ETwSO) compared to TAU resulted in significantly greater naloxone utilization by: 30 days (10.1% vs 4.1%, p = 0.041), 60 days (16.4% vs 5.2%, p<0.001) and 90 days (17.9% vs 9.5%, p = 0.039).. All intensities of OD training were associated with sustained increases in OD knowledge and competency, and equivalent rates of successful naloxone use. More extensive training increased naloxone utilization during the first 3 months. However, the benefits of more comprehensive training should be balanced against feasibility.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders

Despite the authority to dispense naloxone, pharmacists have been reluctant to offer and dispense it, often due to discomfort communicating about the sensitive topic of opioid overdose. Because existing online naloxone trainings do not sufficiently address how to communicate effectively with patients about naloxone, Nalox-Comm, a training module designed to improve pharmacists' self-efficacy to engage in naloxone discussions, was developed.. To describe the study protocol to evaluate the effectiveness of the Nalox-Comm training module on naloxone dispensing rates.. A randomized controlled trial, which began in July 2021, is used to evaluate the pre-post Nalox-Comm training intervention. Sixty pharmacists are being recruited from 62 pharmacies part of a single grocery store chain in rural counties of the southeastern United States. After completing a baseline survey, pharmacists are observed by simulated patients (SPs) who rate the quality of their pre-training naloxone communication. Pharmacists are then invited to complete either a basic online naloxone training module (control group) or a newly developed Nalox-Comm training (experimental group), after which they complete a post-training survey and are observed a second time by SPs. Three months post-training, study participants complete a final follow-up survey. Naloxone dispensing records are obtained from each participating pharmacy to assess change in naloxone dispensing rates.. Informed by rural pharmacist stakeholders, the Nalox-Comm training module addresses communication barriers specific to rural communities. Compared to those in the control group, we hypothesize that pharmacies in the experimental group will dispense more naloxone in the three months post-training intervention.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid Epidemic; Pharmacies; Randomized Controlled Trials as Topic

Take-home naloxone (THN) kits have been designed to provide community members (including people who use drugs, their families and/or significant others) with the necessary resources to address out-of-hospital opioid overdose events. Kits typically include two doses of naloxone. This 'twin-pack' format means that lay responders need information on how to use each dose. Advice given tends to be based on dosage algorithms used by medical personnel. However, little is currently known about how and why people who use drugs, acting as lay responders, decide to administer the second dose contained within single THN kits. The aim of this article is to explore this issue.. Data were generated from a qualitative semi-structured interview study that was embedded within a randomised controlled trial examining the risks and benefits of Overdose Education and Naloxone Distribution (OEND) training in New York City (NYC). Analysis for this article focuses upon the experiences of 22 people who use(d) opioids and who provided repeat naloxone administrations (RNA) during 24 separate overdose events. The framework method of analysis was used to compare the time participants believed had passed between each naloxone dose administered ('subjective response interval') with the 'recommended response interval' (2-4 minutes) given during OEND training. Framework analysis also charted the various reasons and rationale for providing RNA during overdose interventions.. When participants' subjective response intervals were compared with the recommended response interval for naloxone dosing, three different time periods were reported for the 24 overdose events: i. 'two doses administered in under 2 minutes' (n = 10); ii. 'two doses administered within 2-4 minutes' (n = 7), and iii. 'two doses administered more than 4 minutes apart' (n = 7). A variety of reasons were identified for providing RNA within each of the three categories of response interval. Collectively, reasons for RNA included panic, recognition of urgency, delays in retrieving naloxone kit, perceptions of recipients' responsiveness/non-responsiveness to naloxone, and avoidance of Emergency Response Teams (ERT).. Findings suggest that decision-making processes by people who use opioids regarding how and when to provide RNA are influenced by factors that relate to the emergency event. In addition, the majority of RNA (17/24) occurred outside of the recommended response interval taught during OEND training. These findings are discussed in terms of evidence-based intervention and 'evidence-making intervention' with suggestions for how RNA guidance may be developed and included within future/existing models of OEND training.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; New York City; Opiate Overdose; Opioid-Related Disorders

Little is known about trends in overdose behaviors. This study explored non-fatal overdose and engagement in overdose prevention behaviors and compared these trends to city-wide overdose fatality rates from 2017 to 2019 in Baltimore, MD.. The analysis included people who used opioids (PWUO; N = 502) recruited through a community-based study. Enrollment date was used to categorize participants into annual quarters. Logistic regression models examined change in overdose experiences and prevention behaviors with time. Baltimore's fatal overdoses were also mapped over the study period to assess overlaps in trends.. The majority of the sample were male(68 %), Black(61 %), reported past 6 months homelessness(56 %), and were on average 45 years old. Most had witnessed(61 %), and 28 % had personally experienced an overdose in the past 6 months. Witnessing overdose marginally increased(aβ = 0.182;p = 0.058) while experiencing overdose did not significantly change by enrollment quarter. Most participants had or had been prescribed naloxone(72 %), and one fifth(22 %) regularly carried naloxone, with both access to(aβ = 0,408;p = 0.002) and carrying naloxone(aβ = 0.302;p = 0.006) increasing over time. Overdose communication remained stable, with 63 % of participants reporting discussing overdose sometimes/often. Among participants who injected (n = 376), regularly injecting alone decreased(aβ=-0.207;p = 0.055), and reporting others often/always having naloxone with them when injecting increased over time(aβ = 0.573;p < 0.001).. Witnessed overdose marginally increased from 2017 to 2019, aligning with city trends of fatal overdose. Overdose prevention behaviors significantly increased over time. Despite reporting having naloxone or a naloxone prescription, most PWUO did not regularly carry naloxone, and many used alone. Social network diffusion interventions may be a strategy to promote normative overdose prevention behaviors.

Topics: Adult; Analgesics, Opioid; Baltimore; Drug Overdose; Female; Humans; Ill-Housed Persons; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Young Adult

This study looked at the fill rate of naloxone prescriptions, after the implementation of an opioid overdose and naloxone education intervention for adult patients in the emergency department (ED). The study compared fill rates between recipients who received this education by video versus written format.. This was a prospective, randomized controlled study of patients seen in the adult ED for opioid-related complaints between August 1, 2017, and December 1, 2018. The study randomized patients to education through video or written pamphlet, and all patients received a prescription for a free naloxone kit redeemable at the discharge pharmacy. The study calculated and compared naloxone prescription fill rates for the respective education methods.. Of the 770 patients reviewed for recruitment, the study excluded 703. Of the 67 patients enrolled, 59 were contacted at follow-up and eighteen (30.5%) had filled a naloxone prescription. Thirty-three percent (13/39) of patients who received video education and 25% (5/20) who received written pamphlet education filled naloxone prescriptions. The p-value of the chi-square for this data was 0.53.. There is a large population affected by opioid overdose both nationally and locally in Arizona. Opioid overdose and naloxone distribution education for ED patients through both video and pamphlet is feasible but requires more research to determine which education method is superior. Legislative changes, improved identification of patients at high risk for opioid overdose, opiate education for medical providers, and naloxone availability from multiple venues are needed to create a holistic approach to improve naloxone access to those who need it most.

Topics: Adult; Analgesics, Opioid; Drug Overdose; Emergency Service, Hospital; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pamphlets; Prescriptions; Prospective Studies

Access to naloxone is a priority for reducing opioid deaths. Although community members who complete naloxone training are able to administer nasal naloxone successfully and rapidly, little is known about the ability of community members to administer naloxone without training. The objective of this study was to assess the ability of untrained individuals to administer naloxone successfully in a simulated opioid overdose setting.. Prospective single-site open-label randomized usability assessment.. Scenario station at a large state fair during August and September 2017.. A total of 207 healthy adults who were randomly assigned to administer naloxone using a nasal spray (NS) device (69 participants), an intramuscular (IM) kit (68 participants), or an improvised nasal atomizer (AT) kit (70 participants).. Participants were instructed to administer the device to a high-fidelity mannequin in a public environment with distractions to mimic those that might be present in an actual overdose. No device instructions or administration materials were provided.. Participants were assessed by trained study team members who directly observed all naloxone administrations using the predetermined end-point criteria. Individual participant perceptions were evaluated immediately following the naloxone administration using a standardized questionnaire form. The primary outcome was successful administration, defined as administration within 7 minutes and without critical errors. Secondary outcomes were time to successful naloxone administration and ease of use of the device. The NS (66.7%, p<0.001) and IM (51.5%, p<0.001) devices had higher rates of successful administration than the improvised nasal AT device (2.9%). The NS device was administered more rapidly (median 16 sec) than the IM device (median 58 sec, p<0.001) or improvised nasal AT device (median 113 sec, p=0.012) devices, and it was the easiest to use.. In this study of naloxone administration, participants administered the NS and IM devices more successfully than the AT device. The NS device was administered most rapidly and was easiest to use.

Topics: Administration, Intranasal; Analgesics, Opioid; Drug Overdose; Emergency Treatment; Female; Humans; Injections, Intramuscular; Male; Middle Aged; Naloxone; Narcotic Antagonists; Program Evaluation; Prospective Studies; Residence Characteristics; Treatment Outcome

Continuously high rates of overdose deaths in Sweden led to the decision by the Skåne County to initiate the first regional take-home naloxone program in Sweden. The project aims to study the effect of overdose prevention education and naloxone distribution on overdose mortality in Skåne County. Secondary outcome measures include non-fatal overdoses and overdose-related harm in the general population, as well as cohort-specific effects in study participants regarding overdoses, mortality and retention in naloxone program.. Implementation of a multi-site train-the-trainer cascade model was launched in June 2018. Twenty four facilities, including opioid substitution treatment units, needle exchange programs and in-patient addiction units were included for the first line of start-up, aspiring to reach a majority of individuals at-risk within the first 6 months. Serving as self-sufficient naloxone hubs, these units provide training, naloxone distribution and study recruitment. During 3 years, questionnaires are obtained from initial training, follow up, every sixth month, and upon refill. Estimated sample size is 2000 subjects. Naloxone distribution rates are reported, by each unit, every 6 months. Medical diagnoses, toxicological raw data and data on mortality and cause of death will be collected from national and regional registers, both for included naloxone recipients and for the general population. Data on vital status and treatment needs will be collected from registers of emergency and prehospital care.. Despite a growing body of literature on naloxone distribution, studies on population effect on mortality are scarce. Most previous studies and reports have been uncontrolled, thus not being able to link naloxone distribution to survival, in relation to a comparison period. As Swedish registers present the opportunity to monitor individuals and entire populations over time, conditions for conducting systematic follow-ups in the Swedish population are good, serving the opportunity to study the impact of large scale overdose prevention education and naloxone distribution and thus fill the knowledge gap.. Naloxone Treatment in Skåne County - Effect on Drug-related Mortality and Overdose-related Complications, NCT03570099, registered on 26 June 2018.

Topics: Adult; Drug Overdose; Female; Health Knowledge, Attitudes, Practice; Humans; Male; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Social Validity, Research; Sweden; Teacher Training

Naloxone is the usual drug used in opioid-induced respiratory depression but it has a short half-life, precipitates withdrawal in dependent patients, and thus for persistent reversal of long-acting opioids has to be given by titrated doses and infusions. The partial agonist buprenorphine has a much longer duration of action and causes less severe withdrawal, but still should largely reverse respiratory depression induced by full agonist opioids. We aimed to compare the efficacy/safety of buprenorphine and naloxone in reversing respiratory depression in methadone-poisoned opioid-dependent patients.. Patients with methadone-induced respiratory depression were randomized to receive naloxone (titrated doses), or lower or higher doses of buprenorphine (10 μg/kg or 15 μg/kg). The primary outcome was immediate reversal of respiratory depression. We also recorded acute opioid withdrawal, need for intubation/recurrent apnea, repeated doses of opioid antagonists, length of hospital stay, other morbidity, and mortality. The study was registered with the Iranian Registry of Clinical Trials (Trial ID: 18265; Approval code: IRCT2015011020624N1).. Eighty-five patients were randomized; 55/56 patients who received buprenorphine had rapid reversal of respiratory depression, which persisted for at least 12 h. Naloxone was effective in 28/29 patients, but often required very high titrated doses (thus delaying time to respond) and prolonged infusions. Intubation (8/29 vs 5/56) and opioid withdrawal (15/29 vs 7/56) were less common with buprenorphine. There were no serious complications or deaths in those receiving buprenorphine. The 15-μg/kg buprenorphine dose appeared to provide a longer duration of action, but precipitated withdrawal more frequently than the 10-μg/kg dose.. Buprenorphine appears to be a safe and effective substitute for naloxone in overdosed opioid-dependent patients. Further studies are warranted to explore the optimal dosing strategy for buprenorphine to consistently maintain reversal of respiratory depression but not precipitate withdrawal.. IRCT2015011020624N1. Registered 30 September 2015.

Topics: Adult; Analgesics, Opioid; Buprenorphine; Drug Overdose; Female; Humans; Male; Methadone; Middle Aged; Naloxone; Narcotic Antagonists; Respiratory Insufficiency; Young Adult

Immersive video (e.g. virtual reality) poses a promising and engaging alternative to standard in-person trainings and can potentially increase access to evidence-based opioid overdose prevention programs (OOPPs). Therefore, the objective of this equivalence study was to test whether the immersive video OOPP was equivalent to a standard in-person OOPP for changes in opioid overdose knowledge and attitudes.. A team of nurses and communication researchers developed a 9-minute immersive video OOPP. To test whether this immersive video OOPP (treatment) demonstrated equivalent gains in opioid overdose response knowledge and attitudes as in-person OOPPs (standard of care control), researchers deployed a two-day field experiment in Philadelphia, Pennsylvania, USA. In this equivalence trial, 9 libraries were randomly assigned to offer treatment or control OOPP to community members attending naloxone giveaway events. In this equivalence design, a difference between treatment and control groups pre- to post-training scores within -1.0 to 1.0 supports equivalence between the trainings.. Results demonstrate participants (N = 94) exposed to the immersive video OOPP had equivalent improvements on posttest knowledge (β=-0.18, p = .61) and more favorable attitudes about responding to an opioid overdose (β=0.26, p = .02) than those exposed to the standard OOPP. However, these minor differences in knowledge and attitudes were within the equivalence interval indicating that the immersive video OOPP remained equivalently effective for community members.. Community partnerships, like those between public health departments and libraries, can provide opportunities for deploying novel immersive video OOPP that, alongside standard offerings, can strengthen community response to the opioid crisis.

Topics: Adult; Analgesics, Opioid; Drug Overdose; Female; Health Knowledge, Attitudes, Practice; Humans; Male; Naloxone; Narcotic Antagonists; Opiate Overdose; Philadelphia; Technology

Take-home naloxone (THN) is a clinically effective and cost-effective means of reducing opioid overdose fatality. Nonetheless, naloxone administration that successfully saves a person's life can still produce undesirable and harmful effects.. To better understand factors associated with two widely reported adverse outcomes following naloxone administration; namely the person resuscitated displays: i. withdrawal symptoms and ii. anger.. A mixed methods study combining a randomized controlled trial of overdose education and naloxone prescribing to people with opioid use disorder and semi-structured qualitative interviews with trial participants who had responded to an overdose whilst in the trial. All data were collected in New York City (2014-2019). A dataset (comprising demographic, pharmacological, situational, interpersonal, and overdose training related variables) was generated by transforming qualitative interview data from 47 overdose events into dichotomous variables and then combining these with quantitative demographic and overdose training related data from the main trial. Associations between variables within the dataset and reports of: i. withdrawal symptoms and ii. anger were explored using chi-squared tests, t-tests, and logistic regressions.. A multivariate logistic regression found that people who had overdosed were significantly more likely to display anger if the person resuscitating them criticized, berated or chastised them during resuscitation (adjusted OR = 27 [95% CI = 4.0-295]). In contrast, they were significantly less likely to display anger if the person resuscitating them communicated positively with them (OR = 0.10 [95% CI = 0.01-0.78]). Both positive and negative communication styles were independently associated with anger, and communication was associated with 59% of the variance in anger. There was no evidence that people who displayed withdrawal symptoms were more likely to display anger than those not displaying withdrawal symptoms, and neither displaying withdrawal symptoms nor displaying anger were associated with using more drugs after resuscitation.. Contrary to common assumptions, withdrawal symptoms and anger following naloxone administration may be unrelated phenomena. Findings are consistent with previous research that has suggested that a lay responder's positive or reassuring communication style may lessen anger post overdose. Implications for improving THN programmes and naloxone administration are discussed.

Topics: Anger; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; New York City; Opiate Overdose; Opioid-Related Disorders; Substance Withdrawal Syndrome

Intranasal (IN) naloxone is widely used to treat opioid overdoses. The advantage of nasal administration compared with injection lies in its suitability for administration by lay people as it is needless. Approved formulations of nasal naloxone with bioavailability of approximately 50% have only undergone trials in healthy volunteers, while off-label nasal sprays with low bioavailability have been studied in patients. Randomised clinical trials are needed to investigate efficacy and safety of approved IN naloxone in patients suffering overdose. This study investigates whether the administration of 1.4 mg naloxone in 0.1 mL per dose is non-inferior to 0.8 mg intramuscular injection in patients treated for opioid overdose.. Sponsor is the Norwegian University of Science and Technology. The study has been developed in collaboration with user representatives. The primary endpoint is the restoration of spontaneous respiration≥10 breaths/min based on a sample of 200 opioid overdose cases. Double-dummy design ensures blinding, which will be maintained until the database is locked.. The study was approved by the Norwegian Medicines Agency and Regional Ethics Committees (REC: 2016/2000). It adheres to the Good Clinical Practice guidelines as set out by the International Council for Harmonisation of Technical Requirements for Pharmaceuticals for Human Use.Informed consent will be sought through a differentiated model. This allows for deferred consent after inclusion for patients who have regained the ability to consent. Patients who are unable to consent prior to discharge by emergency services are given written information and can withdraw at a later date in line with user recommendations. Metadata will be published in the Norwegian University of Science and Technology Open repository. Deidentified individual participant data will be made available to recipients conditional of data processor agreement being entered.. EudraCT Registry (2016-004072-22) and Clinicaltrials.gov Registry (NCT03518021).

Topics: Administration, Intranasal; Adolescent; Aged; Double-Blind Method; Drug Overdose; Emergency Medical Services; Humans; Naloxone; Narcotic Antagonists; Norway; Randomized Controlled Trials as Topic

Bystander administration with naloxone nasal spray can prevent deaths from opioid overdose. To achieve optimal nasal absorption of naloxone, the spray must be administered at low volume with high concentration of the drug. The study aimed to investigate the bioavailability and absorption pattern for a new naloxone nasal spray.. In an open, randomised, two-way crossover study undertaken in five healthy men, naloxone 2 mg (20 mg/ml) in nasal spray was compared with 1 mg intravenously administered naloxone. A total of 15 blood samples were taken over a period of six hours after administration. The drug concentration was determined using liquid chromatography tandem-mass spectrometry. Pharmacokinetic variables were calculated using non-compartmental analysis.. Bioavailability for intranasal naloxone was 47 % (minimum-maximum values 24-66 %). Maximum concentration (Cmax) was 4.2 (1.5-7.1) ng/ml, and this was achieved (Tmax ) after 16 (5-25) minutes.. The nasal spray resulted in a rapid systemic absorption with higher serum concentrations than intravenous naloxone 10-240 minutes after intake. The pilot study indicated that the highly concentrated nasal spray may provide a therapeutic dose of naloxone with a single spray actuation. The findings led to further commercial development of the medication.

Topics: Administration, Intravenous; Adult; Analgesics, Opioid; Antidotes; Biological Availability; Cross-Over Studies; Drug Overdose; Gas Chromatography-Mass Spectrometry; Humans; Male; Naloxone; Nasal Sprays; Pilot Projects; Tandem Mass Spectrometry; Young Adult

Previous unblinded clinical trials suggested that the intranasal route of naloxone hydrochloride was inferior to the widely used intramuscular route for the reversal of opioid overdose.. To test whether a dose of naloxone administered intranasally is as effective as the same dose of intramuscularly administered naloxone in reversing opioid overdose.. A double-blind, double-dummy randomized clinical trial was conducted at the Uniting Medically Supervised Injecting Centre in Sydney, Australia. Clients of the center were recruited to participate from February 1, 2012, to January 3, 2017. Eligible clients were aged 18 years or older with a history of injecting drug use (n = 197). Intention-to-treat analysis was performed for all participants who received both intranasal and intramuscular modes of treatment (active or placebo).. Clients were randomized to receive 1 of 2 treatments: (1) intranasal administration of naloxone hydrochloride 800 μg per 1 mL and intramuscular administration of placebo 1 mL or (2) intramuscular administration of naloxone hydrochloride 800 μg per 1 mL and intranasal administration of placebo 1 mL.. The primary outcome measure was the need for a rescue dose of intramuscular naloxone hydrochloride (800 μg) 10 minutes after the initial treatment. Secondary outcome measures included time to adequate respiratory rate greater than or equal to 10 breaths per minute and time to Glasgow Coma Scale score greater than or equal to 13.. A total of 197 clients (173 [87.8%] male; mean [SD] age, 34.0 [7.82] years) completed the trial, of whom 93 (47.2%) were randomized to intramuscular naloxone dose and 104 (52.8%) to intranasal naloxone dose. Clients randomized to intramuscular naloxone administration were less likely to require a rescue dose of naloxone compared with clients randomized to intranasal naloxone administration (8 [8.6%] vs 24 [23.1%]; odds ratio, 0.35; 95% CI, 0.15-0.66; P = .002). A 65% increase in hazard (hazard ratio, 1.65; 95% CI, 1.21-2.25; P = .002) for time to respiratory rate of at least 10 and an 81% increase in hazard (hazard ratio, 1.81; 95% CI, 1.28-2.56; P = .001) for time to Glasgow Coma Scale score of at least 13 were observed for the group receiving intranasal naloxone compared with the group receiving intramuscular naloxone. No major adverse events were reported for either group.. This trial showed that intranasally administered naloxone in a supervised injecting facility can reverse opioid overdose but not as efficiently as intramuscularly administered naloxone can, findings that largely replicate those of previous unblinded clinical trials. These results suggest that determining the optimal dose and concentration of intranasal naloxone to respond to opioid overdose in real-world conditions is an international priority.. anzctr.org.au Identifier: ACTRN12611000852954.

Topics: Administration, Intranasal; Adolescent; Adult; Australia; Double-Blind Method; Drug Overdose; Female; Humans; Injections, Intramuscular; Male; Naloxone; Narcotic Antagonists

The surviving opioid overdose with naloxone education and resuscitation (SOONER) project uses co-design and trial methods to develop and evaluate a point-of-care overdose education and naloxone distribution (OEND) tool. We plan to conduct a randomised controlled trial to assess the effectiveness of our OEND tool in comparison with best available standard of care by observing participants' performance as a responder to a simulated overdose. Recruiting and retaining people at risk of or likely to witness opioid overdose raises scientific, logistical and bioethical challenges. A feasibility study is needed to establish the effectiveness of recruitment and retention strategies and acceptability of study procedures prior to launching the full trial.. Strategies to enhance recruitment include candidate-driven recruitment, verbal informed consent, and attractive, destigmatising materials. Adults at risk of or likely to witness opioid overdose will be recruited through an urban emergency department, inpatient and ambulatory addiction medicine service, and outpatient family practice settings. Participants randomised to the intervention arm will receive our OEND intervention; those in the control arm will be referred to existing OEND programme. Retention procedures include participant reminders, flexible scheduling, cash and comfort compensation, and strategies to maintain a consistent relationship between individual study staff and participants. Within 2 weeks following recruitment, participants will engage as a responder to a manikin-simulated overdose, and complete overdose knowledge and attitudes questionnaires. The primary outcome is recruitment and retention feasibility, defined as the recruitment of 28 participants within 28 days of recruitment and <50% attrition at the overdose simulation. Staff and participant feedback will also be collected and considered.. The study has been reviewed by ethics boards at St. Michael's Hospital, Toronto Public Health and the University of Toronto. Dissemination will occur through peer-reviewed publication and presentations.. ClinicalTrials.gov registry (NCT03821649).

Topics: Adult; Ambulatory Care Facilities; Analgesics, Opioid; Canada; Drug Overdose; Harm Reduction; Health Education; Humans; Male; Naloxone; Opioid-Related Disorders; Patient Selection; Randomized Controlled Trials as Topic; Young Adult

The initial dose of naloxone administered to patients who present to the emergency department (ED) with opioid overdose is highly variable. The objective of this study was to determine if the initial dose of intravenous (IV) naloxone given to these patients was associated with the time to recurrence of opioid toxicity.. This was a multicenter retrospective cohort study, conducted at two academic EDs in the United States. Consecutive adults who had a positive response to naloxone for opioid overdose in the ED were included. Patients were categorized into two groups based on initial IV naloxone dose administered: 0.4 mg (lower-dose) or 1-2 mg (higher-dose). The main outcome measure was the time to recurrence of opioid toxicity requiring a second dose of naloxone. Secondary outcomes included the need for naloxone continuous infusion and adverse events.. The study included 84 patients with 42 patients receiving lower-dose and 42 patients receiving higher-dose naloxone. Median time to re-dose of naloxone was similar between the lower-dose (72 [IQR 46-139] minutes) and higher-dose (70 [IQR 44-126] minutes) groups (p=.810). There were 12 patients (29%) in the lower-dose group and 17 patients (41%) in the higher-dose group who subsequently required continuous infusions (p=.359). The proportion of patients with adverse events was similar between lower-dose and higher-dose groups (31% versus 41%, p=.495). There was no difference in the incidence of specific withdrawal related adverse effects.. The initial dose of naloxone given to patients in the ED does not influence the time to recurrence of opioid toxicity.

Topics: Adult; Dose-Response Relationship, Drug; Drug Overdose; Emergency Medical Services; Emergency Service, Hospital; Female; Humans; Infusions, Intravenous; Male; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Recurrence; Retrospective Studies; Secondary Prevention; Time Factors; Treatment Outcome

Naloxone is an opioid antagonist used for emergency resuscitation following opioid overdose. Prisoners with a history of heroin use by injection have a high risk of drug-related death in the first weeks after prison-release. The N-ALIVE trial was planned as a large prison-based randomised controlled trial (RCT) to test the effectiveness of naloxone-on-release in the prevention of fatal opiate overdoses soon after release. The N-ALIVE pilot trial was conducted to test the main trial's assumptions on recruitment of prisons and prisoners, and the logistics for ensuring that participants received their N-ALIVE pack on release.. Adult prisoners who had ever injected heroin, were incarcerated for ≥7 days and were expected to be released within 3 months were eligible. Participants were randomised to receive, on liberation, a pack containing a single 'rescue' injection of naloxone or a control pack with no naloxone syringe. The trial was double-blind prior to prison-release.. We randomised 1685 prisoners (842 naloxone; 843 control) across 16 prisons in England. We stopped randomisation on 8 December 2014 because only one-third of administrations of naloxone-on-release were to the randomised ex-prisoner; two-thirds were to others whom we were not tracing.. Prevention RCTs are seldom conducted within prisons; we demonstrated the feasibility of conducting a multi-prison RCT to prevent fatality from opioid overdose in the outside community. We terminated the N-ALIVE trial due to the infeasibility of individualised randomisation to naloxone-on-release. Large RCTs are feasible within prisons.

Topics: Adult; Double-Blind Method; Drug Overdose; England; Humans; Naloxone; Narcotic Antagonists; Pilot Projects; Prisoners; Prisons; Research Design

Opioid overdose (OD) has become a significant public health problem in need of effective interventions. The majority of existing educational interventions target provision of naloxone and are conducted in-person; these elements present logistical barriers that may limit wide-spread implementation. This study developed and evaluated an easily disseminated opioid OD educational intervention and compared computerized versus pamphlet delivery METHODS: Participants (N=76) undergoing opioid detoxification were randomly assigned to receive OD education via a Pamphlet (N=25), Computer (N=24), or Computer+Mastery (N=27) with identical content for all delivery modalities. Primary outcomes were changes from pre- to post-intervention in knowledge of opioid effects, opioid OD symptoms, and recommended opioid OD responses, as well as intervention acceptability. Also assessed at 1 and 3-month follow-ups were retention of knowledge and change in reported OD risk behaviors.. Knowledge increased following all three intervention-delivery modalities with few between-group differences observed in knowledge gain or acceptability ratings. Largest gains were in the domain of opioid OD response (from 41.8% to 73.8% mean correct responses; p<0.001). Knowledge was well sustained at the 1 and 3-month follow-ups among completers, where a significant reduction was seen in the critical behavioral risk factor of using opioids while alone.. Opioid overdose education delivered by computer or written pamphlet produced sustained increases in knowledge and reduction in a key behavioral risk factor.. Results support further evaluation of this educational intervention that can be used alone or to complement naloxone-training programs.

Topics: Adult; Analgesics, Opioid; Computer-Assisted Instruction; Drug Overdose; Female; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pamphlets; Patient Education as Topic

To review the safety profile of injectable hydromorphone and diacetylmorphine and explore if adverse events (AEs) or serious adverse events (SAEs) were associated with dose and patterns of attendance.. This was a non-inferiority randomized double-blind controlled trial (Vancouver, Canada) testing hydromorphone (n=100) and diacetylmorphine (n=102) for the treatment of severe opioid use disorder. Medications were delivered under the supervision of trained Registered Nurses up to three times daily. AEs were described using MedDRA codes.. Most common related AEs included immediate post-injection reaction or injection site pruritus reactions, somnolence and opioid overdoses. Adjusted analysis indicated that participants in the hydromorphone group were less likely to have any related AE or SAE compared to the diacetylmorphine group. Related somnolence and opioid overdose events were distributed throughout the six months treatment period. In the diacetylmorphine group, five of the eleven related SAE opioid overdoses (requiring naloxone) occurred in the first 30days since most recent treatment initiation. Analysis of somnolence and opioid overdose (AEs and SAEs) event rates by received dose suggested a non-linear relationship. However, in the diacetylmorphine group higher event rates per person days were recorded at lower doses.. When injectable hydromorphone and diacetylmorphine are individually dosed and monitored, their opioid-related side effects, including potential fatal overdoses, are safely mitigated and treated by health care providers. In the midst of an opioid overdose epidemic, injectable options are timely to reach a very important minority of people who inject street opioids and are not attracted to other treatments.

Topics: Adult; Analgesics, Opioid; Canada; Double-Blind Method; Drug Overdose; Female; Heroin; Heroin Dependence; Humans; Hydromorphone; Injections; Male; Middle Aged; Naloxone; Opioid-Related Disorders; Self Administration; Severity of Illness Index; Time Factors

Methadone toxicity is one of the major causes of death in opioiddependent individuals.. We aimed to compare two different protocols of naloxone administration in terms of reversal of overdose signs and symptoms and frequency of complications in opioid-dependent methadone-intoxicated patients.. One-hundred opioid-dependent patients with signs/symptoms of methadone overdose were included. The patients were consecutively assigned into Tintinalli (group 1) or Goldfrank regimen protocol (group 2) of naloxone administration. Group 1 received naloxone with the dose 0.1 mg given every two to three minutes while group 2 received naloxone with the initial dose of 0.04 mg increasing to 0.4, 2, and 10 mg every two to three minutes to reverse respiratory depression. They were then compared regarding reversal of toxicity and risk of development of complications.. The time to reversal of the overdose signs/symptoms was significantly less in Goldfrank regimen protocol (P<0.001). Frequency of withdrawal syndrome and recurrence of respiratory depression were not significantly different between the two groups. Aspiration pneumonia and intubation were more frequent in group 2, as well.. It seems that gradual titration of naloxone by Tintinalli protocol can reduce major complications compared to the Goldfrank regimen. However, this protocol was not perfect in opioid-dependent methadone-overdosed patients, either, since it could induce complications, as well. We may need new protocols in overdosed opioid-dependent patients.

Topics: Adolescent; Adult; Aged; Analgesics, Opioid; Dose-Response Relationship, Drug; Drug Overdose; Female; Humans; Male; Methadone; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Respiratory Insufficiency; Time Factors; Treatment Outcome; Young Adult

Naloxone is an opioid antagonist used for emergency resuscitation following opioid overdose. Prisoners with a history of heroin injection have a high risk of drug-related death soon after release from prison. The NALoxone InVEstigation (N-ALIVE) pilot trial (ISRCTN34044390) tested feasibility measures for randomized provision of naloxone-on-release (NOR) to eligible prisoners in England.. Parallel-group randomized controlled pilot trial.. English prisons.. A total of 1685 adult heroin injectors, incarcerated for at least 7 days pre-randomization, release due within 3 months and more than 6 months since previous N-ALIVE release.. Using 1 : 1 minimization, prisoners were randomized to receive on release a pack containing either a single 'rescue' injection of naloxone or a control pack with no syringe.. Key feasibility outcomes were tested against prior expectations: on participation (14 English prisons; 2800 prisoners), consent (75% for randomization), returned prisoner self-questionnaires (RPSQs: 207), NOR-carriage (75% in first 4 weeks) and overdose presence (80%).. Prisons (16) and prisoners (1685) were willing to participate [consent rate, 95% confidence interval (CI) = 70-74%]; 218 RPSQs were received; NOR-carriage (95% CI = 63-79%) and overdose presence (95% CI = 75-84%) were as expected. We randomized 842 to NOR and 843 to control during 30 months but stopped early, because only one-third of NOR administrations were to the ex-prisoner. Nine deaths within 12 weeks of release were registered for 1557 randomized participants released before 9 December 2014.. Large randomized trials are feasible with prison populations. Provision of take-home emergency naloxone prior to prison release may be a life-saving interim measure to prevent heroin overdose deaths among ex-prisoners and the wider population.

Topics: Adolescent; Adult; Drug Overdose; England; Female; Heroin Dependence; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Pilot Projects; Prisoners; Young Adult

As resources are deployed to address the opioid overdose epidemic in the USA, it is essential that we understand the correlates of more frequent opioid injections-which has been associated not only with HIV and HCV transmission, but also with overdose risk-to inform the development and targeting of effective intervention strategies like overdose prevention and naloxone distribution programs. However, no studies have explored how characteristics of opioid use partnerships may be associated within injection frequency with opioid partnerships.. Using baseline data from a trial of a behavioural intervention to reduce overdose among opioid users in San Francisco, CA, we calculated assortativity among opioid use partnerships by race, gender, participant-reported HIV- and HCV-status, and opioids used using Newman's assortativity coefficient (NC). Multivariable generalized estimating equations linear regression was used to examine associations between individual- and partnership-level characteristics and injection frequency within opioid use partnerships.. Opioid use partnerships (n=134) reported by study participants (n=55) were assortative by race (NC=0.42, 95%CI=0.33-0.50) and participant-reported HCV-status (NC=0.42, 95%CI=0.31-0.52). In multivariable analyses, there were more monthly injections among sexual/romantic partnerships (β=114.4, 95%CI=60.2-168.7, p<0.001), racially concordant partnerships reported by white study participants (β=71.4, 95%CI=0.3-142.5, p=0.049), racially discordant partnerships reported by African American study participants (β=105.7, 95%CI=1.0-210.5, p=0.048), and partnerships in which either member had witnessed the other experience an overdose (β=81.8, 95%CI=38.9-124.6, p<0.001).. Social segregation by race and HCV-status should potentially be considered in efforts to reach networks of opioid users. Due to higher injection frequency and greater likelihood of witnessing their partners experience an overdose, individuals in sexual/romantic opioid use partnerships, white individuals in racially homogenous partnerships, and African American individuals in heterogeneous partnerships may warrant focused attention as part of peer- and network-based overdose prevention efforts, as well as broader HIV/HCV prevention strategies. Developing and targeting overdose prevention education programs that provide information on risk factors and ways to identify overdose, as well as effective responses, including naloxone use and rescue breathing, for more frequently injecting networks may help reduce opioid morbidity and mortality in these most at risk groups.

Topics: Adult; Drug Overdose; Female; Hepatitis C; HIV Infections; Humans; Interpersonal Relations; Linear Models; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pilot Projects; Racial Groups; Risk Factors; San Francisco; Sexual Partners; Substance Abuse, Intravenous

Opioid users in treatment are at high risk of relapse and overdose, making them an important target for efforts to reduce opioid overdose mortality. Overdose Education (OE) is one such intervention, and this study tests the effectiveness of OE in a community substance use disorder treatment program.. Opioid users were recruited from a community treatment center for the study. The Opioid Overdose Knowledge Scale (OOKS) was administered before and after an educational intervention (small group lecture, slideshow, and handout based on previously published content) to assess knowledge of the risks, signs, and actions associated with opioid overdose, including use of naloxone. Additional survey questions assessed naloxone access, naloxone education, and overdose experiences at treatment and 3-month follow-up. Subjects (n = 43) were 28% female and had a mean age of 31 years. OOKS scores were compared at pre-intervention, post-intervention, and follow-up, and results were also compared with a historical non-intervention control group (n = 14).. Total score on the OOKS increased significantly from pre- to post-education, and improvement was maintained at follow-up (p < .0001). OOKS subdomains of actions and naloxone use also had significant increases (p < .0001). Four subjects reported possessing naloxone in the past, and only one subject who did not already have naloxone at the time of treatment had obtained it at follow-up.. Education about opioid overdose and naloxone use in a community treatment program increases overdose knowledge, providing support for the idea of making OE a routine part of substance use disorder treatment. However, the rate of follow through on accessing naloxone was low with this education-only intervention.

Topics: Adult; Drug Overdose; Female; Follow-Up Studies; Health Education; Health Knowledge, Attitudes, Practice; Historically Controlled Study; Humans; Male; Naloxone; Opioid-Related Disorders; Program Evaluation; Recurrence

To evaluate a heroin overdose management training programme for family members based on emergency recovery procedures and take-home naloxone (THN) administration.. A two-group, parallel-arm, non-blinded, randomized controlled trial of group-based training versus an information-only control.. Training events delivered in community addiction treatment services in three locations in England.. A total of 187 family members and carers allocated to receive either THN training or basic information on opioid overdose management (n = 95 and n = 92, respectively), with 123 participants completing the study.. The primary outcome measure was a self-completion Opioid Overdose Knowledge Scale (OOKS; range 0-45) and an Opioid Overdose Attitudes Scale (OOAS; range 28-140) was the secondary outcome measure. Each group was assessed before receiving their assigned condition and followed-up 3 months after. Events of witnessing and managing an overdose during follow-up were also recorded.. At follow-up, study participants who had received THN training reported greater overdose-related knowledge relative to those receiving basic information only [OOKS mean difference, 4.08 (95% confidence interval, 2.10-6.06; P < 0.001); Cohen's d = 0.74 (0.37-1.10)]. There were also more positive opioid overdose-related attitudes among the trained group at follow-up [OOAS mean difference, 7.47 (3.13-11.82); P = 0.001; d = 0.61 (0.25-0.97)]. At the individual level 35 and 54%, respectively, of the experimental group increased their knowledge and attitudes compared with 11 and 30% of the control group. During follow-up, 13 participants witnessed an overdose with naloxone administered on eight occasions: five among the THN-trained group and three among the controls.. Take-home naloxone training for family members of heroin users increases opioid overdose-related knowledge and competence and these benefits are well retained after 3 months.

Topics: Adult; Caregivers; Drug Overdose; England; Family; Female; Health Education; Health Knowledge, Attitudes, Practice; Heroin; Heroin Dependence; Home Nursing; Humans; Male; Naloxone; Narcotic Antagonists

'Take Home' Naloxone (THN) kits for use by peers in the event of an opioid overdose may reduce further overdose and deaths, but distribution through Drugs Services may not reach those at highest risk. Attendance by paramedics at emergency calls for patients who have suffered an overdose presents an opportunity to distribute THN kits. In this feasibility study we will assess the acceptability of this intervention, and gather data to inform definitive trial planning.. Cluster randomised trial with staggered allocation of paramedics (clusters) to groups. We will invite paramedics in an urban area of south Wales, UK to take part. We will randomly allocate those that accept to training sessions during the first 4 months of the trial. Patients attended by paramedics who have been trained and issued THN kits will fall into the intervention group. Patients attended by paramedics following usual practice (until they receive their training and THN kits) will fall into the control group. We will gather data about processes and outcomes of care: numbers of patients eligible for intervention, offered and accepted THN, attended emergency department, suffered further overdose, died within 3 months and about follow-up rates: numbers of patients consented, completed (postal or telephone) questionnaire. We will gather qualitative data about acceptability to patients and paramedics through interviews and focus groups.. Ethical approval for this study was granted on 7 December 2011, by South East Wales Research Ethics Committee, Panel C. Results of this study will be reported through peer-reviewed scientific journals, conference presentations and internal organisational report. We will also seek to report our findings through local and national substance misuse networks and publications.. ISRCTN98216498.

Topics: Adolescent; Adult; Allied Health Personnel; Analgesics, Opioid; Clinical Protocols; Drug Overdose; Emergency Medical Services; Feasibility Studies; Female; Humans; Male; Naloxone; Narcotic Antagonists; Patient Selection; Research Design; Wales; Young Adult

The naloxone investigation (N-ALIVE) randomized trial commenced in the UK in May 2012, with the preliminary phase involving 5,600 prisoners on release. The trial is investigating whether heroin overdose deaths post-prison release can be prevented by prior provision of a take-home emergency supply of naloxone. Heroin contributes disproportionately to drug deaths through opiate-induced respiratory depression. Take-home emergency naloxone is a novel preventive measure for which there have been encouraging preliminary reports from community schemes. Overdoses are usually witnessed, and drug users themselves and also family members are a vast intervention workforce who are willing to intervene, but whose responses are currently often inefficient or wrong. Approximately 10% of provided emergency naloxone is thought to be used in subsequent emergency resuscitation but, as yet, there have been no definitive studies. The period following release from prison is a time of extraordinarily high mortality, with heroin overdose deaths increased more than sevenfold in the first fortnight after release. Of prisoners with a previous history of heroin injecting who are released from prison, 1 in 200 will die of a heroin overdose within the first 4 weeks. There are major scientific and logistical challenges to assessing the impact of take-home naloxone. Even in recently released prisoners, heroin overdose death is a relatively rare event: hence, large numbers of prisoners need to enter the trial to assess whether take-home naloxone significantly reduces the overdose death rate. The commencement of pilot phase of the N-ALIVE trial is a significant step forward, with prisoners being randomly assigned either to treatment-as-usual or to treatment-as-usual plus a supply of take-home emergency naloxone. The subsequent full N-ALIVE trial (contingent on a successful pilot) will involve 56,000 prisoners on release, and will give a definitive conclusion on lives saved in real-world application. Advocates call for implementation, while naysayers raise concerns. The issue does not need more public debate; it needs good science.

Topics: Drug Overdose; Emergencies; Heroin Dependence; Humans; Naloxone; Narcotic Antagonists; Patient Acceptance of Health Care; Prisons

To describe the use and efficacy of nebulized naloxone in patients with suspected opioid intoxication.. This was an observational study conducted at an inner city emergency department. Patients were eligible if they had self-reported or suspected opioid intoxication and a spontaneous respiratory rate ≥6 breaths/minute. Nebulized naloxone (2 mg in 3 mL normal saline) was administered through a standard face mask at the discretion of the treating physician. Structured data collection included demographics, vital signs pre and post naloxone administration and adverse events. The primary outcome was level of consciousness, which was recorded pre and 15 minutes postnaloxone administration using the Glasgow Coma Scale (GCS) and the Richmond Agitation Sedation Scale (RASS).. Of the 73 patients who presented with suspected opioid intoxication and were given naloxone over the study period, 26 were initially treated with nebulized naloxone. After nebulized naloxone administration, median GCS improved from 11 [interquartile range (IQR) 3.5] to 13 (IQR, 2.5), P = .001. Median RASS improved from -3.0 (IQR, -1.0) to -2.0 (IQR, -1.5), P < .0001. Need for supplemental oxygen decreased from 81% to 50%, P = .03. Vital signs did not differ pre/post therapy. There were few adverse effects from nebulized naloxone administration: 12% experienced moderate-severe agitation, 8% were diaphoretic and none vomited. Eleven required subsequent administrations of naloxone, nine of whom self-reported using either heroin, methadone or both. Of these, 5 underwent urine drug screening and all 5 tested positive for either opiates or methadone.. Nebulized naloxone was well-tolerated and led to a reduction in the need for supplemental oxygen as well as improved median GCS and RASS scores in patients with suspected opioid intoxication.

Topics: Administration, Inhalation; Adolescent; Adult; Analgesics, Opioid; Drug Overdose; Glasgow Coma Scale; Humans; Middle Aged; Naloxone; Narcotic Antagonists; Pilot Projects; Prospective Studies; Treatment Outcome; Young Adult

Opioid overdose in dogs is manifested by clinical signs such as excessive sedation, bradycardia, and hypothermia. The ability of two different intramuscular (i.m.) naloxone reversal regimens to reverse the opioid-induced effects of a fivefold overdose of long-acting transdermal fentanyl solution was evaluated in dogs. Twenty-four healthy Beagles were administered a single 13 mg/kg dose (fivefold overdose) of transdermal fentanyl solution and randomized to two naloxone reversal regimen treatment groups, hourly administration for 8 h of 40 (n = 8) or 160 μg/kg i.m. (n = 16). All dogs were sedated and had reduced body temperatures and heart rates (HRs) prior to naloxone administration. Both dosage regimens significantly reduced sedation (P < 0.001), and the 160 μg/kg naloxone regimen resulted in a nearly threefold lower odds of sedation than that of the 40 μg/kg i.m. naloxone regimen (P < 0.05). Additionally, naloxone significantly increased the mean body temperatures and HR (P < 0.001), although the 160 μg/kg regimen increased body temperature and HR more (P < 0.05). However, the narcotic side effects of fentanyl returned within 1-3 h following termination of the naloxone dosage regimens. The opioid-induced effects of an overdose of transdermal fentanyl solution can be safely and effectively reversed by either 40 or 160 μg/kg i.m. naloxone administered at hourly intervals.

Topics: Administration, Topical; Analgesics, Opioid; Animals; Delayed-Action Preparations; Dog Diseases; Dogs; Drug Overdose; Fentanyl; Naloxone; Narcotic Antagonists; Solutions; Time Factors

Traditionally, the opiate antagonist naloxone has been administered parenterally; however, intranasal (i.n.) administration has the potential to reduce the risk of needlestick injury. This is important when working with populations known to have a high prevalence of blood-borne viruses. Preliminary research suggests that i.n. administration might be effective, but suboptimal naloxone solutions were used. This study compared the effectiveness of concentrated (2 mg/ml) i.n. naloxone to intramuscular (i.m.) naloxone for suspected opiate overdose.. This randomized controlled trial included patients treated for suspected opiate overdose in the pre-hospital setting. Patients received 2 mg of either i.n. or i.m. naloxone. The primary outcome was the proportion of patients who responded within 10 minutes of naloxone treatment. Secondary outcomes included time to adequate response and requirement for supplementary naloxone. Data were analysed using multivariate statistical techniques.. A total of 172 patients were enrolled into the study. Median age was 29 years and 74% were male. Rates of response within 10 minutes were similar: i.n. naloxone (60/83, 72.3%) compared with i.m. naloxone (69/89, 77.5%) [difference: -5.2%, 95% confidence interval (CI) -18.2 to 7.7]. No difference was observed in mean response time (i.n.: 8.0, i.m.: 7.9 minutes; difference 0.1, 95% CI -1.3 to 1.5). Supplementary naloxone was administered to fewer patients who received i.m. naloxone (i.n.: 18.1%; i.m.: 4.5%) (difference: 13.6%, 95% CI 4.2-22.9).. Concentrated intranasal naloxone reversed heroin overdose successfully in 82% of patients. Time to adequate response was the same for both routes, suggesting that the i.n. route of administration is of similar effectiveness to the i.m. route as a first-line treatment for heroin overdose.

Topics: Administration, Intranasal; Adolescent; Adult; Allied Health Personnel; Analgesics, Opioid; Drug Overdose; Emergency Medical Services; Female; Heroin; Humans; Injections, Intramuscular; Male; Middle Aged; Naloxone; Narcotic Antagonists; Prospective Studies; Treatment Outcome; Victoria; Young Adult

To determine annual patterns and correlates of nonfatal heroin overdose across 3 years, data were analyzed on 387 heroin users recruited for the Australian Treatment Outcome Study (ATOS), interviewed at 12, 24, and 36 months. A heroin overdose across follow-up was reported by 18.6%, and naloxone had been administered to 11.9%. Annual rates of overdose declined between baseline and 12 months and then remained stable. Previous overdose experience was strongly related to subsequent overdose. Those with a history of overdose before ATOS were significantly more likely to overdose during the study period. In particular, there was a strong association between overdose experience in any 1 year and increased overdose risk in the subsequent year. This is the first study to examine long-term annual trends in nonfatal heroin overdose. While overdose rates declined after extensive treatment, substantial proportions continued to overdose in each year, and this was strongly associated with overdose history.

Topics: Adolescent; Adult; Buprenorphine; Cohort Studies; Drug Overdose; Episode of Care; Female; Follow-Up Studies; Heroin; Heroin Dependence; Humans; Inactivation, Metabolic; Incidence; Interviews as Topic; Male; Methadone; Middle Aged; Naloxone; Needle-Exchange Programs; New South Wales; Substance Abuse Treatment Centers; Treatment Outcome

To determine the effectiveness of intranasal (IN) naloxone compared with intramuscular (IM) naloxone for treatment of respiratory depression due to suspected opiate overdose in the prehospital setting.. Prospective, randomised, unblinded trial of either 2 mg naloxone injected intramuscularly or 2 mg naloxone delivered intranasally with a mucosal atomiser.. 155 patients (71 IM and 84 IN) requiring treatment for suspected opiate overdose and attended by paramedics of the Metropolitan Ambulance Service (MAS) and Rural Ambulance Victoria (RAV) in Victoria.. Response time to regain a respiratory rate greater than 10 per minute. Secondary outcome measures were proportion of patients with respiratory rate greater than 10 per minute at 8 minutes and/or a GCS score over 11 at 8 minutes; proportion requiring rescue naloxone; rate of adverse events; proportion of the IN group for whom IN naloxone alone was sufficient treatment.. The IM group had more rapid response than the IN group, and were more likely to have more than 10 spontaneous respirations per minute within 8 minutes (82% v 63%; P = 0.0173). There was no statistically significant difference between the IM and IN groups for needing rescue naloxone (13% [IM group] v 26% [IN group]; P = 0.0558). There were no major adverse events. For patients treated with IN naloxone, this was sufficient to reverse opiate toxicity in 74%.. IN naloxone is effective in treating opiate-induced respiratory depression, but is not as effective as IM naloxone. IN delivery of naxolone could reduce the risk of needlestick injury to ambulance officers and, being relatively safe to make more widely available, could increase access to life-saving treatment in the community.

Topics: Administration, Intranasal; Adolescent; Adult; Drug Overdose; Emergency Medical Services; Female; Humans; Injections, Intramuscular; Male; Middle Aged; Naloxone; Narcotics; Prospective Studies; Respiratory Insufficiency; Treatment Outcome

Topics: Administration, Intranasal; Bias; Drug Overdose; Emergency Medical Services; Glasgow Coma Scale; Humans; Injections, Intramuscular; Naloxone; Narcotic Antagonists; Narcotics

Prehospital providers are at increased risk for blood-borne exposure and disease due to the nature of their environment. The use if intranasal (i.n.) medications in high-risk populations may limit this risk of exposure. To determine the efficacy of i.n. naloxone in the treatment of suspected opiate overdose patients in the prehospital setting, a prospective, nonrandomized trial of administering i.n. naloxone by paramedics to patients with suspected opiate overdoses over a 6-month period was performed. All adult patients encountered in the prehospital setting as suspected opiate overdose (OD), found down (FD), or with altered mental status (AMS) who met the criteria for naloxone administration were included in the study. i.n. naloxone (2 mg) was administered immediately upon patient contact and before i.v. insertion and administration of i.v. naloxone (2 mg). Patients were then treated by EMS protocol. The main outcome measures were: time of i.n. naloxone administration, time of i.v. naloxone administration, time of appropriate patient response as reported by paramedics. Ninety-five patients received i.n. naloxone and were included in the study. A total of 52 patients responded to naloxone by either i.n. or i.v., with 43 (83%) responding to i.n. naloxone alone. Seven patients (16%) in this group required further doses of i.v. naloxone. In conclusion, i.n. naloxone is a novel alternative method for drug administration in high-risk patients in the prehospital setting with good overall effectiveness. The use of this route is further discussed in relation to efficacy of treatment and minimizing the risk of blood-borne exposures to EMS personnel.

Topics: Administration, Intranasal; Adolescent; Adult; Drug Overdose; Emergency Medical Services; Emergency Medical Technicians; Humans; Injections, Intravenous; Naloxone; Narcotic Antagonists; Narcotics; Needlestick Injuries; Prospective Studies; Treatment Outcome

To develop a clinical prediction rule to identify patients who can be safely discharged one hour after the administration of naloxone for presumed opioid overdose.. Patients who received naloxone for known or presumed opioid overdose were formally evaluated one hour later for multiple potential predictor variables. Patients were classified into two groups: those with adverse events within 24 hours and those without. Using classification and regression tree methodology, a decision rule was developed to predict safe discharge.. Clinical findings from 573 patients allowed us to develop a clinical prediction rule with a sensitivity of 99% (95% CI = 96% to 100%) and a specificity of 40% (95% CI = 36% to 45%). Patients with presumed opioid overdose can be safely discharged one hour after naloxone administration if they: 1) can mobilize as usual; 2) have oxygen saturation on room air of >92%; 3) have a respiratory rate >10 breaths/min and <20 breaths/min; 4) have a temperature of >35.0 degrees C and <37.5 degrees C; 5) have a heart rate >50 beats/min and <100 beats/min; and 6) have a Glasgow Coma Scale score of 15.. This prediction rule for safe early discharge of patients with presumed opioid overdose performs well in this derivation set but requires validation followed by confirmation of safe implementation.

Topics: Adult; Analysis of Variance; British Columbia; Cohort Studies; Drug Administration Schedule; Drug Overdose; Emergency Medicine; Emergency Service, Hospital; Female; Humans; Logistic Models; Male; Middle Aged; Naloxone; Narcotics; Opioid-Related Disorders; Patient Discharge; Predictive Value of Tests; Prognosis; Prospective Studies; Reproducibility of Results; Sensitivity and Specificity; Severity of Illness Index; Survival Rate

To compare the efficacy, safety, and withdrawal symptoms in emergency department patients with suspected narcotic overdose treated with nalmefene, an opioid antagonist with a 4- to 10-hour duration of action, with those treated with naloxone.. Adults in 9 centers who would otherwise receive naloxone for altered consciousness levels were randomly assigned to receive intravenous study drug (1 mg nalmefene, or 2 mg nalmefene or 2 mg naloxone, double-blinded) every 5 minutes as needed for up to 4 doses in a 4-hour study. Outcomes were 20-minute and 4-hour posttreatment changes in respiratory rates, Neurobehavioral Assessment Scale scores, Opioid Withdrawal Scale scores, and incidences of adverse events.. Opioid positivity was recorded for 30 of 63 (1-mg nalmefene), 23 of 55 (2-mg nalmefene), and 24 of 58 (naloxone) cases, 75% of whom also had nonopioid central nervous system depressants. Most patients received only 1 dose of study drug. Similar, clinically meaningful improvements in respiratory rates and Neurobehavioral Assessment Scale scores were seen with all treatments. No statistical differences in efficacy or withdrawal outcomes were seen between treatment groups, and no significant overall time-treatment interactions occurred, in either the entire patient group or among opioid-positive cases (P >.21, all comparisons). Adverse events occurred in 30.9% (2 mg nalmefene), 15.9% (1 mg nalmefene), and 15.5% (naloxone) of patients (P >.08); none were associated with morbidity.. In this study of patients with varied potential causes of altered consciousness, nalmefene (1 mg and 2 mg) and naloxone (2 mg) appeared to be efficacious, safe, and to yield similar clinical outcomes.

Topics: Adult; Double-Blind Method; Drug Overdose; Emergency Treatment; Humans; Injections, Intravenous; Naloxone; Naltrexone; Narcotic Antagonists; Narcotics; Neurologic Examination; Respiration; Time Factors; Treatment Outcome

Naloxone is standard medication for the treatment of heroin intoxications. No large-scale studies have yet been carried out to determine its toxicity in heroin intoxications.. We have undertaken an investigation as to the frequency, type and degree of severity of complications attributable to naloxone administration. Subjects treated between 1991 and 1993 with naloxone for intravenous drug intoxications were prospectively evaluated.. Development of ventricular tachycardia or fibrillation; atrial fibrillation; asystole; pulmonary edema; convulsions; vomiting; and violent behavior within ten minutes after parenteral administration of naloxone.. Six of 453 intoxicated subjects (1.3%; 95% confidence interval 0.4%-3%) suffered severe adverse effects within ten minutes after naloxone administration (one asystole; three generalized convulsions; one pulmonary edema; and one violent behavior). After the ten minute period, no further complications were observed.. The short time between naloxone administration and the occurrence of complications, as well as the type of complications, are strong evidence of a causal link. In 1000 clinically diagnosed intoxications with heroin or heroin mixtures, from 4 to 30 serious complications can be expected. Such a high incidence of complications is unacceptable and could theoretically be reduced by artificial respiration with a bag valve device (hyperventilation) as well as by administering naloxone in minimal divided doses, injected slowly.

Topics: Adolescent; Adult; Aggression; Cocaine; Confidence Intervals; Drug Overdose; Female; Heart Arrest; Heroin; Humans; Illicit Drugs; Injections, Intramuscular; Injections, Intravenous; Male; Middle Aged; Naloxone; Narcotic Antagonists; Prospective Studies; Pulmonary Edema; Seizures; Substance Abuse, Intravenous

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Perception; United States; United States Department of Veterans Affairs; Veterans

With Canada's growing opioid crisis, many communities are attempting to monitor cases in real-time. Paramedic Naloxone Administration (PNA) has become a common metric for monitoring overdoses. We evaluate whether the use of naloxone administration counts represents an effective monitoring tool for community opioid overdoses.. The electronic ambulance call report database of Peterborough Paramedics (Ontario, Canada) was examined. De-identified records from 2016-2019 with problem codes of "Opioid Overdose", along with all patients documented as receiving naloxone were extracted. Chi-square and Bonferroni-adjusted post hoc proportion tests were used for comparison of counts.. 558 opioid overdoses were identified, 124 (22%) of which had PNA documented, 181(32%) had naloxone prior to arrival documented and 264 (47%) received no naloxone. Over the three years, the annual number of overdose cases increased, while the proportion of patients receiving PNA decreased significantly each year. PNA was also associated with calls in a residence. Naloxone was administered by a non-paramedic in 262 cases, with 181 of these identified as opioid overdoses and was more common in later years and in cases occurring in public places.. PNA calls did not account for a significant percentage of opioid overdoses attended to by paramedics. The strong association between PNA and call location being a residence, along with increasing use of community naloxone kits, may cause certain populations to be under-represent if PNA is used as a standalone metric. The decreasing association with time may also lead to a falsely improving metric further reducing its effectiveness. Thus, PNA when used alone may no longer be a suitable metric for opioid overdose tracking.

Topics: Analgesics, Opioid; Drug Overdose; Emergency Medical Services; Humans; Naloxone; Narcotic Antagonists; Ontario; Opiate Overdose

Overdose is a leading cause of death among people who use drugs (PWUDs), but policies to reduce fatal overdose have had mixed results. Summaries of naloxone access and Good Samaritan Laws (GSLs) in prior studies provide limited information about local context. Witnessing overdoses may also be an important consideration in providing services to PWUDs, as it contributes to post traumatic stress disorder (PTSD) symptoms, which complicate substance use disorder treatment.. We aim to estimate the prevalence and correlates of witnessing and responding to an overdose, while exploring overdose context among rural PWUD. The Drug Injection Surveillance and Care Enhancement for Rural Northern New England (DISCERNNE) mixed-methods study characterized substance use and risk behaviors in 11 rural Massachusetts, Vermont, and New Hampshire counties between 2018 and 2019. PWUD completed surveys (n = 589) and in-depth interviews (n = 22).. Among the survey participants, 84% had ever witnessed an overdose, which was associated with probable PTSD symptoms. Overall, 51% had ever called 911 for an overdose, though some experienced criminal legal system consequences despite GSL. Although naloxone access varied, 43% had ever used naloxone to reverse an overdose.. PWUD in Northern New England commonly witnessed an overdose, which they experienced as traumatic. Participants were willing to respond to overdoses, but faced barriers to effective overdose response, including limited naloxone access and criminal legal system consequences. Equipping PWUDs with effective overdose response tools (education and naloxone) and enacting policies that further protect PWUDs from criminal legal system consequences could reduce overdose mortality.

Topics: Drug Overdose; Friends; Humans; Naloxone; Narcotic Antagonists; New England; Opioid-Related Disorders

Prehospital initiation of buprenorphine treatment for Opioid Use Disorder (OUD) by paramedics is an emerging potential intervention to reach patients at greatest risk for opioid-related death. Emergency medical services (EMS) patients who are at high risk for overdose deaths may never engage in treatment as they frequently refuse transport to the hospital after naloxone reversal. The potentially important role of EMS as the initiator for medication for opioid use disorder (MOUD) in the most high-risk patients has not been well described.. This project relies on four interventions: a public access naloxone distribution program, an electronic trigger and data sharing program, an "Overdose Receiving Center," and a paramedic-initiated buprenorphine treatment. For the final intervention, paramedics followed a protocol-based pilot that had an EMS physician consultation prior to administration.. There were 36 patients enrolled in the trial study in the first year who received buprenorphine. Of those patients receiving buprenorphine, only one patient signed out against medical advice on scene. All other patients were transported to an emergency department and their clinical outcome and 7 and 30 day follow ups were determined by the substance use navigator (SUN). Thirty-six of 36 patients had follow up data obtained in the short term and none experienced any precipitated withdrawal or other adverse outcomes. Patients had a 50% (18/36) rate of treatment retention at 7 days and 36% (14/36) were in treatment at 30 days.. In this small pilot project, paramedic-initiated buprenorphine in the setting of data sharing and linkage with treatment appears to be a safe intervention with a high rate of ongoing outpatient treatment for risk of fatal opioid overdoses.

Topics: Analgesics, Opioid; Buprenorphine; Drug Overdose; Emergency Medical Services; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Paramedics; Pilot Projects

Topics: Academic Medical Centers; Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Patient Education as Topic; Pharmacists; Pilot Projects; Prospective Studies; United States

People who inject drugs (PWID) have an elevated risk of fentanyl-related overdoses. This study explores fentanyl overdose concerns among PWID and the role of sex, racial minority status, and overdose prevention efforts in these concerns.. Data were from 498 PWID from Baltimore City, MD, recruited using street-based outreach between 2016 and 2019. Multinomial logistic regressions assessed correlates of participants' level of concern for themselves and their peers overdosing from fentanyl.. A third of participants were female, half were Black, over two-thirds perceived fentanyl to be in all/most of heroin, 40% expressed low fentanyl overdose concern, and a third overdosed in the past 6 months. After controlling for sociodemographic characteristics, female sex was associated with being very concerned about fentanyl overdoses for oneself (adjusted relative risk [aRR]: 2.13; 95% CI: 1.22, 3.72) and peers (aRR: 1.98; 95% CI: 1.14, 3.45). Compared to Black participants, White participants were less likely to be very concerned about fentanyl overdoses for themselves (aRR: 0.35; 95% CI: 0.19, 0.65). Participants who often/always carried naloxone (aRR: 2.91; 95% CI: 1.42, 5.95) perceived fentanyl in most heroin (aRR: 2.78; 95% CI: 1.29, 5.97) or were on medications for opioid use disorder (MOUD) (quite a bit concerned aRR: 2.18; 95% CI: 1.28, 3.69; very concerned: aRR: 1.96; 95% CI: 1.19, 3.22) were more likely than their counterparts to report being concerned for their peers, but not for themselves.. Female sex and racial minority status were associated with greater concern regarding fentanyl overdoses for oneself. Increasing overdose deaths in these populations suggests disparate access to harm-reduction initiatives rather than interest or concern. Furthermore, findings on naloxone, MOUD, and concerns for peers support social network-based interventions among PWID. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Topics: Analgesics, Opioid; Drug Overdose; Drug Users; Ethnic and Racial Minorities; Female; Fentanyl; Heroin; Humans; Male; Naloxone; Opioid-Related Disorders; Substance Abuse, Intravenous

Our aim was to explore perspectives of patients who received naloxone in the emergency department (ED) about (1) naloxone carrying and use following an ED visit and (2) motivation for performing these behaviors.. Semi-structured interviews of patients prescribed naloxone at ED discharge.. Three urban academic EDs in Philadelphia, PA.. 25 participants completed the in-depth, semi-structured interviews and demographic surveys. Participants were majority male, African American, and had previously witnessed or experienced an overdose.. Interviews were recorded, transcribed and analyzed using content analysis. We used a hybrid inductive-deductive approach that included prespecified and emergent themes.. We found that naloxone carrying behavior was variable and influenced by four main motivators: (1) naloxone access; (2) personal experience and salience of naloxone, (3) comfort with naloxone administration, and (4) societal influences on naloxone carrying. In particular, those with personal history of overdose or close friends or family at risk were motivated to carry naloxone.. Participants in this study reported several important motivators for naloxone carrying after an ED visit, including ease of naloxone access and comfort, perceived risk of experiencing or encountering an overdose, and social influences on naloxone carrying behaviors. EDs, health systems, and public health officials should consider these factors influencing motivation when designing future interventions to increase access, carrying, and use of naloxone.

Topics: Drug Overdose; Emergency Service, Hospital; Humans; Male; Motivation; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

Although most US emergency medical services (EMS) systems collect time-to-treatment data in their electronic prehospital patient care reports (PCRs), analysis of these data seldom appears in publications. We believe EMS agencies should routinely analyze the initial time-to-treatment data for various potentially life-threatening conditions. This not only assures that protocol-required treatments have been provided but can discover avoidable delays and drive protocol/treatment priority change. Our study purpose was to analyze the interval from 9-1-1 call receipt until the first administration of naloxone to adult opioid overdose victims to demonstrate the quality assurance importance of analyzing time-to-treatment data.. Retrospective analysis of intervals from 9-1-1 call receipt to initial naloxone treatment in adult opioid overdose victims. We excluded victims <18 years of age and cases where a bystander, police, or a health care worker gave naloxone before EMS arrival. We compared data collected before and during the COVID-19 pandemic to determine its effect on the analysis.. The mean patient age of 582 opioid overdose victims was 40.7 years [95% CI 39.6, 41.8] with 405 males (69.6%). EMS units' scene arrival was 6.7 minutes from the 9-1-1 call receipt. It took 1.8 minutes to reach the victim, and 8.6 additional minutes to administer the first naloxone regardless of administration route (70.4% intravenous, 26.1% intranasal, 2.7% intraosseous, 0.7% intramuscular). EMS personnel administered the first naloxone 17.1 minutes after the 9-1-1 call receipt, with 50.3% of the delay occurring after patient contact. There was no statistically significant difference in the times-to-treatment before vs. during the pandemic.. The prepandemic interval from 9-1-1 call receipt until initial EMS administration of naloxone was substantial and did not change significantly during COVID-19. Our findings exemplify why EMS agencies should analyze initial time-to-treatment data, especially for life-threatening conditions, beyond assuring that protocol-required treatments have been provided. Based on our analysis, fire department crews now carry intranasal naloxone, and intranasal naloxone is given to "impaired" opioid overdose victims the first-arriving fire department or EMS personnel. We continue to collect data on intervals-to-treatment prospectively and monitor our critical process/treatment intervals using the plan-do-study-act model to improve our process/carry out change, and publish our results in a future publication.

Topics: Adult; COVID-19; Drug Overdose; Emergency Medical Services; Humans; Male; Naloxone; Narcotic Antagonists; Opiate Overdose; Pandemics; Retrospective Studies

Opioid overdose is increasing and accounts for two-thirds of poisoning deaths. Opioid induced respiratory depression is life-threatening and can be under-recognised even in the hospital setting. We aimed to evaluate the effect of a care pathway on the management of opioid-poisoned patients.. This is a before-after observational study following the introduction of a nursing care pathway for opioid-poisoned patients presenting to ED. Medical records were retrospectively reviewed pre (6-month period 1 year prior) and post (9-month period following) the introduction of the pathway. The primary outcome was the proportion of documented episodes of respiratory depression (respiratory rate <10 or oxygen saturation <93% on room air) receiving naloxone. Secondary outcomes were time to naloxone, number of documented observations (first 4 h) and length of stay.. There were 111 patients included in the study, 61 pre-intervention and 50 post-intervention (35 followed the pathway). A significantly larger proportion of patients received naloxone for respiratory depression when the pathway was used (134/200 [67%] vs 34/118 [29%], difference 38%, 95% CI 28-48%). The median time to naloxone was similar (pathway 28.5 min vs no pathway 35 min, difference -6.5 min, 95% CI -19 to 12 min). Documentation increased when the pathway was used (12.0 observations/presentation vs 7.5 observations/presentation, difference 4.5 observations/patient, 95% CI 2.1-7.0 observations/patient). Length of stay was similar (pathway 16.7 h vs no pathway 15.3 h, difference 1.4 h, 95% CI -2.4 to 5.9 h).. Following the introduction of a dedicated opioid poisoning nursing care pathway, naloxone delivery and observation documentation increased. A care pathway may improve ED management of opioid poisoning.

Topics: Analgesics, Opioid; Critical Pathways; Drug Overdose; Emergency Service, Hospital; Humans; Naloxone; Narcotic Antagonists; Poisons; Respiratory Insufficiency; Retrospective Studies

The misuse of highly potent benzodiazepines is increasing in the UK, particularly among the opioid-using population in Scotland. Differentiating opioid from benzodiazepine toxicity is not always straightforward in patients with reduced level of consciousness following drug overdose. Patients on long-term opioid substitution who present with acute benzodiazepine intoxication and are given naloxone may develop severe opioid withdrawal while still obtunded from benzodiazepines. This situation can be difficult to manage, and these patients may be at increased risk of vomiting while still unable to protect their airway. Fortunately, the short half-life of naloxone means that the situation is generally short-lived. Naloxone should never be withheld from patients with life-threatening respiratory depression where opioids may be contributing, particularly in community and prehospital settings; however, where appropriate clinical experience exists, naloxone should ideally be administered in small incremental intravenous doses with close monitoring of respiratory function. Increased awareness of the potential risks of naloxone in opioid-dependent patients acutely intoxicated with benzodiazepines may reduce the risk of iatrogenic harm in an already very vulnerable population.

Topics: Analgesics, Opioid; Benzodiazepines; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Substance Withdrawal Syndrome

Between 22 and 30% of prisoners in Germany are reported to be intravenous drug users. There is a 12-fold increase in mortality, mostly as a result of opioid overdose in the first weeks after release from prison. We evaluated the feasibility of first aid training for drug overdose, including take-home naloxone in incarcerated opioid addicts.. Within the Bavarian Take-Home Naloxone Model Project (BayTHN), a subsample of imprisoned opioid addicts was recruited in 5 Bavarian correctional facilities. Manualized first aid training for drug overdose, including take-home naloxone was provided. All surveys were conducted with standardized questionnaires or semi-structured interviews.. Sixty-two long-term opioid addicts were included (age: 36 years (22-53 years); 53.2% women; age at first opioid use: 19.2 years (10-31 years). On average, 3.9 (1-10) opioid addicts participated per training session. At the time of training, the opioid addicts had been in prison on average for 42 (1-228) weeks and expected their release from prison in about 10 (1-64) weeks. 68% of participants reported having experienced a drug overdose by themselves. 84% had already experienced at least one drug emergency with another person, 36% more than once. Nearly one-third had not offered helped in the last emergency they had experienced, mostly out of fear of doing something wrong. Only 50% of participants had called emergency services. 25% tried to help, however, by not very effective means. 75% often consumed in the presence of other persons, such as partners and/or friends. The incarcerated opioid addicts were well motivated to participate and showed a significant increase in knowledge and skills for effective first aid in an opioid overdose situation.. The feasibility study carried out among imprisoned opioid addicts shows that manualized first aid training in handling opioid overdose, including take-home naloxone can be successfully implemented. A best-practice model for reducing initial caveats, organization, and prescribing take-home naloxone at release from prison was established. The high rate of drug overdoses and drug use in the presence of others (potential first responders) proves that the target group for successful use of first aid training along with take-home naloxone could be reached. However, a broad roll-out is needed to achieve a relevant reduction in mortality in opioid addicts after release from prison.. 22–30% der Inhaftierten in Deutschland sollen intravenöse Drogenkonsumenten sein. In den ersten Wochen nach Haftentlassung steigt das Sterberisiko um das 12-fache, meist infolge einer Opioidüberdosis. Als möglicher Baustein zur Mortalitätsreduktion soll die Machbarkeit einer Drogennotfallschulung, inkl. Take-Home Naloxon bei inhaftierten Opioidabhängigen überprüft werden.. Eine Teilstichprobe im Rahmen des Bayerischen Take-Home Naloxon Modellprojektes umfasste inhaftierte Opioidabhängige in 5 bayerischen Justizvollzugsanstalten. Es erfolgte eine manualisierte Drogennotfallschulung, inkl. Take-Home Naloxon. Sämtliche Erhebungen erfolgten mit standardisierten Fragebögen oder teilstrukturierten Interviews.. Durchschnittlich nahmen 3,9 (1–10) inhaftierte Opioidabhängige pro Schulung teil. Zum Zeitpunkt der Schulung waren die Opioidabhängigen seit 42 (1–228) Wochen in Haft und erwarteten ihre Haftentlassung in ca. 10 (1–64) Wochen. Es konnten 62 Opioidabhängige in Haft eingeschlossen werden (Alter: 36 (22–53) Jahre; 53,2% Frauen; Alter bei Opioid-Erstkonsum: 19,2 (10–31) Jahre). 68% waren bereits selbst von einem Drogennotfall betroffen. 84% erlebten bereits mindestens einen Drogennotfall bei einem anderen Konsumierenden, davon 36% sogar mehrmals. Knapp ein Drittel gab an, beim letzten erlebten Notfall nicht geholfen zu haben, meist aus Angst, etwas falsch zu machen. Knapp 50% riefen zumindest den Rettungsdienst. Immerhin 25% versuchten, zu helfen, allerdings mit wenig geeigneten Maßnahmen. 75% gaben an, häufig in Gegenwart anderer Personen zu konsumieren, meist mit Partner und/oder Freunden/Bekannten. Die inhaftierten Opioidabhängigen konnten gut zur Teilnahme motiviert werden und zeigten einen signifikanten Zuwachs an Wissen und Skills zum lebensrettenden Umgang mit einer Opioidüberdosierung.. Die Machbarkeitsstudie zeigt, dass manualisierte Drogenotfallschulungen mit inhaftierten Opioidabhängigen, sowie die Vergabe von Take-Home Naloxon am Haftende umsetzbar sind. Ein Best-Practice Modell wurde etabliert, z. B. Reduktion anfänglicher Vorbehalte, praktische Organisation, Naloxon-Verordnung durch AnstaltsärztInnen. Die hohe Rate an bereits erlebten Drogennotfällen und der häufige Konsum im Beisein Anderer (potentielle Ersthelfer) belegt, dass die Zielgruppe erreicht wurde. Für eine messbare Senkung der Mortalität benötigt es jedoch eine breite Ausrollung.

Topics: Adult; Analgesics, Opioid; Drug Overdose; Feasibility Studies; Female; First Aid; Germany; Humans; Male; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Prisons; Young Adult

Despite opioid prescribing for chronic non-cancer pain (CNCP) having limited therapeutic benefits, recent evidence indicates significant increases in the prescribing of high-strength opioids for individuals with CNCP. Patients prescribed opioids for CNCP have overdose risk factors but generally have low opioid overdose awareness and low perceptions of risk related to prescribed opioids. Currently, there are few bespoke overdose prevention resources for this group.. This qualitative study investigated views on a naloxone intervention for people prescribed high-strength opioids for CNCP delivered via community pharmacies. The intervention included overdose risk awareness and naloxone training and provision. Interviews were conducted with eight patients, four family members and two community pharmacists. Participants were convenience sampled and recruited through networks within the Scottish pain community. The Framework approach was used to analyse findings.. All participants had positive attitudes towards the intervention, but patients and family members considered risk of overdose to be very low. Three themes were identified: potential advantages of the intervention; potential barriers to the intervention; and additional suggestions and feedback about the intervention. Advantages included the intervention providing essential overdose information for CNCP patients. Barriers included resource and time pressures within community pharmacies.. While patients had low overdose knowledge and did not see themselves as being at risk of opioid overdose, they were receptive to naloxone use and positive about the proposed intervention. A feasibility trial is merited to further investigate how the intervention would be experienced within community pharmacy settings.

Topics: Analgesics, Opioid; Chronic Pain; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Pharmacies; Pharmacists; Practice Patterns, Physicians'

Topics: Analgesics, Opioid; Drug Overdose; Drug Users; Fentanyl; Humans; Naloxone; Psychological Distress; Substance Abuse, Intravenous; United States; West Virginia

In response to a surge of drug overdoses involving polysubstance use among Atlanta service industry workers that resulted in the deaths of five people in the Atlanta area in the summer of 2021, a local community of harm reductionists and nurses organized opioid education and naloxone distribution (OEND) training sessions specifically customized for service industry workers in Atlanta. After the sessions, the nurses and harm reductionists asked attendants to participate in a study concerning their response to overdoses. The reason nurses and harm reductionists conducted the study was to determine the efficacy of OEND training adapted for those working in the service industries as well as to evaluate and possibly modify the training sessions for future use. This pre-post study examined if and how participants' knowledge and attitudes toward an opioid-involved overdose changed after engaging with the OEND training. If the study determined that the sessions were successful in teaching service industry workers how to mitigate the immediate and devastating effects of overdose, we recommend expanding and implementing both adaptable training sessions like the OEND training referenced, as well as accompanying studies to improve the training sessions' effectiveness.. The pre-post study used convenience sampling to recruit participants in emergent OEND training. Participants completed an abbreviated version the Opioid Overdose Attitudes Scale (OOAS) which measured how, and to what degree, they changed their attitudes towards overdoses and their responses to them. Participants also completed an abbreviated version of the Opioid Overdose Knowledge Scale (OOKS) which measured how effectively the OEND increased their knowledge when it came to properly responding to an overdose, which included implementing naloxone as part of immediate rehabilitation treatment. Paired nonparametric tests assessed changes in participants' OOAS/OOKS scores.. A total of 161 individuals attended, and 72 consented to be in the study. The sample predominately consisted of white (76.4%) and female (66.7%) adults whose age averaged 34.3 years. Attitude and knowledge score improvements were statistically significant: approximately 11 points (p < .001) and 3 points (p < .001), respectively.. This rapidly implemented training was associated with improving attitudes and knowledge about responding to an opioid-involved overdose. We recommend expanding the scope of studies like these in order to develop and examine effective, dynamic, and targeted OEND training tailored towards specific community groups and situations, such as polysubstance overdose among service industry workers. As the opioid epidemic worsens, it is critical to equip community members themselves with the skills and tools to recognize and respond to opioid overdoses as a frontline prevention to overdose deaths.

Topics: Adult; Analgesics, Opioid; Drug Overdose; Female; Health Knowledge, Attitudes, Practice; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose

Since the COVID-19 pandemic, an increase in fentanyl-combined drugs has led to a surge in opioid overdose deaths in the United States. Higher opioid overdose mortality rates are problematic in rural communities, and there are few prevention, treatment, and recovery resources for individuals experiencing opioid use disorder.. This exploratory project aimed to investigate a hands-on naloxone training for rural clinicians and staff. Rural clinicians and staff at two behavioral health centers were recruited to participate in a 30-min lecture and 30-min hands-on intranasal naloxone training using a low-fidelity mannequin. A pre-post opioid knowledge questionnaire, rubric based on the Substance Abuse and Mental Health Services Administration toolkit, and investigator-generated survey were used to evaluate opioid knowledge and response, demonstration of intranasal naloxone administration, and participants' perceptions of the training. Enrollment characteristics were summarized using descriptive statistics and paired t-tests were used to assess mean differences.. Of the nine participants in the project, seven (87.5%) were female and six (75.0%) were Black. Four participants assumed a therapist role, attained a MS or MA degree, and had 5 or more years of experience working in healthcare. The total mean rubric score for all participants was 96.0 (SD = 8.8). No significant pre-post mean differences among opioid knowledge, overdose risk, and overdose response categories were found, all p > 0.05. However, post-intervention mean scores were slightly higher in all categories except overdose risk. Most participants (77.8%) responded that they felt comfortable handling an opioid situation and teaching the training to community members. Open-ended responses indicated that participants liked the demonstrations, examples used, hands-on nature of the training, and the presentation materials.. A hands-on naloxone training is beneficial for training rural clinicians and staff to respond to opioid overdose. This training may be a promising solution to reduce response time between recognition of opioid symptoms and administration of the life-saving medication, naloxone. Future studies should examine the efficacy of this training in larger samples with the inclusion of rural interdisciplinary teams, trusted community leaders, and family and friends of those impacted by opioid use disorder.. This innovative hands-on naloxone training is designed for rural clinicians and residents who are most likely to witness individuals experiencing opioid toxicity. The primary goal is to reduce response time between recognition of signs and symptoms and administration of the life-saving medication, Naloxone.

Topics: Analgesics, Opioid; COVID-19; Drug Overdose; Female; Humans; Male; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Pandemics; Rural Population; United States

Solitary drug use (SDU) can amplify risks of fatal overdose. We examined competing risks and drivers of SDU, as well as harm reduction strategies implemented during SDU episodes, among women who inject drugs (WWID).. A cross-sectional qualitative study, including telephone and face-to-face in-depth interviews.. Baltimore City, MD, USA.. Twenty-seven WWID (mean age = 39 years, 67% white, 74% injected drugs daily) recruited via outreach and street intercept (April-September 2021).. Interviews explored the physical (i.e. indoor/private, outdoor/public) and social (i.e. alone, accompanied) risk environments in which drug use occurred. Guided by the principles of emergent design, we used thematic analysis to interrogate textual data, illuminating women's preferences/motivations for SDU and strategies for minimizing overdose risks when using alone.. Many participants reported experiences with SDU, despite expressed preferences for accompanied drug use. SDU motivations clustered around three primary drivers: (1) avoiding opioid withdrawal, (2) preferences for privacy when using drugs and (3) safety concerns, including threats of violence. Participants nevertheless acknowledged the dangers of SDU and, at times, took steps to mitigate overdose risk, including naloxone possession, communicating to peers when using alone ('spotting') and using drugs in public spaces.. WWID appear to engage frequently in SDU due to constraints of the physical and social environments in which they use drugs. They express a preference for accompanied drug use in most cases and report implementing strategies to mitigate their overdose risk, especially when using drugs alone.

Topics: Adult; Cross-Sectional Studies; Drug Overdose; Female; Harm Reduction; Humans; Naloxone; Opioid-Related Disorders; Substance Abuse, Intravenous

Since 2017, a total of 10 states have mandated naloxone coprescribing intended to prevent fatal opioid overdoses. This study aims to assess the association between naloxone coprescribing/offering mandates and opioid-involved overdose deaths on the basis of the opioid type.. Data on overdose deaths from 1999 to 2020 came from the National Center for Health Statistics CDC WONDER Online Database. This study examined deaths stratified by illicit/synthetic opioids and prescription/treatment opioids. Difference-in-difference negative binomial regression models estimated average marginal effects and 95% CIs. Covariates included opioid dispensing rate, Good Samaritan law, pharmacy-based naloxone access law, mandatory use of prescription drug monitoring program, and recreational cannabis dispensaries. Data collection and analysis were conducted in 2022.. Ten states implemented naloxone coprescribing/offering mandates during the period. Coprescribing/offering mandates significantly reduced the number of prescription/treatment overdose deaths by 8.61 per state per quarter (95% CI= -15.13, -2.09), a 16% reduction from the counterfactual estimates. Coprescribing/offering mandates did not significantly impact illicit/synthetic overdose deaths (average marginal effect=0.32; 95% CI= -18.27, 18.91).. Coprescribing/offering mandates prevent overdose deaths for its target population, individuals using prescription/treatment opioids. These mandates do not appear to impact populations using illicit/synthetic opioids; thus, expanded efforts are needed to reach these individuals.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Prescriptions; United States

Over 10,000 older adults died from opioid overdose in 2019. Naloxone is an underutilized antidote that could prevent many opioid overdose-related deaths. There is a paucity of literature evaluating naloxone prescribing through meds-to-beds programs and in older adults. This single-center, retrospective, observational cohort study aimed to assess prescribing patterns of naloxone in patients 65 years and older who were prescribed opioids via a meds-to-beds program between December 2020 and November 2021. All patients 65 years and older dispensed an opioid via meds-to-beds were included. Patients receiving hospice or comfort care or those with unavailable records were excluded. The primary outcome was to assess the frequency of naloxone co-prescribing with opioid prescriptions via meds-to-beds. The 144 patients included were primarily females with a median age of 69 years old and opioid prescriptions for 45 morphine milligram equivalents daily. Two patients were prescribed naloxone (1.4%), one of whom was ultimately dispensed naloxone (0.7%). Of the 65 prescribers included in our study, the incidence of naloxone co-prescribing (2/65, 3.1%) was no different from a previously-reported rate among prescribers (3/179, 1.7%),

Topics: Aged; Analgesics, Opioid; Cohort Studies; Drug Overdose; Female; Humans; Naloxone; Opiate Overdose; Practice Patterns, Physicians'; Retrospective Studies

Overdose Prevention Sites (OPS) are low-barrier services where people may use illicit drugs under the monitoring of staff trained to provide life-saving care in the event of an overdose. In British Columbia (BC), Canada, OPS have been rapidly scaled-up as a community-based response to the overdose crisis and are staffed primarily by community members who are also people who use drugs (PWUD). While it is known that PWUD perform vital roles in OPS and other community-based overdose interventions, the expertise and expert knowledge of PWUD in this work remains under-theorised. This study draws on 20 months of ethnographic fieldwork in Vancouver, BC (July 2018 to March 2020), to explore how OPS responders who are PWUD developed and enacted expertise in overdose response. Ethnographic fieldwork focused on four OPS located in Vancouver's Downtown Eastside (DTES) and Downtown South neighbourhoods. Methods included 100 hours of observation in the sites and surrounding areas, three site-specific focus groups with OPS responders (n=20), and semi-structured interviews with OPS responders (n=14) and service users (n=23). Data was analysed with the aim of characterizing the knowledge underpinning responders' expertise, and the arrangements which allow for the formation and enactment of expertise. We found that OPS responders' expertise was grounded in experiential knowledge acquired through their positionality as PWUD and members of a broader community of activists engaged in mutual aid. Responders became skilled in overdose response through frequent practice and drew on their experiential and embodied knowledge of overdose to provide care that was both technically proficient and responsive to the broader needs of PWUD (e.g. protection from criminalization and stigmatizing treatment). Responders emphasized that the spatial arrangements of OPS supported the development of expertise by facilitating more specialized and comprehensive overdose care. OPS became sites of collective expertise around overdose management as responder teams developed shared understandings of overdose management, including processes for managing uncertainty, delegating team responsibilities, and sharing decision-making. This research re-situates theoretical understandings of expertise in community-based overdose response with implications for overdose prevention interventions. Findings underscore the experiential and embodied expertise of PWUD as community-based responders; the importance of sup

Topics: Anthropology, Cultural; British Columbia; Canada; Drug Overdose; Humans; Illicit Drugs; Naloxone

Topics: Adult; Analgesics, Opioid; Appalachian Region; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Prescriptions; Rural Population

The authors of this report present 3 cases of synthetic opioid intoxication complicated by the concomitant presence of the additive xylazine, a nonopioid sedative analgesic and muscle relaxant used in veterinary medicine that potentiates respiratory depression associated with the opioid toxidrome. Three exposed children presented with severe signs and symptoms, 2 of whom experienced cardiac arrest, a need for continuous naloxone infusion or multiple naloxone doses, or mechanical ventilation to treat respiratory failure after their exposures. Additives were detected in urine studies only through the performance of specialized toxicology testing. Detection of xylazine among adult overdose deaths has recently increased sharply, particularly across the northeastern United States. Adulteration by xylazine is an emerging public health threat nationally. Our report reveals that pediatricians should be aware of sentinel drug trends among adults, including the emerging types of illicit, synthetic, or counterfeit formulations of recreational substances, because children may be harmed because of accidental or intentional exposure. Children exposed to dangerous substances also need child protection services that may entail safe relocation outside of the home and the referral of affected caregivers to necessary substance use treatment services. Given epidemic drug use among adults, pediatricians should be competent to recognize common toxidromes and be aware that signs and symptoms may be potentiated by synergistic novel additives or polysubstance exposures. Importantly, standard urine drug screens may not detect synthetic opioid derivatives or contributing additives, so that diagnosis will require specialized toxicology testing.

Topics: Adult; Analgesics, Opioid; Child; Child, Preschool; Drug Overdose; Humans; Naloxone; Respiratory Insufficiency; Substance-Related Disorders; Xylazine

Limited data exist on when to offer naloxone to cancer patients on opioid therapy.. We assessed patient and clinician attitudes on naloxone education (done via surveys at initial and follow up visits) and prescribing rates (via chart reviews) at a single ambulatory palliative care practice. Pharmacy records assessed naloxone dispense rates.. During a three-month period, all new patients receiving opioid therapy were offered naloxone. Standardized educational materials on opioid safety and naloxone use were created and shared by clinical team.. Naloxone prescribing rates increased from 5% to 66%. 92% (n = 23) of clinicians reported education/prescribing took ≤ five minutes, and 100% reported either a positive or neutral impact on the encounter. A total of 81% (n = 25) of patients reported no increased worry about opioid use, 68% (n = 21) felt safer with naloxone, and 97% rated the encounter as neutral or positive. 88% (n = 37) of prescriptions were dispensed and 67% of patients (n = 16) paid <$10.. Opioid safety education and naloxone prescribing can be done quickly and is well-received by clinicians and patients.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Neoplasms; Opioid-Related Disorders; Palliative Care; Quality Improvement

The opioid epidemic remains one of the most pressing public health crises facing the United States. Fentanyl and related synthetic opioid agonists have largely driven the rising rates of associated overdose deaths, in part, because of their surreptitious use as substitutes for other opioids and as adulterants in psychostimulants. Deaths involving opioids typically result from lethal respiratory depression, and it is currently unknown how co-use of psychostimulants with opioids affects respiratory toxicity. Considering psychostimulant overdoses have increased over 3-fold since 2013, and half of those co-involved opioids, this is a cardinal question.. Naloxone, d-amphetamine (AMPH), and (±)-methamphetamine (METH) were evaluated for their effects on basal and fentanyl-depressed respiration. Minute volume (MVb) was measured in awake, freely moving mice via whole-body plethysmography to quantify fentanyl-induced respiratory depression and its modulation by dose ranges of each test drug.. Naloxone immediately reversed respiratory depression induced by fentanyl only at the highest dose tested (10 mg/kg). Both AMPH and METH exhibited bidirectional effects on MVb under basal conditions, producing significant (p ≤ 0.05) depressions then elevations of respiration as dose increased. Under depressed conditions the bidirectional effects of AMPH and METH on respiration were exaggerated, exacerbating and then reversing fentanyl-induced depression as dose increased.. These results indicate that co-use of amphetamines with fentanyl may worsen respiratory depression, but conversely, monoaminergic components of the amphetamines may possibly be exploited to mitigate fentanyl overdose.

Topics: Amphetamine; Analgesics, Opioid; Animals; Central Nervous System Stimulants; Drug Overdose; Fentanyl; Methamphetamine; Mice; Naloxone; Respiration; Respiratory Insufficiency; United States

Overdose is a leading cause of morbidity and mortality among people who inject drugs. Illicitly manufactured fentanyl is now a major driver of opioid overdose deaths.. Semi-structured interviews were conducted with 23 participants (19 persons who inject drugs and 4 service providers) from rural southern Illinois. Data were analyzed using constant comparison and theoretical sampling methods.. Participants were concerned about the growing presence of fentanyl in both opioids and stimulants, and many disclosed overdose experiences. Strategies participants reported using to lower overdose risk included purchasing drugs from trusted sellers and modifying drug use practices by partially injecting and/or changing the route of transmission. Approximately half of persons who inject drugs sampled had heard of fentanyl test strips, however fentanyl test strip use was low. To reverse overdoses, participants reported using cold water baths. Use of naloxone to reverse overdose was low. Barriers to naloxone access and use included fear of arrest and opioid withdrawal.. People who inject drugs understood fentanyl to be a potential contaminant in their drug supply and actively engaged in harm reduction techniques to try to prevent overdose. Interventions to increase harm reduction education and information about and access to fentanyl test strips and naloxone would be beneficial.

Topics: Analgesics, Opioid; Drug Overdose; Drug Users; Fentanyl; Humans; Illinois; Naloxone; Substance Abuse, Intravenous

This education-focused study examined changes in nursing students' knowledge and attitudes towards responding to opioid-involved overdoses following participation in trainings delivered using remote learning modalities.. This pre-post study examined learning outcomes among 17 nursing students.. Participants completed the Opioid Overdose Attitude Scale and Opioid Overdose Knowledge Scale to assess attitudes and knowledge, respectively. Trainings were delivered to two separate groups, one via virtual reality immersive video and another over video conferencing.. Attitude scores increased by an average of 12.2 points and knowledge scores increased by 1.65 points. Within the virtual reality group, attitude scores increased by an average of 10 points, while no significant changes were observed in knowledge scores. The video conferencing group improved in both attitude and knowledge scores, by an average of 16.2 points and 2.1 points, respectively.. These hypothesis generating results illustrate the utility of remote learning approaches to deliver trainings, while maintaining social distance during the ongoing COVID-19 pandemic.

Topics: Analgesics, Opioid; COVID-19; Drug Overdose; Health Knowledge, Attitudes, Practice; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Pandemics

To create a novel emergency medical service (EMS) opioid-related incident (ORI) tiering framework to describe more accurately the opioid epidemic in Massachusetts. By classifying the data, we could more accurately detail differing trends among the new categories.. Free-text fields of Massachusetts EMS reports, from 2013 through 2020, were analyzed to identify ORIs and then categorized into a five-tier severity cascade based on symptom presentation: 'dead on arrival,' 'acute overdose,' 'intoxication,' 'withdrawal' and 'other ORI.' As a validation of the new classification, an emergency medical technician, paramedic and emergency medical physician reviewed clinical reports and assigned a severity category to 100 randomly selected cases. The algorithm then assessed the same 100 cases to determine if it could accurately identify the severity category for each case.. Validation of the algorithm by clinical review indicated a substantial level of agreement between the algorithm and the reviewers. Over half of all ORIs were acute overdose (55%), 21% were intoxication, 20% were other ORI, 3% were withdrawal, and 1% were dead on arrival. Overall ORIs decreased in 2020, but the number of 'dead on arrival' increased 32% from 2019. Administration of naloxone also differed between the categories, with 95% of acute overdose and 29% of intoxication receiving naloxone.. This novel categorization of emergency medical service opioid-related incidents in Massachusetts, United States, reveals new trend details and strains on the emergency medical service system. Using these categories also improves dataset linkage within the state and interstate rate comparisons.

Topics: Analgesics, Opioid; Drug Overdose; Emergency Medical Services; Humans; Massachusetts; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; United States

Opioid-related overdose (OD) deaths continue to increase. Take-home naloxone (THN), after treatment for an OD in an emergency department (ED), is a recommended but under-utilized practice. To promote THN prescription, we developed a noninterruptive decision support intervention that combined a detailed OD documentation template with a reminder to use the template that is automatically inserted into a provider's note by decision rules. We studied the impact of the combined intervention on THN prescribing in a longitudinal observational study.. ED encounters involving an OD were reviewed before and after implementation of the reminder embedded in the physicians' note to use an advanced OD documentation template for changes in: (1) use of the template and (2) prescription of THN. Chi square tests and interrupted time series analyses were used to assess the impact. Usability and satisfaction were measured using the System Usability Scale (SUS) and the Net Promoter Score.. In 736 OD cases defined by International Classification of Disease version 10 diagnosis codes (247 prereminder and 489 postreminder), the documentation template was used in 0.0% and 21.3%, respectively (P < .0001). The sensitivity and specificity of the reminder for OD cases were 95.9% and 99.8%, respectively. Use of the documentation template led to twice the rate of prescribing of THN (25.7% vs 50.0%, P < .001). Of 19 providers responding to the survey, 74% of SUS responses were in the good-to-excellent range and 53% of providers were Net Promoters.. A noninterruptive decision support intervention was associated with higher THN prescribing in a pre-post study across a multiinstitution health system.

Topics: Drug Overdose; Emergency Service, Hospital; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

Topics: Adult; Analgesics, Opioid; Drug Overdose; Emergency Service, Hospital; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Rhode Island

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Nonprescription Drugs; Opioid-Related Disorders

Topics: Adolescent; Adult; Analgesics, Opioid; Drug Overdose; Fentanyl; Humans; Naloxone; Risk; Young Adult

Topics: Adolescent; Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Opioid Epidemic; Opioid-Related Disorders

The Helping End Addictions Long Term (HEALing) Communities Study (HCS) seeks to significantly reduce overdose deaths in 67 highly impacted communities in Kentucky (KY), Massachusetts (MA), New York (NY), and Ohio (OH) by implementing evidence-based practices (EBPs) to reduce overdose deaths. The Opioid-overdose Reduction Continuum of Care Approach (ORCCA) organizes EBP strategies under three menus: Overdose Education and Naloxone Distribution (OEND), Medication Treatment for Opioid Use Disorder (MOUD), and Safer Prescribing and Dispensing Practices (SPDP). The ORCCA sets requirements for strategy selection but allows flexibility to address community needs. This paper describes and compiles strategy selection and examines two hypotheses: 1) OEND selections will differ significantly between communities with higher versus lower opioid-involved overdose deaths; 2) MOUD selections will differ significantly between urban versus rural settings.. Wave 1 communities (n = 33) provided data on EBP strategy selections. Selections were recorded as a combination of EBP menu, sector (behavioral health, criminal justice, and healthcare), and venue (e.g., jail, drug court, etc.); target medication(s) were recorded for MOUD strategies. Strategy counts and proportions were calculated overall and by site (KY, MA, NY, OH), setting (rural/urban), and opioid-involved overdose deaths (high/low).. Strategy selection exceeded ORCCA requirements across all 33 communities, with OEND strategies accounting for more (40.8%) than MOUD (35.1%), or SPDP (24.1%) strategies. Site-adjusted differences were not significant for either hypothesis related to OEND or MOUD strategy selection.. HCS communities selected strategies from the ORCCA menu well beyond minimum requirements using a flexible approach to address unique needs.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Opiate Overdose; Opioid-Related Disorders

Despite the widespread availability of naloxone, US opioid overdose rates continue to rise. The "Cascade of Care" (CoC) is a public health approach that identifies steps in achieving specific outcomes and has been used to identify gaps in naloxone carriage among individuals with opioid use disorder (OUD). We sought to apply this framework to a treatment-seeking population with OUD that may be more inclined to engage in harm reduction behaviors.. Patients were recruited from an urban methadone program to complete a survey. We assessed naloxone familiarity, availability, obtainability, training, and possession, as well as naloxone carriage rates, demographics, and harm reduction behaviors. A multivariable logistic regression examined associations between naloxone carriage and individual-level factors.. Participants (n = 97) were majority male (59%), with a mean age of 48 (SD = 12), 27% had college education or higher, 64% indicated injection drug use, and 84% reported past naloxone training. All participants endorsed familiarity with naloxone, but only 42% regularly carried naloxone. The following variables were associated with carrying naloxone: White race (aOR = 2.94, 95% CI 1.02-8.52), college education (aOR = 8.11, 95% CI 1.76-37.47), and total number of self-reported harm reduction behaviors (aOR = 1.45, 95% CI 1.00-2.11).. We found low rates of naloxone carriage among methadone-treated patients. Methadone programs provide opportunities for naloxone interventions and should target racial/ethnic minorities and individuals with lower education. The spectrum of harm reduction behaviors should be encouraged among these populations to enhance naloxone carriage.

Topics: Analgesics, Opioid; Drug Overdose; Harm Reduction; Humans; Male; Methadone; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

The opioid epidemic is a public health issue in the United States. The objective of this study was to evaluate the association between naloxone coprescription mandates and postoperative outcomes.. Data on naloxone coprescription mandates show mixed evidence for fatal overdoses in the broader population. How these mandates have impacted surgical patients has not been fully explored.. Healthcare claims data were used to identify all patients undergoing 1 of 50 common procedures between January 1, 2004, and June 30, 2019, and categorized as high risk for opioid overdose. The primary outcomes were an emergency department visit or hospital admission within 30 postoperative days. To reduce confounding, the association between this outcome and the implementation of naloxone coprescription mandates was estimated using a difference-in-differences approach.. The study included 429,878 surgical patients with an average age of 54.8 years (SD=15.9 years) and with 257,728 females (60.0%). There was no significant association between naloxone prescribing mandates and the primary outcomes. After adjustment for potential confounders, the incidence of hospital admission was 3.26% after implementation of a naloxone coprescription mandate compared with 3.33% before (difference change: -0.08%, 95% CI: -0.44% to 0.29%, P =0.68). The incidence of an emergency department visit was 7.06% after implementation of a naloxone coprescription mandate compared with 7.73% before (difference: -0.67%, 95% CI: -1.39% to 0.05%, P =0.07). These results were robust to a variety of sensitivity and subgroup analyses.. Naloxone coprescription mandates were not associated with a statistically or clinically significant change in emergency department visits or hospital admissions within 30 postoperative days.

Topics: Analgesics, Opioid; Drug Overdose; Emergency Service, Hospital; Female; Hospitalization; Humans; Middle Aged; Naloxone; United States

There has been a rise in illicit drugs such as fentanyl being mixed with xylazine, a veterinary tranquilizer. Xylazine is not an opioid; although opioids and xylazine induce similar respiratory symptoms, naloxone will not reverse a xylazine overdose. Severe necrotic skin ulcerations are also possible from frequent exposure to xylazine.Nurses who encounter patients with severe necrotic skin ulcerations or respiratory symptoms should consider xylazine overdose and attempt to determine if xylazine abuse is the root cause.

Topics: Analgesics, Opioid; Drug Overdose; Fentanyl; Humans; Illicit Drugs; Naloxone; Xylazine

Topics: Drug Overdose; Humans; Law Enforcement; Naloxone; Narcotic Antagonists; Police

Opioids and stimulants are increasingly implicated in overdose deaths, particularly among minoritized groups. We examined daily opioid and cocaine co-use, nonfatal overdoses, and naloxone carrying among minoritized people who inject drugs (PWID).. The study derived data from 499 PWID in Baltimore City, MD, recruited using street-based outreach between 2016 and 2019. Participants reported overdoses; sociodemographic characteristics; and use of nonmedical prescription opioids, heroin, cocaine, and naloxone.. Among the participants, the mean age was 46, 34 % were female, 64 % self-identified as Black, and 53 % experienced recent homelessness. Black PWID, compared to White PWID, were as likely to use opioids and cocaine daily but were 61 % less likely to have naloxone. After controlling for sociodemographic characteristics, women (aOR:1.88, 95%CI: 1.14, 3.11), persons experiencing homelessness (aOR:3.07, 95%CI: 1.79, 5.24), and those who experienced a recent overdose (aOR:2.14, 95%CI: 1.29, 3.58) were significantly more likely to use opioids and any form of cocaine every day. In a subanalysis of only female PWID, females engaged in sex work (aOR:2.27, 95%CI: 1.02, 5.07) and females experiencing recent homelessness (aOR:5.82, 95%CI: 2.50, 13.52) were significantly more likely to use opioids and cocaine daily. Furthermore, females (aOR:1.69, 95%CI:1.03, 2.77), persons experiencing homelessness (aOR:1.94, 95%CI:1.16, 3.24), and those with higher educational attainment (aOR:2.06, 95%CI:1.09, 3.91) were more likely to often/always carry naloxone, while Black PWID were less likely to have naloxone (aOR:0.39, 95%CI:0.22, 0.69).. These findings highlight the need for targeted naloxone distribution and other harm-reduction interventions among minoritized groups in urban areas.

Topics: Analgesics, Opioid; Cocaine; Cocaine-Related Disorders; Drug Overdose; Female; Humans; Male; Naloxone; Opioid-Related Disorders; Substance Abuse, Intravenous

Opioid overdose-related morbidity and mortality is a pressing public health crisis. Successful overdose reversal through bystander administration of naloxone is well documented, but there is an absence of literature on the implementation and impact of widespread naloxone access in a correctional setting during incarceration. The objective of this study was to describe our efforts to combat opioid overdose, prevent deaths, and examine and identify opioid use and predictors of opioid use through factors including age, sex assigned at birth, and ethnicity among the incarcerated population within the Los Angeles County jail system.. We retrospectively analyzed self-reported substance use information from all newly incarcerated persons from September 2018 to December 2020 to characterize opioid use in the Los Angeles County Jail system and used multivariable logistic regression analysis to determine predictors of substance use. We analyzed data on all cases of naloxone administration by custody personnel (i.e., all correctional officers) during the same period by examining patient demographic information, hospital discharge diagnosis, and patient outcome information. To describe naloxone training and access for incarcerated persons as an overdose prevention strategy, we reviewed electronic health record data on patient health outcomes for all cases of naloxone administration by an incarcerated person.. A total of 6.4 % (11,881 of 187,528) of incarcerated persons reported opioid use. In the multivariable analysis, reported substance use was most significantly associated with any ethnicity other than Black (aOR for White =11.2; 95 % CI 10.4, 12.0, aOR for Hispanic/Latinx 3.0; 95 % CI 2.8, 3.2, aOR for All Others; 5.2 95 % CI 4.6, 5.8) and being <65 years old. Naloxone was administered by custody personnel to a total of 129 patients, where 122 (94.6 %) survived and 7 (5.4 %) died. After the deployment of naloxone in jail housing units, there were two instances of bystander naloxone administration by incarcerated persons that led to successful opioid overdose reversal and survival.. The expansion of naloxone availability to both custody personnel and incarcerated persons is an effective and warranted method to ensure timely naloxone administration and successful overdose reversal in a correctional setting.

Topics: Aged; Analgesics, Opioid; Drug Overdose; Female; Humans; Jails; Los Angeles; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid Epidemic; Opioid-Related Disorders; Retrospective Studies

Drug overdose mortality is rising precipitously among Black people who use drugs. In NYC, the overdose mortality rate is now highest in Black (38.2 per 100,000) followed by the Latinx (33.6 per 100,000) and white (32.7 per 100,000) residents. Improved understanding of access to harm reduction including naloxone across racial/ethnic groups is warranted.. Using data from an ongoing study of people who use illicit opioids in NYC (N = 575), we quantified racial/ethnic differences in the naloxone care cascade.. We observed gaps across the cascade overall in the cohort, including in naloxone training (66%), current possession (53%) daily access during using and non-using days (21%), 100% access during opioid use (20%), and complete protection (having naloxone and someone who could administer it present during 100% of opioid use events; 12%). Naloxone coverage was greater in white (training: 79%, possession: 62%, daily access: 33%, access during use: 27%, and complete protection: 13%, respectively) and Latinx (training: 67%, possession: 54%, daily access: 22%, access during use: 24%, and complete protection: 16%, respectively) versus Black (training: 59%, possession: 48%, daily access:13%, access during use: 12%, and complete protection: 8%, respectively) participants. Black participants, versus white participants, had disproportionately low odds of naloxone training (OR 0.40, 95% CI 0.22-0.72). Among participants aged 51 years or older, Black race (versus white, the referent) was strongly associated with lower levels of being trained in naloxone use (OR 0.20, 95% CI 0.07-0.63) and having 100% naloxone access during use (OR 0.34, 95% CI 0.13-0.91). Compared to white women, Black women had 0.27 times the odds of being trained in naloxone use (95% CI 0.10-0.72).. There is insufficient protection by naloxone during opioid use, with disproportionately low access among Black people who use drugs, and a heightened disparity among older Black people and Black women.

Topics: Analgesics, Opioid; Black People; Drug Overdose; Female; Hispanic or Latino; Humans; Naloxone; New York City; Opiate Overdose; Opioid-Related Disorders; White

Naloxone is a medication that can quickly reverse an opioid overdose. Syringe service programs (SSPs) are community-based prevention programs that provide a range of evidence-based interventions in the USA, including naloxone distribution. Attributes of SSPs make them ideal settings for naloxone distribution-they have staff and delivery models that are designed to reach people who use drugs where they are. We assessed which outer and inner setting factors of SSPs were associated with naloxone distribution in the USA.. We surveyed SSPs in the USA known to the North American Syringe Exchange Network in 2019. Using the exploration, preparation, implementation and maintenance framework, we assessed inner and outer contextual factors associated with naloxone distribution among SSPs (n = 263 or 77% of SSPs). We utilized negative binomial regression to assess which factors were associated with the number of naloxone doses distributed and people receiving naloxone.. SSPs reported distributing 710,232 naloxone doses to 230,506 people in the prior year. Regarding outer setting, SSPs located in areas with high levels of community support had a higher level of naloxone distribution (aIRR = 3.07; 95% confidence interval (CI): 2.09-4.51; p < 0.001) and 110% (p = 0.022) higher rate of people receiving naloxone (aIRR = 2.10; 95% CI 1.46-3.02; p < 0.001) in the past 12 months. The legal status of SSPs and the level of need was not significantly associated with naloxone distribution. Regarding inner setting, SSPs with proactive refill systems (aIRR = 2.08; 95% CI 1.27-3.41; p = 0.004), greater number of distribution days (aIRR = 1.09 per day; 95% CI 1.06-1.11; p < 0.001) and older programs (aIRR = 1.06 per year; 95% CI 1.02-1.11; p = 0.004) were associated with higher levels of naloxone distribution. Also, SSPs with proactive refill systems (aIRR = 2.23; 95% CI 1.38-3.58; p = 0.001); greater number of distribution days (aIRR = 1.04; 95% CI 1.02-1.07; p < 0.001) and older programs (aIRR = 1.11; 95% CI 1.05-1.17; p < 0.001) were associated with a higher number of people receiving naloxone.. We identified outer and inner setting factors of SSPs that were associated with greater naloxone distribution. It is critical to ensure SSPs are adequately resourced to build community support for services and develop service delivery models that maximize naloxone distribution to address the nation's opioid overdose crisis.

Topics: Cross-Sectional Studies; Drug Overdose; Humans; Naloxone; Opiate Overdose; Syringes; United States

Naloxone distribution is central to ongoing efforts to address the opioid overdose crisis. Some critics contend that naloxone expansion may inadvertently promote high-risk substance use behaviors among adolescents, but this question has not been directly investigated.. We examined relationships between naloxone access laws and pharmacy naloxone distribution with lifetime heroin and injection drug use (IDU), 2007-2019. Models generating adjusted odds ratios (aOR) and 95% confidence intervals (CI) included year and state fixed effects, controlled for demographics and sources of variation in opioid environments (e.g., fentanyl penetration), as well as additional policies expected to impact substance use (e.g., prescription drug monitoring). Exploratory and sensitivity analyses further examined naloxone law provisions (e.g., third-party prescribing) and applied e-value testing to assess vulnerability to unmeasured confounding.. Adoption of any naloxone law was not associated with changes in adolescent lifetime heroin or IDU. For pharmacy dispensing, we observed a small decrease in heroin use (aOR: 0.95 [CI: 0.92, 0.99]) and a small increase in IDU (aOR: 1.07 [CI: 1.02, 1.11]). Exploratory analyses of law provisions suggested that third-party prescribing (aOR: 0.80, [CI: 0.66, 0.96]) and non-patient-specific dispensing models (aOR: 0.78, [CI: 0.61, 0.99]) were associated with decreased heroin use but not decreased IDU. Small e-values associated with the pharmacy dispensing and provision estimates indicate that unmeasured confounding may explain observed findings.. Naloxone access laws and pharmacy naloxone distribution were more consistently associated with decreases rather than increases in lifetime heroin and IDU among adolescents. Our findings therefore do not support concerns that naloxone access promotes high-risk adolescent substance use behaviors. As of 2019, all US states have adopted legislation to improve naloxone access and facilitate use. However, further removal of adolescent naloxone access barriers is an important priority given that the opioid epidemic continues to affect people of all ages.

Topics: Adolescent; Analgesics, Opioid; Drug Overdose; Heroin; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; United States

Although naloxone has proven to be an effective opioid reversal agent, concern that high doses of naloxone can cause pulmonary edema may prevent health care providers from administering it in initial high doses.. Our aim was to determine whether increased doses of naloxone are correlated with an increase in pulmonary complications in patients presenting to the emergency department (ED) after an opioid overdose.. This was a retrospective study of patients treated with naloxone by emergency medical services (EMS) or in the ED at an urban level I trauma center and three associated freestanding EDs. Data were queried from EMS run reports and the medical record and included demographic characteristics, naloxone dosing, administration route, and pulmonary complications. Patients were grouped by naloxone dose received, defined as low (≤ 2 mg), moderate (> 2 mg to ≤ 4 mg), and high (> 4 mg).. Of the 639 patients included, 13 (2.0%) were diagnosed with a pulmonary complication. There was no difference in the development of pulmonary complications across groups (p = 0.676). There was no difference in pulmonary complications based on the route of administration (p = 0.342). The administration of higher doses of naloxone was not associated with longer hospital stays (p = 0.0327).. Study results suggest that the reluctance of many health care providers to administer larger doses of naloxone on initial treatment may not be warranted. In this investigation, there were no poor outcomes associated with an increase in naloxone administration. Further investigation in a more diverse population is warranted.

Topics: Analgesics, Opioid; Drug Overdose; Emergency Medical Services; Humans; Naloxone; Narcotic Antagonists; Retrospective Studies

This viewpoint discusses and suggests clinical interventions to be implemented by clinicians and health systems in North America to reduce opioid overdose deaths among at-risk patients.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; North America; Opiate Overdose; Opioid-Related Disorders; Universal Precautions

Angiotensin-converting enzyme (ACE) inhibitor overdose is an uncommonly presenting toxicologic emergency. Management is primarily supportive care, but a small body of evidence exists to support naloxone for management of hypotension.. We present a case of accidental ACE inhibitor overdose. The patient took approximately 300 mg lisinopril over 48 h and presented for evaluation of syncope. He was hypotensive and unresponsive to fluids. We administered naloxone with immediate and sustained resolution in hypotension. The mechanism of action is briefly discussed. WHY SHOULD AN EMERGENCY MEDICINE PHYSICIAN BE AWARE OF THIS?: Naloxone is a rapid, low-risk, low-cost, and effective intervention for hypotension due to ACE inhibitor toxicity. It is supported by basic science research and clinical experience.

Topics: Angiotensin-Converting Enzyme Inhibitors; Drug Overdose; Humans; Hypotension; Lisinopril; Male; Naloxone

Naloxone reverses opioid overdose, but it is not universally prescribed. With increases in opioid-related emergency department visits, emergency medicine providers are in a unique position to identify and treat opioid-related injury, but little is known about their attitudes and practices around naloxone prescribing. We hypothesized that emergency medicine providers would identify multifactorial barriers to naloxone prescribing and report varying levels of naloxone-prescribing behaviors.. A survey designed to assess attitudes and behaviors regarding naloxone prescribing practices was emailed to all prescribing providers at an urban academic emergency department. Descriptive and summary statistics were performed.. The response rate was 29% (36/124). Nearly all respondents (94%) expressed openness to prescribing naloxone from the emergency department, but only 58% had actually done so. Most (92%) believed that patients would benefit from greater access to naloxone, however 31% also believed that opioid use would increase as access to naloxone increases. Time was the most frequently identified barrier (39%) to prescribing, followed by a perceived inability to properly educate patients on naloxone use (25%).. In this study of emergency medicine providers, the majority of respondents were amendable to prescribing naloxone, yet almost half had not done so and some believed that doing so would increase opioid use. Barriers included time constraints and perceived self-reported knowledge deficits regarding naloxone education. More information is needed to gauge the impact of individual barriers to prescribing naloxone, but these findings may provide information that can be incorporated in provider education and potential clinical pathways designed to increase naloxone prescribing.

Topics: Analgesics, Opioid; Drug Overdose; Drug Prescriptions; Emergency Service, Hospital; Health Knowledge, Attitudes, Practice; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Prescription Drugs

Opioid overdose fatalities are preventable with timely administration of naloxone, an opioid antagonist, during an opioid overdose event. Syringe service programs have pioneered naloxone distribution for potential bystanders of opioid overdose. The objective of this study was to pilot test a multi-component implementation strategy-the systems analysis and improvement approach for naloxone (SAIA-Naloxone)-with the goal of improving naloxone distribution by syringe service programs.. Two syringe service programs participated in a 6-month pilot of SAIA-Naloxone, which included (1) analyzing program data to identify gaps in the naloxone delivery cascade, (2) flow mapping to identify causes of attrition and brainstorm programmatic changes for improvement, and (3) conducting continuous quality improvement to test and assess whether modifications improve the cascade. We conducted an interrupted time series analysis using 52 weeks of data before and 26 weeks of data after initiating SAIA-Naloxone. Poisson regression was used to evaluate the association between SAIA-Naloxone and the weekly number of participants receiving naloxone and number of naloxone doses distributed.. Over the course of the study, 11,107 doses of naloxone were distributed to 6,071 participants. Through SAIA-Naloxone, syringe service programs prioritized testing programmatic modifications to improve data collection procedures, proactively screen and identify naloxone-naïve participants, streamline naloxone refill systems, and allow for secondary naloxone distribution. SAIA-Naloxone was associated with statistically significant increases in the average number of people receiving naloxone per week (37% more SPP participants; 95% CI, 12% to 67%) and average number of naloxone doses distributed per week (105% more naloxone doses; 95% CI, 79% to 136%) beyond the underlying pre-SAIA-Naloxone levels. These initial increases were extended by ongoing positive changes over time (1.6% more SSP participants received naloxone and 0.3% more naloxone doses were distributed in each subsequent week compared to the weekly trend in the pre-SAIA Naloxone period).. SAIA-Naloxone has strong potential for improving naloxone distribution from syringe service programs. These findings are encouraging in the face of the worsening opioid overdose crisis in the United States and support testing SAIA-Naloxone in a large-scale randomized trial within syringe service programs.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Pilot Projects; Syringes; Systems Analysis; United States

Distribution of naloxone and training on its proper use are evidence-based strategies for preventing opioid overdose deaths. In-person naloxone training was conducted in major metropolitan areas and urban centers across Texas as part of a state-wide targeted opioid response program. The training program transitioned to a live, virtual format during the COVID-19 public health emergency declaration. This manuscript describes the impact of this transition through analyses of the characteristics of communities reached using the new virtual training format.. Training participant addresses were compared to county rates of opioid overdose deaths and broadband internet access, and census block comparison to health services shortages, rural designation, and race/ethnicity community characteristics.. The virtual training format reached more learners than the in-person events. Training reached nearly half of the counties in Texas, including all with recent opioid overdose deaths. Most participants lived in communities with a shortage of health service providers, and training reached rural areas, those with limited broadband internet availability, and majority Hispanic communities. In the context of restrictions on in-person gathering, the training program successfully shifted to a live, online format. This transition increased participation above rates observed pre-pandemic and reached communities with the need for equipping those most likely to witness an opioid overdose with the proper use of naloxone.

Topics: Analgesics, Opioid; COVID-19; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Pandemics; Texas

Since the emergence of fentanyl in the drug market, syringe services programs (SSPs) have been at the forefront of providing life-saving tools such as naloxone and fentanyl test strips to people who use drugs (PWUD). It is still unclear, however, how the adoption of risk-reduction practices has differed among PWUD in the context of increasing presence of non-pharmaceutical fentanyl in the drug supply. This study aims to assess the adoption of risk-reduction tools (e.g., naloxone) among those engaged with SSP services and those not engaged with SSP services.. We conducted a mixed-methods study following a convergent parallel design integrating both quantitative and qualitative data. Interviews were conducted with 80 people who used street opioids (i.e., heroin or opioid pills not prescribed), 32 of whom were not engaged in SSP services. Quantitative differences between those engaged and those not engaged in SSPs were assessed using independent samples t tests and Fisher's exact tests. A thematic analytic approach was employed to compare qualitative responses between the two groups.. Three main themes emerged in our analysis: (1) Both groups expressed an interest in fentanyl test strips (FTS), but those engaged in SSP services found them to be more accessible; (2) there was greater adoption of and enthusiasm for naloxone among SSP participants; and (3) SSP participants were more likely to have or be interested in having someone check in on them when using alone, but stigma and perceived personal risk of overdose prevented widespread adoption of this practice among all participants.. SSPs provide a vital function by facilitating naloxone and FTS distribution to participants who often have little control over their exposure to fentanyl. However, stigma and misconceptions regarding drug use are barriers to people adopting risk-reduction practices, particularly among those not engaged with SSPs.

Topics: Analgesics, Opioid; Drug Overdose; Fentanyl; Humans; Naloxone; New York City; Risk Reduction Behavior

Opioids were implicated in approximately 88,000 fatal overdoses (OD) globally. However, in principle all opioid OD are reversible with the timely administration of naloxone hydrochloride. Despite the widespread availability of naloxone among people who use opioids (PWUO), many who suffer fatal OD use alone, without others present to administer the reversal agent. Recognising this key aspect of the challenge calls for innovations, a number of technological approaches have emerged which aim to connect OD victims with naloxone. However, the acceptability of OD response technologies to PWUO is of key concern.. Drawing on the Technology People Organisations Macroenvironment (TPOM) framework, this study sought to integrate acceptability-related findings in this space with primary research data from PWUO, affected family members and service providers to understand the factors involved in harm reduction technology acceptability. A qualitative study using a focus group methodology was conducted. The participant groups were people with lived experience of problem opioid use, affected family members and service providers. Data analysis followed a multi-stage approach to thematic analysis and utilised both inductive and deductive methods.. Thirty individuals participated in one of six focus groups between November 2021 and September 2022. The analysis generated six major themes, three of which are reported in this article-selected for their close relevance to PWUO and their importance to developers of digital technologies for this group. 'Trust-in technologies, systems and people' was a major theme and was closely linked to data security, privacy and confidentiality. 'Balancing harm reduction, safety and ambivalence' reflects the delicate balance technological solutions must achieve to be acceptable to PWUO. Lastly, 'readiness-a double bind' encapsulates the perception shared across participant groups, that those at the highest risk, may be the least able to engage with interventions.. Effective digital strategies to prevent fatal OD must be sensitive to the complex relationships between technological, social/human, organisational and wider macroenvironmental factors which can enable or impede intervention delivery. Trust, readiness and performance are central to technology acceptability for PWUO. An augmented TPOM was developed (the TPOM-ODART).

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Technology

The Pennsylvania Opioid Overdose Reduction Technical Assistance Center (ORTAC) was developed to provide community-level support across Pennsylvania with the goal of reducing the opioid-related overdose death (ODD) rate via coalition building/coordination and tailored technical assistance. This study evaluates the initial effects of ORTAC engagement on county-level opioid ODD reductions.. Using quasi-experimental difference-in-difference models, we compared ODD per 100,000 population per quarter between 2016 and 2019 in the 29 ORTAC-implementing counties against the 19 nonengaged counties while controlling for county-level time-varying confounders (e.g., naloxone administration by law enforcement).. Findings reinforce the impact of coordinating communities around addressing the ODD crisis. Future policy efforts should provide a suite of overdose reduction strategies and intuitive data structures that can be tailored to individual communities' needs.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Pennsylvania

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Nonprescription Drugs

Emerging data indicate a disproportionate increase in overdose deaths since the onset of COVID-19. Speculation about causes for the increase center on rising drug use, illicit drug supply changes, and reduced treatment access. Possible overdose mitigation factors include reduced federal MOUD prescribing restrictions, naloxone distribution programs, and increased use of telehealth. Similarly, nonprescribed buprenorphine (NPB) use, increasingly described as a harm reduction strategy in the absence of treatment, may have moderated overdose risk. This study explored factors associated with pandemic-related overdose in people who use opioids (PWUO) in New Jersey.. We surveyed 342 PWUO from March to May 2021. Approximately 50 % of our sample was treated at some time since the COVID-19 emergency declaration in March 2020. The risk and protective factors associated with overdose were identified using Pearson's chi square test and ANOVA and tested in a series of multivariable logistic regression models for the full sample and the subsample of PWUO treated during the pandemic.. Forty-eight percent of respondents increased their drug use during the pandemic, including 32 % who relapsed after previous abstinence. Fifteen percent overdosed at least once since March 2020. In the full sample, overdose was associated with Hispanic ethnicity (AOR = 3.51; 95 % CI = 1.22-10.11), pre-pandemic overdose (AOR = 6.75; 95 % CI = 3.03-15.02), lack/loss of medical insurance (AOR = 3.02; 95 % CI = 1.01-9.02), relapse (AOR = 2.94; 95 % CI = 1.36-6.36), and nonprescribed use of buprenorphine/naloxone (AOR = 3.16; 95 % CI = 1.49-6.70). The study found similar trends in the treatment sample, with the exceptions that heroin/fentanyl use also predicted overdose (AOR = 3.43; 95 % CI = 1.20-9.78) and the association of overdose with nonprescribed buprenorphine/naloxone was stronger (AOR = 4.91; 95 % CI = 2.01-12.03). Potential mitigating factors, such as take-home methadone and telehealth, were not significant.. Relapse during the pandemic was widespread and a significant contributor to overdose. Lack/loss of medical insurance further exacerbated the risk. Despite the growing literature reporting "therapeutic" use of NPB, people using nonprescribed buprenorphine/naloxone in the current study experienced up to five times the risk of overdose as nonusers. This finding suggests that, despite therapeutic intent, PWUO may be using NPB in ways that are ineffectual for addiction management, especially in the context of changing buprenorphine induction protocols in the context of fentanyl.

Topics: Analgesics, Opioid; Buprenorphine, Naloxone Drug Combination; COVID-19; Drug Overdose; Fentanyl; Humans; Naloxone; Opiate Overdose; Pandemics; Recurrence

Take-Home Naloxone (THN) programs were introduced in Sweden in 2018 - a country with one of the highest rates of overdose mortality in the EU and a severe stigmatisation of people who inject drugs. This qualitative study builds on the international research that has expanded a previously narrow and medical focus on overdose deaths. It uses Zinberg's framework to look beyond the role of the "drug" to include the attitudes and personality of the person ("set") and contextual factors ("setting"). This study explores the impacts of THN from the perspective of overdose survivors.. Between November 2021 and May 2022 semi-structured interviews were conducted with 22 opioid overdose survivors, recruited among clients of the Stockholm needle and syringe program. All the participants had been treated with naloxone in an overdose situation. The interviews were processed through thematic analysis using deductive and inductive coding in accordance with the theoretical framework.. Interviewees included men and women who used different types of drugs. THN has impacted on "drug" in terms of naloxone-induced withdrawal symptoms and peers having to deal with survivors' emotions. Exploring "set" revealed feelings of shame following naloxone revival for the person who overdosed. Despite such reactions, participants retained an overwhelmingly positive attitude towards THN. Participants integrated THN into their risk management practices ("setting") and some acknowledged that THN provided a new way to treat overdoses without necessarily needing to interact with authorities, especially the police.. The THN program has influenced "drug, set and setting" for participants, providing increased safety at drug-intake and transferring overdose management and the burden of care to the community. The lived experience of participants also exposes the limitations of THN indicating that there are additional unmet needs beyond THN programs, particularly in terms of "setting".

Topics: Drug Overdose; Female; Humans; Male; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Peer Group

Topics: Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Nasal Sprays; Nonprescription Drugs

Topics: Analgesics, Opioid; Drug Overdose; Emergency Service, Hospital; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

Opioid overdoses are a growing concern, particularly among people who inject drugs. Sweden, with a comparatively high proportion of drug-related mortality, introduced its first Take-Home Naloxone (THN) program in 2018, at the Stockholm needle and syringe program (NSP). In this study we compare THN participant characteristics regarding refills and overdose reversals as well as investigate predictors associated with number of reversals. We also investigate interventions performed in overdose situations and endpoints for naloxone doses.. This was a prospective open inclusion cohort study conducted between January 24. Among study participants (n = 1,295), 66.5% stated opioids as their primary drug, and 61.4% and 81.0% had previous experience of a personal or witnessed overdose, respectively. Overall, 44.0% of participants reported a total of 1,625 overdose reversals and the victim was known to have survived in 95.6% of cases. Stimulant use (aIRR 1.26; 95% CI 1.01, 1.58), benzodiazepine use (aIRR 1.75; 95% CI 1.1, 2.78) and homelessness (aIRR 1.35; 95% CI 1.06, 1.73) were predictors associated with an increased number of reported overdose reversals. Mortality was higher among those who reported at least one overdose reversal (HR 3.4; 95% CI 2.2, 5.2).. An NSP's existent framework can be utilised to effectively implement a THN program, provide basic training and reach numerous high-risk individuals. During the four-year study, THN participants reversed a sizeable number of potentially fatal overdoses, of which many were reported by participants whose primary drug was not opioids. Naloxone refill rate was high, indicating that participants were motivated to maintain a supply of naloxone in case of future overdose events.

Topics: Analgesics, Opioid; Cohort Studies; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Prospective Studies; Sweden

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.. 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.. 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.. 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.

Topics: Drug Overdose; Feasibility Studies; Harm Reduction; Humans; Naloxone; Qualitative Research

Topics: Analgesics, Opioid; Drug Overdose; Health Services Accessibility; Humans; Medically Underserved Area; Naloxone; Narcotic Antagonists

Opioid overdose epidemic is a public health crisis that is impacting communities around the world. Overdose education and naloxone distribution programs equip and train lay people to respond in the event of an overdose. We aimed to understand factors to consider for the design of naloxone distribution programs in point-of-care settings from the point of view of community stakeholders.. We hosted a multi-stakeholder co-design workshop to elicit suggestions for a naloxone distribution program. We recruited people with lived experience of opioid overdose, community representatives, and other stakeholders from family practice, emergency medicine, addictions medicine, and public health to participate in a full-day facilitated co-design discussion wherein large and small group discussions were audio-recorded, transcribed and analysed using thematic approaches.. A total of twenty-four participants participated in the multi-stakeholder workshop from five stakeholder groups including geographic and setting diversity. Collaborative dialogue and shared storytelling revealed seven considerations for the design of naloxone distribution programs specific to training needs and the provision of naloxone, these are: recognizing overdose, how much naloxone, impact of stigma, legal risk of responding, position as conventional first aid, friends and family as responders, support to call 911.. To create an naloxone distribution program in emergency departments, family practice and substance use treatment services, stigma is a central design consideration for training and naloxone kits. Design choices that reference the iconography, type, and form of materials associated with first aid have the potential to satisfy the need to de-stigmatize overdose response.

Topics: Analgesics, Opioid; Drug Overdose; Emergency Service, Hospital; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders

The United States continues to experience unprecedented rates of overdose mortality. Addressing the overdose epidemic has been challenging for policy makers given the lack of effectiveness of existing drug control policy measures. More recently, the implementation of harm reduction-based policies such as Good Samaritan Laws has led to increasing scholarly attention aimed at evaluating their effectiveness at reducing the likelihood of criminal justice-related sanctions for individuals following an overdose incident. The results of these studies, however, have been mixed.. This study utilizes data from a nationally representative survey of law enforcement agencies designed to provide national information on services, policies, practices, operations, and resources of law enforcement drug response around overdoses to assess whether state Good Samaritan Laws reduce the likelihood of overdose victims being cited or being jailed following an overdose incident.. In general, findings indicate that although most agencies reported that overdose victims were not incarcerated or cited following an overdose incident, that this did not vary by whether agencies were in a state that had a GSL arrest protection for possession of controlled substances.. GSLs are often written in complex and confusing language that officers and people who use drugs do not fully understand, which may deter their being used for their intended purpose. Although GSLs are well-intentioned, these findings highlight the need for training and education for law enforcement and people who use drugs around the scope of these laws.

Topics: Drug and Narcotic Control; Drug Overdose; Epidemics; Humans; Intention; Law Enforcement; Naloxone; United States

The opioid overdose epidemic has caused over 600,000 deaths in the U.S. since 1999. Public access naloxone programs show great potential as a strategy for reducing opioid overdose-related deaths. However, their implementation within public transit stations, often characterized as opioid overdose hotspots, has been limited, partly because of a lack of understanding in how to structure such programs. Here, we propose a comprehensive framework for implementing public access naloxone programs at public transit stations to curb opioid overdose-related deaths. The framework, tailored to local contexts, relies on coordination between local public health organizations to provide naloxone at public access points and bystander training, local academic institutions to oversee program evaluation, and public transit organizations to manage naloxone maintenance. We use the city of Cambridge, Massachusetts as a case study to demonstrate how it and other municipalities may implement such an initiative.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders

Opioid drug-related deaths continue to be a significant public health concern in the Republic of Ireland (ROI) and Northern Ireland (NI). While both regions have implemented naloxone to reduce drug related deaths, there remains a gap in the implementation of a supervised injection facility (SIF). This study aimed to identify barriers and facilitators to implementing naloxone and a SIF to reduce opioid drug-related deaths in ROI and NI.. Semi-structured interviews (n=23) were conducted in ROI and NI with experts by experience (n=8), staff from low threshold services (n=9), and individuals involved in policy making (n= 6). Data were analyzed using coding reliability Thematic Analysis and were informed by the Risk Environmental Framework.. The findings illustrated that stigma within the media, health centers, and the community was a significant barrier to naloxone distribution and SIF implementation. Policing and community intimidation were reported to hinder naloxone carriage in both the ROI and NI, while threats of paramilitary violence towards people who use drugs were unique to NI. Municipal government delays and policy maker apathy were reported to hinder SIF implementation in the ROI. Participants suggested peer-to-peer naloxone delivery and amending legislation to facilitate non-prescription naloxone would increase naloxone uptake. Participants recommended using webinars, Town Halls, and a Citizens' Assembly as tools to advocate for SIF implementation.. Local and regional stigma reduction campaigns are needed in conjunction with policy changes to advance naloxone and a SIF. Tailoring stigma campaigns to incorporate the lived experience of people who use drugs, their family members, and the general community can aid in educating the public and change negative perceptions. This study highlights the need for ongoing efforts to reduce stigma and increase accessibility to evidence-based interventions to address opioid drug-related deaths in the ROI, NI, and internationally.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pharmaceutical Preparations; Reproducibility of Results

Workers in physically demanding jobs with high injury rates, long hours, productivity pressures, and lack of job security, such as commercial fishing, are at higher risk for substance use and misuse. In the United States, the federal government is urging employers to consider having naloxone available to reverse the effects of an opioid overdose, especially in workplaces. This study examined naloxone training, naloxone availability, and level of concern over substance use in commercial fishing.. As part of a larger study of commercial fishing vessel captains, we asked participants how worried they are about various potential problems, including substance use by crew members, using a five-point scale. We also asked whether they had completed naloxone training and whether their vessel was equipped with naloxone.. Of the 61 vessel captains who participated, 10 had naloxone training. Most were "not at all worried" about a crew member misusing alcohol (n = 52; 85.2%), a crew member using marijuana (n = 50; 82.0%), a crew member using other drugs (n = 49; 80.3%), or a crew member having a drug overdose (n = 52; 86.7%). Only five fishing vessels were equipped with naloxone.. Our results indicate that few fishing vessels are equipped with naloxone or have captains trained in its use. Fishing captains tend not to be worried about substance use in their crew. Given the higher rate of overdose deaths in the fishing industry compared to other industries, having more vessels equipped with naloxone and captains trained to administer it could save lives.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Hunting; Industry; Naloxone; Opiate Overdose; United States

Naloxone for opioid overdose treatment can be administered by intravenous injection, intramuscular injection, or intranasal administration. Published data indicate differences in naloxone pharmacokinetics depending on the route of administration. The aim of this study was to analyze pharmacokinetic data in the same way that we recently successfully applied the concept of the finite absorption time in orally administered drug formulations.. Using the model equations already derived, we performed least squares analysis on 24 sets of naloxone concentration in the blood as a function of time.. We found that intramuscular and intranasal administration can be described more accurately when considering zero-order absorption kinetics for finite time compared with classical first order absorption kinetics for infinite time.. One-compartment models work well for most cases. Two-compartment models provide better details, but have higher parameter uncertainties. The absorption duration can be determined directly from the model parameters and thus allow an easy comparison between the ways of administration. Furthermore, the precise site of injection for intramuscular delivery appears to make a difference in terms of the duration of the drug absorption.

Topics: Administration, Intranasal; Analgesics, Opioid; Drug Overdose; Humans; Injections, Intramuscular; Naloxone; Narcotic Antagonists

Topics: Analgesics, Opioid; Central Nervous System Stimulants; Cohort Studies; Drug Overdose; Humans; Indiana; Law Enforcement; Naloxone; Narcotic Antagonists; Retrospective Studies; Spatio-Temporal Analysis

In 2021, more than 80 000 US residents died from an opioid overdose. Public health intervention initiatives, such as the Helping to End Addiction Long-term (HEALing) Communities Study (HCS), are being launched with the goal of reducing opioid-related overdose deaths (OODs).. To estimate the change in the projected number of OODs under different scenarios of the duration of sustainment of interventions, compared with the status quo.. This decision analytical model simulated the opioid epidemic in the 4 states participating in the HCS (ie, Kentucky, Massachusetts, New York, and Ohio) from 2020 to 2026. Participants were a simulated population transitioning from opioid misuse to opioid use disorder (OUD), overdose, treatment, and relapse. The model was calibrated using 2015 to 2020 data from the National Survey on Drug Use and Health, the US Centers for Disease Control and Prevention, and other sources for each state. The model accounts for reduced initiation of medications for OUD (MOUDs) and increased OODs during the COVID-19 pandemic.. Increasing MOUD initiation by 2- or 5-fold, improving MOUD retention to the rates achieved in clinical trial settings, increasing naloxone distribution efforts, and furthering safe opioid prescribing. An initial 2-year duration of interventions was simulated, with potential sustainment for up to 3 additional years.. Projected reduction in number of OODs under different combinations and durations of sustainment of interventions.. Compared with the status quo, the estimated annual reduction in OODs at the end of the second year of interventions was 13% to 17% in Kentucky, 17% to 27% in Massachusetts, 15% to 22% in New York, and 15% to 22% in Ohio. Sustaining all interventions for an additional 3 years was estimated to reduce the annual number of OODs at the end of the fifth year by 18% to 27% in Kentucky, 28% to 46% in Massachusetts, 22% to 34% in New York, and 25% to 41% in Ohio. The longer the interventions were sustained, the better the outcomes; however, these positive gains would be washed out if interventions were not sustained.. In this decision analytical model study of the opioid epidemic in 4 US states, sustained implementation of interventions, including increased delivery of MOUDs and naloxone supply, was found to be needed to reduce OODs and prevent deaths from increasing again.

Topics: Analgesics, Opioid; COVID-19; Drug Overdose; Humans; Naloxone; Opiate Overdose; Opioid-Related Disorders; Pandemics; Practice Patterns, Physicians'; Public Health

People using opioids alone in private settings are at elevated risk of dying in the event of an overdose. In San Francisco, single room occupancy (SRO) tenants are 19 times more likely to die of overdose than non-SRO residents. The "SRO Project" pilot aimed to reduce fatal overdoses in SROs by recruiting and training tenants to distribute naloxone and provide overdose education in their buildings. We explore the implementation and program impacts of the SRO Project pilot in two permanent supportive housing SROs.. We conducted eight months of ethnographic fieldwork (May 2021 - Feb 2022), including 35 days observing SRO Project pilot activities, and semi-structured interviews with 11 housing staff and 8 tenant overdose prevention specialists ('specialists'). Data were analyzed using a grounded theory approach to characterize program impacts, implementation strengths, and implementation challenges from the perspective of specialists and housing staff.. We found that the SRO project increased awareness, access to, and understanding of naloxone; facilitated other mutual-aid practices; supported privacy and autonomy of tenants regarding their drug use; and improved rapport, communication and trust between tenants and housing staff. Strengths of the implementation process included involvement of tenants with diverse social locations and skill sets and, at one site, a team-based approach that fostered program innovation, tenant solidarity and a sense of collective ownership over the project. Program implementation was challenged by frequent turnover and capacity constraints of housing staff, particularly during overnight shifts when overdose risks were greatest. Additional challenges arose due to the psychosocial burden of overdose response work, gendered violence, issues with compensation methods, and scope creep in specialists' roles.. This evaluation contributes further evidence regarding the effectiveness of tenant-led naloxone distribution and overdose education in permanent supportive and SRO housing environments. Findings indicate program implementation and sustainability can be improved by expanding tenant specialist training, compensating specialists in cash, and building stronger psychosocial support for tenants responding to overdoses in their homes.

Topics: Aptitude; Communication; Community Support; Drug Overdose; Drug Users; Group Processes; Health Education; Housing; Naloxone; Opioid-Related Disorders; Pilot Projects; Privacy; Program Evaluation; Qualitative Research; San Francisco; Trust; Violence

Accurate naloxone distribution data are critical for planning and prevention purposes, yet sources of naloxone dispensing data vary by location, and completeness of local datasets is unknown. We sought to compare available datasets in Massachusetts, Rhode Island, and New York City (NYC) to a commercially available pharmacy national claims dataset (Symphony Health Solutions).. We utilized retail pharmacy naloxone dispensing data from NYC (2018-2019), Rhode Island (2013-2019), and Massachusetts (2014-2018), and pharmaceutical claims data from Symphony Health Solutions (2013-2019).. We conducted a descriptive, retrospective, and secondary analysis comparing naloxone dispensing events (NDEs) captured via Symphony to NDEs captured by local datasets from the three jurisdictions between 2013 and 2019, when data were available from both sources, using descriptive statistics, regressions, and heat maps.. We defined an NDE as a dispensing event documented by the pharmacy and assumed that each dispensing event represented one naloxone kit (i.e., two doses). We extracted NDEs from local datasets and the Symphony claims dataset. The unit of analysis was the ZIP Code annual quarter.. NDEs captured by Symphony exceeded those in local datasets for each time period and location, except in RI following legislation requiring NDEs to be reported to the PDMP. In regression analysis, absolute differences in NDEs between datasets increased substantially over time, except in RI before the PDMP. Heat maps of NDEs by ZIP code quarter showed important variations reflecting where pharmacies may not be reporting NDEs to Symphony or local datasets.. Policymakers must be able to monitor the quantity and location of NDEs in order to combat the opioid crisis. In regions where NDEs are not required to be reported to PDMPs, proprietary pharmaceutical claims datasets may be useful alternatives, with a need for local expertise to assess dataset-specific variability.

Topics: Drug Overdose; Humans; Information Sources; Massachusetts; Naloxone; Narcotic Antagonists; New York City; Opioid-Related Disorders; Pharmaceutical Preparations; Pharmacies; Pharmacy; Retrospective Studies; Rhode Island

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.

Topics: Drug Overdose; Harm Reduction; Humans; Illicit Drugs; Naloxone; Opioid-Related Disorders

Training and equipping law enforcement officers (LEOs) with naloxone to reverse overdoses is one national preventive strategy to reduce overdose deaths. Web-based interventions can offer convenience, flexibility of use, and can be readily disseminated.. This paper describes our community-academic partnership in developing and evaluating a web-based naloxone training for LEOs.. Using a community-engaged approach, we created a web-based training (www.overdoseaction.org) and conducted a pilot feasibility test using surveys and individual interviews with ten LEOs.. The median time to complete the web-based naloxone training, including the pre- and post-tests, was 45 minutes (range, 37-80 minutes). A significant difference in the pretest and post-test scores of overdose knowledge was observed. The LEOs found the training helpful in responding to overdoses and sustained their attention.. This study demonstrates the feasibility of a web-based naloxone training for LEOs that can be easily disseminated and alternative to in-person trainings.

Topics: Community Participation; Community-Based Participatory Research; Drug Overdose; Feasibility Studies; Humans; Internet; Law Enforcement; Naloxone; Narcotic Antagonists; Police; Stakeholder Participation

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone

Prescribing of buprenorphine and naloxone in the emergency department (ED) has been shown to be an effective intervention. The purpose of this study was to determine the frequency of prescribing of naloxone and buprenorphine and the sub-groups that may be more or less likely to receive treatment.. We used a national electronic health record database to identify patients with opioid poisoning or overdose presenting between January 2019-December 2021. Patients who were prescribed naloxone or buprenorphine were identified in this dataset and then further segmented based on self-identified gender, age, racial and ethnic identity, income categories, and social vulnerability index in order to identify sub-groups that may be less likely to be prescribed treatment.. We found 74,004 patients in the database whom we identified as presenting to the ED with an opioid poisoning or overdose. Overall, 22.8% were discharged with a prescription for naloxone, while 0.9% of patients were discharged with buprenorphine products. Patients were less likely to receive naloxone prescriptions if they were female, White or Pacific Islander, non-Hispanic, not between the ages of 18-65, and non-English speaking. We found the same pattern for buprenorphine prescriptions except that the results were not significant for ethnicity and English-speaking.. Despite evidence supporting its use, buprenorphine is not prescribed from the ED in a substantial proportion of patients. Naloxone is prescribed to a higher percentage, although still a minority of patients receive it. Some sub-groups are disadvantaged in the prescribing of these products. Further study may assist in improving the prescribing of these therapies.

Topics: Analgesics, Opioid; Buprenorphine; Buprenorphine, Naloxone Drug Combination; Drug Overdose; Emergency Service, Hospital; Female; Humans; Male; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

Mainstays of opioid overdose prevention include medications for opioid use disorder (e.g., methadone or buprenorphine) and naloxone distribution. Inadequate access to buprenorphine limits its uptake, especially in communities of color, and people with opioid use disorders encounter multiple barriers to obtaining necessary medications including insurance, transportation, and consistent availability of telephones. UMass Memorial Medical Center and our community partners sought to alleviate these barriers to treatment through the deployment of a mobile addiction service, called the Road to Care. Using this approach, multidisciplinary and interprofessional providers deliver holistic addiction care by centering our patients' needs with respect to scheduling, location, and convenience. This program also extends access to buprenorphine and naloxone among people experiencing homelessness. Additional systemic and individualized barriers encountered are identified, as well as potential solutions for future mobile addiction service utilization. Over a two-year period, we have cared for 1,121 individuals who have accessed our mobile addiction service in over 4,567 encounters. We prescribed buprenorphine/naloxone (Suboxone®) to 330 individuals (29.4% of all patients). We have distributed nearly 250 naloxone kits directly on-site or and more than 300 kits via prescriptions to local pharmacies. To date, 74 naloxone rescue attempts have been reported back to us. We have demonstrated that a community-based mobile addiction service, anchored within a major medical center, can provide high-volume and high-quality overdose prevention services that facilitate engagement with additional treatment. Our experience is described as a case study below.

Topics: Buprenorphine; Buprenorphine, Naloxone Drug Combination; Community Health Services; Drug Overdose; Humans; Naloxone; Opioid-Related Disorders

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose

The increasing toxicity of opioids in the unregulated drug market has led to escalating numbers of overdoses in Canada and worldwide; takehome naloxone (THN) is an evidence-based intervention that distributes kits containing naloxone to people in the community who may witness an overdose. The purpose of this guidance is to provide policy recommendations for territorial, provincial and federal THN programs, using evidence from scientific and grey literature and community evidence that reflects 11 years of THN distribution in Canada.. The Naloxone Guidance Development Group - a multidisciplinary team including people with lived and living experience and expertise of drug use - used the Appraisal of Guidelines for Research & Evaluation (AGREE II) instrument to inform development of this guidance. We considered published evidence identified through systematic reviews of all literature types, along with community evidence and expertise, to generate recommendations between December 2021 and September 2022. We solicited feedback on preliminary recommendations through an External Review Committee and a public input process. The project was funded by the Canadian Institutes of Health Research through the Canadian Research Initiative in Substance Misuse. We used the Guideline International Network principles for managing competing interests.. Existing evidence from the literature on THN was of low quality. We incorporated evidence from scientific and grey literature, and community expertise to develop our recommendations. These were in 3 areas: routes of naloxone administration, THN kit contents and overdose response. Take-home naloxone programs should offer the choice of both intramuscular and intranasal formulations of naloxone in THN kits. Recommended kit contents include naloxone, a naloxone delivery device, personal protective equipment, instructions and a carrying case. Trained community overdose responders should prioritize rescue breathing in the case of respiratory depression, and conventional cardiopulmonary resuscitation in the case of cardiac arrest, among other interventions.. This guidance development project provides direction for THN programs in Canada in the context of limited published evidence, with recommendations developed in collaboration with diverse stakeholders.

Topics: Academies and Institutes; Advisory Committees; Canada; Drug Overdose; Humans; Naloxone

Overdose prevention sites (OPSs) are spaces where individuals can use pre-obtained drugs and trained staff can immediately intervene in the event of an overdose. While some OPSs use a combination of naloxone and oxygen to reverse overdoses, little is known about oxygen as a complementary tool to naloxone in OPS settings. We conducted a mixed methods study to assess the role of oxygen provision at a locally sanctioned OPS in San Francisco, California.. We used descriptive statistics to quantify number and type of overdose interventions delivered in 46 weeks of OPS operation in 2022. We used qualitative data from OPS staff interviews to evaluate experiences using oxygen during overdose responses. Interviews were coded and thematically analyzed to identify themes related to oxygen impact on overdose response.. OPS staff were successful in reversing 100% of overdoses (n = 333) during 46 weeks of operation. Oxygen became available 18 weeks after opening. After oxygen became available (n = 248 overdose incidents), nearly all involved oxygen (91.5%), with more than half involving both oxygen and naloxone (59.3%). Overdoses involving naloxone decreased from 98% to 66%, though average number of overdoses concomitantly increased from 5 to 9 per week. Interviews revealed that oxygen improved overdose response experiences for OPS participants and staff. OPS EMTs were leaders of delivering and refining the overdose response protocol and trained other staff. Challenges included strained relationships with city emergency response systems due to protocol requiring 911 calls after all naloxone administrations, inconsistent supplies, and lack of sufficient staffing causing people to work long shifts.. Although the OPS operated temporarily, it offered important insights. Ensuring consistent oxygen supplies, staffing, and removing 911 call requirements after every naloxone administration could improve resource management. These recommendations may enable success for future OPS in San Francisco and elsewhere.

Topics: Drug Overdose; Humans; Naloxone; Narcotic Antagonists; San Francisco

Opioid overdose has claimed the lives of over 340,000 Americans in the last decade. Over that same period, policymakers have taken steps to increase the availability of naloxone-an opioid antagonist used to rescue overdose victims-to people in the community. Previous studies, most of which have examined the effects of state laws designed to facilitate access to naloxone, have reached mixed conclusions about the effects of naloxone access on fatal and non-fatal overdoses. This paper exploits a unique policy experiment provided by two naloxone giveaways intended to increase naloxone possession among the general public in Pennsylvania to estimate the causal impact of naloxone distribution on fatal overdoses and opioid-related emergency department (ED) visits. Using a difference-in-differences design, I find evidence that opioid overdose deaths fell immediately following the first giveaway but increased following the second giveaway and discuss these apparently contradictory findings in the context of the changing composition of the opioid supply. I also find some evidence of a decline in opioid overdose-related ED visits following the giveaways. This study is the first to examine the effects of untargeted naloxone distribution and has implications for other novel, naloxone distribution efforts currently underway.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose

Topics: Drug Overdose; Humans; Naloxone; Opiate Overdose; Retrospective Studies; Unmanned Aerial Devices

The overdose crisis continues across Canada which calls for novel harm reduction strategies. Previous research indicates that a majority of eHealth solutions are cost-effective however current literature on the cost-benefit of eHealth for harm reduction is sparse. The National Overdose Response Service (NORS) is a Canada-wide telephone-based harm reduction service. Service users can call the phone number and connect to a peer who can virtually monitor the substance use session and dispatch appropriate interventions in the case of overdose.. We aim to assess the cost-benefit of NORS by comparing the estimated cost-savings from prevented overdose mortality to the operating costs of the program, alongside healthcare costs associated with its operation.. Data around systems costs and operational costs were gathered for our calculations. Our primary outcome was cost-benefit ratios, derived from estimates and models of mortality rates in current literature and value of life lost. We presented our main results across a range of values for costs and the probability of death following an unwitnessed overdose. These values were utilized to calculate cost-benefit ratios and value per dollar spent on service provision by NORS over the length of the program's operation (December 2020-2022).. Over the total funded lifespan of the program, and using a Monte Carlo estimate, the benefit-to-cost ratio of the NORS program was 8.59 (1.53-15.28) per dollar spent, depending on estimated mortality rates following unwitnessed overdose and program operation costs. Further, we conservatively estimate that early community-based naloxone intervention results in healthcare system savings of $4470.82 per overdose response.. We found the NORS program to have a positive benefit-to-cost ratio when the probability of death following an unwitnessed overdose was greater than 5%. NORS and potentially other virtual overdose monitoring services have the potential to be cost-effective solutions for managing the drug poisoning crisis.

Topics: Cost-Benefit Analysis; Delivery of Health Care; Drug Overdose; Humans; Naloxone; Substance-Related Disorders

Over 109,000 people in the USA died from a drug overdose in 2022. More alarming is the amount of drug overdose deaths involving synthetic opioids other than methadone (SOOM), primarily fentanyl. From 2015 to 2020, the number of drug overdose deaths from SOOM increased 5.9-fold. SOOM are commonly being found in many other drugs without the user's knowledge. Given the alarming number of overdose deaths from illicit drugs with SOOM, naloxone should be prescribed for all persons using illicit drugs regardless of if they knowingly use opioids. How often providers prescribe naloxone for these patients remains unknown. The aim of this study is to determine the rate of naloxone prescriptions given to patients with any substance use disorder, including when the patient has a urine drug screen positive for fentanyl. Secondary aims include determining what patient factors are associated with receiving a naloxone prescription.. The design was a single-center retrospective cohort study on patients that presented to the Augusta University Medical Center emergency department between 2019 through 2021 and had an ICD-10 diagnosis of a substance use disorder. Analyses were conducted by logistic regression and t-test or Welch's t-test.. A total of 10,510 emergency department visits were by 6787 patients. Naloxone was prescribed in 16.3% of visits with an opioid-related discharge diagnosis and 8.4% of visits with a non-opioid substance use-related discharge diagnosis and a urine drug screen positive for fentanyl. Patients with a fentanyl positive urine drug screen had higher odds of receiving a naloxone prescription (aOR 5.80, 95% CI 2.76-12.20, p < 0.001). Patients with a psychiatric diagnosis had lower odds of being prescribed naloxone (aOR 0.51, p = 0.03). Patients who received naloxone had a lower number of visits (mean 1.23 vs. 1.55, p < 0.001). Patients with a urine drug screen positive for cocaine had higher odds of frequent visits (aOR 3.07, p = 0.01).. Findings should remind providers to prescribe naloxone to all patients with a substance use disorder, especially those with a positive fentanyl urine drug screen or a co-occurring psychiatric condition. Results also show that cocaine use continues to increase healthcare utilization.

Topics: Analgesics, Opioid; Cocaine; Drug Overdose; Emergency Service, Hospital; Fentanyl; Humans; Illicit Drugs; Methadone; Naloxone; Opioid-Related Disorders; Prescriptions; Retrospective Studies

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Naltrexone; Narcotic Antagonists; Nasal Sprays; Opiate Overdose

This Viewpoint advocates for improved strategies to measure naloxone distribution and evaluate how effectively naloxone reaches people most likely to experience or witness an opioid overdose.

Topics: Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

Opioid overdose deaths are of great concern to public health, with over one million lives lost since 1999. While many efforts have been made to mitigate these, Black communities continue to experience a greater burden of fatalities than their white counterparts. This study aims to explore why by working with Black community members in Indianapolis through semi-structured interviews.. Semi-structured one-on-one in-depth interviews were conducted in spring and summer of 2023 with Black residents (N = 23) of zip codes 46202, 46205, 46208, and 46218 in Indianapolis. Ten interview questions were used to facilitate conversations about opioid overdoses, recovery, fatality prevention tools such as calling 911 and naloxone, law enforcement, and racism. Data were analyzed using grounded theory and thematic analysis.. Interviews revealed access barriers and intervention opportunities. Racism was present in both. Mental access barriers such as stigma, fear, and mistrust contributed to practical barriers such as knowledge of how to administer naloxone. Racism exacerbated mental barriers by adding the risk of race-based mistreatment to consequences related to association with substance use. Participants discussed the double stigma of substance use and being Black, fear of being searched in law enforcement encounters and what would happen if law enforcement found naloxone on them, and mistrust of law enforcement and institutions that provide medical intervention. Participants had favorable views of interventions that incorporated mutual aid and discussed ideas for future interventions that included this framework.. Racism exacerbates Blacks' mental access barriers (i.e., help-seeking barriers), which, in turn, contribute to practical barriers, such as calling 911 and administering naloxone. Information and resources coming from people within marginalized communities tend to be trusted. Leveraging inter-community relationships may increase engagement in opioid overdose fatality prevention. Interventions and resources directed toward addressing opioid overdose fatalities in Black communities should use mutual aid frameworks to increase the utilization of the tools they provide.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Substance-Related Disorders

The United States continues to be impacted by decades of an opioid misuse epidemic, worsened by the COVID-19 pandemic and by the growing prevalence of highly potent synthetic opioids (HPSO) such as fentanyl. In instances of a toxicity event, first-response administration of reversal medications such as naloxone can be insufficient to fully counteract the effects of HPSO, particularly when there is co-occurring substance use. In an effort to characterize and study this multi-faceted problem, the Camden Opioid Research Initiative (CORI) has been formed. The CORI study has collected and analyzed post-mortem toxicology data from 42 cases of decedents who expired from opioid-related toxicity in the South New Jersey region to characterize substance use profiles. Co-occurring substance use, whether by intent or through possible contamination of the illicit opioid supply, is pervasive among deaths due to opioid toxicity, and evidence of medication-assisted treatment is scarce. Nearly all (98%) of the toxicology cases show the presence of the HPSO, fentanyl, and very few (7%) results detected evidence of medication-assisted treatment for opioid use disorder, such as buprenorphine or methadone, at the time of death. The opioid toxicity reversal drug, naloxone, was detected in 19% of cases, but 100% of cases expressed one or more stimulants, and sedatives including xylazine were detected in 48% of cases. These results showing complex substance use profiles indicate that efforts at mitigating the opioid misuse epidemic must address the complications presented by co-occurring stimulant and other substance use, and reduce barriers to and stigmas of seeking effective medication-assisted treatments.

Topics: Analgesics, Opioid; Drug Overdose; Fentanyl; Humans; Naloxone; Opioid-Related Disorders; Pandemics; United States

Topics: Bradycardia; Drug Overdose; Fentanyl; Humans; Naloxone; United States; Xylazine

Misuse of opioids can lead to a potential lethal overdose. Timely administration of naloxone is critical for survival. Here, we designed a polymer-naloxone conjugate that can provide on-demand phototriggered opioid reversal. Naloxone was attached to the polymer poly(lactic-

Topics: Analgesics, Opioid; Animals; Drug Overdose; Mice; Naloxone; Narcotic Antagonists; Polymers

Drug use and incarceration have a substantial impact on rural communities, but factors associated with the incarceration of rural people who use drugs (PWUD) have not been thoroughly investigated.. To characterize associations between recent incarceration, overdose, and substance use disorder (SUD) treatment access among rural PWUD.. For this cross-sectional study, the Rural Opioid Initiative research consortium conducted a survey in geographically diverse rural counties with high rates of overdose across 10 US states (Illinois, Wisconsin, North Carolina, Oregon, Kentucky, West Virginia, Ohio, Massachusetts, New Hampshire, and Vermont) between January 25, 2018, and March 17, 2020, asking PWUD about their substance use, substance use treatment, and interactions with the criminal legal system. Participants were recruited through respondent-driven sampling in 8 rural US regions. Respondents who were willing to recruit additional respondents from their personal networks were enrolled at syringe service programs, community support organizations, and through direct community outreach; these so-called seed respondents then recruited others. Of 3044 respondents, 2935 included participants who resided in rural communities and reported past-30-day injection of any drug or use of opioids nonmedically via any route. Data were analyzed from February 8, 2022, to September 15, 2023.. Recent incarceration was the exposure of interest, defined as a report of incarceration in jail or prison for at least 1 day in the past 6 months.. The associations between PWUD who were recently incarcerated and main outcomes of treatment use and overdose were examined using logistic regression.. Of 2935 participants, 1662 (56.6%) were male, 2496 (85.0%) were White; the mean (SD) age was 36 (10) years; and in the past 30 days, 2507 (85.4%) reported opioid use and 1663 (56.7%) reported injecting drugs daily. A total of 1224 participants (41.7%) reported recent incarceration, with a median (IQR) incarceration of 15 (3-60) days in the past 6 months. Recent incarceration was associated with past-6-month overdose (adjusted odds ratio [AOR], 1.38; 95% CI, 1.12-1.70) and recent SUD treatment (AOR, 1.62; 95% CI, 1.36-1.93) but not recent medication for opioid use disorder (MOUD; AOR, 1.03; 95% CI, 0.82-1.28) or currently carrying naloxone (AOR, 1.02; 95% CI, 0.86-1.21).. In this cross-sectional study of PWUD in rural areas, participants commonly experienced recent incarceration, which was not associated with MOUD, an effective and lifesaving treatment. The criminal legal system should implement effective SUD treatment in rural areas, including MOUD and provision of naloxone, to fully align with evidence-based SUD health care policies.

Topics: Adult; Analgesics, Opioid; Cross-Sectional Studies; Drug Overdose; Female; Humans; Male; Naloxone; Rural Population; Substance-Related Disorders

Bystander administration of naloxone is a critical strategy to mitigate opioid overdose mortality. To ensure bystanders' willingness to carry and administer naloxone in response to a suspected overdose, it is critical to select products for community distribution with the highest likelihood of being utilized. This study examines bystanders' preference for and willingness to administer three naloxone products approved by the FDA for bystander use and identify product features driving preference.. The population was a convenience sample of individuals who attended the Kentucky State Fair, August 18-28, 2022, in Louisville, Kentucky. Participants (n = 503) watched a standardized overdose education and naloxone training video, rated their willingness to administer each of three products (i.e., higher-dose nasal spray, lower-dose nasal spray, intramuscular injection), selected a product to take home, and rated factors affecting choice.. After training, 44.4% chose the higher-dose nasal spray, 30.1% chose the intramuscular injection, and 25.5% chose the lower-dose nasal spray. Factors most influencing choice on a 10-point Likert scale were ease of use (9 [7-10]), naloxone dose (8 [5-10]), and product familiarity (5 [5-9]).. Bystanders expressed high willingness to administer all studied formulations of naloxone products. Product choice preference varied as a function of product features. As the number and variety of available products continue to increase, continuous evaluation of formulation acceptability, in addition to including individuals with lived experience who are receiving and administering overdose reversal agents, is critical to support adoption and save lives.

Topics: Administration, Intranasal; Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Nasal Sprays

Scaling up overdose education and naloxone distribution (OEND), an evidence-based practice for reducing opioid overdose mortality, in communities remains a challenge. Novel models and intentional implementation strategies are needed. Drawing upon the EPIS model's phases of Exploration, Preparation, Implementation, and Sustainment (Aarons et al. in Adm Policy Ment Health 38:4-23, 2011), this paper describes the development of the University of Kentucky's unique centralized "Naloxone Hub with Many Spokes" approach to implementing OEND as part of the HEALing Communities Study (HCS-KY).. To scale up OEND in eight Kentucky counties, implementation strategies were utilized at two levels: a centralized university-based naloxone dispensing unit ("Naloxone Hub") and adopting organizations ("Many Spokes"). Implementation strategies varied across the EPIS phases, but heavily emphasized implementation facilitation. The Naloxone Hub provided technical assistance, overdose education resources, and no-cost naloxone to partner organizations. Implementation outcomes across the EPIS phases were measured using data from internal study management trackers and naloxone distribution data submitted by partner organizations.. Of 209 organizations identified as potential partners, 84.7% (n = 177) engaged in the Exploration/Preparation phase by participating in an initial meeting with an Implementation Facilitator about the HCS-KY OEND program. Adoption of the HCS-KY OEND program, defined as receipt of at least one shipment of naloxone, was achieved with 69.4% (n = 145) of all organizations contacted. During the Implementation phase, partner organizations distributed 40,822 units of naloxone, with partner organizations distributing a mean of 281.5 units of naloxone (SD = 806.2). The mean number of units distributed per county was 5102.8 (SD = 3653.3; range = 1057 - 11,053) and the mean county level distribution rate was 8396.5 units per 100,000 residents (SD = 8103.1; range = 1709.5-25,296.3). Of the partner organizations that adopted the HCS-KY OEND program, 87.6% (n = 127) attended a sustainability meeting with an Implementation Facilitator and agreed to transition to the state-funded naloxone program.. These data demonstrate the feasibility of this "Hub with Many Spokes" model for scaling up OEND in communities highly affected by the opioid epidemic. Trial registration ClinicalTrials.gov, NCT04111939. Registered 30 September 2019, https://clinicaltrials.gov/ct2/show/NCT04111939 .

Topics: Analgesics, Opioid; Drug Overdose; Humans; Kentucky; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

The occurrence of behavioral health emergencies (BHEs) in children is increasing in the United States, with patient presentations to Emergency Medical Services (EMS) behaving similarly. However, detailed evaluations of EMS encounters for pediatric BHEs at the national level have not been reported.. This was a secondary analysis of a national convenience sample of EMS electronic patient care records (ePCRs) collected from January 1, 2018 through December 31, 2021. Inclusion criteria were all EMS activations documented as 9-1-1 responses involving patients < 18 years of age with a primary or secondary provider impression of a BHE. Patient demographics, incident characteristics, and clinical variables including administration of sedation medications, use of physical restraint, and transport status were examined overall and by calendar year.. A total of 1,079,406 pediatric EMS encounters were present in the dataset, of which 102,014 (9.5%) had behavioral health provider impressions. Just over one-half of BHEs occurred in females (56.2%), and 68.1% occurred in patients aged 14-17 years. Telecommunicators managing the 9-1-1 calls for these events reported non-BHE patient complaints in 34.7%. Patients were transported by EMS 68.9% of the time, while treatment and/or transport by EMS was refused in 12.5%. Prehospital clinicians administered sedation medications in 1.9% of encounters and applied physical restraints in 1.7%. Naloxone was administered for overdose rescue in 1.5% of encounters.. Approximately one in ten pediatric EMS encounters occurring in the United States involve a BHE, and the majority of pediatric BHEs attended by EMS result in transport of the child. Use of sedation medications and physical restraints by prehospital clinicians in these events is rare. National EMS data from a variety of sources should continue to be examined to monitor trends in EMS encounters for BHEs in children.

Topics: Adolescent; Child; Drug Overdose; Emergencies; Emergency Medical Services; Female; Humans; Naloxone; Retrospective Studies; United States

Whether expanded access to naloxone reduces perceptions of risk about opioid use has been subject to debate. Our aim was to assess how implementation of naloxone access laws shapes perceived risk of heroin use.. Using data from the restricted-access National Survey on Drug Use and Health, Prescription Drug Abuse Policy System and the US Census, we applied two-way fixed-effects models to determine whether naloxone access laws decreased perceived risk of any heroin use or regular heroin use. We used Bayes factors (BFs) to confirm evidence for null findings.. United States.. A total of 884 800 respondents aged 12 and older from 2004 to 2016.. A binary indicator of whether a state implemented naloxone access laws was regressed on respondent-perceived risk of (1) any heroin use and (2) regular heroin use. Ratings of perceived risk were assessed on a scale of 1 (none) to 4 (great risk).. In all instances, the BFs support evidence for the null hypothesis. Across models with three distinct specifications of naloxone access laws, we found no evidence of decreased risk perceptions, as confirmed by BFs ranging from 0.009 to 0.057. Across models of specific vulnerable subgroups, such as people who use opioids (BFs = 0.039-0.225) or young people (BFs = 0.009-0.158), we found no evidence of decreased risk perceptions. Across diverse subpopulations by gender (BFs = 0.011-0.083), socio-economic status (BFs = 0.015-0.168) or race/ethnicity (BFs = 0.016-0.094), we found no evidence of decreased risk perceptions.. There appears to be no empirical evidence that implementation of naloxone access laws has adversely affected perceptions of risk of heroin in the broader US population or within vulnerable subgroups or diverse subpopulations.

Topics: Adolescent; Analgesics, Opioid; Bayes Theorem; Drug Overdose; Heroin; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; United States

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; New York City; Opiate Overdose; Opioid-Related Disorders

Topics: Adult; Attitude of Health Personnel; Drug Overdose; Emergency Medical Services; Emergency Medical Technicians; Female; Health Care Surveys; Humans; Male; Naloxone; Narcotic Antagonists; Patient Education as Topic; San Francisco; Substance Abuse, Intravenous

Emergency department (ED)-based naloxone distribution and peer-based behavioral counseling have been shown to be feasible, but little is known about utilization maintenance over time and clinician, patient, and visit level factors influencing implementation.. We conducted a retrospective cohort study of an ED overdose prevention program providing take-home naloxone, behavioral counseling, and treatment linkage for patients treated for an opioid overdose at two Rhode Island EDs from 2017 to 2020: one tertiary referral center and a community hospital. Utilizing a Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework, we evaluated program reach, adoption, implementation modifiers, and maintenance using logistic and Poisson regression.. Seven hundred forty two patients were discharged after an opioid overdose, comprising 966 visits (median: 32 visits per month; interquartile range: 29, 41). At least one intervention was provided at most (86%, 826/966) visits. Take-home naloxone was provided at 69% of visits (637/919). Over half (51%, 495/966) received behavioral counseling and treatment referral (65%, 609/932). Almost all attending physicians provided take-home naloxone (97%, 105/108), behavioral counseling (95%, 103/108), or treatment referral (95%, 103/108) at least once. Most residents and advanced practice practitioners (APPs) provided take home naloxone (78% residents; 72% APPs), behavioral counseling (76% residents; 67% APPs), and treatment referral (80% residents; 81% APPs) at least once. Most clinicians provided these services for over half of the opioid overdose patients they cared for. Patients were twice as likely to receive behavioral counseling when treated by an attending in combination with a resident and/or APP (adjusted odds ratio: 2.29; 95% confidence interval, 1.68, 3.12) compared to an attending alone. There was no depreciation in use over time.. ED naloxone distribution, behavioral counseling, and referral to treatment can be successfully integrated into usual emergency care and maintained over time with high reach and adoption. Further work is needed to identify low-cost implementation strategies to improve services use and dissemination across clinical settings.

Topics: Analgesics, Opioid; Drug Overdose; Emergency Service, Hospital; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Retrospective Studies

To describe the process used in a clinical pharmacist specialist (CPS)-led Opioid Overdose Education and Naloxone Distribution (OEND) program initiative to increase naloxone distribution to veterans at high risk for overdose via provider education and identification of barriers to naloxone distribution.. Drug overdose is the leading cause of accidental death in the United States. One step toward counteracting the epidemic includes expanding access to and use of naloxone. The Veterans Health Administration has developed initiatives to target veterans at risk for opioid overdose, such as the Veterans Affairs (VA) OEND program. Pharmacists can play a unique role in OEND by both prescribing naloxone and educating patients and providers on risk mitigation strategies. Through provider education, patient education, and facility-wide initiatives, naloxone prescribing was increased by 9-fold from August 2016 to August 2018. In addition, the number of new naloxone prescribers increased by almost 7-fold during the intervention period. Naloxone distribution to high-risk groups drastically increased across all target groups.. CPS involvement in promoting OEND at VAPHS drastically increased rates of prescribing of naloxone kits to veterans at risk for opioid overdose. This initiative showed that a CPS can play multiple roles in supporting OEND outreach at a large healthcare setting.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pharmacists; United States; United States Department of Veterans Affairs; Veterans

Medical settings provide ideal opportunities to identify patients with substance use disorders and provide harm reduction and treatment resources. Medical students often volunteer in the community and can spend substantial time with patients, serving as touchpoints. Accordingly, medical schools have begun training in harm reduction. Initial studies show such training acutely improves knowledge, but sustained effects remain unclear. This pilot study explored longer-term impacts of Opioid Overdose Prevention and Response Training (OOPRT) on medical student knowledge about opioids, overdose, and naloxone.. Students completed a survey about knowledge of opioid use disorder, overdoses, and attitudes towards patients. This included Opioid Overdose Knowledge (OOKS) and Opioid Overdose Attitudes (OOAS) scales. A subset of students was invited to attend OOPRT and complete a post-training survey. All who completed the baseline survey were invited to complete a 6-month follow-up. We analyzed long-term training effects on OOKS and OOAS scores.. 89 students completed baseline and 6-month follow-up surveys; of these, 22 received training. OOPRT yielded significant improvements in knowledge of signs of opioid overdose (F(2,38) = 18.04, P < .001), actions to take during overdose (F(2,38) = 8.32, P = .001), and naloxone use (F(2,38) = 35.46, P < .001), along with attitudes regarding overdose competencies (F(2,38) = 99.40, P < .001) and concerns (F(2,38) = 8.86, P < .001). When comparing over time, students who attended OOPRT retained significantly higher competency scores than those who did not attend F(1,87) = 40.82, P < .001). No other significant differences were observed.. This study demonstrates immediate efficacy of OOPRT in improving opioid overdose knowledge and attitudes and sustained changes at 6 months, compared to standard undergraduate medical curricula alone. Future research with larger sample sizes is underway to validate these preliminary findings and examine the difference in attitudes and knowledge retention over time. Given that students report interest in receiving OOPRT and consider it worthwhile, systematic study is warranted.

Topics: Analgesics, Opioid; Drug Overdose; Health Knowledge, Attitudes, Practice; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Pilot Projects; Students, Medical

Although most opioid-related mortality in Australia involves prescription opioids, most research to understand the impact of naloxone supply on opioid-related mortality has focused upon people who inject heroin. We aimed to examine the cost and probable impact of up-scaling naloxone supply to people who are prescribed opioids.. Decision-tree model. Four scenarios were compared with a baseline scenario (the current status quo): naloxone scale-up between 2020 and 2030 to reach 30 or 90% coverage by 2030, among the subgroups of people prescribed either ≥ 50 or ≥ 100 mg of oral morphine equivalents (OME).. Australia.. People who are prescribed opioids.. Possible deaths averted, costs (ambulance and naloxone distribution) and cost per life saved for different scenarios of naloxone scale-up.. Maintaining the status quo, there would be an estimated 7478 [uncertainty interval (UI) = 6868-8275] prescription opioid overdose deaths between 2020 and 2030, resulting in Australian dollars (A$)51.9 million (49.4, 56.0) in ambulance costs. If naloxone were scaled-up to 90% of people prescribed > 50 mg OME, an estimated 657 (UI = 245, 1489) deaths could be averted between 2020 and 2030 (a 20% reduction in the final year of the model compared with the no naloxone scenario), with a cost of A$43 600 (20 800-110 500) per life saved. If naloxone were scaled-up to 30% of people prescribed > 50 mg OME an estimated 219 (82-496) deaths could be averted with the same cost per live saved. If naloxone were restricted to those prescribed > 100 mg OME, an estimated 130 (UI = 44-289) deaths would be averted if scaled-up to 30% or 390 (UI = 131-866) deaths averted if scaled-up to 90%, with the cost per life saved for both scenarios A$38 200 (UI = 12 400-97 400).. In Australia, scaling-up take-home naloxone by 2030 to reach 90% of people prescribed daily doses of ≥ 50 mg of oral morphine equivalents would be cost-effective and save more than 650 lives.

Topics: Analgesics, Opioid; Australia; Drug Overdose; Heroin; Humans; Morphine; Naloxone

Opioid-related overdose death rates continue to rise in the United States, especially in racial/ethnic minority communities. Our objective was to determine if US municipalities with high percentages of non-white residents have equitable access to the overdose antidote naloxone distributed by community-based organizations.. We used community-based naloxone data from the Massachusetts Department of Public Health and the Rhode Island non-pharmacy naloxone distribution program for 2016-18. We obtained publicly available opioid-related overdose death data from Massachusetts and the Office of the State Medical Examiners in Rhode Island. We defined the naloxone coverage ratio as the number of community-based naloxone kits received by a resident in a municipality divided by the number of opioid-related overdose deaths among residents, updated annually. We used a Poisson regression with generalized estimating equations to analyze the relationship between the municipal racial/ethnic composition and naloxone coverage ratio. To account for the potential non-linear relationship between naloxone coverage ratio and race/ethnicity we created B-splines for the percentage of non-white residents; and for a secondary analysis examining the percentage of African American/black and Hispanic residents. The models were adjusted for the percentage of residents in poverty, urbanicity, state and population size.. Between 2016 and 2018, the annual naloxone coverage ratios range was 0-135. There was no difference in naloxone coverage ratios among municipalities with varying percentages of non-white residents in our multivariable analysis. In the secondary analysis, municipalities with higher percentages of African American/black residents had higher naloxone coverage ratios, independent of other factors. Naloxone coverage did not differ by percentage of Hispanic residents.. There appear to be no municipal-level racial/ethnic inequities in naloxone distribution in Rhode Island and Massachusetts, USA.

Topics: Analgesics, Opioid; Drug Overdose; Ethnic and Racial Minorities; Ethnicity; Humans; Massachusetts; Minority Groups; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Rhode Island; United States

Naloxone is a prescription medication that reverses opioid overdoses. Allowing naloxone to be dispensed directly by a pharmacist without an individual prescription under a naloxone standing order (NSO) can expand access. The community-level factors associated with naloxone dispensed under NSO are unknown.. Using a dataset comprised of pharmacy reports of naloxone dispensed under NSO from 70% of Massachusetts retail pharmacies, we examined relationships between community-level demographics, rurality, measures of treatment for opioid use disorder, and overdose deaths with naloxone dispensed under NSO per ZIP Code-quarter from 2014 until 2018. We used a multi-variable zero-inflated negative binomial model, assessing odds of any naloxone dispensed under NSO, as well as a multi-variable negative binomial model assessing quantities of naloxone dispensed under NSO.. From 2014-2018, quantities of naloxone dispensed under NSO and the number of pharmacies dispensing any naloxone under NSO increased over time. However, communities with greater percentages of people with Hispanic ethnicity (aOR 0.91, 95% CI 0.86-0.96 per 5% increase), and rural communities compared to urban communities (aOR 0.81, 95% CI 0.73-0.90) were less likely to dispense any naloxone by NSO. Communities with more individuals treated with buprenorphine dispensed more naloxone under NSO, as did communities with more opioid-related overdose deaths.. Naloxone dispensing has substantially increased, in part driven by standing orders. A lower likelihood of naloxone being dispensed under NSO in communities with larger Hispanic populations and in more rural communities suggests the need for more equitable access to, and uptake of, lifesaving medications like naloxone.

Topics: Drug Overdose; Humans; Massachusetts; Naloxone; Narcotic Antagonists; Standing Orders

Prescription opioid misuse remains a significant cause of morbidity and mortality associated with drug overdose. Researchers, government agencies, public health interests, and professional organizations support the benefits of naloxone coprescribing for patients on chronic opioid therapy to prevent deaths from opioid overdose. However, gaps remain in the provision of naloxone to patients at risk. Currently, less than 1% of patients who should be prescribed naloxone with their opioid medications obtain a prescription for naloxone, illustrating an opportunity for health care providers to conduct thorough risk assessments for patients taking opioids and coprescribing naloxone to those at risk. There are documented barriers to the provision of naloxone for primary care providers, pharmacists, and patients. Managed care organizations have also created barriers. To better understand and evaluate trends in treatment, coverage, policies, and needs associated with providing health services to patients with substance use disorders, the Academy of Managed Care Pharmacy (AMCP) Addiction Advisory Group conducted a survey in 2019. Eighty percent of the managed behavioral health organizations and 47% of AMCP payer members who responded to the survey encouraged naloxone coprescribing in patients at high risk of overdose; however, no organizations require coprescribing. Health plans, managed care organizations, prescribers, pharmacists, patients, and others have important roles in decreasing the morbidity and mortality associated with opioid overdose. In particular, managed care organizations can take specific and meaningful actions to implement payment policies that improve naloxone coprescribing for patients at risk. In this article, opportunities have been outlined for managed care leadership that actively support public health policies for naloxone coprescribing, and 7 recommendations are presented.

Topics: Advisory Committees; Drug Overdose; Drug Prescriptions; Humans; Managed Care Programs; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pharmaceutical Services; Surveys and Questionnaires

Emergency department (ED) patients with nonfatal opioid overdose are at high risk for subsequent fatal overdose, yet ED programs aimed at reducing harm from opioid use remain underdeveloped.. The objective was to pilot a statewide ED take-home naloxone program and improve the care of patients with opioid use disorder (OUD) and risky drug use through training and interprofessional network building.. Nine hospital EDs with pharmacy, nurse, and physician champions were recruited, surveyed, and trained. Take-home naloxone rescue kits were developed, disseminated, and tracked. Two overdose prevention summits were convened prior to the COVID pandemic, and two X-waiver training courses aimed at emergency physicians and advanced practice providers were arranged, both in person and virtual.. A total of 872 naloxone rescue kits were distributed to ED patients at risk of opioid overdose during the first phase of this project, and more than 140 providers were trained in the use of medications for OUD in acute care settings.. A statewide ED take-home naloxone program was shown to be feasible across a range of different hospitals with varying maturity in preexisting OUD resources and capabilities. Future work will be aimed at both expanding and measuring the effectiveness of this work.

Topics: Analgesics, Opioid; COVID-19; Drug Overdose; Emergency Service, Hospital; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Quality of Health Care

Topics: Correctional Facilities; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders

Describe a series of patients who developed naloxone-associated pulmonary edema after recreational opioid use.. Single center retrospective case series of patients who developed pulmonary edema following the prehospital administration of naloxone.. Academic, urban safety-net hospital.. Adults with recreational opioid overdose who developed naloxone-associated pulmonary edema, defined as the acute onset of respiratory distress, hypoxemia, and radiographic pulmonary edema after naloxone administration for opioid intoxication, provided that gas exchange and chest imaging rapidly improved and pulmonary aspiration of gastric contents was not clinically suspected.. Ten adults (median age 23 years, 90% male) met our case definition for naloxone-associated pulmonary edema. Implicated opioids were heroin in 8 patients and methadone and oxycodone in 1 patient each. The median total dose of naloxone was 4.25 mg (interquartile range [IQR] 3.3-9.8) prior to the onset of clinically-apparent pulmonary edema. Seven patients received invasive mechanical ventilation for a median of two days (IQR 0.8-5), one of whom received veno-venous extracorporeal membrane oxygenation support, and all survived to hospital discharge.. Severe acute pulmonary edema may follow naloxone administration after recreational opioid overdose. Acute care clinicians should be aware of this potentially life-threatening adverse effect of naloxone.

Topics: Adult; Analgesics, Opioid; Drug Overdose; Female; Humans; Male; Naloxone; Narcotic Antagonists; Opiate Overdose; Pulmonary Edema; Retrospective Studies; Young Adult

West Virginia (WV) has the highest overdose mortality rate in the United States and expanding naloxone access is crucial for reducing opioid overdose deaths. We conducted a purchase trial to establish an objective measure of naloxone access under WV's naloxone standing order (NSO) program.. A stratified random sample of 200 chain and independent retail pharmacies across WV were included. Each pharmacy underwent two purchase attempts-one by a person who used illicit opioids (PWUIO) and one by a potential bystander who did not use illicit opioids but had a relationship with a PWUIO. We used matched-pairs analysis to identify differences in outcomes by purchaser type (PWUIO vs bystander). Chi-square and independent-samples t-tests were used to compare outcomes by pharmacy type (chain vs independent).. Overall, 29% of purchase attempts were successful, with no significant difference between PWUIO and bystanders (p = 0.798). Fewer than half (44%) of successful purchases included verbal counseling, and bystanders were more likely to receive counseling than PWUIO (33% vs 4%, p = 0.018). Common reasons for failed purchases were naloxone not being in stock (41%), requiring a naloxone prescription (35%), and/or requiring formal identification (23%). Chain pharmacies were more likely to sell naloxone than independents (35% vs 19%, p = 0.001).. We documented limited naloxone access under the WV NSO. These findings indicate that simply establishing an NSO program is insufficient to expand access. Implementation efforts should ensure adequate naloxone stocks, pro-active delivery of NSO-related information and pharmacist training, and avoidance of recordkeeping requirements that may impede access.

Topics: Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pharmacies; Pharmacists; Pharmacy; United States; West Virginia

In the U.S., overdoses have become a health crisis in both public and private places. We describe the impact of the overdose crisis in public libraries across five U.S. states, and the front-line response of public library workers. We conducted a cross-sectional survey, inviting one worker to respond at each public library in five randomly selected states (CO, CT, FL, MI, and VA), querying participants regarding substance use and overdose in their communities and institutions, and their preparedness to respond. We describe substance use and overdose patterns, as well as correlates of naloxone uptake, in public libraries. Participating library staff (N = 356) reported witnessing alcohol use (45%) and injection drug use (14%) in their libraries in the previous month. Across states surveyed, 12% of respondents reported at least one on-site overdose in the prior year, ranging from a low of 10% in MI to a high of 17% in FL. There was wide variation across states in naloxone uptake at libraries, ranging from 0% of represented libraries in FL to 33% in CO. Prior on-site overdose was associated with higher odds of naloxone uptake by the library (OR 2.5, 95% CI 1.1-5.7). Although 24% of respondents had attended a training regarding substance use in the prior year, over 90% of respondents wanted to receive additional training on the topic. Public health professionals should partner with public libraries to expand and strengthen substance use outreach and overdose prevention efforts.

Topics: Cross-Sectional Studies; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Substance-Related Disorders; Surveys and Questionnaires

Although most unintentional opioid deaths in Australia are attributed to pharmaceutical opioids, take-home naloxone (THN) programmes have to date predominantly targeted people using illicit opioids in drug treatment and harm reduction settings. We sought to examine the feasibility of delivering THN brief interventions (THN-BIs) with intranasal naloxone in EDs.. This pilot feasibility study was conducted across three major metropolitan EDs in Sydney and Melbourne. ED staff were surveyed about their perspectives regarding THN before completing a 30-min training programme in THN-BI delivery. Patients presenting with opioid overdose or considered high risk for future overdose were eligible to receive the THN-BI. Staff survey responses were compared between hospitals and provider types using one-way analysis of variances. Patient demographic and clinical characteristics were extracted from medical records and compared between hospitals and overdose type using Fisher's exact test and one-way analysis of variances.. One hundred and twenty-two ED staff completed the survey. One hundred and ten (90.2%) agreed that EDs should provide THN-BIs, whereas 23 (19.2%) identified time constraints and 17 (12.9%) felt uncomfortable discussing overdose with patients. Fifty-seven patients received the THN-BI, with the majority (n = 50, 87.7%) having presented following opioid overdose. The median age was 44 years and 40 (71.4%) were men. Two-thirds of the overdoses (n = 31, 66.0%) were attributed to heroin with one-third (n = 16, 34%) being attributed to pharmaceutical opioids.. ED-based delivery of THN-BIs can reach a wide range of individuals at-risk of overdose. The present study supports the feasibility of THN interventions in EDs and underscores the importance of addressing implementation barriers including staff training.

Topics: Adult; Analgesics, Opioid; Crisis Intervention; Drug Overdose; Emergency Service, Hospital; Feasibility Studies; Female; Humans; Male; Naloxone; Narcotic Antagonists; Opiate Overdose; Pharmaceutical Preparations; Pilot Projects

Maternal mortality rates have been increasing in the United States for decades. For several years, opioid overdoses have been a leading cause of maternal mortality in several states. New Hampshire (NH) is a particularly severe case, with 50% of all maternal deaths being caused by drug-related overdoses from 2016 to 2017. We report on the implementation of a point-of-care naloxone distribution program for an Ob/Gyn clinic in NH.. Naloxone distribution was tracked to measure program implementation. Proportion of patients screened for naloxone need was calculated monthly. Proportion of patients with which discussions about naloxone took place was calculated quarterly. Patient and provider perspectives on the program were captured periodically. Statistical process control charts monitored change over time and evaluated for special-cause variation.. The clinic has distributed 12 doses of naloxone since program implementation in April 2020. Despite the challenges posed by the COVID-19 pandemic, screening for naloxone need has remained at pre-pandemic rates (moving average: 73%), except for a decrease in April-May 2020. Patient-provider discussions about naloxone have also remained at pre-pandemic rates (moving average: 51%). Qualitative feedback from patients and providers has indicated that the program has been well-received by both groups.. The purpose of this description is to provide a framework for other Ob/Gyn clinics to use in implementing similar naloxone distribution programs. Although too early to determine whether this intervention will result in a significant decrease in maternal mortality due to opioid overdose in our patients, this measure will continue to be tracked annually. Implementation of a naloxone program in the obstetrical context provides an important way to improve outcomes for a vulnerable perinatal population.

Topics: Analgesics, Opioid; COVID-19; Drug Overdose; Humans; Maternal Mortality; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Pandemics; United States

Topics: Adult; Buprenorphine; Contraception; Drug Overdose; Female; Harm Reduction; Heroin; Humans; Male; Methadone; Methamphetamine; Naloxone; Opioid-Related Disorders; Pregnancy; Quality of Life; Referral and Consultation; Substance-Related Disorders

The opioid epidemic is a rapidly growing public health concern in the USA, as the number of overdose deaths continues to increase each year. One strategy for combating the rising number of overdoses is through opioid overdose prevention programs (OOPPs).. To evaluate the effectiveness of an innovative OOPP, with changes in knowledge and attitudes serving as the primary outcome measures.. The OOPP was developed by a group of medical students under guidance from faculty advisors. Training sessions focused on understanding stigmatizing factors of opioid use disorder (OUD), as well as protocols for opioid overdose reversal through naloxone administration. Pre- and post-surveys were partially adapted from the opioid overdose attitudes and knowledge scales and administered to all participants. Paired t-tests were conducted to assess differences between pre- and post-surveys.. A total of 440 individuals participated in the training; 381 completed all or the majority of the survey. Participants came from a diverse set of backgrounds, ages, and experiences. All three knowledge questions showed significant improvements. For attitude questions, significant improvements were found in all three questions evaluating confidence, two of three questions assessing attitudes towards overdose reversal, and four of five questions evaluating stigma and attitudes towards individuals with OUD.. Our innovative OOPP was effective not only in increasing knowledge but also in improving attitudes towards overdose reversal and reducing stigma towards individuals with OUD. Given the strong improvements in attitudes towards those with OUD, efforts should be made to incorporate the unique focus on biopsychosocial and sociohistorical components into future OOPPs.

Topics: Analgesics, Opioid; Drug Overdose; Health Knowledge, Attitudes, Practice; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders

The Stop Overdose Safely (S-O-S) initiative-developed in compliance with WHO guidelines-aims to prevent opioid overdose deaths. Under the umbrella of this initiative a multi-country project was implemented in Kazakhstan, Kyrgyzstan, Tajikistan, and Ukraine, that involved overdose recognition and response training, including the provision of take-home naloxone (THN). More than 14,000 potential overdose witnesses were trained and more than 16,000 THN kits were distributed across the participating countries. This paper reports on the qualitative component of an evaluation aiming to understand the views and experiences of S-O-S project participants.. Data were drawn from focus group discussions with 257 project participants from across all four countries, including people who use and inject drugs, and others likely to witness an opioid overdose. Data were analysed thematically.. Findings revealed how past experiences of trauma and loss related to overdose death were common, as was appreciation and gratitude for the opportunity to participate in the S-O-S training. Participants described how they shared knowledge and skills with others. Empowerment and destigmatising narratives featured prominently, and highlighted how for people who use drugs, feeling valued and cared about-not only by families and friends, but by health care providers, and sometimes police-was a positive outcome of their participation. Nevertheless, findings also revealed how real experiences of fear regarding police intervention was a barrier to carrying naloxone and intervening when faced with an overdose situation.. Our analysis found that the S-O-S project produced positive outcomes that go well beyond saving lives. Despite identifying barriers to THN uptake, our findings support a growing body of evidence that broad access to THN as part of a continuum of care can enhance the health and wellbeing of people who use drugs and their communities, in low- to middle-income countries.

Topics: Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; World Health Organization

State- and county-level reports suggest that the COVID-19 pandemic exacerbated the opioid crisis. We examined US national trends of nonfatal opioid overdose in 2020 in comparison to pre-COVID years 2018-2019.. We used National Emergency Medical Services Information System (NEMSIS) data to conduct a temporal analysis from 2018 to 2020. Opioid-related EMS run was defined using five scenarios of naloxone administration. To determine annual patterns and slope inflection points, we used the Prophet model of the time series analysis. Linear slopes and their 95% confidence intervals (CIs) were calculated for pre-stay-at-home (pre-SaH) and SaH periods in 2020 and compared to the slopes during the same time in 2018-2019. Three cut-points for SaH start were considered: March 19, 24, and 29.. We identified 91,065, 144,802, and 242,904 opioid-related EMS runs in 2018-2020, respectively. In 2020, opioid-related runs increased in January-June, with a pronounced acceleration in March, which coincides with the stay-at-home (SaH) orders. In both 2018 and 2019, opioid-related runs increased in January-August without the spring acceleration. In 2020, weekly increases (95% CI) during SaH for all examined cut-points were significantly greater than in pre-SaH: 18.09 (16.03-20.16) vs. 6.44 (3.42-9.47) for March 19, 17.77 (15.57-19.98) vs. 4.85 (2.07-7.64) for March 24, 18.03 (15.68-20.39) vs. 4.97(2.4-7.54) for March 29. No significant difference was found between these periods in 2018-2019.. The acceleration of opioid-related EMS runs during the SaH period of 2020 suggests that EMS data may serve as an early warning system for local health jurisdictions to deploy harm reduction/prevention resources.

Topics: Acceleration; Analgesics, Opioid; COVID-19; Drug Overdose; Emergency Medical Services; Humans; Information Systems; Naloxone; Narcotic Antagonists; Pandemics; SARS-CoV-2

Drug mortality has increased in Sweden during the 2000s. The vast majority of deaths are opioid overdoses. The National Board of Health and Welfare recommends that the antidote naloxone and a brief overdose education should be offered to people who are at risk of opioid overdose. A retrospective registry study of 193 forensically examined fatal opioid overdoses in Skåne showed that over 80 percent occurred in private residences, most often the deceased's own home. Other people were present in just over 40 percent of the 193 deaths, but usually in another room or asleep. In most cases, the witnesses were friends, partners, parents, or other people close to the deceased. Naloxone programs should be expanded to include family members and other persons who are close to opioid users, and who therefore may witness or be present early in case of an overdose.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Retrospective Studies

Injectable naloxone is already provided as take-home naloxone (THN), and new concentrated intranasal naloxone is now being introduced in Europe. Despite evidence of the effectiveness and cost-effectiveness of THN, little is known about the attitudes of key target populations: people who use opioids (PWUO), family/friends, and staff. We examined the acceptability of different naloxone devices (ampoule, prefilled syringe, and concentrated nasal spray) across 5 European countries.. The aim of this study was to compare THN target groups (PWUO vs. family/friends vs. staff) in their past rates of witnessed overdose and THN administration (as indicators of future use), current THN device preference, and THN carriage on the day of survey.. Cross-sectional survey of respondents (age ≥18) in addiction treatment, harm reduction, and recovery services in Denmark, England, Estonia, Norway, and Scotland. A purpose-developed questionnaire (59 items) was administered in the local language electronically or in a pen-and-paper format.. Among n = 725 participants, 458 were PWUO (63.2%), 214 staff (29.5%), and 53 (7.3%) family members. The groups differed significantly in their likelihood-of-future THN use (p < 0.001): PWUO had the highest rate of previously witnessing overdoses (352; 77.7%), and staff members reported the highest past naloxone use (62; 30.1%). Across all groups, most respondents (503; 72.4%) perceived the nasal spray device to be the easiest to use. Most reported willingness to use the spray in an overdose emergency (508; 73.5%), followed by the prefilled syringe (457; 66.2%) and ampoules (64; 38.2%). Average THN carriage was 18.6%, ranging from 17.4% (PWUO) to 29.6% (family members).. Respondents considered the concentrated naloxone nasal spray the easiest device to use. Still, most expressed willingness to use the nasal spray as well as the prefilled syringe in an overdose emergency. Carriage rates were generally low, with fewer than 1 in 5 respondents carrying their THN kit on the day of the survey.

Topics: Analgesics, Opioid; Attitude; Cross-Sectional Studies; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Nasal Sprays; Opioid-Related Disorders; Surveys and Questionnaires

In May 2018, St. Paul's Hospital (SPH) in Vancouver (Canada) opened an outdoor peer-led overdose prevention site (OPS) operated in partnership with Vancouver Coastal Health and RainCity Housing. At the end of 2020, the partnered OPS moved to a new location, which created a gap in service for SPH inpatients and outpatients. To address this gap, which was magnified by the COVID-19 pandemic, SPH opened a nurse-led OPS in February 2021. This paper describes the steps leading to the implementation of the nurse-led OPS, its impact, and lessons learned.. Four steps paved the way for the opening of the OPS: (1) identifying the problem, (2) seeking ethics guidance, (3) adapting policies and practices, and (4) supporting and training staff.. The OPS is open between 10:00 and 20:00 and staffed by two nurses per shift. It is accessible to all patients including inpatients, patients in the Emergency Department, and patients attending outpatient services. Between February 1, 2021 and October 23, 2021, the OPS recorded 1612 visits for the purpose of injection, for an average weekly visit number of 42. A total of 46 overdoses were recorded in that 9-month period. Thirty-seven (80%) required administration of naloxone and 12 (26%) required a code blue response.. Due to the unique nature of our OPS, we learned many important lessons in the process leading to the opening of the site and the months that followed. We conclude the paper with lessons learned grouped into six main categories, namely engagement, communication, access, staff education and support, data collection, and safety.

Topics: Canada; COVID-19; Drug Overdose; Hospitals; Humans; Naloxone; Nurse's Role; Pandemics; SARS-CoV-2

Drug overdoses occur when the amount of drug or combination of drugs consumed is toxic and negatively affects physiological functioning. Opioid overdoses are responsible for the majority of overdose deaths worldwide. Naloxone is a safe, fast-acting opioid antagonist that can reverse an opioid overdose, and as such, it should be a critical component of community-based responses to opioid overdose. However, the burden of drug overdose deaths remains unquantified in South Africa, and both knowledge about and access to naloxone is generally poor. The objective of this study was to describe the experiences of overdose, knowledge of responses to overdose events, and willingness to call emergency medical services in response to overdose among people who use drugs in Cape Town, Durban, and Pretoria (South Africa).. We used convenience sampling to select people who use drugs accessing harm reduction services for this cross-sectional survey from March to July 2019. Participants completed an interviewer-administered survey, assessing selected socio-demographic characteristics, experiences of overdose among respondents and their peers, knowledge about naloxone and comfort in different overdose responses. Data, collected on paper-based tools, were analysed using descriptive statistics and categorised by city.. Sixty-six participants participated in the study. The median age was 31, and most (77%) of the respondents were male. Forty-one per cent of the respondents were homeless. Heroin was the most commonly used drug (79%), and 82% of participants used drugs daily. Overall, 38% (25/66) reported overdosing in the past year. Most (76%, 50/66) knew at least one person who had ever experienced an overdose, and a total of 106 overdose events in peers were reported. Most participants (64%, 42/66) had not heard of naloxone, but once described to them, 73% (48/66) felt comfortable to carry it. More than two-thirds (68%, 45/66) felt they would phone for medical assistance if they witnessed an overdose.. Drug overdose was common among participants in these cities. Without interventions, high overdose-related morbidity and mortality is likely to occur in these contexts. Increased awareness of actions to undertake in response to an overdose (calling for medical assistance, using naloxone) and access to naloxone are urgently required in these cities. Additional data are needed to better understand the nature of overdose in South Africa to inform policy and responses.

Topics: Adult; Analgesics, Opioid; Cities; Cross-Sectional Studies; Drug Overdose; Humans; Male; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; South Africa; Surveys and Questionnaires

Topics: Drug Overdose; Humans; Naloxone

Topics: Analgesics, Opioid; Animals; Antibodies, Monoclonal; COVID-19; Drug Overdose; Fentanyl; Humans; Naloxone; Narcotic Antagonists; Pandemics; Rats; Respiratory Insufficiency

In 2019-2020, record-high numbers of overdoses have been reported across the UK. We estimated perceived availability to and carriage of naloxone and explored factors associated with carriage among people who inject drugs (PWID) engaged with services in England, Wales, and Northern Ireland.. Participants were PWID enrolled in the Unlinked Anonymous Monitoring Survey in 2019 who reported past-year injection drug use (n = 2,139). Recruitment occurred through specialist and community drug agencies located across the UK, excluding Scotland. Socio-demographic, behavioural and service use characteristics were self-reported. Participants were asked whether they carry naloxone (timeframe unspecified). If they answered "no", they were further asked whether it is available in their area. Perceived naloxone availability and carriage were estimated by requirement region, classified using the Nomenclature of Territorial Units for Statistics 1. We used the Gelberg-Andersen Model of healthcare access to explore predisposing, enabling and need factors associated with regionally-aggregated naloxone carriage.. Perceived naloxone availability was ≥95% in all 11 regions; naloxone carriage varied (mean: 61.1; range: 48%-71%; P<0.01). Among predisposing factors, female gender (adjusted odds ratio (AOR): 1.52; 95% confidence interval (CI): 1.21-1.91) was positively associated with naloxone carriage, whilst recruitment in Yorkshire and the Humber-relative to London-was negatively associated (AOR: 0.55; 95%CI: 0.37-0.82). Among enabling factors, past-year contact with needle and syringe programmes (AOR: 1.74; 95%CI: 1.39-2.18) and currently receiving treatment for drug use (AOR: 1.75; 95%CI: 1.24-2.46) were positively associated with naloxone carriage. Among need characteristics, past-month heroin injection, with or without past-month high-risk drinking or benzodiazepine use, was positively associated with carriage relative to no heroin injection (range of AORs: 1.71-2.58).. Perceived naloxone availability is very high among PWID attending services in England, Wales, and Northern Ireland. Naloxone carriage is moderately high and varying across regions, and appears improved through recent engagement with harm-reduction programs.

Topics: Drug Overdose; Drug Users; Female; Humans; Naloxone; Northern Ireland; Substance Abuse, Intravenous; Wales

During the scaling-up of a national Norwegian take-home naloxone (THN) program, data collection methods shifted from paper-based to electronic. The aim of this study was to explore staff preferences towards the shift in data collection.. In January-February 2020, a survey was sent out via email to personnel involved with the THN program (n = 200). The survey included 17 questions, and covered staff demographics, experiences distributing THN, preferences towards data collection (both paper and electronically), and an open response section. Descriptive statistics were performed for the survey results. The open response section was recorded from each questionnaire and was coded into major themes by the authors.. In total, 122 staff completed the survey. Of these, 62% had experience with both electronic and paper-based forms, and there was a near unanimous preference towards electronic data collection over paper-based forms. From the free-text responses, staff found the electronic form to be a useful tool for conversation and overdose prevention education, and that the electronic form was easier to manage than the paper forms.. The shift towards electronic data collection was necessary for the feasibility of the Norwegian national THN program. This study found that staff not only tolerated the shift, but in most cases preferred this organizational change.

Topics: Cross-Sectional Studies; Data Collection; Drug Overdose; Electronics; Humans; Naloxone; Narcotic Antagonists

Opioid-related overdose deaths have been increasing in the United States (U.S.) in the last twenty years, creating a public health challenge. Take-home naloxone is an effective strategy for preventing opioid-related overdose death, but its widespread use is particularly challenging in smaller cities, towns, and rural areas where it may be stigmatized and/or poorly understood.. We analyzed data on knowledge and beliefs about drug use and naloxone among the general public in Nebraska, a largely rural state in the Great Plains region of the U.S., drawing on the 2020 Nebraska Annual Social Indicators Survey.. Respondents reported negative beliefs about people who use drugs (PWUD) and little knowledge of naloxone. Over half reported that members of their community view PWUD as blameworthy, untrustworthy, and dangerous. Approximately 31% reported being unaware of naloxone. Only 15% reported knowing where to obtain naloxone and less than a quarter reported knowing how to use it. Knowing where to obtain naloxone is associated with access to opioids and knowing someone who has recently overdosed, but having ever used opioids or being close to someone who uses opioids is not associated with naloxone knowledge. Finally, almost a quarter of respondents endorsed the belief that people who use opioids will use more if they have access to naloxone.. Our findings highlight stigmatizing beliefs about PWUD and underscore the need for further education on naloxone as an effective strategy to reduce opioid-related overdose death. We highlight the implications of these findings for public education efforts tailored to non-urban communities.

Topics: Analgesics, Opioid; Drug Overdose; Harm Reduction; Humans; Naloxone; Narcotic Antagonists; Nebraska; Opioid-Related Disorders; United States

Despite increased availability of take-home naloxone, many people who use opioids do so in unprotected contexts, with no other person who might administer naloxone present, increasing the likelihood that an overdose will result in death. Thus, there is a social nature to being "protected" from overdose mortality, which highlights the importance of identifying background factors that promote access to protective social networks among people who use opioids.. We used respondent-driven sampling to recruit adults residing in New York City who reported recent (past 3-day) nonmedical opioid use (n = 575). Participants completed a baseline assessment that included past 30-day measures of substance use, overdose experiences, and number of "protected" opioid use events, defined as involving naloxone and the presence of another person who could administer it, as well as measures of network characteristics and social support. We used modified Poisson regression with robust variance to estimate unadjusted and adjusted prevalence ratios (PRs) and 95% confidence intervals (CIs).. 66% of participants had ever been trained to administer naloxone, 18% had used it in the past three months, and 32% had experienced a recent overdose (past 30 days). During recent opioid use events, 64% reported never having naloxone and a person to administer present. This was more common among those: aged ≥ 50 years (PR: 1.18 (CI 1.03, 1.34); who identified as non-Hispanic Black (PR: 1.27 (CI 1.05, 1.53); experienced higher levels of stigma consciousness (PR: 1.13 (CI 1.00, 1.28); and with small social networks (< 5 persons) (APR: 1.14 (CI 0.98, 1.31). Having a recent overdose experience was associated with severe opioid use disorder (PR: 2.45 (CI 1.49, 4.04), suicidality (PR: 1.72 (CI 1.19, 2.49), depression (PR: 1.54 (CI 1.20, 1.98) and positive urinalysis result for benzodiazepines (PR: 1.56 (CI 1.23, 1.96), but not with network size.. Results show considerable gaps in naloxone protection among people who use opioids, with more vulnerable and historically disadvantaged subpopulations less likely to be protected. Larger social networks of people who use opioids may be an important resource to curtail overdose mortality, but more effort is needed to harness the protective aspects of social networks.

Topics: Adult; Analgesics, Opioid; Drug Overdose; Humans; Middle Aged; Naloxone; Narcotic Antagonists; New York City; Opioid-Related Disorders; Public Policy; Social Networking; Social Support

Naloxone distribution remains a cornerstone of a public health approach to combating the ongoing opioid overdose crisis. Most distribution programs focus on providing naloxone to individuals who use drugs or those closely associated with them (e.g., family). Utilizing businesses as fixed location sources of naloxone could be a valuable supplemental strategy to preventing fatal overdoses that is underexplored in the literature.. We surveyed business owners and employees (N = 149) located in neighborhoods characterized by high rates of drug use in Baltimore City. Participants reported their interactions with people who use drugs as well as if they had heard of naloxone, if the business had naloxone on the premises, and how many employees were trained to use naloxone.. Most participants reported seeing individuals under the influence of drugs (93%), public drug use (80%), and overdose (66%) while at work. 66% of participants had heard of naloxone. Among those who had heard of naloxone, only 39% reported that there was a naloxone kit in the business and 28% of businesses had multiple employees trained to use naloxone.. Businesses are underutilized as potential reliable sources of naloxone. While study participants reported high levels of exposure to drug use and overdose in and around their businesses, their ability to intervene was limited. Efforts to train employees to respond to overdoses and to keep naloxone on site are warranted to supplement existing naloxone distribution efforts and can help empower business staff to help prevent overdose mortality in their communities.

Topics: Analgesics, Opioid; Drug Overdose; Emergencies; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Substance-Related Disorders

To determine whether participation in the United Nations Office on Drugs and Crime (UNODC) and the World Health Organization's (WHO) Stop Overdose Safely (S-O-S) take-home naloxone training project in Kazakhstan, Kyrgyzstan, Tajikistan and Ukraine resulted in naloxone use at witnessed opioid overdoses.. An observational prospective cohort study was performed by recruiting participants in the implementation of the S-O-S project, which was developed as part of the broader S-O-S initiative. Training included instruction on overdose responses and naloxone use. Study participants were followed for 6 months after completing training. The primary study outcome was participants' naloxone use at witnessed overdoses, reported at follow-up.. Between 400 and 417 S-O-S project participants were recruited in each country. Overall, 84% (1388/1646) of participants were interviewed at 6-month follow-up. The percentage who reported witnessing an overdose between baseline and follow-up was 20% (71/356) in Tajikistan, 33% (113/349) in Kyrgyzstan, 37% (125/342) in Ukraine and 50% (170/341) in Kazakhstan. The percentage who reported using naloxone at their most recently witnessed overdose was 82% (103/125) in Ukraine, 89% (152/170) in Kazakhstan, 89% (101/113) in Kyrgyzstan and 100% (71/71) in Tajikistan.. Implementation of the UNODC-WHO S-O-S training project in four low- to middle-income countries resulted in the reported use of take-home naloxone at around 90% of witnessed opioid overdoses. The percentage varied between countries but was generally higher than found in previous studies. Take-home naloxone is particularly important in countries where emergency medical responses to opioid overdoses may be limited.. Déterminer si la participation au projet de formation aux kits de naloxone à emporter Stop Overdose Safely (S-O-S), lancé conjointement par l'Office des Nations Unies contre les drogues et le crime (ONUDC) et l'Organisation mondiale de la Santé (OMS) au Kazakhstan, au Kirghizistan, au Tadjikistan et en Ukraine, a entraîné l'usage de naloxone lorsqu'une surdose d'opioïdes était constatée.. Nous avons mené une étude de cohorte prospective observationnelle en recrutant des participants à la mise en œuvre du projet S-O-S, développé dans le cadre de la vaste initiative S-O-S. La formation leur expliquait notamment comment réagir face à une overdose et comment utiliser la naloxone. À l'issue de leur formation, les participants à l'étude ont fait l'objet d'un suivi pendant 6 mois. L'étude a essentiellement conclu que les participants ont bien fait usage de naloxone lorsqu'ils ont été confrontés à une overdose, conformément à ce qu'ils ont relaté durant la période de suivi.. Entre 400 et 417 participants au projet S-O-S ont été recrutés dans chaque pays. Au total, 84% (1388/1646) d'entre eux ont été interrogés au terme des 6 mois de suivi. Le pourcentage de participants ayant indiqué avoir assisté à une overdose entre la formation initiale et la fin de la période de suivi s'élevait à 20% (71/356) au Tadjikistan, 33% (113/349) au Kirghizistan, 37% (125/342) en Ukraine et 50% (170/341) au Kazakhstan. Enfin, le pourcentage de ceux ayant indiqué avoir eu recours à la naloxone lors de l'overdose la plus récente à laquelle ils ont assisté s'élevait à 82% (103/125) en Ukraine, 89% (152/170) au Kazakhstan, 89% (101/113) au Kirghizistan et 100% (71/71) au Tadjikistan.. Le déploiement du projet de formation S-O-S porté par l'ONUDC et l'OMS dans quatre pays à faible et moyen revenu a encouragé l'usage de kits de naloxone pour 90% des overdoses d'opioïdes constatées. Le pourcentage variait d'un pays à l'autre mais, dans l'ensemble, il était supérieur à celui des études précédentes. Les kits de naloxone à emporter sont particulièrement importants dans les pays où la prise en charge médicale urgente des surdoses d'opioïdes pourrait s'avérer limitée.. Determinar si la participación en el proyecto de formación en naloxona para llevar a casa Stop Overdose Safely (S-O-S) de la Oficina de las Naciones Unidas contra la Droga y el Delito (ONUDD) y la Organización Mundial de la Salud (OMS) en Kazajistán, Kirguistán, Tayikistán y Ucrania generó el uso de naloxona cuando se presenciaron sobredosis de opiáceos.. Se realizó un estudio de cohortes prospectivo y observacional mediante el reclutamiento de participantes en la aplicación del proyecto S-O-S, que se desarrolló como parte de la iniciativa más amplia S-O-S. La formación incluía enseñanzas sobre las respuestas a las sobredosis y el uso de la naloxona. Los participantes del estudio fueron seguidos durante 6 meses después de completar la formación. El desenlace primario del estudio fue el uso de naloxona por parte de los participantes ante la presencia de sobredosis, notificado durante el seguimiento.. En cada país se reclutaron entre 400 y 417 participantes para el proyecto S-O-S. En general, el 84 % (1388/1646) de los participantes fueron entrevistados en el seguimiento a los 6 meses. El porcentaje que declaró haber presenciado una sobredosis entre el inicio y el seguimiento fue del 20 % (71/356) en Tayikistán, el 33 % (113/349) en Kirguistán, el 37 % (125/342) en Ucrania y el 50 % (170/341) en Kazajistán. El porcentaje que declaró haber utilizado naloxona en las sobredosis presenciadas más recientes fue del 82 % (103/125) en Ucrania, del 89 % (152/170) en Kazajistán, del 89 % (101/113) en Kirguistán y del 100 % (71/71) en Tayikistán.. La ejecución del proyecto de formación S-O-S de la ONUDD y la OMS en cuatro países de ingresos bajos y medios permitió notificar el uso de naloxona para llevar a casa en alrededor del 90 % de las sobredosis de opiáceos presenciadas. El porcentaje varió entre los países, pero en general fue más alto que el encontrado en los estudios anteriores. La naloxona para llevar a casa es de especial importancia en los países donde la respuesta médica de emergencia a las sobredosis de opiáceos podría ser limitada.. تحديد ما إذا كانت المشاركة في مكتب الأمم المتحدة الخاص بالمخدرات والجريمة (UNODC)، ومشروع التدريب على إيقاف الجرعة الزائدة من عقار نالوكسون المنزلي بأمان (S-O-S) التابع لمنظمة الصحة العالمية (WHO) في كازاخستان وقيرغيزستان وطاجيكستان وأوكرانيا، قد أدى إلى استخدام عقار نالوكسون في جرعات زائدة مشهودة من الأفيون.. تم إجراء دراسة أترابية قائمة على الملاحظة من خلال تجنيد المشاركين في تنفيذ مشروع S-O-S، الذي تم تطويره كجزء من مبادرة S-O-S الأوسع نطاقًا. وشمل التدريب تعليمات حول الاستجابات للجرعات الزائدة واستخدام عقار نالوكسون. تمت متابعة المشاركين في الدراسة لمدة 6 أشهر بعد إكمال التدريب. كانت نتيجة الدراسة الأولية هي استخدام المشاركين لعقار نالوكسون بجرعات زائدة مشهودة، تم الإبلاغ عنها أثناء المتابعة.. تم تجنيد ما بين 400 و417 مشاركًا في مشروع S-O-S في كل دولة. بشكل عام، تمت مقابلة 84% (1388/1646) من المشاركين بشكل شخصي في متابعة استمرت لمدة 6 أشهر. النسبة المئوية للذين أبلغوا عن مشاهدة جرعة زائدة بين خط الأساس والمتابعة كانت 20% (71/356) في طاجيكستان، و33% (113/349) في قيرغيزستان، و37% (125/342) في أوكرانيا، و50% (170/341) في كازاخستان. النسبة المئوية للذين أبلغوا عن استخدام عقار نالوكسون في أحدث جرعة زائدة مشهودة لديهم كانت 82% (103/125) في أوكرانيا، و89% (152/170) في كازاخستان، و89% (101/113) في قيرغيزستان، و100% (71/71) في طاجيكستان.. إن تنفيذ مشروع التدريب S-O-S، التابع لمكتب الأمم المتحدة الخاص بالمخدرات والجريمة ومنظمة الصحة العالمية، في أربع دول ذات دخل منخفض إلى دخل متوسط، قد أدى إلى الإبلاغ عن استخدام عقار نالوكسون المنزلي في حوالي 90% من الجرعات الزائدة المشهودة من الأفيون. اختلفت النسبة المئوية بين الدول ولكنها كانت أعلى بشكل عام مما تم العثور عليه في الدراسات السابقة. يعتبر تناول عقار نالوكسون المنزلي مهمًا بشكل خاص في الدول التي قد تكون فيها الاستجابات الطبية الطارئة للجرعات الزائدة من الأفيون محدودة.. 旨在确定是否参加联合国毒品和犯罪问题办公室 (UNODC) 和世界卫生组织 (WHO) 在哈萨克斯坦、吉尔吉斯斯坦、塔吉克斯坦和乌克兰开展的安全消除药物过量 (S-O-S) 自主服用纳洛酮培训项目，因为这些国家的鸦片用药过量案例中普遍存在使用纳洛酮的现象。.. 通过招募参与者参与 S-O-S 项目的实施开展观察性前瞻性队列研究，该 S-O-S 项目是范围更大的 S-O-S 方案的组成部分。培训包括解答药物过量问题和指导纳洛酮的使用方法。完成培训后，会对研究参与者进行为其 6 个月的后续追踪。据后续追踪报道，主要研究结果为参与者表明其见证的用药过量案例中会使用纳洛酮。.. 在各个国家分别招募了 400 到 417 名 S-O-S 项目参与者。总体来看，对 84% (1388/1646) 参与者进行了为期 6 个月的后续追踪。在基线到后续追踪期间报告存在用药过量的参与者比例为：哈萨克斯坦 50% (170/341)、吉尔吉斯斯坦 33% (113/349)、塔吉克斯坦 20% (71/356) 和乌克兰 37% (125/342)。报告在其最近一次见证的用药过量中使用纳洛酮的参与者比例为：哈萨克斯坦 89% (152/170)、吉尔吉斯斯坦 89% (101/113)、塔吉克斯坦 100% (71/71)、 和乌克兰 82% (103/125)。.. 在四个中低收入国家实施 UNODC–WHO S-O-S 培训项目后发现，在报告的自主服用纳洛酮案例中，90% 存在鸦片用药过量现象。该比例因不同国家而异，但普遍高于之前研究中发现的数值。在鸦片用药过量应急医疗救治方面资源有限的国家，自主服用纳洛酮的问题尤为严重。.. Определить, привело ли участие в проекте под названием «За безопасную профилактику передозировки» (S-O-S) Управления Организации Объединенных Наций по наркотикам и преступности (УНП ООН) и Всемирной организации здравоохранения (ВОЗ) по обучению использования налоксона в домашних условиях лицами, которые могут стать свидетелями передозировки опиоидов, в Казахстане, Кыргызстане, Таджикистане и на Украине.. Было проведено обсервационное проспективное когортное исследование путем набора участников в рамках реализации проекта S-O-S, который был разработан на базе более широкой инициативы S-O-S. Обучение состояло из указаний по реагированию на передозировку и использованию налоксона. За участниками исследования наблюдали в течение 6 месяцев после завершения обучения. Главным результатом исследования, о котором сообщалось при последующем наблюдении, было использование налоксона лицами, которые могут стать свидетелями передозировки.. В каждой стране было набрано от 400 до 417 участников проекта S-O-S. В целом 84% (1388/1646) участников были опрошены через 6 месяцев наблюдения. Процент тех, кто сообщил о том, что стал свидетелем передозировки, между исходным уровнем и последующим наблюдением составил 20% (71/356) в Таджикистане, 33% (113/349) в Кыргызстане, 37% (125/342) на Украине и 50% (170/341) в Казахстане. Процент лиц, которые стали свидетелями передозировки и использовали налоксон во время последнего такого случая, составил 82% (103/125) на Украине, 89% (152/170) в Казахстане, 89% (101/113) в Кыргызстане и 100% (71/71) в Таджикистане.. Реализация проекта S-O-S от УНП ООН и ВОЗ в четырех странах с низким и средним уровнем дохода привела к тому, что примерно в 90% случаев сообщалось об использовании налоксона в домашних условиях лицами, которые стали свидетелями передозировки опиоидов. Процентное значение варьировалось между странами, но в целом было выше, чем в предыдущих исследованиях. Использование налоксона в домашних условиях особенно важно в тех странах, где неотложная медицинская помощь при передозировке опиоидов может быть ограничена.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Kazakhstan; Kyrgyzstan; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Prospective Studies; Tajikistan; Ukraine

The opioid epidemic in the United States is financially, physically, and emotionally costly. Juvenile residents in detention settings witness overdose through personal opioid use or that of family or friends. Educational programming was developed for residents in a juvenile temporary detention center to increase knowledge of opioid overdose and nonopioid misuse. Using pre-post group surveys, we evaluated knowledge of opioid overdose, naloxone, and attitudes. Most residents recognized opioids and other substances by name, felt comfortable in their ability to recognize opioid overdose symptoms, and knew how to assist. Youth residents may be less likely to use opioids and more likely to become first responders in an overdose situation. However, some would not intervene or call for help. Instead, a potential conflict for themselves was perceived.

Topics: Adolescent; Analgesics, Opioid; Drug Overdose; Health Knowledge, Attitudes, Practice; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; United States

Pharmacists are well-positioned to provide patients with access to the opioid-induced breathing emergency reversal agent naloxone, but many do not feel they have received adequate training to do so. The purpose of this project was to develop, implement, and evaluate an enhanced teaching approach to naloxone education in the doctor of pharmacy (PharmD) curriculum.. The educational intervention incorporated active learning, technology, and interprofessional education components. Surveys were developed and administered pre-intervention and at one-week, six-month, and one-year post-intervention to evaluate changes in knowledge, perceptions, and confidence in clinical skills related to opioid-induced breathing emergencies and naloxone.. After participating, students' confidence (rated 0 to 5) in their ability to administer both intranasal (2.54 vs. 4.37, P < .001) and intramuscular (IM) (2.8 vs. 4.02, P < .001) naloxone increased, which was reflected in their improved performance on an opioid-induced breathing emergency simulation activity. Students ≤25 years old and females experienced significantly greater increases in their confidence to administer IM naloxone than those >25 years old and male. Most of these effects persisted at six months and one-year post-intervention.. The educational intervention increased pharmacy students' skills and confidence related to opioid-induced breathing emergency and naloxone. Improvements observed were in line with results of similar pedagogical studies. Age and gender differences in self-reported confidence levels also reflected previously reported findings. Materials and methods have been made available for other PharmD programs to utilize in expanding their curricula in these areas.

Topics: Adult; Analgesics, Opioid; Curriculum; Drug Overdose; Female; Humans; Male; Naloxone; Narcotic Antagonists; Pharmacy; Students, Pharmacy

Topics: Drug Overdose; Humans; Naloxone; Narcotic Antagonists

A central tenet of harm reduction and prevention of opioid overdose deaths is the distribution and use of naloxone. Patient-centered methods that investigate naloxone acquisition and carrying can guide opioid overdose education and naloxone distribution efforts.. To assess patients' self-reported naloxone acquisition and carrying after an emergency department (ED) encounter using automated text messaging.. This cohort study investigated self-reported patient behaviors involving naloxone after ED discharge in a large, urban academic health system in Philadelphia, Pennsylvania. Adult patients who were prescribed or dispensed naloxone and who had a mobile phone number listed in the electronic health record provided informed consent after ED discharge, and data were collected prospectively using text messaging from October 10, 2020, to March 19, 2021. Patients who did not respond to the survey or who opted out were excluded.. Automated text message-based survey after ED discharge for patients who were prescribed or dispensed naloxone.. The primary outcome was patient-reported naloxone acquisition, carrying, and use. Descriptive statistics were used to summarize patient demographic characteristics.. Of 205 eligible patients, 41 (20.0%) completed the survey; of those patients, the mean (SD) age was 39.5 (13.7) years, and 21 (51.2%) were women. Fifteen (36.6%) had a personal history of being given naloxone after an overdose. As indicated by the ED record, 27 participants (65.9%) had naloxone dispensed in the ED, and 36 (87.8%) self-reported acquiring naloxone during or after their ED visit. Twenty-four participants (58.5%) were not carrying naloxone in the week before their ED visit. Twenty participants (48.8%) were carrying naloxone after the ED visit, and 27 (65.9%) reported planning to continue carrying naloxone in the future. Of the 24 individuals (58.5%) not carrying naloxone before their ED encounter, 13 (54.2%) reported planning to continue carrying naloxone in the future.. In this cohort study of adult patients dispensed or prescribed naloxone from the ED, most reported acquiring naloxone on or after discharge. The ED remains a key point of access to naloxone for individuals at high risk of opioid use and overdose, and text messaging could be a method to engage and motivate patient-reported behaviors in enhancing naloxone acquisition and carrying.

Topics: Adult; Analgesics, Opioid; Cohort Studies; Drug Overdose; Emergency Service, Hospital; Female; Humans; Naloxone; Opiate Overdose; Patient Discharge; Patient Reported Outcome Measures; Philadelphia; Text Messaging

The street homeless, those who spend their nights either in shelters or unofficial camps, whether in tents on a street or in society's hidden spaces such as beneath an overpass, face multiple challenges beyond finding a safe place to sleep. Of further concern is how official actions can worsen these situations, through day-to-day activities or planned intervention strategies. In this paper we explore how a planned intervention may be negatively perceived-even as a form of "structural violence"-and may prevent Narcan (naloxone) use to stop an overdose related death in the Skid Row of Los Angeles. Data for this study consisted of a combination of Spatial Video Geonarratives (SVGs) and 325 incident reports from the Homeless Health Care Los Angeles Center for Harm Reduction (HHCLA-HRC) between November 2014 and December 2015. Chi-square and simple logistic regression models were used to examine the association between fear-of-arrest and other covariates of interest. Mapping results are presented with different sets of shapefiles created for (1) all Narcan uses, (2) all homeless, (3) all homeless with a worry about being arrested, (4) all Narcan uses where an ambulance attended, (5) and the same as 4 but also with police attendance. In the multivariable model, the estimated adjusted odds of fear-of-arrest is over three times higher among Narcan users ages 30-39 when compared to users under the age of 30. Analyzing the association of calling 9-1-1 on Narcan user demographics, socio-contextual characteristics, and overdose victim demographics, the crude estimated probability of calling 9-1-1 for Narcan users aged 50 and older is nearly three times higher when compared to Narcan users aged 19-29. Conclusion: Results suggest that the fear-of-arrest and calling 9-1-1 during an overdose is still a concern among Narcan users despite protective legislation and access to harm reduction resources.

Topics: Aged; Attitude; Drug Overdose; Harm Reduction; Humans; Law Enforcement; Middle Aged; Naloxone

Patients taking high doses of opioids, or taking opioids in combination with other central nervous system depressants, are at increased risk of opioid overdose. Coprescribing the opioid-reversal agent naloxone is an essential safety measure, recommended by the surgeon general, but the rate of naloxone coprescribing is low. Therefore, we set out to determine whether a targeted clinical decision support alert could increase the rate of naloxone coprescribing.. We conducted a before-after study from January 2019 to April 2021 at a large academic health system in the Southeast. We developed a targeted point of care decision support notification in the electronic health record to suggest ordering naloxone for patients who have a high risk of opioid overdose based on a high morphine equivalent daily dose (MEDD) ≥90 mg, concomitant benzodiazepine prescription, or a history of opioid use disorder or opioid overdose. We measured the rate of outpatient naloxone prescribing as our primary measure. A multivariable logistic regression model with robust variance to adjust for prescriptions within the same prescriber was implemented to estimate the association between alerts and naloxone coprescribing.. The baseline naloxone coprescribing rate in 2019 was 0.28 (95% confidence interval [CI], 0.24-0.31) naloxone prescriptions per 100 opioid prescriptions. After alert implementation, the naloxone coprescribing rate increased to 4.51 (95% CI, 4.33-4.68) naloxone prescriptions per 100 opioid prescriptions (P < .001). The adjusted odds of naloxone coprescribing after alert implementation were approximately 28 times those during the baseline period (95% CI, 15-52).. A targeted decision support alert for patients at risk for opioid overdose significantly increased the rate of naloxone coprescribing and was relatively easy to build.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Quality Improvement

Topics: Drug Overdose; Harm Reduction; Humans; Naloxone; Public Policy; Substance-Related Disorders

The British Columbia (BC) Take-Home Naloxone (THN) program provides naloxone to people at risk of experiencing or witnessing an opioid overdose for use in reversing suspected overdose events. This study seeks to examine trends and correlates of individuals obtaining a THN kit in BC between 2017 and 2020.. Records of THN kits distributed between 2017 and 2020 were the primary source of data for this analysis. Frequency tables were used to describe characteristics of people obtaining kits from THN sites. Correlates of individuals obtaining a THN kit to replace a previous kit reported as used to reverse an overdose were assessed with multivariate logistic regression.. Between January 1, 2017, and December 31, 2020, 240,606 THN kits were reported distributed by registered sites to members of the public, with 90,011 records indicating that a kit was obtained to replace a previous kit that had been used to reverse an overdose. There was a significant trend in increasing kits reported used by year (p < 0.01). The kit recipient's risk of overdose was a significant predictor of having reported using a THN kit, and the strength of the association was dependent on gender (Male: Adjusted odds ratio (AOR) 5.37 [95% confidence interval (CI) 5.08 - 5.67]; Female: AOR 8.35 [95% CI 7.90 - 8.82]; Trans and gender expansive: AOR 3.68 [95% CI 2.82 - 4.79]).. Between 2017 and 2020, THN kits were used to reverse tens of thousands of overdose events in BC, with people at risk of overdose (i.e. people who use drugs [PWUD]) having greater odds of using a kit to reverse an overdose than those not at risk. Thus, PWUD are responsible for reversing the vast majority of overdoses. THN kits are being distributed to the people who use them most. However, additional strategies in conjunction with community-based naloxone distribution programs are needed to address the rising number of illicit drug toxicity deaths.

Topics: British Columbia; Drug Overdose; Female; Humans; Illicit Drugs; Male; Naloxone; Narcotic Antagonists

Topics: Drug Overdose; Humans; Naloxone; Narcotic Antagonists

Opioid-related overdoses cause substantial numbers of preventable deaths. Naloxone is an opioid antagonist available in take-home naloxone (THN) kits as a lifesaving measure for opioid overdose. As the emergency department (ED) is a primary point of contact for patients with high-risk opioid use, evidence-based recommendations from the Society of Hospital Pharmacists of Australia THN practice guidelines include the provision of THN, accompanied by psychosocial interventions. However, implementation of these guidelines in practice is unknown. This study investigated ED opioid-related overdose presentations, concordance of post-overdose interventions with the THN practice guidelines, and the impact, if any, of the SARS-CoV-2 (COVID-19) pandemic on case presentations.. A single-centre retrospective audit was conducted at a major tertiary hospital of patients presenting with overdoses involving opioids and non-opioids between March to August 2019 and March to August 2020. Patient presentations and interventions delivered by the paramedics, ED and upon discharge from the ED were collated from medical records and analysed using descriptive statistics, chi square and independent T-tests.. The majority (66.2%) of patients presented to hospital with mixed drug overdoses involving opioids and non-opioids. Pharmaceutical opioids were implicated in a greater proportion (72.1%) of overdoses than illicit opioids. Fewer patients presented in March to August 2020 as compared with 2019 (26 vs. 42), and mixed drug overdoses were more frequent in 2020 than 2019 (80.8% vs. 57.1%). Referral to outpatient psychology (22.0%) and drug and alcohol services (20.3%) were amongst the most common post-discharge interventions. Naloxone was provided to 28 patients (41.2%) by the paramedics and/or ED. No patients received THN upon discharge.. This study highlights opportunities to improve ED provision of THN and other interventions post-opioid overdose. Large-scale multi-centre studies are required to ascertain the capacity of EDs to provide THN and the impact of COVID-19 on opioid overdose presentations.

Topics: Aftercare; Analgesics, Opioid; COVID-19; Drug Overdose; Emergency Service, Hospital; Humans; Naloxone; Opiate Overdose; Patient Discharge; Retrospective Studies; SARS-CoV-2; Tertiary Care Centers

Topics: Adult; Drug Overdose; Humans; Michigan; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pharmacies; Pharmacy; Standing Orders

Opioid addiction and overdose have a large burden of disease and mortality in New York State (NYS). The medication naloxone can reverse an overdose, and buprenorphine can treat opioid use disorder. Efforts to increase the accessibility of both medications include a naloxone standing order and a waiver program for prescribing buprenorphine outside a licensed drug treatment program. However, only a slim majority of NYS pharmacies are listed as participating in the naloxone standing order, and less than 7% of prescribers in NYS have a buprenorphine waiver. Therefore, there is a significant opportunity to increase access.. Identifying the geographic regions of NYS that are farthest from resources can help target interventions to improve access to naloxone and buprenorphine. To maximize the efficiency of such efforts, we also sought to determine where these underserved regions overlap with the largest numbers of actual patients who have experienced opioid overdose.. We used address data to assess the spatial distribution of naloxone pharmacies and buprenorphine prescribers. Using the home addresses of patients who had an opioid overdose, we identified geographic locations of resource deficits. We report findings at the high spatial granularity of census tracts, with some neighboring census tracts merged to preserve privacy.. We identified several hot spots, where many patients live far from the nearest resource of each type. The highest density of patients in areas far from naloxone pharmacies was found in eastern Broome county. For areas far from buprenorphine prescribers, we identified subregions of Oswego county and Wayne county as having a high number of potentially underserved patients.. Although NYS is home to thousands of naloxone pharmacies and potential buprenorphine prescribers, access is not uniform. Spatial analysis revealed census tract areas that are far from resources, yet contain the residences of many patients who have experienced opioid overdose. Our findings have implications for public health decision support in NYS. Our methods for privacy can also be applied to other spatial supply-demand problems involving sensitive data.

Topics: Buprenorphine; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; New York; Opiate Overdose; Opioid-Related Disorders; Vulnerable Populations

Expanding access to the opioid antagonist naloxone to reduce overdose mortality is a public health priority in the United States. Naloxone standing orders (NSOs) have been established in many states to increase naloxone dispensing at pharmacies, but increased pharmacy access does not ensure optimal uptake among those likely to witness an overdose. In a prior statewide purchase trial, we documented high levels of naloxone access at Massachusetts pharmacies under a statewide NSO. In this study, we characterize barriers to pharmacy-based naloxone uptake among potential opioid overdose "bystanders" (friends or family of people who use opioids) that may be amenable to intervention.. Eligible bystanders were Massachusetts residents ≥ 18 years of age, did not use illicit opioids in the past 30 days, and knew someone who currently uses illicit opioids. We used a sequential mixed methods approach, in which a series of semi-structured qualitative interviews (N = 22) were conducted April-July 2018, to inform the development of a subsequent quantitative survey (N = 260), conducted February-July 2020.. Most survey participants (77%) reported ever obtaining naloxone but few (21%) attempted to purchase it at a pharmacy. Qualitative participants revealed that barriers to utilizing the NSO included low perceived risk of overdose, which was rooted in misconceptions regarding the risks of prescription opioid misuse, denial about their loved one's drug use, and drug use stereotypes; inaccurate beliefs about the impact of naloxone on riskier opioid use; and concerns regarding anticipated stigma and confidentiality. Many participants had engaged in mutual support groups, which served as a source of free naloxone for half (50%) of those who had ever obtained naloxone.. Despite high levels of pharmacy naloxone access in Massachusetts, few bystanders in our study had attempted to obtain naloxone under the NSO. Low perceived risk of overdose, misinformation, stigma, and confidentiality were important barriers to pharmacy naloxone uptake, all of which are amenable to intervention. Support groups provided a setting for addressing stigma and misinformation and provided a discreet and comfortable setting for naloxone access. Where these groups do not exist and for bystanders who do not participate in such groups, pharmacies are well-positioned to fill gaps in naloxone availability.

Topics: Analgesics, Opioid; Drug Overdose; Friends; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pharmacies; Pharmacy; United States

Illicitly-manufactured fentanyls (fentanyl) have changed the risk environment of people who use drugs (PWUD). In California and many western US states, the opioid overdose rate spiked from 2016 to 2021, driven largely by fentanyl. Mexican border cities act as transit through-points for the illicit drug supply and similar evolving health risks are likely to be present. Nevertheless, due to data gaps in surveillance infrastructure, little is known about fentanyl prevalence in Mexico.. We employ intensive ethnographic participant-observation among PWUD, as well as key informants including harm reduction professionals, EMTs, and physicians on the front lines in Tijuana, Mexico. We triangulate interview data and direct observations of consumption practices with n=652 immunoassay-based fentanyl tests of drug paraphernalia from mobile harm reduction clinics in various points throughout the city.. PWUD informants described a sharp increase in the psychoactive potency and availability of powder heroin-referred to as "china white"-and concomitant increases in frequency of overdose, soft tissue infection, and polysubstance methamphetamine use. Fentanyl positivity was found among 52.8% (95%CI: 48.9-56.6%) of syringes collected at harm reduction spaces, and varied strongly across sites, from 2.7% (0.0-5.7%) to 76.5% (68.2-84.7%), implying strong market heterogeneity. Controlling for location of collection, syringe-based fentanyl positivity increased by 21.7% (10.1-42.3%) during eight months of testing. Key informants confirm numerous increased public health risks from fentanyl and describe the absence of a systematic or evidence-based governmental response; naloxone remains difficult to access and recent austerity measures have cut funding for harm reduction in Mexico.. Fentanyl, linked to powder heroin, is changing the risk environment of PWUD on the US-Mexico border. Improved surveillance is needed to track the evolving street drug supply in Mexico and related health impacts for vulnerable populations. Structural factors limiting access to naloxone, harm reduction, substance use treatment, and healthcare, and minimal overdose surveillance, must be improved to provide an effective systemic response.

Topics: Analgesics, Opioid; Drug Overdose; Fentanyl; Heroin; Humans; Illicit Drugs; Mexico; Naloxone; Powders

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders

Naloxone is a life-saving medication that reverses opioid overdose; naloxone can be provided on a 'take-home' basis so naloxone can be administered outside of the health-care setting. The Overdose Response and Take Home Naloxone (ORTHN) project established a model of care for take-home naloxone (THN) interventions across alcohol and other drug and harm reduction services in NSW, Australia. This paper evaluates the staff training and credentialing program, and examines staff attitudes and perspectives regarding the provision of THN interventions in these settings.. Staff across seven services were trained through a 'train-the-trainer' credentialing model to deliver ORTHN, including naloxone supply. Staff were surveyed regarding their experience, attitudes and knowledge on THN prior to and after training, and after 6 months. At the 6 months follow up, staff were asked about the interventions they provided, barriers and enablers to uptake, and opinions regarding future rollout.. A total of 204 staff were trained and credentialed to provide the ORTHN intervention. Most (60%) were nurses, followed by needle syringe program workers and allied health/counsellors (32%). Linear and logistic regression analyses indicated that the training program was associated with significant improvements in staff knowledge and attitudes towards overdose and THN; however, only attitudinal improvements were maintained over time. There were high rates of staff satisfaction with the ORTHN intervention and training.. The ORTHN program is 'fit for purpose' for broad implementation in these settings. A number of potential barriers (e.g. time, medication and staffing costs) and enablers (e.g. peer engagement, regulatory framework for naloxone supply) in implementing THN interventions were identified.

Topics: Drug Overdose; Harm Reduction; Health Knowledge, Attitudes, Practice; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

Topics: Analgesics, Opioid; Drug Overdose; Emergency Medical Services; Female; Humans; Male; Naloxone; Narcotic Antagonists; Opiate Overdose

Provider prescribing practices contribute to an excess of opioid-related deaths in the United States. Clinical guidelines exist to assist providers with improving prescribing practices and promoting patient safety. Clinical decision support systems (CDSS) may promote adherence to these guidelines and improve prescribing practices. The aim of this project was to improve opioid guideline adherence, prescribing practices, and rates of opioid-related encounters through the implementation of an opioid CDSS.. A vendor-developed, provider-targeted CDSS package was implemented in a multi-location academic health center. An interrupted time-series analysis was performed, evaluating 30 weeks pre- and post-implementation time periods. Outcomes were derived from vendor-supplied key performance indicators and directly from the electronic health record (EHR) database. Opioid-prescribing outcomes included count of opioid prescriptions, morphine milligram equivalents per prescription, counts of opioids with concurrent benzodiazepines, and counts of short-acting opioids in opioid-naïve patients. Encounter outcomes included rates of encounters for opioid abuse and dependence and rates of encounters for opioid poisoning and overdose. Guideline adherence outcomes included rates of provision of naloxone and documentation of opioid treatment agreements.. The opioid CDSS generated an average of 1,637 alerts per week. Rates of provision of naloxone and opioid treatment agreements improved after CDSS implementation. Vendor-supplied prescribing outcomes were consistent with prescribing outcomes derived directly from the EHR, but all prescribing and encounter outcomes were unchanged.. A vendor-developed, provider-targeted opioid CDSS did not improve opioid-prescribing practices or rates of opioid-related encounters. The CDSS improved some measures of provider adherence to opioid-prescribing guidelines. Further work is needed to determine the optimal configuration of opioid CDSS so that opioid-prescribing patterns are appropriately modified and encounter outcomes are improved.

Topics: Analgesics, Opioid; Decision Support Systems, Clinical; Drug Overdose; Humans; Naloxone; Practice Patterns, Physicians'; United States

The majority of drug overdose deaths in the United States involve opioids, and synthetic opioid-involved overdose death rates are increasing. Naloxone is a key prevention strategy yet estimates of its administration are limited.. We analyzed 2019 data from 37 states and the District of Columbia in CDC's State Unintentional Drug Overdose Reporting System to estimate the percentage of decedents, by sociodemographic subgroup, who experienced a fatal opioid-involved overdose and had no evidence of naloxone administration.. A total of 77.3% of 33,084 opioid-involved overdose deaths had no evidence of naloxone administration. Statistically significant subgroup differences were observed for all sociodemographic groups examined except housing status. The highest percentages of decedents lacking evidence of naloxone administration were those with highest educational attainment (doctorate or professional degree, 87.0%), oldest (55-64 years, 83.4%; ≥65 years, 87.3%) and youngest ages (<15 years, 87.5%), and single marital status (84.5%). The lowest percentages of no evidence of naloxone administration were observed for non-Hispanic American Indian/Alaskan Native persons (66.2%) and those ages 15-24 years (70.8%).. More than three-quarters of opioid-involved overdose deaths had no evidence of naloxone administration, underscoring the need to ensure sufficient naloxone access and capacity for utilization. While fatal overdose data cannot fully characterize sociodemographic disparities in naloxone administration, naloxone education and access efforts can be informed by apparent inequities. Public health partners can assist persons who use drugs (PWUD) by maintaining naloxone supply and amplifying messages about the high risk of using drugs alone among PWUD and their social networks.

Topics: Adolescent; Adult; Analgesics, Opioid; District of Columbia; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; United States; Young Adult

Topics: Analgesics, Opioid; Drug Overdose; Female; Fentanyl; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Standing Orders

The primary aim was to compare concentrations of psychoactive substances in blood in non-fatal and fatal opioid overdoses. The secondary aim was to assess the concentration levels of naloxone in blood in non-fatal overdoses and the association between naloxone findings and concomitantly detected drugs.. Case-control study.. Norway. Fatal overdoses from 2017 and non-fatal overdoses from February 2018 to September 2019.. Thirty-one non-fatal and 160 fatal opioid overdose cases. Data from the non-fatal overdoses were collected from hospital records and blood samples, and data from the fatal overdoses were collected from autopsy reports. Concentrations of psychoactive substances (including ethanol) in blood samples were collected at the time of hospital admission for the non-fatal overdoses and during autopsy for the fatal overdoses.. The median number of different substances detected was four for fatal and five for non-fatal overdoses. The fatal overdoses had higher pooled concentrations of opioids (188 vs 57.2 ng/mL, P < .001), benzodiazepines (5467 vs 2051 ng/mL, P = .005) and amphetamines (581 vs 121 ng/mL, P < .001) than the non-fatal overdoses. A linear relationship between naloxone and concomitant pooled opioid concentrations was found (95% confidence interval = 0.002-0.135, P < .05).. The total load of drug concentrations was associated with the fatal outcome of an overdose, while the number of drugs used, to a lesser extent, differentiated between those who survived and those who died from an overdose. Higher opioid concentrations were associated with treatment with higher naloxone doses.

Topics: Analgesics, Opioid; Case-Control Studies; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose

Large doses of intramuscular (IM) naloxone are commonly used in out-of-hospital settings to reverse opioid toxicity; however, they are used less commonly in hospitals because of concerns about opioid withdrawal, particularly agitation. We aimed to determine the frequency of severe agitation following a single 1.6 mg IM naloxone dose.. We undertook a prospective study of adult (>15 years) patients treated by an Australian state ambulance service with 1.6 mg IM administration of naloxone for respiratory depression (respiratory rate <11 breaths/min and/or oxygen saturation <93% in room air) caused by presumed opioid poisoning. The primary outcome was the proportion of presentations with severe agitation (Sedation Assessment Tool score >1) within 1 hour of naloxone administration. Secondary outcomes were the proportion of presentations with acute opioid withdrawal (tachycardia [pulse rate >100 beats/min], hypertension [systolic >140 mm Hg], vomiting, agitation, seizure, myocardial infarction, arrhythmia, or pulmonary edema), and reversal of respiratory depression (respiratory rate >10 breaths/min and saturation >92% or Glasgow Coma Scale score 15).. From October 2019 to July 2021, there were 197 presentations in 171 patients, with a median age of 41 years (range, 18 to 80 years); of the total patients, 119 were men (70%). The most common opioids were heroin (131 [66%]), oxycodone (14 [7%]), and morphine (11 [6%]). Severe agitation occurred in 14 (7% [95% confidence interval {CI} 4% to 12%]) presentations. Opioid withdrawal occurred in 76 presentations (39% [95% CI 32% to 46%]), most commonly in the form of tachycardia (18%), mild agitation/anxiety (18%) and hypertension (14%). Three presentations (1.5%) received chemical sedation for severe agitation within 1 hour of naloxone administration. A single 1.6 mg dose of naloxone reversed respiratory depression in 192 (97% [95% CI: 94% to 99%]) presentations.. Severe agitation was uncommon following the administration of 1.6 mg IM naloxone and rarely required chemical sedation.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Analgesics, Opioid; Australia; Drug Overdose; Female; Hospitals; Humans; Hypertension; Male; Middle Aged; Naloxone; Narcotic Antagonists; Narcotics; Prospective Studies; Respiratory Insufficiency; Substance Withdrawal Syndrome; Young Adult

Pharmacists tend to provide care to patients with psychiatric disorders less frequently than to other types of patients, yet patients with psychiatric disorders experience more drug-related problems and use more opioids than those without psychiatric disorders. The Opioid and Naloxone Education (ONE) program equipped pharmacists to screen for opioid misuse and overdose risk and to implement a set of interventions for any patient filling an opioid prescription. Patients with a psychiatric disorder (N=1,980; 24.1% of those screened) were significantly more likely to receive more than one intervention from a ONE program pharmacist than were those without a psychiatric disorder. The use of an objective screening tool and training in stigma reduction and nonjudgmental communication approaches, which are part of the ONE program process, deserve further exploration as ways to increase the frequency of pharmacist-provided education and other critical interventions for patients with psychiatric disorders.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pharmacists; Prescriptions

Studies examining the impact of pharmacy-dispensed naloxone programs on fatal opioid overdose rates are lacking. We examined the impact of the publicly funded Ontario Naloxone Program for Pharmacies (ONPP), implemented in June 2016, on provincial rates of opioid overdose deaths.. We conducted a population-based interrupted time-series study between July 1, 2012 and December 31, 2018. We considered a parsimonious model with terms for time, ONPP implementation, and time following the ONPP implementation. Models were adjusted for population characteristics, number of pharmacies and rate of naloxone distributed through non-pharmacy sites within provincial public health units.. In the parsimonious model, the ONPP was associated with a non-significant 9% reduction in the level of fatal opioid overdoses (rate ratio [RR] 0.91; 95% confidence interval [CI] 0.79-1.06), a finding that was most pronounced in regions in the lowest tertile of implementation (RR 0.75; 95% CI 0.62-0.91). Following multivariable adjustment, there was an increase in the level (RR 1.06; 95% CI 0.94-1.19) and slope change (RR 1.06; 95% CI 1.02-1.10) of fatal overdose rates.. The ONPP is insufficient as a single intervention to meaningfully reduce rates of fatal opioid overdoses during a period in which the cause of these deaths shifted from prescription opioids to highly potent fentanyl analogs. Access to additional harm reduction, treatment, and other interventions is necessary to prevent deaths and optimize the health of people who use drugs.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Pharmacies; Pharmacy

Patients who initially survive opioid-related overdose are at high risk for subsequent mortality. Our health system aimed to evaluate the presence of disparities in prescribing naloxone following opioid overdose.. This was a retrospective cohort study of patients seen in our health system, which comprises two academic centers and eight community hospitals. Eligible patients had at least one visit to any of our hospital's emergency departments (EDs) with a diagnosis code indicating opioid-related overdose between May 1, 2018, and April 30, 2021. The primary outcome measure was prescription of nasal naloxone after at least one visit for opioid-related overdose during the study period.. The health system had 1348 unique patients who presented 1593 times to at least one of the EDs with opioid overdose. Of included patients, 580 (43.2%) received one or more prescriptions for naloxone. The majority (68.9%, n = 925) were male. For race/ethnicity, 74.5% (1000) were Non-Hispanic White, 8.0% (n = 108) were Non-Hispanic Black, and 13.0% (n = 175) were Hispanic/Latinx. Compared with the reference age group of 16-24 years, only those 65+ were less likely to receive naloxone (adjusted odds ratio [aOR] 0.41, 95% confidence interval [CI] 0.20-0.84). The study found no difference for gender (male aOR 1.23, 95% CI 0.97-1.57 compared to female). Hispanic/Latinx patients were more likely to receive a prescription when compared to Non-Hispanic White patients (aOR 1.72, 95% CI 1.22-2.44), while no difference occurred between Non-Hispanic Black compared to Non-Hispanic White patients (aOR 1.31, 95% CI 0.87-1.98).. Naloxone prescribing after overdose in our system was suboptimal, with fewer than half of patients with an overdose diagnosis code receiving this lifesaving and evidence-based intervention. Patients who were Hispanic/Latinx were more likely to receive naloxone than other race and ethnicity groups, and patients who were older were less likely to receive it. Health systems need ongoing equity-informed implementation of programs to expand access to naloxone to all patients at risk.

Topics: Adolescent; Adult; Analgesics, Opioid; Drug Overdose; Emergency Service, Hospital; Female; Humans; Male; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Retrospective Studies; Young Adult

Overdose education and naloxone distribution (OEND) to laypersons are key approaches to reduce the incidence of opioid-involved overdoses. While some research has examined attitudes toward OEND, especially among pharmacists and first responders, our understanding of what laypersons believe about overdose and naloxone is surprisingly limited. Further, some scholars have expressed concerns about the prevalence of non-evidence-based beliefs about overdose and naloxone. We designed this study to analyze the prevalence, nature, and context of beliefs about naloxone and overdose among U.S. laypersons.. We conducted a cross-sectional study (n = 702) using Prolific.co (representative of the U.S. population by age, gender, and race). Primary outcomes were the believability of six statements about overdose/naloxone on a seven-point Likert-type scale. Five statements were unsupported, and one was supported, by current scientific evidence. We used latent profile analysis to classify participants into belief groups, then used regression to study correlates of profile classification.. Believability of the statements (7: extremely believable) ranged from m = 5.57 (SD = 1.38) for a scientifically supported idea (trained bystanders can reverse overdose with naloxone), to m = 3.33 (SD = 1.83) for a statement claiming opioid users can get high on naloxone. Participants were classified into three latent belief profiles: Profile 1 (most aligned with current evidence; n = 246), Profile 2 (moderately aligned; n = 351), and Profile 3 (least aligned, n = 105). Compared to Profile 1, several covariates were associated with categorization into Profiles 2 and 3, including lower trust in science (RRR = 0.36, 95%CI = 0.24-0.54; RRR = 0.21, 95%CI = 0.12-0.36, respectively), conservative political orientation (RRR = 1.41, 95%CI = 1.23-1.63; 3:RRR = 1.62, 95%CI = 1.35-1.95, respectively), and never being trained about naloxone (Profile 3: RRR = 3.37, 95%CI = 1.16-9.77).. Preliminary evidence suggests some U.S. laypersons simultaneously believe that bystander overdose prevention with naloxone can prevent overdose and one or more scientifically unsupported claims about naloxone/overdose. Categorization into clusters displaying such belief patterns was associated with low trust in science, conservative political orientation, and not having been trained about naloxone.. This cross-sectional study was preregistered prior to any data collection using the Open Science Framework: https://osf.io/c6ufv.

Topics: Analgesics, Opioid; Cross-Sectional Studies; Drug Overdose; Emergency Responders; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pharmaceutical Services; Pharmacies; Pharmacists; Pharmacy

Fentanyl has replaced most other non-prescribed opioids in much of North America. There is controversy over whether a hypothetical reduced efficacy of naloxone in reversing fentanyl is a major contributor to the coincident rising overdose mortality.. We modified an existing Markov decision analytic model of heroin overdose and naloxone distribution to account for known risks of fentanyl by adjusting overdose risk, the likelihood of death in the event of overdose, and the proportion of cases in which available naloxone was administered in time to prevent death. We assumed near-universal survival when naloxone was administered promptly for heroin or fentanyl overdose, but allowed that to decline in sensitivity analyses for fentanyl. We varied the proportion of use that was fentanyl and adjusted the modified parameters accordingly to estimate mortality as the dominant opioid shifted.. Absent naloxone, the annual overdose death rate was 1.0% and 4.1% for heroin and fentanyl, respectively. With naloxone reaching 80% of those at risk, the overdose death rate was 0.7% and 3.6% for heroin and fentanyl, respectively, representing reductions of 26.4% and 12.0%. Monte Carlo simulations resulted in overdose mortality with fentanyl of 3.3-5.2% without naloxone and 2.6-4.9% with naloxone, with 95% certainty. Positing reduced efficacy for naloxone in reversing fentanyl resulted in 3.6% of fentanyl overdose deaths being prevented by naloxone.. Heightened risk for overdose and subsequent death, alongside the time-sensitive need for naloxone administration, fully account for increased mortality when fentanyl replaces heroin, assuming optimal pharmacologic efficacy of naloxone.

Topics: Analgesics, Opioid; Drug Overdose; Fentanyl; Heroin; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose

Topics: Administration, Intranasal; Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists

The increasing prevalence of highly potent, illicitly manufactured fentanyl and its analogues (IMF) in the USA is exacerbating the opioid epidemic which has worsened during the COVID-19 pandemic. Narcan® (naloxone HCl) Nasal Spray has been approved by the US Food and Drug Administration as a treatment for opioid-related overdoses. Due to the high potency of IMF, multiple naloxone administrations (MNA) may be needed per overdose event. It is essential to determine the patterns of naloxone use, including MNA, and preferences among bystanders who have used naloxone for opioid overdose reversal.. A cross-sectional web-based survey was administered to 125 adult US residents who administered 4 mg Narcan® Nasal Spray during an opioid overdose in the past year. The survey asked about the most recent overdose event, the use of Narcan® during the event and the associated withdrawal symptoms, and participant preferences regarding dosages of naloxone nasal spray. An open-ended voice survey was completed by 35 participants.. Participants were mostly female (70%) and white (78%), while reported overdose events most frequently occurred in people who were males (54%) and white (86%). Most events (95%) were successfully reversed, with 78% using ≥ 2 doses and 30% using ≥ 3 doses of Narcan® Nasal Spray. Over 90% were worried that 1 Narcan® box may not be enough for a successful future reversal. Reported withdrawal symptoms were similar in overdose events where 1 versus ≥ 2 sprays were given. Eighty-six percent of participants reported more confidence in an 8 mg versus a 4 mg naloxone nasal spray and 77% reported a stronger preference for 8 mg over 4 mg.. MNA occurred in most overdose events, often involving more sprays than are provided in one Narcan® nasal spray box, and participants predominantly expressed having a stronger preference for and confidence in an 8 mg compared to a 4 mg nasal spray. This suggests the need and desire for a higher dose naloxone nasal spray formulation option. Given that bystanders may be the first to administer naloxone to someone experiencing an opioid overdose, ensuring access to an adequate naloxone supply is critical in addressing the opioid overdose epidemic.

Topics: Adult; Analgesics, Opioid; COVID-19; Cross-Sectional Studies; Drug Overdose; Female; Humans; Male; Naloxone; Narcotic Antagonists; Nasal Sprays; Opiate Overdose; Pandemics; Substance Withdrawal Syndrome

Intervetions are urgently needed to reduce the trajectory of the US opioid overdose epidemic, yet implementation is often hampered by resistance or opposition from key community stakeholders. While businesses are economically and physically impacted by the opioid epidemic, they are rarely engaged in efforts to reduce its impact. The establishment of overdose prevention sites (OPS) is being discussed throughout many US jurisdictions with limited attention to the potential positive role of businesses in that process. We surveyed business owners and employees of businesses located in neighborhoods with concentrated drug markets. The study's primary aim was to examine their attitudes to locally-placed OPS. An iterative, two-phase sampling strategy was used to identify recruitment zones. In person (December 2019-March 2020) and telephone-based (April-July 2020) surveys were administered to distinct business owners and employees (N = 149). Sixty-five percent of participants supported OPS in their neighborhood and 47% had recently witnessed an overdose in or around their workplace. While 70% had heard of naloxone, and 38% reported having it on the premises. Correlates of supporting an OPS locally included living in the same neighborhood as work (adjusted odds ratio (aOR) 1.99, 95% confidence intervals (CI): 1.30-3.05); having a more positive attitude towards people who use drugs (aOR 1.33, 95% CI: 1.13-1.58); and having recently seen an overdose in/around the workplace (aOR 2.86, 95% CI: 1.11-7.32). Lack of support being an owner (aOR 0.35, 95% CI: 0.15-0.83). These data indicate the extent to which businesses are directly impacted by the opioid epidemic and the power of personal experience in shaping OPS support in advocacy efforts.

Topics: Analgesics, Opioid; Baltimore; Drug Overdose; Epidemics; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Opiate Overdose; Opioid-Related Disorders

Bystanders to drug overdoses often avoid or delay calling 9-1-1 and cite fear of police involvement as a main reason. In 2017, the Good Samaritan Drug Overdose Act (GSDOA) was enacted by the Canadian government to provide people present at an overdose with legal protection from charges for simple drug possession, and conditions stemming from simple possession. Few studies have taken a multi-methods approach to evaluating the GSDOA. We used quantitative surveys and qualitative interviews to explore awareness, understanding, and perceptions of the GSDOA in people at risk of witnessing an overdose.. Quantitative cross-sectional surveys and qualitative telephone interviews were conducted with adults and youth at risk of witnessing an overdose across British Columbia. Cross-sectional survey participants were recruited at 19 Take Home Naloxone sites and online through Foundry. Multivariable logistic regression models were constructed hierarchically to determine factors associated with GSDOA awareness. Telephone interview participants were recruited by research assistants with lived/living experience of substance use. Deductive and inductive thematic analyses were conducted to identify major themes.. Overall, 52.7% (n = 296) of the quantitative study sample (N = 453) reported being aware of the GSDOA. In multivariable analysis, cellphone possession (adjusted odds ratio [AOR] = 2.19; 95% confidence interval [CI] 1.36, 3.54) and having recently witnessed an opioid overdose (AOR = 2.34; 95% CI 1.45, 3.80) were positively associated with GSDOA awareness. Young adults (25 - 34 years) were more likely to be aware of the Act (AOR = 2.10; 95% CI 1.11, 3.98) compared to youth (16-24 years). Qualitative interviews (N = 42) revealed that many overestimated the protections offered by the GSDOA. To increase awareness and knowledge of the Act among youth, participants recommended adding the GSDOA to school curricula and using social media. Word of mouth was suggested to reach adults.. Both awareness and knowledge of the GSDOA remain low in BC, with many overestimating the protections the Act offers. Dissemination efforts should be led by people with lived/living experience and should target those with limited awareness and understanding of the Act as misunderstandings can erode trust in law enforcement and harm reduction policy.

Topics: Adolescent; British Columbia; Cross-Sectional Studies; Drug Overdose; Humans; Law Enforcement; Naloxone; Narcotic Antagonists; Young Adult

Topics: Analgesics, Opioid; Drug Overdose; Drug Users; Fentanyl; Humans; Naloxone; New York City; Opiate Overdose; Opioid-Related Disorders; Ownership; Substance Abuse, Intravenous; United States

Higher-dose formulations of naloxone were recently approved by the FDA for the treatment of opioid overdose. These products were developed based on projected saturation of high-potency fentanyl analogues in the illicit marketplace although the evidence base for their necessity is still under scrutiny. Concern has been raised that unintended reductions in patient acceptance of naloxone may occur due to increased precipitated withdrawal risk associated with higher naloxone doses. A well-founded and time-sensitive call for representation of people who use drugs in this decision-making process has been made. This study provides the first data on patient perceptions of higher-dose formulations to inform this scientific debate and distribution efforts.. Patients (N=1152) entering treatment for opioid use disorder at one of 49 addiction treatment facilities located across the United States completed a preference assessment of naloxone nasal spray formulations. Patients selected a formulation preference across three scenarios (administration for self, administration to others, community responder administration).. A majority of respondents that had been administered naloxone previously reported that their most recent overdose reversal included two or more naloxone administrations (59.9%). Most respondents either had no preference (48.4%) or preferred a higher-dose formulation (35.9%) if personally experiencing an overdose. Similar preference distributions were observed for administration to others and by community responders. Relative to standard-dose preference, respondents preferring higher-dose formulations had a greater odds of recent suspected fentanyl exposure.. These data inform patients, advocates, and policy-makers considering distribution and utilization of naloxone formulations by reporting perspectives of patients with opioid use and overdose experience. Limited evidence for widespread avoidance of higher-dose formulations was found. As real-world evidence of acceptability and effectiveness emerges, either supporting or refuting the widespread need for higher-dose naloxone formulations, it is the responsibility of the scientific and public health community to be responsive to those data.

Topics: Analgesics, Opioid; Drug Overdose; Fentanyl; Humans; Naloxone; Narcotic Antagonists; Nasal Sprays; Opiate Overdose; Opioid-Related Disorders; United States

Opioid-related overdose deaths have surged in the USA over the last two decades. Overdose fatalities are preventable with the timely administration of naloxone. Syringe service programs (SSP) have pioneered community-based naloxone distribution through overdose prevention and naloxone distribution (OEND) programs. There is a dearth of information with regards to best practices for community-based OEND.. We utilized a modified Delphi approach to develop a set of best practices for OEND delivery. Starting with an initial list of best practices, we engaged 27 experts, in the field of OEND programming who reviewed, made recommendations for changes, and assigned a priority to each best practice.. Two rounds of input resulted in a final list of 20 best practices organized into four categories. The mean priority scores ranged from 1.17 to 2.17 (range 1 to 3). The top 5 ranked best practices were ensuring that SSP participants have low barrier, consistent, needs-based access to naloxone and that there is ample naloxone available within communities. While the remaining fifteen best practices were deemed important, they had more to do with organizational culture and implementation climate.. Increasing community-based OEND delivery is essential to reduce opioid overdose deaths; however, it will be insufficient to add programs without an eye toward quality of implementation and fidelity to the model upon which the evidence is based. This list of best practices summarizes the consensus among OEND experts and can serve as a tool for SSPs providing OEND programming to improve services.

Topics: Drug Overdose; Health Education; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose

Topics: Analgesics, Opioid; Drug Overdose; Fentanyl; Humans; Naloxone; Narcotic Antagonists

There are conflicting recommendations for lay rescuer management of patients who are unresponsive and apneic due to opioid overdose. We evaluated the management of such patients at an urban supervised consumption site.. At a single urban supervised consumption site in Vancouver, BC, we conducted a retrospective chart review and administrative database linkage of consecutive patients who were unresponsive and apneic following witnessed opioid overdose between January 1, 2012 and December 31, 2017. We linked these visits with regional hospital records to define the entire care episode, which concluded when the patient was discharged from the supervised consumption site, ED, or hospital, or died. The primary outcome was successful resuscitation, defined as alive and neurologically intact (ambulatory and speaking coherently, or alert and oriented, or Glasgow Coma Scale 15) at the conclusion of the care episode. Secondary outcomes included mortality and predefined complications of resuscitation.. We collected 767 patients, with a median age of 43 and 81.6% male, with complete follow-up on 763 patients (99.5%). All patients were managed with oxygen and ventilation (100%, 95% CI 0.995-1.0); 715 (93.2%, 95% CI 0.911-0.949) received naloxone; no patients underwent chest compressions (0%, 95% CI 0-0.005). All patients with complete follow-up were alive and neurologically intact at the end of their care episode (100%, 95% CI 0.994-1.0). Overall, 191 (24.9%) patients were transported to hospital, and 15 (2.0%) patients required additional naloxone after leaving the supervised consumption site; 16 (2.1%) developed complications, and 1 patient was admitted to hospital.. At an urban supervised consumption site, all unresponsive, apneic patients with witnessed opioid overdose were successfully resuscitated with oxygen and/or naloxone. No patients required chest compressions.

Topics: Analgesics, Opioid; Drug Overdose; Female; Hospitals; Humans; Male; Naloxone; Opiate Overdose; Oxygen; Retrospective Studies

Expanding availability to naloxone is a core harm reduction strategy in efforts to address the opioid epidemic. In the US, state-level legislation is a prominent mechanism to expand naloxone availability through various venues, such as community pharmacies. This qualitative study aimed to identify and summarize the views of experts on state-level naloxone access laws.. We conducted a three-round modified-Delphi process using the online ExpertLens platform. Participants included 46 key stakeholders representing various groups (advocates, healthcare providers, human/social service practitioners, policymakers, and researchers) with expertise naloxone access laws. Participants commented on the effectiveness and implementability of 15 state-level naloxone access laws (NALs). We thematically analyzed participant comments to summarize views on NALs overall and specific types of NAL.. Participants commented that the effectiveness of NALs in reducing opioid-related mortality depends on their ability to make sustained, significant impacts on population-level naloxone availability. Participants generally believed that increased naloxone availability does not have appreciable negative impacts on the prevalence of opioid misuse, opioid use disorder (OUD), and non-fatal opioid overdoses. Implementation barriers include stigma among the general public, affordability of naloxone, and reliance on an inequitable healthcare system.. Experts believe NALs that significantly increase naloxone access are associated with less overdose mortality without risking substantial unintended public health outcomes. To maximize impacts, high-value NALs should explicitly counter existing healthcare system inequities, address stigmatization of opioid use and naloxone, maintain reasonable prices for purchasing naloxone, and target settings beyond community pharmacies to distribute naloxone.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pharmacies

Prompt access to prescribed buprenorphine/naloxone films (BUP/NX) and naloxone nasal spray (NNS) is vital for patients with opioid use disorder (OUD), but multiple studies have documented pharmacy-level barriers.. A cross-sectional secret shopper telephone audit was conducted in a sample of 5734 actively licensed pharmacies in 11 U.S. states from May 2020-April 2021. Primary outcomes included availability of 14 generic BUP/NX 8/2 mg and one unit of NNS 4 mg. Outcomes were compared by pharmacy type, county metropolitan status, state Medicaid expansion status, and state drug overdose death rate.. Data from 4984 pharmacies (3402 chain and 1582 independent) were analyzed. Both medications were available in 41.2 % of pharmacies, BUP/NX was available in 48.3%, and NNS was available in 69.5%. Chain pharmacies were significantly more likely than independent pharmacies to have both medications available, to have each medication available individually, and to be willing to order BUP/NX. Pharmacies in metropolitan counties were more likely to have BUP/NX available than pharmacies in non-metropolitan counties, pharmacies in Medicaid expansion states were more likely to have both medications available and to have NNS available than pharmacies in non-expansion states, and pharmacies in states with high drug overdose death rates were more likely to have NNS available than pharmacies in states with low drug overdose death rates.. BUP/NX and NNS are not readily accessible in many U.S. pharmacies. Deficits in access are most pronounced in independent pharmacies, though county- and state-level factors may also influence availability of these essential medications.

Topics: Buprenorphine; Buprenorphine, Naloxone Drug Combination; Cross-Sectional Studies; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Nasal Sprays; Opioid-Related Disorders; Pharmacies; United States

Novel opioids in the illicit drug supply, such as the "nitazene" group of synthetic opioids, present an ongoing public health problem due to high potency and respiratory depressant effects. We describe three patients in whom. This is a case series of patients with acute opioid overdose enrolled in an ongoing multicenter prospective cohort study. Data collected included reported substance use, clinical course, naloxone dose and response, outcome, and analytes detected in biological samples.. Between October 6, 2020 and October 31, 2021, 1006 patients were screened and 412 met inclusion criteria. Of these, three patients (age 33-55) tested positive for. These cases represent a local outbreak of a novel "nitazene" opioid. Public health toxicosurveillance should incorporate routine testing of this emerging class of synthetic compounds in the illicit drug supply.

Topics: Adult; Alprazolam; Analgesics, Opioid; Benzimidazoles; Cocaine; Codeine; Drug Overdose; Fentanyl; Heroin; Humans; Illicit Drugs; Levamisole; Middle Aged; Naloxone; Narcotic Antagonists; Opiate Overdose; Phenacetin; Prospective Studies; Tramadol

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders

Topics: Analgesics, Opioid; Centers for Disease Control and Prevention, U.S.; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid Epidemic; Opioid-Related Disorders; United States

As the opioid overdose crisis persists and take-home naloxone (THN) programmes expand, it is important that the intervention is targeted towards those most likely to use it. We examined THN program participants to 1) describe those that return for refills, specifically those that reported multiple use (supersavers), and 2) to examine what rescuer characteristics were associated with higher rates of THN use.. This study included a cohort of consenting THN recipients from June 2014-June 2021 who completed initial and refill questionnaires from a widespread program in Norway. Age, gender, number of witnessed and experienced overdoses were assessed for associations with higher reported rates of THN use. 'Supersavers' reported 3 or more THN uses.. A total of 1054 participants returned for a THN refill during the study period. Of these, 558 reported their last THN to have been used on an overdose. Supersavers (those that reported 3 or more THN uses) were younger, primarily reported current opioid use, and had witnessed higher rates of overdoses at the time of initial training when compared to non-supersavers (those that reported 0-2 THN uses).. THN programs should continue to emphasize and prioritize THN for people actively using drugs, particularly those who have witnessed overdoses previously.

Topics: Cohort Studies; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

Topics: Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Pilot Projects

Opioid related overdose deaths in the United States claimed over 100,000 thousand lives during the 12-month period ending in April 2021, an increase of 28.5% from the previous period. Syringe services programs (SSPs) are an evidence-based harm reduction strategy that have been shown to be effective in reducing opioid overdose deaths and infectious complications and increasing rates of entry into recovery programs. Ignoring this evidence, South Carolina (SC) and several states have yet to legalize SSPs. In the absence of full legalization, the operation of SSPs in SC faces many barriers. Despite these barriers, Challenges Inc. has been successful in playing a critical role in preventing opioid overdoses through naloxone and fentanyl test strip distribution, reducing infectious complications by providing clean needles, treating individuals with hepatitis C and HIV, and helping patients remain in sustained recovery from opioids. In order for SSPs to function at their full potential to curb the rising tides of opioid overdose deaths and related health complications, policymakers in SC and similar states need to urgently legalize them.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Needle-Exchange Programs; Opiate Overdose; South Carolina; Syringes; United States

In response to a surge of deaths from synthetic opioid overdoses, there have been increased efforts to distribute naloxone products in community settings. Prior research has assessed the effectiveness of naloxone in the hospital setting; however, it is challenging to assess naloxone dosing regimens in the community/first-responder setting, including reversal of respiratory depression effects of fentanyl and its derivatives (fentanyls). Here, we describe the development and validation of a mechanistic model that combines opioid mu receptor binding kinetics, opioid agonist and antagonist pharmacokinetics, and human respiratory and circulatory physiology, to evaluate naloxone dosing to reverse respiratory depression. Validation supports our model, which can quantitatively predict displacement of opioids by naloxone from opioid mu receptors in vitro, hypoxia-induced cardiac arrest in vivo, and opioid-induced respiratory depression in humans from different fentanyls. After validation, overdose simulations were performed with fentanyl and carfentanil followed by administration of different intramuscular naloxone products. Carfentanil induced more cardiac arrest events and was more difficult to reverse than fentanyl. Opioid receptor binding data indicated that carfentanil has substantially slower dissociation kinetics from the opioid receptor compared with nine other fentanyls tested, which likely contributes to the difficulty in reversing carfentanil. Administration of the same dose of naloxone intramuscularly from two different naloxone products with different formulations resulted in differences in the number of virtual patients experiencing cardiac arrest. This work provides a robust framework to evaluate dosing regimens of opioid receptor antagonists to reverse opioid-induced respiratory depression, including those caused by newly emerging synthetic opioids.

Topics: Analgesics, Opioid; Drug Overdose; Fentanyl; Heart Arrest; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Receptors, Opioid; Receptors, Opioid, mu; Respiratory Insufficiency

Buprenorphine and naloxone are first-line medications for people who use opioids (PWUO). Buprenorphine can reduce opioid use and cravings, help withdrawal symptoms, and reduce risk of opioid overdose. Naloxone is a life-saving medication that can be administered to reverse an opioid overdose. Despite the utility of these medications, PWUO face barriers to access these medications. Downtown Los Angeles has high rates, and number, of opioid overdoses which could potentially be reduced by increasing distribution of naloxone and buprenorphine. This study aimed to determine the accessibility of these medications in a major urban city by surveying community pharmacies regarding availability of buprenorphine and naloxone, and ability to dispense naloxone without a prescription.. Pharmacies were identified in the Los Angeles downtown area by internet search and consultation with clinicians. Phone calls were made to pharmacies at two separate time points-September 2020 and March 2021 to ask about availability of buprenorphine and naloxone. Results were collected and analyzed to determine percentage of pharmacies that had buprenorphine and/or naloxone in stock, and were able to dispense naloxone without a prescription.. Out of the 14 pharmacies identified in the downtown LA zip codes, 13 (92.9%) were able to be reached at either time point. The zip code with one of the highest rates of opioid-related overdose deaths did not have any pharmacies in the area. Most of the pharmacies were chain stores (69.2%). Eight of the 13 (61.5%) pharmacies were stocked and prepared to dispense buprenorphine upon receiving a prescription, and an equivalent number was prepared to dispense naloxone upon patient request, even without a naloxone prescription. All of the independent pharmacies did not have either buprenorphine or naloxone available.. There is a large gap in care for pharmacies in high overdose urban zip codes to provide access to medications for PWUO. Unavailability of medication at the pharmacy-level may impede PWUO ability to start or maintain pharmacotherapy treatment. Pharmacies should be incentivized to stock buprenorphine and naloxone and encourage training of pharmacists in harm reduction practices for people who use opioids.

Topics: Analgesics, Opioid; Buprenorphine; COVID-19; Drug Overdose; Humans; Los Angeles; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Pandemics; Pharmacies

An estimated 100,306 people died from an overdose from May 2020 to April 2021. Emergency Medical Services (EMS) are often the first responder to opioid overdose, and EMS encounter records can provide granular epidemiologic data on opioid overdose. This study describes the demographic, temporal, and geographic epidemiology of suspected opioid overdose in Baltimore City using data from Baltimore City Fire Department EMS encounters with the administration of the opioid antagonist naloxone.. The present analyses used patient encounter data from 2012 to 2017 from the Baltimore City Fire Department, the city's primary provider of EMS services. The analytic sample included patient encounters within the city that involved naloxone administration to patients 15 years of age or older (. From 2012 to 2017, the annual number of EMS encounters with naloxone administrations approximately doubled every 2 years, and the temporal pattern of naloxone administration was similar to the pattern of fatal opioid-related overdoses. For most census tracts, incidence rates significantly increased over time. Population-based incidence of naloxone administration varied significantly by socio-demographic characteristics. Males, non-whites, and those 25-69 years of age had the highest incidence rates.. The incidence of naloxone administration increased dramatically over the study period. Despite significant cross-sectional variation in incidence across demographically and geographically defined groups, there were significant proportional increases in incidence rates, consistent with fatal overdose rates over the period. This study demonstrated the value of EMS data for understanding the local epidemiology of opioid-related overdose. Key MessagesPatterns of EMS encounters with naloxone administration appear to be an excellent proxy for patterns of opioid-related overdoses based on the consistency of fatal overdose rates over time.EMS plays a central role in preventing fatal opioid-related overdoses through the administration of naloxone, provision of other emergency services, and transportation to medical facilities.EMS encounters with naloxone administration could also be used to evaluate the impact of overdose prevention interventions and public health services.

Topics: Analgesics, Opioid; Baltimore; Drug Overdose; Emergency Medical Services; Humans; Male; Naloxone; Opiate Overdose

Take-Home Naloxone (THN) is a core intervention aimed at addressing the toxic illicit opioid drug supply crisis. Although THN programs are available in all provinces and territories throughout Canada, there are currently no standardized guidelines for THN programs. The Delphi method is a tool for consensus building often used in policy development that allows for engagement of stakeholders.. We used an adapted anonymous online Delphi method to elicit priorities for a Canadian guideline on THN as a means of facilitating meaningful stakeholder engagement. A guideline development group generated a series of key questions that were then brought to a 15-member voting panel. The voting panel was comprised of people with lived and living experience of substance use, academics specializing in harm reduction, and clinicians and public health professionals from across Canada. Two rounds of voting were undertaken to score questions on importance for inclusion in the guideline.. Nine questions that were identified as most important include what equipment should be in THN kits, whether there are important differences between intramuscular and intranasal naloxone administration, how stigma impacts access to distribution programs, how effective THN programs are at saving lives, what distribution models are most effective and equitable, storage considerations for naloxone in a community setting, the role of CPR and rescue breathing in overdose response, client preference of naloxone distribution program type, and what aftercare should be provided for people who respond to overdoses.. The Delphi method is an equitable consensus building process that generated priorities to guide guideline development.

Topics: Canada; Delphi Technique; Drug Overdose; Humans; Illicit Drugs; Naloxone; Narcotic Antagonists

The opioid crisis is a growing public health emergency and increasing resources are being directed towards overdose education. Simulation has emerged as a novel strategy for training overdose response, yet little is known about training non-clinicians in bystander resuscitation. Understanding the perspectives of individuals who are likely to experience or witness opioid overdose is critical to ensure that emergency response is effective. The Surviving Opioid Overdose with Naloxone Education and Resuscitation (SOONER) study evaluates the effectiveness of a novel naloxone education and distribution tool among people who are non-clinicians and likely to witness opioid overdose. Participants' resuscitation skills are evaluated using a realistic overdose simulation as the primary outcome of the trial. The purpose of our study is to describe the experience of participants with the simulation process in the SOONER study. We employed a semi-structured debriefing interview and a follow up qualitative interview to understand the experience of participants with simulation. A qualitative content analysis was performed using data from 21 participants who participated in the SOONER study. Our qualitative analysis identified 5 themes and 17 subthemes which described the experience of participants within the simulation process. These themes included realism, valuing practical experience, improving self-efficacy, gaining new perspective and bidirectional learning. Our analysis found that simulation was a positive and empowering experience for participants in the SOONER trial, most of whom are marginalized in society. Our study supports the notion that expanding simulation-based education to non-clinicians may offer an acceptable and effective way of supplementing current opioid overdose education strategies. Increasing the accessibility of simulation-based education may represent a paradigm shift whereby simulation is transformed from a primarily academic practice into a patient-based community resource.

Topics: Drug Overdose; Humans; Naloxone; Opiate Overdose; Resuscitation; Self Efficacy; Simulation Training

Benzonatate is a local anesthetic-like sodium channel antagonist that is widely prescribed as an antitussive. While it may be reasonable to assume that patients would present with a prolonged QRS interval following benzonatate overdose, the published literature does not support this. We report a case of a patient presenting following a benzonatate overdose with a prolonged QRS on her initial electrocardiograph (ECG) rhythm strip with rapid normalization of QRS duration.. A 14-year-old girl presented in cardiac arrest following a benzonatate overdose. The patient was found in cardiac arrest within minutes of last being known well. Bystanders immediately provided cardiopulmonary resuscitation (CPR), and she was in asystole on emergency medical services (EMS) arrival. Return of spontaneous circulation (ROSC) was obtained following administration of intraosseous epinephrine and naloxone. EMS obtained an ECG rhythm strip following ROSC demonstrating a sinus rhythm with a QRS duration of 160 ms. Over the ensuing 30 minutes, there was progressive narrowing of the QRS. A 12-lead ECG obtained on arrival in the emergency department (ED) 44 minutes later demonstrated a QRS duration of 94 ms. Initially, EMS ECG rhythm strips were unavailable and an isolated benzonatate ingestion was considered less likely as ECG intervals were normal. Benzonatate exposure was later confirmed with a urine benzonatate concentration, which was 8.5 mcg/mL. The patient made a full recovery.. Cases of pediatric benzonatate overdose with rapid development of cardiac arrest and full recovery have been previously reported. In this case, evidence of cardiac sodium channel blockade was demonstrated with a prolonged QRS interval on initial ECG rhythm strip analysis. However, unlike previous cases, rapid resolution of QRS prolongation occurred in this case. While transient QRS prolongation may be observed, finding a normal QRS interval should not discount the possibility of benzonatate overdose.

Topics: Adolescent; Anesthetics, Local; Antitussive Agents; Arrhythmias, Cardiac; Butylamines; Child; Drug Overdose; Epinephrine; Female; Heart Arrest; Humans; Naloxone; Sodium Channels

Prior work has suggested that first responders have mixed feelings about harm reduction strategies used to fight the opioid epidemic, such as the use of naloxone to reverse opioid overdose. Researchers have also noted that provider-based stigma of people who use opioids (PWUO) may influence perceptions of appropriate interventions for opioid use disorder (OUD). This study examined first responders' perceptions of naloxone and the relationship between stigma of OUD and perceptions of naloxone.. A web-based survey assessing perceptions of PWUO and naloxone was administered to 282 police officers and students enrolled in EMT and paramedic training courses located in the Northeastern United States. Bivariate and multivariable analyses assessed the relationship between variants of stigma (e.g., perceived dangerousness, blame, social distance, and fatalism) and self-reported perceptions of naloxone.. Participants, in the aggregate, held slightly negative attitudes toward the use of naloxone. Findings from multivariable modeling suggest that stigma of OUD, living in a rural area, and prior experience administering naloxone, were significantly and inversely related to support for the use of naloxone. Support for the disease model of addiction and associating drug use with low socioeconomic status were positively related to support for the use of naloxone.. Efforts to alleviate perceptions of PWUO as dangerous, blameworthy, or incapable of recovery may increase first responders' support for naloxone. To this end, first responder training programs should include instruction on the disease model of addiction, and more broadly, attempt to foster familiarity between PWUO and the professionals who serve them.

Topics: Analgesics, Opioid; Drug Overdose; Emergency Responders; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

Pennsylvania has one of the highest opioid overdose rates in the US; however, since 2018 approximately 80% of people who experienced an opioid overdose in the state survived. More attention has been paid to opioid overdose mortality despite notable individual and geographic differences in overdose survival. Naloxone is an essential tool in increasing chances of survival after opioid overdose, but its availability and the rate at which it is administered differs by county in Pennsylvania and nationally.. We use 2018-2020 Pennsylvania Overdose Information Network data on opioid incidents and where they occurred, combined with 2015-2019 American Community Survey data, to evaluate opioid overdose survival and naloxone administration by county over a three-year period.. Individuals who received at least one dose of naloxone following overdose had 11 times greater odds of survival. White, middle-aged men were least likely to survive opioid overdose. Both survival and naloxone administration rates differed by county with lower rates in less populated counties.. Expanding naloxone distribution and administration and ensuring proper education about standing orders for naloxone administration are important tools for addressing opioid overdose mortality.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Pennsylvania

Brimonidine is a topical ophthalmic alpha-2 adrenergic agonist solution used to treat glaucoma. The toxidrome includes drowsiness, lethargy, hypotension, bradycardia, and respiratory depression when ingested in infants. We report a case of intentional subcutaneous injection of brimonidine in an elderly patient resulting in hypotension and CNS depression that responded to naloxone. A 73-year-old female with a past medical history significant for glaucoma, hypertension, and indwelling pacemaker presented to the emergency department after injecting her brimonidine tartrate ophthalmic solution subcutaneously (SQ). The patient was not taking any antihypertensive medications or opioids. Initial presentation consisted of lethargy, a paced rhythm of 60 bpm, and blood pressure of 91/24 mmHg with a MAP of 46. Due to central nervous system depression, 3 mg of intranasal naloxone was administered. The patient was treated with intravenous fluids and escalating doses of naloxone and required a continuous infusion. Mental status and vital signs subsequently improved. The patient was admitted to the ICU and naloxone was subsequently weaned over 12 h. Systemic central alpha-2 adrenergic agonist toxicity resulted from SQ brimonidine injection. Central alpha-2 adrenergic agonist overdoses present as sympatholytic effects including CNS depression, bradycardia, hypotension, and may mimic the opioid toxidrome. Brimonidine SQ injection has not previously been reported and this case has similar findings to other central alpha-2 adrenergic agonist poisonings. Naloxone has previously shown variable reversal of CNS depression in central alpha-2 overdose. In this case, high-dose naloxone was useful for reversing CNS depression and hemodynamic instability.

Topics: Adrenergic alpha-Agonists; Aged; Analgesics, Opioid; Bradycardia; Brimonidine Tartrate; Drug Overdose; Female; Glaucoma; Humans; Hypotension; Infant; Injections, Subcutaneous; Lethargy; Naloxone; Ophthalmic Solutions; Quinoxalines

Topics: Drug Overdose; Humans; Naloxone

Topics: Drug Overdose; Humans; Naloxone

In March 2020, the World Health Organization declared COVID-19 a global pandemic. In the following weeks, most European countries implemented national lockdowns to mitigate viral spread. Services for people who use drugs had to quickly revise their operating procedures to rearrange service provision while adhering to lockdown requirements. Given the scarcity of literature published on overdose prevention during COVID-19 in Europe, we aimed to examine how these changes to service provision affected take-home naloxone (THN) programmes and naloxone availability across Europe.. Between November 2020 and January 2021, we conducted a rapid assessment with country experts from European countries that provide THN. We sent country experts a template to report monthly THN distribution data (January 1, 2019-October 31, 2020) and a structured 6-item survey for completion.. Responses were received from 14 of the 15 European countries with THN provision of which 11 participated in the rapid assessment: Austria, Denmark, England, Estonia, Lithuania, Northern Ireland, Norway, Scotland, Spain (Catalonia only), Sweden, and Wales. All reported reduced organisational capacity during COVID-19, and some put into place a range of novel approaches to manage the restrictions on face-to-face service provision. In six countries, the introduction of programme innovation occurred alongside the publication of government guidelines recommending increased THN provision during COVID-19. Eight of the eleven participating countries managed to maintain 2019-level monthly THN distribution rates or even increase provision during the pandemic.. Through programme innovation supported by public guidelines, many European THN programmes managed to ensure stable or even increased THN provision during the pandemic, despite social distancing and stay-at-home orders affecting client mobility.

Topics: Communicable Disease Control; COVID-19; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

Prevention of opioid-involved overdose deaths remains a public health priority in the United States. While expanding access to naloxone is a national public health strategy, it is largely implemented at the state and local level, where significant variability in policies, resources, and norms exist. The aims of the current study were to examine the social context of naloxone access in three different states (Connecticut, Kentucky, Wisconsin) from the perspectives of key informants (first responders, harm reduction personnel, and pharmacists), who play some role in dispensing or administering naloxone within their communities.. Interviews were conducted with key informants who were in different local areas (urban, suburban, rural) across Connecticut, Kentucky, and Wisconsin. Interview guides explored the key informants' experiences with administering or dispensing naloxone, and their perspectives on opioid overdose prevention efforts in their areas. Data analysis was conducted using multistage inductive coding and comparative methods to identify dominant themes within the data.. Key informants in each of the three states noted progress toward expanding naloxone access, especially among people who use opioids, but also described inequities. The key role of harm reduction programs in distributing naloxone within their communities was also highlighted by participants, as well as barriers to increasing naloxone access through pharmacies. Although there was general consensus regarding the effectiveness of expanding naloxone access to prevent overdose deaths, the results indicate that communities are still grappling with stigma associated with drug use and a harm reduction approach.. Findings suggest that public health interventions that target naloxone distribution through harm reduction programs can enhance access within local communities. Strategies that address stigmatizing attitudes toward people who use drugs and harm reduction may also facilitate naloxone expansion efforts, overall, as well as policies that improve the affordability and awareness of naloxone through the pharmacy.

Topics: Analgesics, Opioid; Connecticut; Drug Overdose; Humans; Kentucky; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; United States; Wisconsin

US overdose deaths have reached a record high. Syringe services programs (SSPs) play a critical role in addressing this crisis by providing multiple services to people who use drugs (PWUD) that help prevent overdose death. This study examined the perspectives of leadership and staff from a geographically diverse sample of US SSPs on factors contributing to the overdose surge, their organization's response, and ongoing barriers to preventing overdose death.. From 2/11/2021 to 4/23/2021, we conducted semi-structured interviews with leadership and staff from 27 SSPs sampled from the North American Syringe Exchange Network directory. Interviews were transcribed and qualitatively analyzed using a Rapid Assessment Process.. Respondents reported that increased intentional and unintentional fentanyl use (both alone and combined with other substances) was a major driver of the overdose surge. They also described how the COVID-19 pandemic increased solitary drug use and led to abrupt increases in use due to life disruptions and worsened mental health among PWUD. In response to this surge, SSPs have increased naloxone distribution, including providing more doses per person and expanding distribution to people using non-opioid drugs. They are also adapting overdose prevention education to increase awareness of fentanyl risks, including for people using non-opioid drugs. Some are distributing fentanyl test strips, though a few respondents expressed doubts about strips' effectiveness in reducing overdose harms. Some SSPs are expanding education and naloxone training/distribution in the broader community, beyond PWUD and their friends/family. Respondents described several ongoing barriers to preventing overdose death, including not reaching certain groups at risk of overdose (PWUD who do not inject, PWUD experiencing homelessness, and PWUD of color), an inconsistent naloxone supply and lack of access to intranasal naloxone in particular, inadequate funding, underestimates of overdoses, legal/policy barriers, and community stigma.. SSPs remain essential in preventing overdose deaths amid record numbers likely driven by increased fentanyl use and COVID-19-related impacts. These findings can inform efforts to support SSPs in this work. In the face of ongoing barriers, support for SSPs-including increased resources, political support, and community partnership-is urgently needed to address the worsening overdose crisis.

Topics: Analgesics, Opioid; COVID-19; Drug Overdose; Fentanyl; Humans; Naloxone; Pandemics; Syringes

Topics: Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Police

To describe the prevalence of incarceration among survivors of non-fatal overdose addressed through an emergency medical services (EMS) response, and compare incarceration by whether the emergency was for opioid-involved or stimulant-involved overdose.. Administrative records on 192,113 EMS incidents and 70,409 jail booking events occurring between January 1, 2019 and December 31, 2020 in Indianapolis, Indiana were record-linked at the event level. Incarceration taking place within 6-hours of an EMS incident was associated with that incident. Logistic regression was used to calculate adjusted odds ratios (AOR) of incarceration after an overdose.. Among all EMS incidents, 2.6% were followed by incarceration. For overdose EMS incidents, the prevalence of incarceration was 10.0%. Overdose incidents had higher odds than non-overdose incidents of leading to a charge of felony, booked on a warrant, and transferred to another law enforcement agency upon release. Prevalence of incarceration following a stimulant-involved overdose was 21.3%, compared to 9.3% for opioid-involved overdose survivors. Compared to persons from other EMS incidents, overdose survivors had greater odds of incarceration (AOR=3.48, 95% confidence interval (CI)= 3.22, 3.75, p < .001), with opioid-involved overdoses (AOR=3.03, 95% CI=2.76, 3.33, p < .001) and stimulant-involved overdoses (AOR=6.70, 95% CI=5.26, 8.55, p < .001) leading to higher odds of incarceration.. Incarceration in county jail followed one in ten overdose-involved EMS responses. As illicit drug consumption increasingly involves stimulants, the frequency of incarceration following these events is likely to increase. Policy changes and interventions are needed to reduce incarceration after overdose emergencies.

Topics: Analgesics, Opioid; Drug Overdose; Emergency Medical Services; Humans; Naloxone; Opiate Overdose; Prevalence

Overdose Good Samaritan laws (GSLs) aim to reduce mortality by providing limited legal protections when a bystander to a possible drug overdose summons help. Most research into the impact of these laws is dated or potentially confounded by coenacted naloxone access laws. Lack of awareness and trust in GSL protections, as well as fear of police involvement and legal repercussions, remain key deterrents to help-seeking. These barriers may be unequally distributed by race/ethnicity due to racist policing and drug policies, potentially producing racial/ethnic disparities in the effectiveness of GSLs for reducing overdose mortality. We used 2015-2019 vital statistics data to estimate the effect of recent GSLs on overdose mortality, overall (8 states) and by Black/White race/ethnicity (4 states). Given GSLs' near ubiquity, few unexposed states were available for comparison. Therefore, we generated an "inverted" synthetic control method (SCM) to compare overdose mortality in new-GSL states with that in states that had GSLs throughout the analytical period. The estimated relationships between GSLs and overdose mortality, both overall and stratified by Black/White race/ethnicity, were consistent with chance. An absence of effect could result from insufficient protection provided by the laws, insufficient awareness of them, and/or reticence to summon help not addressable by legal protections. The inverted SCM may be useful for evaluating other widespread policies.

Topics: Drug Overdose; Ethnicity; Humans; Naloxone; United States

Per the CDC, it is estimated that 69,710 opioid overdose deaths occurred in the United States from September 2019 to September 2020. However, it is unclear whether naloxone prescribing also increased or otherwise fluctuated in this time. The objective of this study was to characterize the naloxone prescribing rate in patients with opioid use disorder (OUD) at the University of Alabama at Birmingham Hospital in 2019 and 2020.. A cross-sectional, retrospective medical record review was performed on patients with OUD from January 2019 through December 2020. Naloxone prescribing, defined as either a written prescription or a provided take-home kit, was assessed for all patients with OUD.. In 2019, 11,959 visits were made by 2962 unique patients with OUD, compared to 11,661 visits from 2,641 unique patients in 2020; 609 naloxone prescriptions were provided in 2019 (5.1%) and 619 in 2020 (5.3%). In both years, most OUD-related visits and naloxone prescriptions were from and to male, white, individuals. Compared with 2019, more naloxone prescriptions were given to uninsured patients in 2020 (33.2% vs 44.3%, p < 0.05), and more OUD patients were admitted to inpatient settings (26.0% vs 31.2%, p < 0.05) and received more naloxone prescriptions in the inpatient setting (46.3% vs 62.0%, p < 0.05) in 2020. The proportion of frequent users (i.e., visits ≥ 4 times/year) increased in 2020 for the emergency department (21.5% vs 26.4%, p < 0.001) and inpatient setting (24.9% vs 28.6%, p = 0.03).. Our findings indicate the need for improving naloxone awareness in providers and prescribing for patients with OUD, particularly in emergency department and outpatient settings. Our results also demonstrated a disparity in naloxone prescribing; a disproportionate number of opioid-related emergency department visits and overdose deaths were noted in Black people and frequent users.

Topics: Analgesics, Opioid; COVID-19; Cross-Sectional Studies; Drug Overdose; Hospitals; Humans; Male; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pandemics; Prescriptions; Retrospective Studies; United States

States have enacted multiple types of laws, with a variety of constituent provisions, in response to the opioid epidemic, often simultaneously. This temporal proximity and variation in state-to-state operationalization has resulted in significant challenges for empirical research on their effects. Thus, expert consensus can be helpful to classify laws and their provisions by their degree of helpfulness and impact.. We conducted a four-stage modified policy Delphi process to identify the top 10 most helpful and 5 most harmful provisions from eight opioid-related laws. This iterative consultation with six types of opioid experts included a preliminary focus group (n=12), two consecutive surveys (n=56 and n=40, respectively), and a final focus group feedback session (n=5).. On a scale of very harmful (0) to very helpful (4), overdose Good Samaritan laws received the highest average helpfulness rating (3.62, 95% CI: 3.48-3.75), followed by naloxone access laws (3.37, 95% CI: 3.22-3.51), and pain management clinic laws (3.08, 95% CI: 2.89-3.26). Drug-induced homicide (DIH) laws were rated the most harmful (0.88, 95% CI: 0.66-1.11). Impact ratings aligned similarly, although Medicaid laws received the second highest overall impact rating (3.71, 95% CI: 3.45, 3.97). The two most helpful provisions were naloxone standing orders (3.94, 95% CI: 3.86-4.02) and Medicaid coverage of medications for opioid use disorder (MOUD) (3.89, 95% CI: 3.82). Mandatory minimum DIH laws were the most harmful provision (0.73, 95% CI 0.53-0.93); followed by requiring prior authorization for Medicaid coverage of MOUD (1.00 95% CI: 0.72-1.27).. Overall, experts rated laws and provisions that facilitated harm reduction efforts and access to MOUD as most helpful. Laws and provisions rated as most harmful criminalized substance use and placed restrictions on access to MOUD. These ratings provide a foundation for evaluating the overall overdose policy environment for each state.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Legislation, Drug; Naloxone; Opioid-Related Disorders; United States

Overdose education and naloxone distribution (OEND) programmes equip and train people who are likely to witness an opioid overdose to respond with effective first aid interventions. Despite OEND expansion across North America, overdose rates are increasing, raising questions about how to improve OEND programmes. We conducted an iterative series of codesign stakeholder workshops to develop a prototype for take-home naloxone (THN)-kit (i.e., two doses of intranasal naloxone and training on how to administer it).. We recruited people who use opioids, frontline healthcare providers and public health representatives to participate in codesign workshops covering questions related to THN-kit prototypes, training on how to use it, and implementation, including refinement of design artefacts using personas and journey maps. Completed over 9 months, the workshops were audio-recorded and transcribed with visible results of the workshops (i.e., sticky notes, sketches) archived. We used thematic analyses of these materials to identify design requirements for THN-kits and training.. We facilitated 13 codesign workshops to identify and address gaps in existing opioid overdose education training and THN-kits and emphasize timely response and stigma in future THN-kit design. Using an iterative process, we created 15 prototypes, 3 candidate prototypes and a final prototype THN-kit from the synthesis of the codesign workshops.. The final prototype is available for a variety of implementation and evaluation processes. The THN-kit offers an integrated solution combining ultra-brief training animation and physical packaging of nasal naloxone to be distributed in family practice clinics, emergency departments, addiction medicine clinics and community settings.. The codesign process was deliberately structured to involve community members (the public), with multiple opportunities for public contribution. In addition, patient/public participation was a principle for the management and structuring of the research team.

Topics: Addiction Medicine; Drug Overdose; Emergency Service, Hospital; Family Practice; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose

While improving opioid safety has been a national priority, the coronavirus disease 2019 (COVID-19) pandemic has been associated with increased rates of opioid overdose. The present study characterized outpatient opioid and naloxone prescribing patterns during the COVID-19 pandemic. A retrospective chart review was conducted of adult patients receiving opioid therapy between August 2020 through October 2020 from outpatient clinics within a Texas health system. The primary outcome was naloxone co-prescription during the study period or within the year prior. During the study period, 1,368 patients received an opioid prescription, most of which were prescribed for chronic pain treatment (63.0%). Most opioid prescriptions (91.5%) were written for < 50 MME/day. For prescriptions written for acute pain, 78% were written for ≤ 10 days supply. While 31.1% of patients received gabapentinoid prescriptions, few (7.9%) received benzodiazepine or Z-hypnotic prescriptions. Twenty-two (1.6%) patients were co-prescribed naloxone. In this study, naloxone was rarely prescribed for outpatients receiving opioid prescriptions during the COVID-19 pandemic. Health systems should continue to prioritize adherence to evidence-based clinical guidelines and increase access to naloxone.

Topics: Academic Medical Centers; Adult; Analgesics, Opioid; COVID-19 Drug Treatment; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Outpatients; Pandemics; Practice Patterns, Physicians'; Retrospective Studies

The intersecting epidemics of opioid misuse, injection drug use, and HIV/HCV have resulted in record overdose deaths and sustained high levels of HIV/HCV transmissions. Literature on social networks suggests opportunities to connect people who use drugs (PWUD) and their peers to HIV/HCV and opioid overdose prevention services. However, little evidence exists on how to design such peer referral interventions in emergency department (ED) settings.. A mixed-method study was conducted to assess the feasibility of an mHealth-facilitated 'patient to peer social network referral program' for PWUD. In-depth interviews (IDIs) and quantitative surveys were conducted with urban ED patients (n = 15), along with 3 focus group discussions (FGDs) (n = 19).. Overall, 34 participants were enrolled (71 % males, 53 % Black). 13/15 IDI participants reported a history of opioid overdose; all had witnessed overdose events; all received HIV/HCV testing. From survey responses, most would invite their peers for HIV/HCV testing and naloxone training; and anticipated peers to accept referrals (HIV: 60 %, HCV: 73 %, naloxone: 93 %). Qualitative data showed PWUD shared health-related information with each other but preferred word of mouth rather than text messages. Participants used smartphones regularly and suggested using Internet advertising for prevention services. Participants expressed enthusiasm for ED-based peer mHealth referral platform to prevention services, as well as referring their peers to proposed services, with monetary incentives.. ED-based peer referral intervention to HIV/HCV testing and naloxone training was viewed favorably by PWUD. Frequent smartphone use among PWUD suggests that the medium could be a promising mode for peer referral.

Topics: Drug Overdose; Emergency Service, Hospital; Female; Hepatitis C; HIV Infections; Humans; Male; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Pilot Projects; Referral and Consultation; Telemedicine

Given the continued rise in opioid-related overdoses, many states have expanded access to the opioid antagonist naloxone. We sought to provide comprehensive data on one such strategy: the authority of providers at different emergency medical services (EMS) licensure levels to administer naloxone.. We conducted a systematic legal review of state laws and protocols governing the authority of different EMS licensure levels to administer naloxone. We used Westlaw, state government websites and scope of practice protocols. We coded relevant policies regarding which, if any, administration routes and dosages of naloxone are permitted for each licensure level: emergency medical responder (EMR), emergency medical technician (EMT), advanced emergency medical technician (AEMT), and paramedic.. As of July 2020, all states with relevant laws or protocols authorize paramedics, AEMTs, and EMTs to administer naloxone. Thirty-nine states with an EMR licensure level and statewide protocol authorize naloxone administration by EMRs, up from only two in 2013. Permissible routes of administration have increased across all EMS provider levels, providing advanced life support providers (i.e., paramedics and AEMTs) with expanded discretion; however, authorization for intravenous and intramuscular administration remains relatively uncommon for basic life support (BLS) providers. When specified, maximum doses authorized ranged widely, from 2.0 to 12.0 milligrams.. Naloxone administration authority is now widely granted to EMS providers. Most states allow all licensed EMS provider levels to administer naloxone, a substantial increase for EMRs and EMTs since 2013. Paramedics and AEMTs have the greatest authority to select the dosage and route of administration.

Topics: Drug Overdose; Emergency Medical Services; Humans; Naloxone; Narcotic Antagonists; Policy

Violations of the positivity assumption (also called the common support condition) challenge health policy research and can result in significant bias, large variance, and invalid inference. We define positivity in the single- and multiple-timepoint (i.e., longitudinal) health policy evaluation setting, and discuss real-world threats to positivity. We show empirical evidence of the practical positivity violations that can result when attempting to estimate the effects of health policies (in this case, Naloxone Access Laws). In such scenarios, an alternative is to estimate the effect of a shift in law enactment (e.g., the effect if enactment had been delayed by some number of years). Such an effect corresponds to what is called a modified treatment policy, and dramatically weakens the required positivity assumption, thereby offering a means to estimate policy effects even in scenarios with serious positivity problems. We apply the approach to define and estimate the longitudinal effects of Naloxone Access Laws on opioid overdose rates.

Topics: Analgesics, Opioid; Drug Overdose; Health Policy; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose

Professions compete over jurisdictions by laying claim to specific tasks. Research shows that they enhance their professional status by siphoning off tasks and seizing control of social problems that belong to other professions. Not all tasks are equally desirable, though. Studies find that workers resist helping stigmatized groups or taking on "unsolvable" social problems. This raises a critical question for social scientists: How do professionals respond when opportunities for jurisdictional expansion are contingent on aiding a stigmatized population? Our study draws on research from the sociology of culture, professions, and stigma and empirical evidence about naloxone provision to develop a theory of professional ambivalence that explains how professionals respond to this fundamental tension. In response to rising rates of overdose deaths in the U.S., many cities have adopted naloxone provision programs in which first responders-police, firefighters, and EMTs-carry and administer naloxone, an opioid overdose antidote. For police and firefighters, this task enables them to venture into medical territory, but for all three professionals, it requires working with the stigmatized population of people who use drugs. We use abductive analysis of qualitative interviews (n = 20) conducted in a Midwestern metropolitan area from 2018 to 2019 to explore professionals' attitudes about naloxone. We find that professionals' willingness to take on new tasks is largely grounded in how they construct patients as deserving or undeserving of care. Deservingness construction is a constitutive process through which first responders draw on cultural imaginaries about addiction and treatment as well as their own experiences providing naloxone. This results in three mechanisms of deservingness construction-experiential, behavioral, and interactional-that reinforce cultural imaginaries and affect how they think about patients, naloxone, and addiction. Findings contribute to theory of professional ambivalence and offer policy implications to enhance the effectiveness of naloxone provision programs.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Police

Opioid overdose remains a significant public health issue in the United States and is the leading cause of accidental death. Naloxone has become increasingly accessible, with greater emphasis placed by health systems and pharmacies on distribution of the safety tool. While the utility of pharmacists in advancing this work is clear, there is limited research on the success of integrating pharmacy students into a naloxone outreach program. The purpose of this project was to implement and evaluate the success of integrating pharmacy student interns into a naloxone telephone outreach service for Veteran patients at risk for opioid overdose. A telephone outreach protocol was developed and reviewed by Clinical Pharmacist Practitioners (CPPs) at the site. Pharmacy student interns were trained to complete naloxone outreach calls, which were supervised by a CPP. In the first three months, 160 patients were identified for outreach based on prescription opioid risk factors. Of the 118 reached by telephone, 92 (78.0%) accepted naloxone and 26 (22.0%) declined. In total, 150 (93.8%) patients received naloxone education via either telephone discussion or letter. Integrating supervised pharmacy student interns into a naloxone telephone outreach service was feasible for interns and CPPs and resulted in a high naloxone acceptance rate.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Pharmacists; Students, Pharmacy; Telephone; United States

Emergency departments (EDs) are important venues for the distribution of naloxone to patients at high risk of opioid overdose, but less is known about patient perceptions on naloxone or best practices for patient education and communication. Our aim was to conduct an in-depth exploration of knowledge and attitudes toward ED naloxone distribution among patients who received a naloxone prescription.. We conducted semi-structured telephone interviews with 25 adult participants seen and discharged from three urban, academic EDs in Philadelphia, PA, with a naloxone prescription between November 2020 and February 2021. Interviews focused on awareness of naloxone as well as attitudes and experiences receiving naloxone in the ED. We used thematic content analysis to identify key themes reflecting patient attitudes and experiences.. Of the 25 participants, 72% had previously witnessed an overdose and 48% had personally experienced a non-fatal overdose. Nineteen participants (76%) self-disclosed a history of substance use or overdose, and one reported receiving an opioid prescription during their ED visit and no history of substance use. In interviews, we identified wide variability in participant levels of knowledge about overdose risk, the role of naloxone in reducing risk, and naloxone access. A subset of participants was highly engaged with community harm reduction resources and well versed in naloxone access and use. A second subset was familiar with naloxone, but largely obtained it through healthcare settings such as the ED, while a final group was largely unfamiliar with naloxone. While most participants expressed positive attitudes about receiving naloxone from the ED, the quality of discussions with ED providers was variable, with some participants not even aware they were receiving a naloxone prescription until discharge.. Naloxone prescribing in the ED was acceptable and valued by most participants, but there are missed opportunities for communication and education. These findings underscore the critical role that EDs play in mitigating risks for patients who are not engaged with other healthcare or community health providers and can inform future work about the effective implementation of harm reduction strategies in ED settings.

Topics: Adult; Analgesics, Opioid; Drug Overdose; Emergency Service, Hospital; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

Topics: Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Rhode Island

Substance use management in hospitals can be challenging. In response, a Canadian hospital opened an overdose prevention site (OPS) where community members and hospital inpatients can inject pre-obtained illicit drugs under supervision. This study aims to: (1) describe program utilization patterns; (2) characterize OPS visits; and (3) evaluate overdose events and related outcomes.. A retrospective chart review was completed at one hospital in Vancouver, Canada. All community members and hospital inpatients who visited the OPS between May 2018 and July 2019 were included. Client measures included: hospital inpatient status, use of intravenous access line for drug injection, and substances used. Program measures included: number of visits (daily/monthly), overdose (fatal/non-fatal) events and overdose-related outcomes.. Overall, 11,673 OPS visits were recorded. Monthly visits increased from 306 to 1198 between May 2018 and July 2019 respectively. On average, 26 visits occurred daily. Among all visits, 20% reported being a hospital inpatient, and 5% reported using a hospital intravenous access line for drug injection. Opioids (56%) and stimulants (24%) were the most common substances used. Overall 39 overdose events occurred - 82% required naloxone reversal, 28% required transfer to the hospital's emergency department and none were fatal. Overdose events were more common among hospital inpatients compared to community clients (6.6 vs 2.2 per 1000 visits respectively; p value = 0.046).. This unique OPS is an example of a hospital-based harm reduction initiative. Use of the site increased over time among both groups with no fatal overdose events occurring.

Topics: Canada; Drug Overdose; Harm Reduction; Hospitals; Humans; Illicit Drugs; Naloxone; Needle-Exchange Programs; Retrospective Studies

Opioid overdose-related deaths continue to rise. Despite public health efforts, there is still variability in obtainment of naloxone, a lifesaving antidote. We share our experience in the implementation of a novel opioid overdose education and naloxone distribution (OEND) program at a large academic medical center.. Collaborative efforts made by pharmacists, pharmacy students, physicians, nurses, and recovery coaches were employed in the design of the program. The service was available Monday through Friday, 9 am to 6 pm, and primarily carried out by pharmacy students on a rotating basis. Services offered included bedside delivery of naloxone and education prior to the day of discharge. In preparation for their role, the pharmacy students were required to complete a series of trainings and competency assessments.. A total of 40 patients were included in the program evaluation. Of the completed consults 96.7% (n = 30) of patients received both counseling and naloxone delivery. Eighty percent of patients had a history of nonfatal opioid overdose, but only 37.5% had naloxone listed as a home medication. OEND services were provided to 66% of individuals with patient-directed discharges.. Implementation of an inpatient OEND program by mobilizing trained student pharmacists is feasible and expands naloxone access to patients during transitions of care. A similar model could be considered in the future for the delivery of harm reduction supplies to this patient population.

Topics: Academic Medical Centers; Analgesics, Opioid; Drug Overdose; Humans; Inpatients; Naloxone; Narcotic Antagonists; Opiate Overdose

Prescription opioids have been increasingly prescribed for chronic pain while the opioid-related death rates grow. Naloxone, an opioid antagonist, is increasingly recommended in these patients, yet there is limited research that investigates the intention to get naloxone. This study aimed to investigate intention toward getting naloxone in patients prescribed opioids for chronic pain and to assess the predictive utility of the theory of reasoned action (TRA) constructs in explaining intention to get naloxone.. This was a cross-sectional study of a panel of U.S. adult patients prescribed opioids for chronic pain using a Qualtrics. A total of 549 participants completed the survey. Most of them were female (53.01%), White or Caucasian (83.61%), non-Hispanic (87.57%) and had a mean age of 44.16 years (SD = 13.37). Of these, 167 (30.42%) had high intention to get naloxone. The TRA construct of subjective norm was significantly associated with increased likelihood of higher intentions to get naloxone (OR 3.04, 95% CI 2.50-3.70, P < 0.0001).. Our study provides empirical support of the TRA in predicting intention to get naloxone among chronic pain patients currently taking opioids. Subjective norms significantly predicted intention to get naloxone in these patients. The interventions targeting important reference groups of these patients would have greater impact on increasing intention to get naloxone in this population. Future studies should test whether theory-based interventions focusing on strengthening subjective norms increase intention to get naloxone in this population.

Topics: Adult; Analgesics, Opioid; Chronic Pain; Cross-Sectional Studies; Drug Overdose; Female; Humans; Intention; Male; Naloxone; Narcotic Antagonists

Implementing public health vending machines (PHVMs) is an evidence-based strategy for mitigating substance use-associated morbidity and mortality. Monthly counts of opioid-involved overdose fatalities among Clark County residents that occurred from January 2015 to December 2020 were used to build an autoregressive integrated moving averages (ARIMA) model to measure the impact of naloxone dispensation at PHVMs. We forecasted the number of expected opioid-involved overdose fatalities had naloxone dispensation at PHVMs not occurred and compared to observed monthly counts. Interrupted time series analyses (ITSA) were used to evaluate the step (i.e. the immediate impact of naloxone dispensation at PHVMs on opioid-involved overdose fatalities) and slope change (i.e. changes in trend and directionality of monthly counts of opioid-involved overdose fatalities following naloxone dispensation at PHVMs).. During the 12-months immediately following naloxone dispensation at PHVMs, our model forecasted 270 opioid-involved overdose fatalities, but death certificate data indicated only 229 occurred, suggesting an aversion of 41 deaths. ITSA identified a significant negative step change in opioid-involved overdose fatalities at the time naloxone dispensation at PHVMs was launched (B = -8.52,. Naloxone dispensation at PHVMs was associated with immediate reductions in opioid-involved overdose fatalities. Key MessagesNaloxone dispensation at PHVMs was associated with immediate reductions in opioid-involved overdose fatalities.Communities should consider implementing public health vending machines in efforts to prevent opioid-involved overdose fatalities.The COVID-19 pandemic worsened the overdose crisis.

Topics: Analgesics, Opioid; COVID-19; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Nevada; Opioid-Related Disorders; Pandemics; Public Health; United States

Topics: Aged; Analgesics, Opioid; COVID-19; Drug Overdose; Humans; Naloxone; Opiate Overdose; Opioid-Related Disorders

The Choctaw Nation Health Care Center established a first responder naloxone program in 2015. Limited data is available on community naloxone programs specific to tribal communities and the opinions of first responders who may utilize naloxone in the field. The purpose of this article is to highlight the model of a tribal first responder naloxone program in Talihina, Oklahoma and present analysis of the impact of program trainings on first responders' understanding and willingness to administer intranasal naloxone through pre- and post-surveys (n = 758) collected from May 2018 to November 2019. Descriptive analyses were conducted to compare first responders' rating of their support, willingness, and confidence in using naloxone. Overall, 95.1% of first responders reported learning something new from the training. However, the most significant changes in pre- to post-test results were among first responders that had never been at the scene of an overdose. Almost 77% of trainees who reported they never were at a scene of an overdose and responded "not very willing" in administering naloxone at pre-test, responded that they were "very willing" to administer naloxone at post-test.

Topics: Analgesics, Opioid; Drug Overdose; Emergency Responders; Humans; Indians, North American; Naloxone; Narcotic Antagonists

Topics: Drug Overdose; Harm Reduction; Humans; Medicine; Naloxone; Narcotic Antagonists

Opioid-related overdose death is a public health epidemic in much of the USA, yet little is known about how people who use opioids (PWUO) experience overdose deaths in their social networks. We explore these experiences through a qualitative study of opioid-related overdose death bereavement among PWUO.. We recruited 30 adults who inject opioids from a syringe service program in the Midwestern USA and interviewed them using a semi-structured guide that addressed experiences of opioid use, opioid-related overdose, and overdose reversal via the medication naloxone. Interviews were transcribed verbatim and analyzed thematically.. Participants described overdose death as ever-present in their social worlds. Most (approximately 75%) reported at least one overdose death in their social network, and many came to consider death an inevitable end of opioid use. Participants described grief shaped by complex social relations and mourning that was interrupted due to involvement with social services and criminal legal systems. They also reported several ways that overdose deaths influenced their drug use, with some increasing their use and others adopting safer drug use practices. Despite the high prevalence of overdose deaths in their social networks, only one participant reported receiving grief support services.. Findings underscore the need for interventions that not only maintain life, such as naloxone distribution, but also improve quality of life by attending to grief related to overdose death bereavement. We discuss policies and practices with the potential to address the unique psychological, social, and structural challenges of grief for this population.

Topics: Adult; Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Quality of Life

In 2014, the Norwegian government funded a large-scale take-home naloxone (THN) program to address high overdose mortality rates. The aims of this study are to describe characteristics among persons trained to receive THN, describe actions taken following THN use at an overdose event and to explore factors associated with naloxone use.. This was a prospective cohort study of individuals who received THN from 2014 to 2021. Descriptive characteristics were collected at initial training. When returning for refill, participants reported on their previous naloxone use. In a multivariable logistic regression model exploring associations with naloxone use: gender, age, opioid use history, concomitant drug use, injecting, history of experienced or witnessed overdose were included.. In total, 3527 individuals were included in this study. There were 958 individuals who returned for refills 2303 times. Most participants were male (63.6%), with a history of opioid use (77.5%). Those who reported naloxone use were more likely to have a history of opioid use (aOR= 4.1; 95% CI=2.77,6.1), were younger (aOR=0.98; 95% CI=0.97,0.99) and had witnessed overdoses (aOR=3.3; 95% CI=1.98,5.34). Among current opioid users, the odds were higher for injectors (aOR=1.57; 95% CI=1.18,2.1). Naloxone use was reported 1282 times. Additional actions such as waking the person and calling the ambulance were frequently reported. Survival was reported in almost all cases (94%).. People who use drugs are a suitable target group for THN-programs, as they seem to be willing and capable to reverse overdoses effectively. Given their personal risk factors for overdosing, recipients will likely also benefit from overdose prevention education.

Topics: Analgesics, Opioid; Drug Overdose; Female; Humans; Male; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Prospective Studies

The Substance Abuse and Mental Health Services Administration's (SAMHSA) Harm Reduction grant program expanded access to several harm reduction strategies to mitigate opioid overdose fatalities, including expanding access to naloxone. Interviews with first responders in a frontier and remote (FAR) state were conducted to understand their job responsibilities in relation to overdose response and prevention and their perceptions of training laypersons to administer naloxone. This study includes 22 interviews with law enforcement, EMS and/or fire personnel, and members of harm reduction-focused community organizations. The study finds widespread support for increasing access to naloxone and training laypersons in naloxone administration throughout Montana, due to rural first responders' inability to meet the needs of residents and an overall lack of resources to address addiction and the effects of fentanyl. Participants from harm reduction-focused community organizations convey support for training lay persons, but also illuminate that real and perceived cultural opposition to harm reduction strategies could reduce the likelihood that laypeople enroll in naloxone training. This study adds to the literature because it focuses on first responders in a FAR area that would benefit from layperson naloxone education and administration training due to its geographic expansiveness and the area's overall lack of access to medications for opioid use disorder or other treatment services. Expanding harm reduction approaches, like increasing access and training laypersons to administer naloxone, might be FAR residents' best chance for surviving an opioid overdose.

Topics: Analgesics, Opioid; Cardiopulmonary Resuscitation; Drug Overdose; Emergency Responders; Fentanyl; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders

Improving access to naloxone is a critical component of the nation's strategy to curb fatal overdoses in the opioid crisis. Standing or protocol orders, prescriptive authority laws, and immunity provisions have been passed by states to expand access, but less attention has been given to potential financial barriers to naloxone access.. To assess trends in out-of-pocket (OOP) costs for naloxone and examine variation in OOP costs by drug brand and payer.. This observational study analyzed US naloxone claims data from Symphony Health and associated OOP costs for individuals filling naloxone prescriptions by drug brand and payer between January 1, 2010, to December 31, 2018. The data were analyzed from March 31, 2021, to April 12, 2022.. The main measures were trends in annual number of naloxone claims (overall, by payer, and by drug brand) and mean annual OOP costs per claim (overall, by payer, and by drug brand).. Of 719 612 naloxone claims (172 894 generic naloxone, 501 568 Narcan, and 45 150 Evzio) for 2010 through 2018, the number of naloxone claims among insured patients began rapidly increasing after 2014; at the same time, the mean OOP cost of naloxone increased dramatically among the uninsured population. Comparing 2014 with 2018, the mean OOP cost of naloxone decreased by 26% among those with insurance but increased by 506% among uninsured patients. For the uninsured population, the impediment of cost was even larger for certain brands of the drug. In 2016, the mean OOP cost for Evzio among uninsured patients rose to $2136.37 (a 2429% increase relative to 2015) compared with the mean cost of generic naloxone, $72.88, and the cost of Narcan in its first year, $87.95. Throughout the period, the mean OOP costs paid by uninsured patients were higher for Evzio at $1089.17 (95% CI, $884.17-$1294.17) compared with $73.62 (95% CI, $69.24-$78.00) for Narcan and $67.99 (95% CI, $61.42-$74.56) for generic naloxone.. In this observational study, the findings indicated that the OOP cost of naloxone had been an increasingly substantial barrier to naloxone access for uninsured patients, potentially limiting use among this population, which constituted approximately 20% of adults with opioid use disorder.

Topics: Adult; Drug Overdose; Drugs, Generic; Health Expenditures; Humans; Naloxone; Opioid-Related Disorders

To differentiate the severity of acute opioid toxicity and describe both the clinical and physiological features associated with heroin overdose in a cohort of witnessed overdose cases.. Witnessed heroin overdose cases over a 12-month period (30 June 2018 - 30 June 2019) at the Medically Supervised Injecting Room (MSIR) in Melbourne, Australia were examined. The severity of acute opioid toxicity was classified according to the level of clinical intervention required to manage the overdose cases where an escalating level of care was provided. Heroin overdose cases were classified into one of three graded severity categories and a fourth complicated heroin overdose category.. A total of 1218 heroin overdose cases were identified from 60,693 supervised injecting visits over the study period. On the spectrum of toxicity, 78% (. We demonstrated that heroin overdose is a dynamic illness and cases differ in the severity of acute opioid toxicity. The risk of airway occlusion including positional asphyxia was an early and consistent feature across all levels of toxicity, while exaggerated respiratory depression together with exaggerated depression of consciousness was increasingly observed with greater levels of toxicity. We also demonstrated the importance of early intervention in overdose cases, where in a large cohort of heroin overdose cases there were no fatal outcomes, a very low hospitalisation rate and most cases were able to be managed to clinical resolution on-site.

Topics: Analgesics, Opioid; Australia; Cohort Studies; Drug Overdose; Heroin; Humans; Naloxone; Narcotic Antagonists; Narcotics; Needle-Exchange Programs; Opiate Overdose; Retrospective Studies

Law enforcement officer (LEO) administered naloxone is an effective intervention for treating prehospital opioid overdoses. Our objective is to determine the rate and factors associated with adverse behavioral effects and efficacy following LEO naloxone administration.. This is a retrospective cohort study of patients treated with naloxone law enforcement over 5 years in one county EMS system. Law enforcement officers utilized intranasal 4 mg/0.1 mL for suspected opioid overdose. Data were acquired from forms completed by LEO following administration of naloxone. We performed descriptive statistics. Univariate regression analysis with a primary outcome of improved neurological status and a secondary outcome of patient irritability/combativeness post-naloxone.. A total of 597 cases of LEO administered naloxone were reported. Naloxone was felt to be effective by the LEO in 370 (62%) of these cases with 6 (1%) exhibiting combativeness and 57 (10%) having the composite outcome of irritability or combativeness. The perceived rate of efficacy was higher when an opioid, rather than a non-opioid agent was suspected (239/346 [67%] vs. 83/165 [50%], OR 2.21, 95% CI 1.51-3.23), and for heroin and fentanyl specifically. Suspected fentanyl exposure was the only variable associated with our secondary outcome of irritability or combativeness (7/22 [32%] vs. 45/489 [9%], OR 4.60, 95% CI 1.78-11.8).. LEO administered naloxone remains an effective intervention for overdose victims, with higher perceived efficacy when opioids are specifically implicated. Combativeness is rare following LEO naloxone administration. Further research is needed to understand a relationship between suspected fentanyl intoxication and post-naloxone behavioral disturbances.

Topics: Analgesics, Opioid; Drug Overdose; Fentanyl; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Police; Retrospective Studies

The Opioid Overdose Knowledge Scale (OOKS) is widely used as an adjunct to opioid education and naloxone distribution (OEND) for assessing pre- and post-training knowledge. However, the extent to which the OOKS performs comparably for bystander and first responder groups has not been well determined. We used exploratory structural equation modeling (ESEM) to assess the measurement invariance of an OOKS item subset when used as an OEND training pre-test. We used secondary analysis of pre-test data collected from 446 first responders and 1,349 bystanders (N = 1,795) attending OEND trainings conducted by two county public health departments. Twenty-four items were selected by practitioner/trainer consensus from the original 45-item OOKS instrument with an additional 2 removed owing to low response variation. We used exploratory factor analysis (EFA) followed by ESEM to identify a factor structure, which we assessed for configural, metric, and scalar measurement invariance by participant group using the 22 dichotomous items (correct/incorrect) as factor indicators. EFA identified a 3-factor model consisting of items assessing: basic overdose risk information, signs of an overdose, and rescue procedures/advanced overdose risk information. Model fit by ESEM estimation versus confirmatory factor analysis showed the ESEM model afforded a better fit. Measurement invariance analyses indicated the 3-factor model fit the data across all levels of invariance per standard fit statistic metrics. The reduced set of 22 OOKS items appears to offer comparable measurement of pre-training knowledge on opioid overdose risks, signs of an overdose, and rescue procedures for both bystanders and first responders.

Topics: Analgesics, Opioid; Drug Overdose; Emergency Responders; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose

Opioid overdose response training (OORT) and the need for its rapid expansion have become more significant as the opioid epidemic continues to be a health crisis in the USA. Limitation of funding and stigmatization often hinders expansion of OORT programs. Primarily due to the COVID-19 pandemic, there has been widespread transition from in-person to virtual communication. However, OORT programs may benefit from long-term use of this modality of education if it can be as effective.. To measure the change in participant attitude after a brief, virtual OORT.. A 6.5-min OORT video explained recognition of opioid overdose, appropriate response and proper administration of intranasal naloxone. Pre- and post-video scores from a 19-item survey were used to determine the video's impact on participants' self-perceived competence and readiness to administer naloxone to a person with a suspected opioid overdose. Paired t tests were used in the analysis of pre- and post-video scores. Mann-Whitney U and Kruskal-Wallis H testing were used to compare variance between several demographic subgroups of interest.. A sample of 219 participants had a significant mean difference of 15.12 (SD 9.48; 95% CI 13.86-16.39, p < 0.001) between pre- and posttest scores. Improvements were found to be greatest in content-naïve participants with lower levels of education and non-health care-related jobs than participants endorsing previous content awareness, formal naloxone training, masters, doctorate or professional degrees and health care-related jobs.. This pilot study demonstrated encouraging evidence that a brief, virtual, pre-recorded educational intervention improved participant-rated competence and readiness to administer intranasal naloxone in a suspected opioid overdose. Due to scalability and ability to overcome common healthcare accessibility barriers, short-form videos focused on key facts about naloxone and the benefits of its use could be part of a strategy for rapid expansion of OORT programs to mitigate opioid overdose fatalities.

Topics: Analgesics, Opioid; COVID-19; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Pandemics; Pilot Projects

Narrow or non-existent Good Samaritan Law protections and harsh drug selling statutes in the USA have been shown to deter bystanders from seeking medical assistance for overdoses. Additionally, little is known about the actions that police take when responding to overdose events. The objectives of this study were to assess the prevalence and correlates of naloxone administration by police, as well as to examine overdose events where arrests were made and those in which the person who overdosed was described as combative.. We analyzed incident reports of police responding to an overdose between September 1, 2019, and August 31, 2020 (i.e., 6 months prior to and during the COVID-19 pandemic), from a city in Rhode Island. We examined characteristics of incidents, as well as individual characteristics of the person who overdosed. Correlates of police naloxone administration were assessed using Wilcoxon rank sum tests and Fisher's exact tests, and we examined incidents where arrests occurred and incidents in which the person who overdosed was described as combative descriptively.. Among the 211 incidents in which police responded to an overdose during the study period, we found that police administered naloxone in approximately 10% of incidents. In most incidents, police were the last group of first responders to arrive on scene (59%), and most often, naloxone was administered by others (65%). Police were significantly more likely to administer naloxone when they were the first professionals to arrive, when naloxone had not been administered by others, and when the overdose occurred in public or in a vehicle. Arrests at overdose events were rarely reported (1%), and people who overdosed were rarely (1%) documented in incident reports as being 'combative.'. Considering these findings, ideally, all jurisdictions should have sufficient first responder staffing and resources to ensure a rapid response to overdose events, with police rarely or never dispatched to respond to overdoses. However, until this ideal can be achieved, any available responders should be dispatched concurrently, with police instructed to resume patrol once other professional responders arrive on scene; additionally, warrant searches of persons on scene should be prohibited.

Topics: COVID-19; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Pandemics; Police; Rhode Island

Between 2017 and 2020, Ontario implemented overdose prevention sites (OPS) and consumption and treatment services (CTS) in nine of its 34 public health units (PHU). We tested for the effect of booth-hours (spaces within OPS/CTSs for supervised consumption) on opioid-related health service use and mortality rates at the provincial- (aggregate) and PHU-level.. We used monthly rates of all opioid-related emergency department (ED) visits, hospitalizations, and deaths between January 2015 and March 2021 as our three outcomes. For each PHU that implemented OPS/CTSs, we created a synthetic control as a weighted combination of unexposed PHUs. Our exposure was the time-varying rate of booth-hours provided. We estimated the population-level effects of the intervention on each outcome per treated/synthetic-control pair using controlled interrupted time series with segmented regression; and tested for the aggregate effect using a multiple baseline approach. We adjusted for time-varying provision of prescription opioids for pain management, opioid agonist treatment (OAT), and naloxone kits; and corrected for seasonality and autocorrelation. All rates were per 100,000 population. For sensitivity analysis, we restricted the post-implementation period to before COVID-19 public health measures were implemented (March 2020).. Our aggregate analyses found no effect per booth-hour on ED visits (0.00, 95% CI: -0.01, 0.01; p-value=0.6684), hospitalizations (0.00, 95% CI: 0.00, 0.00; p-value=0.9710) or deaths (0.00, 95% CI: 0.00, 0.00; p-value=0.2466). However, OAT reduced ED visits (-0.20, 95% CI: -0.35, -0.05; p-value=0.0103) and deaths (-0.04, 95% CI: -0.05, -0.03; p-value=<0.0001). Conversely, prescription opioids for pain management modestly increased deaths (0.0008, 95% CI: 0.0002, 0.0015; p-value=0.0157) per 100,000 population, respectively. Except for a few treated PHU/synthetic control pairs, disaggregate results were congruent with overall findings.. Booth-hours had no population-level effect on opioid-related overdose ED visit, hospitalization, or death rates.

Topics: Analgesics, Opioid; COVID-19; Drug Overdose; Emergency Service, Hospital; Humans; Naloxone; Opioid-Related Disorders

Racial/ethnic minorities have experienced disproportionate opioid-related overdose death rates in recent years. In this context, we examined inequities in community-based naloxone access across racial/ethnic groups in Massachusetts.. We used data from: the Massachusetts Department of Public Health on community-based overdose education and naloxone distribution (OEND) programs; the Massachusetts Office of the Chief Medical Examiner on opioid-related overdose deaths, and; the United States Census American Community Survey for regional demographic/socioeconomic details to estimate community populations by race/ethnicity and racial segregation between African American/Black and white residents. Race/ethnicity groups included in the analysis were African American/Black (non-Hispanic), Hispanic, white (non-Hispanic), and "other" (non-Hispanic). We evaluated racial/ethnic differences in naloxone distribution across regions in Massachusetts and neighborhoods in Boston descriptively and spatially, plotting the race/ethnicity-specific number of kits per opioid-related overdose death per jurisdiction. Lastly, we constructed generalized estimating equations models with a negative binomial distribution to compare the race/ethnicity-specific naloxone distribution rate by OEND programs.. From 2016-2019, the median annual rate of naloxone kits received from OEND programs in Massachusetts per racial/ethnicity group ranged between 160 and 447 per 100,000. In a multivariable analysis, we found that the naloxone distribution rates for racial/ethnic minorities were lower than the rate for white residents. We also found naloxone was more likely to be distributed in racially segregated communities than non-segregated communities.. We identified racial/ethnic inequities in naloxone receipt by individuals in Massachusetts. Additional resources focused on designing and implementing OEND programs for racial/ethnic minorities are warranted to ensure equitable access to naloxone.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Massachusetts; Naloxone; Opiate Overdose; Racial Groups; United States; United States Department of Veterans Affairs

Topics: Community Health Services; Drug Overdose; Health Services Accessibility; Humans; Naloxone; Narcotic Antagonists

In 2021, the state of Rhode Island distributed 10 000 additional naloxone kits compared with the prior year through partnerships with community-based organizations.. To compare various strategies to increase naloxone distribution through community-based programs in Rhode Island to identify one most effective and efficient strategy in preventing opioid overdose deaths (OODs).. In this decision analytical model study conducted from January 2016 to December 2022, a spatial microsimulation model with an integrated decision tree was developed and calibrated to compare the outcomes of alternative strategies for distributing 10 000 additional naloxone kits annually among all individuals at risk for opioid overdose in Rhode Island.. Distribution of 10 000 additional naloxone kits annually, focusing on people who inject drugs, people who use illicit opioids and stimulants, individuals at various levels of risk for opioid overdose, or people who misuse prescription opioids vs no additional kits (status quo). Two expanded distribution implementation approaches were considered: one consistent with the current spatial distribution patterns for each distribution program type (supply-based approach) and one consistent with the current spatial distribution of individuals in each of the risk groups, assuming that programs could direct the additional kits to new geographic areas if required (demand-based approach).. Witnessed OODs, cost per OOD averted (efficiency), geospatial health inequality measured by the Theil index, and between-group variance for OOD rates.. A total of 63 131 simulated individuals were estimated to be at risk for opioid overdose in Rhode Island based on current population data. With the supply-based approach, prioritizing additional naloxone kits to people who use illicit drugs averted more witnessed OODs by an estimated mean of 18.9% (95% simulation interval [SI], 13.1%-30.7%) annually. Expanded naloxone distribution using the demand-based approach and focusing on people who inject drugs had the best outcomes across all scenarios, averting an estimated mean of 25.3% (95% SI, 13.1%-37.6%) of witnessed OODs annually, at the lowest mean incremental cost of $27 312 per OOD averted. Other strategies were associated with fewer OODs averted at higher costs but showed similar patterns of improved outcomes and lower unit costs if kits could be reallocated to areas with greater need. The demand-based approach reduced geospatial inequality in OOD rates in all scenarios compared with the supply-based approach and status quo.. In this decision analytical model study, variations in the effectiveness, efficiency, and health inequality of the different naloxone distribution expansion strategies and approaches were identified. Future efforts should be prioritized for people at highest risk for overdose (those who inject drugs or use illicit drugs) and redirected toward areas with the greatest need. These findings may inform future naloxone distribution priority settings.

Topics: Delivery of Health Care; Drug Overdose; Health Status Disparities; Humans; Illicit Drugs; Naloxone; Opiate Overdose; Rhode Island

The aim was to determine the association between the receipt of naloxone and emergency department (ED) visits within 60 days after the receipt of an opioid.. A retrospective cohort of individuals 18 years of age or above, enrolled in TRICARE, and were dispensed an opioid at any time from January 1, 2019, through September 30, 2020 was identified within the United States Military Health System. Individuals receiving naloxone within 5 days of the opioid dispensing date were propensity score matched with individuals receiving opioids only. A logistic regression was used to estimate the odds of an ED visit in the 60-day follow-up period after the index opioid dispense event among those co-dispensed naloxone and those receiving opioids only.. Of the 2,136,717 individuals who received an opioid prescription during the study period, 800,071 (10.1%) met study inclusion criteria. Overall, 5096 (0.24%) of individuals who received an opioid prescription were co-dispensed naloxone. Following propensity score matching, those who received naloxone had a significantly lower odds of ED utilization in the 60 days after receiving an opioid prescription (odds ratio: 0.74, 95% CI: 0.68-0.80, P<0.001).. This study highlights the importance of expanding access to naloxone in order to reduce ED utilization. Future research is needed to examine additional outcomes related to naloxone receipt and develop programs that make naloxone prescribing a routine practice.

Topics: Analgesics, Opioid; Drug Overdose; Emergency Service, Hospital; Humans; Military Health Services; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Retrospective Studies; United States

In response to the ongoing opioid overdose crisis, US officials urged the expansion of access to naloxone for opioid overdose reversal. Since then, emergency medical services' (EMS) dispensing of naloxone kits has become an emerging harm reduction strategy.. We created a naloxone training and low-barrier distribution program in San Francisco: Project FRIEND (First Responder Increased Education and Naloxone Distribution). The team assembled an advisory committee of stakeholders and subject-matter experts, worked with local and state EMS agencies to augment existing protocols, created training curricula, and developed a naloxone-distribution data collection system. Naloxone kits were labeled for registration and data tracking. Emergency medical technicians and paramedics were asked to distribute naloxone kits to any individuals (patient or bystander) they deemed at risk of experiencing or witnessing an opioid overdose, and to voluntarily register those kits.. Training modalities included a video module (distributed to over 700 EMS personnel) and voluntary, in-person training sessions, attended by 224 EMS personnel. From September 25, 2019-September 24, 2020, 1,200 naloxone kits were distributed to EMS companies. Of these, 232 kits (19%) were registered by EMS personnel. Among registered kits, 146 (63%) were distributed during encounters for suspected overdose, and 103 (44%) were distributed to patients themselves. Most patients were male (n = 153, 66%) and of White race (n = 124, 53%); median age was 37.5 years (interquartile range 31-47).. We describe a successful implementation and highlight the feasibility of a low-threshold, leave-behind naloxone program. Collaboration with multiple entities was a key component of the program's success.

Topics: Adult; Drug Overdose; Female; Humans; Male; Naloxone; Narcotic Antagonists; Opiate Overdose; San Francisco

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Prescriptions

Topics: Adult; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Students; Universities; Young Adult

Opioid overdose is a preventable injury leading to high morbidity and premature mortality in communities across the United States. Overdoses take place where people use drugs, including commercial and public locations like community pharmacies, and necessitate swift detection and response to avoid harm and, even more seriously, death. The presence of emergency and safety protocols improves occupational health and safety for all in the workplace. The aim of this study was to assess the prevalence of experience with on-site pharmacy overdose and to explore pharmacist and site characteristics associated with having a known protocol for responding to on-site overdose emergencies.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pharmacies; Pharmacists; Pharmacy; United States

Topics: Analgesics, Opioid; Drug Overdose; Emergency Medical Services; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose

Communities across the United States are confronting the precipitous rise in opioid overdose fatalities that has occurred over the past decade. Naloxone, an opioid antagonist, is a safe rescue medication that laypeople can administer to reverse an overdose. Community naloxone training programs have been well-documented. Less is known about overdose survivors' subjective experiences with naloxone reversal and its impacts on drug use behavior.

Topics: Adult; Analgesics, Opioid; Drug Overdose; Drug Tolerance; Humans; Naloxone; Substance Withdrawal Syndrome

We are sadly experiencing unprecedented levels of overdose mortalities attributed to the increased availability of synthetic opioids in illegal markets. While the majority of attention in North America has focused on preventing drug overdose cases through the distribution and administration of naloxone, in addition to stricter regulations of opioid prescriptions and greater law enforcement in illegal markets, little attention has been given to other alternative models and treatments for people who use drugs that are tailored specifically to the health care needs of this marginalized population. Through this analysis, the implications of task-shifting in health care via the distribution of naloxone for an already marginalized population are discussed. Alternatively, the role of pioneering harm-reduction programs - such as supervised injection/consumption sites, a variety of opioids maintenance therapies, and social-structural interventions - are highlighted as crucial interventions in the current ongoing opioid crisis. Moreover, people with lived experiences of illegal drug use are discussed as having a pivotal role but being ultimately overshadowed by public health partners.

Topics: Analgesics, Opioid; Delivery of Health Care; Drug Overdose; Harm Reduction; Humans; Naloxone; Opioid Epidemic; Pharmaceutical Preparations

Opioid overdose deaths are a major health issue in Australia and around the world. Programmes to provide opioid consumers with 'take-home' naloxone to reverse overdose exist internationally, but uptake by mainstream health services and consumers remains inconsistent. Researchers have identified a range of important educational, training and logistical impediments to take-home naloxone uptake and distribution, yet they have focused less on the social dynamics that can enhance or limit access, such as stigma. In this article, we also explore impediments to uptake, drawing on qualitative interview data gathered for an Australian research project on take-home naloxone. Mobilising a performative approach to stigma, we argue that overdose and prevention are shaped by the social dynamics of stigma and, as such, responsibility for dealing with overdose, as with take-home naloxone, should also be considered social (i.e. shared among peers, the public, communities and governments). Our interview data illuminate the various ways in which addiction stigma limits the possibilities and capacities of take-home naloxone and overdose prevention. First, we focus on how stigma may impede professional information provision about take-home naloxone by limiting the extent to which it is presented as a matter of interest for

Topics: Analgesics, Opioid; Australia; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders

Topics: Drug Overdose; Health Knowledge, Attitudes, Practice; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Students; Universities

Georgia state lawmakers enacted legislation designed to reduce opioid overdose deaths by increasing public access to rescue products, such as Narcan®. This article explores whether pharmacy employees have effectively adopted such changes into pharmacy practice. We analyzed unsolicited remarks noted during a parent telephone survey of 120 Georgia pharmacy staff regarding price, availability and barriers to layperson purchase of Narcan®. Comments regarding dispensing requirements and challenges in obtaining inventory and changes in communication style were recorded. Around 15% were unfamiliar with Narcan® as an opioid overdose reversal agent or were unaware of their pharmacy's policies governing its sale. Nearly half of those contacted did not have Narcan® in stock with some reporting that receiving Narcan® would take several days after placing an order. Over half specified requirements for purchasing Narcan® not required by law. Fewer than 15% had Narcan® available and imposed no unnecessary requirements for its purchase. During approximately 10% of the survey calls, respondents used a tone of voice or made comments suggestive of bias. We conclude that non-compliance with current laws, lack of familiarity with Narcan® and negative communication tendencies that suggest implicit bias and stigmatizing behaviors could ultimately inhibit access to opioid overdose treatment.

Topics: Drug Overdose; Georgia; Humans; Naloxone; Narcotic Antagonists; Pharmacy; Surveys and Questionnaires

Topics: Analgesics, Opioid; Child; Drug Overdose; Emergency Service, Hospital; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

Topics: Analgesics, Opioid; Drug Overdose; Health Knowledge, Attitudes, Practice; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Social Work; Students

Intranasal naloxone is commonly used to treat prehospital opioid overdose. However, the optimal dose is unclear, and currently, no study exists comparing the clinical effect of intranasal naloxone at different doses.. The goal of this investigation was to compare the safety, efficacy, and cost of 0.4- versus 2-mg intranasal naloxone for treatment of prehospital opioid overdose.. A retrospective, cross-sectional study was performed of 218 consecutive adult patients receiving intranasal naloxone in 2 neighboring counties in Southeast Michigan: one that used a 0.4-mg protocol and one that used a 2-mg protocol. Primary outcomes were response to initial dose, requirement of additional dosing, and incidence of adverse effects. Unpooled, 2-tailed, 2-sample. There was no statistically significant difference between the 2 populations in age, mass, gender, proportion of exposures suspected as heroin, response to initial dose, required redosing, or total number of doses by any route. The overall rate of adverse effects was 2.1% under the lower-dose protocol and 29% under the higher-dose protocol (. Treatment of prehospital opioid overdose using intranasal naloxone at an initial dose of 0.4 mg was equally effective during the prehospital period as treatment at an initial dose of 2 mg, was associated with a lower rate of adverse effects, and represented a 79% reduction in cost.

Topics: Administration, Intranasal; Adult; Analgesics, Opioid; Cross-Sectional Studies; Drug Overdose; Emergency Medical Services; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Retrospective Studies

There is a need to strengthen the standard surveillance of the opioid overdose crisis in the USA. The role of Google Trends (GT) was explored in this context.. In this study, a systemic GT search was done for a period from January 2004 to December 2018. "Naloxone" and "drug overdose" were chosen as search inputs. By using locally weighted scatterplot smoothing, we locally regressed and smoothed the relative search data generated by the GT search. We conducted a changepoint analysis (CPA) to detect significant statistical changes in the "naloxone" trend from 2004 to 2018. Cross-correlation function analyses were done to examine the correlation between 2 time series: year-wise relative search volume (RSV) for "naloxone" and "drug overdose" with the age-adjusted drug overdose mortality rate. Pearson's correlation was performed for the state-wise age-adjusted mortality rate due to drug overdose and RSV for "naloxone" and "drug overdose.". Smoothed and regressed GT of "naloxone" were similar to the "opioid overdose" trend published by the National Center for Health Statistics. The CPA showed 2 statistically significant points in 2011 and 2015. CPA of year-wise RSV for "naloxone" and "drug overdose" showed significantly positive correlation with the age-adjusted drug overdose mortality at lag zero. State-wise RSV for "naloxone" and "drug overdose" too showed a strong and significant positive correlation with the state-wise mortality data.. Inexpensive, publicly accessible, real-time GT data could supplement and strengthen the monitoring of opioid overdose epidemic if used in conjunction with the existing official data sources.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid Epidemic; Opioid-Related Disorders; Search Engine

Non-pharmaceutical fentanyl and its analogs have driven striking increases in opioid-associated overdose deaths. These highly potent opioids can be found at low concentrations in biological specimens. Little is known regarding the concentrations of these substances among survivors of non-fatal overdoses. In a locale where fentanyl is responsible for the majority of non-fatal opioid overdoses, we compared the concentration of fentanyl in blood to naloxone dosing in the presence and absence of a concurrent sedative-hypnotic exposure.. In this pilot study, we enrolled adult patients presenting to the emergency department (ED) who: (1) arrived after an overdose requiring naloxone for the reversal of respiratory depression; and (2) who required venipuncture or intravenous access as part of their clinical care. Blood specimens (. Nineteen of twenty participants (95%) were exposed to fentanyl prior to their overdose; the remaining participant tested positive for heroin metabolites. No participants reported pharmaceutical fentanyl use. Fentanyl analogs - acetylfentanyl or carfentanil - were present in three specimens. In 11 cases, fentanyl and its metabolites were the only opioids identified. Among the fentanyl-exposed, blood concentrations ranged from <0.1-19 ng/mL with a mean of 6.2 ng/mL and a median of 3.6 ng/mL. There was no relationship between fentanyl concentration and naloxone dose administered for reversal. We detected sedative-hypnotics (including benzodiazepines, muscle relaxants, and antidepressants) in nine participants. Among the sedative-hypnotic exposed, fentanyl concentrations were lower, but naloxone dosing was similar to those without a concomitant exposure.. In this study, we found that: 1) fentanyl was present in the blood of nearly all participants; 2) fentanyl concentrations were lower among study participants with concomitant sedative-hypnotic exposure; and 3) the dose of naloxone administered for overdose reversal was not associated with the measured fentanyl concentration in blood specimens. Our results underscore the role that tolerance and concomitant drug exposure play in the precipitation and resuscitation of management of opioid overdose.

Topics: Adult; Analgesics, Opioid; Drug Overdose; Fentanyl; Heroin; Humans; Naloxone; Narcotic Antagonists; Pilot Projects

Topics: Analgesics, Opioid; Cross-Sectional Studies; Drug Overdose; Emergency Medical Services; Female; Humans; Male; Massachusetts; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Substance-Related Disorders

To assess whether naloxone prescribing in clinical contexts targeted pain patients most at risk for opioid overdose.. A retrospective cohort study using data from the Health Facts Database.. Over 600 United States healthcare facilities.. Three patient groups were followed for 2 years during 2009 to 2017: individuals with shoulder or long bone fractures (n = 252 424), chronic pain syndrome (CPS) (n = 76 141), or non-traumatic low back pain (n = 792 956) who received an opioid prescription. Groups were chosen based on previous work.. The outcome was opioid overdose identified by International Classification of Diseases codes (ICDs) and the primary predictor was number of naloxone prescriptions identified by National Drug Codes (NDCs).. Opioid overdoses occurred among 0.16% of fracture patients (average follow-up time to overdose [AFU] = 240 days), 1.28% of CPS patients (AFU = 244 days), and 0.30% low back pain patients (AFU = 264 days). A total of 58 083 bone fracture patients received naloxone prescriptions, and naloxone prescription was associated with subsequent opioid overdose (hazard ratio [HR] = 1.87, 95% CI = 1.68-2.09), and number of subsequent overdoses (incidence rate ratio [IRR] = 1.89, 95% CI = 1.69-2.12). A total of 19 529 CPS patients received naloxone prescriptions, and naloxone prescription was associated with subsequent opioid overdose (HR = 1.69, 95% CI = 1.61-1.78) and number of subsequent overdoses (IRR = 1.74, 95% CI = 1.67-1.83). A total of 110 608 low back pain patients received naloxone prescriptions, and naloxone prescription was associated with subsequent opioid overdose (HR = 1.33, 95% CI = 1.27-1.40) and number of subsequent overdoses (IRR = 1.35, 95% CI = 1.29-1.41).. Receiving a naloxone prescription appears to be associated with increased risk of subsequent opioid overdose among patients with acute and chronic pain, suggesting prescribers often identify patients most in need of naloxone.

Topics: Analgesics, Opioid; Chronic Pain; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Retrospective Studies; United States

People who use drugs (PWUD) must weigh complex legal scenarios when seeking help during overdose events. Good Samaritan laws (GSL) offer limited immunity for certain low-level drug crimes to encourage PWUD to call 911. Drug-induced homicide laws (DHL) allow for criminal prosecution of people delivering drugs that result in overdose death and may exert opposing effects on the decision-making process. We examined whether perceptions of these laws were related to overall perceived vulnerability to overdose-related arrests, which can impact help-seeking and overdose mortality.. We conducted a cross-sectional study of PWUD (N = 173) in Anne Arundel County, Maryland and measured sociodemographic characteristics, structural vulnerabilities, and knowledge of GSL and DHL. Perceived vulnerability to overdose-related arrest was defined as self-reported concern arising from calling 911, receiving medical help, or supplying drugs in the event of an overdose. Multivariable logistic regression was used to identify significant correlates of perceived vulnerability to overdose-related arrest.. Most participants were aware of DHL (87%) and half were aware of GSL (53%). Forty-seven percent of PWUD expressed concern about arrest during or due to an overdose. After adjustment, positive correlates of perceived vulnerability to arrest were non-white race (aOR 2.0, 95% CI 1.5-2.5) and hearing of somebody charged with DHL (aOR 3.1, 95%CI 1.9-5.0), and negative correlates were history of drug treatment (aOR 0.6, 95%CI 0.4-1.0), receiving naloxone (aOR 0.6, 95% CI 0.4-1.0), and having made, sold or traded drugs in the past 3 months (aOR 0.4, 95% CI 0.2-0.9).. We report persisting concern about arrest during overdose events among street-based PWUD facing a complicated landscape of legal protections and liabilities. Findings demonstrate clear racial disparities of concern outside an urban centre, where impacts of policing on health are less studied, and present evidence that DHL may compromise overdose prevention efforts. Changes to drug policy and enforcement including police nonattendance at overdose scenes may be necessary to promote help-seeking among PWUD and reduce overdose fatalities.

Topics: Cross-Sectional Studies; Drug Overdose; Humans; Maryland; Naloxone; Pharmaceutical Preparations

Topics: Drug Overdose; Health Services Accessibility; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose

The opioid crisis in the United States continues to worsen. Several states have passed laws granting pharmacists the authority to independently prescribe (not just dispense) naloxone. Since pharmacists are accessible healthcare providers, enhancing their ability to prescribe naloxone, an effective opioid overdose reversal agent, may help combat the ongoing opioid overdose epidemic.. Using a nationally representative database on drug dispensing in 2010 to 2018 from Symphony Health, we conducted a cross-sectional study to assess whether state laws authorizing pharmacists to prescribe naloxone were associated with increased naloxone dispensing from retail pharmacies.. The number of naloxone prescriptions dispensed from retail pharmacies increased from 2010 to 2018 and doubled from 2017 to 2018. The presence of state laws authorizing pharmacists to prescribe naloxone is associated with an average increase of 331(95% CI = 43.56, 618.49) prescription dispensed per state per quarter. This represents an approximately 53% increase in naloxone dispensed compared to pharmacies in states where there were no such laws.. Our study suggests that state laws that allow pharmacists to prescribe and not just dispense naloxone at retail pharmacies can increase the availability and accessibility of naloxone. Adopting and implementing such laws may help reduce serious and life-threatening opioid overdoses.

Topics: Cross-Sectional Studies; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pharmacies; Pharmacists; United States

Rates of fatal opioid overdose in Massachusetts (MA) and Rhode Island (RI) far exceed the national average. Community-based opioid education and naloxone distribution (OEND) programs are effective public health interventions to prevent overdose deaths. We compared naloxone distribution and opioid overdose death rates in MA and RI to identify priority communities for expanded OEND.. We compared spatial patterns of opioid overdose fatalities and naloxone distribution through OEND programs in MA and RI during 2016 to 2019 using public health department data. The county-level ratio of naloxone kits distributed through OEND programs per opioid overdose death was estimated and mapped to identify potential gaps in naloxone availability across geographic regions and over time.. From 2016 to 2019, the statewide community-based naloxone distribution to opioid overdose death ratio improved in both states, although more rapidly in RI (from 11.8 in 2016 to 35.6 in 2019) than in MA (from 12.3 to 17.2), driven primarily by elevated and increasing rates of naloxone distribution in RI. We identified some urban/non-urban differences, with higher naloxone distribution relative to opioid overdose deaths in more urban counties, and we observed some counties with high rates of overdose deaths but low rates of naloxone kits distributed through OEND programs.. We identified variations in spatial patterns of opioid overdose fatalities and naloxone availability, and these disparities appeared to be widening in some areas over time. Data on the spatial distribution of naloxone distribution and opioid overdose deaths can inform targeted, community-based naloxone distribution strategies that optimize resources to prevent opioid overdose fatalities.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Massachusetts; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Rhode Island

Tramadol is a synthetic opioid and poisoning is increasing around the world day by day. Various treatments are applied for tramadol poisoning. Due to the unknown effects of tramadol poisoning and some of its treatments on blood glucose levels, this study was conducted to investigate the overdose of tramadol and its common treatments (naloxone, diazepam), and their combination on blood glucose levels in male rats.. This study was conducted in 45 male Wistar rats. The animals were randomly divided into five groups of 9. They received a 75 mg/kg dose of tramadol alone with naloxone, diazepam, and a combination of both of these two drugs. On the last day, animals' tail vein blood glucose levels (BGL) were measured using a glucometer at different times, including before the tramadol injection (baseline) and 1 hour, 3 hours, and 6 hours after wards. The rats were anesthetized and sacrificed 24 h after the last injection. Blood samples were then taken, and the serum obtained was used to verify the fasting glucose concentration. Data were analyzed using SPSS software at a significance level of 0.05 using a one-way analysis of variance (ANOVA) and a generalized estimating equation (GEE).. According to the GEE model results, the diazepam-tramadol and naloxone-diazepam-tramadol groups showed blood glucose levels five units higher than the tramadol group (p < 0.05). The diazepam-tramadol group had significantly higher blood glucose levels than the naloxone-tramadol group (p < 0.05). The mean blood glucose levels before the intervention, 3 hours and 6 hours after the injection of tramadol did not differ between the groups, but the blood glucose levels 1 hour after the injection of tramadol in the group of naloxone-tramadol were significantly lower than in the control group (p < 0.05). Blood glucose levels did not differ between the groups 24 h after injection of tramadol.. The results of the present study showed tramadol overdose does not affect blood glucose levels. The diazepam-tramadol combination and the diazepam-naloxone-tramadol combination caused an increase in blood glucose levels.

Topics: Analgesics, Opioid; Animals; Blood Glucose; Diazepam; Drug Overdose; Hyperglycemia; Hypnotics and Sedatives; Male; Naloxone; Narcotic Antagonists; Rats; Rats, Wistar; Tramadol

High doses of the synthetic opioid fentanyl cause rapid and sustained vocal cord closure (VCC) leading to airway obstruction that prevents overdose victims from breathing. This airway effect is not caused by morphine-derived opiates (e.g. heroin), is distinct from respiratory depression, resistant to naloxone, and can be lethal. However, VCC has not been previously included in animal models of opioid overdose.. Video laryngoscopy was used to monitor vocal cord movement in anesthetized Sprague-Dawley rats. Rats were administered saline, fentanyl (5, 25, or 50 μg/kg) or morphine (5 mg/kg) in an intravenous (IV) bolus delivered over a 10 s period. The mu opioid receptor (MOR) antagonist naloxone was administered as a pre-treatment (1 mg/kg, IV) 5 min prior to fentanyl (25 μg/kg) or a post-treatment (1 and 2 mg/kg) 1 min after fentanyl (25 μg/kg).. Fentanyl (25 and 50 μg/kg) caused sustained and lethal VCC within 10 s. Morphine (5 mg/kg) and fentanyl (5 μg/kg) caused only brief laryngospasm with full recovery. Pre-treatment with naloxone (1 mg/kg) prevented fentanyl-induced VCC, but naloxone (1 and 2 mg/kg) was unable to reverse VCC when administered after fentanyl.. These results indicate sustained VCC is a lethal physiological reaction, specific to fentanyl and resistant to naloxone treatment. While pre-treatment with naloxone prevented fentanyl-induced VCC, naloxone was unable to reverse the effect, suggesting a non-opioid receptor-mediated mechanism. These findings demonstrate the necessity of VCC inclusion in animal models of synthetic opioid overdose and the urgent need for more effective treatments for fentanyl-related overdoses.

Topics: Analgesics, Opioid; Animals; Drug Overdose; Fentanyl; Naloxone; Narcotic Antagonists; Opiate Overdose; Rats; Rats, Sprague-Dawley; Receptors, Opioid, mu; Vocal Cords

We present the case of an 89-year-old patient with impaired consciousness for whom the emergency services were called. She was soporose and showed a pronounced generalized muscle rigidity. Due to a third-party history the incorrect use of a fentanyl patch was found out to be at cause.. The antidote administration of naloxone led to restoration. The need for repetitive administration confirmed the clinical hypothesis.. The application of fentanyl via the skin in the form of transdermal therapeutic systems (TTS) has become more popular over the years. Incorrect administration causes intoxication with the leading symptoms of loss of consciousness and respiratory depression. This case report extends the spectrum of symptoms to include skeletal muscle rigidity otherwise only described in connection with intravenous administration, especially in anaesthetic settings.. Wir berichten über eine 89-jährige Patientin, für die aufgrund einer Bewusstseinsstörung der Notarzt alarmiert wurde. Sie war soporös und zeigte eine deutliche generalisierte Muskelrigidität. Fremdanamnestisch war der fehlerhafte Gebrauch eines Fentanyl-Pflasters zu eruieren.. Durch die Antidot-Gabe von Naloxon kam es zu einer Restitution. Die Notwendigkeit einer repetitiven Gabe bestätigte die Verdachtsdiagnose.. Die Gabe von Fentanyl über die Haut in Form transdermaler therapeutischer Systeme (TTS) erfreut sich seit Jahren einer zunehmenden Beliebtheit. Bei unsachgemäßer Verabreichung treten Intoxikationen mit den führenden Symptomen Bewusstseinsminderung und Atemdepression auf. Dieser Fallbericht ergänzt das Spektrum um den Rigor der quergestreiften Skelettmuskulatur, der sonst im Zusammenhang mit der intravenösen Applikation beschrieben wird.

Topics: Aged, 80 and over; Analgesics, Opioid; Consciousness Disorders; Drug Overdose; Female; Fentanyl; Humans; Naloxone; Narcotic Antagonists; Transdermal Patch

The Centers for Disease Control and Prevention's (CDC) Guideline for Prescribing Opioids for Chronic Pain recommends that providers consider co-prescribing naloxone when factors that increase the risk of overdose are present. Naloxone is an opioid receptor antagonist that counteracts the effects of an opioid overdose. This paper explores trends in naloxone dispensing and out-of-pocket costs among commercially insured individuals in the United States. Administrative claims data from the IBM Watson Health MarketScan database are analyzed to assess trends in naloxone dispensing from 2015 to 2018. Descriptive statistics on concurrent dispensing of naloxone with opioid analgesics are performed among several at-risk populations. The rate of commercially insured individuals being co-dispensed naloxone increased between 2015 and 2018 across all population sub-groups. In 2018, 16.2 individuals were co-dispensed naloxone for every 1000 receiving an opioid dosage ≥ 90 MME/day compared to 0.9 in 2015, 27.6 individuals were co-dispensed naloxone for every 1000 concurrently dispensed benzodiazepines and an opioid dosage ≥ 90 MME/day compared to 7.6 in 2015, and 43.7 individuals were co-dispensed naloxone for every 1000 receiving an opioid dosage ≥90 MME/day with a past overdose compared to 17.6 in 2015. Median out-of-pocket cost for naloxone increased from $12 in 2015 to $25 in 2018. Despite increases in naloxone dispensing from 2015 to 2018, the provision of naloxone to the commercially insured population remains low. Opportunities remain to increase the supply of naloxone to at-risk populations. Considering ways to reduce out-of-pocket costs associated with naloxone may be a potential strategy to increase access to this life-saving drug.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Risk Factors; United States

Academic detailing (AD) is an educational outreach intervention designed to provide clinicians with current evidenced-based education to improve patient care and is effective in mitigating opioid risks. Student pharmacists' abilities to apply naloxone training can benefit from concomitant AD training by highlighting skills needed to effectively assess patient and provider needs and handle objections in a non-biased, evidence-supported manner while reinforcing the application of naloxone administration. Most states have a standing order for pharmacist prescribed naloxone. School of pharmacy clinical science faculty sought to create a combined educational activity teaching naloxone AD in conjunction with hands-on naloxone training to better prepare students to apply the standing order in their future careers.. Students in an accelerated pharmacy program applied their AD skills during pharmaceutical skills laboratory activities, emphasizing the use of naloxone administration under the standing order. Students then demonstrated their ability to administer naloxone to a "patient" who experienced an emergency after opioid use.. While many schools of pharmacy offer either naloxone or AD training to students, none were identified that offered both trainings combined for use with mitigation strategies for opioid management.. The combination of simulated AD with naloxone administration training was designed as a unique opportunity to foster naloxone education and enhance student understanding and demonstration of naloxone administration. School of pharmacy programs should recognize the opportunity to combine these activities to prepare students for application of statewide naloxone standing orders.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Pharmacists; Students, Pharmacy

Opioid use disorder has been designated a worsening epidemic with over 100,000 deaths due to opioid overdoses recorded in 2021 alone. Unintentional deaths due to opioid overdoses have continued to rise inexorably. While opioid overdose antidotes such as naloxone, and nalmefene are available, these must be administered within a critical time window to be effective. Unfortunately, opioid-overdoses may occur in the absence of antidote, or may be unwitnessed, and the rapid onset of cognitive impairment and unconsciousness, which frequently accompany an overdose may render self-administration of an antidote impossible. Thus, many lives are lost because: (1) an opioid overdose is not anticipated (i.e., monitored/detected), and (2) antidote is either not present, and/or not administered within the critical frame of effectiveness. Currently lacking is a non-invasive means of automatically detecting, reporting, and treating such overdoses. To address this problem, we have designed a wearable, on-demand system that comprises a safe, compact, non-invasive device which can monitor, and effectively deliver an antidote without human intervention, and report the opioid overdose event. A novel feature of our device is a needle-stow chamber that stores needles in a sterile state and inserts needles into tissue only when drug delivery is needed. The system uses a microcontroller which continuously monitors respiratory status as assessed by reflex pulse oximetry. When the oximeter detects the wearer's percentage of hemoglobin saturated with oxygen to be less than or equal to 90%, which is an indication of impending respiratory failure in otherwise healthy individuals, the microcontroller initiates a sequence of events that simultaneously results in the subcutaneous administration of opioid antidote, nalmefene, and transmission of a GPS-trackable 911 alert. The device is compact (4 × 3 × 3 cm), adhesively attaches to the skin, and can be conveniently worn on the arm. Furthermore, this device permits a centralized remotely accessible system for effective institutional, large-scale intervention. Most importantly, this device has the potential for saving lives that are currently being lost to an alarmingly increasing epidemic.

Topics: Analgesics, Opioid; Disease Management; Drug Delivery Systems; Drug Overdose; Equipment Design; Humans; Hypoxia; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Treatment Outcome; Wearable Electronic Devices

Topics: Drug Overdose; Humans; Naloxone; Politics

The province of British Columbia is currently experiencing the highest rate of apparent opioid-related deaths within Canada. This dramatic increase in overdose deaths has been primarily driven by the increase of fentanyl and fentanyl-analogues within the unregulated, highly unpredictable and toxic street drug supply. A public health emergency was declared in B.C. in April 2016. After the emergency was declared, overdose-related death rates continued to rise, reaching unprecedented levels. In the context of enhanced collaboration between government organizations and researchers, a series of mathematical studies improved the ability of government and service providers to understand the impact of scaled-up strategies, including harm reduction and treatment services. In this commentary we describe how government agencies collaborated with researchers and other experts to use modelling results, and describe lessons learned for enhancing these collaborations. Mathematical modelling provides a viable and timely approach to the generation of intelligence, combining disparate data to assess the on-going impact of a comprehensive package of interventions during a public health emergency, and enhancing accountability for investments.

Topics: Analgesics, Opioid; British Columbia; Drug Overdose; Fentanyl; Health Policy; Humans; Naloxone; Opiate Overdose; Opioid-Related Disorders

The overdose crisis is affecting public libraries. In a 2017 survey of public librarians, half reported providing patrons support regarding substance use and mental health in the previous month, and 12% reported on-site drug overdose at their library in the previous year. Given the magnitude of the overdose crisis and the fact that public libraries host 1.4 billion visits annually, our aim was to understand how libraries currently assist with substance use and overdose and how they can further address these issues.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Substance-Related Disorders; Surveys and Questionnaires

Naloxone is a drug that reverses opioid overdose. Naloxone Access Laws (NALs) increase public access to naloxone and have been considered as one promising solution to reducing opioid-related harm. However, previous studies on whether NALs are effective in reducing opioid overdose mortality found somewhat contradictory results. Our study attempts to provide a more definitive answer to this question by utilizing an approach that matches NAL vs non-NAL states and stratifies by US region and years of implementation.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders

When managing opioid overdose (OD) patients, the optimal naloxone regimen should rapidly reverse respiratory depression while avoiding opioid withdrawal. Published naloxone administration guidelines have not been empirically validated and most were developed before fentanyl OD was common. In this study, rates of opioid withdrawal symptoms (OW) and reversal of opioid toxicity in patients treated with two naloxone dosing regimens were evaluated.. In this retrospective matched cohort study, health records of patients who experienced an opioid OD treated in two urban emergency departments (ED) during an ongoing fentanyl OD epidemic were reviewed. Definitions for OW and opioid reversal were developed. HDN patients were more likely to have OW but also more likely to meet reversal criteria versus LDN patients.

Topics: Adult; Analgesics, Opioid; Drug Administration Schedule; Drug Overdose; Female; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Retrospective Studies; Substance Withdrawal Syndrome; Treatment Outcome

Expanding naloxone training stands to reduce opioid-related overdose deaths. The current study assessed the prevalence of overdose response training and use of naloxone among people who inject drugs (PWID).. Data were from a survey of PWID in San Francisco in 2018, recruited by respondent-driven sampling (RDS). Eligibility criteria were age over 18 years, injected non-prescribed drugs in the last year, San Francisco residence, and referral by another participant. Interviews collected demographic characteristics and injection-related behavior.. The sample (N=458) was majority male (67.5%) and over 45.5 years. Over three-fourths (76.0%) injected primarily opioids. Overall, 62.9% received overdose response training and 68.8% owned a naloxone kit. A majority (77.9%) had witnessed an overdose in the past year, of whom 55.8% used naloxone the last time they witnessed an overdose. Receiving overdose response training was significantly lower among persons of non-white race/ethnicity compared to whites (adjusted odds ratio [AOR] 0.43, 95% CI 0.27, 0.69) and higher among those who owned naloxone (AOR 6.29, 95% confidence interval [CI] 3.95, 10.02) and used syringe exchange programs (AOR 3.51, 95% CI 1.41, 8.79).. While the majority of PWID have had overdose response training, gaps and disparities persist in promotion of naloxone use.

Topics: Adolescent; Analgesics, Opioid; Drug Overdose; Humans; Male; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Pharmaceutical Preparations; Prevalence; San Francisco; Substance Abuse, Intravenous

Topics: Analgesics, Opioid; Computer Simulation; Drug Overdose; Health Policy; Humans; Naloxone; Narcotic Antagonists; Opioid Epidemic; Opioid-Related Disorders; United States

To evaluate an overdose response training program in public libraries.. Mixed methods evaluation including pre- and post-intervention questionnaires and debriefing interviews.. Ten Philadelphia public libraries.. Overdose response training participants (library staff and community members).. Public, hour-long overdose response trainings run by the Philadelphia Department of Public Health, the Free Library of Philadelphia, and the University of Pennsylvania between March and December 2018.. Questionnaires assessed motivation for attending trainings, overdose response readiness, and intention to acquire and carry naloxone. Debriefing interviews elicited training feedback.. We assessed changes in overdose response readiness and intention to carry naloxone and performed thematic analysis on interview data.. At 29 trainings, 254 people attended, of whom 203 (80%) completed questionnaires and 23 were interviewed. 30% of participants had witnessed an overdose, but only 3% carried naloxone at baseline. Following training, overdose response readiness and intention to acquire/carry naloxone improved significantly (. In Philadelphia, library-based overdose response trainings were well-attended and reached a population with prior overdose encounters. Similar trainings could be deployed as a scalable overdose prevention strategy in the nation's 16 568 public libraries.

Topics: Analgesics, Opioid; Drug Overdose; Health Knowledge, Attitudes, Practice; Humans; Naloxone; Narcotic Antagonists; Philadelphia

Increasing naloxone awareness and carrying among individuals who misuse opioid analgesic medications (OAs) could reduce opioid overdose mortality.

Topics: Adult; Analgesics, Opioid; Drug Overdose; Heroin; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

Topics: Drug Overdose; Emergency Medical Services; Emergency Service, Hospital; Humans; Naloxone; Narcotic Antagonists

To assess the feasibility and acceptability of a take-home naloxone program for people with a history of opioid use released from prison in New South Wales, Australia.. Cross-sectional interviews with people with a history of opioid use who were recently released from prison (n = 105), and semi-structured interviews with key clinical and operational staff of Justice Health and Forensic Mental Health Network and Corrective Services NSW (n = 9).. Among people with a history of opioid use who had recently left prison, there was very high awareness of the elevated risk of overdose following release from prison (95%) and the potential for naloxone to reverse an opioid overdose (97%). Participants considered that their personal risk of overdose was low, despite ongoing opioid use being common. Participants were largely supportive of take-home naloxone, but the majority (83%) stated that proactively obtaining naloxone would be a low priority for them following release. Key informants were supportive of introducing naloxone training and supply and identified barriers to implementation, including adequate resourcing, identifying the population for training, and developing an appropriate model of training and implementation.. There was widespread support for naloxone training in custody and distribution at release among people recently released from prison and key stakeholders in health-care provision and prisons administration. As proactively accessing naloxone is a low priority for patients, naloxone supply at release may be more effective than programs that refer releasees to local pharmacies, but developing a sustainable supply model requires consideration of several barriers.

Topics: Cross-Sectional Studies; Drug Overdose; Feasibility Studies; Humans; Naloxone; Narcotic Antagonists; New South Wales; Opioid-Related Disorders; Prisoners

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Prospective Studies

Topics: Analgesics, Opioid; Child; Drug Overdose; Hispanic or Latino; Humans; Los Angeles; Naloxone; Opioid-Related Disorders

Overdose deaths related to illegal drugs in North American markets are now dominated by potent synthetic opioids such as fentanyl, a circumstance foreshadowed by often-overlooked events in Estonia since the turn of the century. Market transitions generate important and far-reaching implications for drug policy.. The supplier-driven introduction of illegally manufactured synthetic opioids into street opioids is elevating the risk of fatal overdose. Using the most recent overdose mortality and drug seizure data in North America, we find that overdose deaths and seizures involving synthetic opioids are geographically concentrated, but this might be changing. Examination here suggests that in some places fentanyl and its analogues have virtually displaced traditional opioids, such as heroin. The concealing of synthetic opioids in powders sold as heroin or pressed into counterfeit medications substantially increases harms. The nature and scale of the challenge posed by synthetic opioids is unprecedented in recent drug policy history.. There is urgent need for policy and technological innovation to meet the challenges posed by illegally produced synthetic opioids. Novel interventions worth examining include supervising drug use, proactively deterring on-line distribution and new technologies aimed at improving transparency, such as point-of-use drug content testing. Continuing to approach this problem only with existing policies and available methods, such as naloxone, is unlikely to be enough and will result in many premature deaths.

Topics: Analgesics, Opioid; Drug Overdose; Fentanyl; Heroin; Humans; Illicit Drugs; Naloxone

Overdose education and naloxone distribution programmes are known to reduce opioid-related deaths. A state-wide naloxone distribution effort of 8250 rescue kits was undertaken by government, community and university partners in West Virginia in 2016-2017. The purpose of this study was to discern the barriers, facilitators and lesson learnt from implementing this endeavour in a rural state with the highest opioid overdose fatality rate in the US.. Structured interviews (n=26) were conducted among both internal and external stakeholders. Those who participated were >18 years of age and were the lead representative from agencies that either received naloxone (ie, external stakeholders) or helped implement the distribution (ie, internal stakeholders). The interviews followed standardised scripts and lasted approximately 40 min. Sessions were audio-recorded and transcribed. Qualitative content analysis was performed by two researchers to determine themes surrounding facilitators or barriers to programme implementation.. The primary facilitators reported by stakeholders included collaborative partnerships, ease of participating in the programme, being established in prevention efforts, demand for naloxone and the need for personal protection from overdose. The primary barriers identified by stakeholders included bureaucracy/policy/procedures of their organisation or agency, stigma, logistical or planning issues, problems with reporting, lack of communication post distribution and sustainability. Numerous lessons were learnt.. Based on the implementation of the programme in 87 organisations, including law enforcement and fire departments, the impact of facilitators outweighed that of barriers. These findings may inform others planning to conduct a similar, large-scale project.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Law Enforcement; Naloxone; West Virginia

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pharmacists; Retrospective Studies; Telephone

Topics: Administration, Intranasal; Adult; Drug Overdose; Female; Humans; Naloxone; Narcotic Antagonists; Psychomotor Agitation

Opioid overdose is a major public health concern in the United States. Naloxone education and distribution can decrease the risk of overdose deaths. A previous study showed that a longitudinal, multi-attempt telephone intervention by a single pharmacy resident was effective for distributing naloxone to a high-risk veteran population.. The purpose of this project was to investigate whether a team-based, single-attempt telephone outreach event is effective for distributing naloxone to at-risk outpatient veterans.. The Risk Index for Overdose or Serious Opioid-Induced Respiratory Depression (RIOSORD) tool was used to identify patients with risk class ≥4. Pharmacy trainees contacted 164 patients and offered naloxone. The primary outcome was the proportion of patients with RIOSORD risk class ≥4 who had naloxone before versus after the intervention.. The proportion of patients with RIOSORD class ≥4 who had a naloxone kit before and after the event was 0.28 and 0.63, respectively (difference = 0.35, p < 1 × 10. A team-based telephone outreach event is an effective method for distributing naloxone to at-risk outpatient veterans.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Opioid-Related Disorders; Outpatients; Telephone; United States; Veterans

The evolving opioid epidemic in the United States has increased drug-related overdose rates exponentially (Centers for Disease Control and Prevention in Opioid overdose, 2020c, https://www.cdc.gov/drugoverdose/data/otherdrugs.html#:~:text=Polysubstance%20drug%20use%20occurs%20with,or%20other%20non%2Dopioid%20substances ). Fentanyl, a synthetic opioid, has recently fueled the epidemic, increasing overdose death rates (Centers for Disease Control and Prevention in Drug overdose deaths involving fentanyl, 2011-2016, 2019a, https://www.cdc.gov/nchs/data/nvsr/nvsr68/nvsr68_03-508.pdf ). Harm reduction strategies (drug checking, naloxone administration, etc.) are at the forefront of preventing opioid-related overdoses in high-risk populations (Kennedy et al. in Drug Alcohol Depend 185:248-252, 2018, https://doi.org/10.1016/j.drugalcdep.2017.12.026 ; Laing et al. in Int J Drug Policy 62:59-66, 2018, https://doi.org/10.1016/j.drugpo.2018.10.001 ). Little is known, however, about how people who inject drugs (PWID) may modify their drug use behaviors after suspected fentanyl contamination in their drugs. We conducted a cross-sectional survey among 105 opioid-dependent PWID enrolled in a methadone maintenance program. We assessed their willingness to engage in various harm reduction methods (i.e., slowing down drug use, not using drugs, carrying naloxone, using with someone who has naloxone) after suspected fentanyl contamination of their drugs. In a multivariable analysis, participants who were white, low-income, polysubstance users, and had previously experienced an overdose or had previously administered naloxone were more likely to report a willingness to engage in harm reduction measures. These findings provide an evidence-based understanding of PWID's engagement in harm reduction behaviors after suspecting potential fentanyl exposure as well as a basis for tailoring intervention strategies in the context of fentanyl-adulterated markets.

Topics: Analgesics, Opioid; Cross-Sectional Studies; Drug Overdose; Female; Fentanyl; Harm Reduction; Humans; Male; Naloxone; Opioid-Related Disorders; United States

To examine, among a cohort of opioid dependent people with a history of opioid agonist treatment (OAT), the frequency and incidence rates of non-fatal overdose (NFOD) hospital separations over time, by age and sex.. Retrospective cohort study of people with a history of OAT using state-wide linked New South Wales (NSW) data. The incidence of NFOD hospital separations involving an opioid, sedative, stimulant or alcohol was defined according to the singular or combination of poisoning/toxic effect using ICD-10-AM codes. Crude incidence rates were calculated by gender, age group and calendar year.. There were 31.8 (31.3-32.3) NFOD per 1,000 person-years (PY). Opioid NFOD incidence was higher in women than men: incidence rate ratio (IRR) 1.11 per 1,000PY; 95 %CI: [1.06-1.17]; women had higher sedative NFOD rates than men, IRR 1.27 per 1,000PY [1.21-1.34]. Participants ≤25 years, 26-30yrs, and 31-35yrs had higher incidence of opioid NFOD compared to 46+yrs, with IRRs of: 1.45 per 1,000PY; [1.32-1.59]; 1.20 per 1,000PY; [1.11-1.30] and 1.22 per 1,000PY; [1.13-1.32], respectively. Between 2006-7 and 2016-17, the cohort accounted for 19 % of NSW opioid NFOD episodes, 12 % of sedative, 14 % of stimulant and 5 % of acute alcohol-related NFOD.. Hospital stays due to NFOD are a relatively frequent occurrence among opioid-dependent people. There are clear differences in rates and substances involved by sex, age and over time. Evidence-based interventions that prevent overdose among people who are opioid dependent need to be delivered to scale, including widespread community provision of naloxone.

Topics: Adult; Analgesics, Opioid; Australia; Avena; Cohort Studies; Drug Overdose; Female; Hospitalization; Humans; Incidence; Male; Middle Aged; Naloxone; New South Wales; Opiate Overdose; Opioid-Related Disorders; Retrospective Studies

As the overdose emergency continues in British Columbia (BC), paramedic-attended overdoses are increasing, as is the proportion of people not transported to hospital following an overdose. This study investigated risk of death and subsequent healthcare utilization for people who were and were not transported to hospital after a paramedic-attended non-fatal overdose.. Using a linked administrative health data set which includes all overdoses that come into contact with health services in BC, we conducted a prospective cohort study of people who experienced a paramedic-attended non-fatal overdose between 2015 and 2016. People were followed for 365 days after the index event. The primary outcomes assessed were all-cause mortality and overdose-related death. Additionally, we examined healthcare utilization after the index event.. In this study, 8659 (84%) people were transported and 1644 (16%) were not transported to hospital at the index overdose event. There were 279 overdose deaths (2.7% of people, 59.4% of deaths) during follow-up. There was no significant difference in risk of overdose-related death, though people not transported had higher odds of a subsequent non-fatal overdose event captured in emergency department and outpatient records within 90 days. People transported to hospital had higher odds of using hospital and outpatient services for any reason within 365 days.. Transport to hospital after a non-fatal overdose is an opportunity to provide care for underlying and chronic conditions. There is a need to better understand factors that contribute to non-transport, particularly among people aged 20-59 and people without chronic conditions.

Topics: Adult; Allied Health Personnel; Ambulatory Care; British Columbia; Delivery of Health Care; Drug Overdose; Emergency Service, Hospital; Female; Hospitals; Humans; Male; Middle Aged; Naloxone; Prospective Studies; Young Adult

Topics: Analgesics, Opioid; Drug Overdose; Health Knowledge, Attitudes, Practice; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Students, Medical

In June 2016, the Ontario, Canada government implemented the Ontario Naloxone Program for Pharmacies (ONPP), authorizing pharmacists to provide injectable naloxone kits at no charge to all Ontario residents. In March 2018, the program was amended to include intranasal naloxone and remove the requirement to present a government health card to the dispensing pharmacist. We examined whether these changes increased naloxone dispensing through the ONPP.. Population-based time-series analysis using interventional autoregressive integrated moving average models.. Ontario, Canada.. All Ontario residents between 1 July 2016 and 31 March 2020.. Monthly rates of pharmacy naloxone dispensing.. Overall, 199 484 individuals were dispensed a naloxone kit during the study period. In the main analysis, the rate of pharmacy naloxone dispensing increased by 65.1% following program changes (55.6-91.8 kits per 100 000 population between February 2018 and May 2018; P = 0.01). In subgroup analyses, naloxone dispensing increased among individuals receiving opioid agonist therapy (OAT) (3374.9-7264.2 kits per 100 000 OAT recipients; P = 0.04) among individuals receiving other prescription opioids (192.8-381.8 kits per 100 000 population prescribed opioids; P < 0.01), among individuals with past opioid exposure (134.7-205.6 kits per 100 000 population with past opioid exposure; P < 0.01) and in urban centers (56.2-91.4 kits per 100 000 population; P < 0.01). We did not observe a clear impact on pharmacy-dispensed naloxone to individuals with no or unknown opioid exposure (34.4-39.3 kits per 100 000 population with no/unknown opioid exposure; P = 0.42) and in rural regions (50.4-97.2 kits per 100 000 population; P = 0.09).. Changes to the Ontario Naloxone Program for Pharmacies to add intranasal naloxone and remove the requirement to present a government health card appeared to increase pharmacy-based naloxone dispensing uptake in Ontario, Canada, particularly among individuals at high risk of inadvertent opioid overdose.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Ontario; Opioid-Related Disorders; Pharmacies; Policy

Topics: Career Mobility; Cooperative Behavior; Drug Approval; Drug Compounding; Drug Overdose; Humans; Interinstitutional Relations; Naloxone; Narcotic Antagonists; Opioid Epidemic; Opioid-Related Disorders; Research Personnel; Staff Development; Stakeholder Participation; United States; United States Food and Drug Administration

Patients with opioid use disorder (OUD) are at increased risk for overdose and death. Clinical practice guidelines and professional organization policy statements recommend providing naloxone to patients at risk for overdose. We sought to characterize fidelity to naloxone practice recommendations in a cohort of Emergency Department (ED) patients in whom opioid use disorder was suspected by the treating physician.. This single-center cross-sectional study evaluated electronic health records from an urban academic ED with 73,000 annual encounters in a region with a high prevalence of OUD. Patients ≥18 years old with encounters from January 1, 2018 to November 30, 2019 were included if discharged from the ED and either administered buprenorphine in the ED or referred to outpatient substance use treatment. The primary outcome measure was the percentage of included patients provided naloxone (take-home or prescription). We used random effects multivariable logistic regression (accounting for multiple patient encounters) to estimate the odds ratio (OR) for receiving naloxone.. Of 1036 eligible patient encounters, 320 resulted in naloxone provision (30.9%, 95% CI: 28.1-33.8). Naloxone provision occurred for 33.6% (95% CI 30.5-36.7) of 900 patients referred to outpatient substance use treatment without ED buprenorphine administration, 10.6% (95% CI 5.0-19.2) of 85 patients administered buprenorphine and not referred to outpatient substance use treatment, and 17.6% (95% CI 8.4-30.9) of 51 patients administered buprenorphine and referred to outpatient treatment. After controlling for age, sex, race, and prior provision of naloxone, the administration of buprenorphine was associated with a 94% lower odds (aOR = 0.06 [95% CI 0.011-0.33]) for naloxone provision compared to those only referred to outpatient treatment.. A majority of ED patients who received an intervention targeted at OUD, in an ED where take-home naloxone is freely available, did not receive either take-home naloxone or a prescription for naloxone at discharge. Patients receiving buprenorphine were less likely to receive naloxone than patients only referred to outpatient treatment. These data suggest barriers other than recognition of potential OUD and naloxone availability impact provision of naloxone and argue for a treatment "bundle" as a conceptual model for care of ED patients with suspected OUD.

Topics: Adult; Cross-Sectional Studies; Drug Overdose; Emergency Service, Hospital; Female; Hospitals, Urban; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Practice Patterns, Physicians'; Retrospective Studies

Research on socio-ecological factors that may impede or facilitate access to naloxone in pharmacies remains limited. This study investigated associations between socio-ecological factors, pharmacy participation in the naloxone cost assistance program (NCAP), pharmacy characteristics and having naloxone in stock among pharmacies in New York City.. Phone interviews were conducted with 662 pharmacies selected from the New York City Naloxone Standing Order List. Multi-level generalized linear modeling estimated associations between neighborhood racial and ethnic composition, poverty rates, overdose fatality rates, pharmacy participation in N-CAP, having private physical spaces within the pharmacy, knowledge of where to refer people to obtain naloxone and adjusted relative risk (aRR) that the pharmacy would have naloxone in stock.. Findings from this study supported several of the hypotheses. Greater neighborhood poverty was associated with a lower likelihood of carrying naloxone compared to neighborhoods with less poverty (aRR = .79, CI95 % = .69, .90, p < .001). Pharmacies that provided a private window for consultations (aRR = 1.34, CI95 % = 1.19, 1.51, p < .001), a private room (aRR = 1.42, CI95 % = 1.30, 1.56, p < .001), and a private area (aRR = 1.42, CI95 % = 1.30, 1.56, p < .001) were associated with a higher likelihood of carrying naloxone compared than those that did not.. Findings from this study suggest that community-level socioeconomic marginalization is a contributor to disparities in naloxone availability among pharmacies in New York City. Findings support harm reduction interventions tailored to the built environment of pharmacies that respect privacy to those seeking naloxone.

Topics: Drug Overdose; Ethnicity; Female; Harm Reduction; Humans; Male; Naloxone; New York City; Pharmaceutical Services; Pharmacies; Pharmacy; Racial Groups; Residence Characteristics; Standing Orders; Surveys and Questionnaires

Take-home naloxone, a key response to heroin overdose, may be compromised by the way in which overdose cases are coded in EMS dispatch systems as call-takers direct callers at cardiac arrest events against using any medication. We examined the ways in which confirmed heroin overdose cases attended by ambulances are coded at dispatch to determine whether incorrect coding of overdoses as cardiac arrests may limit the use of take-home naloxone.. We conducted a retrospective analysis of coded ambulance clinical records collected in Victoria, Australia from 2012-2017. Counts of heroin overdose cases were examined by dispatch coding (heroin overdose, cardiac/respiratory arrest and 'other'), along with age, sex, GCS and respiratory rate. Data were analysed using chi-square and Poisson regression for quarterly counts, adjusting for age, sex and patient GCS.. A total of 5637 heroin overdose cases were attended over the period 2012-2017 (71.4% male, 36.4% aged under 35 years). Almost half (n = 2674, 47.4%) were coded as cardiac/respiratory arrest at dispatch, with 36.8% (n = 2075) coded as heroin overdose and 15.7% (n = 886) coded as other/unknown.. Almost half of the heroin overdoses were dispatched according to a protocol that would preclude the use of take-home naloxone prior to ambulance arrival and this changed little over the period in which take-home naloxone programs were operating in Victoria, Australia. EMS should move as quickly as possible to newer versions of dispatch systems that enable the use of naloxone in cases of obvious opioid overdose that may be classified as cardiac/respiratory arrest.

Topics: Aged; Drug Overdose; Female; Heroin; Humans; Male; Naloxone; Narcotic Antagonists; Retrospective Studies; Software; Victoria

The COVID-19 pandemic resulted in stay-at-home orders, which presented a significant challenge to the design and operation of an essential harm-reduction strategy in the opioid epidemic: community-based, take-home naloxone (THN) programs. This commentary describes how four rural and/or Appalachian communities quickly pivoted their existing THN programs to respond to community need. These pivots, which reflect both the context of each community and the capacities of its service delivery and technology platforms, resulted in enhancements to THN training and distribution that have maintained or expanded the reach of their efforts. Additionally, all four community pivots are both highly sustainable and transferrable to other communities planning to or currently implementing THN training and distribution programs.

Topics: Community Health Services; COVID-19; Drug Overdose; Harm Reduction; Home Care Services; Humans; Naloxone; Narcotic Antagonists; Narcotic-Related Disorders; Pandemics; Quarantine

Expanding access to and utilization of naloxone is a vitally important harm reduction strategy for preventing opioid overdose deaths, particularly in vulnerable populations like Medicaid beneficiaries. The objective of this study was to characterize the landscape of monthly prescription fill limit policies in Medicaid programs and their potential implications for expanding naloxone use for opioid overdose harm reduction.. A cross-sectional, multi-modal online and telephonic data collection strategy was used to identify and describe the presence and characteristics of monthly prescription fill limit policies across state Medicaid programs. Contextual characteristics were described regarding each state's Medicaid enrollment, opioid prescribing rates, and overdose death rates. Data collection and analysis occurred between February and May 2020.. Medicaid-covered naloxone fills are currently subject to monthly prescription fill limit policies in 10 state Medicaid programs, which cover 20 % of the Medicaid population nationwide. Seven of these programs are located in states ranking in the top 10 highest per-capita opioid prescribing rates in the country. However, 8 of these programs are located in states with opioid overdose death rates below the national average.. Medicaid beneficiaries at high risk of opioid overdose living in states with monthly prescription fill limits may experience significant barriers to obtaining naloxone. Exempting naloxone from Medicaid prescription limit restrictions may help spur broader adoption of naloxone for opioid overdose mortality prevention, especially in states with high opioid prescribing rates. Achieving unfettered naloxone coverage in Medicaid is critical as opioid overdoses and Medicaid enrollment increase amid the COVID-19 pandemic.

Topics: Analgesics, Opioid; COVID-19; Cross-Sectional Studies; Drug Overdose; Drug Prescriptions; Humans; Medicaid; Naloxone; Narcotic Antagonists; Pandemics; Practice Patterns, Physicians'; Surveys and Questionnaires; United States

Topics: Data Mining; Databases, Factual; Drug Overdose; Electronic Health Records; Humans; Naloxone

Opioid misuse and overdose deaths remain a public health concern in the United States. Pennsylvania has one of the highest rates of opioid overdose deaths in the country, with Philadelphia County's being 3 times higher than the national average. Despite several multimodal interventions, including use of SBIRT (screening, brief intervention, and referral to treatment) methods and naloxone distribution, the rate of overdose deaths remains high.. To gain insights on strategies for improving access to naloxone and naloxone distribution by pharmacists in Philadelphia County, a study was conducted in 11 community pharmacies (chain and independent) in Philadelphia. Twenty-four pharmacists were recruited and completed SBIRT and naloxone trainings. Each pharmacy elected to have at least 1 pharmacy champion who received additional training on and helped develop pharmacy site-specific naloxone dispensing protocols.. Pre-post survey results showed a reduction in stigmatizing attitudes regarding naloxone dispensing and an increase in pharmacists' understanding of the standing order and appropriate naloxone use. There was an increase in pharmacists' self-reported confidence in their ability to appropriately identify, discuss, and dispense naloxone to patients. All pharmacies increased their average monthly dispensing rate following protocol implementation.. Pharmacists who received both trainings were more likely to change naloxone dispensing practices, leading to an overall increase in naloxone dispensing by community pharmacists. The study addressed overall gaps in pharmacists' knowledge, reduced stigma, and prepared pharmacists to address opioid use and overdose prevention with their patients. The described pharmacist-led patient counseling and intervention service for overdose prevention may be explored as a model for other community pharmacies to adopt to improve naloxone dispensing and similar interventions to reduce overdose deaths.

Topics: Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pennsylvania; Pharmacies; Pharmacists; Self Report; Standing Orders; United States

We have recently demonstrated that a significant proportion of fatal out-of-hospital cardiac arrests (OHCAs) are precipitated by occult overdose, which could benefit from antidote therapy administered adjunctively with other cardiac resuscitation measures. We sought to develop simple decision instruments that EMS providers and other first responders can use to rapidly identify occult opioid overdose-associated OHCAs.. We examined data from February 2011 through December 2017 in the Postmortem Systematic Investigation of Sudden Cardiac Death study, in which San Francisco (California) County EMS-attended OHCA deaths received autopsy and expert panel adjudication of cause of death. Using classification tree analyses, we derived highly sensitive and specific decision instruments that predicted our primary outcome of occult opioid OD-associated OHCA. We then calculated screening performance characteristics of these instruments.. Of 767 OHCA deaths, 80 (10.4%) were associated with occult opioid overdose. Of the eight models with 100% sensitivity for opioid overdose-associated cardiac arrest, the highest specificity model (23.4%, 95% confidence interval [CI] 20.3-26.7%) was age < 60 years OR race = black or non-Latinx white OR arrest in public place. The highest specificity instrument (96.3%, 95% CI 94.6-97.5%) consisting of age < 60 years AND race = black or non-Latinx white AND unwitnessed arrest AND female sex had 25% (95% CI 16-35.9%) sensitivity.. We have derived simple decision instruments that can identify patients whose OHCA precipitant was occult opioid overdose. These instruments may be used to guide selective administration of the antidote naloxone in OHCA resuscitations.

Topics: Antidotes; Cardiopulmonary Resuscitation; Drug Overdose; Emergency Medical Services; Female; Humans; Middle Aged; Naloxone; Opiate Overdose; Out-of-Hospital Cardiac Arrest

Illicitly manufactured fentanyl and fentanyl analogues (IMFs) are being increasingly suspected in overdose deaths. However, few prior outbreaks have been reported thus far of patients with laboratory-confirmed IMF toxicity after reporting intent to use only nonopioid substances. Herein we report a case series of nine patients without opioid use disorder who presented to two urban emergency departments (EDs) with opioid toxicity after insufflating a substance they believed to be cocaine.. Over a period of under three hours, nine patients from five discrete locations were brought to two affiliated urban academic EDs. All patients denied prior illicit opioid use. All patients endorsed insufflating cocaine shortly prior to ED presentation. Soon after exposure, all developed lightheadedness and/or respiratory depression. Seven patients received naloxone en route to the hospital; all had improvement in respiratory function by arrival to the ED. None of the patients required any additional naloxone administration in the ED. All nine patients were discharged home after observation. Blood +/- urine samples were obtained from eight patients. All patients who provided specimens tested positive for cocaine metabolites and had quantifiable IMF concentrations, as well as several detectable fentanyl derivatives, analogues, and synthetic opioid manufacturing intermediates.. IMF-contamination of illicit drugs remains a public health concern that does not appear to be restricted to heroin. This confirmed outbreak demonstrates that providers should elevate their level of suspicion for concomitant unintentional IMF exposure even in cases of non-opioid drug intoxication. Responsive public health apparatuses must prepare for future IMF-contamination outbreaks.

Topics: Adult; Cocaine; Drug Overdose; Emergency Service, Hospital; Female; Fentanyl; Humans; Illicit Drugs; Laboratories; Male; Naloxone; Narcotic Antagonists; New York City; Opioid-Related Disorders

Since late 2014, fentanyl has become the major driver of opioid mortality in the United States. However, a descriptive analysis of fentanyl victims is limited. We studied the 2016 fentanyl and heroin overdose deaths and compared them to previously studied heroin-associated fatalities from 2012 over a wide range of demographic and investigative variables, including overdose scene findings, toxicology results, and prescription drug history. We observed a significant increase in fentanyl-related deaths (n = 421, 2016) versus heroin deaths (n = 160, 2012) but the baseline demographics between both cohorts remained similar. Victims were predominantly of ages 35-64 years (60%-64%), White (83%-85%), and male (73%-76%). 2016 fentanyl decedents were more likely to have naloxone administered upon overdose, and the majority still had a positive prescription history for a controlled substance. Toxicology data showed a decrease in mean morphine and 6-monoacetylmorphine concentrations when cointoxication with fentanyl occurred. Our study emphasizes the medical examiner's role as a public health data source and bridge between different stakeholders combating the opioid epidemic.

Topics: Adult; Age Distribution; Coroners and Medical Examiners; Drug Overdose; Drug Prescriptions; Female; Fentanyl; Heroin; Humans; Illicit Drugs; Male; Middle Aged; Naloxone; Narcotic Antagonists; Ohio; Opioid-Related Disorders; Racial Groups; Sex Distribution

Community rapid response may reduce opioid overdose harms, but is hindered by the lack of timely data. To address this need, we created and evaluated the Michigan system for opioid overdose surveillance (SOS). SOS integrates suspected fatal overdose data from Medical Examiners (MEs), and suspected non-fatal overdoses (proxied by naloxone administration) from the Michigan Emergency Medical Services (EMS) into a web-based dashboard that was developed with stakeholder feedback. Authorised stakeholders can view approximate incident locations and automated spatiotemporal data summaries, while the general public can view county-level summaries. Following Centers for Disease Control and Prevention (CDC) surveillance system evaluation guidelines, we assessed simplicity, flexibility, data quality, acceptability, sensitivity, positive value positive (PVP), representativeness, timeliness and stability of SOS. Data are usually integrated into SOS 1-day postincident, and the interface is updated weekly for debugging and new feature addition, suggesting high timeliness, stability and flexibility. Regarding representativeness, SOS data cover 100% of EMS-based naloxone adminstrations in Michigan, and receives suspected fatal overdoses from MEs covering 79.1% of Michigan's population, but misses those receiving naloxone from non-EMS. PVP of the suspected fatal overdose indicator is nearly 80% across MEs. Because SOS uses pre-existing data, added burden on MEs/EMS is minimal, leading to high acceptability; there are over 300 authorised SOS stakeholders (~6 new registrations/week) as of this writing, suggesting high user acceptability. Using a collaborative, cross-sector approach we created a timely opioid overdose surveillance system that is flexible, acceptable, and is reasonably accurate and complete. Lessons learnt can aid other jurisdictions in creating analogous systems.

Topics: Drug Overdose; Emergency Medical Services; Humans; Michigan; Naloxone; Narcotic Antagonists; Opiate Overdose

Topics: Adrenergic alpha-2 Receptor Agonists; Adult; Bradycardia; Clonidine; Drug Overdose; Emergency Service, Hospital; Female; Humans; Hyperglycemia; Naloxone

As a response to mounting overdose fatalities, cross-agency outreach efforts have emerged to reduce future risk among overdose survivors. We aimed to characterize such programs in Massachusetts, with focus on team composition, approach, services provided, and funding.. We conducted a two-phase cross-sectional survey of public health and safety providers in Massachusetts. Providers in all 351 municipalities received a screening survey. Those with programs received a second, detailed survey. We analyzed responses using descriptive statistics.. As of July 2019, 44 % (156/351) of Massachusetts municipalities reported post-overdose outreach programs, with 75 % (104/138) formed between 2016-2019. Teams conducted home-based outreach 1-3 days following overdose events. Police departments typically supplied location information on overdose events (99 %, 136/138) and commonly participated in outreach visits (86 %, 118/138) alongside public health personnel, usually from community-based organizations. Teams provided or made referrals to services including inpatient addiction treatment, recovery support, outpatient medication, overdose prevention education, and naloxone. Some programs deployed law enforcement tools, including pre-visit warrant queries (57 %, 79/138), which occasionally led to arrest (11 %, 9/79). Many programs (81 %, 112/138) assisted families with involuntary commitment to treatment - although this was usually considered an option of last resort. Most programs were grant-funded (76 %, 104/136) and engaged in cross-municipal collaboration (94 %, 130/138).. Post-overdose outreach programs have expanded, typically as collaborations between police and public health. Further research is needed to better understand the implications of involving police and to determine best practices for increasing engagement in treatment and harm reduction services and reduce subsequent overdose.

Topics: Community-Institutional Relations; Cross-Sectional Studies; Drug Overdose; Harm Reduction; Humans; Law Enforcement; Male; Massachusetts; Naloxone; Narcotic Antagonists; Opiate Overdose; Organizations; Police; Public Health; Surveys and Questionnaires

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone

First responders-including police officers-play a prominent role in managing the risk of fentanyl overdoses. In many jurisdictions, they have Naloxone (also commercially available as Narcan) at their disposal to counter the effects of an opioid overdose. Little empirical research exists on how effectively police are incorporating this emergency rescue medication into routine practice. Between 2018 and 2019, we conducted semi-structured interviews with police officers from two Western Canadian police organizations. We also administered organization-wide web surveys to determine what factors facilitate or inhibit the incorporation of Narcan into police practice by looking at two domains: 1) the inner setting of the police organization and 2) personal knowledge of, and attitudes toward, an intervention. Whether officers administered Narcan depended on several personal and organizational factors, including: 1) having sufficient knowledge and concern about the fentanyl situation, 2) being knowledgeable about Narcan and trained in its use, 3) the medication being readily available to officers, and 4) being willing to administer it to citizens.

Topics: Canada; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Police

Treating an opioid overdose using an opioid receptor antagonist (such as naloxone) makes mechanistic sense and can be effective. Unfortunately, the majority of current drug overdose deaths involve polysubstance use (i.e., an opioid plus a non-opioid).. Respiratory depression induced by opioids results from excessive opioid molecules binding to opioid receptors. This effect can be reversed by an opioid receptor antagonist. However, the respiratory depression induced by non-opioid drugs is not due to action at opioid receptors; thus, an opioid receptor antagonist is ineffective in many of these cases. For respiratory depression induced by non-opioids, receptor antagonists are either not available (e.g., for propofol overdose) or there may be attendant risks with their use (e.g., seizures with flumazenil). This gives rise to a need for more effective ways to treat polysubstance overdose.. A new approach to treating opioid-induced respiratory depression due to drug overdose focuses on agents that stimulate respiratory drive rather than competing for opioid receptors. Such an approach is "agnostic" to the cause of the respiratory depression, so might be a potential way to treat polysubstance overdose.

Topics: Analgesics, Opioid; Carotid Body; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Perioperative Care; Respiratory Insufficiency

Topics: Analgesics, Opioid; Drug Overdose; Hospitals, Teaching; Humans; Mental Health; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Pharmacists

Opioid overdose education and naloxone distribution (OEND) for use by laypersons has been shown to be safe and effective, but implementation in the emergency department (ED) setting is challenging. Recent literature has shown a discouragingly low rate of obtainment of naloxone that is prescribed in the ED setting. We conducted a study to evaluate the feasibility of point-of-care (POC) distribution of naloxone in an ED, hypothesizing a rate of obtainment higher than prescription fill rates reported in previous studies.. A multidisciplinary team of experts, including pharmacists, physicians, nurses, and case management professionals used an iterative process to develop a protocol for POC OEND in the ED. The protocol includes 5 steps: (1) patient screening, (2) order placement in the electronic health record (EHR), (3) a patient training video, (4) dispensing of naloxone kit, and (5) written discharge instructions. The naloxone kits were assembled, labeled to meet requirements for a prescription, and stored in an automated dispensing cabinet. Two pharmacists, 30 attending physicians, 65 resident physicians, and 108 nurses were trained. In 8 months, 134 orders for take-home naloxone were entered and 117 naloxone kits were dispensed, resulting in an obtainment rate of 87.3%. The indication for take-home naloxone kit was heroin use for 61 patients (92.4%).. POC naloxone distribution is feasible and yielded a rate of obtainment significantly higher than previous studies in which naloxone was prescribed. POC distribution can be replicated at other hospitals with low rates of obtainment.

Topics: Analgesics, Opioid; Drug Overdose; Emergency Service, Hospital; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pilot Projects; Point-of-Care Systems

To characterize the experiences of individuals accessing pharmacy-based naloxone and relate these experiences to the risk environments and discourses in which they are embedded.. We conducted a qualitative study using in-depth interviews of 37 adults aged 18 years and over who had accessed pharmacy-dispensed naloxone. Participants were recruited from across Ontario, Canada, and comprised individuals taking opioids for chronic pain, those taking opioids for reasons other than chronic pain, and individuals acquiring naloxone to act as bystanders in an opioid overdose setting. We drew upon risk environment theory to interpret participants' accounts.. Following analysis and interpretation, we generated five theoretically-informed themes characterizing the experiences of individuals accessing pharmacy-dispensed naloxone: 'intersection of naloxone narrative with pharmacy environment', 'individual risk environment and pharmacy-dispensed naloxone uptake', 'safe spaces: creating an enabling environment for pharmacy-dispensed naloxone', 'individuation: becoming a first responder' and 'beyond naloxone: the macro risk environment'. Specifically, participants described how judgement and stereotyping associated with the broader naloxone narrative can be amplified in the space of the pharmacy, leading to fears of reprisals and strategies to mitigate social risk. In addition, the social construction of naloxone as a drug for 'problematic' opioid use and a lack of pharmacist awareness regarding the risk environments in which opioid use occurs was perceived to limit opportunities for optimizing naloxone distribution and training. Finally, participants described approaches that could create enabling environments in the space of the pharmacy while remaining cognizant of the structural changes required in the macro risk environments of people who take opioids.. Despite increasing the availability of naloxone, participants characterized several social and environmental factors that could limit the accessibility of the drug from pharmacies. Strategies to address these factors could create enabling environments within pharmacies that optimize the reach and impact of pharmacy-dispensed naloxone.

Topics: Adolescent; Adult; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Ontario; Opioid-Related Disorders; Pharmacies; Pharmacy

This cross-sectional study describes naloxone rescue kit receipt among people with HIV (PWH) on chronic opioid therapy (COT) and HIV clinician opioid overdose prevention care in two clinics between 2015 and 2017. Naloxone rescue kit receipt was uncommon. History of overdose was associated with receiving naloxone but having a clinician who reported providing overdose prevention care was not. This study suggests that clinicians prescribing COT to PWH should improve overdose prevention care, including naloxone co-prescribing.

Topics: Analgesics, Opioid; Cross-Sectional Studies; Drug Overdose; HIV Infections; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

The COVID-19 crisis has had profound impacts on health service provision, particularly those providing client facing services. Supervised injecting facilities and drug consumption rooms across the world have been particularly challenged during the pandemic, as have their client group-people who consume drugs. Several services across Europe and North America closed due to difficulties complying with physical distancing requirements. In contrast, the two supervised injecting facilities in Australia (the Uniting Medically Supervised Injecting Centre-MSIC-in Sydney and the North Richmond Community Health Medically Supervised Injecting Room-MSIR-in Melbourne) remained open (as at the time of writing-December 2020). Both services have implemented a comprehensive range of strategies to continue providing safer injecting spaces as well as communicating crucial health information and facilitating access to ancillary services (such as accommodation) and drug treatment for their clients. This paper documents these strategies and the challenges both services are facing during the pandemic. Remaining open poses potential risks relating to COVID-19 transmission for both staff and clients. However, given the harms associated with closing these services, which include the potential loss of life from injecting in unsafe/unsupervised environments, the public and individual health benefits of remaining open are greater. Both services are deemed 'essential health services', and their continued operation has important benefits for people who inject drugs in Sydney and Melbourne.

Topics: Australia; COVID-19; COVID-19 Testing; Delivery of Health Care; Drug Overdose; Harm Reduction; Housing; Humans; Infection Control; Masks; Naloxone; Narcotic Antagonists; Needle-Exchange Programs; New South Wales; Opiate Overdose; Opiate Substitution Treatment; Opioid-Related Disorders; Personal Protective Equipment; Physical Distancing; Referral and Consultation; Resuscitation; SARS-CoV-2; Substance Abuse, Intravenous; Substance-Related Disorders; Victoria

Needle EXchange Technology (NEXT) Harm Reduction is an online, mail-based platform designed for sending (1) naloxone kits to people at risk for overdose and (2) sterile syringes and other equipment directly to people who otherwise cannot access safe supplies. From its inception in 2017 through the end of 2019, NEXT Harm Reduction sent naloxone kits to 3609 individuals and 1230 packages of sterile syringes and supplies and received 335 reports of overdose reversals using naloxone provided by NEXT Harm Reduction and its affiliates.

Topics: Adult; Aged; Delivery of Health Care; Drug Overdose; Female; Harm Reduction; Humans; Internet; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Postal Service; Syringes; United States; Young Adult

In recent years, a number of emergency department (ED)-based interventions have been developed to provide supports and/or treatment linkage for people who use opioids. However, there is limited research supporting the effectiveness of the majority of these interventions. Project POINT is an ED-based intervention aimed at providing opioid overdose survivors with naloxone and recovery supports and connecting them to evidence-based medications for opioid use disorder (MOUD). An evaluation of POINT was conducted.. A difference-in-difference analysis of electronic health record data was completed to understand the difference in outcomes for patients admitted to the ED when a POINT staff member was working versus times when they were not. The observation window was January 1, 2012 to July 6, 2019, which included N = 1462 unique individuals, of which 802 were in the POINT arm. Outcomes of focus include MOUD opioid prescriptions dispensed, active non-MOUD opioid prescriptions dispensed, naloxone access, and drug poisonings.. The POINT arm had a significant increase in MOUD prescriptions dispensed, non-MOUD prescriptions dispensed, and naloxone access (all p-values < 0.001). There was no significant effect related to subsequent drug poisoning-related hospital admissions.. The results support the assertion that POINT is meeting its two primary goals related to increasing naloxone access and connecting patients to MOUD. Generalization of these results is limited; however, the evaluation contributes to a nascent area of research and can serve a foundation for future work.

Topics: Adult; Analgesics, Opioid; Drug Overdose; Drug Prescriptions; Electronic Health Records; Emergency Medical Services; Emergency Service, Hospital; Female; Hospitalization; Humans; Male; Middle Aged; Naloxone; Opiate Overdose; Opioid-Related Disorders; Survivors

Topics: Analgesics, Opioid; Drug Overdose; Harm Reduction; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders

Naloxone has a high affinity for the µ-opioid receptor and acts as a competitive antagonist, thus reversing the effects of opioids. Naloxone is often administrated intravenously, but there is a growing interest in the intranasal route in treating patients with opioid overdose, and in reversing effects after therapeutic use of opioids. As administration is painless and no intravenous access is needed, the intranasal route is especially useful in children.. The aim of this study was to investigate the uptake of naloxone 0.4 mg/ml during the first 20 min after administration as a nasal spray in a pediatric population, with special focus on the time to achieve maximum plasma concentration.. Twenty children, 6 months-10 years, were included in the study. The naloxone dose administered was 20 µg/kg, maximum 0.4 mg, divided into repeated doses of 0.1 ml in each nostril. Venous blood samples were collected at 5, 10, and 20 min after the end of administration.. All patients had quantifiable concentrations of naloxone in venous blood at 5 min, and within 20 min, peak concentration had been reached in more than half of the children. At 20 min after intranasal administration, the plasma naloxone concentrations were within the range of 2-6 nanogram/ml.. This study confirms the clinical experience that the rapid effect of naloxone after intranasal administration in children was reflected in rapid systemic uptake to achieve higher peak plasma concentrations than previously reported in adults.

Topics: Administration, Intranasal; Adult; Child; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Nasal Sprays

BACKGROUND Naloxone remains the mainstay for the treatment of opioids overdose both in the clinical and public settings. Naloxone has been showing relative safety, leading to trivial adverdse effects which are mostly due to acute withdrawal effects, but when used in patients with known long-term addiction, it usually requires additional dosing or rapid infusion to achieve detoxification effects in a timely manner or to sustain the effects after they fade away. In some patients this has resulted in fatal adverse effects, including non-cardiogenic pulmonary edema (NCPE), which may require intensive care for those patients. Whether the higher dose is the cause has been debatable and not enough studies have looked into this subject. CASE REPORT Here, we report a series of 2 cases where 2 young patients were given naloxone following opioid overdose. Both our patients required frequent dosing due to insufficient response or owing to the washout of the naloxone effect shortly after, given its short half-life. Although the administered doses were different, both patients developed the adverse effect of NCPE and required ventilator support. CONCLUSIONS Evidence suggests that such a catastrophic adverse effect following the administration of such a critical medication, which is known to be relatively safe and is being publicized for saving lives, might limit its use and would require more attention and further studies to standardize a safe dose, limiting these life-threatening events and decreasing the need for unnecessary invasive respiratory support as well as admissions to intensive care units, which might create an additional burden on the health care system.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Pulmonary Edema

Up to 35% of veterans with opioid use disorder (OUD) are homeless, and veterans with OUD are nearly 29 times higher risk for homelessness; however, few are prescribed naloxone, an evidence-based intervention to reverse life-threatening opioid overdose.. Many housing facilities for homeless veterans contracted with the San Francisco Veterans Affairs Health Care System are located in neighborhoods with high rates of opioid overdose. No systematic interventions have been implemented to provide opioid overdose education and naloxone kits to veterans and staff at these facilities. This quality improvement (QI) initiative aimed to increase provision of opioid overdose education and naloxone for veterans and staff at contracted housing facilities.. This was a prospective single-arm cohort QI intervention. All contracted veteran housing programs were included. Descriptive statistics evaluated results.. A total of 18 contracted veteran housing programs were contacted from July 2019 through January 2020 to schedule training.. Of those, 13 programs responded to outreach and 10 visits were completed at 8 housing facilities. Training was provided by pharmacist and nurse practitioner trainers to 26 staff members and 59 veterans. Naloxone was prescribed to 37 veterans.. A pharmacist-led and nurse practitioner-led initiative was effective in increasing veteran and staff access to opioid overdose education and naloxone at >44% contracted veteran housing facilities. Challenges included lack of response from housing programs, low veteran turn out, and inability to provide naloxone to veterans not enrolled/ineligible for health care. Future initiatives should examine strategies to standardize access in homeless veterans' programs.

Topics: Analgesics, Opioid; Drug Overdose; Housing; Humans; Ill-Housed Persons; Naloxone; Opiate Overdose; Prospective Studies; Veterans

Amid increasing opioid overdose deaths in Canada since 2010 and a changing naloxone access landscape, there is a need for up-to-date research on Canadian women's experiences with opioids. Studies on Canadian take-home naloxone programs are promising, but research beyond these programs is limited. Our study is the first to focus on women's experiences and perspectives on the opioid crisis in Ontario, Canada's most populous province, since the opioid crisis began in 2010.. Our objective was to address research knowledge gaps involving Canadian women with criminal justice involvement who use opioids, and identify flaws in current policies, responses, and practices. While the opioid overdose crisis persists, this lack of research inhibits our ability to determine whether overdose prevention efforts, especially involving naloxone, are meeting their needs.. We conducted semi-structured, qualitative interviews from January to April 2018 with 10 women with experience of opioid use. They were recruited through the study's community partner in Toronto. Participants provided demographic information, experiences with opioids and naloxone, and their perceptions of the Canadian government's responses to the opioid crisis. Interviews were transcribed verbatim and inductive thematic analysis was conducted to determine major themes within the data.. Thematic analysis identified seven major concerns despite significant differences in participant life and opioid use experiences. Participants who had used illicit opioids since naloxone became available over-the-counter in 2016 were much more knowledgeable about naloxone than participants who had only used opioids prior to 2016. The portability, dosage form, and effects of naloxone are important considerations for women who use opioids. Social alienation, violence, and isolation affect the wellbeing of women who use opioids. The Canadian government's response to the opioid crisis was perceived as inadequate. Participants demonstrated differing needs and views on ideal harm reduction approaches, despite facing similar structural issues surrounding stigma, addiction management, and housing.. Participants experienced with naloxone use found it to be useful in preventing fatal overdose, however many of their needs with regards to physical, mental, and social health, housing, harm reduction, and access to opioid treatment remained unmet.

Topics: Analgesics, Opioid; Drug Overdose; Female; Humans; Naloxone; Narcotic Antagonists; Ontario; Opioid-Related Disorders

Topics: Analgesics, Opioid; Drug Overdose; Drug Prescriptions; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Prescriptions

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

Topics: Administration, Intranasal; Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists

Access to naloxone is essential as the overdose crisis persists. We described barriers to accessing naloxone among individuals who requested and received the medication from a free mailed program and explored the relationship between how individuals with and without personal proximity to overdose learned about the program.. Secondary analysis of data from a web-based form collected 1st March 2020 to 31st January 2021. Access barriers, personal proximity to overdose (broadly defined as personally overdosing or witnessing/worrying about others overdosing), and method of learning about the program were categorized and described.. Among 422 respondents, the most frequently reported barriers to accessing naloxone were: COVID quarantine (25.1%), lack of knowledge about access (13.2%), and cost (11.2%). Compared to those without personal proximity to overdose (38.2%), individuals with personal proximity (61.8%) heard about the program more often through an active online search (21.4% vs. 8.8%; p-value = 0.001) and less often through word of mouth (19.8% vs. 40.9%; p-value = <0.001).. Longstanding barriers to naloxone access are compounded by the COVID-19 pandemic, making mailing programs especially salient. Differences in ways that individuals with and without personal proximity to substance use and overdose learned about this program can inform how such programs can effectively reach their target audience.

Topics: COVID-19; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pandemics; Philadelphia; SARS-CoV-2

12-step programs aim to address drug-related harms, like opioid overdose, via abstinence. However, abstaining from opioids can diminish tolerance, which increases risk for overdose death upon resumption. A recent study found that desire to abstain from drugs inhibited willingness to participate in take-home naloxone programming, which was linked to perceptions of harm reduction strategies being tied to drug use. In the present study, we uncovered a similar phenomenon occurring among newly-abstinent participants who were refusing to carry naloxone.. This study is an analysis of broader qualitative data collected throughout Southern California among persons who use opioids, including those recently abstinent. Preliminary analysis revealed that those newly abstinent refused to accept naloxone at the end of interviews, and so we began probing about this (N=44). We used thematic analysis and author positionality to explicate the emergent phenomenon and applied social identity theory to conceptualize findings.. Mechanisms underlying naloxone refusal included its tie to a drug-using identity that newly-abstinent participants were attempting to retire. Carrying naloxone was also viewed as pointless due to doubt of witnessing an overdose again. Furthermore, the thought of being equipped with naloxone was not believed to be congruent with an abstinent identity, e.g. "me carrying it [naloxone] is making me feel like I'm going to be hanging out with people that are doing it [using drugs].". Recent detoxification heightens vulnerability to overdose, which other newly-abstinent peers might be positioned to respond to as bonds are formed through 12-step identity formation. However, naloxone is often refused by this group due to perceived 12-step identity clash. While some treatment spaces distribute naloxone, 12-step identity associated behavioral expectations appear to conflict with this strategy. Reframing these disconnects is essential for expanding the lifesaving naloxone community safety net.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone

Emergency department (ED) visits for opioid overdose continue to rise. Evidence-based harm reduction strategies for opioid use disorder (OUD), such as providing home naloxone, can save lives, but ED implementation remains challenging.. The researchers aimed to increase prescribing of naloxone to ED patients with OUD and opioid overdose by employing a model for improvement methodology, a multidisciplinary team, and high-reliability interventions. Monthly naloxone prescribing rates among discharged ED patients with opioid overdose and OUD-related diagnoses were tracked over time. Interventions included focused ED staff education on OUD and naloxone, and creation of electronic medical record (EMR)-based work-aids, including a naloxone Best Practice Advisory (BPA) and order set. Autoregressive interrupted time series was used to model the impact of these interventions on naloxone prescribing rates. The impact of education on ED staff confidence and perceived barriers to prescribing naloxone was measured using a published survey instrument.. After adjusting for education events and temporal trends, ED naloxone BPA and order set implementation was associated with a significant immediate 21.1% increase in naloxone prescribing rates, which was sustained for one year. This corresponded to increased average monthly prescribing rates from 1.5% before any intervention to 28.7% afterward. ED staff education had no measurable impact on prescribing rates but was associated with increased nursing perceived importance and increased provider confidence in prescribing naloxone.. A significant increase in naloxone prescribing rates was achieved after implementation of high-reliability EMR work-aids and staff education. Similar interventions may be key to wider ED staff engagement in harm reduction for patients with OUD.

Topics: Drug Overdose; Electronic Health Records; Emergency Service, Hospital; Humans; Naloxone; Narcotic Antagonists; Reproducibility of Results

To determine the rate at which commercially-insured patients fill prescriptions for naloxone after an opioid-related ED encounter as well as patient characteristics associated with obtaining naloxone.. This is a retrospective cohort study of adult patients discharged from the ED following treatment for an opioid-related condition from 2016 to 2018 using a commercial insurance claims database (Optum Clinformatics® Data Mart). The primary outcome was a pharmacy claim for naloxone in the 30 days following the ED encounter. A multivariable logistic regression model examined the association of patient characteristics with filled naloxone prescriptions, and predictive margins were used to report adjusted probabilities with 95% confidence intervals.. 21,700 patients had opioid-related ED encounters during the study period, of which 1743 (8.0%) had encounters for heroin overdose, 8825 (40.7%) for overdose due to other opioids, 5400 (24.9%) for withdrawal, and 5732 (26.4%) for other opioid use disorder conditions. 230 patients (1.1%) filled a prescription for naloxone within 30 days. Patients with heroin overdose (2.6%; 95%CI 1.7 to 3.4), recent prescriptions for opioid analgesics (1.4%; 95%CI 1.1 to 1.7), recent prescriptions for buprenorphine (1.9%; 95%CI 1.0 to 2.9), and naloxone prescriptions in the prior year (3.3%; 95%CI 1.8 to 4.8) were more likely to obtain naloxone. The rate was significantly higher in 2018 [1.9% (95%CI 1.5 to 2.2)] as compared to 0.4% (95%CI 0.3 to 0.6) in 2016.. Few patients use insurance to obtain naloxone by prescription following opioid-related ED encounters. Clinical and policy interventions should expand distribution of this life-saving medication in the ED.

Topics: Adult; Databases, Factual; Drug Overdose; Drug Prescriptions; Emergency Service, Hospital; Female; Humans; Insurance, Health; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Retrospective Studies; Substance Withdrawal Syndrome; Young Adult

Over the past two decades, opioid use and overdose have increased substantially. Naloxone, an opioid overdose reversal agent, has been one of many risk mitigation strategies for preventing mortality due to overdose. Most literature describing naloxone utilization has been about populations of illicit drug users and patients in hospitals, primary care, and pharmacies. There is limited information regarding naloxone prescribing and training for opioid users in specialty pain management clinics. Furthermore, there are no known publications concerning patients receiving palliative care services and overdose prevention. Pain and palliative care patients are commonly at risk of opioid overdose. In an interdisciplinary outpatient pain and palliative care clinic, pharmacists implemented naloxone prescribing and education. Eleven patients at increased risk for overdose were prescribed naloxone and educated on overdose risk factors, recognition, and management. Seven patients reported picking up their naloxone prescription from the pharmacy, and none reported using it within two weeks of the initial education. This intervention was deemed successful within the clinic, but small sample size and the pharmacist role may not be replicable within other pain and palliative care settings. It encourages further research of overdose risk and prevention in pain management and palliative care.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Outpatients; Pain Management; Palliative Care

Take-home naloxone (THN) provision to people who use drugs, their family/friends, and non-medical personnel is considered a public health strategy to improve community-based naloxone access and reduce the time to antidote treatment for opioid overdose in order to prevent fatal outcome. THN programs typically report up to three performance indicators: the volume of THN kits distributed, the rate of requests for re-supply of THN kits (e.g., following naloxone use for overdose reversal), and - increasingly - THN "carriage". In this Research Methods piece, we discuss the current shortcomings in the latter measurement of THN carriage from a mixed-methods perspective and describe possible implications for public health related research and improved data analyses. We present an argument for the need to improve research methods in the case of THN "carriage" and propose a multidimensional measurement structure that takes into account: 1) the location of the THN kit relative to its owner, 2) the owner's immediate access to the kit in an emergency, 3) the type of THN device, and 4) the purpose of THN ownership (i.e., for use in self or known/unknown other/s).

Topics: Drug Overdose; Emergency Service, Hospital; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

Bystander naloxone distribution is an important component of public health initiatives to decrease opioid-related deaths. While there is evidence supporting naloxone distribution programs, the effects of increasing naloxone availability on the behavior of people who use drugs have not been adequately delineated. In this study we sought to 1) evaluate whether individuals' drug use patterns have changed due to naloxone availability; and 2) explore individuals' knowledge of, access to, experiences with, and perceptions of naloxone.. We conducted a pilot study of adults presenting to the emergency department whose medical history included non-medical opioid use. Semi-structured interviews were conducted with participants and thematic analysis was used to code and analyze interview transcripts.. Ten participants completed the study. All were aware of naloxone by brand name (Narcan) and had been trained in its use, and all but one had either currently or previously possessed a kit. Barriers to naloxone administration included fear of legal repercussions, not having it available, and a desire to avoid interrupting another user's "high." Of the eight participants who reported being revived with naloxone at least once during their lifetime, all described experiencing a noxious physical response and expressed a desire to avoid receiving it again. Furthermore, participants did not report increasing their use of opioids when naloxone was available.. Participants were accepting of and knowledgeable about naloxone, and were willing to administer naloxone to save a life. Participants tended to use opioids more cautiously when naloxone was present due to fears of experiencing precipitated withdrawal. This study provides preliminary evidence countering the unsubstantiated narrative that increased naloxone availability begets more high-risk opioid use and further supports increasing naloxone access.

Topics: Adult; Drug Overdose; Drug Users; Emergency Service, Hospital; Female; Health Services Accessibility; Humans; Male; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pilot Projects

We sought to determine the influence of the Levels of Care for Rhode Island Emergency Departments and Hospitals for Treating Overdose and Opioid Use Disorder (Levels of Care) on emergency department (ED) provision of take-home naloxone, behavioral counseling, and referral to treatment.. A retrospective analysis of Rhode Island ED visits for opioid overdose from 2017 to 2018 was performed using data from a statewide opioid overdose surveillance system. Changes in provision of take-home naloxone, behavioral counseling, and referral to treatment before and after Levels of Care implementation were assessed using interrupted time series analysis. We compared outcomes by hospital type using multivariable modified Poisson regression models with generalized estimating equation estimation to account for hospital-level variation.. We analyzed 245 overdose visits prior to Levels of Care implementation (January to March 2017) and 1340 overdose visits after implementation (hospital certification to December 2018). After implementation, the proportion of patients offered naloxone increased on average by 13% (95% confidence interval [CI] 5.6% to 20.4%). Prior to implementation, the proportion of patients receiving behavioral counseling and treatment referral was declining. After implementation, this decline slowed and stabilized, and on average 18.6% more patients received behavioral counseling (95% CI 1.3% to 35.9%) and 23.1% more patients received referral to treatment (95% CI 2.7% to 43.5%). Multivariable analysis showed that after implementation, there was a significant increase in the likelihood of being offered naloxone at Level 1 (adjusted relative risk [aRR] 1.31 [95% CI 1.06 to 1.61]) and Level 3 (aRR 3.13 [95% CI 1.08 to 9.06]) hospitals and an increase in referrals for medication for opioid use disorder (from 2.5% to 17.8%) at Level 1 hospitals (RR 7.73 [95% CI 3.22 to 18.55]). Despite these increases, less than half of the patients treated for an opioid overdose received behavioral counseling or referral to treatment CONCLUSION: The establishment of ED policies for treatment and services after opioid overdose improved naloxone distribution, behavioral counseling, and referral to treatment at hospitals without previously established opioid overdose services. Future investigations are needed to better characterize implementation barriers and evaluate policy influence on patient outcomes.

Topics: Adult; Counseling; Drug Overdose; Emergency Service, Hospital; Female; Humans; Interrupted Time Series Analysis; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Referral and Consultation; Retrospective Studies; Rhode Island

Targeted naloxone distribution to potential lay responders increases the timeliness of overdose response and reduces mortality. Little is known, however, about the patterns of decision-making among overdose lay responders. This study explored heuristic decision-making among laypersons equipped with an emergency response smartphone app.. UnityPhilly, a smartphone app that connects lay responders equipped with naloxone to overdose victims, was piloted in Philadelphia from March 2019 to February 2020. Participants used the app to signal overdose alerts to peer app users and emergency medical services, or respond to alerts by arriving at overdose emergency sites. This study utilised in-depth interviews, background information, and app use data from a sample of 18 participants with varying histories of opioid use and levels of app use activity.. The sample included 8 people who used opioids non-medically in the past 30 days and 10 people reporting no opioid misuse. Three prevailing, not mutually exclusive, heuristics were identified. The heuristic of unconditional signalling ("Always signal for help or backup") was used by 7 people who valued external assistance and used the app as a replacement for a 911 call; this group had the highest number of signalled alerts and on-scene appearances. Nine people, who expressed confidence in their ability to address an overdose themselves, followed a heuristic of conditional signalling ("Rescue, but only signal if necessary"); these participants had the highest frequency of prior naloxone administrations. Eleven participants used the heuristic of conditional responding ("Assess if I can make a difference"), addressing an alert if they carried naloxone, were nearby, or received a signal before dark hours.. The deployment of specific heuristics was influenced by prior naloxone use and situational factors. Success of overdose prevention interventions assisted by digital technologies may depend on the involvement of people with diverse overdose rescue backgrounds.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Mobile Applications; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Smartphone

Deaths from overdose have risen dramatically over the past decade, driven mainly by opioids. In response, the Centers for Disease Control and Prevention released guidance on safe prescribing, safe storage of medications, Medication-Assisted Treatment (MAT), and the use of Naloxone to reverse an overdose. Even with this guidance, overdose deaths continue to rise. Suicide prevention is a strategy that may help address this problem. Suicide rose 32.4% between 1999 and 2019, from 10.5 to 13.9 per 100,000. Closely linked to overdose, the suicide rate among those with opioid use disorder is 87 per 100,000 population, six times that of the general US population. With multiple shared individual-level risk factors, strict standards for case ascertainment, and high potential for misclassification of opioid suicides, the distinction between overdose and suicide is often unclear, and the number of suicides is likely underestimated. The Surgeon General recently released a call to action for a public health approach to suicide prevention. Primary care and emergency departments have a major role to play. This commentary describes suicide as a hidden contributor to the opioid crisis; the rationale for integration of suicide prevention in primary care and emergency departments; and screening, education, brief intervention, and follow up and monitoring techniques that these settings can employ. Done effectively, this strategy has the potential to save countless lives.

Topics: Analgesics, Opioid; Drug Overdose; Emergency Medicine; Humans; Naloxone; Opioid Epidemic; Opioid-Related Disorders; Primary Health Care; Suicide Prevention

Naloxone distribution programs have been a cornerstone of the public health response to the overdose crisis in the USA. Yet people who use opioids (PWUO) continue to face a number of barriers accessing naloxone, including not knowing where it is available.. We used data from 173 PWUO from Anne Arundel County, Maryland, which is located between Baltimore City and Washington, DC. We assessed the prevalence of recently (past 6 months) receiving naloxone and currently having naloxone, the type(s) of the naloxone kits received, and the perceived ease/difficultly of accessing naloxone. We also assessed participants knowledge of where naloxone was available in the community.. One third (35.7%) of participants had recently received naloxone. Most who had received naloxone received two doses (72.1%), nasal naloxone (86.9%), and education about naloxone use (72.1%). Most currently had naloxone in their possession (either on their person or at home; 78.7%). One third (34.4%) believed naloxone was difficult to obtain in their community. Only half (56.7%) knew of multiple locations where they could get naloxone. The health department was the most commonly identified naloxone source (58.0%). Identifying multiple sources of naloxone was associated with being more likely to perceive that naloxone is easy to access.. Our results suggest that additional public health efforts are needed to make PWUO aware of the range of sources of naloxone in their communities in order to ensure easy and continued naloxone access to PWUO.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Prevalence; Public Health

Pharmacies sometimes restrict access to buprenorphine-naloxone (buprenorphine) for individuals with opioid use disorder. The objective of this study was to quantify the frequency of barriers encountered by patients seeking to fill buprenorphine prescriptions from pharmacies in United States (US) counties with high opioid-related mortality.. To characterize buprenorphine availability, we conducted a telephone audit ("secret shopper") study using a standardized script in two randomly selected pharmacies (one chain, one independent) in US counties reporting higher than average opioid overdose rates. Availability across pharmacy type (chain versus independent), county characteristics (rurality, region, overdose rate), and day of week were analyzed using univariate tests of categorical data. Independent predictors of buprenorphine availability were then identified using a multivariable binomial regression model.. Among 921 pharmacies contacted (467 chain, 454 independent), 73 % were in urban counties and 42 % were in Southern states. Of these pharmacies, 675 (73 %) reported being able to dispense buprenorphine. There were 183 (20 %) pharmacies that indicated they would not dispense buprenorphine. Independent pharmacies (adjusted prevalence ratio [aPR], 1.59; 95 % CI 1.21-2.08) and pharmacies in Southern states (aPR 2.06; 95 % CI 1.43-2.97) were significantly more likely to restrict buprenorphine.. In US counties with high overdose mortality rates, one in five pharmacies indicated they would not dispense buprenorphine. Buprenorphine access limitations were more common among independent pharmacies and those in Southern states. Pharmacy-directed interventions may be necessary to ensure timely buprenorphine access for patients with opioid use disorder.

Topics: Buprenorphine; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Pharmacies; Pharmacy; United States

The opioid epidemic was declared a national public health emergency in 2017. In Georgia, standing orders for the opioid antagonist, naloxone, have been implemented to reduce mortality from opioid overdoses. Service industry workers in the Atlanta, Georgia, inner-city community of Little Five Points (L5P) have access to naloxone, potentially expanding overdose rescue efforts in the community setting. To explore the issues facing L5P, our research brings together qualitative descriptive inquiry, ethnography, community-based research, a community advisory board, and a local artist to maximize community dissemination of research findings through a graphic novel that describes encountering an opioid overdose. This format was chosen due to the ethical responsibility to disseminate in participants' language and for its potential to empower and educate readers. This article describes the process of working on this study with the community and a local artist to create sample pages that will be tested for clarity of the message in a later phase. Working with an artist has revealed that while dissemination and implementation for collaboration begin before findings are ready, cross-collaboration with the artist requires early engagement, substantial funding, artist education in appropriate content, and member checking to establish community acceptability altering illustrations that reinforce negative stereotypes. By sharing the experiences of actions taken during an opioid overdose in L5P through a graphic novel, we can validate service industry workers' experiences, acknowledge their efforts to contribute to harm reduction, and provide much-needed closure to those who encounter opioid overdoses in the community.

Topics: Drug Overdose; Georgia; Humans; Naloxone; Narcotic Antagonists; Public Health

Topics: Adult; Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Primary Health Care

Topics: Drug Overdose; Emergency Service, Hospital; Humans; Naloxone

Topics: Antidotes; Drug Overdose; Heart Arrest; Humans; Naloxone; Opiate Overdose

Topics: Antidotes; Drug Overdose; Heart Arrest; Humans; Naloxone; Opiate Overdose

The BC Centre for Disease Control implemented the Facility Overdose Response Box (FORB) program December 1st, 2016 to train and support non-healthcare service providers who may respond to an overdose in the workplace. The program aims to support staff at non-profit community-based organizations by ensuring policy development, training, practice overdose response exercises, and post-overdose debriefing opportunities are established and implemented.. Three data sources were used in this descriptive cross-sectional study: FORB site registration data; naloxone administration forms; and a survey that was distributed to FORB sites in February 2019. FORB program site and naloxone administration data from December 1st, 2016 to December 31st, 2019 were analyzed using descriptive statistics. A Cochran-Armitage test was used to assess trends over time in naloxone administration event characteristics. Site coordinator survey results are reported to supplement findings from administrative data.. As of December 31st, 2019, FORB was implemented at 613 sites across BC and 1,758 naloxone administration events were reported. The majority (86.3%, n = 1,517) were indicated as overdose reversals. At registration, 43.6% of sites provided housing services, 26.3% offered harm reduction supplies, and 18.6% provided Take Home Naloxone. Refusal to be transported to hospital following overdose events when emergency services were called showed an increasing trend over time. Most respondents (81.3%) reported feeling confident in their ability to respond to the overdose and 59.6% were offered staff debrief. Based on the 89 site survey responses, supports most commonly made available following an overdose were debrief with a fellow staff member (91.0%), debrief with a supervisor (89.9%), and/or counselling services (84.3%).. The uptake of the FORB program has contributed to hundreds of overdose reversals in community settings in BC. Findings suggest that the FORB program supports developing staff preparedness and confidence in overdose response in community-based settings.

Topics: Adult; British Columbia; Cross-Sectional Studies; Drug Overdose; Female; Government Programs; Harm Reduction; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Organizations, Nonprofit; Reaction Time; Workplace

Opioid overdose is preventable and reversible. To target overdose prevention training and naloxone distribution, it is important to understand characteristics of those people who use drugs most likely to witness an overdose. In this paper we report the proportion and characteristics of women who use heroin that have witnessed an opioid overdose in Dar es Salaam, Tanzania.. We conducted a cross-sectional survey with 200 women who use heroin. We fitted unadjusted and adjusted logistic regression models with witnessing an opioid overdose as the dependent variable and sociodemographic and drug use-related variables as independent variables.. The majority of participants (85%) reported having ever witnessed an opioid overdose. Age (adjusted Odds Ratio [aOR] = 1.09; 95% CI: 1.02-1.12), having ever attempted to stop heroin use (aOR = 11.27; 95% CI: 2.25-56.46), history of arrest (aOR = 3.75; 95% CI: 1.32-10.63), and spending time daily in places where people use drugs (aOR = 3.72; 95% CI: 1.43-9.64) were found to be independently associated with ever witnessing an overdose.. Findings suggest the need for expanded access to naloxone to lay people and community and peer-based overdose prevention training in Tanzania, including the distribution of naloxone in settings with high drug use.

Topics: Analgesics, Opioid; Cross-Sectional Studies; Drug Overdose; Female; Heroin; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Tanzania

The opioid crisis in the United States may be exacerbated by the COVID-19 pandemic. Increases in opioid use, emergency medical services (EMS) runs for opioid-related overdoses, and opioid overdose deaths have been reported. No study has examined changes in multiple naloxone administrations, an indicator of overdose severity, during the COVID-19 pandemic.. This study examines changes in the occurrence of naloxone administrations and multiple naloxone administrations during EMS runs for opioid-related overdoses during the COVID-19 pandemic in Guilford County, North Carolina (NC).. Using a period-over-period approach, we compared the occurrence of opioid-related EMS runs, naloxone administrations, and multiple naloxone administrations during the 29-week period before (September 1, 2019, to March 9, 2020) and after NC's COVID-19 state of emergency declaration (ie, the COVID-19 period of March 10 to September 30, 2020). Furthermore, historical data were used to generate a quasi-control distribution of period-over-period changes to compare the occurrence of each outcome during the COVID-19 period to each 29-week period back to January 1, 2014.. All outcomes increased during the COVID-19 period. Compared to the previous 29 weeks, the COVID-19 period experienced increases in the weekly mean number of opioid-related EMS runs (25.6, SD 5.6 vs 18.6, SD 6.6; P<.001), naloxone administrations (22.3, SD 6.2 vs 14.1, SD 6.0; P<.001), and multiple naloxone administrations (5.0, SD 1.9 vs 2.7, SD 1.9; P<.001), corresponding to proportional increases of 37.4%, 57.8%, and 84.8%, respectively. Additionally, the increases during the COVID-19 period were greater than 91% of all historical 29-week periods analyzed.. The occurrence of EMS runs for opioid-related overdoses, naloxone administrations, and multiple naloxone administrations during EMS runs increased during the COVID-19 pandemic in Guilford County, NC. For a host of reasons that need to be explored, the COVID-19 pandemic appears to have exacerbated the opioid crisis.

Topics: COVID-19; Drug Overdose; Emergency Medical Services; Humans; Naloxone; North Carolina; Opioid-Related Disorders; Pandemics; Retrospective Studies

Topics: Anthropology, Cultural; California; Decision Trees; Drug Overdose; Emergency Medical Services; Female; Humans; Interviews as Topic; Male; Models, Theoretical; Naloxone; Opiate Overdose; Qualitative Research; Racial Groups; Sex Factors; Socioeconomic Factors

The opioid crisis has put an increasing strain on US states over the last two decades. In response, all states have passed legislation to implement a portfolio of policies to address the crisis. Although effects of some of these policies have been studied, research into factors associated with state policy adoption decisions has largely been lacking. We address this gap by focusing on factors associated with adoption of naloxone access laws (NAL), which aim to increase the accessibility and availability of naloxone in the community as a harm reduction strategy to reduce opioid-related morbidity and mortality.. We used event history analysis (EHA) to identify predictors of the diffusion of naloxone access laws (NAL) from 2001, when the first NAL was passed, to 2017, when all states had adopted NAL. A variety of state characteristics were included in the model as potential predictors of adoption.. We found that state adoption of NAL increased gradually, then more rapidly starting in 2013. Consistent with this S-shaped diffusion process, the strongest predictor of adoption was prior adoption by neighboring states. Having a more conservative political ideology and having a higher percentage of residents who identified as evangelical Protestants were associated with later adoption of NAL.. States appear to be influenced by their neighbors in deciding whether and when to adopt NAL. Advocacy for harm reduction policies like NAL should take into account the political and religious culture of a state.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid Epidemic; Opioid-Related Disorders; United States

Opioid overdoses are a leading cause of injury death in the United States. Providing people who inject drugs (PWID) with naloxone is essential to preventing deaths. However, research regarding gaps in naloxone delivery is limited.. We interviewed 536 PWID in San Francisco and Los Angeles, California from 2017 to 2018. We described naloxone engagement and re-engagement cascades, and identified factors associated with receiving naloxone in the past six months and currently owning naloxone.. The engagement cascade showed 72 % of PWID ever received naloxone, 49 % received it in the past six months, and 35 % currently owned naloxone. The re-engagement cascade showed, among PWID who received naloxone in the past six months, 74 % used and/or lost naloxone, and 67 % refilled naloxone. In multivariable analyses, identifying as Latinx (aRR = 0.53; 95 % CI: 0.39, 0.72) and Black (aRR = 0.73; 95 % CI: 0.57, 0.94) vs White were negatively associated with receiving naloxone in the past six months, while using opioids 1-29 times (aRR = 1.35; 95 % CI: 1.04, 1.75) and 30+ times (aRR = 1.52; 95 % CI: 1.17, 1.99) vs zero times in the past 30 days and witnessing an overdose in the past six months (aRR = 1.69; 95 % CI: 1.37, 2.08) were positively associated with receiving naloxone in the past six months. In multivariable analyses, being unhoused vs housed (aRR = 0.82; 95 % CI: 0.68, 0.99) was negatively associated with currently owning naloxone.. Our study adds to the literature by developing naloxone engagement and re-engagement cascades to identify disparities. Naloxone scale-up should engage populations facing inequitable access, including people of color and those experiencing homelessness.

Topics: Drug Overdose; Humans; Los Angeles; Naloxone; Opioid-Related Disorders; Pharmaceutical Preparations; San Francisco; Substance Abuse, Intravenous

Opioid overdose is a leading cause of death in the United States. Emergency medical services (EMS) encounters following overdose may serve as a critical linkage to care for people who use drugs (PWUD). However, many overdose survivors refuse EMS transport to hospitals, where they would presumably receive appropriate follow-up services and referrals. This study aims to (1) identify reasons for refusal of EMS transport after opioid overdose reversal; (2) identify conditions under which overdose survivors might be more likely to accept these services; and (3) describe solutions proposed by both PWUD and EMS providers to improve post-overdose care.. The study comprised 20 semi-structured, qualitative in-depth interviews with PWUD, followed by two semi-structured focus groups with eight EMS providers.. PWUD cited intolerable withdrawal symptoms; anticipation of inadequate care upon arrival at the hospital; and stigmatizing treatment by EMS and hospital providers as main reasons for refusal to accept EMS transport. EMS providers corroborated these descriptions and offered solutions such as titration of naloxone to avoid harsh withdrawal symptoms; peer outreach or community paramedicine; and addressing provider burnout. PWUD stated they might accept EMS transport after overdose reversal if they were offered ease for withdrawal symptoms, at either a hospital or non-hospital facility, and treated with respect and empathy.. Standard of care by EMS and hospital providers following overdose reversal should include treatment for withdrawal symptoms, including buprenorphine induction; patient-centered communication; and effective linkage to prevention, treatment, and harm reduction services.

Topics: Buprenorphine; Drug Overdose; Emergency Medical Services; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; United States

Several overdoses of the antiepileptic drug perampanel have been reported in adults, but very few have been reported in children. We report the case of an observed exploratory ingestion of perampanel in a 2-year-old child that resulted in ataxia and prolonged coma.. A previously healthy 2-year-old female patient presented to the emergency department (ED) 30 minutes after the witnessed ingestion of 30 mg of perampanel (2 mg/kg). Within minutes of ingestion, she displayed ataxia and inability to walk. Upon ED presentation, she had normal vital signs but was minimally responsive with physical stimulation. Naloxone was given without response. She was intubated because of profound central nervous system depression and transferred to a pediatric tertiary care facility. She remained intubated with no pharmacological sedation. Physical exam showed a horizontal nystagmus. Detailed neurologic examination of ataxia and coordination was not possible, and she did not demonstrate hyperreflexia, clonus, or rigidity. Her mental status gradually improved, and she was extubated approximately 72 hours after exposure. After extubation, the patient still exhibited truncal ataxia and did not return to baseline until 96 hours post ingestion. Serum drawn approximately 16 hours after exposure showed 870 ng/mL perampanel (ref < 20 ng/mL). She remained hemodynamically stable throughout her hospital course, despite protracted depressed mental status.. Given the severity of our patient's presentation, pediatric patients showing symptoms of perampanel overdose should be triaged to the ED for evaluation in anticipation of a prolonged clinical course with decreased consciousness and hypoventilation.

Topics: Anticonvulsants; Ataxia; Child, Preschool; Coma; Drug Overdose; Female; Humans; Naloxone; Nitriles; Pyridones; Treatment Outcome

To evaluate racial (Black/White) differences in overdose response training and take-home naloxone (THN) possession and administration among clients and nonclients of the Baltimore syringe service program (SSP).. The study derived data from a cross-sectional survey of 263 (183 SSP clients, 80 nonclients) people who inject drugs (PWID). The study recruited SSP clients using targeted sampling and recruited nonclients through peer referral from April to November 2016.. In our sample, 61% of the participants were Black, 42% were between the ages of 18 and 44, and 70% were males. SSP clients, regardless of race, were more likely to have received overdose response training than Black nonclients (Black clients AOR: 3.85, 95% CI: 1.88, 7.92; White clients AOR: 2.73, 95% CI: 1.29, 5.75). The study found no significant differences in overdose response training between Black and White nonclients. SSP clients and White nonclients were more likely to possess THN than Black nonclients (Black clients: AOR: 4.21, 95% CI: 2.00, 8.87; White clients: AOR: 3.54, 95% CI: 1.56, 8.04; White nonclients AOR: 4.49, 95% CI: 1.50,13.47).. SSP clients were more likely to receive overdose response training than their nonclient peers who they referred to the study, illustrating the utility of SSPs in reaching PWID at high risk of overdose. We also observed that Black PWID, who did not access services at the SSP, were the least likely to possess THN, suggesting the need to employ outreach targeting Black PWID who do not access this central harm reduction intervention.

Topics: Adolescent; Adult; Cross-Sectional Studies; Drug Overdose; Humans; Male; Naloxone; Narcotic Antagonists; Race Factors; Substance Abuse, Intravenous; Syringes; Young Adult

As of July 2018, 45 United States (US) states and the District of Columbia have enacted an overdose Good Samaritan law (GSL). These laws, which provide limited criminal immunity to individuals who request assistance during an overdose, may be of importance in the current wave of the overdose epidemic, which is driven primarily by illicit opioids including heroin and fentanyl. There are substantial differences in the structures of states' GSL laws which may impact their effectiveness. This study compared GSLs which have legal provisions protecting from arrest and laws which have more limited protections.. Using national county-level overdose mortality data from 3109 US counties, we examined the association of enactment of GSLs with protection from arrest and GSLs with more limited protections with subsequent overdose mortality between 2013 and 2018. Since GSLs are often enacted in conjunction with Naloxone Access Laws (NAL), we examined the effect of GSLs separately and in conjunction with NAL. We conducted these analyses using hierarchical Bayesian spatiotemporal Poisson models.. GSLs with protections against arrest enactment in conjunction with a NAL were associated with 7% lower rates of all overdose deaths (rate ratio (RR): 0.93% Credible Interval (CI): 0.89-0.97), 10% lower rates in opioid overdose deaths (RR: 0.90; CI: 0.85-0.95) and 11% lower rates of heroin/synthetic overdose mortality (RR: 0.89; CI: 0.82-0.96) two years after enactment, compared to rates in states without these laws. Significant reductions in overdose mortality were not seen for GSLs with protections for charge or prosecution.. GSLs with more expansive legal protections combined with a NAL, were associated with lower rates of overdose deaths, although these risk reductions take time to manifest. Policy makers should consider enacting and implementing more expansive GSLs with arrest protections to increase the likelihood people will contact emergency services in the event of an overdose.

Topics: Analgesics, Opioid; Bayes Theorem; Drug Overdose; Fentanyl; Humans; Naloxone; United States

Police officers have frequent encounters with people who use drugs, either by making an arrest for a drug-related offense or responding to a drug overdose call. Yet, little is known about how police officers view drug addiction - as a disease, a moral failure, or something else - and how their frameworks for conceptualizing addiction impact their attitudes toward drug policies, including the use of naloxone. This research examined police officers' adherence to a moralistic addiction framework in relation to their support for treatment-oriented drug policies. Officers (N = 618) were surveyed about their beliefs on drug policy and the extent to which drug addiction was a product of one's morals or related to social or biological reasons. Results found that approximately 22% of the variance in drug policy attitudes could be explained by addiction frameworks and control variables. Officers who embraced a biological perspective of addiction were more supportive of policies that expanded treatment, including access to naloxone, and less punitive sanctions. Those with stronger moralistic views were less supportive of expanding treatment initiatives and endorsed expanding punitive sanctions. Officer age and education was positively related with expanding treatment and naloxone use while exposure to overdoses was negatively related to policy support. These results demonstrate that officers' frameworks about drug addiction play an important role in drug policy attitudes and, by extension, how they might interact with people who use drugs.

Topics: Attitude; Drug Overdose; Humans; Naloxone; Police; Policy

Naloxone is a medication with a largely benign safety profile that is frequently administered in the emergency department to patients presenting with altered mental status. Ventricular tachycardia has been reported after naloxone administration in adult patients with prior use of opiate or sympathomimetic medications. However, no such reports exist in the pediatric population or in patients who have no known history of opiate or sympathomimetic medication use. We describe a case of ventricular tachycardia after naloxone administration in a 17-year-old male with no known prior use of opiate or sympathomimetic agents who presented to the emergency department with altered mental status of unknown etiology. Emergency physicians may wish to prepare for prompt treatment of ventricular arrythmias when administering naloxone to pediatric patients presenting with altered mental status.

Topics: Adolescent; Drug Overdose; Female; Humans; Naloxone; Narcotic Antagonists; Tachycardia, Ventricular

The objective of this study was to evaluate the utilization of the naloxone nasal spray kit provided to patients after discharge from Cermak Health Services of Cook County (CHS). During May and June 2018, the records of currently incarcerated CHS patients were reviewed to identify patients who (1) received the naloxone education and nasal spray kit upon previous discharge from CHS and (2) were then readmitted to the facility. Of the 76 potential participants, 60 interviews were conducted. This study has shown that 38.3% of patients utilized the nasal sprays provided to them upon discharge. Of those who reported using the nasal spray, 95.7% achieved positive outcomes. This study showed the positive impact the Naloxone Education/Dispensing Program had on patients discharged from CHS. In addition to identifying success in the number of lives saved, the study recognizes the long-term effect on patient safety that emerges from the program.

Topics: Drug Overdose; Health Services; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Outcome Assessment, Health Care

Between the years 2017-2019 in Philadelphia, more than 70% of all deaths from opioid overdose occurred in a private residence. To learn more about home-based opioid use and overdose, researchers conducted qualitative interviews with next of kin of overdose victims to learn their perceptions about the decedent's drug use and their opinions about city-led harm reduction efforts, specifically naloxone administration and collaborative efforts to open an overdose prevention site.. In 2019, researchers conducted 35 qualitative interviews with next of kin of persons who died of opioid overdose in Philadelphia in 2017. Data were coded and analyzed using NVivo software.. Data reveal that while persons who use drugs may benefit from enhanced harm reduction interventions that target their family members and caregivers including naloxone education and public health messaging about overdose prevention, these efforts may be up against other realities that Philadelphia families navigate-in particular structural inequalities exacerbated by decades of "War on Drugs" policies.. Existing health disparities and structural barriers to care increase vulnerability to overdose and highlight the urgency to collaborate with impacted families and communities to design relevant harm reduction interventions. Without efforts to redress the consequences of war on drug policies, however, harm reduction interventions will not reach their full potential.

Topics: Analgesics, Opioid; Drug Overdose; Harm Reduction; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Pharmaceutical Preparations; Philadelphia

Rural areas of the United States have been disproportionately impacted by the opioid epidemic, exacerbated by COVID-19-related economic upheavals. While polysubstance use is an important determinant of overdose risk, variability in polysubstance use as a result of numerous factors (e.g., access, preference) has yet to be described, particularly among rural persons with opioid use disorder (PWOUD). Survey data on past-month use of prescription and illicit opioids and 12 non-opioid psychoactive drug classes were analyzed from a national sample of rural (n = 3872) and urban (n = 8153) residents entering treatment for OUD from 2012 to 2019. Trend analyses for opioid and stimulant use were compared between rural and urban PWOUD. Latent class analyses assessed substance use trends through identified typologies of rural/urban PWOUD, which then underwent comparative analyses. By 2019, prescription opioid use remained greater in rural versus urban PWOUD, and methamphetamine use showed greater growth in rural, compared to urban areas. Latent class analyses identified variability in polysubstance use, with five identical subgroups in rural/urban PWOD: high polysubstance, polyprescription, prescription opioid-focused, prescription opioid-focused with polysubstance use, and illicit opioid-focused. Polyprescription was highest in rural areas, with illicit opioid-focused use highest in urban areas. Demographic characteristics, co-morbid conditions and healthcare coverage were all associated with between-group differences. There is significant variability in polysubstance use that may identify specific prevention and treatment needs for subpopulations of OUD patients: interventions focused on reducing opioid prescriptions, early engagement with mental health resources, wider distribution of naloxone, and screening/treatment plans that take into account the use of multiple substances.

Topics: Analgesics, Opioid; COVID-19; Drug Overdose; Humans; Naloxone; Opioid-Related Disorders; SARS-CoV-2; United States

Topics: Drug Overdose; Humans; Medicaid; Naloxone; Narcotic Antagonists; Prescriptions

Naloxone is an opioid antagonist that can be effectively administered by bystanders to prevent overdose. We determined the proportion of people who had naloxone and identified predictors of naloxone ownership among two samples of people who inject drugs (PWID) who use opioids in Portland and rural Western Oregon.. We used data from participants in Portland's National HIV Behavioral Surveillance (NHBS, N = 477) and the Oregon HIV/Hepatitis and Opioid Prevention and Engagement Study (OR-HOPE, N = 133). For each sample, we determined the proportion of participants who had naloxone and estimated unadjusted and adjusted relative risk of having naloxone associated with participant characteristics.. Sixty one percent of NHBS and 30 % of OR-HOPE participants had naloxone. In adjusted analysis, having naloxone was associated with female gender, injecting goofballs (compared to heroin alone), housing stability, and overdose training in the urban NHBS sample, and having naloxone was associated with drug of choice, frequency of injection, and race in the rural OR-HOPE sample. In both samples, having naloxone was crudely associated with SSP use, but this was attenuated after adjustment.. Naloxone ownership was insufficient and highly variable among two samples of PWID who use opioids in Oregon. People who use methamphetamine, males, and people experiencing homelessness may be at increased risk for not having naloxone and SSP may play a key role in improving access.

Topics: Drug Overdose; Female; Humans; Male; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Oregon; Substance Abuse, Intravenous

The United States is in the midst of an opioid epidemic within the COVID-19 pandemic, and veterans are twice as likely to die from accidental overdose compared to non-veterans. This article describes the Veterans Health Administration (VHA) Rapid Naloxone Initiative, which aims to prevent opioid overdose deaths among veterans through (1) opioid overdose education and naloxone distribution (OEND) to VHA patients at risk for opioid overdose, (2) VA Police naloxone, and (3) select automated external defibrillator (AED) cabinet naloxone.. VHA has taken a multifaceted, theory-based approach to ensuring the rapid availability of naloxone to prevent opioid overdose deaths. Strategies targeted at multiple levels (for example, patient, provider, health care system) have enabled synergies to speed diffusion of this lifesaving practice.. As of April 2021, 285,279 VHA patients had received naloxone from 31,730 unique prescribers, with 1,880 reported opioid overdose reversals with naloxone; 129 VHA facilities had equipped 3,552 VA Police officers with naloxone, with 136 reported opioid overdose reversals with VA Police naloxone; and 77 VHA facilities had equipped 1,095 AED cabinets with naloxone, with 10 reported opioid overdose reversals with AED cabinet naloxone. Remarkably, the COVID-19 pandemic had minimal impact on naloxone dispensing to VHA patients.. The VHA Rapid Naloxone Initiative saves lives. VHA is sharing many of the tools and resources it has developed to support uptake across other health care systems. Health care systems need to work together to combat this horrific epidemic within a pandemic and prevent a leading cause of accidental death (opioid overdose).

Topics: COVID-19; Drug Overdose; Humans; Naloxone; Pandemics; SARS-CoV-2; United States; United States Department of Veterans Affairs; Veterans Health

Naloxone distribution, a key global strategy to prevent fatal opioid overdose, has been a recent target of legislation in the U.S., but there is insufficient empirical evidence from causal inference methods to identify which components of these policies successfully reduce opioid-related harms. This study aimed to examine expert consensus on the effectiveness and implementability of various state-level naloxone policies.. We used the online ExpertLens platform to conduct a three-round modified-Delphi process with a purposive sample of 46 key stakeholders (advocates, healthcare providers, human/social service practitioners, policymakers, and researchers) with naloxone policy expertise. The Effectiveness Panel (n = 24) rated average effects of 15 types of policies on naloxone pharmacy distribution, opioid use disorder (OUD) prevalence, nonfatal opioid-related overdoses, and opioid-related overdose mortality. The Implementation Panel (n = 22) rated the same policies on acceptability, feasibility, affordability, and equitability. We compared ratings across policies using medians and inter-percentile ranges, with consensus measured using the RAND/UCLA Appropriateness Method Inter-Percentile Range Adjusted for Symmetry technique.. Experts reached consensus on all items. Except for liability protections and required provision of education or training, experts perceived all policies to generate moderate-to-large increases in naloxone pharmacy distribution. However, only three policies were expected to yield substantive decreases on fatal overdose: statewide standing/protocol order, over-the-counter supply, and statewide "free naloxone." Of these, experts rated only statewide standing/protocol orders as highly affordable and equitable, and unlikely to generate meaningful population-level effects on OUD or nonfatal opioid-related overdose. Across all policies, experts rated naloxone prescribing mandates relatively lower in acceptability, feasibility, affordability, and equitability.. Experts believe statewide standing/protocol orders are an effective, implementable, and equitable policy for addressing opioid-related overdose mortality. While experts believe many other broad policies are effective in reducing opioid-related harms, they also believe these policies face implementation challenges related to cost and reaching vulnerable populations.

Topics: Analgesics, Opioid; Consensus; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Policy

Physicians trained in opioid use disorder (OUD) harm reduction can mitigate opioid overdose deaths by prescribing naloxone and educating patients about its use. Unfortunately, many physicians possess OUD stigma. Training during medical school presents an opportunity to reduce OUD stigma and improve opioid overdose reversal knowledge. This study assessed the efficacy of Opioid Overdose Awareness and Reversal Training (OOART) and evaluated the equivalency of the online and in-person OOART.

Topics: Analgesics, Opioid; Drug Overdose; Health Knowledge, Attitudes, Practice; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Students, Medical

Drug overdose is the leading cause of death among formerly incarcerated people. Distribution of the opioid overdose medication naloxone to people who use drugs reduces overdose mortality, and officials in many jurisdictions are now considering or implementing programs to offer naloxone to people exiting jails and prisons. The principles and practices of harm reduction programs such as naloxone distribution conflict with those of penal institutions, raising the question of how organizations based on opposing institutional logics can collaborate on lifesaving programs. Using in-depth interviews and observations conducted over four years with 34 penal, medical, public health, and harm reduction practitioners, we introduce and conceptualize two organizational features to explain why this therapeutic intervention was implemented in local jails in two of three California counties. First, interorganizational bridges between harm reduction, medical, and penal organizations facilitated mutual understanding and ongoing collaboration among administrators and frontline workers in different agencies. Second, respected and influential champions within public health and penal organizations put jail-based naloxone distribution on the local agenda and cultivated support among key officials. Our findings offer guidance for future studies of institutional logics and policy responses to the overdose crisis.

Topics: California; Drug Overdose; Harm Reduction; Humans; Jails; Logic; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

Increasing the availability of naloxone among people who use opioids, and friends and family of past and present people who use opioids is a vitally important mission to reduce the occurrence of opioid-related overdose deaths. The purpose of this study was to determine the availability of naloxone in independent community pharmacies in Georgia. Secondary objectives include determining pharmacists' knowledge regarding the standing order and ability to counsel regarding naloxone.. A cross-sectional study using a secret shopper approach with phone contact was conducted over a period of 10 months. The study was population based and was conducted at all independent pharmacies in the state of Georgia. All independent community pharmacies in the state of Georgia were contacted and asked the naloxone questions with a 96% response rate (n = 520).. Five hundred fifty-eight independent community pharmacies were called, with a 96% response rate (n = 520 pharmacies). Two hundred-twenty pharmacies reported having naloxone in stock. Of the 335 pharmacists asked, 174 (51.9%) incorrectly said that a prescription was required. The mean (SD) cash price was $148.02 (27.40), with a range of $0 to $300. Of 237 pharmacists asked who had naloxone in stock or who stated they could get naloxone in stock, 212 stated that they could demonstrate how to use it, 8 stated they could not, and 17 said that they possibly could or were unsure how to use it.. This study provided insight into the limited availability of naloxone at independent community pharmacies in Georgia after the standing order was issued. The majority of pharmacists at independent pharmacies in Georgia were not using the publicly available state naloxone standing order. Additionally, the low availability of naloxone and its high cost for uninsured individuals are significant structural barriers for reducing opioid-related mortality.

Topics: Cross-Sectional Studies; Drug Overdose; Georgia; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pharmacies; Pharmacists

Along with an increase in opioid deaths, there has been a desire to increase the accessibility of naloxone. However, in the absence of respiratory depression, naloxone is unlikely to be beneficial and may be deleterious if it precipitates withdrawal in individuals with central nervous system (CNS) depression due to non-opioid etiologies.. The aim of this study was to evaluate how effective prehospital providers were in administering naloxone.. This is a retrospective study of naloxone administration in two large urban Emergency Medical Service (EMS) systems. The proportion of patients who had a respiratory rate of at least 12 breaths per minute at the time of naloxone administration by prehospital providers was determined.. During the two-year study period, 2,580 patients who received naloxone by prehospital providers were identified. The median (interquartile range) respiratory rate prior to naloxone administration was 12 (6-16) breaths per minute. Using an a priori respiratory rate of under 12 breaths per minute to define respiratory depression, only 1,232 (47.8%; 95% CI, 50.3%-54.2%) subjects who received naloxone by prehospital providers had respiratory depression.. This study showed that EMS providers in Los Angeles County, California (USA) frequently administered naloxone to individuals without respiratory depression.

Topics: Analgesics, Opioid; Drug Overdose; Emergency Medical Services; Humans; Los Angeles; Naloxone; Narcotic Antagonists; Respiratory Insufficiency; Retrospective Studies

People who use drugs (PWUD) are known to fear calling emergency medical services (EMS) for drug overdoses. In response, drug-related Good Samaritan Laws (GSLs) have been widely adopted in the USA and Canada to encourage bystanders to call emergency medical services (EMS) in the event of a drug overdose. However, the effect of GSLs on EMS-calling behaviours has been understudied. We sought to identify factors associated with EMS-calling, including the enactment of the Canadian GSL in May 2017, among PWUD in Vancouver, Canada, a setting with an ongoing overdose crisis.. Data were derived from three prospective cohort studies of PWUD in Vancouver in 2014-2018. Multivariable logistic regression was used to determine factors associated with EMS-calling among PWUD who witnessed an overdose event. An interrupted time series (ITS) analysis was employed to assess the impact of GSL on monthly prevalence of EMS-calling.. Among 540 eligible participants, 321 (59%) were males and 284 (53%) reported calling EMS. In multivariable analysis, ever having administered naloxone three or more times (adjusted odds ratio [AOR] 2.00; 95% confidence interval [CI] 1.08-3.74) and residence in the Downtown Eastside (DTES) neighbourhood of Vancouver (AOR 1.96; 95% CI 1.23-3.13) were positively associated with EMS-calling, while living in a single occupancy hotel (SRO) was negatively associated with EMS-calling (AOR 0.51; 95% CI 0.30-0.86). The post-GSL enactment period was not associated with EMS-calling (AOR 0.81; 95% CI 0.52-1.25). The ITS found no significant difference in the monthly prevalence of EMS-calling between pre- and post-GSL enactment periods.. We observed EMS being called about half the time and the GSL did not appear to encourage EMS-calling. We also found that individuals living in SROs were less likely to call EMS, which raises concern given that fatal overdose cases are concentrated in SROs in our setting. The link between many naloxone administrations and EMS-calling could indicate that those with prior experience in responding to overdose events were more willing to call EMS. Increased efforts are warranted to ensure effective emergency responses for drug overdoses among PWUD.

Topics: Canada; Drug Overdose; Emergency Medical Services; Humans; Male; Naloxone; Pharmaceutical Preparations; Prospective Studies

Overdose is a major cause of morbidity and mortality among people who use opioids. Naloxone can reverse opioid overdoses and can be distributed and administered with minimal training. People with experience of overdose are a key population to target for overdose prevention strategies. This study aims to understand if factors associated with recent non-fatal opioid overdose are the same as factors associated with naloxone access and naloxone training in people who recently used opioids or received opioid agonist treatment (OAT).. ETHOS Engage is an observational study of people who inject drugs in Australia. Logistic regression models were used to estimate odds ratios for non-fatal opioid overdose, naloxone access and naloxone training.. Between May 2018-September 2019, 1280 participants who recently used opioids or received OAT were enrolled (62% aged >40 years; 35% female, 80% receiving OAT, 62% injected drugs in the preceding month). Recent opioid overdose (preceding 12 months) was reported by 7% of participants, lifetime naloxone access by 17%, and lifetime naloxone training by 14%. Compared to people receiving OAT with no additional opioid use, recent opioid, benzodiazepine (preceding six months), and hazardous alcohol use was associated with recent opioid overdose (aOR 3.91; 95%CI: 1.68-9.10) and lifetime naloxone access (aOR 2.12; 95%CI 1.29-3.48). Among 91 people who reported recent overdose, 65% had never received take-home naloxone or naloxone training.. Among people recently using opioids or receiving OAT, benzodiazepine and hazardous alcohol use is associated with non-fatal opioid overdose. Not all factors associated with non-fatal overdose correspond to factors associated with naloxone access. Naloxone access and training is low across all groups. Additional interventions are needed to scale up naloxone provision.

Topics: Analgesics, Opioid; Drug Overdose; Female; Humans; Male; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders

The U.S. is facing an unprecedented number of opioid-related overdose deaths, and an array of other countries have experienced increases in opioid-related fatalities. In the U.S., naloxone is increasingly distributed to first responders to improve early administration to overdose victims, but its cost-effectiveness has not been studied. Lay distribution, in contrast, has been found to be cost-effective, but rising naloxone prices and increased mortality due to synthetic opioids may reduce cost-effectiveness. We evaluate the cost-effectiveness of increased naloxone distribution to (a) people likely to witness or experience overdose ("laypeople"); (b) police and firefighters; (c) emergency medical services (EMS) personnel; and (d) combinations of these groups.. We use a decision-analytic model to analyze the cost-effectiveness of eight naloxone distribution strategies. We use a lifetime horizon and conduct both a societal analysis (accounting for productivity and criminal justice system costs) and a health sector analysis. We calculate: the ranking of strategies by net monetary benefit; incremental cost-effectiveness ratios; and number of fatal overdoses.. High distribution to all three groups maximized net monetary benefit and minimized fatal overdoses; it averted 21% of overdose deaths compared to minimum distribution. High distribution to laypeople and one of the other groups comprised the second and third best strategies. The majority of health gains resulted from increased lay distribution. In the societal analysis, every strategy was cost-saving compared to its next-best alternative; cost savings were greatest in the maximum distribution strategy. In the health sector analysis, all undominated strategies were cost-effective. Results were highly robust to deterministic and probabilistic sensitivity analysis.. Increasing naloxone distribution to laypeople and first responder groups would maximize health gains and be cost-effective. If feasible, communities should distribute naloxone to all groups; otherwise, distribution to laypeople and one of the first responder groups should be emphasized.

Topics: Analgesics, Opioid; Cost-Benefit Analysis; Decision Support Techniques; Drug Overdose; Emergency Medical Services; Emergency Responders; Humans; Naloxone; Narcotic Antagonists; United States

Illicitly manufactured fentanyl (IMF) is responsible for a growing number of deaths. Some case series have suggested that IMF overdoses require significantly higher naloxone doses than heroin overdoses. Our objective was to determine if the naloxone dose required to treat an opioid overdose is associated with the finding of fentanyl, opiates, or both on urine drug screen (UDS).. A retrospective chart review was conducted at a single emergency department and its affiliated emergency medical services (EMS) agency. The charts of all patients who received naloxone through this EMS from 1/1/2017 to 6/15/2018 were reviewed. The study included patients diagnosed with a non-suicidal opioid overdose whose UDS was positive for opiates, fentanyl, or both. Data collected included demographics, vital signs, initial GCS, EMS and ED naloxone administrations, response to treatment, laboratory findings, and ED disposition. The fentanyl-only and fentanyl + opiate groups were compared to the opiate-only group using the stratified (by ED provider) variant of the Mann-Whitney U test.. Eight hundred and thirty-seven charts were reviewed, and 121 subjects were included in the final analysis. The median age of included subjects was 38 years and 75% were male. In the naloxone dose analysis, neither the fentanyl-only (median 0.8 mg, IQR 0.4-1.6; p = 0.68) nor the fentanyl + opiate (median 0.8 mg, IQR 0.4-1.2; p = 0.56) groups differed from the opiate-only group (median 0.58 mg, IQR 0.4-1.6).. Our findings refute the notion that high potency synthetic opioids like illicitly manufactured fentanyl require increased doses of naloxone to successfully treat an overdose. There were no significant differences in the dose of naloxone required to treat opioid overdose patients with UDS evidence of exposure to fentanyl, opiates, or both. Further evaluation of naloxone stocking and dosing protocols is needed.

Topics: Adolescent; Adult; Aged; Analgesics, Opioid; Drug Dosage Calculations; Drug Overdose; Emergency Service, Hospital; Female; Fentanyl; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Retrospective Studies; Substance Abuse Detection; Treatment Outcome; Urinalysis; Young Adult

This pilot study evaluated the feasibility of the Recovery Initiation and Management after Overdose (RIMO) intervention to link individuals to medication-assisted treatment (MAT) following an opioid overdose. The study team worked with the Chicago Fire Department to train Emergency Medical Service (EMS) teams to request permission from individuals after an opioid overdose reversal to release their contact information; individuals were subsequently contacted by the study team for participation. A mixed-methods study design comprised: (1) an experimental pilot study that examined participation at each stage of the intervention and compared the odds of treatment received for individuals who were randomly assigned to either the RIMO intervention (n = 16) or a passive referral control (n = 17); and (2) a focus group that was subsequently conducted with participants in the RIMO group to obtain their feedback on the intervention components. Quantitative data was collected on participant characteristics at study intake and treatment received was based on self-report at a 30-day follow-up. The RIMO group had higher odds of receiving any treatment for opioid use (OR = 7.94) and any MAT (OR = 20.2), and received significantly more days of opioid treatment (Ms=15.2 vs. 3.4) and more days of MAT in the 30 days post-randomization (Ms=11.2 vs. 0.76), relative to the control group (all p < .05). Qualitative data illustrated that participants valued the assertive outreach, engagement, and persistent follow-up components of RIMO, which differed from their prior experiences. The pilot study suggests that the RIMO intervention is able to address the challenges of linking and engaging individuals into MAT after an opioid overdose.

Topics: Chicago; Drug Overdose; Emergency Responders; Female; Humans; Male; Motivational Interviewing; Naloxone; Narcotic Antagonists; Pilot Projects; Qualitative Research; Referral and Consultation

Topics: Analgesics, Opioid; Drug Overdose; Ethnicity; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders

Overdose education with naloxone distribution (OEND) is a key national strategy to reduce morbidity and mortality related to opioid overdoses. Train-the-trainer model has been one method to increase the pool of trainers to facilitate greater dissemination of OEND. This exploratory study seeks to (1) evaluate participant's change in knowledge and confidence, (2) examine if pre- and post-training test outcomes differed by occupation and level of experience, and (3) determine if train-the-trainer participants trained others 6 months later.

Topics: Drug Overdose; Health Knowledge, Attitudes, Practice; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose

Topics: Adult; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Risk Factors; Substance-Related Disorders

Academic detailing is an educational outreach program that aligns providers' prescribing with evidence-based practice. The U.S. Department of Veterans Affairs (VA) Opioid Overdose Education and Naloxone Distribution (OEND) Program partnered with the VA Pharmacy Benefits Management National Academic Detailing Service to deliver naloxone education to providers who cared for patients at risk of opioid overdose. In this pilot study, we interviewed providers' who received academic detailing to capture their perceptions of facilitators and barriers to prescribing naloxone.. To identify providers' perceptions of facilitators and barriers to prescribing naloxone for patients at risk for opioid overdose after implementation of a national academic detailing program.. This was a hybrid inductive-deductive qualitative pilot using semi-structured interviews with VA providers to explore constructs associated with facilitators and barriers to prescribing take-home naloxone to patients at risk for opioid overdose from August 2017 to April 2018.. Eleven participants were interviewed, six physicians, three clinical psychiatric pharmacists, and two nurse practitioners. Participants identified patient-level barriers (social stigma and lack of homeless patient support), poor data integration, and burden of data validation as barriers to prescribing naloxone. However, they also identified patient lists, repeat visits, and face-to-face/one-on-one video conferencing visits as important facilitators for naloxone prescribing.. Academic detailing will need to address issues of social stigma regarding naloxone, educate providers about existing support systems for homeless veterans, and develop tools for data integration to improve naloxone access for veterans at risk for an opioid overdose.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Perception; Pilot Projects

We examine racial disparities in drug overdose death rates by analyzing trends in fatal and nonfatal overdose outcomes in a large metropolitan area (Indianapolis, Indiana).. Death certificate and toxicology records for accidental drug overdose deaths from 2011 to 2018 were linked with emergency medical services (EMS) data. Bivariate comparisons examined differences in toxicology findings at the time of death as well as prior EMS events both overall and by indicator of non-fatal overdose.. From 2011-2018, 2204 residents (29.4 per 100,000) died of drug overdose, 18.6% were Black (N = 410, 19.5 per 100,000) and 78.5% White (N = 1730, 35.2 per 100,000). In the year prior to death, 33.5% (N = 656) of decedents had an EMS event, 12.1% (N = 237) had an overdose event, and 9.4% (N = 185) had naloxone administered. Overdose complaint and naloxone administration were more likely to occur among White than Black patients. White decedents were more likely than Black decedents to have had naloxone administered in the year prior to death (10.1% vs. 6.8%, χ. Recent racial disparities in overdose deaths are driven by a combination of fentanyl and cocaine, which disproportionally impacts African American drug users, but may be addressed through expanded harm reduction and community outreach services. Additionally, there is a need to assess the role of differing practices in overdose emergency service provision as a contributing factor to disparities.

Topics: Adult; Black or African American; Cocaine; Drug Overdose; Drug Utilization; Emergency Medical Services; Female; Fentanyl; Humans; Indiana; Male; Naloxone; Urban Population; White People

Despite increases in opioid prescribing and related morbidity and mortality, few studies have comprehensively documented harms across opioid types. We examined a population-wide indicator of extramedical pharmaceutical opioid-related harm to determine if the supply-adjusted rates of ambulance presentations, the severity of presentations or other attendance characteristics differed by opioid type.. Retrospective observational study of coded ambulance patient care records related to extramedical pharmaceutical opioid use, January 2013 to September 2018.. Australia CASES: Primary analyses used Victorian data (n = 9823), with available data from other Australian jurisdictions (n = 4338) used to determine generalizability.. We calculated supply-adjusted rates of attendances using Poisson regression, and used multinomial logistic regression to compare demographic, presentation severity, mental health, substance use and other characteristics of attendances associated with seven pharmaceutical opioids.. In Victoria, the highest rates of attendance [per 100 000 oral morphine equivalent mg (OME)] were for codeine (0.273/100 000) and oxycodone (0.113/100 000). The lowest rates were for fentanyl (0.019/100 000) and tapentadol (0.005/100 000). Oxycodone-naloxone rates (0.031/100 000) were lower than for oxycodone as a single ingredient (0.113/100 000). Fentanyl-related attendances were associated with the most severe characteristics, most likely to be an accidental overdose, most likely to have naloxone administered and least likely to be transferred to hospital. In contrast, codeine-related attendances were more likely to involve suicidal thoughts/behaviours, younger females and be transported to hospital. Supply-adjusted attendance rates for individual opioids were stable over time. Victorian states were broadly consistent with non-Victorian states.. In Australia, rates and characteristics of opioid-related harm vary by opioid type. Supply-adjusted ambulance attendance rates appear to be both stable over time and unaffected by large changes in supply.

Topics: Adolescent; Adult; Aged; Ambulances; Analgesics, Opioid; Child; Codeine; Drug Overdose; Emergency Medical Services; Female; Fentanyl; Humans; Male; Middle Aged; Morphine; Naloxone; Oxycodone; Practice Patterns, Physicians'; Prescription Drug Misuse; Retrospective Studies; Victoria; Young Adult

Non-fatal opioid overdose (NFOO) predicts future fatal opioid overdose and is associated with significant morbidity. There is limited literature on the rates and risk factors for NFOO in people who inject drugs (PWID) from India. We aimed to study the rates of NFOO and documented risk factors for NFOO, as well as knowledge-level of NFOO among PWID from India.. Community-based, cross-sectional and observational study. We interviewed 104 adult male participants receiving HIV prevention services. Drug use patterns, rates of NFOO and opioid overdose risk factors, knowledge about opioid overdose and its management were assessed.. The mean age of the participants was 27.9 years. The most common opioid used for injecting was heroin followed by buprenorphine. About 45% (n = 47) participants had experienced an opioid overdose at least once in their lifetime. Around 25% (n = 26) participants had overdosed in the past year, while 21% (n = 22) participants had overdosed within the past 3 months. The majority had risk factors that could predispose them to NFOO. No participant was aware of the use of naloxone for opioid overdose.. The rates of NFOO as well as risk factors for overdose among PWID from India are high, with poor knowledge on overdose management. There is urgent need for a program to prevent and manage opioid overdose among PWID in India.

Topics: Adult; Analgesics, Opioid; Buprenorphine; Drug Overdose; Female; Humans; India; Male; Naloxone; Opioid-Related Disorders; Risk Factors; Substance Abuse, Intravenous

The United States continues to face a public health emergency of opioid-related harm, the effects of which could be dramatically reduced through increased access to the opioid antagonist naloxone. Unfortunately, naloxone is too often unavailable when and where it is most needed, partly due to its continued status as a prescription medication. Although states and the federal Food and Drug Administration (FDA) have acted to increase access to naloxone, these changes are insufficient to address this unprecedented crisis. In this Commentary, we argue that FDA can and should immediately reclassify naloxone from prescription-only to over-the-counter status, a change that could save hundreds if not thousands of lives in the United States every year.

Topics: Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Nonprescription Drugs; Opioid-Related Disorders; United States; United States Food and Drug Administration

Take-home naloxone (THN) interventions are an effective response to preventing overdose deaths, however uptake across Australia remains limited. This project designed, implemented and evaluated a model of care targeting opioid users attending alcohol and other drug (AOD) treatment, needle and syringe programs (NSP) and related health services targeting people who inject drugs.. Service providers, consumers and regulators collaboratively designed a THN brief intervention (ORTHN, Overdose Response with Take-Home Naloxone) involving client education and supply of naloxone in pre-filled syringes, delivered by nursing, allied health and NSP workers. ORTHN interventions were implemented in over 15 services across New South Wales, Australia. The evaluation included client knowledge, attitudes, substance use and overdose experiences immediately before and 3 months after ORTHN intervention in a subsample of participants.. Six hundred and sixteen interventions were delivered, with 145 participants recruited to the research subsample, of whom 95 completed the three-month follow up. Overdose-related attitudes amongst participants improved following ORTHN, with no evidence of increased substance use or failure to implement other 'first responses' (e.g. calling an ambulance). Nine participants (10%) reversed an overdose using THN in the follow-up period. Participants identified a willingness to access THN from a range of services. While a minority (16%) indicated they were unwilling to pay for THN, the median price that participants were willing to pay was $AUD20 (IQR $10.40).. The ORTHN model of care for THN appears an effective way to disseminate THN to people who use opioids attending AOD, NSP and related health-care settings.

Topics: Adolescent; Adult; Aged; Analgesics, Opioid; Australia; Drug Overdose; Female; Harm Reduction; Health Knowledge, Attitudes, Practice; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Program Evaluation

Since 2016 an increase has been observed in the availability of new synthetic opioids (NSO) in Europe. Cyclopropylfentanyl is a very potent and selective μ-opioid agonist, which was reported for the first time in August 2017 in Europe.. The case was included in a prospective observational study of patients treated in emergency departments after the intake of novel psychoactive substances (NPS). Clinical features were acquired using a structured questionnaire for physicians. Serum and/or urine samples of ED patients were analyzed using liquid chromatography-electrospray ionization-tandem mass spectrometry (LC-ESI-MS/MS) screening methods for NPS.. Within 10 min after intranasal intake of fentanyl, a 25-year-old male developed nausea, profuse sweating and dyspnoe. Because soon afterwards coma and respiratory insufficiency was noticed, the patient was admitted to hospital. After administration of naloxone (0.8 mg) breathing stabilized. However, the patient displayed recurrent decreases of oxygen saturation for 12 h. The intake of cyclopropylfentanyl was analytically confirmed.. The constantly growing diversity of NSO still poses a high risk for drug users and can be a challenging task for clinicians and forensic toxicologists. Clinicians treating opioid overdoses should be aware of the potentially long lasting respiratory depression induced by fentanyl analogs.

Topics: Administration, Intranasal; Adult; Aerosols; Analgesics, Opioid; Chromatography, High Pressure Liquid; Drug Overdose; Fentanyl; Humans; Male; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Predictive Value of Tests; Severity of Illness Index; Spectrometry, Mass, Electrospray Ionization; Substance Abuse Detection; Tandem Mass Spectrometry; Treatment Outcome

We implemented a naloxone education and distribution program in our academic health system. Despite the program, naloxone prescribing was not fully realized. This study aimed to identify the barriers to prescribing.. We conducted a prospective, cross-sectional, mixed-methods study of naloxone prescribers. Participants completed a questionnaire regarding their prescribing practices, attitudes, facilitators, and barriers to prescribing naloxone. Participants were then invited for an interview to further explore these topics and elicit more in-depth explanations.. Sixty-four physicians and eight pharmacists completed the questionnaire (n = 72). The most commonly reported barrier to prescribing naloxone was time constraints (33%). During the interviews, 14 subthemes emerged within four themes: provider competency, provider beliefs, health care system, and patient factors/social climate.. Prescribers identified barriers to naloxone prescribing despite implementation of an institutional overdose education and naloxone distribution (OEND) program. The results were similar to those previously reported prior to initiation of such programs.. In this study, we examined barriers and facilitators to naloxone prescribing. Although previous studies have shown that health care providers endorsed similar barriers, our study indicates that some of those barriers persist despite a concerted effort to educate and promote prescribing via an OEND. While our study is limited by a small, selective sample size the results indicate that improvements to our OEND program are warranted.. Our study addressed an unexplored area of OEND research and may inform future program development. (Am J Addict 2019;00:00-00).

Topics: Adult; Cross-Sectional Studies; Drug Overdose; Female; Health Knowledge, Attitudes, Practice; Humans; Naloxone; Narcotic Antagonists; Pharmacists; Physicians; Prospective Studies; Surveys and Questionnaires; United States

Opioid and Naloxone Education (ONE Rx) is a program that focuses on community pharmacy-based patient screening and interventions to improve population health with regard to opioid use. The objective for this paper is to describe how ONE Rx was implemented, report on the populations impact using the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) Model, and explain future implications of the program.. ONE Rx is a statewide program in which pharmacists screen patients who receive an opioid prescription for the risk of opioid misuse and accidental overdose. The five domains of the RE-AIM Model were used to evaluate ONE Rx. Reach was defined as the proportion of patients receiving opioid prescriptions who completed the screening. Efficacy was defined as the proportion of individuals identified as at risk of opioid misuse or accidental overdose and who received a pharmacist intervention. Adoption was defined as the proportion of eligible community pharmacies who enrolled in ONE Rx. Implementation was defined as the proportion of pharmacies that enrolled in ONE Rx that provided at least five patient screenings. Maintenance was defined as the proportion of pharmacies that adopted ONE Rx that completed at least one screening three months after the initial provision.. Approximately 16.9% of all patients receiving opioid prescriptions were screened for risk of opioid misuse and accidental overdose. Of the patients screened, 97.1% of patients at risk for opioid misuse or accidental overdose received a pharmacist-led intervention. Additionally, 44.8% of the pharmacist that enrolled in ONE Rx completed at least five screenings and of those, 80.0% maintained the program three months later.. ONE Rx demonstrated success and positive population impact. The RE-AIM Model identified strength in the areas of efficacy, adoption and maintenance, and the need for improvement in the areas of reach and implementation.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Opioid-Related Disorders; Pharmacists; Program Evaluation

Prescribing naloxone to patients is a key strategy to prevent opioid overdoses, but little is known about the reach of naloxone prescribing.. Determine patient factors associated with receiving naloxone and trends over time in patients with key overdose risk factors.. Retrospective observational study.. Using the Clinformatics DataMart, a US-wide health insurance claims dataset, we compared adults who received opioids and naloxone (opioid+naloxone) from January 2014 to June 2017 with adults who received opioids without naloxone (opioids only), matched on gender, age ± 5 years, month/year of opioid fill, and number of opioid claims.. Key patient-level opioid overdose risk factors included receipt of high-dosage opioids, concurrent benzodiazepines, history of opioid and other substance use disorders, and history of opioid overdose.. We included 3963 opioid+naloxone and 19,815 opioid only patients. Key factors associated with naloxone fills included high opioid daily dosage (50 to < 90 morphine milligram equivalents (MME): AOR = 2.43, 95% CI 2.15-2.76 and ≥ 90 MME: AOR = 3.94, 95% CI 3.47-4.46; reference: < 50 MME), receiving concurrent benzodiazepines (AOR = 1.27, 95% CI 1.16-1.38), and having a diagnosis of opioid use disorder (AOR = 1.56, 95% CI 1.40-1.73). History of opioid overdose was not associated with naloxone (AOR = 0.92, 95% CI 0.74-1.15). The percent of patients receiving naloxone increased, yet less than 2% of patients in any of the key overdose risk factor groups received naloxone by the last 6 months of the study period.. Naloxone prescribing has increased and was more likely to be co-prescribed to patients with some risk factors for overdose. However, overall prescribing remains minimal. Additional efforts are needed across health systems to increase naloxone prescribing for patients at risk for opioid overdose.

Topics: Adult; Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Risk Factors

Rural communities in the United States have been disproportionately affected by the opioid crisis. Little research has explored the relationship between polysubstance use and overdose experiences among people who inject drugs (PWID) in rural communities. We sought to identify classes of polysubstance drug use among rural PWID and evaluate the associations between polysubstance drug use classes, recent overdose experiences, and receipt of take-home naloxone (THN).. We surveyed 420 PWID (June-July 2018) who had injected drugs in the previous 6 months in Cabell County, West Virginia. Participants were recruited from the local syringe services program and through street-based recruitment. We conducted a latent class analysis using 9 measures of injection and non-injection drug use and tested for associations with having experienced an overdose in the past 6 months and having received THN in the past 6 months.. We identified four substance use classes in our sample: polydrug/polyroute use (35.0% of the sample), polyroute stimulant/injection opioid use (33.3%), polyroute stimulant use (20.3%), and injection opioid use (11.3%). Overall, 42.6% of the sample had experienced an overdose in the past 6 months. The classes differed in terms of overdose (χ=91.53, p<0.001), with the polydrug/polyroute use class having the highest probability of overdose and the polyroute stimulants class having the lowest. Only 46.5% of participants had received THN, and probabilities differed between classes (χ=21.93, p<0.001). The polyroute stimulants/injection opioid use and polydrug/polyroute use classes had the highest levels of THN receipt while the polyroute stimulants use class had the least.. Among rural PWID in West Virginia, polysubstance use was prevalent and associated with overdose and THN acquisition. These analyses demonstrate the importance of scaling up naloxone distribution in rural settings. Overdose prevention initiatives are reaching persons at high risk of overdose, but expansion of services is needed.

Topics: Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pharmaceutical Preparations; Rural Population; Substance Abuse, Intravenous; West Virginia

Substance misuse continues to be a significant concern in the United States, with over 700,000 lives lost from a drug overdose between 1999 and 2017. However, nursing curricula have failed to keep pace with the epidemic.. The current study used a pre-post study design and involved a convenience sample of undergraduate nursing students (n = 37) enrolled in a community health nursing course. Students completed an 11-item online survey examining naloxone stigma, naloxone self-efficacy, and naloxone knowledge. A paired sample t test was conducted to evaluate the impact of the in-person training and education event.. There was a statistically significant increase in post-intervention naloxone knowledge scores from the pre-survey (M = 3.57, SD = 0.959) to the post-survey (M = 4.70, SD = 0.520). Stigma toward naloxone demonstrated a statistically significant increase in the post-intervention stigma survey (M = 9.00, SD = 1.312) compared with the pre-intervention stigma survey (M = 7.78, SD = 2.228). Naloxone self-efficacy also demonstrated a statistically significant increase in the post-intervention naloxone efficacy survey (M = 10.08, SD = 1.064) compared with the pre-intervention naloxone efficacy scores (M = 7.38, SD = 2.22).. The students' scores demonstrated a significant increase in naloxone knowledge, self-efficacy, and stigma. Future research is needed to explore the impact of integrating naloxone education in the undergraduate nursing curriculum.

Topics: Adolescent; Adult; Community Health Nursing; Community-Institutional Relations; Curriculum; Drug Overdose; Education, Nursing, Baccalaureate; Female; Humans; Male; Naloxone; Nursing Education Research; Nursing Evaluation Research; Students, Nursing; Surveys and Questionnaires; United States; Young Adult

Out-of-hospital naloxone has been championed as a lifesaving solution during the opioid epidemic. However, the long-term outcomes of out-of-hospital naloxone recipients are unknown. The objectives of this study are to describe the 1-year mortality of presumed opioid overdose victims identified by receiving out-of-hospital naloxone and to determine which patient factors are associated with subsequent mortality.. This was a regional retrospective cohort study of out-of-hospital records from 7 North Carolina counties from January 1, 2015 to February 28, 2017. Patients who received out-of-hospital naloxone were included. Out-of-hospital providers subjectively assessed patients for improvement after administering naloxone. Naloxone recipients were cross-referenced with the North Carolina death index to examine mortality at days 0, 1, 30, and 365. Naloxone recipient mortality was compared with the age-adjusted, at-large population's mortality rate in 2017. Generalized estimating equations and Cox proportional hazards models were used to assess for mortality-associated factors.. Of 3,085 out-of-hospital naloxone encounters, 72.7% of patients (n=2,244) improved, whereas 27.3% (n=841) had no improvement with naloxone. At day 365, 12.0% (n=269) of the improved subgroup, 22.6% (n=190) of the no improvement subgroup, and 14.9% (n=459) of the whole population were dead. Naloxone recipients who improved were 13.2 times (95% confidence interval 13.0 to 13.3) more likely to be dead at 1 year than a member of the general populace after age adjusting of the at-large population to match this study population. Older age and being black were associated with 1-year mortality, whereas sex and multiple overdoses were not.. Opioid overdose identified by receiving out-of-hospital naloxone with clinical improvement carries a 13-fold increase in mortality compared to the general population. This suggests that this is a high-risk population that deserves attention from public health officials, policymakers, and health care providers in regard to the development of long-term solutions.

Topics: Adolescent; Adult; Analgesics, Opioid; Child; Child, Preschool; Drug Overdose; Emergency Medical Services; Female; Humans; Infant; Infant, Newborn; Life Support Care; Male; Middle Aged; Mortality; Naloxone; Narcotic Antagonists; North Carolina; Proportional Hazards Models; Retrospective Studies; Young Adult

Naloxone is an antidote to opioid overdose, and community pharmacies nationwide now provide broad access to this medication.. The aim of this qualitative study was to understand how leaders in pharmacy organizations perceive pharmacies and pharmacy staff can optimize dispensing of naloxone.. In-depth interviews were conducted with 12 pharmacy leaders in Massachusetts and Rhode Island. Participants were recruited from three types of community pharmacies: (1) chain; (2) independent; and (3) hospital outpatient. Theory-driven immersion crystallization, using Brownlee et al.'s model of healthcare quality improvement, was used to inform coding of the interview data, with predetermined categories of staff; organization; and process.. Five main themes were identified: (1) Importance of staff training to increase comfort; (2) Strength through coordination of efforts; (3) Pharmacy as a community leader in the opioid crisis; (4) Persisting stigma; and (5) Ongoing workflow challenges.. The results uniquely reflect the experiences and insights of pharmacy leaders implementing public health initiatives during the opioid crisis and can be used for gaining insight into how pharmacists can efficiently provide naloxone to their communities.

Topics: Community Pharmacy Services; Drug Overdose; Humans; Massachusetts; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pharmacies; Pharmacists; Pharmacy; Rhode Island

Between 2015 and 2017, Ohio had the second highest number of opioid-related deaths. In July 2015, the Ohio General Assembly approved a law allowing pharmacists to dispense naloxone without a prescription in accordance with a physician-approved protocol. This change in the law allowed pharmacists to have more opportunity to participate in the management of patients who were addicted to opioids.. To determine the association between the implementation of an Ohio law allowing pharmacists to dispense naloxone without a prescription in accordance with a physician-approved protocol and naloxone dispensing rates.. A segmented regression analysis of an interrupted time series was performed for 30 consecutive months to evaluate the change in the naloxone dispensing rate before and after the implementation of the state law. Ohio Medicaid naloxone claims and Kroger Pharmacy naloxone claims for all 88 counties in Ohio were examined. Any patient 18 years or older with at least 1 naloxone order dispensed through Ohio Medicaid or by a Kroger Pharmacy in Ohio during the study period of July 16, 2014, to January 15, 2017, was included in the study. Data were analyzed from April 23, 2018, to July 7, 2019.. The primary independent variable was implementation of an Ohio law allowing pharmacists to dispense naloxone without a prescription in accordance with a physician-approved protocol, which took effect in July 2015.. The primary outcome measure was the naloxone dispensing rate per month per county.. In the Ohio Medicaid population, the number of naloxone orders dispensed after the policy was implemented increased by 2328%, from 191 in the prepolicy period to 4637 in the postpolicy period. The rate of naloxone orders dispensed per month per county after the policy was implemented increased by 4% in the Ohio Medicaid population and 3% in the Kroger Pharmacy population compared with the prepolicy period. The rate of naloxone orders dispensed after the policy was implemented increased by 18% per month in low-employment counties compared with high-employment counties in the Ohio Medicaid population.. The implementation of a state law allowing pharmacists to dispense naloxone without a prescription in accordance with a physician-approved protocol was associated with an increase in the number of naloxone orders dispensed in the Ohio Medicaid and Kroger Pharmacy populations. Moreover, a significant increase was observed in the naloxone dispensing rate among the Ohio Medicaid population in counties with low employment and high poverty.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Cohort Studies; Drug Overdose; Drug Prescriptions; Female; Humans; Male; Medicaid; Middle Aged; Naloxone; Narcotic Antagonists; Ohio; Practice Patterns, Physicians'; Retrospective Studies; United States; Young Adult

Opioid overdose deaths have been rising steadily over the past decade in Rhode Island (RI), and although deaths have decreased slightly over the past year, there were 314 deaths in 2018 and there have been 208 deaths in the first 9 months of 2019.1 The objective of this spatial study is to identify the RI regions with the greatest need for opioid emergency response and rehabilitation resources. Using geographic information systems (GIS), we identify areas in RI with high overdose rates and that are far from emergency departments, and areas with high rates of treatment admissions that are far away from Centers of Excellence (COEs) which provide effective medication-assisted treatment (MAT). Ultimately, we identified Burrillville, Coventry, Bristol, and Portsmouth as towns needing more emergency resources and Western Hopkinton, Western Richmond, and Western Scituate as areas needing more high-quality rehabilitation resources. These findings should inform future decisions when considering new locations for COEs or emergency resources to respond to the Rhode Island opioid epidemic.

Topics: Analgesics, Opioid; Drug Overdose; Geographic Information Systems; Humans; Naloxone; Opiate Substitution Treatment; Rhode Island

Topics: Analgesics, Opioid; Drug Overdose; Humans; Law Enforcement; Naloxone; Pennsylvania; Police; Surveys and Questionnaires

The continued toll of opioid-related overdoses has motivated efforts to expand availability of naloxone to persons at high risk of overdose, with 2016 federal guidance encouraging clinicians to co-prescribe naloxone to patients with increased overdose risk. Some states have pursued analogous or stricter legal requirements that could more heavily influence prescriber behavior.. We conducted a systematic legal review of state laws that mandate or recommend that healthcare providers prescribe naloxone to patients with indicators for opioid overdose risk. We coded relevant statutes and regulations for: applicable populations, patient criteria, educational requirements, and exemptions.. As of September 2019, 17 states had enacted naloxone co-prescribing laws, the earliest of which was implemented by Louisiana in January 2016. If patient overdose risk criteria are met, over half of these states mandate that providers prescribe naloxone (7 states, 41.1 %) or offer a naloxone prescription (2 states, 11.8 %); the remainder encourage prescribers to consider prescribing naloxone (8 states). Most states (58.8 %) define patient overdose risk based on opioid dosages prescribed, although the threshold varies substantially; other common overdose risk criteria include concomitant opioid and benzodiazepine prescriptions and patient history of substance use disorder or mental illness.. A growing minority of states has adopted a naloxone prescribing law, although these policies remain less prevalent than other naloxone access laws. By targeting higher-risk patients during clinical encounters, naloxone prescribing requirements could increase naloxone prescribed, destigmatize naloxone use, and reduce overdose harms. Further investigation into policy effectiveness, unintended consequences, and appropriate parameters is warranted.

Topics: Analgesics, Opioid; Databases, Factual; Drug Overdose; Drug Prescriptions; Female; Humans; Legislation, Drug; Male; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; United States

Topics: Community Pharmacy Services; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pharmacists; Professional Role; Supermarkets

The US opioid crisis was deemed a public health emergency in 2017. More than 130 individuals in the US die daily as a result of unintentional opioid overdose deaths.. To measure use of take-home naloxone for overdose reversals performed by study participants with opioid use disorder receiving treatment at an opioid treatment program.. In a year-long cohort study, between April 4, 2016, and May 16, 2017, 395 study participants enrolled at the University of New Mexico Addiction and Substance Abuse Opioid Treatment Program, an outpatient clinic treating substance use disorders. Inclusion criteria included all patients enrolled at University of New Mexico Addiction and Substance Abuse Opioid Treatment Program during the study enrollment period; positive history of opioid use disorder treated with methadone, buprenorphine, or naltrexone; and age 18 years or older. Exclusion criteria included allergy to naloxone and age younger than 18 years. The study closed 1 year after enrollment, on May 17, 2018. Data analysis was performed from May 2018 to July 2019.. Two doses of take-home naloxone combined with opioid overdose education were provided to study participants.. The primary outcome was to measure the association of take-home naloxone with overdose reversals performed by patients with opioid use disorder enrolled in an opioid treatment program.. We enrolled 395 study participants (270 female [68.4%]; mean [SD] age, 35.4 [12.6] years; 260 [65.8%] with Hispanic white race/ethnicity) in the 1-year prospective trial. Sixty-eight female participants (25.2% of all female participants) were pregnant at the time of enrollment. Seventy-three of the 395 study participants (18.0%) performed 114 overdose reversals in the community. All community reversals were heroin related. Most study participants (86.8%) stated that the person on whom they performed an overdose reversal was a friend, relative, acquaintance, or significant other. In the year before enrollment, only 18 study participants (4.5%) had been prescribed naloxone.. Take-home naloxone as part of overdose education and naloxone distribution provided to patients in an opioid treatment program may be associated with a strategic targeted harm reduction response for reversing opioid overdose-related deaths. Policy makers may consider regulations to mandate overdose education and naloxone distribution in opioid treatment programs.

Topics: Adult; Analgesics, Opioid; Drug Overdose; Female; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pregnancy; Prospective Studies; Young Adult

It is unknown if targeted risk reduction counseling in the health care setting, after documented exposure to fentanyl, can affect behavior change to reduce risks and increase utilization of evidence-based overdose prevention strategies.. We conducted a retrospective analysis of results (7/2018-6/2019) from questionnaire-facilitated counseling by recovery coaches in the emergency department (ED) and primary care settings following disclosure of a urine toxicology positive for fentanyl.. Seventy-five percent of N = 101 respondents were neither aware of nor expecting fentanyl in their substances of use. Fifty-three (70 %) of those initially unaware answered that learning about exposure to and the risks from fentanyl changed their thoughts about reducing or abstaining from use. A greater proportion of patients seen in the ED expressed desire to stop or reduce opioid use as compared to ambulatory clinic patients (91 % vs. 46 %, p < 0.001). Of those not already engaged in treatment, 18 % and 15 % were interested in medication and behavioural health treatment, respectively, and each of them indicated a change in thought based on the counseling. Forty-five percent of individuals not yet receiving naloxone endorsed interest in receiving it, and 22 % of all respondents were somewhat or very interested in access to safe consumption sites.. This study suggests a novel clinical utility in toxicology screens to inform behavior in the setting of illicit fentanyl exposure. In addition to linkages to evidence-based treatment, linkages to harm-mitigating strategies associated with ongoing substance use may be critical to a comprehensive overdose prevention strategy in the clinical setting.

Topics: Adult; Analgesics, Opioid; Drug Overdose; Emergency Service, Hospital; Female; Fentanyl; Health Knowledge, Attitudes, Practice; Heroin; Heroin Dependence; Humans; Male; Middle Aged; Naloxone; Opioid-Related Disorders; Retrospective Studies; Risk Reduction Behavior; Surveys and Questionnaires; Young Adult

In 2017, Ohio had the second highest rate of drug overdose deaths in the United States. Current opioid related epidemiologic literature has begun to uncover the environmental level influences on the opioid epidemic and how the end results may ultimately manifest over space and time. This work is still nascent however, with most clustering research conducted at a spatial unit such as county level, which (1) can obscure differences between urban and rural communities, (2) does not consider dynamics that cross county lines, and (3) is difficult to interpret directly into strategic and localized intervention efforts. We address this gap by describing, at the Census block level, the spatial-temporal clustering of opioid related events in rural Ohio.. We use the outcome of the administration of naloxone emergency medical service (EMS) calls in rural Ohio Census blocks during 2010-16 in a Poisson model of spatial scan statistics.. We found that naloxone event clustering in rural Ohio in the recent decade was widely dispersed over time and space, with clusters that average 17 times the risk of having an event compared to areas outside the cluster. Many of the larger spatial clusters crossed administrative boundaries (i.e., county lines) suggesting that opioid misuse may be less responsive to county level policies than to other factors.. Timely identification of localized overdose event clustering can guide affected communities toward rapid interventions aimed at minimizing the morbidity and mortality resulting from contagious opioid misuse.

Topics: Cluster Analysis; Drug Overdose; Emergency Medical Services; Female; Humans; Male; Naloxone; Narcotic Antagonists; Ohio; Rural Population; Spatial Analysis; Time Factors

Topics: Drug Overdose; Fentanyl; Humans; Illinois; Naloxone; Substance-Related Disorders

Overdose is a leading cause of death in the United States, especially among people who inject drugs (PWID). Improving naloxone access and carrying among PWID may offset recent increases in overdose mortality associated with the influx of synthetic opioids in the drug market. This study characterized prevalence and correlates of several naloxone outcomes among PWID.. During 2018, a survey to assess experience with naloxone was administered to 915 participants in the AIDS Linked to the IntraVenous Experience (ALIVE) study, an ongoing community-based observational cohort of people who currently inject or formerly injected drugs in Baltimore, Maryland. We examined the associations of naloxone outcomes (training, supply, use, and regular possession) with socio-demographic, substance use and healthcare utilization factors among PWID in order to characterize gaps in naloxone implementation among this high-risk population.. Median age was 56 years, 34% were female, 85% were African American, and 31% recently injected. In the past six months, 46% (n = 421) reported receiving training in overdose prevention, 38% (n = 346) had received a supply of naloxone, 9% (n = 85) had administered naloxone, and 9% (n = 82) reported usually carrying a supply of naloxone. Recent non-fatal overdose was not associated with any naloxone outcomes in adjusted analysis. Active opioid use (aOR = 2.10, 95% CI: 1.03, 4.28) and recent treatment of alcohol or substance use disorder (aOR = 2.01, 95% CI: 1.13, 3.56) were associated with regularly carrying naloxone.. Further work is needed to encourage PWID to carry and effectively use naloxone to decrease rates of fatal opioid overdose. While accessing treatment for substance use disorder was positively associated with carrying naloxone, EMS response to 911 calls for overdose, the emergency department, and syringe services programs may be settings in which naloxone access and carrying could be encouraged among PWID.

Topics: Adult; Baltimore; Cohort Studies; Cross-Sectional Studies; Drug Overdose; Female; Harm Reduction; Humans; Male; Maryland; Middle Aged; Naloxone; Opioid-Related Disorders; Prevalence; Risk Factors; Substance Abuse, Intravenous

Opioid overdose is a growing problem in the US. Often, residents are first responders to community and in-hospital opioid overdoses, and so, hands-on naloxone administration education is necessary. While residents get a brief algorithm on suspected opioid overdose during their mandatory American Heart Association basic life support training, there is a lack of hands-on standardized curricula on how to administer this lifesaving medication.. To fill this gap, we developed a hands-on workshop for medical trainees on how to respond to an opioid overdose. Trainees who completed our workshop left with a first-responder naloxone kit using the Massachusetts statewide open prescription. All attendees were asked to take a voluntary pre- and posttraining survey.. A total of 80 trainees from a variety of specialties and training levels participated in this workshop. We were able to successfully link the pre- and postdata of 29 participants. Trainees were assessed on comfort in administering naloxone as a first responder and in teaching patients how to administer naloxone (via a 5-point Likert scale) and on percentage of time they prescribed naloxone to high-risk patient populations. We saw statistically significant increases in comfort in using naloxone and comfort in teaching patients to administer naloxone.. This innovative curriculum provides an adaptable, short, and effective workshop with hands-on practice for medical trainees at a variety of training levels. The workshop can efficiently train future health care professionals how to approach an opioid overdose.

Topics: Academic Medical Centers; Analgesics, Opioid; Drug Overdose; Emergency Responders; Health Personnel; Hospitals; Humans; Internal Medicine; Massachusetts; Naloxone; Surveys and Questionnaires

Topics: Analgesics, Opioid; Drug Overdose; Epidemics; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders

Drug overdose is a significant public health problem, yet little is known about racial/ethnic differences in drug overdose rates and/or in responses to a drug overdose following naloxone administration. This paper examines differences in rates of survivorship, response, revival and administration of naloxone by race and ethnicity among those who experienced a drug overdose in Pennsylvania between January 1, 2018 and December 31, 2019. Spatio-temporal variations in drug overdose locations were examined to facilitate understanding of service development, planning, and delivery of effective treatment need.. Ten thousand two hundred and ninety drug overdose incidents were analyzed from the Pennsylvania Overdose Information Network (ODIN). The ODIN is a centralized repository that contains information on drug overdoses victims including age, gender and race/ethnicity, naloxone administrations and survivorship, drug(s) suspected of causing the overdose, victim outcomes (e.g. hospitalizations and arrests) and average naloxone dosage per victim. Between group differences were tested using χ2 -tests of independence. Multivariate logistic regression was used to estimate the predicted probability of survivorship according to victim characteristics. All statistical analyses and mapping were performed using the R statistical programming environment.. About eighty-seven percent of drug overdose response victims were white, and seventy-one percent were between the ages of 20-39. White females were more likely to receive an overdose response compared to black or Hispanic females. A non-opioid was indicated more frequently in overdoses involving black victims compared to either whites or Latinos. Latinos and blacks were more likely to survive a drug overdose. However, following naloxone administration, no racial or ethnic differences in survivorship were noted. Differences in responsiveness to naloxone and transitions to care following the drug overdose event were also found. Finally, overdoses among Blacks and Latinos demonstrated a stronger spatial patterning across counties compared to whites.. This study found a significant, disparate impact of race/ethnicity on fatal drug overdoses when naloxone is not administered. Further, individuals who were administered naloxone and subsequently received medical care in a hospital experienced lower drug-related mortality, suggesting that first responders are critical intervention points for individuals in need of medical treatment following a drug overdose. However, while naloxone administration is a necessary first step in the recovery process, longitudinal pathways towards treatment are critical to stem the drug overdose crisis.

Topics: Adult; Analgesics, Opioid; Drug Overdose; Emergency Responders; Female; Humans; Naloxone; Narcotic Antagonists; Pennsylvania; Young Adult

Topics: Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Nonprescription Drugs; Pharmacies

Opioid use and overdose are epidemic in the United States. While there is concern regarding the abuse of illegal opioids, overdose is also strongly associated with prescription opioids. The Centers for Disease Control and Prevention supports coprescribing of naloxone with opioids; however, a review of naloxone prescriptions recorded within a primary care group indicated limited use of the reversal agent.. Through the collaboration of pharmacy and information services personnel, a report was created to identify all patients receiving chronic opioid therapy. To assess the risk of overdose, a validated risk scoring method was used. If patients were determined to be at high risk for overdose, outreach by a clinical pharmacist was conducted to educate them on the benefits of naloxone. For patients agreeable to receiving naloxone, prescriptions were entered into the electronic health record for primary care provider (PCP) verification. Contact was made following order verification to ensure patient understanding of proper naloxone use and naloxone accessibility.. Prior to the project (ie, in calendar year 2016), only 5 prescriptions for naloxone had been prescribed within the medical group. During the naloxone coprescribing initiative, 230 patients were identified by clinical pharmacists as being at elevated risk for opioid overdose. Of these, 86 (37%) were deemed ineligible for naloxone. Out of the 144 patients determined to be eligible, 63 (44%) were agreeable to receiving naloxone. Further review determined that 7 additional patients were agreeable after a follow-up conversation with their PCP. Of the patients that agreed to receive naloxone, 48 (76%) confirmed that they had picked up naloxone from their pharmacy.. The naloxone coprescribing initiative was an innovative project that focused on an epidemic that affects communities across the United States. This program embraced the strengths of multiple departments for the good of the patient, in keeping with the idea of team-based care. The pharmacy-driven approach highlighted the importance of having pharmacists within an ambulatory care setting and allowed high-level pharmacist practice without adding to the workload of other members of the healthcare team.

Topics: Cooperative Behavior; Drug Overdose; Health Services Accessibility; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Patient Care Team; Pharmaceutical Services; Pharmacists; Primary Health Care; Professional Role

Topics: Analgesics, Opioid; Drug Overdose; Humans; Mississippi; Naloxone; Narcotic Antagonists; United States

In the context of the opioid overdose crisis, local health departments are on the front lines, coordinating programs and services and translating state and federal policies into community action. While media reports describe growth of Overdose Education and Naloxone Distribution (OEND) programs among local health departments, little is known about program features, scope, and target populations.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Policy; United States

Topics: Alcoholism; Cocaine-Related Disorders; Dopamine; Drug Overdose; Heroin Dependence; History, 20th Century; History, 21st Century; Humans; Marijuana Abuse; Methadone; Methamphetamine; Naloxone; National Institutes of Health (U.S.); Neurosciences; Opioid-Related Disorders; Positron-Emission Tomography; Prefrontal Cortex; Psychiatry; Reward; Socioeconomic Factors; United States

Despite consensus recommendations from the American College of Emergency Physicians (ACEP), the Centers for Disease Control and Prevention, and the surgeon general to dispense naloxone to discharged ED patients at risk for opioid overdose, there remain numerous logistic, financial, and administrative barriers to implementing "take-home naloxone" programs at individual hospitals. This article describes the recent collective experience of 7 Chicago-area hospitals in implementing take-home naloxone programs. We highlight key barriers, such as hesitancy from hospital administrators, lack of familiarity with relevant rules and regulations in regard to medication dispensing, and inability to secure a supply of naloxone for dispensing. We also highlight common facilitators of success, such as early identification of a "C-suite" champion and the formation of a multidisciplinary team of program leaders. Finally, we provide recommendations that will assist emergency departments planning to implement their own take-home naloxone programs and will inform policymakers of specific needs that may facilitate dissemination of naloxone to the public.

Topics: Chicago; Drug Overdose; Emergency Service, Hospital; Health Plan Implementation; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Patient Discharge; State Government

Naloxone is an opioid antagonist that can reverse an opioid overdose. Increased opioid-related mortality rates led to greater distribution of naloxone without a prescription and administration of naloxone by laypersons. This study fills a gap in knowledge of naloxone experiences among active users of opioids living in suburban communities.. The purpose of this article is to provide nurse practitioners with an in-depth understanding of current naloxone use practices among people who experience overdose events. The specific aims are to compare access to naloxone in diverse suburban towns, to examine administration differences across settings, and to understand perspectives on naloxone experiences from people who are actively using opioids.. The data for this analysis were drawn from an ethnographic study in the suburban towns around Atlanta, Georgia; Boston, Massachusetts; and New Haven, Connecticut. Short surveys and in-depth interviews were collected. Inductive methods were used to compare data across settings.. The sample of 106 included 48% female, 62% White, 24% African American/Black, 13% more than one race, and 21% Hispanic/Latinx. The mean age was 41.35 years.. Differences between study settings in access to naloxone, administration frequency, and delivery systems were found. Findings suggest more education and training is needed in overdose prevention and harm reduction intervention. Studies on delivery systems need to address the increase in fentanyl-related overdoses.. Nurse practitioners can help to target distribution of naloxone in local communities, facilitate collaboration with harm reduction services, and provide evidence-based education and training to laypersons.

Topics: Adult; Analgesics, Opioid; Drug Overdose; Female; Harm Reduction; Humans; Male; Naloxone; Narcotic Antagonists

Emergency department (ED)-based naloxone distribution programs are a widespread harm reduction strategy. However, data describing the community penetrance of naloxone distributed from these programs are lacking. This study gauges acceptance of naloxone use and monitoring technology among people who use drugs (PWUD), and explores the use of real-time location systems (RTLS) in monitoring naloxone movements.. A prospective observational study was conducted on a convenience sample of individuals (N = 30) presenting to a tertiary-care academic medical center ED for an opioid-related complaint. A naloxone kit equipped with a low-energy Bluetooth (BLE) tracking system was employed to detect movement of naloxone off the hospital campus as a proxy for community penetrance, followed by a qualitative interview to gauge participant acceptance of naloxone use and monitoring technology.. Detection of BLE signals verified transit of 24 distributed naloxone kits off our hospital campus. Three participants whose BLE signals were not captured reported taking their kits with them following discharge, suggesting technological errors occurred; another three participants were lost to follow-up. Qualitative interviews demonstrated that participants accepted ED-based naloxone distribution programs and passive tracking technologies, but revealed concerns regarding hypothetical continuous monitoring systems and problematic interactions with first responders and law enforcement personnel.. Based on acquired BLE signals, 80% of dispensed naloxone kits left the hospital campus. Use of RTLS to passively geolocate naloxone rescue kits is feasible, but detection can be adversely affected by technological errors. PWUD are amenable to transient monitoring technologies but identified barriers to implementation.

Topics: Adult; Drug Overdose; Emergency Service, Hospital; Female; Geographic Information Systems; Harm Reduction; Humans; Male; Naloxone; Narcotic Antagonists; Opioid Epidemic; Opioid-Related Disorders; Patient Acceptance of Health Care; Program Evaluation; Prospective Studies; Wireless Technology

Topics: Drug and Narcotic Control; Drug Overdose; Drug Prescriptions; Health Services Accessibility; Humans; Naloxone; United States

To determine the cost-effectiveness of pharmacy-based intranasal naloxone distribution to high-risk prescription opioid (RxO) users.. We developed a Markov model with an attached tree for pharmacy-based naloxone distribution to high-risk RxO users using 2 approaches: one-time and biannual follow-up distribution. The Markov structure had 6 health states: high-risk RxO use, low-risk RxO use, no RxO use, illicit opioid use, no illicit opioid use, and death. The tree modeled the probability of an overdose happening, the overdose being witnessed, naloxone being available, and the overdose resulting in death. High-risk RxO users were defined as individuals with prescription opioid doses greater than or equal to 90 morphine milligram equivalents (MME) per day. We used a monthly cycle length, lifetime horizon, and US healthcare perspective. Costs (2018) and quality-adjusted life-years (QALYs) were discounted 3% annually. Microsimulation was performed with 100 000 individual trials. Deterministic and probabilistic sensitivity analyses were conducted.. One-time distribution of naloxone prevented 14 additional overdose deaths per 100 000 persons, with an incremental cost-effectiveness ratio (ICER) of $56 699 per QALY. Biannual follow-up distribution led to 107 additional lives being saved with an ICER of $84 799 per QALY compared with one-time distribution. Probabilistic sensitivity analyses showed that a biannual follow-up approach would be cost-effective 50% of the time at a willingness-to-pay (WTP) threshold of $100 000 per QALY. Naloxone effectiveness and proportion of overdoses witnessed were the 2 most influential parameters for biannual distribution.. Both one-time and biannual follow-up naloxone distribution in community pharmacies would modestly reduce opioid overdose deaths and be cost-effective at a WTP of $100 000 per QALY.

Topics: Administration, Intranasal; Analgesics, Opioid; Community Pharmacy Services; Cost-Benefit Analysis; Drug Costs; Drug Overdose; Humans; Markov Chains; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Quality-Adjusted Life Years; Risk

Our objective was to assess how a naloxone counseling experience impacted student pharmacists' confidence in counseling patients on naloxone use and their attitudes towards people who use drugs.. Students who completed a naloxone counseling experience at a syringe exchange program were recruited to conduct individual interviews. Investigators asked student participants open-ended questions to identify their perceptions in the following domains: experiences with naloxone, reported impact of naloxone counseling experience on confidence, experiences with people who use drugs, value of the experience, and suggestions for improvement for the experience.. Fifteen student pharmacists participated in semi-structured interviews. Fourteen of these students reported the experience as extremely valuable in developing their confidence with naloxone. The average change in confidence was 5.2 points on a 1 through 10 scale, and seven of the student pharmacists independently suggested that a naloxone counseling experience be incorporated the required doctor of pharmacy curriculum. The qualitative themes that emerged from student feedback were breaking down the stigma of addiction and feeling useful during this experience.. Participation in a naloxone counseling experience at a syringe exchange program was perceived as helpful in improving student pharmacist confidence in counseling patients on naloxone use. Incorporation of required experiential learning about naloxone and people who use drugs may positively impact student pharmacists by giving them more confidence and experience with this underserved population.

Topics: Adult; Attitude of Health Personnel; Counseling; Drug Overdose; Female; Humans; Male; Naloxone; Narcotic Antagonists; Needle-Exchange Programs; Ohio; Schools, Pharmacy; Social Stigma; Students, Pharmacy; Surveys and Questionnaires

Topics: Analgesics, Opioid; Antidotes; Buprenorphine; Drug Overdose; Humans; Methadone; Naloxone; Prospective Studies; Respiratory Insufficiency

Topics: Drug Overdose; Drug Therapy; Guidelines as Topic; Humans; Naloxone; Prescription Drugs; Preventive Health Services; United States

Topics: Administration, Intranasal; Canada; COVID-19; Drug Overdose; Emergency Medical Services; Humans; Naloxone; Narcotic Antagonists; Pandemics; Risk; SARS-CoV-2

Naloxone is a safe and effective medication to help reverse opioid overdose. Providing take-home naloxone to patients in opioid treatment settings is a critical step to reducing opioid overdose deaths. In New Mexico, a US state with one of the highest rates of opioid overdose deaths, legislation was passed in 2017 (House Bill 370) to support take-home naloxone, and followed by naloxone training of Opioid Treatment Program staff to increase distribution.. Naloxone training was offered to all New Mexico Opioid Treatment Programs along with a baseline survey to assess current practices and barriers to take-home naloxone distribution. Focus groups were conducted approximately 1 year post-training with staff at a subset of the trained Opioid Treatment Programs to assess the impact of the legislation and training provided.. Baseline survey results show most Opioid Treatment Program staff were unfamiliar with House Bill 370, reported conflicting understandings of their agency's current take-home naloxone practices, and reported a number of barriers at the patient, agency, and policy level. Follow-up focus groups revealed support for House Bill 370 but persistent barriers to its implementation at the patient, agency, and policy level including patient receptivity, cost of naloxone, staff time, and prohibitive pharmacy board regulations.. In spite of targeted legislation and training, provision of take-home naloxone at remained low. This is alarming given the need for this lifesaving medication among the Opioid Treatment Program patient population, and high opioid death rate in New Mexico. Locally, important next steps include clarifying regulatory guidelines and supporting policy/billing changes to offset costs to Opioid Treatment Programs. Globally, additional research is needed to identify the prevalence of take-home naloxone distribution in similar settings, common barriers, and best practices that can be shared to increase access to this vital lifesaving medication in this critical context.

Topics: Adult; Drug Overdose; Female; Health Services Accessibility; Humans; Male; Naloxone; Narcotic Antagonists; New Mexico; Opioid-Related Disorders; Program Evaluation

North America is experiencing an unprecedented overdose crisis driven by the proliferation of fentanyl and its analogues in the illicit drug supply. In 2018 there were 67,367 drug overdose deaths in the United States, and since 2016, there have been more than 14,700 overdose deaths in Canada, with most related to fentanyl. Despite concerted efforts and some positive progress, current public health, substance use treatment, and harm reduction interventions (such as widespread naloxone distribution and implementation of supervised consumption sites) have not been able to rapidly decrease overdose fatalities. In view of the persistent gaps in services and the limitations of available options, immediate scale-up of low-barrier opioid distribution programs are urgently needed. This includes "off-label" prescription of pharmaceutical grade opioids (e.g., hydromorphone) to disrupt the toxic drug supply and make safer opioids widely available to people at high risk of fatal overdose.

Topics: Analgesics, Opioid; Canada; Drug Overdose; Fentanyl; Humans; Naloxone; North America; United States

The opioid crisis highlights the need to increase access to naloxone, possibly through regulatory approval for over-the-counter sales. To address industry-perceived barriers to such access, the Food and Drug Administration (FDA) developed a model drug facts label for such sales to assess whether consumers understood the key statements for safe and effective use.. In this label-comprehension study, we conducted individual structured interviews with 710 adults and adolescents, including 430 adults who use opioids and their family and friends. Eight primary end points were developed to assess user comprehension of each of the key steps in the label. Each of these end points included a prespecified target threshold ranging from 80 to 90% that was evaluated through a comparison of the lower boundary of the 95% exact confidence interval.. The results for performance on six primary end points met or exceeded thresholds, including the steps "Check for a suspected overdose" (threshold, 85%; point estimate [PE], 95.8%; 95% confidence interval [CI], 94.0 to 97.1) and "Give the first dose" (threshold, 85%; PE, 98.2%; 95% CI, 96.9 to 99.0). The lower boundaries for four other primary end points ranged from 88.8 to 94.0%. One exception was comprehension of "Call 911 immediately," but this instruction closely approximated the target of 90% (PE, 90.3%; 95% CI, 87.9 to 92.4). Another exception was comprehension of the composite step of "Check, give, and call 911 immediately" (threshold, 85%; PE, 81.1%; 95% CI, 78.0 to 83.9).. Consumers met thresholds for sufficient understanding of six of eight components of the instructions in the drug facts label for naloxone use and came close on two others. Overall, the FDA found that the model label was adequate for use in the development of a naloxone product intended for over-the-counter sales.

Topics: Adolescent; Adult; Analgesics, Opioid; Comprehension; Drug Labeling; Drug Overdose; Government Regulation; Humans; Interviews as Topic; Naloxone; Narcotic Antagonists; Nonprescription Drugs; United States; United States Food and Drug Administration

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.

Topics: Analgesics, Opioid; Cross-Sectional Studies; Drug Overdose; Health Services Accessibility; Humans; Naloxone; Narcotic Antagonists; Retrospective Studies; State Government; United States

Rapid resuscitation of an opioid overdose with naloxone, an opioid antagonist, is critical. We developed an opioid receptor quantitative systems pharmacology (QSP) model for evaluation of naloxone dosing. In this model we examined three opioid exposure levels that have been reported in the literature (25 ng/ml, 50 ng/ml, and 75 ng/ml of fentanyl). The model predicted naloxone-fentanyl interaction at the mu opioid receptor over a range of three naloxone doses. For a 2 mg intramuscular (IM) dose of naloxone at lower fentanyl exposure levels (25 ng/ml and 50 ng/ml), the time to decreasing mu receptor occupancy by fentanyl to 50% was 3 and 10 minutes, respectively. However, at a higher fentanyl exposure level (75 ng/ml), a dose of 2 mg IM of the naloxone failed to reduce mu receptor occupancy by fentanyl to 50%. In contrast, naloxone doses of 5 mg and 10 mg IM reduced mu receptor occupancy by fentanyl to 50% in 5.5 and 4 minutes respectively. These results suggest that the current doses of naloxone (2 mg IM or 4 mg intranasal (IN)) may be inadequate for rapid reversal of toxicity due to fentanyl exposure and that increasing the dose of naloxone is likely to improve outcomes.

Topics: Analgesics, Opioid; Binding, Competitive; Computer Simulation; Dose-Response Relationship, Drug; Drug Overdose; Fentanyl; Humans; Models, Theoretical; Naloxone; Narcotic Antagonists; Receptors, Opioid, mu; Treatment Outcome

The prevalence of opioid use and misuse in the United States contributed to 48,000 opioid related deaths in 2018. Naloxone, a potent opioid reversal agent, can be dispensed by pharmacists without a prescription, however few do so. Previous studies on naloxone dispensing have contributed to our understanding of the determinants of naloxone in community pharmacy, however, none have focused on comprehensive behavioral change. This study utilized the Capability, Opportunity, Motivation, and Behavior (COM-B) model, a behavioral change and intervention design framework, to examine community pharmacists' comfort dispensing naloxone.. A 48-item questionnaire grounded in the COM-B and theoretical domains framework was developed and mailed to 1,000 community pharmacists in Texas, USA using a modified Dillman cross-sectional survey design. Confirmatory factor analysis was used to refine and establish dimensionality of the hypothesized scales and structural equation modeling was used to estimate the fit of the COM-B in explaining pharmacists' comfort dispensing naloxone.. The usable response rate was 19.4%. Of surveyed pharmacists, 29.7% had ever had a patient request naloxone and 35.1% had dispensed naloxone without a prescription. Capability and opportunity explained 60% of the variance in motivation. Opportunity and motivation were the most salient predictors of comfort dispensing naloxone. Together, capability, opportunity, and motivation explained 78.1% of variance in pharmacists' comfort dispensing naloxone, indicating that the COM-B model is useful in this setting.. Despite previous findings, policy interventions to increase naloxone dispensing should go beyond providing additional education to the pharmacy workforce. Rather, these results suggest that a complex intervention designed with pharmacist input that enables them to act autonomously and evaluate whether patients need naloxone may increase their comfort dispensing. Without collaboration from pharmacy and managed care corporations, dissemination efforts will continue to be limited.

Topics: Cross-Sectional Studies; Drug Overdose; Humans; Latent Class Analysis; Motivation; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pharmacists; Texas

In New Mexico, drug overdose rates have been among the highest in the nation for the past two decades, with 332 overdose deaths involving opioids in 2017. While interventions aimed at enhancing distribution and uptake of take-home naloxone (THN) have identified people who use opioids as viable candidates, there exists a gap in applying these findings to underserved, ethnic minority women.. We conducted qualitative interviews with participants recruited from a parent study which recruited 395 women diagnosed with OUD who participated in a two year study (April 2016-May 2018) during which they received opioid overdose education and two free THN kits for their use.. Findings characterize the social dynamics of persistent opioid exposure, accidental overdose, and take home naloxone use to reverse overdose, and we identified three overarching themes: 1) Crisis management and community responsibility; 2) Complex social networks as informal channels for family to family and peer to peer naloxone distribution and education; and 3) Participant preferences and strategies for THN distribution and education.. Participants in the ASAP program demonstrated an unquestionable willingness to distribute naloxone when they had access to it, and the ability to replace it. Further research is warranted to apply these findings in interventional contexts to refine strategies toward prioritizing distribution of THN, enhance training tools and optimize community locations for engagement.

Topics: Drug Overdose; Ethnicity; Female; Humans; Minority Groups; Naloxone; Narcotic Antagonists; New Mexico; Opioid-Related Disorders

Topics: Analgesics, Opioid; Drug Overdose; Harm Reduction; Humans; Naloxone; Narcotic Antagonists; Needle-Exchange Programs; Opioid Epidemic; Opioid-Related Disorders; Public Health Practice; Substance Abuse Treatment Centers; Substance Abuse, Intravenous; United States

While rates of opioid overdose deaths in North American have increased exponentially in recent years, most overdoses are not fatal, especially when witnesses are present and can intervene. Previous research has found that some people who use drugs [PWUDs] trained in overdose response might cut social ties with frequent overdosers, leading to more solitary opioid use and risk of death if someone overdoses alone. To examine the phenomenon of social distancing of people who overdose frequently, we used data from fifty-two in-depth qualitative interviews collected in Southern California with PWUDs who had recently witnessed an opioid overdose. Transcripts were reviewed and coded thematically, using the Integrated Threat Theory (ITT) to conceptualize the observed phenomenon. ITT outlines how realistic and symbolic threats are experienced by a group. We found that while some participants acknowledged the role of adulterated street drugs in overdoses, individualized blame was nonetheless imposed. Accusations of careless drug use practices fostered negative stereotyping towards frequent overdosers. This was attributed to the need to summon 911 for rescue, which often resulted in police dispatch. The intergroup relationship between police and PWUDs is precarious as police pose realistic threats onto PWUDs - such as incarceration, eviction, and manslaughter charges - leading to intragroup anxiety among PWUDs about future overdose events, and labelled frequent overdosers as liabilities. These threats, and inter/intra-group conflict, explained one reason how and why non-fatal overdoses led to social distancing events. People who overdose frequently were also accused of breaking the norm of drug user surreptitiousness; a symbolic threat that endangered the group due to police exposure. Social distancing might dampen exposure to the protective effect of peer-led interventions such as take-home naloxone programs, increasing risk of overdose death. This phenomenon highlights how intergroup dynamics are driving intragroup processes. Suggestions for tailoring public health interventions are discussed.

Topics: Drug Overdose; Drug Users; Humans; Naloxone; Opioid-Related Disorders; Physical Distancing

Current rates of opioid-related mortality have been increasing globally. An effective harm reduction program consists of overdose education and naloxone distribution (OEND) programs. Incorporating both education and naloxone administration, OENDs have been reported to improve knowledge, self-efficacy and have resulted in multiple overdose reversals. Similarly effective has been the incorporation of Behaviour Change Theories within harm reduction programs. Although limited, literature that does exist surrounding this intersection, explains how theories such as social cognitive theory and the transtheoretical model have proven to reduce harms relating to injection drug use. Engaging with participants at multiple levels while using a context-dependent and iterative approach have been documented strengths of behaviour change theories with respect to minimizing substance use behaviours. This commentary argues for the potential benefit, incorporating behaviour change theories in OENDs has in reducing opioid-related overdoses.

Topics: Analgesics, Opioid; Drug Overdose; Harm Reduction; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

Topics: Adult; Analgesics, Opioid; British Columbia; Cross-Sectional Studies; Drug Overdose; Drug Users; Female; Fentanyl; Humans; Illicit Drugs; Male; Middle Aged; Naloxone; Prevalence; Prospective Studies; Substance Abuse, Intravenous; Substance-Related Disorders

Methadone is well known for its long duration of action and propensity for mortality after an overdose. The present research was aimed at evaluating the clinical manifestations and time trends of methadone exposure in patients in US hospitals.. We queried the American College of Medical Toxicology's Toxicology Investigators Consortium case registry for all cases of methadone exposure between January 1, 2010, and December 31, 2017. The collected information included demographic features, clinical presentations, therapeutic interventions, poisoning type (acute, chronic, or acute on chronic), and the reason(s) for exposure. Descriptive data and relative frequencies were used to investigate the participants' characteristics. Our data analysis was performed using SPSS version 19 and Prism software. The trends and clinical manifestations of methadone poisoning over the time period of the study were specifically investigated.. Nine hundred and seventy-three patients who met our inclusion criteria, with a mean age of 41.9 ± 16.6 years (range: 11 months-78 years) were analyzed. Five hundred eighty-two (60.2%) were male. The highest rate of methadone poisoning was observed in 2013. There was an increasing rate of methadone exposures in 2010-2013, followed by a decline in 2014-2017. The most common clinical manifestations in methadone-poisoned patients were coma (48.6%) and respiratory depression (33.6%). The in-hospital mortality rate of methadone poisoning was 1.4%.. ToxIC Registry data showed that inpatient methadone exposures enhanced from 2010 to 2013, after which a reduction occurred in the years 2014 to 2017.

Topics: Adolescent; Adult; Aged; Analgesics, Opioid; Child; Child, Preschool; Coma; Drug Overdose; Female; Hospital Mortality; Hospitalization; Humans; Infant; Male; Methadone; Middle Aged; Naloxone; Registries; Respiratory Insufficiency; United States; Young Adult

Topics: COVID-19; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pharmaceutical Services; SARS-CoV-2; United States

The opioid epidemic has prompted the expansion of take-home naloxone (THN) distribution programs. The proportion of emergency department (ED) patients with opioid misuse who have access to a naloxone kit (NK) and barriers to using it are unclear.

Topics: Analgesics, Opioid; Baltimore; Drug Overdose; Emergency Service, Hospital; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

Currently, ≤5% of bystanders witnessing an opioid overdose (OD) in the US administer antidote to the victim. A possible model to mitigate this crisis would be a system that enables 9-1-1 dispatchers to both rapidly deliver naloxone by drone to bystanders at a suspected opioid OD and direct them to administer it while awaiting EMS arrival.. A simulated 9-1-1 dispatcher directed thirty subjects via 2-way radio to retrieve naloxone nasal spray from atop a drone located outside the simulation building and then administer it using scripted instructions. The primary outcome measure was time from first contact with the dispatcher to administration of the medication.. All subjects administered the medication successfully. The mean time interval from 9 -1-1 contact until antidote administration was 122 [95%CI 109-134] sec. There was a significant reduction in time interval if subjects had prior medical training (p = 0.045) or had prior experience with use of a nasal spray device (p = 0.030). Five subjects had difficulty using the nasal spray and four subjects had minor physical impairments, but these barriers did not result in a significant difference in time to administration (p = 0.467, p = 0.30). A significant number of subjects (29/30 [97%], p = 0.044) indicated that they felt confident they could administer intranasal naloxone to an opioid OD victim after participating in the simulation.. Our results suggest that bystanders can carry out 9-1-1 dispatcher instructions to fetch drone-delivered naloxone and potentially decrease the time interval to intranasal administration which supports further development and testing of a such a system.

Topics: Administration, Intranasal; Adult; Aged; Aircraft; Drug Overdose; Emergency Medical Services; Feasibility Studies; Female; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; United States

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,

Topics: Drug Overdose; Health Education; Humans; Naloxone; Needle-Exchange Programs; Opioid-Related Disorders; United States

People who smoke drugs (PWSD) are at high risk of both infectious disease and overdose. Harm reduction activities organized by their peers in the community can reduce risk by providing education, safer smoking supplies, and facilitate access to other services. Peers also provide a network of people who provide social support to PWSD which may reinforce harm reducing behaviors. We evaluated the numbers of supportive network members and the relationships between received support and participants' harm-reducing activities.. Initial peer-researchers with past or current lived drug use experience were employed from communities in Abbotsford and Vancouver to interview ten friends from their social networks who use illegal drugs mainly through smoking. Contacts completed a questionnaire about people in their own harm reduction networks and their relationships with each other. We categorized social support into informational, emotional, and tangible aspects, and harm reduction into being trained in the use of, or carrying naloxone, assisting peers with overdoses, using brass screens to smoke, obtaining pipes from service organizations and being trained in CPR.. Fifteen initial peer researchers interviewed 149 participants who provided information on up to 10 people who were friends or contacts and the relationships between them. People who smoked drugs in public were 1.46 (95% CI, 1.13-1.78) more likely to assist others with possible overdoses if they received tangible support; women who received tangible support were 1.24 (95% CI; 1.02-1.45) more likely to carry and be trained in the use of naloxone. There was no relationship between number of supportive network members and harm reduction behaviors.. In this pilot study, PWSD who received tangible support were more likely to assist peers in possible overdoses and be trained in the use of and/or carry naloxone, than those who did not receive tangible support. Future work on the social relationships of PWSD may prove valuable in the search for credible and effective interventions.

Topics: Adult; British Columbia; Drug Overdose; Female; Harm Reduction; Humans; Male; Naloxone; Narcotic Antagonists; Peer Group; Pilot Projects; Smoking; Social Networking; Social Support; Substance-Related Disorders

To develop a validated instrument that measures knowledge about prescription opioid overdose.. Within an integrated health care system, we adapted, piloted, and tested the reliability and predictive validity of a modified Opioid Overdose Knowledge Scale (OOKS) instrument specific to prescription opioids (Rx-OOKS) with a patient population prescribed long-term opioid therapy and potentially at risk of opioid overdose. We used an interdisciplinary team approach and patient interviews to adapt the instrument. We then piloted the survey on a patient sample and assessed it using Cronbach's alpha and logistic regression.. Rx-OOKS (N = 56) resulted in a three-construct, 25-item instrument. Internal consistency was acceptable for the following constructs: "signs of an overdose" (10 items) at α = 0.851, "action to take with opioid overdose" (seven items) at α = 0.692, and "naloxone use knowledge" (eight items) at α = 0.729. One construct, "risks of an overdose" (three items), had an α of 0.365 and was subsequently eliminated from analysis due to poor performance. We conducted logistic regression to determine if any of the constructs was strongly associated with future naloxone receipt. Higher scores on "actions to take in an overdose" had nine times the odds of receiving naloxone (odds ratio [OR] = 9.00, 95% confidence interval [CI] = 1.42-57.12); higher "naloxone use knowledge" scores were 15.8 times more likely to receive naloxone than those with lower scores (OR = 15.83, 95% CI = 1.68-149.17).. The Rx-OOKS survey instrument can reliably measure knowledge about prescription opioid overdose recognition and naloxone use. Further, knowledge about actions to take during an opioid overdose and naloxone use were associated with future receipt of naloxone.

Topics: Analgesics, Opioid; Drug Overdose; Health Knowledge, Attitudes, Practice; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Pilot Projects; Prescriptions; Reproducibility of Results

Emergency department encounters are an opportunity to distribute naloxone kits to patients at risk of opioid overdose. Several programs cite mixed uptake and implementation barriers including staff education and burden. Emergency nurses can facilitate many approaches to naloxone distribution (eg, prescription, overdose education, dispensing take-home naloxone). To evaluate acceptance, we investigated nurse perceptions about take-home naloxone, describing potential barriers to program implementation.. This qualitative study enrolled 17 emergency nurses from an urban trauma center emergency department and affiliated community emergency department. During the study period, nurses in both sites could distribute take-home naloxone kits stocked in the medication dispensing system. We conducted 12 individual, in-depth interviews and 3 distinct focus groups involving 12 nurses in aggregate. A semistructured interview guide was used with a range of topics surrounding pain management, addiction, opioid overdose, and emergency care. We employed conventional content analysis to enable thematic analysis of transcripts.. Six component themes emerged as part of the overarching theme "mixed feelings about naloxone-morally distressing." One positive theme identified naloxone as an opportunity for discussion. Negative themes included (1) Addiction is a choice, why can't we help other diseases? It's unfair; (2) Providing naloxone enables and condones the behavior; (3) Emergency departments cannot treat social issues; (4) Patients can't give it to themselves; it's wasting money; and (5) Moral distress.. Perceptions and moral distress may be a barrier to ED-based take-home naloxone programs. Development of interventions targeting naloxone misperceptions and addiction stigma should be a goal of expanded implementation efforts.

Topics: Adult; Aged; Attitude of Health Personnel; Drug Overdose; Emergency Nursing; Emergency Service, Hospital; Female; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Qualitative Research

This paper explores how a peer-and street-based naloxone distribution program (Bmore POWER) reshapes narratives and practices around drug use and harm reduction in an urban context with an enduring opioid epidemic. Data collection included observations of Bmore POWER outreach events and interviews with peers. Bmore POWER members create a sense of community responsibility around overdose prevention and reconfigure overdose hotspots from places of ambivalence to places of grassroots action. It expands a harm reduction approach to Black communities that have not traditionally embraced it and that have been underserved by drug treatment programs. Policy makers should consider ways to use peers grounded in specific communities to expand other aspects of harm reduction, such as syringe and support services.

Topics: Analgesics, Opioid; Drug Overdose; Harm Reduction; Humans; Naloxone; Politics

Amidst the ongoing opioid crisis there are debates regarding the optimal route of administration and dosages of naloxone. This applies both for lay people administration and emergency medical services, and in the development of new naloxone products. We examined the characteristics of naloxone administration, including predictors of dosages and multiple doses during patient treatment by emergency medical service staff in order to enlighten this debate.. This was a prospective observational study of patients administered naloxone by the Oslo City Center emergency medical service, Norway (2014-2018). Cases were linked to The National Cause of Death Registry. We investigated the route of administration and dosage of naloxone, clinical and demographic variables relating to initial naloxone dose and use of multiple naloxone doses and one-week mortality.. Overall, 2215 cases were included, and the majority (91.9%) were administered intramuscular naloxone. Initial doses were 0.4 or 0.8 mg, and 15% of patients received multiple dosages. Unconscious patients or those in respiratory arrest were more likely to be treated with 0.8 mg naloxone and to receive multiple doses. The one-week mortality from drug-related deaths was 4.1 per 1000 episodes, with no deaths due to rebound opioid toxicity.. Intramuscular naloxone doses of 0.4 and 0.8 mg were effective and safe in the treatment of opioid overdose in the prehospital setting. Emergency medical staff appear to titrate naloxone based on clinical presentation.

Topics: Adult; Decision Making; Drug Overdose; Emergency Medical Services; Female; Humans; Male; Naloxone; Narcotic Antagonists; Norway; Prospective Studies

Regional variation in pharmacy-dispensed naloxone rates could create access disparities that undermine the effectiveness of this approach. We explored individual and public health unit (PHU)-level determinants of regional variation in naloxone distribution through the Ontario Naloxone Program for Pharmacies.. We conducted a population-based study between April 1, 2017 and March 31, 2018. We calculated age- and sex-standardized pharmacy-dispensed naloxone rates for the 35 Ontario PHUs, and identified determinants of these rates using generalized estimating equations negative binomial regression.. The age- and sex-standardized pharmacy-dispensed naloxone rate in Ontario was 5.5 (range 1.8-11.6) kits per 1000 population. Variables associated with higher naloxone dispensing rates included opioid use disorder history [rate ratio (RR) 2.27; 95% confidence interval (CI) 1.75-2.96], opioid agonist therapy (RR 11.17; 95% CI 7.15-17.44), and PHU opioid overdose rate (RR 1.09 per 10 deaths; 95% CI 1.06-1.13). Pharmacy-dispensed naloxone rates were lower in rural areas (RR 0.83; 95% CI 0.73-0.94) and among individuals dispensed one (RR 0.72; 95% CI 0.65-0.79), two to five (RR 0.67; 95% CI 0.54-0.84) or 6-10 (RR 0.92; 95% CI 0.74-1.14) opioids in the prior year relative to those receiving no opioids.. Pharmacy-dispensed naloxone programs are important components of a public health response to the opioid overdose crisis. We found considerable variation in pharmacy-dispensed naloxone rates that could limit program effectiveness, particularly in rural settings with limited access to health and harm reduction services..

Topics: Adult; Analgesics, Opioid; Drug Overdose; Female; Harm Reduction; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Ontario; Opiate Substitution Treatment; Opioid-Related Disorders; Pharmaceutical Services; Pharmacies; Small-Area Analysis

British Columbia's (BC) Take-Home Naloxone (THN) program provides naloxone to bystanders for use in cases of suspected opioid overdose. This study seeks to provide trends and analysis from the provincial BC THN program since inception in 2012 to the end of 2018.. BC THN shipment and distribution records from 2012-2018 were retrieved. Frequency distributions were used to describe characteristics of individuals accessing the program. To evaluate correlates of distribution after the addition of hundreds of pharmacy distribution sites, an analytic sample was limited to records from 2018, and multivariate logistic regression was used to evaluate correlates of collecting naloxone at a pharmacy site.. Since program inception to the end of 2018, there were 398,167 naloxone kits shipped to distribution sites, 149,999 kits reported distributed, and 40,903 kits reported used to reverse an overdose in BC. There was a significant increasing trend in the number of naloxone kits used to reverse an overdose over time (p<0.01), and more than 90% of kits that were reported used were distributed to persons at risk of an overdose. Individuals not personally at risk of overdose had higher odds of collecting naloxone at a pharmacy site, compared to other community sites (including harm reduction supply distribution sites, peer led organizations, drop-in centers, and supportive housing sites) (Adjusted Odds Ratio (AOR): 2.69; 95% CI: 2.50-2.90).. This study documents thousands of opioid overdose reversals facilitated through the BC THN program. While those at highest risk of overdose may preferentially access naloxone through community sites, naloxone distribution through pharmacies has allowed the BC THN program to expand dramatically, increasing naloxone availability through longer opening hours on evenings and weekends. and in rural and remote regions. A diversity of naloxone distribution sites and strategies is crucial to prevent rising opioid overdose deaths.

Topics: Adult; British Columbia; Drug Overdose; Female; Harm Reduction; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pharmacies

The devastating impact of the current opioid overdose crisis has led to new involvement of law enforcement officers. Training programs have focused on overdose recognition and response without targeting core attitudinal change by covering addiction or harm reduction principles.. This study examined the impact of a comprehensive overdose education and naloxone distribution (OEND) training on officers' attitudes toward overdose victims, knowledge of and competence to respond to an opioid overdose, and concerns about using naloxone. The training included the common information about overdose recognition and response, with added components covering broader content about addiction and harm reduction principles and philosophies.. A total of 787 (83% male) officers were administered surveys before and after attending a 2.5-3 hour comprehensive OEND training. Survey items measured overdose-related knowledge and attitudes, including attitudes about people who use drugs and who overdose.. Following the training, participants' overdose-related knowledge and perceived competence to use naloxone improved. However, there were more nuanced changes in attitudes toward overdose victims: though 55.3% of officers reported more positive post-training attitudes, 31% reported more negative attitudes, and 13.7% reported no attitudinal change. Younger officers were most likely to report worsened attitudes. Improvements in attitudes toward overdose victims were associated with reductions in both naloxone-related concerns and risk compensation beliefs.. Despite a comprehensive OEND training that addressed addiction and harm reduction and directly targeted hypothesized drivers of negative attitudes (e.g., risk compensation beliefs), some officers' attitudes worsened after the training. Randomized experiments of different training approaches would elucidate the mediators and moderators underlying these unexpected responses.

Topics: Adolescent; Adult; Analgesics, Opioid; Drug Overdose; Female; Harm Reduction; Health Knowledge, Attitudes, Practice; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Police; Surveys and Questionnaires; Young Adult

Rates of fatal overdose (OD) from synthetic opioids rose nearly 60 % from 2016 to 2018. 911 Good Samaritan Laws (GSLs) are an evidenced-based strategy for preventing OD fatality. This study describes patrol officers' knowledge of their state's GSL, experience with OD response, and their perspectives on strategies to prevent and respond to opioid OD.. An electronic survey assessed officers' knowledge of state GSLs and experiences responding to OD. Descriptive statistics and hierarchical linear modeling were generated to examine differences in knowledge, preparedness, and endorsement of OD response efforts by experience with OD response.. 2,829 officers responded to the survey. Among those who had responded to an OD call in the past six months (n = 1,946), 37 % reported administering naloxone on scene and 36 % reported making an arrest. Most (91 %) correctly reported whether their state had a GSL in effect. Only 26 % correctly reported whether that law provides limited immunity from arrest. Fifteen percent of officers who had responded to an OD work in departments that do not carry naloxone. Compared with officers who had not responded to any OD calls, those who reported responding OD calls at least monthly and at least weekly, were significantly less likely to endorse OD response efforts.. Officers who respond to OD calls are generally receiving training and naloxone supplies to respond, but knowledge gaps and additional training needs persist. Additional training and strategies to relieve compassion fatigue among those who have more experience with OD response efforts may be indicated.

Topics: Adult; Analgesics, Opioid; Compassion Fatigue; Cross-Sectional Studies; Drug Overdose; Female; Health Knowledge, Attitudes, Practice; Humans; Law Enforcement; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opiate Overdose; Police; Surveys and Questionnaires

The purpose of this study was to evaluate prehospital and emergency department (ED) interventions and outcomes of patients who received prehospital naloxone for a suspected opioid overdose.. The primary objective was to evaluate if the individual dose, individual route, total dose, number of prehospital naloxone administrations, or occurrence of a prehospital adverse event (AE) were associated with the occurrence of AEs in the ED. Secondary objectives included a subset analysis of patients who received additional naloxone while in the ED, or were admitted to an intensive care or step-down unit (ICU).. This was a retrospective, observational chart review of adult patients who received prehospital naloxone and were transported by ambulance to a suburban academic tertiary care center between 2014 and 2017. Descriptive, univariate, and multivariate statistics were used, with p < 0.05 indicating significance.. There were 513 patients included in the analysis, with a median age of 29 years, and median total prehospital naloxone dose of 2 mg. An increasing number of prehospital naloxone doses, an occurrence of a prehospital AE, and a route of administration other than intranasally for the first dose of prehospital naloxone were significantly associated with an increased likelihood of an ED AE. Patients who received < 2 mg of prehospital naloxone had the least likelihood of being admitted to an ICU, whereas patients who received at least 6 mg had a dramatically increased likelihood of ICU admission.. Our results suggest that an increasing number of prehospital naloxone doses was significantly associated with an increased likelihood of an ED adverse event.

Topics: Adult; Drug Overdose; Emergency Medical Services; Emergency Service, Hospital; Humans; Naloxone; Narcotic Antagonists; Retrospective Studies

Topics: Analgesics, Opioid; Drug Labeling; Drug Overdose; Humans; Naloxone; Narcotic Antagonists

We described the change in drug overdoses during the COVID-19 pandemic in one urban emergency medical services (EMS) system. Data was collected from Marion County, Indiana (Indianapolis), including EMS calls for service (CFS) for suspected overdose, CFS in which naloxone was administered, and fatal overdose data from the County Coroner's Office. With two sample t tests and ARIMA time series forecasting, we showed changes in the daily rates of calls (all EMS CFS, overdose CFS, and CFS in which naloxone was administered) before and after the stay-at-home order in Indianapolis. We further showed differences in the weekly rate of overdose deaths. Overdose CFS and EMS naloxone administration showed an increase with the social isolation of the Indiana stay-at-home order, but a continued increase after the stay-at-home order was terminated. Despite a mild 4% increase in all EMS CFS, overdose CFS increased 43% and CFS with naloxone administration increased 61% after the stay-at-home order. Deaths from drug overdoses increased by 47%. There was no change in distribution of age, race/ethnicity, or zip code of those who overdosed after the stay-at-home order was issued. We hope this data informs policy-makers preparing for future COVID-19 responses and other disaster responses.

Topics: Adult; Age Factors; Analgesics, Opioid; COVID-19; Drug Overdose; Emergency Medical Services; Female; Humans; Indiana; Male; Middle Aged; Naloxone; Narcotic Antagonists; Pandemics; Residence Characteristics; SARS-CoV-2; Sex Factors; Socioeconomic Factors

Topics: Altruism; Attitude of Health Personnel; Drug Overdose; Ethics, Medical; Health Knowledge, Attitudes, Practice; Humans; Naloxone; Narcotic Antagonists; Opioid Epidemic; Opioid-Related Disorders; Physician's Role

Deaths due to opioid overdose have reached unprecedented levels in Canada; over 12,800 opioid-related deaths occurred between January 2016 and March 2019, and overdose death rates increased by approximately 50% from 2016 to 2018.1 In 2016, Health Canada declared the opioid epidemic a national public health crisis,2 and life expectancy increases have halted in Canada for the first time in decades.3 Children are not exempt from this crisis, and the Chief Public Health Officer of Canada has recently prioritized the prevention of problematic substance use among Canadian youth.4.

Topics: Adolescent; Analgesics, Opioid; Canada; Child; Drug Overdose; Emergency Service, Hospital; Humans; Naloxone; Opioid-Related Disorders

Topics: Adult; Community Health Services; Coroners and Medical Examiners; Drug Overdose; Emergency Service, Hospital; Female; Humans; Male; Naloxone; Narcotic Antagonists; Prisoners

The COVID-19 epidemic in the United States has hit in the midst of the opioid overdose crisis. Emergency medical services (EMS) clinicians may limit their use of intranasal naloxone due to concerns of novel coronavirus infection. We sought to determine changes in overdose events and naloxone administration practices by EMS clinicians.. Between April 29, 2020 and May 15, 2020, we surveyed directors of EMS fellowship programs across the US about how overdose events and naloxone administration practices had changed in their catchment areas since March 2020.. Based on 60 respondents across all regions of the country, one fifth of surveyed communities have experienced an increase in opioid overdoses and events during which naloxone was administered, and 40% have experienced a decrease. The findings varied by region of the country. Eighteen percent of respondents have discouraged or prohibited the use of intranasal naloxone with 10% encouraging the use of intramuscular naloxone.. These findings may provide insight into changes in opioid overdose mortality during this time and assist in future disaster planning.

Topics: Analgesics, Opioid; Coronavirus Infections; COVID-19; Drug Overdose; Emergency Medical Services; Humans; Infection Control; Naloxone; Narcotic Antagonists; Nasal Sprays; Pandemics; Pneumonia, Viral; Surveys and Questionnaires; United States

Topics: Drug Overdose; Female; Humans; Naloxone; Narcotic Antagonists; Pregnancy

West Virginia is a largely rural state with strong ties of kinship, mutual systems of support and charitable giving. At the same time, wealth inequalities are extreme and the state's drug overdose fatality rate stands above all others in the USA at 51.5/100,000 in 2018, largely opioid-related. In recent years, harm reduction services have been active in the state but in 2018 Charleston's needle and syringe program was forced to close. This paper considers the risk environment in which the state's drug-related loss of life, and those attempting to prevent it, exist.. This rapid ethnographic study involved semi-structured interviews (n = 21), observation and video recordings of injection sequences (n = 5), initially recruiting people who inject heroin/fentanyl (PWIH) at the Charleston needle and syringe program. Snowball sampling led the research team to surrounding towns in southern West Virginia. Telephone interviews (n = 2) with individuals involved in service provision were also carried out.. PWIH in southern West Virginia described an often unsupportive, at times hostile risk environment that may increase the risk of overdose fatalities. Negative experiences, including from some emergency responders, and fears of punitive legal consequences from calling these services may deter PWIH from seeking essential help. Compassion fatigue and burnout may play a part in this, along with resentment regarding high demands placed by the overdose crisis on impoverished state resources. We also found low levels of knowledge about safe injection practices among PWIH.. Hostility faced by PWIH may increase their risk of overdose fatalities, injection-related injury and the risk of HIV and hepatitis C transmission by deterring help-seeking and limiting the range of harm reduction services provided locally. Greater provision of overdose prevention education and naloxone for peer distribution could help PWIH to reverse overdoses while alleviating the burden on emergency services. Although essential for reducing mortality, measures that address drug use alone are not enough to safeguard longer-term public health. The new wave of psychostimulant-related deaths underline the urgency of addressing the deeper causes that feed high-risk patterns of drug use beyond drugs and drug use.

Topics: Analgesics, Opioid; Drug Overdose; Empathy; Harm Reduction; Hostility; Humans; Naloxone; Opiate Overdose; Opioid-Related Disorders; West Virginia

The number of opioid-involved overdose deaths in the United States remains a national crisis. The HEALing Communities Study (HCS) will test whether Communities That HEAL (CTH), a community-engaged intervention, can decrease opioid-involved deaths in intervention communities (n = 33), relative to wait-list communities (n = 34), from four states. The CTH intervention seeks to facilitate widespread implementation of three evidence-based practices (EBPs) with the potential to reduce opioid-involved overdose fatalities: overdose education and naloxone distribution (OEND), effective delivery of medication for opioid use disorder (MOUD), and safer opioid analgesic prescribing. A key challenge was delineating an EBP implementation approach useful for all HCS communities.. A workgroup composed of EBP experts from HCS research sites used literature reviews and expert consensus to: 1) compile strategies and associated resources for implementing EBPs primarily targeting individuals 18 and older; and 2) determine allowable community flexibility in EBP implementation. The workgroup developed the Opioid-overdose Reduction Continuum of Care Approach (ORCCA) to organize EBP strategies and resources to facilitate EBP implementation.. The ORCCA includes required and recommended EBP strategies, priority populations, and community settings. Each EBP has a "menu" of strategies from which communities can select and implement with a minimum of five strategies required: one for OEND, three for MOUD, and one for prescription opioid safety. Identification and engagement of high-risk populations in OEND and MOUD is an ORCCArequirement. To ensure CTH has community-wide impact, implementation of at least one EBP strategy is required in healthcare, behavioral health, and criminal justice settings, with communities identifying particular organizations to engage in HCS-facilitated EBP implementation.

Topics: Analgesics, Opioid; Clinical Trials as Topic; Continuity of Patient Care; Delivery of Health Care; Drug Overdose; Evidence-Based Practice; Humans; Naloxone; Opiate Overdose; Opioid-Related Disorders; United States; United States Department of Veterans Affairs

The US opioid epidemic is complex and dynamic, yet relatively little is known regarding its likely future impact and the potential mitigating impact of interventions to address it.. To estimate the future burden of the opioid epidemic and the potential of interventions to address the burden.. A decision analytic dynamic Markov model was calibrated using 2010-2018 data from the National Survey on Drug Use and Health, Centers for Disease Control and Prevention, National Health and Nutrition Examination Survey, the US Census, and National Epidemiologic Survey on Alcohol and Related Conditions-III. Data on individuals 12 years or older from the US general population or with prescription opioid medical use; prescription opioid nonmedical use; heroin use; prescription, heroin, or combined prescription and heroin opioid use disorder (OUD); 1 of 7 treatment categories; or nonfatal or fatal overdose were examined. The model was designed to project fatal opioid overdoses between 2020 and 2029.. The model projected prescribing reductions (5% annually), naloxone distribution (assumed 5% reduction in case-fatality), and treatment expansion (assumed 35% increase in uptake annually for 4 years and 50% relapse reduction), with each compared vs status quo.. Projected 10-year overdose deaths and prevalence of OUD.. Under status quo, 484 429 (95% confidence band, 390 543-576 631) individuals were projected to experience fatal opioid overdose between 2020 and 2029. Projected decreases in deaths were 0.3% with prescribing reductions, 15.4% with naloxone distribution, and 25.3% with treatment expansion; when combined, these interventions were associated with 179 151 fewer overdose deaths (37.0%) over 10 years. Interventions had a smaller association with the prevalence of OUD; for example, the combined intervention was estimated to reduce OUD prevalence by 27.5%, from 2.47 million in 2019 to 1.79 million in 2029. Model projections were most sensitive to assumptions regarding future rates of fatal and nonfatal overdose.. The findings of this study suggest that the opioid epidemic is likely to continue to cause tens of thousands of deaths annually over the next decade. Aggressive deployment of evidence-based interventions may reduce deaths by at least a third but will likely have less impact for the number of people with OUD.

Topics: Analgesics, Opioid; Cost of Illness; Drug Overdose; Female; Humans; Male; Markov Chains; Naloxone; Narcotic Antagonists; Opioid Epidemic; Opioid-Related Disorders; Practice Patterns, Physicians'; United States

In 2015 a county sheriff department in Michigan began a training program for its deputies on administration of naloxone for non-medical providers.. A descriptive analysis was used to evaluate the effectiveness of the program. Data collected from the Sheriff's department allowed the study to quantify the incidence of naloxone administration, describe characteristics related to the administration, and report on aggregate outcomes.. Of the reported 184 incidents involving naloxone use the sheriff department had an overall successful administration rate of 94.6% in the cases from 2015 to 2017. It was also noted that the overall number of naloxone administrations showed an upward trend with a greater number of trained deputies.. The outcome of training non-medical first responders in naloxone administration has been shown to be successful with regard to resuscitation of patients with opioid overdose.

Topics: Adolescent; Adult; Aged; Child; Drug Overdose; Female; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Police; Socioeconomic Factors; Young Adult

The aim of this quality improvement (QI) project was to increase the coprescription of naloxone kits at patient discharge as a harm reduction strategy to combat the opioid epidemic. An interdisciplinary team identified hospitalized medical patients who were at high risk for an opioid overdose or opioid-related adverse event.. Led by a physician champion, an interdisciplinary QI team composed of physicians (MDs and doctors of osteopathic medicine), advanced practice providers (NPs and physician assistants), RNs, care coordinators, social workers, and pharmacists developed and implemented a naloxone distribution program on one medical unit at an academic tertiary care center. The team developed and implemented criteria to identify high-risk patients, workflow for patient screening, staff and patient education programs, and processes for naloxone kit delivery to the patient's bedside. Data on naloxone kit distribution from the seven months prior to implementation (March 2018 to September 2018) and the seven months after implementation (October 2018 to April 2019) were evaluated and are reported descriptively.. Two patients preimplementation and 64 patients postimplementation received a naloxone kit at discharge. In the postimplementation group, common reasons for identifying a patient as at high risk for an overdose or adverse event were a prescription for a pain medication at a daily dosage greater than or equal to 50 morphine milligram equivalents (50% of patients), concomitant opioid and benzodiazepine use (19%), history of substance use disorder (11%), and medication-assisted treatment (9%). Most patients in the postimplementation group (86%) received a naloxone kit at a personal cost of $1 or less.. This unit-based pilot project was successful in identifying patients at high risk for an opioid overdose or opioid-related adverse event and in providing naloxone kits and education at hospital discharge.

Topics: Analgesics, Opioid; Drug Overdose; Female; Harm Reduction; Hospitals; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Patient Discharge; Patient Education as Topic; Pilot Projects; Quality Improvement; Retrospective Studies; Risk Factors

The San Francisco Department of Public Health initiated naloxone prescribing at 6 safety net clinics. We evaluated this intervention, demonstrating that naloxone prescribing from primary care clinics is feasible and acceptable.. To evaluate acceptability of naloxone dispensing to patients prescribed opioids among pharmacists serving clinics participating in a naloxone intervention.. We surveyed 58 pharmacists from November 2013 through January 2015 at pharmacies that serviced San Francisco safety net clinics. Surveys collected information on demographics, experiences in dispensing naloxone, and interest in prescriptive authority. We conducted descriptive analyses and assessed bivariate relationships.. Most respondents were staff (56.9%) or supervising pharmacists (34.5%). Most (92.9%) were aware their pharmacy stocked naloxone and 86.8% felt it should be prescribed to some or all patients on long-term opioids. Most (82.1%) dispensed naloxone at least once in the past 12 months. More than half were comfortable providing naloxone education. Nearly half (43.4%) indicated they would want authority to furnish without a prescription. Over half (55.2%) reported no problems dispensing. The common problem was insufficient naloxone knowledge. Only 12% reported more than one problem in dispensing naloxone, which was associated with being uncomfortable with educating patients (. Naloxone dispensing was acceptable among pharmacists. Their most cited problem was insufficient naloxone education. This may be resolved with improved instructional materials, incentives for patient education, or mandatory training.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Pharmaceutical Services; Pharmacies; Pharmacists

As opioid overdose deaths climb, legislation supporting pharmacists in developing their role to address the crisis has expanded. Although Minnesota pharmacists are encouraged to utilize opiate antagonist, syringe access and authorized collector legislation, the use patterns of these tools are unknown.. A mixed-methods approach was used to survey 8405 Minnesota-licensed pharmacists on their practices related to the opioid crisis. An analysis of community pharmacist utilization of opioid-related legislation was conducted.. The majority (88.64%) of respondents indicated that they had not dispensed naloxone in the past month using a protocol; 59.69% reported that they had not dispensed naloxone by any method in the past month. Over sixty percent (60.61%) of respondents agreed they are comfortable with dispensing syringes and would dispense noninsulin syringes in their pharmacy under the statewide Syringe Access Initiative; 25.86% reported that they are not comfortable dispensing syringes. The majority (78.64%) of respondents reported that they do not participate in collecting unwanted pharmaceuticals.. While pharmacists have the potential to play a key role in efforts focused on addressing the opioid crisis through harm reduction strategies, this role and the use of supporting legislation is currently underutilized in the state of Minnesota.

Topics: Adult; Drug Overdose; Female; Humans; Male; Middle Aged; Minnesota; Naloxone; Opioid Epidemic; Opioid-Related Disorders; Pharmacists; Young Adult

We aim to determine whether administration of higher doses of naloxone for the treatment of opioid overdose is associated with increased pulmonary complications.. This was a retrospective, observational, cross-sectional study of 1,831 patients treated with naloxone by the City of Pittsburgh Bureau of Emergency Medical Services. Emergency medical services and hospital records were abstracted for data in regard to naloxone dosing, route of administration, and clinical outcomes, including the development of complications such as pulmonary edema, aspiration pneumonia, and aspiration pneumonitis. For the purposes of this investigation, we defined high-dose naloxone as total administration exceeding 4.4 mg. Multivariable analysis was used to attempt to account for confounders such as route of administration and pretreatment morbidity.. Patients receiving out-of-hospital naloxone in doses exceeding 4.4 mg were 62% more likely to have a pulmonary complication after opioid overdose (42% versus 26% absolute risk; odds ratio 2.14; 95% confidence interval 1.44 to 3.18). This association remained statistically significant after multivariable analysis with logistic regression (odds ratio 1.85; 95% confidence interval 1.12 to 3.04). A secondary analysis showed an increased risk of 27% versus 13% (odds ratio 2.57; 95% confidence interval 1.45 to 4.54) when initial naloxone dosing exceeded 0.4 mg. Pulmonary edema occurred in 1.1% of patients.. Higher doses of naloxone in the out-of-hospital treatment of opioid overdose are associated with a higher rate of pulmonary complications. Furthermore, prospective study is needed to determine the causality of this relationship.

Topics: Administration, Intranasal; Adult; Analgesics, Opioid; Case-Control Studies; Cross-Sectional Studies; Dose-Response Relationship, Drug; Drug Overdose; Emergency Medical Services; Female; Humans; Lung Diseases; Male; Middle Aged; Naloxone; Narcotic Antagonists; Retrospective Studies

Naloxone is an established antidote for the treatment of heroin poisoning; however, dosing regimens vary widely, with a current trend towards small titrated intravenous dosing. This study aims to characterise naloxone use in the treatment of patients presenting with suspected heroin poisoning.. This was a retrospective review of poisoned patients presenting to a clinical toxicology unit in Brisbane from January 2015 to December 2017. Patient demographics, clinical effects, naloxone dosing, observation periods and complications were extracted from the patient's medical records.. There were 117 presentations accounted for by 108 patients. Prehospital naloxone was provided to 57 (49%) patients, 46 of which received a standardised 1.6 mg i.m. dose. The remaining 60 (51%) patients received their first naloxone in hospital, with 58 (97%) receiving this by titrated i.v. doses. A subsequent naloxone infusion was required significantly more often in those treated with i.v. titrated naloxone compared to i.m. dose (27/69 [39%] vs 5/48 [10%], P = 0.0006). The need for parenteral sedation to manage acute behavioural disturbance following naloxone provision was rare (3/117 [3%]).. In this retrospective observational study, a single large i.m. dose of naloxone reversed the toxicity of suspected heroin overdose in the majority of patients. In addition, patients were less likely to require repeated intermittent doses or naloxone infusion than those treated solely with i.v. naloxone. Further comparison in a prospective study is warranted to validate these observations in confirmed heroin overdose. Requirement for sedation secondary to acute behavioural disturbance was rare regardless of the route.

Topics: Adolescent; Adult; Drug Overdose; Emergency Service, Hospital; Female; Heroin; Humans; Injections, Intramuscular; Male; Middle Aged; Naloxone; Narcotic Antagonists; Queensland; Retrospective Studies

The CDC Guideline for Prescribing Opioids for Chronic Pain recommends considering prescribing naloxone when factors that increase risk for overdose are present (e.g., history of overdose or substance use disorder, opioid dosages ≥50 morphine milligram equivalents per day [high-dose], and concurrent use of benzodiazepines). In light of the high numbers of drug overdose deaths involving opioids, 36% of which in 2017 involved prescription opioids, improving access to naloxone is a public health priority. CDC examined trends and characteristics of naloxone dispensing from retail pharmacies at the national and county levels in the United States.. CDC analyzed 2012-2018 retail pharmacy data from IQVIA, a health care, data science, and technology company, to assess U.S. naloxone dispensing by U.S. Census region, urban/rural status, prescriber specialty, and recipient characteristics, including age group, sex, out-of-pocket costs, and method of payment. Factors associated with naloxone dispensing at the county level also were examined.. The number of naloxone prescriptions dispensed from retail pharmacies increased substantially from 2012 to 2018, including a 106% increase from 2017 to 2018 alone. Nationally, in 2018, one naloxone prescription was dispensed for every 69 high-dose opioid prescriptions. Substantial regional variation in naloxone dispensing was found, including a twenty-fivefold variation across counties, with lowest rates in the most rural counties. A wide variation was also noted by prescriber specialty. Compared with naloxone prescriptions paid for with Medicaid and commercial insurance, a larger percentage of prescriptions paid for with Medicare required out-of-pocket costs.. Despite substantial increases in naloxone dispensing, the rate of naloxone prescriptions dispensed per high-dose opioid prescription remains low, and overall naloxone dispensing varies substantially across the country. Naloxone distribution is an important component of the public health response to the opioid overdose epidemic. Health care providers can prescribe or dispense naloxone when overdose risk factors are present and counsel patients on how to use it. Efforts to improve naloxone access and distribution work most effectively with efforts to improve opioid prescribing, implement other harm-reduction strategies, promote linkage to medications for opioid use disorder treatment, and enhance public health and public safety partnerships.

Topics: Adolescent; Adult; Aged; Child; Child, Preschool; Drug Overdose; Epidemics; Female; Humans; Infant; Infant, Newborn; Male; Middle Aged; Naloxone; Opioid-Related Disorders; Pharmacies; Prescriptions; United States; Young Adult

Topics: Analgesics, Opioid; Drug Overdose; Emergency Medicine; Emergency Service, Hospital; Humans; Naloxone; Narcotic Antagonists; Practice Patterns, Physicians'; United States

The objective of our study was to incorporate stricter probable nonfatal opioid overdose case criteria, and advanced epidemiologic approaches to more reliably detect local clustering in nonfatal opioid overdose activity in EMS runs data.. Data were obtained using emsCharts for our study area in southwestern Pennsylvania from 2007 to 2018. Cases were identified as emergency medical service (EMS) responses where naloxone was administered, and improvement was noted in patient records between initial and final Glasgow Coma Score. A subsample of all-cause EMS responses sites were used as controls and exact matched to cases on sex and 10-year-age category. Clustering was assessed using difference in Ripley's K function for cases and controls and Kulldorff scan statistics.. Difference in K functions indicated no significant difference in probable nonfatal overdose EMS runs across the study area compared to all-cause EMS runs. However, scan statistics did identify significant local clustering of probable nonfatal overdose EMS runs (maximum likelihood = 16.40, P = 0.0003).. Results highlight relevance of EMS data to detect community-level overdose activity and promote reliable use through stricter case definition criteria and advanced methodological approaches. Techniques examined have the potential to improve targeted delivery of neighborhood-level public health response activities using a near real-time data source.

Topics: Analgesics, Opioid; Case-Control Studies; Cluster Analysis; Drug Overdose; Emergency Medical Services; Geographic Information Systems; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pennsylvania; Spatial Analysis

Relay, a peer-delivered response to nonfatal opioid overdoses, provides overdose prevention education, naloxone, support, and linkage to care to opioid overdose survivors for 90 days after an overdose event. From June 2017 to December 2018, Relay operated in seven New York City emergency departments and enrolled 649 of the 876 eligible individuals seen (74%). Preliminary data show high engagement, primarily among individuals not touched by harm reduction or naloxone distribution networks. Relay is a novel and replicable response to the opioid epidemic.

Topics: Adolescent; Adult; Drug Overdose; Emergency Service, Hospital; Female; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Narcotics; New York City; Opioid-Related Disorders; Patient Education as Topic; Peer Group; Program Evaluation; Young Adult

Topics: Drug Overdose; History, 20th Century; History, 21st Century; Humans; Nalorphine; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Social Change; United States

Overdose deaths can be prevented by distributing take home naloxone (THN) kits. The emergency department (ED) is an opportune setting for overdose prevention, as people who use opioids frequently present for emergency care, and those who have overdosed are at high risk for future overdose death. We evaluated the implementation of an ED-based THN program by measuring the extent to which THN was offered to patients presenting with opioid overdose. We analyzed whether some patients were less likely to be offered THN than others, to identify areas for program improvement.. We retrospectively reviewed medical records from all ED visits between April 2016 and May 2017 with a primary diagnosis of opioid overdose at a large, urban tertiary hospital located in Alberta, Canada. A wide array of patient data was collected, including demographics, opioid intoxicants, prescription history, overdose severity, and whether a naloxone kit was offered and accepted. Multivariable analyses were used to identify patient characteristics and situational variables associated with being offered THN.. Among the 342 ED visits for opioid overdose, THN was offered in 49% (n = 168) of cases. Patients were more likely to be offered THN if they had been found unconscious (Adjusted Odds Ratio 3.70; 95% Confidence Interval [1.63, 8.37]), or if they had smoked or injected an illegal opioid (AOR 6.05 [2.15,17.0] and AOR 3.78 [1.32,10.9], respectively). In contrast, patients were less likely to be offered THN if they had a current prescription for opioids (AOR 0.41 [0.19, 0.88]), if they were admitted to the hospital (AOR 0.46 [0.22,0.97], or if they unexpectedly left the ED without treatment or before completing treatment (AOR 0.16 [0.22, 0.97).. In this real-world evaluation of an ED-based THN program, we observed that only half of patients with opioid overdose were offered THN. ED staff readily identify patients who use illegal opioids or experience a severe overdose as potentially benefitting from THN, but may miss others at high risk for future overdose. We recommend that hospital EDs provide additional guidance to staff to ensure that all eligible patients at risk of overdose have access to THN.

Topics: Adult; Alberta; Analgesics, Opioid; Drug Overdose; Emergency Medical Services; Emergency Service, Hospital; Female; Home Care Services; Hospitals, Urban; Humans; Male; Medical Records; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Retrospective Studies

In August 2013, a naloxone distribution program was implemented in North Carolina (NC). This study evaluated that program by quantifying the association between the program and county-level opioid overdose death (OOD) rates and conducting a cost-benefit analysis.. One-group pre-post design. Data included annual county-level counts of naloxone kits distributed from 2013 to 2016 and mortality data from 2000-2016. We used generalized estimating equations to estimate the association between cumulative rates of naloxone kits distributed and annual OOD rates. Costs included naloxone kit purchases and distribution costs; benefits were quantified as OODs avoided and monetized using a conservative value of a life.. The rate of OOD in counties with 1-100 cumulative naloxone kits distributed per 100,000 population was 0.90 times (95% CI: 0.78, 1.04) that of counties that had not received kits. In counties that received >100 cumulative kits per 100,000 population, the OOD rate was 0.88 times (95% CI: 0.76, 1.02) that of counties that had not received kits. By December 2016, an estimated 352 NC deaths were avoided by naloxone distribution (95% CI: 189, 580). On average, for every dollar spent on the program, there was $2742 of benefit due to OODs avoided (95% CI: $1,237, $4882).. Our estimates suggest that community-based naloxone distribution is associated with lower OOD rates. The program generated substantial societal benefits due to averted OODs. States and communities should continue to support efforts to increase naloxone access, which may include reducing legal, financial, and normative barriers.

Topics: Adolescent; Adult; Cost-Benefit Analysis; Delivery of Health Care; Drug Overdose; Female; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; North Carolina; Opioid-Related Disorders; Program Evaluation; Young Adult

Topics: Analgesics, Opioid; Drug Delivery Systems; Drug Overdose; Harm Reduction; Humans; Naloxone; Opioid-Related Disorders

Community overdose responders do not always seek help from emergency services when administering naloxone. We aimed to identify responder, overdose event, and community characteristics associated with help seeking from emergency services during overdoses reported by Massachusetts Overdose Education and Naloxone Distribution (OEND) enrollees, and to assess trends in help seeking over time.. We analyzed overdose reports submitted between 2007 and 2017 to the Massachusetts Department of Public Health. We used logistic regression, stratified by responder drug use status, to assess associations of characteristics with help seeking during an overdose.. From January 2007 through December 2017, there were 69,870 OEND enrollees. 5,588 enrollees reported 10,246 overdoses. Help seeking was more likely among responders who did not use drugs. Among responders who did not use drugs, help seeking was more likely when: the responder was older or female, the victim was a stranger or client, and when naloxone did not work. Among responders who used drugs, help seeking was more likely when: the responder was female or had not previously reported responding to an overdose, the victim was a stranger or client or did not use fentanyl, naloxone took a longer time to work, and when the overdose was public or occurred more recently. The percentage of overdoses where help seeking occurred reached a maximum in 2016 at 50%.. Help seeking by OEND enrollees was significantly associated with several responder, victim, and event characteristics. Targeted interventions to promote help seeking are warranted, particularly as the lethality of opioid supplies rises.

Topics: Adult; Drug Overdose; Emergency Medical Services; Emergency Responders; Female; Help-Seeking Behavior; Humans; Logistic Models; Male; Massachusetts; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

Factors surrounding opioid overdose and naloxone use must be explored from the user perspective in order to more effectively combat the current opioid crisis.. AIDS Resource Center of Wisconsin needle exchange clients were surveyed regarding overdose victim demographics, interventions, experience with naloxone, and overdose outcomes.. Most respondents (102/108, 94.4%) reported either experiencing or witnessing an overdose. While naloxone was often used (64/102, 62.7%), other recommended interventions, such as calling 911 (44/102, 43.1%) and rescue breathing (31/102, 30.4%) often were not. Potential legal consequences were cited as a major barrier for contacting emergency medical services (42.3%).. There appears to be a need for education and/or policy change to facilitate appropriate overdose prevention and use of emergency medical services in the setting of opioid overdose.

Topics: Adult; Drug Overdose; Emergency Medical Services; Emergency Treatment; Female; Humans; Male; Naloxone; Narcotic Antagonists; Needle-Exchange Programs; Opioid-Related Disorders; Surveys and Questionnaires; Wisconsin

Topics: Analgesics, Opioid; Cardiopulmonary Resuscitation; Child Abuse; Child, Preschool; Drug Overdose; Female; Fentanyl; Foster Home Care; Humans; Illicit Drugs; Infant; Naloxone; Narcotic Antagonists; Retrospective Studies

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid Epidemic

Take-home naloxone (THN) possession among people who inject drugs (PWID) in rural communities is understudied. Better understanding the nature of THN possession among rural PWID could inform the implementation of overdose prevention initiatives. The purpose of this research is to determine factors associated with rural PWID having recently received THN.. Data from a PWID population estimation study implemented in Cabell County, West Virginia were used for this research. Multivariable Poisson regression with a robust variance estimator was used to evaluate the independent effects of several measures (e.g., sociodemographics, structural vulnerabilities, substance use) on PWID having received THN in the past 6 months.. Forty-eight percent of our sample (n = 371) of PWID reported having received THN in the past 6 months. Factors associated with having received THN were: age (adjusted Prevalence Ratio [aPR] = 1.02; 95% Confidence Interval [CI]: 1.01-1.03), having recently accessed sterile syringes at a needle exchange program (aPR = 1.82; 95% CI: 1.35-2.46), believing that doctors judge people who use drugs (aPR = 1.50; 95% CI: 1.07-2.12), and having witnessed at least one non-fatal overdose in the past 6 months (aPR = 1.44; 95% CI: 1.06-1.94). Greater numbers of overdose events in the past 6 months were also associated with having received THN.. Among rural PWID in West Virginia, slightly less than half received THN in the past 6 months. Rural communities need overdose prevention interventions that are responsive to the unique needs of rural PWID, decrease stigma, and ensure PWID have access to harm reduction services and drug treatment programs.

Topics: Adult; Drug Overdose; Female; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Needle-Exchange Programs; Rural Population; Social Stigma; Substance Abuse, Intravenous; West Virginia

Topics: Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Pharmacies; Pharmacists

Topics: Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Pharmacies; Pharmacists

In response to the devastating overdose epidemic across Canada, overdose education and naloxone distribution programs (OEND) targeted at people who use drugs have been scaled-up. The ways in which people who use drugs (PWUD) - who experience social and structural vulnerabilities due to their drug use - enact advice from these health education campaigns remains underexplored. This study examines structural vulnerabilities that constrain PWUD as they attempt to implement OEND program advice.. Data were drawn from an ethnographic study of "Satellite Sites", a program where PWUD are employed by a community health center to operate satellite harm reduction programs within their homes. Data collection included participant observation within the Satellite Sites, complemented by semi-structured interviews and a focus group with Satellite Site workers. Thematic analysis was used to explore impacts of responding to overdose.. OEND advice includes not injecting alone, carrying naloxone, and calling 911 if overdose occurs. The ability of Satellite Site workers to respond according to public health guidelines is complicated by contextual and structural factors, including a lack of supervised injection services, vulnerability to eviction, and continued criminalization of drug use. Participants described how responding to increasing numbers of overdoses was stressful, with stress compounded by their close relationships with those who were overdosing. These factors were impacting the willingness of Satellite Site workers to continue to supervise drug use.. OEND programs are essential and effective; however, they are a response to a crisis within a policy and legal environment framed by the criminalization of drug use. Efforts to expand access to complementary interventions, such as supervised injection services, safer supply interventions, and protection against evictions, are necessary to complement OEND programs and address multiple contextual factors within the risk environment for overdose. Additionally, criminalization will continue to impede and constrain the public health response to drug use.

Topics: Aged; Canada; Drug Overdose; Drug Users; Female; Focus Groups; Harm Reduction; Health Personnel; Humans; Interviews as Topic; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

The United States is in the midst of a devastating opioid crisis, and the state of New Hampshire (NH) has been disproportionately impacted. Naloxone is an opioid overdose reversal medication that is critical for saving lives. This study was conducted to understand emergency responders' and opioid users' experiences with, and opinions about, naloxone use and distribution in NH.. Semi-structured interviews were conducted with 76 opioid users and 36 emergency responders in six NH counties in 2016-2017. Interviews focused on respondents' experiences with opioid use and overdose. Interviews were transcribed, coded, and reviewed for consensus among coders. Directed content analysis was used to review high-level domains and identify subthemes.. Users and responders largely agreed that naloxone had become increasingly available in NH at the time of the study. Reported responder barriers to naloxone acceptance included perceptions that increased naloxone availability may enable riskier opioid use and fails to address the underlying causes of addiction. Reported opioid-user barriers included cost, legality, and lack of knowledge regarding distribution locations and indications for use.. Opioid users' and emergency responders' perceptions about naloxone may limit the optimal use of naloxone within the community. This study identifies opportunities to address misconceptions about naloxone and challenges in accessing naloxone, which may improve opioid overdose prevention strategies.

Topics: Adult; Drug Overdose; Emergency Responders; Emergency Service, Hospital; Female; Humans; Interviews as Topic; Male; Middle Aged; Naloxone; Narcotic Antagonists; New Hampshire; Opioid Epidemic; Opioid-Related Disorders; Patient Acceptance of Health Care

Topics: Drug Overdose; Education, Pharmacy; Educational Measurement; Health Knowledge, Attitudes, Practice; Humans; Naloxone; Narcotic Antagonists; Opioid Epidemic; Opioid-Related Disorders; Pharmaceutical Services; Pharmacists; Professional Role; Students, Pharmacy

Topics: Adolescent; Drug Overdose; Humans; Naloxone; Opioid-Related Disorders; Pharmaceutical Services; Pharmacies

In response to North America's opioid crisis, access to naloxone has increased. However, our understanding of the correlates of possessing a naloxone kit is limited. This study seeks to determine the prevalence and correlates of kit possession among people who use drugs (PWUD) in British Columbia (BC) Canada.. This analysis used cross-sectional survey data collected in 2018 from 27 harm reduction sites in BC. Descriptive statistics and Poisson regression with robust error variance were used to examine factors associated with naloxone kit possession.. Overall, 70.7% (n = 246) of the total sample (n = 348) reported having a naloxone kit. Having a kit was significantly associated with self-reported opioid use in comparison with non-opioid use (Adjusted Prevalence Ratio (APR): 2.39; 95% CI: 1.33-4.32). Those reporting 'injection' as their preferred drug administration method were also more likely to possess a kit compared to those that predominantly preferred inhalation, smoking, or snorting (APR: 2.39; 95% CI: 1.25-4.58). Urbanicity, age, gender, and having regular housing were not significantly associated with possessing a kit.. This study is the first to examine naloxone kit possession across geographies, including non-urban areas. Lower kit possession among those that preferred inhaling, smoking or snorting drugs may reflect misconceptions around overdose risk of non-injection drug administration. Our study supports the need for enhanced awareness around the risk of opioid overdose with non-injection administration and suggests a need for comprehensive public health messaging that aims to address overdose risk and response.

Topics: Adult; British Columbia; Cross-Sectional Studies; Drug Overdose; Female; Harm Reduction; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Self Report

This study describes the 2016 expansion of the British Columbia Take Home Naloxone (BCTHN) programme quantitatively and explores the challenges, facilitators and successes during the ramp up from the perspectives of programme stakeholders.. Mixed-methods study.. The BCTHN programme was implemented in 2012 to reduce opioid overdose deaths by providing naloxone kits and overdose recognition and response training in BC, Canada. An increase in the number of overdose deaths in 2016 in BC led to the declaration of a public health emergency and a rapid ramp up of naloxone kit production and distribution. BCTHN distributes naloxone to the five regional health authorities of BC.. Focus groups and key informant interviews were conducted with 18 stakeholders, including BC Centre for Disease Control staff, urban and rural site coordinators, and harm reduction coordinators from the five regional health authorities across BC.. Take Home Naloxone (THN) programme activity, qualitative themes and lessons learnt were identified.. In 2016, BCTHN responded to a 20-fold increase in demand of naloxone kits and added over 300 distribution sites. Weekly numbers of overdose events and overdose deaths were correlated with increases in THN kits ordered the following week, during 2013-2017. Challenges elicited include forecasting demand, operational logistics, financial, manpower and policy constraints. Facilitators included outsourcing kit production, implementing standing orders and policy changes in naloxone scheduling, which allowed for easier hiring of staff, reduced paperwork and expanded client access.. For THN programmes preparing for potential increases in naloxone demand, we recommend creating an online database, implementing standing orders and developing online training resources for standardised knowledge translation to site staff and clients.

Topics: Analgesics, Opioid; British Columbia; Delivery of Health Care; Drug Overdose; Health Policy; Health Services Accessibility; Humans; Naloxone; Narcotic Antagonists; Opioid Epidemic; Public Health; Qualitative Research

Carfentanil is a synthetic opioid with an estimated potency that is 10,000 times more than that of morphine and 100 times more than that of fentanyl. Although there is a paucity of evidence, when considering the potency of carfentanil, it is reasonable to speculate that larger doses of naloxone may be required to resuscitate patients after carfentanil ingestion. This case report discusses the use of high-dose naloxone in 2 patients with suspected carfentanil overdose presenting to a small community hospital.. Two patients with suspected carfentanil overdose presented to a 30-bed emergency department at a community hospital in New Hampshire. Cyanosis and respiratory distress were noted in both instances, and airway intervention was ultimately deemed necessary. Patient 1 required a total of 12 mg of naloxone to be successfully resuscitated, while patient 2 required a total of 10 mg for resuscitation. Both patients were successfully resuscitated with high doses of naloxone. The use of high-dose naloxone prevented the need for intubation in these patients.. While more robust studies should be considered, emergency personnel should be comfortable using higher-than-standard doses of naloxone in appropriate cases.

Topics: Adult; Analgesics, Opioid; Cardiopulmonary Resuscitation; Cyanosis; Drug Overdose; Female; Fentanyl; Hospitals, Community; Humans; Male; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Schizophrenia; Substance-Related Disorders

People leaving incarceration are at high risk of opioid-related overdose. Overdose fatalities are preventable with administration of naloxone. In response to this risk, overdose education and naloxone distribution (OEND) programs have been implemented in a handful of jails and prisons in the United States. We document the history, structure, and data from the San Francisco County Jail OEND program. During 4 years of operation, 637 people participated; 67% received naloxone upon release, of whom only 3.5% had been previously trained in community-based OEND programs. Of those who received naloxone, 32% reported reversing an overdose and 44% received refills from community-based programs after reentry. This confirms that implementation of OEND in criminal justice settings is feasible and reaches people who have not previously been trained as well as those willing to act as overdose responders.

Topics: Adult; Curriculum; Drug Overdose; Female; Humans; Male; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Prisons; San Francisco; Substance-Related Disorders; United States

Fatal opioid overdose is a pressing public health concern in the United States. Addressing barriers and augmenting facilitators to take-home naloxone (THN) access and administration could expand program reach in preventing fatal overdoses.. THN access (i.e., being prescribed or receiving THN) was assessed in a Baltimore, Maryland-based sample of 577 people who use opioids (PWUO) and had a history of injecting drugs. A sub-analysis examined correlates of THN administration among those with THN access and who witnessed an overdose (N = 345). Logistic generalized estimating equations with robust standard errors were used to identify facilitators and barriers to accessing and using THN.. The majority of PWUO (66%) reported THN access. In the multivariable model, decreased THN access was associated with the fear that a person may become aggressive after being revived with THN (aOR: 0.55, 95% CI: 0.35-0.85), police threaten people at an overdose event (aOR: 0.68, 95% CI: 0.36-1.00), and insufficient overdose training (aOR: 0.43, 95% CI: 0.28-0.68). Enrollment in medication-assisted treatment, personally experiencing an overdose, and graduating from high school were associated with higher access. About half (49%) of PWUO with THN access and who had witnessed an overdose reported having administered THN. THN use was positively associated with "often" or "always" carrying THN (aOR: 3.47, 95% CI: 1.99-6.06), witnessing more overdoses (aOR:5.18, 95% CI: 2.22-12.07), experiencing recent homelessness, and injecting in the past year. THN use was reduced among participants who did not feel that they had sufficient overdose training (aOR: 0.56, 95% CI: 0.32-0.96).. THN programs must bolster confidence in administering THN and address barriers to use, such as fear of a THN recipient becoming aggressive. Normative change around carrying THN is an important component in an overdose prevention strategy.

Topics: Baltimore; Drug Overdose; Female; Health Services Accessibility; Humans; Male; Middle Aged; Multivariate Analysis; Naloxone

Fatal opioid overdoses remain the leading cause of accidental deaths in the United States, which have contributed to implementation of standing order laws that allow pharmacists to dispense naloxone to patients. Although pharmacy distribution of naloxone is a promising approach to increase access to this intervention, understanding barriers preventing greater uptake of this service is needed.. Data for the current study were collected via telephone survey assessing the availability of various formulations of naloxone at chain and independent pharmacies in rural and urban areas in Birmingham, Alabama (N = 222). Pharmacists' attitudes toward naloxone and potential barriers of pharmacy naloxone distribution were also assessed. One-way analysis of variance (ANOVA) and logistic regression analyses were utilized to examine differences in stocking of naloxone in chain and independent pharmacies and to determine predictors of the number of kits dispensed by pharmacies.. Independent pharmacies were less likely to have naloxone in stock, especially those in rural areas. Furthermore, rural pharmacies required more time to obtain all four formulations of naloxone, and offered less extensive training on naloxone use. Pharmacists endorsing the belief that naloxone allows avoidance of emergent treatment in an overdose situation was associated with fewer dispensed kits by the pharmacies. Over 80% of pharmacists endorsed at least one negative belief about naloxone (e.g., allowing riskier opioid use). Pharmacists noted cost to patients and the pharmacy as contributing to not dispensing more naloxone kits.. The current study demonstrates the lower availability of naloxone stocked at pharmacies in independent versus chain pharmacies, particularly in rural communities. This study also highlights several barriers preventing greater naloxone dispensing including pharmacists' attitudes and costs of naloxone. The potential benefit of standing order laws is not being fully actualized due to the structural and attitudinal barriers identified in this study. Strategies to increase naloxone access through pharmacy dispensing are discussed.

Topics: Adult; Aged; Aged, 80 and over; Alabama; Attitude of Health Personnel; Community Pharmacy Services; Drug Overdose; Female; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pharmacists; Rural Health Services; Surveys and Questionnaires; Urban Health Services; Young Adult

Although much is known about the correlates of heroin overdose, less is known about pharmaceutical opioid (PO) overdose. This study aimed to examine correlates of opioid overdose deaths by opioid and compare correlates between opioids.. Analysis of opioid overdose deaths in Australia between 2000-2015, extracted from the National Coronial Information System (NCIS). The NCIS is an online database of deaths reportable to the coroner, and contains coroner's findings, autopsy and toxicology reports. Deaths were categorized into mutually exclusive groups: 1) Heroin deaths; and 2) PO deaths (excluding heroin). PO deaths were examined by individual opioid.. There were 10,795 opioid overdose deaths over the study period. Relative to deaths occurring in major cities, deaths in regional/remote areas had 15.2 (95 % CI: 11.5-20.2) times the risk of being attributed to pharmaceutical fentanyl than heroin. Relative to deaths among people without a recorded history of chronic pain, deaths among people with a recorded history of chronic pain had a 1.9-10.7-fold increased risk of the death being attributed to POs than heroin. Deaths among people with a recorded history of substance use problems where the opioid was injected prior to death had 7.2 and 1.7 times the risk of being attributed to methadone and pharmaceutical fentanyl (respectively) than heroin.. Findings suggest the need to: educate PO consumers about the risks of overdose at the time of prescribing; increase coverage and engagement in opioid dependence treatment (particularly in regional/remote areas); and increase uptake of take-home naloxone to reduce opioid overdose mortality.

Topics: Adolescent; Adult; Analgesics, Opioid; Australia; Chronic Pain; Drug Overdose; Drug Prescriptions; Female; Fentanyl; Heroin; Humans; Male; Methadone; Middle Aged; Morphine; Naloxone; Opioid-Related Disorders; Tramadol; Young Adult

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

Topics: Adult; Aged; Aged, 80 and over; Denmark; Drug Overdose; Education; Female; First Aid; Follow-Up Studies; Helping Behavior; Humans; Interview, Psychological; Male; Middle Aged; Naloxone; Retrospective Studies; Risk-Taking; Social Environment; Teacher Training; Young Adult

Opioid overdoses are at an epidemic in the United States causing the deaths of thousands each year. Project DAWN (Deaths Avoided with Naloxone) is an opioid overdose education and naloxone distribution program in Ohio that distributes naloxone rescue kits at clinics and in the emergency departments of a single hospital system.. We performed a retrospective analytic cohort study comparing heroin overdose survivors who presented to the emergency department and were subsequently discharged. We compared those who received a naloxone rescue kit at discharge with those who did not. Our composite outcome was repeat opioid overdose related emergency department visit(s), hospitalization and death at 0-3 months and at 3-6 months following emergency department overdose. Heroin overdose encounters were identified by ICD- 9 or 10 codes and data was abstracted from the electronic medical record for emergency department patients who presented for heroin overdose and were discharged over a 31- month period between 2013 and 2016. Patients were excluded for previous naloxone access, incarceration, suicidal ideation, admission to the hospital or death from acute overdose on initial emergency department presentation. Data was analyzed with the Chi- square statistical test.. We identified 291emergency department heroin overdose encounters by ICD-9 or 10 codes and were analyzed. A total of 71% of heroin overdose survivors received a naloxone rescue kit at emergency department discharge. Between the patients who did not receive a naloxone rescue kit at discharge, no overdose deaths occurred and 10.8% reached the composite outcome. Of the patients who received a naloxone rescue kit, 14.4% reached the composite endpoint and 7 opioid overdose deaths occurred in this cohort. No difference in mortality at 3 or 6 months was detected, p = 0.15 and 0.36 respectively. No difference in the composite outcome was detected at 3 or 6 months either, p = 0.9 and 0.99 respectively.. Of our emergency department patients receiving a naloxone rescue kit we did not find a benefit in the reduction of repeat emergency department visits hospitalizations, or deaths following a non-fatal heroin overdose.

Topics: Adult; Aged; Aged, 80 and over; Drug Overdose; Emergency Service, Hospital; Female; Health Services Research; Heroin; Hospitalization; Humans; Male; Middle Aged; Naloxone; Ohio; Pilot Projects; Retrospective Studies; Young Adult

Opioid overdose is a major and increasing cause of injury and death. There is an urgent need for interventions to reduce overdose events among high-risk persons.. Adults at elevated risk for opioid overdose involving heroin or pharmaceutical opioids who had been cared for in an emergency department (ED) were randomised to overdose education combined with a brief behavioural intervention and take-home naloxone or usual care. Outcomes included: (1) time to first opioid overdose-related event resulting in medical attention or death using competing risks survival analysis; and (2) ED visit and hospitalisation rates, using negative binomial regression and adjusting for time at risk.. During the follow-up period, 24% of the 241 participants had at least one overdose event, 85% had one or more ED visits and 55% had at least one hospitalisation, with no significant differences between intervention and comparison groups. The instantaneous risk of an overdose event was not significantly lower for the intervention group (sub-HR: 0.83; 95% CI 0.49 to 1.40).. These null findings may be due in part to the severity of the population in terms of housing insecurity (70% impermanently housed), drug use, unemployment and acute healthcare issues. Given the high overdose and healthcare utilisation rates, more intensive interventions, such as direct referral and provision of housing and opioid agonist treatment medications, may be necessary to have a substantial impact on opioid overdoses for this high-acuity population in acute care settings.. NCT0178830; Results.

Topics: Adult; Analgesics, Opioid; Drug Overdose; Early Medical Intervention; Emergency Service, Hospital; Female; Health Surveys; Humans; Male; Middle Aged; Motivational Interviewing; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Program Evaluation

The Centers for Disease Control and Prevention (CDC) reports a 200% escalation in the rate of opioid overdose deaths in the United States. Unfortunately, Ohio has been deemed the epicenter of the nation's opioid epidemic. In 2015, Ohio passed a bill that permits a pharmacist to distribute naloxone without a prescription.. This survey was aimed to discover pharmacists' knowledge of naloxone and Ohio law, perceived barriers that may prohibit naloxone dispensing, and Ohio pharmacists' general confidence, comfort, perception, and experience dispensing naloxone per physician protocol.. Pharmacists' knowledge of naloxone and Ohio law pertaining to dispensing naloxone; perceived barriers to naloxone distribution; and overall experience, willingness, comfort, and perceptions of personally supplying naloxone were assessed using multiple-choice and Likert-type scale questions through an e-mail survey.. Overall, Ohio pharmacists were knowledgeable about naloxone and displayed confidence in their training and ability to provide patient education on naloxone. Pharmacists were less certain about Ohio law pertaining to naloxone distribution, especially those who have been in practice longer. Pharmacists indicated several barriers to dispensing naloxone and the need for more training. Younger pharmacists were more likely to report a concern with clientele who would frequent their pharmacy and moral and ethical concerns as barriers to dispensing naloxone.. Additional educational programs should be delivered to Ohio pharmacists to inform them of the state law and policies. Continuing education programs that review substance abuse and attempt to reduce social stigma may assist with increasing naloxone distribution to those in need, especially, if directed toward younger pharmacists in Ohio.

Topics: Adult; Age Factors; Aged; Drug and Narcotic Control; Drug Overdose; Drug Prescriptions; Female; Health Care Surveys; Health Knowledge, Attitudes, Practice; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Ohio; Opioid-Related Disorders; Patient Education as Topic; Pharmaceutical Services; Pharmacists

Topics: Analgesics, Opioid; Cities; Dose-Response Relationship, Drug; Drug Overdose; Fentanyl; Humans; Illicit Drugs; Naloxone; Narcotic Antagonists

Expanding access to naloxone is crucial for mitigating the public health epidemic of opioid overdose deaths in America. Pharmacists now have greater independent authority to dispense naloxone to the public due to a wave of enhanced pharmacy naloxone access laws. It is unknown to what extent pharmacists are required to receive specialized training to serve in this capacity.. The goal of this study was to review naloxone training mandates from states with enhanced pharmacy naloxone access laws.. Structured internet searches were completed using publicly available legislative, regulatory, and administrative records to identify the type of enhanced pharmacy naloxone access law and the presence and characteristics of a pharmacist naloxone training mandate in each state.. As of November 22, 2017, all 50 states have implemented an enhanced pharmacy naloxone access law. Only 19 states mandated targeted naloxone education before pharmacists engaged in independent naloxone dispensing/prescribing activities.. A lack of standardized naloxone training requirements for naloxone-dispensing pharmacists may affect the rate of adoption of enhanced pharmacy naloxone dispensing practices at community pharmacies and suboptimal education of patients at risk of opioid overdose. Ensuring pharmacists' preparedness to serve as naloxone providers is necessary to meaningfully prevent opioid overdose deaths in their communities.

Topics: Drug Overdose; Education, Pharmacy, Continuing; Humans; Legislation, Pharmacy; Naloxone; Narcotic Antagonists; Pharmacists; United States

This report documents a successful intervention by a community-based naloxone distribution program in San Francisco. The program and its partner organizations, working with participants who use drugs, first identified the appearance of illicitly made fentanyl and increased outreach and naloxone distribution. Distribution of naloxone and reported use of naloxone to reverse opioid-involved overdoses increased significantly while the number of opioid-involved and fentanyl-involved overdose deaths did not. Community-based programs that provide training and naloxone to people who use drugs can serve as an early warning system for overdose risk and adaptively respond to the rapidly changing overdose risk environment.

Topics: Adult; Aged; Aged, 80 and over; Analgesics, Opioid; Community Health Services; Disease Outbreaks; Drug Overdose; Female; Fentanyl; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; San Francisco

Take-home naloxone (THN) reduces deaths from opioid overdose. To increase THN distribution to at-risk emergency department (ED) patients, we explored reasons for patients' refusing or accepting THN.. In an urban teaching hospital ED, we identified high opioid overdose risk patients according to pre-specified criteria. We offered eligible patients THN and participation in researcher-administered surveys, which inquired about reasons to refuse or accept THN and about THN dispensing location preferences. We analyzed refusal and acceptance reasons in open-ended responses, grouped reasons into categories (absolute versus conditional refusals,) then searched for associations between patient characteristics and reasons.. Of 247 patients offered THN, 193 (78.1%) provided reasons for their decision. Of those included, 69 (35.2%) were female, 91 (47.2%) were under age 40, 61 (31.6%) were homeless, 144 (74.6%) reported injection drug use (IDU), and 131 (67.9%) accepted THN. Of 62 patients refusing THN, 19 (30.7%) felt "not at risk" for overdose, while 28 (45.2%) gave conditional refusal reasons: "too sick," "in a rush," or preference to get THN elsewhere. Non-IDU was associated with stating "not at risk," while IDU, homelessness, and age under 40 were associated with conditional refusals. Among acceptances, 86 (65.7%) mentioned saving others as a reason. Most respondents preferred other dispensing locations beside the ED, whether or not they accepted ED THN.. ED patients refusing THN felt "not at risk" for overdose or felt their ED visit was not the right time or place for THN. Most accepting THN wanted to save others.

Topics: Adult; British Columbia; Drug Overdose; Emergency Service, Hospital; Female; Hospitals, Teaching; Hospitals, Urban; Humans; Male; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Patient Acceptance of Health Care; Treatment Refusal

Topics: Drug Overdose; Drug Prescriptions; Emergency Service, Hospital; Female; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Retrospective Studies

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Ambulances; Analgesics, Opioid; Drug Overdose; Emergency Medical Services; Female; Housing; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Needle-Exchange Programs; Norway; Parks, Recreational; Private Facilities; Prospective Studies; Public Facilities; Severity of Illness Index; Transportation of Patients; Young Adult

We examined the acceptability, feasibility, and implementation of the Tenant Overdose Response Organizers program (TORO)-a tenant-led naloxone training and distribution intervention. This pilot project was implemented in privately owned single room occupancy (SRO) hotels that were disproportionately affected by overdose in Vancouver's Downtown Eastside (DTES) neighborhood. Semi-structured qualitative interviews were conducted with 20 tenants who had participated in a TORO training session and administered naloxone to someone in their SRO hotel or had overdosed in their SRO hotel and received naloxone from another tenant. Focus groups were conducted with 15 peer workers who led the TORO program in their SRO building. Interviews and focus groups were transcribed and analyzed thematically. Ethnographic observation at SRO hotels involved in the intervention was also co-led with peer research assistants. Ten SROs were included in the study. The level of acceptability of the TORO program was high, with participants describing the urgency for an intervention amid the frequency of overdoses in their buildings. Overdose response training enhanced participants' knowledge and skills, and provided them a sense of recognition. Additionally, the TORO program was feasible in some buildings more than others. While it provided important training and engaged isolated tenants, there were structural barriers to program feasibility. The implementation of the TORO program was met with some successes in terms of its reach and community development, but participants also discussed a lack of emotional support due to overdose frequency, leading to burnout and vulnerability. Our findings suggest that the TORO program was affected by social, structural, and physical environmental constraints that impacted program feasibility and implementation. Despite these constraints, peer-led in-reach overdose response interventions are effective tools in addressing overdose risk in SROs. Future housing interventions should consider the intersecting pathways of overdose risk, including how these interventions may exacerbate other harms for people who use drugs. Further research should explore the impacts of environmental factors on overdose response interventions in other housing contexts.

Topics: Adult; Aged; Aged, 80 and over; Canada; Drug Overdose; Female; Focus Groups; Housing; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Peer Group; Pilot Projects

Rising rates of opioid overdose deaths require innovative programs to prevent and reduce opioid-related morbidity and mortality. This study evaluates adoption, utilization, and maintenance of an emergency department (ED) take-home naloxone and peer recovery coach consultation program for ED patients at risk of opioid overdose.. Using a Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework, we conducted a retrospective provider survey and electronic medical record (EMR) review to evaluate implementation of a naloxone distribution and peer recovery coach consultation program at two EDs. Provider adoption was measured by self-report using a novel survey instrument. EMRs of discharged ED patients at risk for opioid overdose were reviewed in three time periods: preimplementation, postimplementation, and maintenance. Primary study outcomes were take-home naloxone provision and recovery coach consultation. Secondary study outcome was referral to treatment. Chi-square analysis was used for study period comparisons. Logistic regression was conducted to examine utilization moderators. Poisson regression modeled utilization changes over time.. Most providers reported utilization (72.8%, 83/114): 95.2% (79/83) provided take-home naloxone and 85.5% (71/83) consulted a recovery coach. There were 555 unique patients treated and discharged during the study periods: 131 preimplementation, 376 postimplementation, and 48 maintenance. Postimplementation provision of take-home naloxone increased from none to more than one-third (35.4%, p < 0.001), one-third received consultation with a recovery coach (33.1%, 45/136), and discharge with referral to treatment increased from 9.16% to 20.74% (p = 0.003). Take-home naloxone provision and recovery coach consultation did not depreciate over time.. ED naloxone distribution and consultation of a community-based peer recovery coach are feasible and acceptable and can be maintained over time.

Topics: Adult; Drug Overdose; Emergency Service, Hospital; Female; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Patient Discharge; Program Evaluation; Referral and Consultation; Retrospective Studies; Surveys and Questionnaires; Young Adult

Rhode Island (RI) ninth graders report lifetime nonmedical use of prescription opioids (NMUPO) of 8.9%. NMUPO is associated with transition to heroin use, opioid overdose, and death.. Measure changes in 9th grade students' knowledge, confidence, perceptions of opioid use disorder prevention, overdose response with naloxone, treatment, and recovery, following the delivery of an interactive substance use disorder curriculum.. Eight RI public high schools were recruited to participate. Freshman in each school were administered identical surveys that collected demographic data, substance use and misuse knowledge, students' perceptions of substance misuse harm, reported drug use, and risk and protective behaviors before and after the curriculum.. Among 969 pre-intervention survey respondents, 19% reported use of marijuana, 3% heroin use, and 21% nonmedical use of prescription opioids. Between the pre-intervention to the post-intervention survey, significantly more students identified that addiction is a chronic brain disease (79%-83%, p = 0.05), drug users are not responsible for their addiction (81%-88%, p = 0.001), and that non-medical use of a prescription medication is use without a prescription (81%-88%, p = 0.001). Improved confidence was also reported in identifying opioid withdrawal symptoms (26%-45%, p < 0.0001), identifying signs of an opioid overdose from 29% to 46% (p < 0.0001), and knowing when to administer naloxone (17%-45%, p < 0.0001). Confidence to refer someone to treatment improved from 31% to 45% (p < 0.0001). Logistic regression showed associations between mental health, peer use, parental affection, and academic performance factors as related to NMUPO.. Students reported significant NMUPO prevalence. Ninth grade students' knowledge and confidence of opioid misuse, overdose response, and recovery resources increased following the delivery of a multi-modal interactive substance use disorder curriculum. Community, school, and student-level interventions are needed to reduce NMUPO.

Topics: Adolescent; Drug Overdose; Female; Health Education; Health Knowledge, Attitudes, Practice; Health Surveys; Humans; Male; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Prevalence; Rhode Island; Students

To examine uptake following a large-scale naloxone programme by estimating distribution rates since programme initiation and the proportion among a sample of high-risk individuals who had attended naloxone training, currently possessed or had used naloxone. We also estimated the likelihood of naloxone possession and use as a function of programme duration, individual descriptive and substance use indicators.. (1) Distribution data (June 2014-August 2017) and date of implementation for each city and (2) a cross-sectional study among a sample of illicit substance users interviewed September 2017.. Seven Norwegian cities.. A total of 497 recruited users of illegal opioids and/or central stimulants.. Primary outcomes: naloxone possession and use. Random-intercepts logistic regression models (covariates: male, age, homelessness/shelter use, overdose, incarceration, opioid maintenance treatment, income sources, substance use indicators, programme duration).. Overall, 4631 naloxone nasal sprays were distributed in the two pilot cities, with a cumulative rate of 495 per 100 000 population. In the same two cities, among high-risk individuals, 44% and 62% reported current naloxone possession. The possession rates of naloxone corresponded well to the duration of each participating city's distribution programme. Overall, in the six distributing cities, 58% reported naloxone training, 43% current possession and 15% naloxone use. The significant indicators for possession were programme duration [adjusted odds ratios (aOR) = 1.44, 95% confidence interval (CI = 0.82-2.37], female gender (aOR = 1.97, 95% CI = 1.20-3.24) and drug-dealing (aOR = 2.36, 95% CI = 1.42-3.93). The significant indicators for naloxone use were programme duration (aOR = 1.49 95%, CI = 1.15-1.92), homelessness/shelter use (aOR = 2.06, 95% CI = 1.02-4.17), opioid maintenance treatment (OMT) (aOR = 2.07, 95% CI = 1.13-3.78), drug-dealing (aOR = 2.40, 95% CI = 1.27-4.54) and heroin injecting (aOR = 2.13, 95% CI = 1.04-4.38).. A large-scale naloxone programme in seven Norwegian cities with a cumulative distribution rate of 495 per 100 000 population indicated good saturation in a sample of high-risk individuals, with programme duration in each city as an important indicator for naloxone possession and use.

Topics: Adult; Analgesics, Opioid; Drug Overdose; Drug Trafficking; Female; Heroin Dependence; Humans; Ill-Housed Persons; Likelihood Functions; Logistic Models; Male; Middle Aged; Naloxone; Narcotic Antagonists; Nasal Sprays; Norway; Opiate Substitution Treatment; Sex Factors; Substance Abuse, Intravenous

Rhode Island has the tenth highest rate of accidental drug overdose deaths in the United States. In response to this crisis, Anchor Recovery Center, a community-based peer recovery program, developed programs deploying certified Peer Recovery Specialists to emergency departments (AnchorED) and communities with high rates of accidental opioid overdoses (AnchorMORE).. The purpose of this paper is to describe AnchorED and AnchorMORE's activities and implementation process.. AnchorED data were analyzed from a standard enrollment questionnaire that includes participant contact information, demographics, and a needs assessment. The AnchorED program outcomes include number of clients enrolled, number of naloxone training sessions, and number of referrals to recovery and treatment services. Overdose deaths and naloxone distribution through AnchorMORE were mapped using Tableau software.. From July 2016-June 2017, AnchorED had 1329 contacts with patients visiting an emergency department for reported substance misuse cases or suspected overdose. Among the contacts, 88.7% received naloxone training and 86.8% agreed to continued outreach with a Peer Recovery Specialist after their ED discharge. Of those receiving peer recovery services from the Anchor Recovery Community Center, 44.7% (n = 1055/2362) were referred from an AnchorED contact. From July 2016-June 2017, AnchorMORE distributed 854 naloxone kits in high-risk communities and provided 1311 service referrals.. These findings indicate the potential impact peer recovery programs may have on engaging high-risk populations in treatment, overdose prevention, and other harm reduction activities. Additional research is needed to evaluate the reach of implementation and services uptake.

Topics: Adult; Aged; Community Health Services; Drug Overdose; Emergency Service, Hospital; Female; Harm Reduction; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Peer Group; Program Evaluation; Rhode Island; Young Adult

Fatal opioid overdoses can be prevented by opioid overdose prevention programs (OOPPs). The present study qualitatively examined the diffusion process of an OOPP among 30 persons who inject drugs (PWIDs) in an opioid-saturated community. Purposive sampling was used to recruit participants into three groups based on familiarity with the OOPP. Findings revealed that participants often adopted the OOPP, which was offered by a local harm reduction organization, if first exposed by staff hosting and implementing it. Barriers to adoption included belief that OOPP training was lengthy or unnecessary, lack of perceived relative advantage, nonengagement with the host organization, and trepidation of administering withdrawal-causing medication to fellow PWIDs. Participants outside of networks diffusing the OOPP were isolated from other PWIDs. Staff from the host organization were influential in encouraging OOPP adoption, which underscores their importance in the effort to reduce fatal overdoses.

Topics: Adult; Decision Making; Diffusion of Innovation; Drug Overdose; Female; Health Knowledge, Attitudes, Practice; Humans; Interviews as Topic; Male; Middle Aged; Naloxone; Narcotics; Opioid-Related Disorders; Philadelphia; Qualitative Research; Socioeconomic Factors; Substance Withdrawal Syndrome; Time Factors

Opioid overdoses (OD) cause substantial morbidity and mortality globally, and current emergency management is typically limited to supportive care, with variable emphasis on harm reduction and addictions treatment. Our urban setting has a high concentration of patients with presumed fentanyl OD, which places a burden on both pre-hospital and emergency department (ED) resources. From December 13, 2016, to March 1, 2017, we placed a modified trailer away from an ED but near the center of the expected area of high OD and accepted low-risk patients with presumed fentanyl OD. We provided OD treatment as well as on-site harm reduction, addictions care, and community resources. The primary outcome was the proportion of patients requiring transfer to an ED for clinical deterioration, while secondary outcomes were the proportion of patients initiated on opioid agonists and provided take-home naloxone kits. We treated 269 patients with opioid OD, transferred three (1.1%) to a local ED, started 43 (16.0%) on opioid agonists, and provided 220 (81.7%) with THN. Our program appears to be safe and may serve as a model for other settings dealing with a large numbers of opioid OD.

Topics: Adult; Analgesics, Opioid; Drug Overdose; Emergency Service, Hospital; Female; Fentanyl; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

Topics: Adult; Drug Overdose; Female; Hospitals, Community; Hospitals, Teaching; Humans; Inpatients; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid Epidemic; Opioid-Related Disorders; Patient Education as Topic; Program Evaluation; Rhode Island

Opioid overdose mortality has increased in North America; however, recent regional trends in the proportion of treated overdose-related out-of-hospital cardiac arrest (OD-OHCA) compared to out-of-hospital cardiac arrest of presumed cardiac etiology (C-OHCA) are largely unknown. Our aim is to assess trends in the prevalence and outcomes of OD-OHCAs compared to C-OHCAs in Arizona.. Statewide, observational study utilizing an Utstein-style database with EMS-first care reports linked with hospital records, and vital statistics data from 2010 to 2015.. There were 21,658 OHCAs during the study period. After excluding non-C-OHCAs, non-OD-OHCAs, and cases missing outcome data, 18,562 cases remained. Of these remaining cases, 17,591 (94.8%) were C-OHCAs and 971 (5.2%) were OD-OHCAs. There was a significant increase in the proportion of OD-OHCAs from 2010, 4.7% (95% CI: 3.9-5.5) to 2015, 6.6% (95% CI: 5.8-7.5). Mean age for OD-OHCAs was 38 years compared to 66 years for C-OHCAs, (p < 0.0001). Initial shockable rhythm was present in 7.1% of OD-OHCAs vs. 22.6% of C-OHCAs (p < 0.0001). Overall survival to discharge in the OD-OHCA group was 18.6% vs. 11.9% in C-OHCA (p < 0.0001). After risk adjustment, we found an aOR of 2.1 (95% CI: 1.8-2.6) for survival in OD-OHCA compared to C-OHCA.. There has been a significant increase in the proportion of OD-OHCAs in Arizona between 2010-2015. OD-OHCA patients were younger, were less likely to present with a shockable rhythm, and more likely to survive than patients with C-OHCA. These data should be considered in prevention and treatment efforts.

Topics: Adult; Aged; Analgesics, Opioid; Arizona; Case-Control Studies; Databases, Factual; Drug Overdose; Female; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Out-of-Hospital Cardiac Arrest; Retrospective Studies

Topics: Analgesics, Opioid; Cardiopulmonary Resuscitation; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid Epidemic

Topics: Adult; Aged; Analgesics, Opioid; Attitude of Health Personnel; Cross-Sectional Studies; Drug Overdose; Female; Humans; Internal Medicine; Male; Middle Aged; Naloxone; Narcotic Antagonists; Risk Assessment; Surveys and Questionnaires

Take-home naloxone (THN) programs have been implemented in order to reduce the number of heroin-overdose deaths. Because of recent legislative changes in Australia, there is a provision for a greater distribution of naloxone in the community, however, the potential impact of these changes for reduced heroin mortality remains unclear. The aim of this study was to examine the characteristics of the entire cohort of fatal heroin overdose cases and assess whether there was an opportunity for bystander intervention had naloxone been available at the location and time of each of the fatal overdose events to potentially avert the fatal outcome in these cases.. The circumstances related to the fatal overdose event for the cohort of heroin-overdose deaths in the state of Victoria, Australia between 1 January 2012 and 31 December 2013 were investigated. Coronial data were investigated for all cases and data linkage was performed to additionally investigate the Emergency Medical Services information about the circumstances of the fatal heroin overdose event for each of the decedents.. There were 235 fatal heroin overdose cases identified over the study period. Data revealed that the majority of fatal heroin overdose cases occurred at a private residence (n = 186, 79%) and where the decedent was also alone at the time of the fatal overdose event (n = 192, 83%). There were only 38 cases (17%) where the decedent was with someone else or there was a witness to the overdose event, and in half of these cases the witness was significantly impaired, incapacitated or asleep at the time of the fatal heroin overdose. There were 19 fatal heroin overdose cases (8%) identified where there was the potential for appropriate and timely intervention by a bystander or witness.. This study demonstrated that THN introduction alone could have led to a very modest reduction in the number of fatal heroin overdose cases over the study period. A lack of supervision or a witness to provide meaningful and timely intervention was evident in most of the fatal heroin overdose cases.

Topics: Delivery of Health Care; Drug Overdose; Emergency Medical Services; Heroin Dependence; Humans; Naloxone; Narcotic Antagonists; Risk Assessment; Risk Factors; Time Factors; Treatment Outcome; Victoria

Topics: Analgesics, Opioid; Drug Overdose; Harm Reduction; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

This analysis uses network and spatial data to identify optimal individuals to target with overdose prevention interventions in rural Appalachia. Five hundred and three rural persons who use drugs were recruited to participate in the Social Networks among Appalachian People Study (2008-2010). Interviewer-administered surveys collected information on demographic characteristics, risk behaviors (including overdose history), network members, and residential addresses. We restricted the sample to individuals with at least one confirmed relationship to another study participant (N = 463). Using dyadic analyses (N = 1428 relationships), we identified relationship-level correlates of relationships with network members who have previously overdosed. We then examined individual- and network-level factors associated with (1) having at least one first-degree alter (i.e., network member) with a prior overdose and (2) each additional network member with a prior overdose (N = 463 study participants). Overall, 28% of the sample had previously overdosed and 57% were one-degree away from someone who previously overdosed. Relationships with those who had overdosed were characterized by closer residential proximity. Those with at least one network member who previously overdosed were more geographically central and occupied more central network positions. Further, the number of network members with an overdose history increased with decreasing distance to the town center, increasing network centrality, and prior enrollment in an alcohol detox program. Because fatal overdoses can be prevented through bystander intervention, these findings suggest that strategies that target more central individuals (both geographically and based on their network positions) and those who have previously enrolled in alcohol detox programs with overdose prevention training and naloxone may optimize intervention reach and have the potential to curb overdose fatalities in this region.

Topics: Adult; Appalachian Region; Drug Overdose; Female; Health Promotion; Humans; Male; Naloxone; Narcotic Antagonists; Risk-Taking; Rural Population

Topics: Analgesics, Opioid; Community Pharmacy Services; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Patient Participation; Pilot Projects

Topics: Academic Medical Centers; Adult; Aged; Aged, 80 and over; Analgesics, Opioid; Drug Overdose; Female; Humans; Inpatients; Male; Middle Aged; Naloxone; Narcotic Antagonists; Patient Education as Topic; Pilot Projects; Program Development; Program Evaluation; Young Adult

Providing take-home naloxone (THN) to people who use opioids is an increasingly common strategy for reversing opioid overdose. However, implementation is hindered by doubts regarding the ability of people who use opioids to administer naloxone and respond appropriately to overdoses. We aimed to increase understanding of the competencies required and demonstrated by opioid users who had recently participated in a THN programme and were subsequently confronted with an overdose emergency.. Qualitative study designed to supplement findings from a randomized controlled trial of overdose education and naloxone distribution. Interviews were audio-recorded, transcribed, systematically coded and analysed via Iterative Categorization.. New York City, USA.. Thirty-nine people who used opioids (32 men, 7 women; aged 22-58 years).. Trial participants received brief or extended overdose training and injectable or nasal naloxone.. The systematic coding frame comprised deductive codes based on the topic guide and more inductive codes emerging from the data.. In 38 of 39 cases the victim was successfully resuscitated; the outcome of one overdose intervention was unknown. Analyses revealed five core overdose response 'tasks': (1) overdose identification; (2) mobilizing support; (3) following basic first aid instructions; (4) naloxone administration; and (5) post-resuscitation management. These tasks comprised actions and decisions that were themselves affected by diverse cognitive, emotional, experiential, interpersonal and social factors over which lay responders often had little control. Despite this, participants demonstrated high levels of competency. They had acquired new skills and knowledge through training and brought critical 'insider' understanding to overdose events and the resuscitation actions which they applied.. People who use opioids can be trained to respond appropriately to opioid overdoses and thus to save their peers' lives. Overdose response requires both practical competency (e.g. skills and knowledge in administering basic first aid and naloxone) and social competency (e.g. willingness to help others, having the confidence to be authoritative and make decisions, communicating effectively and demonstrating compassion and care to victims post-resuscitation).

Topics: Adult; Analgesics, Opioid; Drug Overdose; Emergency Treatment; Female; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; New York City; Program Evaluation; Qualitative Research; Young Adult

Topics: Drug Overdose; Humans; Naloxone; Narcotic Antagonists

Topics: Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

In March 2017, Rhode Island released treatment standards for care of adult patients with opioid use disorder. These standards prescribe three levels of hospital and emergency department treatment and prevention of opioid use disorder and opioid overdose and mechanisms for referral to treatment and epidemiological surveillance. By June 2018, all Rhode Island licensed acute care facilities had implemented policies meeting the standards' requirements. This policy has standardized care for opioid use disorder, enhanced opioid overdose surveillance and response, and expanded linkage to peer recovery support, naloxone, and medication for opioid use disorder.

Topics: Drug Overdose; Emergency Service, Hospital; Hospital Costs; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Patient Discharge; Public Health; Rhode Island

The Los Angeles County Jail system is the largest jail system in the United States, with an average daily inmate population of 17,024 in 2017. Existing literature shows the weeks following release from incarceration are associated with increased risk of overdose death among individuals who previously used opioids. One response is to train inmates in overdose prevention and response (OPR) and to provide the opioid antagonist naloxone on release. However, in large jail systems training all inmates can be logistically and financially difficult, leading to interest identifying individuals most likely to benefit from such programs.. In 2017, the Los Angeles County Office of Diversion and Reentry collaborated with the Los Angeles County Sheriff Department to conduct an OPR needs assessment evaluation with all inmates entering the jail over a two week period.. 3781 inmates provided complete data for this analysis (3315 men, 466 women). 17% reported using opioids within the last 12 months, 7% reported witnessing an overdose within the last 12 months, and 5% report ever having received medication assisted treatment (MAT). 39% reported interest in being trained in overdose prevention and response. The single largest predictor of interest in OPR was being present at an overdose in the past year.. Our results suggest OPR should be provided to all inmates who opt-in to receiving training regardless of other risk factors. Our results also suggest this population has had little prior exposure to MAT and incarceration could represent a significant opportunity to provide such evidence-based treatments.

Topics: Drug Overdose; Female; Humans; Los Angeles; Male; Naloxone; Narcotic Antagonists; Prisoners; Prisons; Risk Factors

Topics: Drug Overdose; Emergency Service, Hospital; Fentanyl; Humans; Naloxone

St. Paul's Early Discharge Rule was derived to determine which patients could be safely discharged from the emergency department after a 1-hour observation period following naloxone administration for opiate overdose. The rule suggested that patients could be safely discharged if they could mobilize as usual and had a normal oxygen saturation, respiratory rate, temperature, heart rate, and Glasgow Coma Scale score. Validation of the St. Paul's Early Discharge Rule is necessary to ensure that these criteria are appropriate to apply to patients presenting after an unintentional presumed opioid overdose in the context of emerging synthetic opioids and expanded naloxone access.. In this prospective, observational validation study, emergency medicine providers assessed patients 1 hour after administration of prehospital naloxone. Unlike in the derivation study the threshold for normal oxygen saturation was set at 95% and patients were not immediately discharged after a normal 1-hour evaluation. Patients were judged to have a normal 1-hour evaluation if all six criteria of the rule were met. Patients were judged to have an adverse event (AE) if they had one or more of the preestablished AEs.. A total of 538 patients received at least one administration of prehospital naloxone, were transported to the study hospital, and had a 1-hour evaluation performed by a provider. AEs occurred in 82 (15.4%) patients. The rule exhibited a sensitivity of 84.1% (95% confidence interval [CI] = 76.2%-92.1%), a specificity of 62.1% (95% CI = 57.6%-66.5%), and a negative predictive value of 95.6% (95% CI = 93.3%-97.9%). Only one patient with a normal 1-hour evaluation subsequently received additional naloxone following a presumed heroin overdose.. This rule may be used to risk stratify patients for early discharge following naloxone administration for suspected opioid overdose.

Topics: Adult; Analgesics, Opioid; Decision Support Techniques; Drug Overdose; Emergency Service, Hospital; Female; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Patient Discharge; Predictive Value of Tests; Prospective Studies

In 2016, drug overdose deaths exceeded 64,000 in the United States, driven by a sixfold increase in deaths attributable to illicitly manufactured fentanyl. Rapid fentanyl test strips (FTS), used to detect fentanyl in illicit drugs, may help inform people who use drugs about their risk of fentanyl exposure prior to consumption. This qualitative study assessed perceptions of FTS among young adults.. From May to September 2017, we recruited a convenience sample of 93 young adults in Rhode Island (age 18-35 years) with self-reported drug use in the past 30 days to participate in a pilot study aimed at better understanding perspectives of using take-home FTS for personal use. Participants completed a baseline quantitative survey, then completed a training to learn how to use the FTS. Participants then received ten FTS for personal use and were asked to return 2-4 weeks later to complete a brief quantitative and structured qualitative interview. Interviews were transcribed, coded, and double coded in NVivo (Version 11).. Of the 81 (87%) participants who returned for follow-up, the majority (n = 62, 77%) used at least one FTS, and of those, a majority found them to be useful and straightforward to use. Positive FTS results led some participants to alter their drug use behaviors, including discarding their drug supply, using with someone else, and keeping naloxone nearby. Participants also reported giving FTS to friends who they felt were at high risk for fentanyl exposure.. These findings provide important perspectives on the use of FTS among young adults who use drugs. Given the high level of acceptability and behavioral changes reported by study participants, FTS may be a useful harm reduction intervention to reduce fentanyl overdose risk among this population.. The study protocol is registered with the US National Library of Medicine, Identifier NCT03373825, 12/24/2017, registered retrospectively. https://clinicaltrials.gov/ct2/show/NCT03373825?id=NCT03373825&rank=1.

Topics: Adolescent; Adult; Analgesics, Opioid; Drug Overdose; Female; Fentanyl; Follow-Up Studies; Harm Reduction; Hematologic Tests; Humans; Male; Naloxone; Narcotic Antagonists; Narcotic-Related Disorders; Pilot Projects; Reagent Strips; Retrospective Studies; Rhode Island; Substance-Related Disorders; Young Adult

Take-home naloxone, an opioid antagonist, has become part of a multimodal approach to curbing opioid-related mortality. However, there is little information about the utility of take-home naloxone in pediatric patients. We report a case of opioid toxicity after exposure to methadone in a pediatric patient, which was successfully reversed with take-home naloxone.. A previously healthy 22-month-old girl ingested an unknown amount of liquid methadone. The child became progressively somnolent. The mother administered intranasal naloxone at home with reversal of somnolence. The patient presented to the emergency department and had recurrence of symptoms. The patient was placed on a naloxone infusion and discharged from a tertiary care facility, uneventfully, 2 days after ingestion.. To our knowledge, we report the first case of pediatric opioid toxicity reversed by take-home naloxone. In the setting of rising opioid-related mortality, providers and public health officials should consider expanding access of take-home naloxone for children at high risk for opioid overdose.

Topics: Administration, Intranasal; Analgesics, Opioid; Drug Overdose; Female; Home Care Services; Humans; Infant; Methadone; Naloxone; Narcotic Antagonists

Drug overdose is the major cause of morbidity and mortality among persons who inject drugs (PWID). We assessed factors associated with the non-fatal drug overdose among PWID in three Croatian cities and national trends of overdose-related mortality (OM), and rates of uptake of opioid agonist drug treatment (OAT).. We used a respondent-driven sampling method to recruit 830 PWID in Zagreb, Split and Rijeka in 2014/2015. Participants completed behavioural questionnaires that included questions about overdose history, and we used Poisson regression to assess factors associated with self-reported overdose. We used joinpoint regression to calculate national trends of OM from 2001 to 2015 and rates of uptake of drug treatment from 2005 to 2015.. Lifetime prevalence of self-reported drug overdose in our RDS sample was 45.2%, while 4.1% of PWID reported overdose in the past 12 months; PWID who injected more than one type of drug in the past 12 months (adjusted prevalence ratio [aPR] = 4.56, 95% confidence intervals [CI] = 1.35-15.38) compared to injecting only heroin, and those enrolled in OAT (aPR = 1.94, 95% CI = 1.01-3.74) were more likely to report overdose in the past 12 months. We observed an increase in annual percent change (APC) of the national OM rates from 2001 to 2007 (APC = 22.5%, 95% CI = 16.3-29.0) and a decline from 2007 to 2015 (APC = -8.0%, 95% CI = -5.3- -10.5). The national rates of drug treatment enrollment increased from 2005 to 2010 (APC = 12.0%, 95% CI = 10.3-13.8), mostly due to increase in provision of buprenorphine from 2005 to 2008 (APC = 130.4%, 95% CI = 102.1-162.7).. Injecting more than one type of drugs and enrollment in OAT while still injecting drugs was positively associated with non-fatal overdose in our sample. To further reduce OM in Croatia we suggest improvements in coverage and delivery of OAT and establishment of provision of naloxone for PWID.

Topics: Adult; Buprenorphine; Croatia; Cross-Sectional Studies; Drug Overdose; Female; Harm Reduction; Humans; Male; Methadone; Middle Aged; Mortality; Naloxone; Opiate Substitution Treatment; Self Report; Substance Abuse, Intravenous; Surveys and Questionnaires

British Columbia (BC), Canada, is experiencing an unprecedented number of opioid overdoses mainly due to the contamination of illicit drugs with fentanyl and its analogues. Reluctance to seek emergency medical help (i.e., by calling 9-1-1) has been identified as a barrier to optimal care for overdose victims. This study aimed to identify the correlates of seeking help during an overdose event when naloxone was administered via BC's Take Home Naloxone (THN) program.. In this cross-sectional study, we reviewed administrative records (from July 2015 to December 2017) about overdose events submitted by THN participants when they received their replacement naloxone kits (n = 2350). The primary outcome of the study was reported calling 9-1-1 and modified Poisson regression models were built to investigate the factors associated with help-seeking during an overdose event.. Most overdose victims were men (69.0%) and >30 years old (61.5%). Overall, participants reported calling 9-1-1 in 1310 (55.7%) overdose events. In the multivariable model, the likelihood of calling 9-1-1 was significantly and positively associated with the overdose victim being male and receiving rescue breathing. The likelihood of calling 9-1-1 was significantly and negatively associated with the overdoses occurring in private residences and health regions other than Vancouver Coastal which delivers services to mostly urban residents.. Overall, medical help was sought for 55.7% of overdoses where naloxone was administered. Overdoses occurring among male victims as well as those receiving higher doses of naloxone and mouth-to-mouth rescue breathing were associated with a higher likelihood of help-seeking by responders. Future interventions need to encourage people who witness an overdose to seek emergency medical help.

Topics: Adult; British Columbia; Cross-Sectional Studies; Drug Overdose; Emergency Medical Dispatch; Female; Fentanyl; Humans; Male; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Scotland

Topics: Drug Overdose; Government Programs; Humans; Mortality, Premature; Naloxone; Narcotic Antagonists; Patient Discharge; Prisons; Scotland

Opioid overdose is an increasing burden world-wide and is a major cause of death in Australia. To reduce the number of opioid-related deaths, access to take-home naloxone has expanded in Australia and is now accessible without prescription. Emergency departments (ED) could be ideal settings for the distribution of take-home naloxone, due to regular encounters with patients who experience opioid overdoses. The aim of this study was to gain insight into ED physicians' and pharmacists' perspectives on take-home naloxone in the ED setting.. Semi-structured interviews were carried out with ED physicians and pharmacists about their perceptions of take-home naloxone. Participants were recruited through their involvement with professional bodies and through 'snowball' recruitment. Interviews were audio recorded and transcribed verbatim to be analysed using an inductive thematic approach.. Twenty-five interviews were conducted with 13 pharmacists and 12 physicians. Responses were categorised into three main themes: (i) Attitudes-the majority of participants supported take-home naloxone in principle, but had numerous concerns; (ii) Clinical Application-where challenges in terms of its patient use, implementation and pharmacological actions were raised; and (iii) Logistical Considerations-where many hindrances in relation to the distribution of take-home naloxone from the ED such as time considerations, education and resourcing were discussed.. Despite the majority supporting take-home naloxone, participants identified barriers to take-home naloxone in the ED. In the future, emphasis should be placed on educating and training staff in the ED about take-home naloxone and implementing standardised protocols.

Topics: Attitude of Health Personnel; Australia; Drug Overdose; Emergency Service, Hospital; Female; Humans; Male; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pharmacists; Physicians; Self Administration; Surveys and Questionnaires

'Take-home naloxone' refers to a life-saving intervention in which a drug (naloxone) is made available to nonmedically trained people for administration to other people experiencing an opioid overdose. In Australia, it has not been taken up as widely as would be expected, given its life-saving potential. We consider the actions of take-home naloxone, focusing on how care relations shape its uses and effects. Mobilising Science and Technology Studies insights, we suggest that the uses and effects of naloxone are co-produced within social relations and, therefore, this initiative 'affords' multiple outcomes. We argue that these affordances are shaped by a politics of care, and that these politics relate to uptake. We analyse two complementary case studies, drawn from an interview-based project, in which opioid consumers discussed take-home naloxone and its uses. Our analysis maps the ways take-home naloxone can afford (i) a regime of care within an intimate partnership (allowing a terminally ill man to more safely consume opioids) and (ii) a political process of care (in which a consumer takes care of others treated with the medication by administering it 'gently'). We conclude by exploring the political affordances of a politics of care approach for the uptake of take-home naloxone.

Topics: Adult; Australia; Drug Overdose; Female; Harm Reduction; Humans; Interviews as Topic; Male; Middle Aged; Naloxone; Opioid-Related Disorders; Politics

To examine the effects of a harm reduction policy, specifically Good Samaritan (GS) policy, on overdose deaths.. Secondary data from multiple cause of death, mortality records paired with state harm reduction and substance use prevention policy.. We estimate fixed effects Poisson count models to model the effect of GS policy on overdose deaths for all, prescription, and illicit drugs, controlled substances, and opioids, while controlling for other harm reduction and substance use prevention policies.. We merge secondary data sources by state and year between 1999 and 2016.. We fail to identify a statistically significant effect of GS policy in reducing overdose deaths broadly.. While we are unable to identify an effect of GS policy on overdose deaths, GS policy may have important effects on first-stage outcomes not investigated in this paper. Given recent state policy changes and rapid increase in many categories of overdose deaths, additional research should continue to examine the implementation and effects of harm reduction policy specifically and substance use prevention policy broadly.

Topics: Analgesics, Opioid; Drug Overdose; Harm Reduction; Humans; Illicit Drugs; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Prescription Drugs; Public Policy

Drug overdose is the leading cause of unintentional death in the USA and the majority of deaths involve an opioid. Pharmacies are playing an increasingly important role in getting naloxone-the antidote to an opioid overdose-into the community. The aim of the current study was to understand, from the perspective of those who had obtained naloxone at the pharmacy, whose drug using status and pain patient status was not known until the interviews were conducted, as well as those who had not obtained naloxone at the pharmacy but were at risk for overdose, factors that impact the likelihood of obtaining pharmacy-based naloxone (PBN). Fifty-two participants from two New England states were interviewed between August 2016 and April 2017. We used a phenomenological approach to investigate participants' beliefs about pharmacy-based naloxone. The social contextual model was chosen to structure the collection and analysis of the qualitative data as it takes into account individual, interpersonal, organizational (pharmacy), community, and societal influences on a specific health behavior. Of the 52 people interviewed, 24 participants had obtained naloxone from the pharmacy in the past year, of which 4% (n = 1) self-disclosed during the interview current illicit drug use and 29% (n = 7) mentioned using prescribed opioid pain medication. Of the 28 people who had not obtained naloxone from the pharmacy, 46% (n = 13) had obtained an over the counter syringe from a pharmacy in the past month and had used an opioid in the past month, and 54% (n = 15) had used a prescribed opioid pain medication in the past month but did not report a syringe purchase. Several main themes emerged from the interview data. Individual-level themes were as follows: helplessness and fear, naloxone as empowerment to help, and past experiences at the pharmacy. Interpersonal-level themes were as follows: concern for family and friends, and sources of harm reduction information. Themes associated with pharmacy-level influence were as follows: perceived stigma from pharmacists, confusion at the pharmacy counter, and receptivity to pharmacists' offer of naloxone; community-level themes were as follows: community caretaking and need for education and training. Finally, themes at the societal-level of influence were as follows: generational crisis, and frustration at lack of response to opioid crisis. Overall our findings reveal factors at multiple levels which may play a role in likelihood of obtaining

Topics: Adult; Attitude; Drug Overdose; Female; Harm Reduction; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; New England; Opioid-Related Disorders; Pharmacies; Qualitative Research; Risk Factors; Social Stigma; Socioeconomic Factors

Canada and the United States (U.S.) face an opioid use disorder (OUD) and opioid overdose epidemic. The most effective OUD treatment is opioid agonist therapy (OAT)-buprenorphine (with and without naloxone) and methadone. Although federal approval for OAT occurred decades ago, in both countries, access to and use of OAT is low. Restrictive policies and complex regulations contribute to limited OAT access. Through a non-systematic literature scan and a review of publicly available policy documents, we examined and compared OAT policies and practice at the federal (Canada vs. U.S.) and local levels (British Columbia [B.C.] vs. Oregon). Differences and similarities were noted between federal and local OAT policies, and subsequently OAT access. In Canada, OAT policy control has shifted from federal to provincial authorities. Conversely, in the U.S., federal authorities maintain primary control of OAT regulations. Local OAT health insurance coverage policies were substantively different between B.C. and Oregon. In B.C., five OAT options were available, while in Oregon, only two OAT options were available with administrative limitations. The differences in local OAT access and coverage policies between B.C. and Oregon, may be explained, in part, to the differences in Canadian and U.S. federal OAT policies, specifically, the relaxation of special federal OAT regulatory controls in Canada. The analysis also highlights the complicating contributions, and likely policy solutions, that exist within other drug policy sub-domains (e.g., the prescription regime, and drug control regime) and broader policy domains (e.g., constitutional rights). U.S. policymakers and health officials could consider adopting Canada's regulatory policy approach to expand OAT access to mitigate the harms of the ongoing opioid overdose epidemic.

Topics: Buprenorphine; Canada; Drug Overdose; Health Policy; Humans; Insurance Coverage; Methadone; Naloxone; Opiate Substitution Treatment; Opioid Epidemic; Opioid-Related Disorders; United States

Topics: Analgesics, Opioid; Attitude of Health Personnel; Clinical Competence; Drug Overdose; Education, Distance; Education, Medical, Undergraduate; Humans; Naloxone; Narcotic Antagonists; Retrospective Studies; Students, Medical

There has been a dramatic increase of deaths due to illicit fentanyl. We examined the pharmacology of fentanyl and reviewed data on the number of repeat doses of naloxone used to treat fentanyl overdoses. Multiple sequential doses of naloxone have been required in a certain percentage of opioid overdoses due to fentanyl. In addition, fentanyl appears to differ from other opioids as having a very rapid onset with high systemic levels found in overdose victims. A rapid competition is required by naloxone to out-compete large numbers of opioid receptors occupied by fentanyl in the CNS. Taken together, we propose that higher doses of naloxone are needed to combat the new era of overdoses due to the more potent synthetic opioids such as fentanyl.

Topics: Dose-Response Relationship, Drug; Drug Overdose; Fentanyl; Humans; Naloxone; Narcotic Antagonists; Narcotics

France has temporarily authorized addictology centers to use a form of intranasal naloxone (Nalscue. Patient data are those requested under Nalscue. Over this period, in the two addiction centers, 370 kits (35% of the national total) were distributed to 330 patients including 312 opioid users. Of these users, 15% report injecting and 85% are poly-consumers. In 14% of the cases, a patient's relative was formed to administrate the Nalscue. The interest of intranasal naloxone is no longer to be demonstrated in a context of opioid overdose, but the preauthorized framework did not allow a major diffusion of the antidote within the population most at risk. Let us hope that the availability in pharmacy can promote its distribution and thus reduce the number of deaths.

Topics: Administration, Intranasal; Adult; Aged; Ambulatory Care Facilities; Drug Overdose; Female; France; Health Knowledge, Attitudes, Practice; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Surveys and Questionnaires; Young Adult

[Full article available at http://rimed.org/rimedicaljournal-2019-03.asp].

Topics: Adolescent; Adult; Age Distribution; Aged; Aged, 80 and over; Child; Databases, Factual; Drug Overdose; Emergency Medical Services; Female; Humans; Incidence; Male; Middle Aged; Mortality; Naloxone; Opioid-Related Disorders; Rhode Island; Sex Distribution; Young Adult

To understand how the Take Home Naloxone (THN) program is implemented in two pilot correctional facilities in British Columbia (BC), Canada, in order to identify areas for program improvement and inform the expansion of the program to other Canadian correctional facilities The paper aims to discuss these issues.. Two focus groups and one interview were conducted with healthcare staff at two pilot correctional facilities. Sessions were audio recorded, transcribed verbatim and divergent and convergent experiences within and between the facilities were explored in an iterative process. Key themes and lessons learned were identified and later validated by focus group participants.. Key themes that emerged included: challenges and importance of the train-the-trainer program for healthcare staff conducting participant training sessions; potential for improved prison population engagement and awareness of the program; tailoring program resources to the unique needs of an incarcerated population; challenges connecting participants to community harm reduction resources following release; and clarifying and enhancing the role of correctional officers to support the program.. The correctional setting presents unique challenges and opportunities for the THN program that must be considered for program effectiveness.. This evaluation was conducted to inform program expansion amidst a historic opioid overdose epidemic in BC, and adds to the limited yet growing body of literature on the implementation and evaluation of this program in correctional settings globally.

Topics: Awareness; British Columbia; Drug Overdose; Harm Reduction; Humans; Inservice Training; Interviews as Topic; Naloxone; Narcotic Antagonists; Prisons; Program Evaluation

Topics: Analgesics, Opioid; Drug Overdose; Humans; Infusions, Intravenous; Injections, Intramuscular; Injections, Intravenous; Naloxone; Narcotic Antagonists

In response to the current opioid crisis in Canada, establishing safe injection services (SIS) in high risk communities has become more prevalent. In November 2017, The Trailer opened in Ottawa, Canada and tracks client use, overdose treatment and overdoses reversed. We analyzed data collected between November 2017 and August 2018. During peak hours, demand for services consistently exceeded The Trailer's capacity. Overdoses treated and reversed in this facility increased substantially during this period. Results suggest The Trailer provided an important though not optimal (due to space restrictions) harm reduction service to this high-risk community.. L’établissement de services d’injection supervisée (SIS) est devenu courant dans les collectivités à risque élevé afin de réagir à la crise des opioïdes qui sévit actuellement au Canada. Le service de La Roulotte (The Trailer), qui a ouvert ses portes en novembre 2017 à Ottawa (Canada), suit de près la consommation des clients, le traitement des surdoses et l'inversion des effets d’une surdose. Nous avons analysé les données recueillies entre novembre 2017 et août 2018 par ce service. Aux heures de pointe, la demande de services a constamment dépassé la capacité de La Roulotte. Le nombre de traitements de surdoses et d'inversions des effets d’une surdose a considérablement augmenté au cours de la période. D’après les résultats, La Roulotte a fourni un service important – quoique non optimal (en raison de contraintes d’espace) – de réduction des méfaits dans cette collectivité à risque élevé.. The Trailer (supervised injection service) was established as a response to the opioid crisis in Ottawa, Canada. The Trailer offers a 24-hour service to clients. Overdose reversals during the tracking period increased significantly. The demand for services has consistently exceeded capacity.. La Roulotte (service d’injection supervisée) a été établie en réponse à la crise des opioïdes à Ottawa, Canada. La Roulotte offre un service 24 heures sur 24 aux clients. Le nombre d’inversions des effets d’une surdose effectuées a augmenté considérablement au cours de la période de suivi. La demande de services a constamment dépassé la capacité de La Roulotte.

Topics: Adolescent; Adult; Analgesics, Opioid; Cities; Cocaine-Related Disorders; Drug Overdose; Female; Harm Reduction; Health Services Needs and Demand; Humans; Illicit Drugs; Male; Middle Aged; Naloxone; Narcotic Antagonists; Needle-Exchange Programs; Ontario; Opioid-Related Disorders; Oxygen Inhalation Therapy; Young Adult

Topics: Drug Overdose; Fentanyl; Humans; Muscle Rigidity; Naloxone; Narcotic Antagonists; Narcotics; Receptors, Opioid, mu; Respiratory Insufficiency; Respiratory Muscles

Topics: Causality; Drug Overdose; Humans; Naloxone; Registries; Seizures; Tramadol

Topics: Analgesics, Opioid; Drug Overdose; Emergencies; Humans; Naloxone; Narcotic Antagonists

Topics: Administration, Intravenous; Adult; Digestive System; Drug Overdose; Foreign Bodies; Heroin; Humans; Iran; Male; Naloxone; Narcotic Antagonists; Radiography, Abdominal; Therapeutic Irrigation

and Aims: Opioid overdose can be reversed with timely administration of naloxone. In Australia, naloxone was rescheduled from prescription only (S4) to pharmacist only over-the-counter (OTC, S3) in February 2016, increasing access for the general public. A key barrier to naloxone supply by pharmacists is a lack of knowledge, highlighting the role of pharmacist education. Community pharmacists' education, experience, and training preferences related to naloxone provision, overdose, and substance use disorder were examined.. Online survey data from a national sample of Australian pharmacists on their educational preferences regarding naloxone and overdose prevention, and prior training on substance use disorder (n = 595) was analyzed using bivariate and multivariate regression analysis. Data from qualitative semi-structured telephone interviews with pharmacists about OTC naloxone provision (n = 21) was analyzed using thematic analysis.. Most pharmacists (81%, n = 479) were willing to be trained in opioid overdose prevention, with greater willingness to attend training associated with younger age, being female, fewer years of practice, not having attended previous education on substance use disorder, and higher confidence in issues relating to substance use disorder. Qualitative interviews confirmed community pharmacists' willingness to attend training but analysis revealed low awareness, knowledge, and confidence about naloxone and preventing opioid overdose. Most pharmacists preferred online training or webinars.. Most community pharmacists in Australia are willing to attend training on providing naloxone and preventing opioid overdose. There are opportunities to develop and expand the online presence of training, guidelines, and education materials to facilitate the expanded supply of OTC naloxone.

Topics: Adult; Analgesics, Opioid; Australia; Drug Overdose; Education, Pharmacy; Female; Humans; Inservice Training; Male; Middle Aged; Naloxone; Narcotic Antagonists; Nonprescription Drugs; Opioid-Related Disorders; Patient Education as Topic; Pharmacists; Professional Role; Surveys and Questionnaires

Canada continues to experience an escalating opioid overdose crisis that has claimed more than 8000 lives in the country since 2016. The presence of the synthetic opioid fentanyl and its analogues is a central contributor to the increases in preventable opioid-related deaths. However, a number of converging social-structural factors (e.g., the continued criminalisation of drug use, political changes) and political barriers are also complicating and contributing to the current crisis. We briefly outline four harm reduction interventions (i.e., injectable opioid agonist treatment, naloxone distribution programs, overdose prevention sites, and drug checking services) as emerging and rapidly expanding responses to this crisis in Canada. These examples of innovation and expansion are encouraging but also occurring at the same time that the opioid overdose crisis shows few signs of abating. To truly address the crisis, Canada needs political environments at all government levels that are responsive and foster harm reduction innovation and drug policy experimentation.

Topics: Canada; Drug Overdose; Fentanyl; Harm Reduction; Humans; Naloxone; Narcotic Antagonists; Opioid Epidemic; Opioid-Related Disorders; Politics

Federal, state and local US governments have sought interventions to reduce deaths due to opioid overdoses by increasing the availability of naloxone. The Affordable Care Act (ACA) expanded Medicaid coverage to low-income, childless adults, potentially giving this group financial access to naloxone. The aims of this paper are: (1) to describe the changes in the amount of Medicaid-covered naloxone used between 2009 and 2016 and (2) to quantify the differential change in the amount of dispensed naloxone between states that expanded their Medicaid programs and states that did not.. A quasi-experimental approach based on states' ongoing choice to expand their Medicaid program to all adults with incomes between 100 and 138% of the federal poverty line (FPL), starting in 2014. As of 2018, 37 states had expanded and 14 states had not. Estimation of the policy impact relies on a difference-in-difference method.. US state Medicaid programs.. Data are from the Medicaid Drug Rebate Program and include all dispensed prescriptions of naloxone through the Medicaid program. State/quarters with fewer than 10 prescriptions are suppressed; n = 1632.. Prior to Medicaid expansion, the number of Medicaid-covered naloxone prescriptions was very similar in expansion and non-expansion states. On average, states that expanded Medicaid had 78.2 (95% confidence interval = 16.0-140.3, P = 0.02) more prescriptions per year for naloxone compared with states that did not expand Medicaid coverage, a nearly 10 increase over the pre-expansion years. Medicaid expansion contributed to this growth in Medicaid-covered naloxone more than other state-level naloxone policies.. Medicaid accounts for approximately a quarter of naloxone sales. Medicaid expansion generated 8.3% of the growth in naloxone units from 2009 to 2016, holding other factors constant.

Topics: Adolescent; Adult; Aged; Drug Overdose; Eligibility Determination; Female; Health Services Accessibility; Humans; Male; Medicaid; Middle Aged; Naloxone; Narcotic Antagonists; Patient Protection and Affordable Care Act; United States; Young Adult

Topics: Clinical Decision Rules; Drug Overdose; Emergency Service, Hospital; Humans; Naloxone; Narcotic Antagonists; Prospective Studies; Risk Assessment

Distribution of take-home naloxone (THN) to emergency department (ED) patients who have survived an opioid overdose (OD) could reduce future opioid mortality, but is not commonly performed. We examined whether electronic health record (EHR) prompts provided to ED physicians when discharging a patient after an OD could improve THN distribution.. Interrupted time-series analysis to compare the percentage of OD patients who received THN during the 11 months before and after implementation of an EHR prompt on 18 June 2017.. A total of 3492 adult patients with diagnoses of OD discharged from nine EDs in a single health system in Western Pennsylvania from July 2016 to April 2018.. The EHR prompt was triggered by the presence of specific terms in the nurse's initial assessment note. The EHR displayed a pop-up window during the ED physician discharge process asking the physician to consider prescribing or providing naloxone to the patient. The comparator was 'no EHR prompt'.. Measurements were based on standard criteria from ICD diagnostic codes and chief complaint keywords.. In July 2016, 16.3% [95% confidence interval (CI) = 14.0, 18.5] of OD patients received THN, which decreased every month through June 2017 by 1.2% (P < 0.0001, 95% CI = 0.8,1.7). For each month post-EHR prompt there was an increase of 2.8% of OD patients receiving THN (P < 0.001, 95% CI = 2.0, 3.5). No increases occurred in the ED with the highest pre-EHR prompt THN distribution. Rates of THN distribution varied by patient age and race prior to, but not after, implementation of EHR prompts.. Electronic health record prompts are associated with increased take-home naloxone distribution for emergency department patients discharged after opioid overdoses.

Topics: Adult; Analgesics, Opioid; Decision Support Systems, Clinical; Drug Overdose; Electronic Health Records; Emergency Medicine; Emergency Service, Hospital; Female; Humans; Interrupted Time Series Analysis; Male; Middle Aged; Naloxone; Narcotic Antagonists; Patient Discharge; Pennsylvania; Practice Patterns, Physicians'; Retrospective Studies; Young Adult

Topics: Drug Overdose; Health Policy; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Resuscitation

Given high rates of opioid-related fatal overdoses, improving naloxone access has become a priority. States have implemented different types of naloxone access laws (NALs) and there is controversy over which of these policies, if any, can curb overdose deaths. We hypothesize that NALs granting direct authority to pharmacists to provide naloxone will have the greatest potential for reducing fatal overdoses.. To identify which types of NALs, if any, are associated with reductions in fatal overdoses involving opioids and examine possible implications for nonfatal overdoses.. State-level changes in both fatal and nonfatal overdoses from 2005 to 2016 were examined across the 50 states and the District of Columbia after adoption of NALs using a difference-in-differences approach while estimating the magnitude of the association for each year relative to time of adoption. Policy environments across full state populations were represented in the primary data set. The association for 3 types of NALs was associated: NALs providing direct authority to pharmacists to prescribe, NALs providing indirect authority to prescribe, and other NALs. The study was conducted from January 2017 to January 2019.. Fatal and nonfatal overdoses in states that adopted NAL laws were compared with those in states that did not adopt NAL laws. Further consideration was given to the type of NAL passed in terms of its association with these outcomes. We hypothesize that NALs granting direct authority to pharmacists to provide naloxone will have the greatest potential for reducing fatal overdoses.. Fatal overdoses involving opioids were the primary outcome. Secondary outcomes were nonfatal overdoses resulting in emergency department visits and Medicaid naloxone prescriptions.. In this evaluation of the dispensing of naloxone across the United States, NALs granting direct authority to pharmacists were associated with significant reductions in fatal overdoses, but they may also increase nonfatal overdoses seen in emergency department visits. The effect sizes for fatal overdoses grew over time relative to adoption of the NALs. These policies were estimated to reduce opioid-rated fatal overdoses by 0.387 (95% CI, 0.119-0.656; P = .007) per 100 000 people in 3 or more years after adoption. There was little evidence of an association for indirect authority to dispense (increase by 0.121; 95% CI, -0.014 to 0.257; P = .09) and other NALs (increase by 0.094; 95% CI, -0.040 to 0.227; P = .17).. Although many states have passed some type of law affecting naloxone availability, only laws allowing direct dispensing by pharmacists appear to be useful. Communities in which access to naloxone is improved should prepare for increases in nonfatal overdoses and link these individuals to effective treatment.

Topics: Adult; Analgesics, Opioid; Drug and Narcotic Control; Drug Overdose; Health Services Accessibility; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Risk Assessment; United States

Opioid overdose is a significant public health issue among people who use pharmaceutical opioids and/or heroin. One response to reducing overdose deaths is to expand public access to naloxone. The Australian Therapeutic Goods Administration down-scheduled naloxone from prescription only (S4) to pharmacist only over-the-counter (OTC, schedule 3) in February 2016. There is little research examining pharmacists' perspectives or experiences of this change.. Thirty-seven semi-structured interviews with Australian community pharmacists were conducted in 2016-2017 to investigate pharmacists' attitudes to and experiences of OTC naloxone. Transcripts were thematically analysed, guided by a broad interest in facilitators and barriers to OTC supply.. Around half of the pharmacists were aware of the down-scheduling and only two had provided OTC naloxone. Core barriers to pharmacist provision of OTC naloxone included limited understanding of opioid overdose, confusion about the role and responsibilities of pharmacists in providing OTC naloxone, concerns about business, stigma related to people who inject drugs (PWID) and system-level challenges.. Pharmacy provision of OTC naloxone offers an important opportunity to reduce overdose mortality. Our study suggests this opportunity is yet to be realised and highlights several individual- and structural-level impediments hindering the expansion of public access to naloxone via community pharmacies. There is a need to develop strategies to improve pharmacists' knowledge of OTC naloxone and opioid overdose as well as to address other logistical and cultural barriers that limit naloxone provision in pharmacy settings. These need to be addressed at the individual level (training) as well as the system level (information, regulation and supply).

Topics: Adult; Australia; Drug Overdose; Female; Humans; Interviews as Topic; Male; Naloxone; Narcotic Antagonists; Nonprescription Drugs; Opioid-Related Disorders; Pharmacists; Professional Role; Qualitative Research

To facilitate surveillance and evaluate interventions addressing opioid-related overdoses, algorithms are needed for use in large health care databases to identify and differentiate community-occurring opioid-related overdoses from inpatient-occurring opioid-related overdose/oversedation.. Data were from Kaiser Permanente Northwest (KPNW), a large integrated health plan. We iteratively developed and evaluated an algorithm for electronically identifying inpatient overdose/oversedation in KPNW hospitals from 1 January 2008 to 31 December 2014. Chart audits assessed accuracy; data sources included administrative and clinical records.. The best-performing algorithm used these rules: (1) Include events with opioids administered in an inpatient setting (including emergency department/urgent care) followed by naloxone administration within 275 hours of continuous inpatient stay; (2) exclude events with electroconvulsive therapy procedure codes; and (3) exclude events in which an opioid was administered prior to hospital discharge and followed by readmission with subsequent naloxone administration. Using this algorithm, we identified 870 suspect inpatient overdose/oversedation events and chart audited a random sample of 235. Of the random sample, 185 (78.7%) were deemed overdoses/oversedation, 37 (15.5%) were not, and 13 (5.5%) were possible cases. The number of hours between time of opioid and naloxone administration did not affect algorithm accuracy. When "possible" overdoses/oversedations were included with confirmed events, overall positive predictive value (PPV) was very good (PPV = 84.0%). Additionally, PPV was reasonable when evaluated specifically for hospital stays with emergency/urgent care admissions (PPV = 77.0%) and excellent for elective surgery admissions (PPV = 97.0%).. Algorithm performance was reasonable for identifying inpatient overdose/oversedation with best performance among elective surgery patients.

Topics: Algorithms; Analgesics, Opioid; Databases, Factual; Drug Overdose; Electronic Health Records; Emergency Service, Hospital; Hospitalization; Humans; Inpatients; Naloxone; Narcotic Antagonists; Predictive Value of Tests

Syringe services programs (SSPs) are evidence-based interventions that are associated with decreases in prevalence and incidence rates of HIV and viral hepatitis among people who inject drugs (PWID). SSPs are also effective conduits to deliver overdose prevention resources among PWID. In December 2015, the Kanawha-Charleston Health Department (KCHD) in West Virginia implemented a SSP; however, the program was indefinitely suspended in early 2018 following policy changes that would have forced the program to operate in ways that conflicted with established best practices. The purpose of this research is to explore the public health implications of the suspension of the KCHD SSP among rural PWID.. We conducted semi-structured interviews with 27 PWID (59.3% male, 88.9% White) to explore access to sterile injection equipment and overdose prevention resources, high-risk injection practices, and HIV risk perceptions following the KCHD SSP suspension. Participants were recruited from street locations frequented by PWID. Interviews were audio-recorded and transcribed verbatim. We employed an iterative, modified constant comparison approach to systematically code and synthesize textual interview data.. Participants described the KCHD SSP as providing a variety of harm reduction services to PWID and being able to speak honestly with SSP staff about their drug use without fear of stigmatization. The suspension of the KCHD SSP fundamentally changed the public health landscape for PWID, ushering in a new era of increased risks for acquiring bloodborne infections and overdose. PWID described more frequently injecting with used syringes and engaging in a range of high-risk injection practices after the SSP was suspended. PWID also discussed having decreased access to naloxone and being less likely to get routinely tested for HIV following the KCHD SSP suspension.. This research demonstrates that the suspension of a SSP in rural West Virginia increased risks for HIV/HCV acquisition and overdose among PWID. The suspension of the SSP led to community-wide decreases in access to sterile injection equipment and naloxone among PWID. The suspension of the KCHD SSP should be viewed as a call to action for sustaining evidence-based interventions in the face of sociopolitical forces that attempt to subvert public health.

Topics: Adult; Amphetamine-Related Disorders; Drug Overdose; Female; Harm Reduction; Health Services Accessibility; Heroin Dependence; HIV Infections; Humans; Ill-Housed Persons; Male; Methamphetamine; Middle Aged; Naloxone; Narcotic Antagonists; Needle Sharing; Needle-Exchange Programs; Opioid-Related Disorders; Public Health; Qualitative Research; Risk-Taking; Rural Health Services; Social Stigma; Substance Abuse, Intravenous; West Virginia

The U.S. and worldwide death toll from opioids and other drugs has accelerated, rivaling all other causes of premature death. Emergency medical services (EMS) now has an evolving role in providing solutions.. EMS medical directors from the majority of the largest U.S. cities and global counterparts met to share/compile an inventory of best practices derived from their respective high-volume experiences in jurisdictions with >114 million residents combined. In turn, they created a consensus guideline document for the purposes of information-sharing among themselves and other interested parties.. The group concluded that EMS personnel have evolving training needs with respect to new medical care challenges, but they also recommended that agencies have a special place within the collective of those hoping to provide solutions to the public health crisis of addiction and drug-related epidemics. In addition to intervening in real-time overdose events, it was recommended that they partner with other key stakeholders to develop mechanisms to end the repetitive cycle of emergency rescue followed by an almost immediate return to addictive behaviors. EMS providers should be trained to optimally communicate, refer, and direct the affected individuals to appropriate resources that will provide viable and evidence-based pathways directed toward long-term recovery.. Beyond a need to update acute medical rescue practices and improved assessment techniques, EMS providers should also learn to optimally communicate, encourage, and even participate in facilitating management continuity for the affected individuals by identifying and using the appropriate resources that will provide viable, evidence-based pathways toward sustained recovery.

Topics: Drug Overdose; Emergency Medical Services; Guidelines as Topic; Humans; Naloxone; Narcotic Antagonists; Opioid Epidemic; Opioid-Related Disorders; United States

To describe the implementation and evaluation of an interdisciplinary quality improvement (QI) project to increase prescription of take-home naloxone (THN) to reduce risks associated with opioids for patients admitted to an acute inpatient rehabilitation unit.. Prospective cohort quality improvement project.. Eighteen-bed acute comprehensive inpatient rehabilitation (ACIR) unit at a large academic institution.. Patients admitted to ACIR between December 2015-November 2016 (N=788).. An interdisciplinary QI model comprised of planning, education, implementation, and maintenance was used to implement a THN and opioid risk-reduction program involving provider and patient education. Analyses consisted of comparisons between baseline, early, and late phases of the project.. (1) The proportion of eligible patients who received a prescription for naloxone upon discharge from ACIR; (2) the proportion of patients originally admitted to ACIR on opioids that were weaned off upon discharge.. The adjusted odds of eligible patients being discharged from ACIR with a naloxone prescription during the late QI period were 7 (95% confidence interval [CI]: 3-21) times higher than during the early QI period (late QI period: 43%, 95% CI: 25%-63%; early QI period: 10%, 95% CI: 3%-28%; P<.001). For patients admitted on opioids, the adjusted odds of being weaned off opioids during the late QI period were 10 (95% CI: 4-25) times higher than during baseline (late QI period: 29%, 95% CI: 17%-45%; baseline: 4%, 95% CI: 1%-10%; P<.001).. Implementation of a THN and opioid risk reduction QI project in an inpatient rehabilitation setting led to significantly more eligible patients receiving naloxone and more patients weaned off schedule II opioids.

Topics: Analgesics, Opioid; Drug Overdose; Female; Humans; Inpatients; Inservice Training; Male; Middle Aged; Models, Organizational; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Patient Education as Topic; Practice Patterns, Physicians'; Prospective Studies; Quality Improvement; Rehabilitation Centers; Risk Reduction Behavior

As the overdose crisis in North America continues to deepen, public health leaders find themselves responding to sensational media stories, many of which carry forms and themes that mark them as urban legends.This article analyzes one set of media accounts - stories of misuse of naloxone, an opioid overdose antidote distributed to people who use drugs - through the lens of social science scholarship on urban legends. We suggest that these stories have met a public need to feel a sense of safety in uncertain times, but function to reinforce societal views of people who use drugs as undeserving of support and resources.Our field has a duty to speak out in favour of evidence-based programs that support the health of people who use drugs, but the optimal communication strategies are not always clear. Drawing attention to the functions and consequences of urban legends can help frame public health communication in a way that responds to needs without reinforcing prejudices, with application beyond naloxone to the other urban legends that continue to emerge in response to this crisis.

Topics: Analgesics, Opioid; Communications Media; Drug Overdose; Health Communication; Humans; Naloxone; North America; Opioid-Related Disorders; Professional Role; Public Health

Topics: Adult; Crisis Intervention; Drug Overdose; Female; Humans; Inpatients; Male; Mental Disorders; Naloxone; Opioid-Related Disorders; Patient Education as Topic

Topics: Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Pilot Projects; Prisons

The province of British Columbia (BC) Canada has experienced a rapid increase in illicit drug overdoses and deaths during the last 4 years, with a provincial emergency declared in April 2016. These deaths have been driven primarily by the introduction of synthetic opioids into the illicit opioid supply. This study aimed to measure the combined impact of large-scale opioid overdose interventions implemented in BC between April 2016 and December 2017 on the number of deaths averted.. We expanded on the mathematical modelling methodology of our previous study to construct a Bayesian hierarchical latent Markov process model to estimate monthly overdose and overdose-death risk, along with the impact of interventions.. Overdose events and overdose-related deaths in BC from January 2012 to December 2017.. The interventions considered were take-home naloxone kits, overdose prevention/supervised consumption sites and opioid agonist therapy MEASUREMENTS: Counterfactual simulations were performed with the fitted model to estimate the number of death events averted for each intervention and in combination.. Between April 2016 and December 2017, BC observed 2177 overdose deaths (77% fentanyl-detected). During the same period, an estimated 3030 (2900-3240) death events were averted by all interventions combined. In isolation, 1580 (1480-1740) were averted by take-home naloxone, 230 (160-350) by overdose prevention services and 590 (510-720) were averted by opioid agonist therapy.. A combined intervention approach has been effective in averting overdose deaths during British Columbia's opioid overdose crisis in the period since declaration of a public health emergency (April 2016-December 2017). However, the absolute numbers of overdose deaths have not changed.

Topics: Bayes Theorem; British Columbia; Drug Overdose; Harm Reduction; Humans; Markov Chains; Models, Theoretical; Naloxone; Narcotic Antagonists; Needle-Exchange Programs; Opiate Substitution Treatment; Opioid Epidemic; Opioid-Related Disorders

Topics: Drug Overdose; Humans; Naloxone; Philadelphia; United States

All 50 states have implemented policies to improve access to naloxone through community pharmacies. Many states require naloxone-based training for pharmacists before participating in these activities. The purpose of this study was to determine the effects of an opioid misuse and overdose training program on students' knowledge, self-efficacy, and value of pharmacists' role in preventing overdose.. The training program was implemented with third-year professional pharmacy students. Students participated in a 50-min lecture followed by a two-hour hands-on laboratory activity. Students took a pre-survey immediately before the lecture and a post-survey immediately following the laboratory activity.. Seventy students completed the pre- and post-surveys. Students showed a significant (p < 0.05) gain in self-efficacy and value after completing the training program, and a significant gain in knowledge from six of the eight related survey items. There was a significant correlation between students' self-efficacy and perceived value of the pharmacists' role in preventing opioid overdose.. A training program implemented for third-year pharmacy students increases students' knowledge, self-efficacy, and perceived value. Specifically, the strong correlation seen between self-efficacy and perceived value after completing the training program is important to note as we prepare future pharmacists for their role in fighting the opioid epidemic.

Topics: Drug Overdose; Drug Prescriptions; Education, Pharmacy; Educational Measurement; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Students, Pharmacy; Surveys and Questionnaires

North America is in the midst of an unabated opioid overdose epidemic due to the increasing non-medical use of fentanyl and ultra-potent opioids. Naloxone is an effective antidote to opioid toxicity, yet its optimal dosing in the context of fentanyl and ultra-potent opioid overdoses remains unknown. This review aims to determine the relationship between the first empiric dose of naloxone and reversal of toxicity, adverse events, and the total cumulative dose required among patients with undifferentiated opioid overdoses and those with suspected toxicity from ultra-potent opioids. Secondary objectives include evaluating the relationship between the cumulative naloxone dose and toxicity reversal and adverse events, among patients with undifferentiated opioid overdoses and those with suspected toxicity from ultra-potent opioids.. To identify studies, we will search MEDLINE, Embase, CENTRAL, DARE, CDAG, CINAHL, Science Citation Index, multiple trial registries, and the gray literature. Included studies will evaluate patients with suspected or confirmed opioid toxicity from undifferentiated opioids and ultra-potent opioids, who received an empiric and possibly additional doses of naloxone. The main outcomes of interest are the relationship between naloxone dose and toxicity reversal and adverse events. We will include controlled and non-controlled interventional studies, observational studies, case reports/series, and reports from poison control centers. We will extract data and assess study quality in duplicate with discrepancies resolved by consensus or a third party. We will use the Downs and Black and Cochrane risk of bias tools for observational and randomized controlled studies. If we find sufficient variation in dose, we will fit a random effects one-stage model to estimate a dose-response relationship. We will conduct multiple subgroup analyses, including by type of opioid used and by suspected high and low prevalence of ultra-potent opioid use based on geographic location and time of the original studies.. Our review will include the most up-to-date available data including ultra-potent opioids to inform the current response to the opioid epidemic, addressing the limitations of recent reviews. We anticipate limitations relating to study heterogeneity. We will disseminate study results widely to update overdose treatment guidelines and naloxone dosing in Take Home Naloxone programs.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists

Opioid-related overdose rates continue to climb. However, little research has examined the reach of overdose education and naloxone trainings among people who inject drugs (PWID). Understanding gaps in coverage is essential to improving the public health response to the ongoing crisis.. We surveyed 298 PWID in Baltimore City, MD. We conducted a latent class analysis of drug use indicators and tested for differences by class in past month overdose, having received overdose training, and currently having naloxone.. Three classes emerged: cocaine/heroin injection (40.2%), heroin only injection (32.2%), and multi-drug/multi-route use (27.6%). The prevalence of past month overdose differed marginally by class (p = 0.06), with the multi-drug/multi-route use class having the highest prevalence (22.5%) and the heroin only class having the lowest (4.6%). The prevalence of previous overdose training differed significantly by class (p = 0.02), with the heroin/cocaine class (76.5%) having more training than the other two classes. Training was least common amongst the multi-drug/multi-route class (60.3%), though not statistically different from the heroin only class (63.0%). Classes did not differ significantly in current naloxone possession, although the multi-drug/multi-route class exhibited the lowest prevalence of naloxone possession (37.2%).. People who inject multiple substances are at high risk for overdose and are also the least likely to receive overdose trainings. The current service landscape does not adequately reach individuals with high levels of structural vulnerability and high levels of drug use and homelessness. Actively including this subgroup into harm reduction efforts are essential for preventing overdose fatalities.

Topics: Adolescent; Adult; Baltimore; Cocaine-Related Disorders; Drug Overdose; Female; Harm Reduction; Heroin Dependence; Humans; Ill-Housed Persons; Latent Class Analysis; Male; Middle Aged; Naloxone; Narcotic Antagonists; Patient Education as Topic; Prevalence; Public Health; Socioeconomic Factors; Substance Abuse, Intravenous; Substance-Related Disorders; Young Adult

Topics: Cross-Sectional Studies; Drug Overdose; Female; Fentanyl; Harm Reduction; Humans; Male; Motivation; Naloxone; Patient Acceptance of Health Care; Reagent Strips; Recurrence; Self Administration; Substance-Related Disorders; Young Adult

Evaluations of overdose response programs suggest effectiveness in preventing overdose-related death and individual willingness to respond to an overdose. However, knowledge of and confidence in performing response behaviors is necessary for individuals to intervene. This study assessed overdose responding self-efficacy among adults who reported lifetime opioid use.. Data come from a cross-sectional survey, part of a randomized controlled trial designed for adults living with hepatitis C. Participants were 18 years old or older, and reported lifetime opioid use. Overdose responding self-efficacy was assessed by perceived knowledge and/or need for additional training to have confidence responding to an overdose. Univariate statistics were calculated for overdose responding self-efficacy, and individual characteristics and experiences. Adjusted logistic regression was used to identify variables associated with low overdose responding self-efficacy.. Of the 424 participants, 67.2% reported low overdose responding self-efficacy. Sixty percent witnessed and 30.4% experienced an overdose in the past year. Witnessing an overdose in the past year, experience with naloxone training, and receiving and using naloxone were associated with high overdose responding self-efficacy. While, apprehension with particular response behaviors (e.g. rescue breathing) was associated with low overdose responding self-efficacy.. A large proportion of adults who reported lifetime opioid use did not feel confident or knowledgeable responding to an overdose. This could be influenced by overdose exposure, specific response behaviors, and response trainings.

Topics: Adult; Cross-Sectional Studies; Drug Overdose; Female; Health Knowledge, Attitudes, Practice; Hepatitis C; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Self Efficacy; Substance Abuse, Intravenous; Surveys and Questionnaires

To mitigate the opioid overdose crisis, states have implemented a variety of legal interventions aimed at increasing access to the opioid antagonist naloxone. Recently, Virginia and Vermont mandated the coprescription of naloxone for potentially at-risk patients.. To assess the association between naloxone coprescription legal mandates and naloxone dispensing in retail pharmacies.. This was a population-based, state-level cohort study. The sample included all prescriptions dispensed for naloxone in the retail pharmacy setting contained in IQVIA's national prescription audit, which represents 90% of all retail pharmacies in the United States. The unit of observation was state-month and the study period was January 1, 2011, to December 31, 2017.. State legal intervention mandating naloxone coprescription.. Number of naloxone prescriptions dispensed. State rates of naloxone prescriptions dispensed per month per 100 000 standard population were calculated.. The rate of naloxone dispensing increased after implementation of legal mandates for naloxone coprescription. An estimated 88 naloxone prescriptions per 100 000 were dispensed in Virginia and 111 prescriptions per 100 000 were dispensed in Vermont during the first full month the legal requirement was effective. In comparison, 16 naloxone prescriptions per 100 000 were dispensed in the 10 states (including the District of Columbia) with the highest opioid overdose death rates and 6 prescriptions per 100 000 were dispensed in the 39 remaining states. The number of naloxone prescriptions dispensed was associated with the legal mandate for naloxone coprescription (incidence rate ratio [IRR], 7.75; 95% CI, 1.22-49.35). Implementation of the naloxone coprescription mandate was associated with an estimated 214 additional naloxone prescriptions dispensed per month in the period following the mandates, holding all other variables constant. Among covariates, naloxone access laws (IRR, 1.37; 1.05-1.78), opioid overdose death rates (IRR, 1.06; 95% CI, 1.04-1.08), the percentage of naloxone prescriptions paid by third-party payers (IRR 1.009; 1.008-1.010), and time (IRR, 1.06; 95% CI, 1.05-1.07) were significantly associated with naloxone prescription dispensing.. These study findings suggest that legally mandated naloxone prescription for those at risk for opioid overdose may be associated with substantial increases in naloxone dispensing and further reduction in opioid-related harm.

Topics: Analgesics, Opioid; Drug Overdose; Drug Prescriptions; Humans; Longitudinal Studies; Naloxone; Narcotic Antagonists; Practice Patterns, Physicians'; United States

Naloxone is an opioid antagonist with high affinity for μ-opioid receptor, and for this reason it is used for the emergency treatment of opioid overdose. Originally, it was available only as an injectable product. However, for the ease of administration, intranasal (IN) formulations have also become available. These IN formulations contain preservatives and stabilizers such as benzalkonium chloride (BKC), benzyl alcohol (BA), and ethylenediaminetetraacetic acid (EDTA). Some of these ingredients are known to affect permeability of drugs. This study focuses on investigating the effect of formulation variables including choice of preservatives, stabilizer, and pH on the permeability and stability of naloxone IN formulations. The in vitro permeability of naloxone was evaluated employing EpiAirway™ tissue-mounted Ussing chambers. BKC was found to enhance the apparent permeability (P

Topics: Administration, Intranasal; Analgesics, Opioid; Drug Compounding; Drug Overdose; Edetic Acid; Humans; Hydrogen-Ion Concentration; Naloxone; Narcotic Antagonists; Permeability

Topics: Adult; Analgesics, Opioid; Buprenorphine; Drug Overdose; Emergency Service, Hospital; Humans; Male; Naloxone; Narcotic Antagonists; Opiate Substitution Treatment

Topics: Drug Overdose; Humans; Naloxone; Survivors

These 2 cases offer insights to faster recognition of a common cause of drug overdose.

Topics: Adult; Benzodiazepines; Cocaine; Diagnosis, Differential; Drug Overdose; Fentanyl; Heroin; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists

Persons in addiction treatment are likely to experience and/or witness drug overdoses following treatment and thus could benefit from overdose education and naloxone distribution (OEND) programs. Diverting individuals from the criminal justice system to addiction treatment represents one treatment engagement pathway, yet OEND needs among these individuals have not been fully described.. We characterized justice involvement patterns among 514 people who use opioids (PWUO) participating in a criminal justice diversion addiction treatment program during 2014-2016 using a gender-stratified latent class analysis. We described prevalence and correlates of naloxone knowledge using quasi-Poisson regression models with robust standard errors.. Only 56% of participants correctly identified naloxone as an opioid overdose treatment despite that 68% had experienced an overdose and 79% had witnessed another person overdose. We identified two latent justice involvement classes: low involvement (20.3% of men, 46.5% of women), characterized by older age at first arrest, more past-year arrests, and less time incarcerated; and high involvement (79.7% of men, 53.5% of women), characterized by younger age at first arrest and more lifetime arrests and time incarcerated. Justice involvement was not associated with naloxone knowledge. Male participants who had personally overdosed more commonly identified naloxone as an overdose treatment after adjustment for age, race, education level, housing status, heroin use, and injection drug use (prevalence ratio [95% confidence interval]: men 1.5 [1.1-2.0]).. All PWUO in criminal justice diversion programs could benefit from OEND given the high propensity to experience and witness overdoses and low naloxone knowledge across justice involvement backgrounds and genders.

Topics: Adult; Alcoholism; Clinical Competence; Correlation of Data; Criminal Law; Cross-Sectional Studies; Drug Overdose; Female; Humans; Male; Middle Aged; Naloxone; Narcotic-Related Disorders; Sex Factors; Survival Rate; United States

A community-based research (CBR) approach is critical to redressing the exclusion of women-particularly, traditionally marginalized women including those who use substances-from HIV research participation and benefit. However, few studies have articulated their process of involving and engaging peers, particularly within large-scale cohort studies of women living with HIV where gender, cultural and linguistic diversity, HIV stigma, substance use experience, and power inequities must be navigated.. Through our work on the Canadian HIV Women's Sexual and Reproductive Health Cohort Study (CHIWOS), Canada's largest community-collaborative longitudinal cohort of women living with HIV (n = 1422), we developed a comprehensive, regionally tailored approach for hiring, training, and supporting women living with HIV as Peer Research Associates (PRAs). To reflect the diversity of women with HIV in Canada, we initially hired 37 PRAs from British Columbia, Ontario, and Quebec, prioritizing women historically under-represented in research, including women who use or have used illicit drugs, and women living with HIV of other social identities including Indigenous, racialized, LGBTQ2S, and sex work communities, noting important points of intersection between these groups.. Building on PRAs' lived experience, research capacity was supported through a comprehensive, multi-phase, and evidence-based experiential training curriculum, with mentorship and support opportunities provided at various stages of the study. Challenges included the following: being responsive to PRAs' diversity; ensuring PRAs' health, well-being, safety, and confidentiality; supporting PRAs to navigate shifting roles in their community; and ensuring sufficient time and resources for the translation of materials between English and French. Opportunities included the following: mutual capacity building of PRAs and researchers; community-informed approaches to study the processes and challenges; enhanced recruitment of harder-to-reach populations; and stronger community partnerships facilitating advocacy and action on findings.. Community-collaborative studies are key to increasing the relevance and impact potential of research. For women living with HIV to participate in and benefit from HIV research, studies must foster inclusive, flexible, safe, and reciprocal approaches to PRA engagement, employment, and training tailored to regional contexts and women's lives. Recommendations for best practice are offered.

Topics: Canada; Clinical Competence; Cohort Studies; Community-Based Participatory Research; Criminal Law; Drug Overdose; Epidemiologic Studies; Female; HIV Infections; Humans; Inservice Training; Longitudinal Studies; Naloxone; Narcotic Antagonists; Peer Group; Personnel Selection; Research; Research Design; Sex Factors; Social Marginalization

The present phase of the overdose epidemic is characterized by fentanyl-contaminated heroin, particularly in the eastern United States (U.S.). However, there is little research examining how changes in drug potency are affecting urban, racial minority individuals who have been affected by both the "old" epidemic of the 1940s through 1980s, as well as the "new" present day epidemic. A focus on the drug using experiences of racial minorities is needed to avoid perpetuating discriminatory responses to drug use in communities of color, which have characterized past U.S. policies. This qualitative study was conducted from March through June 2018 to examine recent experiences of urban, individuals of color who inject drugs to assess the impact of the current overdose epidemic on this understudied population. Interviews were conducted with 25 people who reported current injection drug use. The interviews were transcribed and analyzed using a general inductive approach to identify major themes. Fifteen of 25 participants reported experiencing a non-fatal overdose in the past two years; eight suspected their overdose was fentanyl-related. Likewise, 15 had ever witnessed someone else overdose at least once. Overdoses that required multiple doses of naloxone were also reported. Participants employed several methods to attempt to detect the presence of fentanyl in their drugs, with varying degrees of success. Carrying naloxone and utilizing trusted drug sellers (often those who also use) were strategies used to minimize risk of overdose. Contaminated heroin and increased risk for overdose was often encountered when trusted sources were unavailable. This population is suffering from high rates of recent overdose. Removal of trusted drug sources from a community may inadvertently increase overdose risk. Ensuring access to harm reduction resources (naloxone, drug testing strips) will remain important for addressing ever-increasing rates of overdose among all populations affected.

Topics: Adult; Aged; Drug Contamination; Drug Overdose; Female; Fentanyl; Heroin; Heroin Dependence; Humans; Interviews as Topic; Male; Middle Aged; Naloxone; Narcotic Antagonists; Racial Groups; Substance Abuse, Intravenous; United States; Urban Population; Young Adult

Topics: Adolescent; Analgesics, Opioid; Drug Overdose; Global Health; Humans; Mass Screening; Naloxone; Opioid-Related Disorders; Practice Patterns, Physicians'

Overdose prevention programs are effective at reducing opioid overdose deaths through training people who inject drugs (PWID) how to respond to witnessed overdoses and use naloxone. This report examines prevalence and correlates of carrying naloxone among a community-based sample of PWID.. Using respondent driven sampling, PWID (n = 571) in Philadelphia, PA were recruited for the 2015 National HIV Behavioral Surveillance project. The impact of socio-demographics, social services, and law enforcement interaction on naloxone carrying were analyzed using multivariable logistic regression.. Odds of carrying naloxone were higher among PWID who were: homeless (adjusted odds ratio [aOR] = 1.65, 95% confidence interval [CI]: 1.01, 2.83), reported a syringe exchange program as their primary source of syringes (aOR = 2.92, CI: 1.68, 5.09), and had been stopped by police ≥6 times (aOR = 2.16, CI: 1.12, 4.16) or arrested (aOR = 1.84, CI: 1.02, 3.30) in the past year.. Syringe exchange access was associated with naloxone carrying and is likely a primary source for naloxone and overdose reversal training for PWID. Homelessness and law enforcement encounters are known barriers to harm reducing behaviors; however, both were positively associated with carrying naloxone in this sample. Larger studies are needed to explore these relationships in greater depth.

Topics: Adult; Behavioral Risk Factor Surveillance System; Drug Overdose; Female; Humans; Ill-Housed Persons; Male; Naloxone; Narcotic Antagonists; Needle-Exchange Programs; Opioid-Related Disorders; Philadelphia; Police; Prevalence; Substance Abuse, Intravenous

Topics: Analgesics, Opioid; Centers for Disease Control and Prevention, U.S.; Chronic Pain; Drug Overdose; Harm Reduction; Health Knowledge, Attitudes, Practice; Humans; Naloxone; Narcotic Antagonists; Neoplasms; United States

Take-home naloxone (THN) is recommended in response to pharmaceutical opioid-related mortality. Some health professionals are reluctant to discuss THN for fear of causing offense. The aims of this study were to assess knowledge of opioid overdose and attitudes toward THN for opioid overdose reversal in people with chronic noncancer pain (CNCP).. Prospective cohort study.. Australia, September to October 2015.. A subset of participants (N = 208) from a cohort of people prescribed restricted opioids for CNCP.. Questions added in the two-year telephone interviews examined knowledge of overdose symptoms and attitudes toward community supply of naloxone. Associations with overdose risk factors and naloxone supply eligibility criteria with attitudes toward naloxone were explored.. Fourteen percent reported ever experiencing opioid overdose symptoms. Participants correctly identified fewer than half of the overdose signs and symptoms. After receiving information on naloxone, most participants (60%), thought it was a "good" or "very good" idea. Few participants reported that they would be "a little" (N = 21, 10%) or "very" offended (N = 7, 3%) if their opioid prescriber offered them naloxone. Positive attitudes toward THN were associated with male gender (odds ratio [OR] = 1.96, 95% confidence interval [CI] = 1.09-3.50), past year cannabis use (OR = 2.52, 95% CI = 1.03-6.16), and past year nicotine use (OR = 2.11, 95% CI = 1.14-3.91).. Most participants had positive attitudes toward THN but low knowledge about opioid overdose symptoms. Strategies for educating patients and their caregivers on opioid toxicity are needed. THN may be best targeted toward those with risk factors in terms of overdose prevention and acceptability.

Topics: Adult; Aged; Analgesics, Opioid; Chronic Pain; Drug Overdose; Female; Harm Reduction; Health Knowledge, Attitudes, Practice; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Prospective Studies

Launched in 2011, the Scottish national naloxone program marked an important development in public health policy. Central to its design were strategies to engage prisoners given their elevated risk of drug-related death in the weeks following liberation. Implementation across Scottish prisons has posed particular challenges linked to both operational issues within prison establishments and individual factors affecting staff delivering, and prisoners engaging, with the program. Barriers have been overcome through innovation and partnership working. This commentary has described how the development of the program in prisons has adapted to these challenges to a point where a largely consistent model is in place and where prisoners-on-release are reaping the benefits in terms of reduced opioid-related mortality.

Topics: Drug Overdose; Harm Reduction; Humans; Naloxone; Narcotic Antagonists; Prisoners; Prisons; Scotland

The Bradford Hill criteria for assessing causality are useful in assembling evidence, including within complex policy analyses. In this paper, we argue that the implementation of take-home naloxone (THN) programs in Australia and elsewhere reflects sensible, evidence-based public health policy, despite the absence of randomised controlled trials. However, we also acknowledge that the debate around expanding access to THN would benefit from a careful consideration of causal inference and health policy impact of THN program implementation. Given the continued debate around expanding access to THN, and the relatively recent access to new data from implementation studies, two research groups independently conducted Bradford Hill analyses in order to carefully consider causal inference and health policy impact. Hill's criteria offer a useful analytical tool for interpreting current evidence on THN programs and making decisions about the (un)certainty of THN program safety and effectiveness.

Topics: Australia; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Policy Making; Public Policy

Topics: Administration, Intranasal; Adult; Analgesics, Opioid; Drug Overdose; Emergency Nursing; Emergency Service, Hospital; Female; Heroin; Humans; Injections, Intravenous; Naloxone; Narcotic Antagonists; Ohio; Referral and Consultation; Young Adult

The Massachusetts Department of Public Health Overdose Education and Naloxone Distribution Program provides overdose education and naloxone rescue kits to people at risk for overdose and bystanders, including family members. Using Massachusetts Department of Public Health data, the aims are to: (i) describe characteristics of family members who receive naloxone; (ii) identify where family members obtain naloxone; and (iii) describe characteristics of rescues by family members.. We conducted a retrospective review using program enrollee information collected on a standardised form between 2008 and 2015. We calculated descriptive statistics, including demographics, current substance use, enrolment location, history of witnessed overdoses and rescue attempt characteristics. We conducted a stratified analysis comparing family members who used drugs with those who did not.. Family members were 27% of total program enrollees (n = 10 883/40 801). Family members who reported substance use (n = 4679) were 35.6 years (mean), 50.6% female, 76.3% non-Hispanic white, 75.6% had witnessed an overdose, and they obtained naloxone most frequently at HIV prevention programs. Family members who did not report substance use (n = 6148) were 49.2 years (mean), 73.8% female, 87.9% non-Hispanic white, 35.3% had witnessed an overdose, and they obtained naloxone most frequently at community meetings. Family members were responsible for 20% (n = 860/4373) of the total rescue attempts.. The Massachusetts experience demonstrates that family members can be active participants in responding to the overdose epidemic by rescuing family members and others. Targeted intervention strategies for families should be included in efforts to expand overdose education and naloxone in Massachusetts.

Topics: Adult; Drug Overdose; Family; Female; Health Education; Health Knowledge, Attitudes, Practice; Humans; Male; Massachusetts; Naloxone; Narcotic Antagonists

Numerous studies and systematic reviews have concluded that naloxone for take-home use is an effective intervention to reduce overdose morbidity and mortality, with few side effects and no abuse potential. One barrier to supply is that naloxone has traditionally been a prescription medication. In May 2015, the Therapeutic Goods Administration of Australia announced the intention to down-schedule naloxone when used for the treatment of opioid overdose, enabling sale in pharmacies without a prescription. The aim of this article is to describe process of rescheduling of naloxone and some of the challenges observed.. We describe the process of rescheduling from initial proposal development to gaining support and submissions from a range of individuals and professional bodies to support this change. The implications of the change, particularly for pharmacy supply of naloxone, are discussed, including next steps to facilitate implementation of this change in the Australian context.. A submission to reschedule naloxone was successfully instigated by a member of the public. The change may help remove access barriers to naloxone by allowing pharmacist supply. Cost, pharmacist training, existing naloxone formulation, presentation and packaging remain challenges to address.. Naloxone down-scheduling has opened up an additional way to supply naloxone through community pharmacy. Further expansion of naloxone availability may be achieved through addressing cost as a barrier, and making naloxone more widely accessible through needle syringe programs, and other services that do not have medical staff.

Topics: Australia; Community Pharmacy Services; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Nonprescription Drugs; Pharmacists

Naloxone hydrochloride, an opioid antagonist, has been approved as a concentrated 4 mg dose intranasal formulation for the emergency treatment of known or suspected opioid overdose. This new formulation is easier to use and contains a higher dose of naloxone compared with earlier, unapproved kits. A survey of first responders and community-based organizations was conducted to understand initial real-world experiences with this new formulation for opioid overdose reversal.. In August 2016, 152 US organizations known to have received units of the approved 4 mg dose/unit naloxone nasal spray (Narcan. Eight first-responder or community-based organizations provided case report data on 261 attempted overdose reversals using NNS, with survival reported for 245 cases. Successful overdose reversals were reported in 98.8% (242/245) of cases; most cases (73.5%; 125/170) reported a time to response of ≤5 minutes after NNS administration. Heroin was the substance reportedly involved in a majority (95.4%; 165/173) of these cases; fentanyl was reported to be involved in 5.2% (9/173) of the cases. Many reversals (97.6%; 248/254) involved administration of ≤2 units of NNS. Three deaths were reported (NNS was reported to have been administered too late for two cases [the individuals were deceased prior to NNS administration]; details were not provided for the third case). The most commonly reported observed events were "withdrawal" (14.3%; 28/196); "nausea", "vomiting", or "gagging/retching" (10.2%; 20/196); and "irritability" or "anger" (8.7%; 17/196).. This survey of data provided by first-responder and community-based organizations indicated that NNS was successful at reversing the effects of opioid overdose in most reported cases.

Topics: Administration, Intranasal; Adolescent; Adult; Analgesics, Opioid; Drug Overdose; Female; Fentanyl; Humans; Male; Naloxone; Narcotic Antagonists; Nasal Sprays; Surveys and Questionnaires; Young Adult

Prescription opioid overdose is a leading cause of injury-related morbidity and mortality in the United States. We aimed to identify characteristics associated with clinical severity in emergency department patients with prescription opioid overdose.. This was a secondary data analysis of adult prescription opioid overdoses from a large prospective cohort of acute overdoses. We examined elements of a typical emergency department evaluation using a multivariable model to determine which characteristics were associated with clinical severity, specifically severe respiratory depression (SRD).. This study was conducted at two urban academic emergency departments in New York City, USA.. Adult patients who presented with acute prescription opioid overdose between 2009 and 2013 were included in the current study. We analyzed 307 patients (mean age = 44.7, 42% female, 2.0% mortality).. Patient demographics, reported substances ingested, suspected intent for ingesting the substance, vital signs, laboratory data, treatments including antidotes and intubation and outcome of death were recorded by trained research assistants. Intent was categorized into four mutually exclusive categories: suicide, misuse, therapeutic error and undetermined. The primary outcome was SRD, defined as administration of either (a) naloxone or (b) endotracheal intubation (ETI).. A total of 109 patients suffered SRD with 90 patients receiving naloxone alone, nine ETI alone and 10 both naloxone and ETI. The most common opioids were oxycodone (n = 124) and methadone (n = 116). Mean age was higher in patients with SRD (51.1 versus 41.1, P < 0.001). Opioid misuse was associated with SRD in the multivariable analysis [odds ratio (OR) = 2.07, 95% confidence interval (CI) = 1.21-3.55]. The unadjusted relative risk of SRD was high for fentanyl (83.3% SRD) and lowest for codeine (3.6% SRD).. In emergency department patients in the United States with prescription opioid overdose, worse clinical severity was associated with opioid misuse, increased with age and was widely variable, depending on the specific opioid medication involved.

Topics: Adult; Age Factors; Analgesics, Opioid; Cohort Studies; Drug Overdose; Emergency Service, Hospital; Female; Fentanyl; Humans; Intubation, Intratracheal; Male; Methadone; Middle Aged; Multivariate Analysis; Naloxone; Narcotic Antagonists; Odds Ratio; Oxycodone; Prescription Drug Misuse; Prospective Studies; Respiration, Artificial; Respiratory Insufficiency; Risk Factors; Severity of Illness Index; United States

To compare user self-identification of nonpharmaceutical fentanyl exposure with confirmatory urine drug testing in emergency department (ED) patients presenting after heroin overdose.. This was a cross-sectional study of adult ED patients who presented after a heroin overdose requiring naloxone administration. Participants provided verbal consent after which they were asked a series of questions regarding their knowledge, attitudes and beliefs toward heroin and nonpharmaceutical fentanyl. Participants also provided urine samples, which were analyzed using liquid chromatography coupled to quadrupole time-of-flight mass spectrometry to identify the presence of fentanyl, heroin metabolites, other clandestine opioids, common pharmaceuticals and drugs of abuse.. Thirty participants were enrolled in the study period. Ten participants (33%) had never required naloxone for an overdose in the past, 20 participants (67%) reported recent abstinence, and 12 participants (40%) reported concomitant cocaine use. Naloxone was detected in all urine drug screens. Heroin or its metabolites were detected in almost all samples (93.3%), as were fentanyl (96.7%) and its metabolite, norfentanyl (93.3%). Acetylfentanyl was identified in nine samples (30%) while U-47700 was present in two samples (6.7%). Sixteen participants self-identified fentanyl in their heroin (sensitivity 55%); participants were inconsistent in their qualitative ability to identify fentanyl in heroin.. Heroin users presenting to the ED after heroin overdose requiring naloxone are unable to accurately identify the presence of nonpharmaceutical fentanyl in heroin. Additionally, cutting edge drug testing methodologies identified fentanyl exposures in 96.7% of our patients, as well as unexpected clandestine opioids (like acetylfentanyl and U-47700).

Topics: Adolescent; Adult; Cross-Sectional Studies; Drug Overdose; Emergency Service, Hospital; Fentanyl; Heroin; Humans; Naloxone; Self Report; Young Adult

Recently implemented New York State policy allows police and fire to administer intranasal naloxone when responding to opioid overdoses. This work describes the geographic distribution of naloxone administration (NlxnA) by police and fire when responding to opioid overdoses in Erie County, NY, an area of approximately 920,000 people including the City of Buffalo. Data are from opioid overdose reports (N = 800) filed with the Erie County Department of Health (July 2014-June 2016) by police/fire and include the overdose ZIP code, reported drug(s) used, and NlxnA. ZIP code data were geocoded and mapped to examine spatial patterns of NlxnA. The highest NlxnA rates (range: 0.01-84.3 per 10,000 population) were concentrated within the city and first-ring suburbs. Within 3 min 27.3% responded to NlxnA and 81.6% survived the overdose. The average individual was male (70.3%) and 31.4 years old (SD = 10.3). Further work is needed to better understand NlxnA and overdose, including exploring how the neighborhood environment creates a context for drug use, and how this context influences naloxone use and overdose experiences.

Topics: Adult; Community Health Services; Drug Overdose; Emergency Medical Services; Female; Firefighters; Humans; Male; Naloxone; Narcotic Antagonists; New York; Police; Young Adult

The USA is experiencing an epidemic of drug overdoses and deaths with a 200% increase in overdose deaths involving opioids including heroin. Legislation since 2013 has created paths to reduce opioid overdose deaths and since, basic life support (BLS) and police agencies have been administering naloxone to patients with suspected opioid overdoses as part of standard treatment protocols. Charts were reviewed from 1 January 2016 to 15 April 2016 on the de-identified electronic medical records of patients in a two-county system comprising the 'Jersey Shore' who received naloxone to determine the number of naloxone administrations and heroin overdoses. Additionally, narratives were examined for evidence of heroin use. Of the 312 patients, 213 received a first dose of naloxone by a family member or bystander, police, or by BLS; 99 received a first dose by a paramedic (ALS). About 233 were initially unresponsive or had altered mental status that improved after naloxone administration. About210 (67.3%) charts illustrated obvious opioid use. Of the note, 282 patients arrived to an emergency department alive. About 30 patients were pronounced dead. From 1 February 2016 to 31 March 2016, the number of opioid overdoses increased and the subsequent use of naloxone has increased by 176%.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Child; Drug Overdose; Drug Utilization; Emergency Service, Hospital; Female; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; New Jersey; Opioid-Related Disorders; Police; Retrospective Studies; Young Adult

Since the banning of dextropropoxyphene from the market, overdoses, and fatalities attributed to tramadol, a WHO step-2 opioid analgesic, have increased markedly. Tramadol overdose results not only in central nervous system (CNS) depression attributed to its opioid properties but also in seizures, possibly related to non-opioidergic pathways, thus questioning the efficiency of naloxone to reverse tramadol-induced CNS toxicity.. To investigate the most efficient antidote to reverse tramadol-induced seizures and respiratory depression in overdose.. Sprague-Dawley rats overdosed with 75 mg/kg intraperitoneal (IP) tramadol were randomized into four groups to receive solvent (control group), diazepam (1.77 mg/kg IP), naloxone (2 mg/kg intravenous bolus followed by 4 mg/kg/h infusion), and diazepam/naloxone combination. Sedation depth, temperature, number of seizures, and intensity, whole-body plethysmography parameters and electroencephalography activity were measured.. Naloxone reversed tramadol-induced respiratory depression (p < .05) but significantly increased seizures (p < .01) and prolonged their occurrence time. Diazepam abolished seizures but significantly deepened rat sedation (p < .05) without improving ventilation. Diazepam/naloxone combination completely abolished seizures, significantly improved rat ventilation by reducing inspiratory time (p < .05) but did not worsen sedation. None of these treatments significantly modified rat temperature.. Diazepam/naloxone combination is the most efficient antidote to reverse tramadol-induced CNS toxicity in the rat.

Topics: Analgesics, Opioid; Animals; Antidotes; Drug Overdose; Naloxone; Rats; Rats, Sprague-Dawley; Respiratory Insufficiency; Seizures; Tramadol

Topics: Drug Overdose; Home Care Services; Humans; Naloxone; Narcotic Antagonists; Prevalence; Prisons; Surveys and Questionnaires; United Kingdom

The past decade has seen over a four-fold increase in deaths from opioid overdose in the United States. To address this growing epidemic, many localities initiated policies to expand access to naloxone (a drug that reverses the effects of opioids); however, little is known how naloxone access affects opioid use behaviours.. The present qualitative study used semi-structured, in-depth interviews with inpatients at a substance use treatment centre. All patients who met study inclusion criteria (in treatment for opioid use, between the ages of 18 and 40, able to speak and understand English, and had not previously completed an interview with the research team) were invited to participate. Interviews were conducted until thematic saturation was reached (N=20) and covered the participant's naloxone knowledge, access, and attitudes, as well as experience(s) with opioid use and opioid overdose, and their naloxone use in the context of opioid overdose. Thematic content analysis was used to analyze interview transcripts.. Five main themes were uncovered during analysis; first, awareness about naloxone, including, content knowledge and source information for naloxone. Naloxone awareness was very common among opioid users; however, depth of knowledge varied; some participants did not make any efforts to have naloxone available, and others felt that it was "just as important as a clean needle." The second theme explored how naloxone access intersects with drug selling. The third theme explored naloxone availability while using, including attitudes about naloxone, occasions with no naloxone availability, when naloxone is "good to have," and when naloxone is a priority for users. The fourth theme examined changes in opioid use behaviours associated with naloxone access. Primarily, participants discussed changing how much heroin they used in a given situation to achieve a bigger high. The final theme explored naloxone behaviours that alter overdose mortality risk, such as how users distinguish when to use naloxone, dis-incentives to naloxone use, and solo opioid use.. Results indicate that though naloxone awareness was high, there was great variation in the associated attitudes and practices. Participants generally described naloxone as an important resource, but not all were inclined to carry or use it appropriately. Future research needs to examine why different groups of opioid users access naloxone differently, particularly to identify those at risk for experimental opioid use while carrying naloxone.

Topics: Adult; Behavioral Symptoms; Drug Overdose; Female; Health Knowledge, Attitudes, Practice; Humans; Male; Naloxone; Opioid-Related Disorders; Risk Assessment; United States

With the opioid overdose mortality rates rising nationally, The New York City Department of Health and Mental Hygiene (NYC DOHMH) has worked to expand overdose rescue training (ORT) and naloxone distribution. This study sought to determine rates of overdose witnessing and naloxone use among overdose rescue-trained visitors to the NYC jails on Rikers Island. We conducted a six-month prospective study of visitors to NYC jails on Rikers Island who received ORT. We collected baseline characteristics of study participants, characteristics of overdose events, and responses to witnessed overdose events, including whether the victim was the incarcerated individual the participant was visiting on the day of training. Bivariate analyses compared baseline characteristics of participants who witnessed overdoses to those who did not, and of participants who used naloxone to those who did not. Overall, we enrolled 283 participants visiting NYC's Rikers Island jails into the study. Six months after enrollment, we reached 226 participants for follow-up by phone. 40 participants witnessed 70 overdose events, and 28 participants reported using naloxone. Of the 70 overdose events, three victims were the incarcerated individuals visited on the day of training; nine additional victims were recently released from jail and/or prison. Visitors to persons incarcerated at Rikers Island witness overdose events and are able to perform overdose rescues with naloxone. This intervention reaches a population that includes not only those recently released, but also other people who experienced overdose.

Topics: Adolescent; Adult; Analgesics, Opioid; Drug Overdose; Female; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; New York City; Prisons; Young Adult

HIV/AIDS rates are higher in the Southern United States compared to other regions of the country. Reasons for disparities include poverty, health care access, and racism. People who inject drugs (PWID) account for 8% of HIV/AIDS incidence rates. Harm reduction can connect PWID to needed resources. AIDS United Southern REACH grantees developed the Southern Harm Reduction Coalition (SHRC) as a means to decrease HIV/AIDS and viral hepatitis rates, criminalization of drug users and sex workers, and drug overdose.. Investigators used an intrinsic case study design to examine the context of harm reduction in the Southern United States, successful strategies, and outcomes. Data collection included key informant interviews and coalition documents. The community coalition action theory was used to examine the data.. The SHRC initiated regional conferences and customized trainings. Strengths-based language and utilization of diverse strengths among coalition members were used to effect change. Coalition outcomes included syringe decriminalization legislation, syringe exchange, naloxone access, naloxone funding legislation, and 911 Good Samaritan laws, along with expanded support for PWID.. Advocacy successes can be applied to similar organizations in the Southern United States to promote harm reduction and potentially decrease HIV/AIDS burden, viral hepatitis, criminalization, and overdose.

Topics: Acquired Immunodeficiency Syndrome; Adult; Community Participation; Drug Overdose; Female; Harm Reduction; Health Services Accessibility; Health Status Disparities; Hepatitis; HIV Infections; Humans; Naloxone; Needle-Exchange Programs; Public Health; United States

Naloxone is a safe and effective antidote for reversing opioid overdose. Layperson administration of naloxone is increasingly common, yet little is known about demographic and clinical factors associated with opioid users' likelihood of having administered naloxone to another opioid user who had overdosed. We examined predictors of reported naloxone administration in the past year.. Four hundred and sixty-eight patients were interviewed upon admission to brief, inpatient opioid detoxification between May and December of 2015. Between group differences were tested using t-tests for differences in means and χ. Participants averaged 32years of age, 28.9% were female, and 86.8% were White. Most (86.8%) reported detoxifying from heroin, 69.0% had injected drugs in the last 30days. One sixth (n=68) of those detoxifying from heroin, but none of those detoxifying from other opioids (n=62) had administered naloxone in the past year. Among the small number of Black/African American participants (n=20), none had administered naloxone, although 90% were heroin users. Respondents were more likely to have administered naloxone if they reported recent injection drug use (IDU), had a history of overdose, or witnessed an overdose in the past year (ps<0.05), even though less than one-third of bystanders of overdose reported administering naloxone.. Higher opioid-related mortality risk (heroin use, IDU, past overdose) was associated with greater likelihood of reported naloxone administration in the past year. The non-use of naloxone among certain groups-prescription pill users and Blacks-was unexpected.

Topics: Adult; Analgesics, Opioid; Drug Overdose; Drug Users; Female; Heroin; Humans; Male; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

Opiate use disorder is a common condition in healthcare services in Ireland, where over 200 opiate overdose deaths occur annually. There is limited addiction medicine education at undergraduate level and medical graduates may not be adequately prepared to diagnose and manage opioid use disorders and emergency drug overdose presentations. Therefore, we examined final-year medical students' learning experiences and attitudes toward opioid use disorder, overdose and community naloxone provision as an emerging overdose treatment.. We administered an anonymous paper-based survey to 243 undergraduate medical students undertaking their final professional completion module prior to graduation from University College Dublin, Ireland. Results were compared with parallel surveys of General Practitioners (GPs) and GP trainees.. A total of 197 (82.1%) completed the survey. Just under half were male, and most were aged under 25 (63.3%) and of Irish nationality (76.7%). The students felt moderately prepared to recognise opioid use disorder, but felt less prepared to manage other aspects of its care. Most had taken a history from a patient with an opioid use disorder (82.8%), and a third had witnessed at least one opioid overdose. Although 10.3% had seen naloxone administered, most had never administered naloxone themselves (98.5%). Half supported wider naloxone availability; this was lower than support rates among GPs (63.6%) and GP trainees (66.1%).. Our findings suggest an unmet learning need in undergraduate training on opioid use disorder, with potential consequences for patient care.

Topics: Adult; Analgesics, Opioid; Attitude of Health Personnel; Drug Overdose; Education, Medical, Undergraduate; Female; Health Services Accessibility; Humans; Ireland; Male; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Personal Satisfaction; Students, Medical; Young Adult

Topics: Cross-Sectional Studies; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Program Development; Program Evaluation; United States

Topics: Adult; Drug Overdose; Emergency Service, Hospital; Female; Follow-Up Studies; Humans; Male; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Young Adult

Programs have recently been established in Australia and internationally to allow wider access to naloxone to people at risk of opioid overdose yet there are no guidelines relating to the administration of naloxone to pregnant women, particularly regarding dose requirements and resuscitative measures peculiar to pregnancy. This paper provides practical guidelines to health workers in relation to any complications that may arise during opioid overdose response (including the administration of naloxone) for pregnant women and the follow up required ensuring best possible outcomes for mother and baby.

Topics: Analgesics, Opioid; Australia; Drug Overdose; Female; Humans; Injections, Intramuscular; Naloxone; Narcotic Antagonists; Practice Guidelines as Topic; Pregnancy; Pregnancy Complications; Self Care

The current opioid overdose crisis in North America is heightening awareness of the need for and the challenges of implementing harm reduction, notably within complex and diverse settings such as homeless shelters. In this paper, we explore the implementation of harm reduction in homeless shelters during an emerging overdose emergency.. The objective of this qualitative study was to identify and understand micro-environment level factors within emergency shelters responding to homelessness and substance use, and the macro-level influences that produce and sustain structural vulnerabilities. We conducted eight focus groups with a total of 49 participants during an emerging overdose emergency. These included shelter residents (n = 23), shelter staff (n = 13), and harm reduction workers (n = 13).. The findings illustrate the challenges of implementing an overdose response when substance use is prohibited onsite, without an expectation of abstinence, and where harm reduction services are limited to the distribution of supplies. In this context, harm reduction is partially implemented and incomplete. Shelters can be a site of risks and trauma for residents and staff due to experiencing, witnessing, and responding to overdoses.. The current overdose crisis heightens the challenges of implementing harm reduction, particularly within complex and diverse settings such as homeless shelters. When harm reduction is limited to the distribution of supplies such as clean equipment and naloxone, important principles of engagement and the development of trust necessary to the provision of services are overlooked with negative implications for service users.

Topics: Adult; Drug Overdose; Emergency Medical Services; Environment; Female; Harm Reduction; Humans; Ill-Housed Persons; Male; Middle Aged; Naloxone; Narcotic Antagonists; Needle-Exchange Programs; Substance-Related Disorders

Naloxone is a life-saving opioid antagonist. Chronic pain guidelines recommend that physicians co-prescribe naloxone to patients at high risk for opioid overdose. However, clinical tools to efficiently identify patients who could benefit from naloxone are lacking.. To develop and validate an overdose predictive model which could be used in primary care settings to assess the need for naloxone.. Retrospective cohort.. Derivation site was an integrated health system in Colorado; validation site was a safety-net health system in Colorado.. We developed a predictive model in a cohort of 42,828 patients taking chronic opioid therapy and externally validated the model in 10,708 patients.. Potential predictors and outcomes (nonfatal pharmaceutical and heroin overdoses) were extracted from electronic health records. Fatal overdose outcomes were identified from state vital records. To match the approximate shelf-life of naloxone, we used Cox proportional hazards regression to model the 2-year risk of overdose. Calibration and discrimination were assessed.. A five-variable predictive model showed good calibration and discrimination (bootstrap-corrected c-statistic = 0.73, 95% confidence interval [CI] 0.69-0.78) in the derivation site, with sensitivity of 66.1% and specificity of 66.6%. In the validation site, the model showed good discrimination (c-statistic = 0.75, 95% CI 0.70-0.80) and less than ideal calibration, with sensitivity and specificity of 82.2% and 49.5%, respectively.. Among patients on chronic opioid therapy, the predictive model identified 66-82% of all subsequent opioid overdoses. This model is an efficient screening tool to identify patients who could benefit from naloxone to prevent overdose deaths. Population differences across the two sites limited calibration in the validation site.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Analgesics, Opioid; Chronic Pain; Cohort Studies; Colorado; Drug Administration Schedule; Drug Overdose; Electronic Health Records; Female; Humans; Male; Middle Aged; Models, Statistical; Naloxone; Narcotic Antagonists; Primary Health Care; Prognosis; Retrospective Studies; Risk Assessment; Risk Factors; Substance-Related Disorders; Young Adult

With the rise of the opioid epidemic in the United States and increased mortality as a result of opioid overdoses, there have been many national and statewide initiatives to combat this health crisis. Many states have expanded accessibility to naloxone, an opioid-reversal agent. Naloxone is safe, cost-effective, and nonaddictive. In addition, simple administration allows naloxone to be used by patients, family members, caregivers, and bystanders in the event of an opioid overdose. While a great emphasis has been placed on the prescribing practices of health care providers as it pertains to opioid therapy for chronic pain, a new focus has been placed on coprescribing naloxone with opioids for high-risk patients. Naloxone standing orders have allowed health care providers, including pharmacists, to prescribe, dispense, and/ or administer the medication in an attempt to save lives. In addition, pharmacists play a role in counseling and educating patients, family members, caregivers, and bystanders on the safe administration of naloxone in the event of an emergency.

Topics: Analgesics, Opioid; Chronic Pain; Drug Overdose; Health Personnel; Humans; Naloxone; Narcotic Antagonists; Patient Education as Topic; Pharmaceutical Services; Pharmacists; Professional Role; United States

Opioid prescriptions have significantly increased in recent years and are used for a wide variety of indications. Electronic medical records of 45 patients who received naloxone by a rapid response team over an 18-month period were retrospectively reviewed. This study found inconsistencies in the management of possible opioid toxicity with variation in the total naloxone dose and number of doses administered. This highlights the importance of a standardised protocol for recognition and management of opioid overdose.

Topics: Adult; Aged; Aged, 80 and over; Analgesics, Opioid; Drug Overdose; Emergency Medical Services; Female; Hospitals, Urban; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Patient Care Team; Retrospective Studies; Treatment Outcome; Victoria; Young Adult

Topics: Administration, Intranasal; Analgesics, Opioid; Drug Overdose; Healthy Volunteers; Humans; Naloxone; Nasal Sprays

Despite escalating opioid overdose death rates, addiction medicine is underrepresented in residency curricula. Providing naloxone to at-risk patients, relatives, and first responders reduces overdose deaths, but rates of naloxone prescribing remain low. The goal of this study is to examine the impact of a brief curricular intervention for internal medicine residents on naloxone prescribing rates, knowledge, and attitudes.. Internal medicine residents (N = 160) at an urban, tertiary care medical center received two 1-hour didactic sessions addressing overdose prevention, including intranasal naloxone. The number of naloxone prescriptions generated by residents was compared to faculty, who received no similar intervention, in the 3-month periods before and after the curriculum. Resident knowledge and attitudes, as assessed by pre- and post-intervention surveys, were compared.. The resident naloxone prescribing rate increased from 420 to 1270 per 100,000 inpatient discharges (P = .01) and from 0 to 370 per 100,000 ambulatory visits (P < .001) post-intervention. Similar increases were not observed among inpatient faculty, whose prescribing rate decreased from 1150 to 880 per 100,000 discharges (P = .08), or among outpatient faculty, whose rate increased from 30 to 180 per 100,000 ambulatory visits (P < .001) but was lower than the post-intervention resident rate (P = .01). Residents demonstrated high baseline knowledge about naloxone, but just 13% agreed that they were adequately trained to prescribe pre-intervention. Post-intervention, residents were more likely to agree that they were adequately trained to prescribe (Likert mean 2.5 vs. 3.9, P < .001), to agree that treating addiction is rewarding (Likert mean 2.9 vs. 3.3, P = .03), and to attain a perfect score on the knowledge composite (57% vs. 33%, P = .05).. A brief curricular intervention improved resident knowledge and attitudes regarding intranasal naloxone for opioid overdose reversal and significantly increased prescribing rates.

Topics: Administration, Intranasal; Analgesics, Opioid; Attitude of Health Personnel; Clinical Competence; Curriculum; Drug Overdose; Education, Medical, Graduate; Humans; Internship and Residency; Naloxone; Narcotic Antagonists; Practice Patterns, Physicians'

Overdose education and naloxone training was recently implemented into the required curriculum of the College of Pharmacy at the University of Rhode Island. The objective of this study was to compare the retention of knowledge between student pharmacists who received a didactic lecture only versus student pharmacists who received the same lecture plus a skills-based objective structured clinical examination (OSCE) with a standardized patient actor.. Students in their first-professional year (P1) of the Doctor of Pharmacy program (n = 129) and students in their second-professional (P2) year (n = 123) attended a required lecture on opioid overdose, including detailed naloxone training. P2 students were additionally required to participate in an OSCE assessment following the didactic lecture component. An anonymous, voluntary survey was offered to all students approximately 6 months later. A Chi-Square or Fisher's Exact Test was performed on the survey responses to assess any difference in the responses between the two groups.. A total of 99 P1 students (76.7%) and 116 P2 students (94.3%) completed the survey. P1 students were found to be more knowledgeable regarding the duration of naloxone action and identification of risk factors for opioid overdose. P2 students were found to be more knowledgeable regarding non-medical ways patients may obtain opioids and the correct order of emergency response during a suspected opioid overdose… Conclusions: P2 students did not demonstrate superior retention of information regarding naloxone and opioid use disorder on survey questions compared with P1 students. There was a trend towards P2 students feeling more confident in their ability to counsel patients for overdose prevention and reporting disagreement with the statement that "overdose prevention for people who use drugs is a waste of time and money" compared with the P1 students, but these did not reach statistical significance. Since the opioid crisis continues unabated, naloxone training using OSCE and didactic methods remain an on-going required part of the pharmacy curriculum.

Topics: Drug Overdose; Education, Pharmacy; Health Knowledge, Attitudes, Practice; Humans; Naloxone; Narcotic Antagonists; Patient Simulation; Students, Pharmacy

Overdose is the leading cause of unintentional injury-related death. Rhode Island (RI) has the highest rate of illicit drug use nationally and the 5th highest overdose mortality rate. RI has experienced an outbreak of fentanyl-related overdoses. In incarcerated populations, risk of overdose is greatly elevated. However, little is known about fentanyl-related overdose post-release. In the current analyses, we identify changes in fentanyl-related fatal overdose among those who died in 2014 and 2015 who were incarcerated in the year before death. We linked data from the RI Office of the Medical Examiner with records from the RI Department of Corrections. We calculated risk ratios and 95% confidence intervals using log-binomial regression to compare risk of fentanyl-involved overdose death. We also compared median time to death since release, median sentence length, and median number of incarcerations in 2014 and 2015. Results indicate that the risk of dying of a fentanyl-related overdose increased (RR: 1.99 (95% CI: 1.11-3.57, p = 0.014)) from 2014 to 2015 among those with past year incarceration. This study is one of the first to describe fentanyl-related fatal overdose among those with past year incarceration. In 2015 the median sentence was longer among those with a fentanyl-related overdose death and the median time from release to death among all who had past year incarceration extended past 90 days. Access to medications for addiction treatment, overdose education, and naloxone should be available during community re-entry and extended beyond the early post-release period.

Topics: Adolescent; Adult; Drug Overdose; Female; Fentanyl; Humans; Illicit Drugs; Male; Naloxone; Rhode Island; Risk; Young Adult

Take-home naloxone (THN) programs have been operating in Australia since 2012 in a variety of settings. We examine whether THN programs were effective in increasing knowledge about opioid overdose and appropriate responses in program participants.. Data were obtained from pre- and post-training questionnaires administered as part of the early evaluations of THN naloxone programs operated in Sydney (n = 67), Melbourne (n = 280), Perth (n = 153) and Canberra (n = 183). Pooled data from comparable items, analysed in the domains specified in previously-developed evaluation scales, were compared using repeated-measures analysis of variance and random effects logistic regression. Results pre- and post-training were compared as well as results across sites.. High levels of knowledge about overdose risks and signs and appropriate actions to take were observed at baseline and this generally improved over time. No substantial differences were identified across cities. Knowledge also increased with participant age but the improvements over time were similar in each age group. There were small differences by participant gender with knowledge generally higher among females.. THN programs are effective in improving knowledge related to overdose response. Major improvements in knowledge were limited to overdose recognition and effect of naloxone suggesting that education may best be focused on overdose signs and the use of naloxone among populations accessed through these programs. A focus on younger people also appears warranted. Further work is needed to understand the impact of training and knowledge on actual behaviours around overdose events.

Topics: Adult; Australia; Drug Overdose; Female; Health Education; Health Knowledge, Attitudes, Practice; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Surveys and Questionnaires; Young Adult

Topics: Analgesics, Opioid; Attitude of Health Personnel; Cross-Sectional Studies; Drug Overdose; Emergency Service, Hospital; Humans; Naloxone; Ohio; Practice Patterns, Physicians'

Topics: Adult; Clinical Protocols; Counseling; Drug Overdose; Emergency Service, Hospital; Female; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Patient Education as Topic; Prescription Drug Monitoring Programs; Referral and Consultation; Secondary Prevention; Substance Abuse Treatment Centers

A program at a family medicine clinic to provide naloxone prescriptions in conjunction with education on naloxone use and opioid hazards to patients at risk for opioid overdose is described.. Consistent with a 2016 Centers for Disease Control and Prevention (CDC) guideline on opioid prescribing for chronic pain, a family medicine clinic implemented updated controlled substance agreements and medical record templates for documentation of pain management visits and established a pharmacist-led naloxone clinic. Chart reviews were performed to identify patients eligible for naloxone, as defined by the CDC guideline. A standard visit template was constructed to guide patient education regarding overdose risks and naloxone use. The teach-back method was used to ensure patient understanding, and patients were encouraged to bring a friend or family member to clinic visits. To address medication access barriers, community resources for patient referral for assistance were identified. Barriers to attendance at pharmacist-conducted visits necessitated changes in clinic workflow to incorporate education into prescheduled physician visits and education of some patients via telephone. During the first 6 months of clinic operations, 49 patients were identified as being at risk for opioid overdose; pharmacists educated 84% of those patients and subsequently confirmed that 69% had filled a naloxone prescription.. Naloxone prescribing and provision of education on naloxone use to at-risk patients in a family medicine clinic can help ensure access to life-saving medication and reinforce CDC recommendations on safe prescribing of opioids.

Topics: Analgesics, Opioid; Chronic Pain; Drug Overdose; Family Practice; Humans; Naloxone; Narcotic Antagonists; Patient Education as Topic; Pharmaceutical Services; Pharmacists; Practice Guidelines as Topic

Opioid overdose deaths in the US rose dramatically in the past 16 years, creating an urgent national health crisis with no signs of immediate relief. In 2017, the President of the US officially declared the opioid epidemic to be a national emergency and called for additional resources to respond to the crisis. Distributing naloxone to community laypersons and people at high risk for opioid overdose can prevent overdose death, but optimal distribution methods have not yet been pinpointed.. We conducted a sequential exploratory mixed methods design using qualitative data to inform an agent-based model to improve understanding of effective community-based naloxone distribution to laypersons to reverse opioid overdose. The individuals in the model were endowed with cognitive and behavioral variables and accessed naloxone via community sites such as pharmacies, hospitals, and urgent-care centers. We compared overdose deaths over a simulated 6-month period while varying the number of distribution sites (0, 1, and 10) and number of kits given to individuals per visit (1 versus 10). Specifically, we ran thirty simulations for each of thirteen distribution models and report average overdose deaths for each. The baseline comparator was no naloxone distribution. Our simulations explored the effects of distribution through syringe exchange sites with and without secondary distribution, which refers to distribution of naloxone kits by laypersons within their social networks and enables ten additional laypersons to administer naloxone to reverse opioid overdose.. Our baseline model with no naloxone distribution predicted there would be 167.9 deaths in a six month period. A single distribution site, even with 10 kits picked up per visit, decreased overdose deaths by only 8.3% relative to baseline. However, adding secondary distribution through social networks to a single site resulted in 42.5% fewer overdose deaths relative to baseline. That is slightly higher than the 39.9% decrease associated with a tenfold increase in the number of sites, all distributing ten kits but with no secondary distribution. This suggests that, as long as multiple kits are picked up per visit, adding secondary distribution is at least as effective as increasing sites from one to ten. Combining the addition of secondary distribution with an increase in sites from one to ten resulted in a 61.1% drop in deaths relative to the baseline. Adding distribution through a syringe exchange site resulted in a drop of approximately 65% of deaths relative to baseline. In fact, when enabling distribution through a clean-syringe site, the secondary distribution through networks contributed no additional drops in deaths.. Community-based naloxone distribution to reverse opioid overdose may significantly reduce deaths. Optimal distribution methods may include secondary distribution so that the person who picks up naloxone kits can enable others in the community to administer naloxone, as well as targeting naloxone distribution to sites where individuals at high-risk for opioid overdose death are likely to visit, such as syringe-exchange programs. This study design, which paired exploratory qualitative data with agent-based modeling, can be used in other settings seeking to implement and improve naloxone distribution programs.

Topics: Computer Simulation; Delivery of Health Care; Drug Overdose; Humans; Models, Theoretical; Naloxone; Social Networking

Fentanyl overdoses are increasing and few data guide emergency department (ED) management. We evaluate the safety of an ED protocol for patients with presumed fentanyl overdose.. At an urban ED, we used administrative data and explicit chart review to identify and describe consecutive patients with uncomplicated presumed fentanyl overdose (no concurrent acute medical issues) from September to December 2016. We linked regional ED and provincial vital statistics databases to ascertain admissions, revisits, and mortality. Primary outcome was a composite of admission and death within 24 hours. Other outcomes included treatment with additional ED naloxone, development of a new medical issue while in the ED, and length of stay. A prespecified subgroup analysis assessed low-risk patients with normal triage vital signs.. There were 1,009 uncomplicated presumed fentanyl overdose, mainly by injection. Median age was 34 years, 85% were men, and 82% received out-of-hospital naloxone. One patient was hospitalized and one discharged patient died within 24 hours (combined outcome 0.2%; 95% confidence interval [CI] 0.04% to 0.8%). Sixteen patients received additional ED naloxone (1.6%; 95% CI 1.0% to 2.6%), none developed a new medical issue (0%; 95% CI 0% to 0.5%), and median length of stay was 173 minutes (interquartile range 101 to 267). For 752 low-risk patients, no patients were admitted or developed a new issue, and one died postdischarge; 3 (0.4%; 95% CI 0.01% to 1.3%) received ED naloxone.. In our cohort of ED patients with uncomplicated presumed fentanyl overdose-typically after injection-deterioration, admission, mortality, and postdischarge complications appear low; the majority can be discharged after brief observation. Patients with normal triage vital signs are unlikely to require ED naloxone.

Topics: Adult; Canada; Drug Overdose; Emergency Service, Hospital; Female; Humans; Length of Stay; Male; Mortality; Naloxone; Practice Guidelines as Topic; Retreatment; Retrospective Studies; Urban Health Services

Following clonidine ingestion, naloxone is seldom administered as it is considered ineffective in reversing somnolence, bradycardia, or hypotension. However, this conclusion has been based on administration of small doses (2 mg or less) of naloxone. The somnolence is frequently treated with endotracheal intubation (ETI), a procedure with significant morbidity.. We aimed to determine if naloxone administration reversed the effects of clonidine or caused any adverse effects.. We performed a retrospective descriptive cohort (IRB approved) of hospital medical records for pediatric patients (6 months-16 years) with clonidine exposure. Demographics, history, co-ingestants, clinical data, treatments, and outcome were recorded in a de-identified database.. The most common clinical findings in the 52 patients were sedation (n = 51), bradycardia (n = 44), and hypotension (n = 11). Of 51 somnolent patients, naloxone administration awoke 40 patients, five of which had co-ingestants. Nine patients experienced recurrent sedation that resolved with a repeat bolus of naloxone. Twenty somnolent bradycardic patients (11 less than 3 years old) received 10 mg naloxone via intravenous bolus. Thirteen awoke; bradycardia persisted in six of the awake patients. Of the remaining 31 patients, 22 awoke following 6 mg or less of naloxone. Naloxone reversed hypotension in 7 of 11 hypotensive patients. Only one hypotensive patient (with a coingestion) received vasopressors for hypotension. Three awake normotensive patients received vasopressors for bradycardia. Seven patients awoke and had normal vital signs following naloxone administration, but were chemically sedated and intubated for transport. There were no adverse events following the administration of any dose of naloxone.. Administration of naloxone to somnolent pediatric patients with clonidine toxicity awoke the majority (40/51) and resolved bradycardia and hypotension in some. Persistent bradycardia was benign. Hypotension was rare and clinically insignificant. No adverse effects occurred in any patient including the 21 patients who received 10 mg naloxone. Morbidity in this overdose may be due to ETI, a procedure that could be prevented if high-dose naloxone (10 mg) were administered. Administration of high-dose naloxone should be considered in all children with clonidine toxicity.

Topics: Adolescent; Antidotes; Antihypertensive Agents; Child; Child, Preschool; Clonidine; Cohort Studies; Dose-Response Relationship, Drug; Drug Overdose; Female; Humans; Hypertension; Infant; Male; Naloxone; Retrospective Studies

Topics: Analgesics, Opioid; Drug Overdose; Drug Prescriptions; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Quality Improvement; Students, Medical

In recognition of the importance of safe and effective pain management, the Department of Veterans Affairs and the Office of the Under Secretary for Health have encouraged implementation of opioid overdose education and naloxone distribution (OEND) programs at Veterans Affairs Medical Centers (VAMCs).. An OEND program was developed in August 2015 and implemented in September 2015 at a VAMC which allowed for pharmacist-lead individual and group patient education. An OEND consult service was developed to streamline referrals of patients for naloxone education and distribution. At the conclusion of the class, participants were ordered a naloxone auto-injector or nasal spray kit. To evaluate the utility of this quality-improvement initiative, data was collected from September 2015 until May 2016. Examples of data collected included participant satisfaction with education, risk for accidental overdose, and number of naloxone kits dispensed to participants.. Of a total of 243 consults placed, 71 individuals participated in OEND education. A large quantity of consults were discontinued due to patients no-showing education. Sixty-four consult referrals were identified to have a mental health diagnosis. Most participants who received education had a risk for accidental opioid overdose of 14%. Sixty-nine education participants were provided a naloxone kit. Based on the OEND class survey, participants felt that their knowledge of accidental opioid overdose increased and were generally satisfied with the education.. OEND educated 30% of the Veterans referred into the program via the consult service, the majority of whom were at a relatively low risk for opioid overdose.

Topics: Analgesics, Opioid; Drug Overdose; Drug Utilization; Humans; Naloxone; Patient Education as Topic; Patient Satisfaction; Program Development; Program Evaluation; United States; United States Department of Veterans Affairs; Veterans

Opioid-related overdose death rates in rural communities in the United States are much higher than their urban counterparts. However, basic life support (BLS) personnel, who are more common in rural areas, have much lower rates of naloxone administration than other levels of emergency medical services (EMS). Training and equipping basic level Emergency Medical Technician (EMTs) to administer naloxone for an opioid overdose could yield positive outcomes.. Following a legislative change that allowed EMTs to administer naloxone in one rural state, we evaluated an EMT training program by examining EMTs' opioid overdose knowledge and attitudes before and after the training.. One-hundred-seventeen rural EMTs participated the training. They demonstrated statistically significant improvements on almost all of the knowledge questions after the training (p's = 0.0469 to <0.0001). The opioid overdose competency and concern scales showed statistically significant improvement (p < 0.0001) and reduction (p < 0.0001), respectively. Furthermore, statistically significant changes in knowledge and opinions of state law regarding naloxone administration were observed. Significantly more EMTs supported the idea of expanding naloxone to people at risk for overdose (p = 0.0026) after the training.. At a time when states are passing legislation to expand first responders' access to naloxone, this study provides evidence about authorizing EMTs to administer naloxone.

Topics: Adult; Aged; Analgesics, Opioid; Clinical Competence; Drug and Narcotic Control; Drug Overdose; Emergency Medical Technicians; Female; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Nevada; Rural Population; Young Adult

Since 2014, the Department of Veterans Affairs (VA) has been working to address the ongoing opioid epidemic through opioid-education initiatives, the development of risk calculators, and other risk stratification tools. One primary focus of VA efforts has been the distribution of rescue naloxone kits to veterans at greatest risk of opioid-related adverse events. The purpose of this project was to identify primary care veterans at highest risk for serious opioid-related adverse events using the Risk Index for Overdose and Serious Opioid-Induced Respiratory Depression (RIOSORD) and offer rescue naloxone kits by telephone-based outreach. RIOSORD is a risk-stratification tool developed and validated within the veteran population.. Veterans identified at highest risk of overdose or opioid-related adverse effects were contacted by telephone or letter to offer to provide a rescue naloxone kit between November 1. Of 41 veterans targeted by this project, most were successfully reached by telephone within three attempts (92.7%, n = 38). Approximately two-thirds of those reached by telephone agreed to a prescription for rescue naloxone (n = 26, 63.4%). The veterans that requested rescue naloxone selected the nasal formulation (n = 17) over the intramuscular auto-injector (n = 9).. This project demonstrated that telephone-based outreach can be one method of distributing rescue naloxone to a high-risk patient population without requiring an in-person visit to a provider.

Topics: Analgesics, Opioid; Drug Overdose; Female; Humans; Male; Middle Aged; Naloxone; Outpatients; Respiratory Insufficiency; Risk Factors; Telemedicine; Telephone; Veterans

Topics: Adult; Aged; Attitude of Health Personnel; Drug Overdose; Emergency Medicine; Female; Harm Reduction; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Prospective Studies; Self Care

To determine the rate of patients visiting the emergency department who are at risk of opioid overdose.. The electronic records of a 412 bed tertiary care county teaching hospital were searched for emergency department (ED) visits from January 1, 2013 to October 31, 2016 to find patients on at least 100mg morphine equivalents (MME) of oral opioid therapy, or an opioid in combination with a benzodiazepine. Records were also searched for patients with a positive urinalysis for opioids when no opioid was present on their home medication list. Medication reconciliations were searched for patients at risk of opioid overdose who were subsequently discharged on naloxone.. An analysis of 2521 patients visiting the ED was performed, and the overall rate of risk of opioid overdose increased from 25.84% to 47.41% (p<0.0001) in patients meeting inclusion criteria from 2013 to 2016. For patients on opioids, the rate of patients on 100 MME daily or greater increased from 9.72% to 28.24% (p<0.0001) from 2013 to 2016. The rate of patients on opioid therapy in combination with benzodiazepine therapy did not change significantly from 2013 to 2016. When comparing patients at risk of opioid overdose to total emergency department visits, we found the rate of at risk patients increased significantly from 0.12% to 0.56% (p<0.0001) from 2013 to 2016.. The rate of patients visiting the emergency department at risk of opioid overdose increased significantly from 2013 to 2016. Naloxone was not routinely prescribed to this patient cohort.

Topics: Adult; Aged; Analgesics, Opioid; Drug Overdose; Emergency Service, Hospital; Female; Humans; Male; Medication Reconciliation; Middle Aged; Naloxone; Narcotic Antagonists; Retrospective Studies; Tertiary Care Centers; Texas; Young Adult

Overdose is a major cause of death among injecting drug users in Wales. Few studies, however, have explored the overdose responses of witnesses in this context. This study applies Rhodes' concept of the 'risk environment' to examine how witnesses respond to opiate overdose.. In depth, semi-structured interviews were conducted with fifty-five participants recruited from statutory and third sector drug treatment providers operating across South Wales and from two Welsh prisons. Eligibility was based on whether the person was, or had recently been, an opiate user and whether they had personally experienced or witnessed an overdose event.. Witnesses were amenable to assisting overdosed peers. However, a number of micro- and macro-level factors impeded the successful implementation of harm reduction techniques in response to an overdose. At micro level, the social setting of injecting drug use, peer group drug use norms and difficulties in identifying an overdose were linked to ineffective response. Macro-level factors including laws governing the possession of drugs and harm reduction discourse were also found to limit the uptake of overdose response techniques.. Findings suggest a need to insert pragmatic solutions into overdose prevention programmes and training to counter the factors hindering effective responses to overdose. This includes simpler techniques and harnessing the support and knowledge of injecting drug users' social networks. Although these will go some way to addressing specific micro-level barriers, we also emphasise the need for additional policy measures that can address the macro-environmental conditions that produce and maintain features of injecting drug users' risk environments.

Topics: Adult; Analgesics, Opioid; Drug Overdose; Drug Users; Female; Harm Reduction; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Peer Group; Qualitative Research; Risk Factors; Substance-Related Disorders; Young Adult

Since the 1990's, governmental and non-governmental organizations have adopted several measures to increase access to the opioid overdose reversal medication naloxone. These include the implementation of laws that increase layperson naloxone access and overdose-specific Good Samaritan laws that protect those reporting overdoses from criminal sanction. The association of these legal changes with overdose mortality and non-medical opioid use is unknown. We assess the relationship of (1) naloxone access laws and (2) overdose Good Samaritan laws with opioid-overdose mortality and non-medical opioid use in the United States.. We used 2000-2014 National Vital Statistics System data, 2002-2014 National Survey on Drug Use and Health data, and primary datasets of the location and timing of naloxone access laws and overdose Good Samaritan laws.. By 2014, 30 states had a naloxone access and/or Good Samaritan law. States with naloxone access laws or Good Samaritan laws had a 14% (p = 0.033) and 15% (p = 0.050) lower incidence of opioid-overdose mortality, respectively. Both law types exhibit differential association with opioid-overdose mortality by race and age. No significant relationships were observed between any of the examined laws and non-medical opioid use.. Laws designed to increase layperson engagement in opioid-overdose reversal were associated with reduced opioid-overdose mortality. We found no evidence that these measures were associated with increased non-medical opioid use.

Topics: Analgesics, Opioid; Drug and Narcotic Control; Drug Overdose; Harm Reduction; Health Services Accessibility; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; United States

Topics: Analgesics, Opioid; Drug Overdose; Emergency Treatment; Humans; Naloxone; Narcotic Antagonists

To reduce fatal drug overdoses, two approaches many states have followed is to pass laws expanding naloxone access and Good Samaritan protections for lay persons with high likelihood to respond to an opioid overdose. Most prior research has examined attitudes and knowledge among lay responders in large metropolitan areas who actively use illicit substances. The present study addresses current gaps in knowledge related to this issue through an analysis of data collected from a broader group of lay responders who received naloxone kits from 20 local health departments across Indiana.. Postcard surveys were included inside naloxone kits distributed in 20 Indiana counties, for which 217 returned cards indicated the person completing it was a lay responder. The survey captured demographic information and experiences with overdose, including the use of 911 and knowledge about Good Samaritan protections.. Few respondents had administered naloxone before, but approximately one third had witnessed a prior overdose and the majority knew someone who had died from one. Those who knew someone who had overdosed were more likely to have obtained naloxone for someone other than themselves. Also, persons with knowledge of Good Samaritan protections or who had previously used naloxone were significantly more likely to have indicated calling 911 at the scene of a previously witnessed overdose. Primary reasons for not calling 911 included fear of the police and the person who overdosed waking up on their own.. Knowing someone who has had a fatal or non-fatal overdose appears to be a strong motivating factor for obtaining naloxone. Clarifying and strengthening Good Samaritan protections, educating lay persons about these protections, and working to improve police interactions with the public when they are called to an overdose scene are likely to improve implementation and outcomes of naloxone distribution and opioid-related Good Samaritan laws.

Topics: Adolescent; Adult; Aged; Drug Overdose; Emergencies; Female; Health Knowledge, Attitudes, Practice; Health Services Accessibility; Humans; Indiana; Male; Middle Aged; Naloxone; Narcotic Antagonists; Surveys and Questionnaires; Young Adult

Opioid-related overdose has increased 137% in the past decade. Training nonmedical bystanders to administer naloxone (Narcan™) is a widely-researched intervention that has been associated with decreases in overdose rates in the communities in which it has been implemented. A recent review advocated for noninjectable formulations of naloxone, however patient preference for naloxone formulations has not yet been examined (Strang et al., 2016).. Two cohorts of respondents (N. Results were remarkably similar across both cohorts. Specifically, respondents preferred noninjectable formulations (intranasal, sublingual, buccal) over injectable (intravenous, intramuscular) formulations. A small percent (8.9%-9.8%) said they would never be willing to administer naloxone. An identical percent of respondents in both cohorts (44.9%) rated intranasal as their most preferred formulation.. Two independent cohorts of respondents who were receiving opioid medications for pain management reported a preference for noninjectable over injectable formulations of naloxone to reverse an opioid overdose. Though initial preference is only one of many factors that impacts ultimate public acceptance and uptake of a new product, these results support the additional research and development of noninjectable naloxone formulations.

Topics: Administration, Buccal; Administration, Intranasal; Administration, Intravenous; Administration, Sublingual; Adolescent; Adult; Analgesics, Opioid; Drug Overdose; Female; Humans; Injections, Intramuscular; Male; Middle Aged; Naloxone; Narcotic Antagonists; Pain; Patient Preference; Young Adult

This article reports on the first implementation of an online opioid-overdose prevention, recognition and response training for laypeople. The training was disseminated nationally in November 2014. Between 2000 and 2014, U.S. opioid deaths increased by 200%. The importance of complementary approaches to reduce opioid overdose deaths, such as online training, cannot be overstated.. A retrospective evaluation was conducted to assess perceived knowledge, skills to intervene in an overdose, confidence to intervene, and satisfaction with the training.. Descriptive statistics were used to report sample characteristics, compare experiences with overdose and/or naloxone between subgroups, and describe participants' satisfaction with the trainings. Z-ratios were used to compare independent proportions, and paired t-tests were used to compare participant responses to items pre- and posttraining, including perceived confidence to intervene and perceived knowledge and skills to intervene successfully.. Between January and October 2015, 2,450 laypeople took the online training; 1,464 (59.8%) agreed to be contacted. Of these, 311 (21.2% of those contacted) completed the survey. Over 80% reported high satisfaction with content, format and mode of delivery and high satisfaction with items related to confidence and overdose reversal preparedness. Notably, 89.0% of participants felt they had the knowledge and skills to intervene successfully posttraining compared to 20.3% pretraining (z = -17.2, p <.001). Similarly, posttraining, 87.8% of participants felt confident they could successfully intervene compared to 24.4% pretraining (z = -15.9, p <.001).. This study demonstrates the effectiveness of the GetNaloxoneNow.org online training for laypeople.

Topics: Analgesics, Opioid; Curriculum; Drug Overdose; Harm Reduction; Health Education; Health Knowledge, Attitudes, Practice; Humans; Internet; Naloxone; Narcotic Antagonists; Personal Satisfaction; Program Evaluation; Retrospective Studies; Surveys and Questionnaires

Topics: Adult; Aged; Analgesics, Opioid; Chicago; Drug Overdose; Female; Health Services Accessibility; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Urban Population; Young Adult

The purpose of this study was to determine if employing a home healthcare model for education and treatment of opioid overdose using the Evzio (Naloxone) auto-injector in a private practice pain clinic.. A prospective survey was used to determine the feasibility of integrating a naloxone auto-injector within the patient's home with a home care training model. Twenty moderate or high-risk patients were enrolled from the chronic pain clinic. Patients who were moderate or high risk completed an evaluation survey. The naloxone auto-injector was dispensed to all patients meeting criteria. The treating provider after prescribing the naloxone auto-injector then consulted home health per standard clinical practice. All patients had home health consulted to perform overdose identification and rescue training. A Cochran's Q test was conducted to examine differences in patient knowledge pre- and post-training. The post training test was done 2-4 weeks later.. Forty subjects enrolled after meeting inclusion/exclusion criteria. Twenty withdrew because their insurance declined coverage for the naloxone auto-injector. Those completing home health showed a statistically significant difference in their ability to correctly identify the steps needed to effectively respond to an overdose (p = .03).. Preliminary evidence would suggest training on overdose symptom recognition and proper use of prescription naloxone for treatment in the home setting by home health staff would prove more beneficial than the clinic setting, but feasibility was hindered by unaffordable costs related to insurance coverage limitations.

Topics: Adult; Aged; Ambulatory Care Facilities; Analgesics, Opioid; Drug Overdose; Feasibility Studies; Female; Home Care Services; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Pain; Pain Clinics; Private Practice; Prospective Studies

Illicit use of high-potency synthetic opioids has become a global issue over the past decade. This misuse is particularly pronounced in British Columbia, Canada, where a rapid increase in availability of fentanyl and other synthetic opioids in the local illicit drug supply during 2016 led to a substantial increase in overdoses and deaths. In response, distribution of take-home naloxone (THN) overdose prevention kits was scaled up (6·4-fold increase) throughout the province. The aim of this study was to estimate the impact of the THN programme in terms of the number of deaths averted over the study period.. We estimated the impact of THN kits on the ongoing epidemic among people who use illicit opioids in British Columbia and explored counterfactual scenarios for the provincial response. A Markov chain model was constructed explicitly including opioid-related deaths, fentanyl-related deaths, ambulance-attended overdoses, and uses of THN kits. The model was calibrated in a Bayesian framework incorporating population data between Jan 1, 2012, and Oct 31, 2016.. 22 499 ambulance-attended overdoses and 2121 illicit drug-related deaths (677 [32%] deaths related to fentanyl) were recorded in the study period, mostly since January, 2016. In the same period, 19 074 THN kits were distributed. We estimate that 298 deaths (95% credible interval [CrI] 91-474) were averted by the THN programme. Of these deaths, 226 (95% CrI 125-340) were averted in 2016, following a rapid scale-up in distribution of kits. We infer a rapid increase in fentanyl adulterant at the beginning of 2016, with an estimated 2·3 times (95% CrI 2·0-2·9) increase from 2015 to 2016. Counterfactual modelling indicated that an earlier scale-up of the programme would have averted an additional 118 deaths (95% CrI 64-207). Our model also indicated that the increase in deaths could parsimoniously be explained through a change in the fentanyl-related overdose rate alone.. The THN programme substantially reduced the number of overdose deaths during a period of rapid increase in the number of illicit drug overdoses due to fentanyl in British Columbia. However, earlier adoption and distribution of the THN intervention might have had an even greater impact on overdose deaths. Our findings show the value of a fast and effective response at the start of a synthetic opioid epidemic. We also believe that multiple interventions are needed to achieve an optimal impact.. Canadian Institutes of Health Research Partnerships for Health Systems Improvement programme (grant 318068) and Natural Science and Engineering Research Council of Canada (grant 04611).

Topics: Analgesics, Opioid; Bayes Theorem; British Columbia; Drug Overdose; Epidemics; Fentanyl; Harm Reduction; Humans; Illicit Drugs; Naloxone; Narcotic Antagonists; Program Evaluation

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.. 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).. 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.. 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.. 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.

Topics: Cost-Benefit Analysis; Decision Support Techniques; Decision Trees; Drug Costs; Drug Overdose; Health Services Accessibility; Heroin Dependence; Humans; Injections, Intramuscular; Markov Chains; Models, Economic; Naloxone; Narcotic Antagonists; Quality-Adjusted Life Years; State Medicine; United Kingdom

Intranasal naloxone aims at preventing opioid overdose related deaths in active drug users. In France, it has been available since July 2016 through a temporary approval which requires a hospital-based pharmacy and a nominative registration of each patient. We present the characteristics of the first patients who could receive this prescription in our hospital-based addiction center and how they used naloxone during follow-up. Results favor a larger dispensing of naloxone. Patients' as well as peers' and families' education is needed.

Topics: Addiction Medicine; Administration, Intranasal; Adult; Ambulatory Care Facilities; Behavior, Addictive; Drug Approval; Drug Overdose; Female; France; Government Agencies; Health Plan Implementation; Humans; Male; Middle Aged; Naloxone; National Health Programs; Opioid-Related Disorders; Paris; Practice Patterns, Physicians'; Referral and Consultation; Time Factors

Topics: Adult; Airports; Analgesics, Opioid; Body Packing; Drug Overdose; Humans; India; Male; Naloxone; Narcotic Antagonists; Radiography; Toxicology

Topics: Australia; Drug Overdose; Harm Reduction; Humans; Naloxone; Narcotic Antagonists

Take-home naloxone (THN) programs targeting people who inject drugs (PWID) have been running in some Australian states and territories since 2012. In this study, we aimed to determine the extent to which PWID in the capital cities of all Australian states and territories are aware of naloxone and THN programs, whether awareness of these programs has changed over time.. Data were obtained from cross-sectional surveys of a total of 2088 PWID conducted annually as part of the Illicit Drug Reporting System from 2013 to 2015. Specific questions about THN added to the survey in 2013 allowed assessment of the extent to which sampled PWID were aware of naloxone and its function and THN programs in Australia and whether they had participated in a THN program. These main outcomes were examined over time and across states and territories using a mix of descriptive statistics and logistic regression.. Over 80% of the sample reported having heard of naloxone across survey years. Less than half of the participants reported having heard of THN programs in 2013 (35%), but this increased to just over (52%) half in 2015 (P < 0.01). Changes over time differed across cities with increases in reports of having heard of THN occurring over time most clearly in those cities with operational THN programs.. Around half of the PWID sampled for this study are aware of THN programs. Further work is needed to ensure widespread awareness of THN programs which should include implementing THN in all Australian states and territories.

Topics: Adult; Australia; Cities; Cross-Sectional Studies; Drug Overdose; Female; Harm Reduction; Health Knowledge, Attitudes, Practice; Humans; Illicit Drugs; Male; Middle Aged; Naloxone; Narcotic Antagonists; Substance Abuse, Intravenous

Take-home naloxone (THN) programs commenced in Australia in 2012 in the Australian Capital Territory and programs now operate in five Australian jurisdictions. The purpose of this paper is to record the progress of THN programs in Australia, to provide a resource for others wanting to start THN projects, and provide a tool for policy makers and others considering expansion of THN programs in this country and elsewhere.. Key stakeholders with principal responsibility for identified THN programs operating in Australia provided descriptions of program development, implementation and characteristics. Short summaries of known THN programs from each jurisdiction are provided along with a table detailing program characteristics and outcomes.. Data collected across current Australian THN programs suggest that to date over 2500 Australians at risk of overdose have been trained and provided naloxone. Evaluation data from four programs recorded 146 overdose reversals involving naloxone that was given by THN participants.. Peer drug user groups currently play a central role in the development, delivery and scale-up of THN in Australia. Health professionals who work with people who use illicit opioids are increasingly taking part as alcohol and other drug-related health agencies have recognised the opportunity for THN provision through interactions with their clients. Australia has made rapid progress in removing regulatory barriers to naloxone since the initiation of the first THN program in 2012. However, logistical and economic barriers remain and further work is needed to expand access to this life-saving medication.

Topics: Australia; Drug Overdose; Drug Users; Harm Reduction; Humans; Naloxone; Narcotic Antagonists; Program Development; Program Evaluation

The opioid overdose crisis in the United States continues to worsen. Opioid overdose mortality is entirely preventable with timely administration of naloxone. Since 2001, many states have passed laws to create an enabling environment for the implementation of overdose education and naloxone distribution (OEND) programs. We assessed whether state-level naloxone laws and their provisions stimulated the implementation of OEND programs in the United States.. Covering the period from 2000 to 2014, we utilized five data sources including the Westlaw legal database, the Prescription Drug Abuse Policy System, the Harm Reduction Coalition's OEND database, National Center of Health Statistics and the United States Census. Random effects logistic regression models with robust variances were used to examine the association of naloxone access laws and their provisions with OEND program implementation as of 2014.. At the end of 2014, 8% of counties had OEND programs implemented within them. Counties within states that had a naloxone law (aOR = 28.98; p < 0.001) or a law with any one of the six provisions - third party (aOR = 12.86; p = 0.001), standing order (aOR = 11.45; p < 0.001), possession (aOR = 45.97; p < 0.001), prescriber immunity (aOR = 5.19; p = 0.007), dispenser immunity (aOR = 3.50; p = 0.028) or layperson dispensing (aOR = 12.91; p = 0.001) - had increased odds of an OEND program implemented within them, compared to counties within states without a law or specific provision, respectively.. Our findings suggest that naloxone laws facilitated the implementation of OEND programs. With only 8% of counties having an OEND program within them, future studies should investigate strategies to improve the implementation of OEND programs.

Topics: Analgesics, Opioid; Cohort Studies; Databases, Factual; Drug Overdose; Female; Humans; Male; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Patient Education as Topic; Retrospective Studies; United States

Emergency department (ED) visits for unintentional opioid overdoses have increased dramatically. Naloxone hydrochloride (Narcan®) is an opioid antagonist commonly used to treat these overdoses.. This study was undertaken to identify experiences regarding naloxone use among ED patients with opioid overdose.. This prospective survey study was conducted at an urban level I trauma center. A survey was administered to eligible ED patients after unintentional opioid overdose. This study identified current and previous use of naloxone among ED patients with opioid overdose.. Eight-nine ED patients with accidental overdose of opioids participated (90% participation rate). Most participants reported a history of opioid overdose (n = 62 [70%]). A significant minority stated they have had access to a naloxone kit (n = 28 [31%]). Most participants with a naloxone kit stated that their frequency and dosage of opiate use did not change after access to naloxone (n = 17 [63%]), and a few used opiates more often (n = 1 [4%]) or less often (n = 9 [33%]). There was a significant negative correlation between total dose and age (Spearman ρ -0.27; p = 0.01). There was no association between dose and sex.. Many patients presenting with opioid overdose have had a history of opioid overdose. Patients with opioid overdose required a highly variable dose of naloxone. Higher doses of naloxone were associated with lower age. Despite widespread availability of naloxone to consumers, a minority of patients in this study reported access to naloxone. Participants who had access to a naloxone kit stated that their frequency and dosage of opioid use did not change.

Topics: Adult; Aged; Analgesics, Opioid; Drug Overdose; Emergency Service, Hospital; Female; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Prospective Studies; Surveys and Questionnaires

Topics: Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Nonprescription Drugs; Opioid-Related Disorders; United States

Hospitalized patients are at risk for opioid overdose. Little is known about the risk factors for these events.. Opioid overdose cases were identified by naloxone orders in computerized order entry system from a single institution. For each case, two controls were randomly selected. Data were collected on factors including age, gender, weight, opioid dose, route of administration, concomitant CNS depressants, renal function and comorbid conditions.. Between 2010 and 2013, we identified 44 cases of opioid overdose (OD), none of which were fatal, and matched these to 88 controls (no OD). Patients with a history of substance use disorder were excluded from the study. Factors associated with opioid overdose included age of 65 or older (40.9% OD vs 29.5% no OD, P = .026), being in an ICU (MICU/CICU 27.3% OD vs. 3.4% no OD, P < .001; SICU 18.1% OD vs 5.7% no OD, P = .031) and renal impairment (eGFR ≤60, 50.0% OD vs 28.4% no OD, P = .034). Total 24-hour opioid dose was lower in OD group, but the difference was not statistically significant (71.9 vs 107.2 mg morphine equivalent, P = .116). OD cases were more likely to have received concomitant CNS depressants, but the difference was statistically significant only for those who received 3 or more (15.9% OD vs 0% no OD, P = <.001). Heart disease was the only comorbidity significantly associated with an increased risk of opioid overdose (43.2% vs 20.5%, P = .025). Patient's BMI, duration of opioid use, route of administration and history of COPD and/or psychiatry were not associated with opioid overdoses.. Among hospitalized patients, risk factors of opioid overdose include age of 65 or greater, being in an ICU, renal impairment and concomitant administration of CNS depressant medications. These findings may help with the development and implementation of measures to prevent overdose.

Topics: Age Factors; Aged; Analgesics, Opioid; Drug Interactions; Drug Overdose; Female; Hospitalization; Humans; Intensive Care Units; Male; Middle Aged; Naloxone; Narcotic Antagonists; Renal Insufficiency; Risk Factors

The supply of naloxone, the opioid antagonist, for peer administration ('take-home naloxone' (THN)) has been promoted as a means of preventing opioid-related deaths for over 20 years. Despite this, little is known about PWID experiences of take-home naloxone administration. The aim of this study was to advance the evidence base on THN by producing one of the first examinations of the lived-experience of THN use among PWID.. Qualitative, face to face, semi-structured interviews were undertaken at a harm reduction service with individuals known to have used take-home naloxone in an overdose situation in a large urban area in Scotland. Interpretative Phenomenological Analysis (IPA) was then applied to the data from these in-depth accounts.. The primary analysis involved a total of 8 PWID (seven male, one female) known to have used take-home naloxone. This paper focuses on the two main themes concerning naloxone administration: psychological impacts of peer administration and role perceptions. In the former, the feelings participants encounter at different stages of their naloxone experience, including before, during and after use, are explored. In the latter, the concepts of role legitimacy, role adequacy, role responsibility and role support are considered.. This study demonstrates that responding to an overdose using take-home naloxone is complex, both practically and emotionally, for those involved. Although protocols exist, a multitude of individual, social and environmental factors shape responses in the short and longer terms. Despite these challenges, participants generally conveyed a strong sense of therapeutic commitment to using take-home naloxone in their communities.

Topics: Adolescent; Adult; Drug Overdose; Female; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Peer Group; Qualitative Research; Self Care; Substance Abuse, Intravenous; Young Adult

Topics: Adult; Ambulatory Care; Drug Overdose; Emergency Medical Services; Female; Heroin; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Patient Safety; Practice Guidelines as Topic; Victoria; Young Adult

High overdose mortality after release from state prison systems is well documented; however, little is known about overdose mortality following release from local criminal justice systems (CJS). The purpose of this study was to assess overdose mortality following release from a local CJS in Philadelphia, PA.. We conducted a retrospective cohort study of individuals released to the community from a local CJS between 2010 and 2016. Incarceration records were linked to overdose fatality data from the Medical Examiner's Office and death certificate records. All-cause, overdose, and non-overdose mortality were examined.. Of the 82,780 individuals released between 2010 and 2016, 2,522 (3%) died from any cause, of which 837 (33%) succumbed to overdose. Individuals released from incarceration had higher risk of overdose death compared to the non-incarcerated population (Standardized Mortality Ratio [SMR]: 5.29, 95% CI 4.93-5.65), and risk was greatest during the first two weeks following release (SMR: 36.91, 95% CI: 29.92-43.90). Among released individuals, black, non-Hispanic individuals (Hazard Rate [HR]: 0.17, 95% CI: 0.14-0.19) and Hispanic individuals (HR: 0.41, 95% CI: 0.34-0.50) were at lower risk for overdose than white, non-Hispanic individuals. Individuals released with a serious mental illness (SMI) were at higher risk of overdose (HR: 1.54, 95% CI: 1.27-1.87) than those without a SMI.. Previously incarcerated individuals are at high risk of overdose death following release from a local CJS, especially in the earliest weeks following release. Prevention measures including behavioral health treatment and referral and take-home naloxone may reduce overdose mortality after release.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Cohort Studies; Drug Overdose; Female; Humans; Male; Middle Aged; Mortality; Naloxone; Philadelphia; Prisoners; Prisons; Retrospective Studies; Risk Factors; Young Adult

The Government of Manitoba launched the provincial Take-Home Naloxone Program in January 2017. By the end of September 2017, there were over 60 sites operating in Manitoba. These sites distributed 765 kits to people at risk of opioid overdose, and 93 of these kits were replacement kits used in overdose events. Most of these events occurred among males (60.2%) and in a private residence (72.0%). Fentanyl and carfentanil were the most common substances reported during overdose events. Take-Home Naloxone Program data provide important information about the unique context of the opioid crisis in Manitoba.. Le gouvernement du Manitoba a lancé son programme de naloxone à emporter à domicile en janvier 2017. Fin septembre 2017, plus de 60 sites de distribution fonctionnaient dans la province. Ces sites ont distribué 765 trousses aux personnes à risque de surdose d’opioïdes, dont 93 en remplacement d'une trousse utilisée lors d’une surdose. La plupart de ces surdoses ont touché des hommes (60,2 %) et ont eu lieu dans une résidence privée (72,0 %). Le fentanyl et le carfentanil ont été les substances en cause les plus fréquemment rapportées dans les cas de surdose. Les données du programme de naloxone à emporter à domicile fournissent des renseignements importants sur le contexte spécifique de la crise des opioïdes au Manitoba.

Topics: Adolescent; Adult; Analgesics, Opioid; Child; Drug Overdose; Female; Fentanyl; Humans; Male; Manitoba; Naloxone; Narcotic Antagonists; Program Evaluation; Recurrence; Sex Factors; Young Adult

Topics: Analgesics, Opioid; Consumer Advocacy; Drug Overdose; Humans; Legislation, Drug; Naloxone; Needle-Exchange Programs; Nurse Practitioners; Opioid-Related Disorders; Practice Patterns, Nurses'; United States

Topics: Aircraft; Drug Overdose; First Aid; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

A growing body of research points to increasing peer involvement in programs for people who use drugs, although this work has focused primarily on naloxone education and distribution. This study extends this work by examining the roles of peers in leading a novel overdose response program within emergency shelters.. Semi-structured qualitative interviews were conducted with 24 people who use drugs, recruited from two emergency shelters, as well as ethnographic observation in these settings. Interviews were transcribed and analyzed thematically with attention to peer roles.. Four themes emerged from the data. First, participants discussed the development of peer support through relationship building and trust. Second, participants described a level of safety using drugs in front of peer workers due to their shared lived experience. Third, peer workers were described as favorable compared to non-peer staff because of nominal power dynamics and past negative experiences with non-peer staff. Last, given the context of the overdose crisis, peer worker roles were often routinized informally across the social networks of residents, which fostered a collective obligation to respond to overdoses.. Findings indicate that participants regarded peer workers as providing a range of unique benefits. They emphasized the critical role of both social networks and informal roles in optimizing overdose responses. The scaling up of peer programming in distinct risk environments such as emergency shelters through both formal and informal roles has potential to help improve overdose prevention efforts, including in settings not well served by conventional public health programming.

Topics: Adult; Drug Overdose; Emergency Shelter; Female; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Patient Preference; Peer Group; Risk Factors

Naloxone is a prescription medication that can quickly and effectively reverse opioid overdose. Medicaid is a major payer of substance use disorder services, and Medicaid beneficiaries experience especially high rates of opioid overdose. As opioid overdose rates have risen sharply, every state has modified its laws to make naloxone easier to access. The aim of this paper is to determine whether implementation of different provisions of naloxone access laws led to increased naloxone dispensing financed by Medicaid.. We reviewed naloxone legislation passed by every state between 2007 and 2016. We used the Medicaid State Drug Utilization dataset to examine the effect of different types of state naloxone access law provisions, separately and as a whole, on the number of outpatient naloxone prescriptions reimbursed by Medicaid from 2007 to 2016. We included state-level covariates in our models that may be correlated with naloxone utilization in Medicaid and passage of naloxone access laws.. We found that the presence of any naloxone law was significantly associated with increases in outpatient naloxone reimbursed through Medicaid. Laws containing standing order provisions were most consistently associated with increases in naloxone dispensing across models. Standing order provisions led on average to an increase of approximately 33 naloxone prescriptions per state-quarter, which is equivalent to 74% of the average number of naloxone prescriptions per state-quarter.. Naloxone access laws, particularly those with standing order provisions, appear to be an effective policy approach to increasing naloxone access among Medicaid beneficiaries.

Topics: Ambulatory Care; Analgesics, Opioid; Drug Overdose; Drug Prescriptions; Drug Utilization; Humans; Medicaid; Naloxone; Narcotic Antagonists; Outpatients; Prescription Drugs; United States

Topics: Analgesics, Opioid; Canada; Designer Drugs; Drug Overdose; Emergency Responders; Epidemics; Health Services Needs and Demand; Humans; Illicit Drugs; Mental Health Services; Naloxone; Opioid-Related Disorders

Opioid overdose deaths are increasing in Australia and around the world. Despite this, measures aimed at reducing these deaths such as safe injecting facilities and take-home naloxone continue to face obstacles to uptake. The reasons for this are manifold, but a key contributor is public discourse on opioid consumption and overdose. In this article we explore this public discourse using Judith Butler's work on 'grievable lives'. The article analyses mainstream newspaper coverage of opioid overdose in Australia to map key articulations of overdose and to consider how public understandings of overdose are shaped. It then goes on to consider ways these understandings might be reshaped, looking at what have been called overdose 'anti-memorials' and a new website Livesofsubstance.org. In concluding we argue that until the lives of opioid consumers come to be considered grievable, the measures known to reduce overdose deaths may struggle to find public support.

Topics: Analgesics, Opioid; Australia; Disenfranchised Grief; Drug Overdose; Female; Humans; Male; Mass Media; Naloxone; Narcotic Antagonists; Newspapers as Topic; Opioid-Related Disorders; Patient Acceptance of Health Care

In the United States, access to naloxone has been expanded as a measure to address growing opioid overdose mortality. The study aimed to describe the national trends in naloxone use as reported to the US poison centers (PCs).. The National Poison Data System (NPDS) was queried for cases reporting naloxone therapy from 1 January 2001 to 31 December 2016. Demographic and clinical characteristics were assessed descriptively. Trends in naloxone reports were evaluated by using generalized linear mixed models that were adjusted for age, gender and random effects of the geographical census region. Cumulative incidence rates (CIR) of naloxone reports at the state- and national-level were calculated.. There were 304 249 cases reporting naloxone therapy during the study period. The frequency of naloxone reports increased from 9498 in 2000 to 26 826 in 2016. The proportion of cases where naloxone was used prior to PC recommendation increased from 59.8% in 2000 to 81.5% in 2016. The mean number of NPDS naloxone reports per 100 000 human exposures increased from 9.6 [95% confidence interval (CI) = 6.4-14.2] to 31.7 (95% CI = 21.4-46.9, P < 0.001). Among the cases, 52.4% were female and the most frequent age group was 20-39 years (39.1%). The principal reason for a toxic exposure resulting in a naloxone report was suspected suicide (55.0%). Life-threatening symptoms were seen in one-fifth of the cases, with 53.9% cases being admitted to critical care units. Opioids (59.7% cases), were the most commonly reported exposure agents, with hydrocodone being most frequently reported. The national CIR of naloxone reports to the US PCs was 6.3 cases per 100 000 population, with West Virginia demonstrating the highest incidence.. Analysis of calls to the United States poison centers indicates an increasing trend of naloxone use from 2000 to 2016.

Topics: Adolescent; Adult; Analgesics, Opioid; Child; Child, Preschool; Databases, Factual; Drug Overdose; Female; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Poison Control Centers; Population Growth; Retrospective Studies; United States; Young Adult

Topics: Drug Overdose; Harm Reduction; Humans; Liability, Legal; Naloxone; Narcotic Antagonists; Police; Primary Health Care

The epidemic of opioid use disorder and opioid overdose carries extensive morbidity and mortality and necessitates a multi-pronged, community-level response. Bystander administration of the opioid overdose antidote naloxone is effective, but it is not universally available and requires consistent effort on the part of citizens to proactively carry naloxone. An alternate approach would be to position naloxone kits where they are most needed in a community, in a manner analogous to automated external defibrillators. We hypothesized that opioid overdoses would show geospatial clustering within a community, leading to potential target sites for such publicly deployed naloxone (PDN).. We performed a retrospective chart review of 700 emergency medical service (EMS) runs that involved opioid overdose or naloxone administration in Cambridge, Massachusetts, between October 16, 2016 and May 10, 2017. We used geospatial analysis to examine for clustering in general, and to identify specific clusters amenable to PDN sites.. Opioid-related emergency medical services (EMS) runs in Cambridge, Massachusetts (MA), exhibit significant geospatial clustering, and we identified three clusters of opioid-related EMS runs in Cambridge, MA, with distinct characteristics. Models of PDN sites at these clusters show that approximately 40% of all opioid-related EMS runs in Cambridge, MA, would be accessible within 200 meters of PDN sites placed at cluster centroids.. Identifying clusters of opioid-related EMS runs within a community may help to improve community coverage of naloxone, and strongly suggests that PDN could be a useful adjunct to bystander-administered naloxone in stemming the tide of opioid-related death.

Topics: Analgesics, Opioid; Drug Overdose; Emergency Medical Services; Geographic Information Systems; Humans; Massachusetts; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Retrospective Studies

To improve public health surveillance and response by using spatial optimization.. We identified cases of suspected nonfatal opioid overdose events in which naloxone was administered from April 2013 through December 2016 treated by the city of Pittsburgh, Pennsylvania, Bureau of Emergency Medical Services. We used spatial modeling to identify areas hardest hit to spatially optimize naloxone distribution among pharmacies in Pittsburgh.. We identified 3182 opioid overdose events with our classification approach, which generated spatial patterns of opioid overdoses within Pittsburgh. We then used overdose location to spatially optimize accessibility to naloxone via pharmacies in the city. Only 24 pharmacies offered naloxone at the time, and only 3 matched with our optimized solution.. Our methodology rapidly identified communities hardest hit by the opioid epidemic with standard public health data. Naloxone accessibility can be optimized with established location-allocation approaches. Public Health Implications. Our methodology can be easily implemented by public health departments for automated surveillance of the opioid epidemic and has the flexibility to optimize a variety of intervention strategies.

Topics: Community Pharmacy Services; Drug Overdose; Epidemics; Humans; Medical Audit; Naloxone; Narcotic Antagonists; Narcotics; Opioid-Related Disorders; Pennsylvania; Population Surveillance; Quality Improvement; Resource Allocation; Urban Population

Opioid overdose is a leading cause of death across the United States. Rho Chi Pharmacy Honor Society students at the University of Kentucky initiated a project to provide fellow students a volunteer opportunity to educate at-risk patients about naloxone using a physician-approved protocol. The goal was to improve student counseling skills by allowing them to apply knowledge learned during didactic and simulated training.. Third and fourth year pharmacy students at the University of Kentucky voluntarily provided opioid overdose and naloxone counseling to patients at the health department and other locations. Students who counseled at the health department were asked to complete an Institutional Review Board (IRB)-approved, anonymous, electronic survey at the end to gauge their perceptions of the experience.. Thirty-five of forty-five participating students responded to the survey, indicating a 78% response rate. The results suggested that student comfort with naloxone counseling increased after real-world counseling, compared with their perceived comfort levels entering the experience. The majority of the respondents (77%, n = 27) reported a change in their personal views on drug addiction and the associated patient population. Ninety-one percent (n = 32) of students plan to pursue certification to dispense naloxone as part of their future pharmacy practice. Most (94%, n = 33) perceived the counseling experience as practical application of their didactic education.. As opioid addiction and accidental overdose plagues the nation, pharmacists are prepared to lead the battle against this disease. Pharmacy education and hands-on opportunities provide students with the practical knowledge and skills necessary to have impact on their patients and the opioid epidemic.

Topics: Adult; Counseling; Drug Overdose; Female; Humans; Kentucky; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Perception; Students, Pharmacy; Surveys and Questionnaires

Develop a naloxone training activity and assess the activity's impact on increasing student pharmacist knowledge and confidence to counsel about management of opioid overdose and naloxone administration.. First-year student pharmacists participated in a naloxone training activity in an abilities laboratory course. The students completed pre-lab questions, received a brief lecture about responding to an opioid overdose, and then practiced counseling and administering intranasal and intramuscular naloxone using training kits. An Objective Structured Clinical Examination (OSCE) was conducted to assess students' ability to counsel on intranasal naloxone use in response to opioid overdose. Students completed self-assessments about their confidence in counseling patients about management of opioid overdose and naloxone administration following the OSCE and at course end.. 158 students participated and the average OSCE score was 82%. In the post-encounter self-assessment, 93% of students agreed or completely agreed that the OSCE improved their confidence in counseling about management of an opioid overdose and intranasal naloxone administration. Fifty-nine students completed the end-of-course survey and >90% of respondents reported they were somewhat or very confident in their ability to administer intranasal or intramuscular naloxone, recognize the opioid overdose symptoms, and counsel about intranasal naloxone use. Confidence in counseling about use of intramuscular naloxone was slightly lower.. Further study of training programs to increase future healthcare professionals' ability to respond to opioid overdoses is warranted. Incorporation of a short training activity can increase student pharmacists' knowledge and confidence in counseling patients about opioid overdose and naloxone administration.

Topics: Administration, Intranasal; Analgesics, Opioid; Drug Overdose; Education, Pharmacy; Humans; Naloxone; Narcotic Antagonists; Program Evaluation; Students, Pharmacy; Surveys and Questionnaires; Teaching

Over the course of these last decades, we observed a change on opioid use with the marketing of opiate maintenance treatment, an increase of opioids used for pain management and recent concerns have arisen around the use of synthetic opioid. The World Health Organization (WHO) reports around 70,000 people opioid overdose death each year. In France, according to the DRAMES program (fatalities in relation with abuse of licit or illicit drugs) of the French addictovigilance network, most of deaths are related to opioids overdose (especially methadone, following by heroin, buprenorphine and opioid used for pain management). Opioid overdose is treatable with naloxone, an opioid antagonist which rapidly reverses the effects of opioids. In recent years, a number of programs around the world have shown that it is feasible to provide naloxone to people likely to witness an opioid overdose. In 2014, the WHO published recommendations for this provision and the need to train users and their entourage in the management of opioid overdose. In this context, in July 2016, French drug agency has granted a temporary authorization for use of a naloxone nasal spray Nalscue

Topics: Addiction Medicine; Drug Overdose; France; Home Care Services; Humans; Medication Errors; Naloxone; Opioid-Related Disorders

Despite promising findings of opioid overdose education and naloxone distribution (OEND) programs, overdose continues to be a major cause of mortality. The "cascade of care" is a tool for identifying steps involved in achieving optimal health outcomes. We applied the cascade concept to identify gaps in naloxone use.. Data came from a cross-sectional survey of 353 individuals aged 18 and older who self-reported lifetime history of heroin use.. The sample was majority male (65%) and reported use of heroin (74%) and injection (57%) in the past 6 months. Ninety percent had ever witnessed an overdose and of these 59% were in the prior year. Awareness of naloxone (90%) was high. Of those aware, over two-thirds reported having ever received (e.g. access) (69%) or been trained to use naloxone (60%). Of those who had ever received naloxone (n = 218) over one-third reported possession never (36%) or rarely/sometimes carrying naloxone (38%), while 26% reported always carrying. Nearly half of those who had ever received naloxone reported ever use to reverse an opiate overdose (45%). Among individuals who had ever received naloxone, possession often/always compared to never was associated with being female (RRR = 2.88, 95%CI = 1.31-6.27) and ever used naloxone during an overdose (RRR = 4.68, 95%CI = 2.00-11.0).. This study identifies that consistent possession is a gap in the naloxone cascade. Future research is needed to understand reasons for not always carrying naloxone.

Topics: Adolescent; Adult; Aged; Awareness; Cross-Sectional Studies; Drug Overdose; Female; Health Services Accessibility; Heroin; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Young Adult

An interprofessional initiative to operationalize outpatient naloxone prescribing at a large academic medical center is described.. The initiative was carried out by a work group of clinical pharmacists and pharmacy administrators in collaboration with physicians and nursing staff leaders from multiple practice settings. An opioid overdose risk-assessment guide was developed on the basis of literature review and expert opinion. An institutional policy to guide identification of high-risk patient populations and facilitate naloxone prescribing and dispensing was developed and vetted by multiple expert committees. Patient education materials were created, and patients at high risk for opioid overdose were educated about overdose risk factors and naloxone use by a pharmacist and/or nurse before discharge or, in some cases, by outpatient pharmacists; when feasible, patients' friends, family members, and/or caregivers were included in education sessions. Interventions included distribution of a pamphlet emphasizing the importance of contacting emergency medical services personnel immediately in the event of an overdose, depicting the process for administration of injectable and nasal spray formulations of naloxone, and providing information on other first-response steps. Collaboration with outpatient pharmacies allowed for successful dispensing of naloxone prescriptions.. The implementation of an outpatient naloxone prescribing policy at a large academic medical center created a streamlined approach for the interprofessional healthcare team to use in providing naloxone education and improved naloxone access to patients at high risk for opioid overdose.

Topics: Academic Medical Centers; Drug Overdose; Drug Prescriptions; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Organizational Policy; Patient Care Team; Patient Education as Topic; Pharmacy Service, Hospital; Program Development

As the opioid epidemic in the United States has continued since the early 2000s (1,2), most descriptions have focused on misuse and deaths. Increased cooperation with state and local partners has enabled more rapid and comprehensive surveillance of nonfatal opioid overdoses (3).* Naloxone administrations obtained from emergency medical services (EMS) patient care records have served as a useful proxy for overdose surveillance in individual communities and might be a previously unused data source to describe the opioid epidemic, including fatal and nonfatal events, on a national level (4-6). Using data from the National Emergency Medical Services Information System (NEMSIS),

Topics: Adolescent; Adult; Aged; Analgesics, Opioid; Child; Child, Preschool; Drug Overdose; Emergency Medical Services; Female; Humans; Infant; Infant, Newborn; Male; Middle Aged; Naloxone; Narcotic Antagonists; United States; Young Adult

Naloxone is a specific, high affinity opioid antagonist that has been used to treat suspected or confirmed overdose for more than 40 years. Naloxone use was initially confined to an emergency room setting, but the dramatic rise in opioid overdose events over the past two decades has, with increasing frequency, shifted naloxone use to first responders including police, emergency medical technicians, and the friends and family of overdose victims. The opioids responsible for overdose events have also evolved, from prescription opioids to heroin and most recently, very high potency synthetic opioids such as fentanyl. In 2016, synthetic opioids were linked to more overdose fatalities than either prescription opioids or heroin. In this review, I will discuss the evolution and use of naloxone products by first responders and the development of additional rescue medications in response to the unprecedented dangers posed by synthetic opioids.

Topics: Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

Expanded access to naloxone has been identified as a key intervention for reducing opioid-related morbidity and mortality. It is not known which naloxone device will result in rapid, successful administration when administered by community members. The aims of this study were to estimate and compare (1) the rate of successful administration and (2) time to successful administration for single-step nasal spray, multi-step atomized nasal spray and intramuscular simulated naloxone by community members.. A prospective, single-site, open-label, randomized usability assessment of simulated naloxone administration in a convenience sample of community members. Participants were randomized to single-step nasal spray (SP), multi-step atomized nasal spray (AT) or intramuscular simulated (IM) naloxone and asked to administer the simulated medication to a mannequin after completing a 2-minute training video.. New York, USA at a state fair that attracts between 60 000 and 120 000 individuals daily.. A total of 138 participants completed the study over a 2-day period in September 2016. All participants were at least 18 years of age and had no prior naloxone training.. The rate of successful administration and time to successful administration were recorded for each device.. The SP device (100%; P < 0.001) had a higher rate of success compared with the IM device (69.6%). Although success differed between the AT (89.1%) device and IM device, as well as the AT device and SP device, these differences were not significant. The SP device also had a shorter median time to successful administration (34.3 sec) compared with the IM (99.9 sec; P < 0.001) and AT (110.3; P < 0.001) devices.. After video training, community members are able to (1) administer single-step nasal spray naloxone with a higher rate of success than intramuscular naloxone in a simulated overdose setting and (2) administer single-step nasal spray naloxone more rapidly than both intramuscular and multi-step atomized nasal spray naloxone.

Topics: Administration, Intranasal; Adult; Aged; Drug Overdose; Female; Humans; Injections, Intramuscular; Male; Manikins; Middle Aged; Naloxone; Narcotic Antagonists; Simulation Training; Video Recording

Topics: Computer Simulation; Drug Overdose; Drug Tolerance; Drug Users; Drug Utilization; Emergency Service, Hospital; Facilities and Services Utilization; Female; Fentanyl; Heroin; Heroin Dependence; HIV Infections; Humans; Models, Psychological; Naloxone; Opioid-Related Disorders; Prescription Drugs; Rural Population; Social Networking; Unemployment; United States; Video Recording

Topics: Adult; Analgesics, Opioid; Drug Overdose; Emergency Service, Hospital; Humans; Male; Naloxone; Narcotic Antagonists; Respiratory Aspiration; Tomography, X-Ray Computed

Topics: Adult; Analgesics, Opioid; Drug Overdose; Emergency Medical Services; Epidemics; Humans; Naloxone; Nursing Assessment; United States

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

Topics: Drug Overdose; Harm Reduction; Heroin Dependence; Humans; Naloxone; Narcotic Antagonists; Needle-Exchange Programs; Opiate Substitution Treatment; Opioid-Related Disorders; Public Policy; Quality-Adjusted Life Years; United States

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.

Topics: Analgesics, Opioid; Drug Overdose; Health Services Accessibility; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Patents as Topic; Public Health; United States

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.

Topics: Analgesics, Opioid; Drug Industry; Drug Overdose; Harm Reduction; Health Services Accessibility; Humans; Indians, North American; Naloxone; Narcotic Antagonists; Opiate Substitution Treatment; Opioid-Related Disorders; Punishment; Social Support; Substance Abuse Treatment Centers; United States; United States Indian Health Service

Pediatricians play a role in reducing opioid-related harms, including deaths, for patients and families. We examine knowledge, attitudes, and barriers to overdose prevention and naloxone prescribing in the clinical setting by pediatric trainees.. Pediatric trainees at an academic medical center were surveyed using an adapted 17-item instrument examining knowledge, beliefs, and attitudes of naloxone and overdose prevention.. Eighty-two percent reported frequent exposure to patients using opioids and at risk of overdose. While 94% felt they had the responsibility to educate patients about overdose risk, only 42% ever discussed overdose prevention. The majority (71%) were aware of naloxone as a prevention measure, but only 10% ever prescribed naloxone.. Pediatric residents frequently encountered patients using opioids, but the majority failed to deliver interventions to reduce overdose and related harms. We need concerted efforts to educate pediatric providers on delivering overdose harm prevention to opioid-using adolescents as part of routine clinical care.

Topics: Adolescent; Adult; Analgesics, Opioid; Drug Overdose; Female; Health Knowledge, Attitudes, Practice; Humans; Internship and Residency; Male; Naloxone; Opioid-Related Disorders; Pediatrics; Surveys and Questionnaires

Use of strong opioids like morphine as analgesics for painful conditions in haematological malignancies is a challenging task. We report a unique case of chronic myelomonocytic leukaemia presenting with opioid toxicity overlapping with tumour lysis syndrome. The patient was on hydroxyurea-based chemotherapy for the primary disease. She was receiving oral morphine for abdominal pain due to splenomegaly. She was brought to the emergency in unresponsive state with pinpoint pupils. Opioid overdose leading to unconsciousness was suspected as the first diagnosis. Further workup revealed a final diagnosis of tumour lysis syndrome overlapping with opioid overdose. The patient was ventilated and started on naloxone infusion, and supportive measures for managing tumour lysis were added. The patient gradually improved and was extubated on the fifth day of ventilation. This case presents several learning points for the treating physician. Haematological malignancies have a dynamic course of disease with waxing and waning tumour burden during the course of chemotherapy. This fact should be kept in mind when prescribing strong opioids like morphine on outpatient basis to these patients. Massive tumour cell lysis during the course of chemotherapy may precipitate tumour lysis syndrome and may lead to renal dysfunction which makes the patient susceptible to morphine-related adverse effects. Pain physician should keep a watch for therapy-related adverse effects to avoid diagnostic and therapeutic dilemma associated with coexisting features of these two fatal conditions.

Topics: Abdominal Pain; Aged; Analgesics, Opioid; Drug Overdose; Female; Humans; Leukemia, Myelomonocytic, Chronic; Morphine; Naloxone; Splenomegaly; Treatment Outcome; Tumor Lysis Syndrome

Sublingual buprenorphine is used in opioid maintenance treatment but buprenorphine is also widely abused and causes fatal poisonings. The aim of this study was to investigate buprenorphine-positive fatalities in order to gain novel information on the magnitude and nature of buprenorphine abuse. All post-mortem toxicology cases positive for urinary buprenorphine, including fatal poisonings caused by buprenorphine and fatalities in which the cause of death was unrelated to buprenorphine, in the five year period of 2010-2014 in Finland were characterized according to urine buprenorphine and naloxone concentrations (n=775). Urine concentrations were used to assess which buprenorphine preparation had been used; mono-buprenorphine or a buprenorphine-naloxone combination, and whether they had been administered parenterally. In at least 28.8% of the buprenorphine-positive cases the drug had been administered parenterally. The majority of the parenteral users (68.6%) had taken mono-buprenorphine. Fatal poisoning was significantly more common among the identified parenteral users (65.5%) than among other users of buprenorphine products (45.3%). The proportion of buprenorphine-related poisoning was similar in identified parenteral users of mono-buprenorphine (68.6%) and buprenorphine-naloxone (64.1%). In nearly all of the fatal poisoningss the deceased had used other drugs and/or alcohol along with buprenorphine (98.7%). The median age of the deceased increased significantly over the study period, from 32 to 38 years. Our results show that there is ongoing parenteral abuse of both mono-buprenorphine and buprenorphine-naloxone combination. Parenteral users of buprenorphine put themselves into a great risk of fatal poisoning or other accidental injury death which is further exacerbated by the frequent poly-drug use.

Topics: Adult; Age Distribution; Aged; Aged, 80 and over; Blood Alcohol Content; Buprenorphine; Chromatography, Liquid; Drug Overdose; Female; Finland; Humans; Male; Mass Spectrometry; Middle Aged; Naloxone; Opioid-Related Disorders; Sex Distribution; Substance Abuse, Intravenous; Young Adult

Unintentional opioid overdoses are a growing public health epidemic in the United States. Rhode Island is also faced with a challenging crisis of drug overdose deaths. The State Unintentional Drug Overdose Reporting Surveillance (SUDORS) data from the second half of 2016 were used to present opioid overdose deaths and characteristics in Rhode Island. During July-December 2016, 142 individuals died of opioid overdose in Rhode Island. People who died by opioid overdose were more likely to be 25-65 years old, male, and non-Hispanic white. The most common precipitating circumstances were substance abuse (88%), current mental health problems (43%), and physical health problems (27.5%). Over 83% of decedents had 2 or more substances attribute to causing their death, with fentanyl (71.1%) as the most common substance. Only 36.6% of decedents had naloxone administered. Fatal opioid overdose data are important for understanding this public health crisis and can guide overdose intervention efforts.

Topics: Adolescent; Adult; Adverse Drug Reaction Reporting Systems; Age Distribution; Aged; Analgesics, Opioid; Drug Overdose; Female; Humans; Male; Middle Aged; Naloxone; Rhode Island; Sex Distribution; Young Adult

Opioid overdose deaths have been on the rise in the United States since 1999. Naloxone is a competitive opioid antagonist that rapidly reverses opioid overdose. The implementation of naloxone access laws and development of naloxone formulations that can be administered by laypersons have coincided with changes in the landscape of naloxone availability in the United States. Using data from IQVIA's National Prescription Audit

Topics: Analgesics, Opioid; Drug Overdose; Drug Prescriptions; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; United States

British Columbia, Canada, is experiencing a public health emergency related to opioid overdoses driven by consumption of street drugs contaminated with illicitly manufactured fentanyl. This cross-sectional study evaluates a drug checking intervention for the clients of a supervised injection facility (SIF) in Vancouver.. Insite is a facility offering supervised injection services in Vancouver's Downtown East Side, a community with high levels of injection drug use and associated harms, including overdose deaths. During July 7, 2016, to June 21, 2017, Insite clients were offered an opportunity to check their drugs for fentanyl using a test strip designed to test urine for fentanyl. Results of the drug check were recorded along with information including the substance checked, whether the client intended to dispose of the drug or reduce the dose and whether they experienced an overdose. Logistic regression models were constructed to assess the associations between drug checking results and dose reduction or drug disposal. Crude odds ratios (OR) and 95% confidence intervals (CI) were reported.. About 1% of the visits to Insite during the study resulted in a drug check. Out of 1411 drug checks conducted by clients, 1121 (79.8%) were positive for fentanyl. Although most tests were conducted post-consumption, following a positive pre-consumption drug check, 36.3% (n = 142) of participants reported planning to reduce their drug dose while only 11.4% (n = 50) planned to dispose of their drug. While the odds of intended dose reduction among those with a positive drug check was significantly higher than those with a negative result (OR = 9.36; 95% CI 4.25-20.65), no association was observed between drug check results and intended drug disposal (OR = 1.60; 95% CI 0.79-3.26). Among all participants, intended dose reduction was associated with significantly lower odds of overdose (OR = 0.41; 95% CI 0.18-0.89).. Although only a small proportion of visits resulted in a drug check, a high proportion (~ 80%) of the drugs checked were contaminated with fentanyl. Drug checking at harm reduction facilities such as SIFs might be a feasible intervention that could contribute to preventing overdoses in the context of the current overdose emergency.

Topics: Analgesics, Opioid; British Columbia; Cross-Sectional Studies; Drug Contamination; Drug Overdose; Fentanyl; Harm Reduction; Heroin; Humans; Illicit Drugs; Naloxone; Narcotic Antagonists; Needle-Exchange Programs; Opioid-Related Disorders; Reagent Strips; Substance Abuse, Intravenous

Take-home naloxone (THN) programmes are an evidence-based opioid overdose prevention initiative. Elevated opioid overdose risk following prison release means release from custody provides an ideal opportunity for THN initiatives. However, whether Australian prisoners would utilise such programmes is unknown. We examined the acceptability of THN in a cohort of male prisoners with histories of regular injecting drug use (IDU) in Victoria, Australia.. The sample comprised 380 men from the Prison and Transition Health (PATH) Cohort Study; all of whom reported regular IDU in the 6 months prior to incarceration. We asked four questions regarding THN during the pre-release baseline interview, including whether participants would be willing to participate in prison-based THN. We describe responses to these questions along with relationships between before- and during-incarceration factors and willingness to participate in THN training prior to release from prison.. Most participants (81%) reported willingness to undertake THN training prior to release. Most were willing to resuscitate a friend using THN if they were trained (94%) and to be revived by a trained peer (91%) using THN. More than 10 years since first injection (adjusted odds ratio [AOR] 2.22, 95%CI 1.03-4.77), having witnessed an opioid overdose in the last 5 years (AOR 2.53, 95%CI 1.32-4.82), having ever received alcohol or other drug treatment in prison (AOR 2.41, 95%CI 1.14-5.07) and injecting drugs during the current prison sentence (AOR 4.45, 95%CI 1.73-11.43) were significantly associated with increased odds of willingness to participate in a prison THN programme. Not specifying whether they had injected during their prison sentence (AOR 0.37, 95%CI 0.18-0.77) was associated with decreased odds of willingness to participate in a prison THN training.. Our findings suggest that male prisoners in Victoria with a history of regular IDU are overwhelmingly willing to participate in THN training prior to release. Factors associated with willingness to participate in prison THN programmes offer insights to help support the implementation and uptake of THN programmes to reduce opioid-overdose deaths in the post-release period.

Topics: Adult; Cohort Studies; Deinstitutionalization; Drug Overdose; Humans; Male; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Patient Acceptance of Health Care; Patient Education as Topic; Prisoners; Prisons; Substance Abuse, Intravenous; Victoria

Topics: Adult; Analgesics, Opioid; Cohort Studies; Drug Overdose; Emergency Service, Hospital; Female; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Patient Navigation; Patient Outcome Assessment; Peer Group; Retrospective Studies; Young Adult

Despite rising rates of opioid overdose in the United States, few studies have examined the frequency of non-fatal overdose events or mortality outcomes following resuscitation. Given the widespread use of naloxone to respond to overdose-related deaths, naloxone administration may provide a useful marker of overdose events to identify high-risk users at heightened risk of mortality. We used naloxone administration by emergency medical services as a proxy measure of non-fatal overdose to examine repeat events and mortality outcomes during a 6-year period.. We conducted a retrospective investigation of all cases in Marion County, Indiana between January 2011 and December 2016 where emergency medical services used naloxone to resuscitate a patient. Cases were linked to vital records to assess mortality and cause of death during the same time-period. We used Cox regression survival analysis to assess whether repeat non-fatal overdose events during the study period were associated with the hazard of mortality, both overall and by cause of death.. Of 4726 patients administered naloxone, 9.4% (n = 444) died an average of 354 days [standard deviation (SD) = 412.09, range = 1-1980] following resuscitation. Decedents who died of drug-related causes (34.7%, n = 154) were younger and more likely to have had repeat non-fatal overdose events. Patients with repeat non-fatal overdose events (13.4%, n = 632) had a ×2.07 [95% confidence interval (CI) = 1.59, 2.71] higher hazard of all-cause mortality and a ×3.06 (95% CI = 2.13, 4.40) higher hazard of drug-related mortality.. Among US emergency medical service patients administered naloxone for opioid overdose, those with repeat non-fatal opioid overdose events are at a much higher risk of mortality, particularly drug-related mortality, than those without repeat events.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Analgesics, Opioid; Cause of Death; Child; Drug Overdose; Emergency Medical Services; Female; Humans; Indiana; Male; Middle Aged; Mortality; Naloxone; Narcotic Antagonists; Proportional Hazards Models; Retrospective Studies; Young Adult

The problem of injection drug use in public bathrooms has been documented from the perspectives of people who inject drugs and service industry employees (SIEs). Previous studies suggest that SIEs are unaware of how to respond to opioid overdoses, yet there are no behavioral interventions designed for SIEs to address their specific needs. In response to this gap in the field, we constructed, implemented, and evaluated a three-module behavioral intervention for SIEs grounded in the Information-Motivation-Behavioral skills model. This paper focuses on the evaluation of one module, namely, the intervention component addressing overdose response and naloxone administration (ORNA).. Participants were SIEs (N = 18 from two separate business establishments) recruited using convenience sampling. The study utilized a pre-/post-test concurrent nested mixed method design and collected quantitative and qualitative data including an evaluation of the intervention module. The primary outcomes were opioid overdose-related knowledge and attitudes. Acceptability was also assessed.. SIEs demonstrated significant improvements (p <  0.01, Cohen's d = 1.45) in opioid overdose-related knowledge as well as more positive opioid overdose-related attitudes (p< 0.01, Cohen's d = 2.45) following the intervention. Participants also reported high levels of acceptability of the module and suggestions for improvement (i.e., more role-playing).. This study highlights the acceptability and evidence of efficacy of the ORNA module, as well as the utility of training SIEs in ORNA. The expansion of this training to other SIEs and public employees (librarians, etc.) who manage public bathrooms warrants further investigation.

Topics: Adult; Analgesics, Opioid; Commerce; Drug Overdose; Emotions; Female; Humans; Male; Naloxone; Narcotic Antagonists; New York City; Occupational Health Services; Patient Acceptance of Health Care; Substance Abuse, Intravenous; Treatment Outcome

The national opioid crisis requires medical education to develop a proactive response centering on prevention and treatment. Primary care providers (PCPs)-many of whom are family medicine physicians-commonly treat patients on opiates, and write nearly 50% of opioid prescriptions. Despite linkages between PCP opioid prescribing patterns and the associated potential for overdose, little is known about how family medicine clerkship students are trained to prevent opioid overdose, including training on the use of naloxone. This study describes the presence of opioid overdose education at the national level and barriers to inclusion. It also discusses implementation strategies along with instructional methodology and learner evaluation.. Data were collected as part of a cross-sectional survey administered electronically by the Council of Academic Family Medicine Educational Research Alliance to 139 family medicine clerkship directors.. A total of 99 clerkship directors (71.2% response rate) responded to the survey. A large majority (86.4%) agreed that it is important to offer opioid overdose prevention education in the clerkship, yet only 25.8% include this topic. Of these, only 50.0% address naloxone use. The most common barriers to including opioid overdose prevention education were prioritization of educational topics (82.1%) followed by lack of available faculty with sufficient experience/expertise (67.7%).. Findings point to a disparity between perceived importance of opioid overdose prevention education and inclusion of this topic in family medicine clerkship-level medical education. Innovative use of online education and partnering with community resources may address barriers related to curricular prioritization while supporting interprofessional education principles.

Topics: Analgesics, Opioid; Clinical Clerkship; Cross-Sectional Studies; Curriculum; Drug Overdose; Family Practice; Humans; Naloxone; Narcotic Antagonists

We seek to identify conditions under which a plan by the Toronto District School Board (TDSB) to equip high schools with naloxone kits would be cost-effective.. We developed a decision-analytic model to evaluate the costs, benefits, and cost-effectiveness of a school-based naloxone program. We estimated model inputs from the medical literature and used Toronto-specific sources whenever available. We present our results varying both the expected total number of opioid overdoses per year across all 112 TDSB high schools and the effectiveness of a school-based naloxone program in reducing mortality.. A school naloxone program likely costs less than CAD$50,000 per quality-adjusted life-year gained if the overdose frequency is at least once each year and it reduces opioid poisoning mortality by at least 40% (from 10% to <6.0%) or if the overdose frequency is at least two per year and the program reduces mortality by at least 20% (from 10% to <8.0%). The results are sensitive to the intensity and cost of staff training, the lifetime costs and life-expectancy of overdose survivors, and the probability of an overdose being fatal in the absence of a school naloxone program.. School naloxone programs are relatively inexpensive, but that does not ensure that they are a cost-effective use of resources. While potentially cost-effective, if the risk of an overdose in a Toronto high school is low, then other programs aimed at improving the health and wellbeing of students may be better use of limited resources.

Topics: Adolescent; Cost-Benefit Analysis; Decision Making; Drug Overdose; Female; Humans; Male; Naloxone; Narcotic Antagonists; Quality-Adjusted Life Years; Schools; Students

North America is experiencing an opioid overdose epidemic, fuelled by the proliferation of fentanyl, related analogues, and fentanyl-adulterated opioids. British Columbia, Canada has similarly experienced a rapid increase in the proportion of opioid overdose deaths associated with fentanyl. This study builds off of research characterizing fentanyl exposure to further explore the presentation of fentanyl use and related overdoses among people who use drugs.. From December 2016 to April 2017, rapid ethnographic fieldwork was conducted in Vancouver, Canada to examine the implementation of low-threshold overdose prevention sites, where people use drugs under the supervision of staff and peers trained to respond to overdose. Data collection included 185 h of ethnographic observation and in-depth interviews with 72 people who inject drugs, 44 of whom reported experiencing an overdose in the year prior to the interviews.. While most participants had experienced previous opioid-related overdose, they characterized how fentanyl was markedly distinct in terms of: potency, and rapid onset. Ethnographic observations and participant narratives highlighted how fentanyl use and related overdoses had implications for frontline response, including: rapid onset, multiple concurrent overdoses, body and chest rigidity, and the need to administer larger doses of naloxone.. Participant narratives and observational data documented distinct symptoms for fentanyl-attributed overdoses compared to other opioid related overdose events, which had implications for response. Findings may serve to inform best practices in responding to fentanyl-related overdoses including; the provision of oxygen and effective doses of naloxone, and also considerations regarding overdose identification.

Topics: Adult; Aged; Analgesics, Opioid; British Columbia; Drug Overdose; Female; Fentanyl; Humans; Male; Middle Aged; Naloxone; Young Adult

Topics: Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Poisons

Rate of naloxone given for overdoses also increases by 75%.

Topics: Adult; Drug Overdose; Emergency Medical Services; Female; Forecasting; Humans; Middle Aged; Naloxone; Opioid-Related Disorders; Pregnancy; Pregnant Women; United States

In 2016, Clallam County became the first county in Washington State to mandate reporting of fatal and nonfatal opioid overdoses. This reporting improved our understanding of opioid overdoses in the community and allowed us to provide harm reduction and case management services after nonfatal overdoses. By using the Washington State Prescription Monitoring Program, we have been able to notify health care providers when their patients have experienced a fatal or nonfatal opioid overdose to help better guide their prescribing practices.

Topics: Adolescent; Adult; Data Accuracy; Drug Overdose; Female; Humans; Male; Mandatory Reporting; Middle Aged; Naloxone; Narcotic Antagonists; Narcotics; Opioid-Related Disorders; Program Development; Program Evaluation; Public Health Administration; Risk Factors; Rural Population; Washington; Young Adult

Topics: Analgesics, Opioid; Buprenorphine; Drug Overdose; Drug Prescriptions; Epidemics; Evidence-Based Practice; Health Communication; Humans; Massachusetts; Naloxone; Narcotic Antagonists; New York; Opioid-Related Disorders; Patient Education as Topic; Prescription Drug Diversion; Public Health Administration; Vermont

Topics: Cooperative Behavior; Drug Overdose; Humans; Interinstitutional Relations; Naloxone; Narcotic Antagonists; Narcotics; Program Development; Program Evaluation; Public Health Administration; Rhode Island; Risk Factors

Topics: California; Drug Overdose; Humans; Legislation, Drug; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Pharmacists; Surveys and Questionnaires

A service learning program for student pharmacists was developed to train other university students to respond effectively to opioid overdoses with naloxone. Assessments were analyzed to determine the effect of program participation on student pharmacists' overdose-related knowledge retention and harm reduction attitudes.. Student pharmacists were invited to attend a 90-min train-the-trainer seminar to obtain foundational knowledge regarding opioid overdose risk, symptoms, and response. Attendees were eligible to participate in a series of 10 community outreach events to educate university students. These two-hour events included a 30-min team huddle, 60-min workshop, and 30-min team debrief. Student pharmacists were asked to complete a follow-up assessment to evaluate knowledge retention and harm reduction attitudes.. Responses from students who participated in community outreach events (intervention) were compared to those who only attended the train-the-trainer seminar (control). A total of 116 subjects attended a train-the-trainer seminar and 94 completed the follow-up assessment. Thirty-six subjects voluntarily participated in at least one community outreach event while 58 did not participate. The intervention group demonstrated superior knowledge retention compared to the control group (p < 0.001). Cumulative harm reduction attitudes did not differ between groups (p = 0.89). The intervention group exhibited more positive attitudes regarding naloxone access for individuals who use illicit opioids (p = 0.015).. The Operation Naloxone service learning program enabled student pharmacists to engage with their community while reinforcing overdose-related knowledge. Student pharmacists exhibited progressive attitudes regarding harm reduction interventions.

Topics: Adult; Chi-Square Distribution; Drug Overdose; Education, Pharmacy; Female; Humans; Male; Naloxone; Narcotic Antagonists; Program Development; Statistics, Nonparametric; Students, Pharmacy; Surveys and Questionnaires; Universities

Topics: Drug and Narcotic Control; Drug Overdose; Humans; Law Enforcement; Naloxone; Opioid-Related Disorders; Substance-Related Disorders; United States

Little is known about opioid overdose or naloxone access among pregnant women.. The objectives of this study were to determine the prevalence of non-fatal overdose, risk factors for overdose, and naloxone access among third trimester women in treatment for opioid use disorder.. We collected baseline data from a case management parental-support intervention study. To explore the association of variables with past year overdose, we used Wilcoxon rank-sum test, Chi square or Fisher's exact tests.. Among 99 participants, 14% (95% CI 7-21%) reported past year overdose and 67% (95% CI 57-76%) had received overdose education and a naloxone kit. Younger age was the only variable associated with past year overdose.. In this sample, past year non-fatal overdose was common, younger age was a risk factor, and most participants had received a naloxone kit. Further work is needed to understand whether younger age is a risk factor in the general population of pregnant women with opioid use disorder and to identify other potential risk factors for overdose in this population.

Topics: Adult; Age Factors; Drug Overdose; Female; Health Knowledge, Attitudes, Practice; Health Services Accessibility; Humans; Mental Disorders; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Patient Education as Topic; Pregnancy; Risk Factors; Socioeconomic Factors; Young Adult

State policy approaches designed to provide opioid treatment options have received significant attention in addressing the opioid epidemic in the United States. In particular, expanded availability of naloxone to reverse overdose, Good Samaritan laws intended to protect individuals who attempt to provide or obtain emergency services for someone experiencing an opioid overdose, and expanded coverage of medication-assisted treatment (MAT) for individuals with opioid abuse or dependence may help curtail hospital readmissions from opioids. The objective of this retrospective cohort study was to evaluate the association between the presence of state opioid treatment policies-naloxone standing orders, Good Samaritan laws, and Medicaid medication-assisted treatment (MAT) coverage-and opioid-related hospital readmissions.. We used 2013-2015 hospital inpatient discharge data from 13 states from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project. We examined the relationship between state opioid treatment policies and 90-day opioid-related readmissions after a stay involving an opioid diagnosis.. Our sample included 383,334 opioid-related index hospitalizations. Patients treated in states with naloxone standing-order policies at the time of the index stay had higher adjusted odds of an opioid-related readmission than did those treated in states without such policies; however, this relationship was not present in states with Good Samaritan laws. Medicaid methadone coverage was associated with higher odds of readmission among all insurance groups except Medicaid. Medicaid MAT coverage generosity was associated with higher odds of readmission among the Medicaid group but lower odds of readmission among the Medicare and privately insured groups. More comprehensive Medicaid coverage of substance use disorder treatment and a greater number of opioid treatment programs were associated with lower odds of readmission.. Differences in index hospitalization rates suggest that states with opioid treatment policies had a higher level of need for opioid-related intervention, which also may account for higher rates of readmission. More research is needed to understand how these policies can be most effective in influencing acute care use.

Topics: Adult; Analgesics, Opioid; Costs and Cost Analysis; Drug Overdose; Female; Health Policy; Hospitalization; Humans; Insurance Coverage; Insurance, Health; Male; Medicaid; Medicare; Middle Aged; Naloxone; Opioid-Related Disorders; Patient Readmission; Retrospective Studies; United States

To implement a telephone-based pharmacy driven clinic and increase access to opioid overdose education and naloxone distribution (OEND) in an effort to reduce opioid mortality across the catchment area of one Department of Veterans Affairs (VA) Medical Center. The project intended to assess the feasibility of telephone-based OEND, which has not been reported in the literature.. The VA is America's largest integrated healthcare system. The Aleda E. Lutz VA Medical Center located in Saginaw, Michigan (Saginaw VAMC) serves veterans throughout Northern Michigan. Pharmacist at the VA serve veterans' healthcare needs in a variety of roles, from traditional medication dispensing to functioning as prescribers of evidence-based medicine. The VA is among the first large health systems to adopt and implement OEND.. Public health organizations recommend increasing access to naloxone as a key strategy to address the opioid overdose epidemic. Providing lay-persons with naloxone kits is a new concept for patients with long-term opioid therapy. There are no practice models published regarding pharmacy driven telephone-based OEND programs in any setting. A telephone-based OEND consult clinic was created to improve OEND access.. The success of the Clinic was measured by the number of Clinic consults, and a comparison of local naloxone distribution numbers pre- and post-implementation.. The Clinic received 326 consults and 232 were completed January through March of 2017. In calendar-year 2016, 14 naloxone kits were distributed each month on average, whereas 77 naloxone kits on average were released in the first three months of 2017.. Using a combination of printed material and telephone discussion with a pharmacist, the Clinic greatly increased naloxone access in the catchment area. No statistical tests or analysis were performed, however, the clinic dramatically increased the raw number of patients with access to OEND.

Topics: Ambulatory Care Facilities; Drug Overdose; Health Services Accessibility; Humans; Michigan; Naloxone; Narcotic Antagonists; Patient Education as Topic; Pharmaceutical Services; Referral and Consultation; Telephone; United States; United States Department of Veterans Affairs

Opioid overdose prevention programs providing take-home naloxone have been expanding internationally. This paper summarises findings and lessons learnt from the Overdose Prevention and Emergency Naloxone Project which is the first take-home naloxone program in Australia implemented in a health care setting.. The Project intervention provided education and take-home naloxone to opioid-using clients at Kirketon Road Centre and The Langton Centre in Sydney. The evaluation study examined uptake and acceptability of the intervention; participants' knowledge and attitudes regarding overdose and participants' experience in opioid overdose situations six months after the intervention. Participants completed baseline, post-training and follow-up questionnaires regarding overdose prevention and management which were analysed using repeated measures analysis of variance.. Eighty-three people participated in the intervention, with 35 (42%) completing follow-up interviews-51% reporting using naloxone with 30 overdoses successfully reversed. There were significant improvements in knowledge and attitudes immediately following training with much retained at follow-up, particularly regarding feeling informed enough (97%) and confident to inject naloxone (100%).. Take-home naloxone programs can be successfully implemented in Australian health settings. Barriers to uptake, such as lengthy processes and misperceptions around interest in overdose prevention, should be addressed in future program implementation.

Topics: Australia; Drug Overdose; Female; Harm Reduction; Health Knowledge, Attitudes, Practice; Health Services; Health Services Accessibility; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Program Evaluation

This paper examines overdose prevention programs based on peer administration of the opioid antagonist naloxone. The data for this study consist of 40 interviews and participant observation of 10 overdose prevention training sessions at harm reduction agencies in the Bronx, New York, conducted between 2010 and 2012. This paper contends that the social logic of peer administration is as central to the success of overdose prevention as is naloxone's pharmacological potency. Whereas prohibitionist drug policies seek to isolate drug users from the spaces and cultures of drug use, harm reduction strategies like peer-administered naloxone treat the social contexts of drug use as crucial resources for intervention. Such programs utilize the expertise, experience, and social connections gained by users in their careers as users. In revaluing the experience of drug users, naloxone facilitates a number of harm reduction goals. But it also raises complex questions about responsibility and risk. This paper concludes with a discussion of how naloxone's social logic illustrates the contradictions within broader neoliberal trends in social policy.

Topics: Drug Overdose; Drug Users; Harm Reduction; Humans; Naloxone; Narcotic Antagonists; Peer Group; Public Policy; Social Support; Substance-Related Disorders

Some fear that distribution of naloxone to persons at risk of experiencing an opioid overdose may reduce the perceived negative consequences of drug use, leading to riskier patterns of use. This study assessed whether participation in naloxone/overdose training altered drug use frequency, quantity or severity among heroin users in and out of treatment.. Clinical interviews were performed assessing patterns of heroin and other drug use prior to, and at multiple timepoints after overdose education and naloxone training. This study compared baseline drug use to that at 1 and 3months post training.. Both current heroin users (n=61) and former users in agonist maintenance (n=69) typically showed decreases in heroin and polydrug use at both 1 and 3months after training. The Addiction Severity Index drug composite score also decreased at follow up.. This analysis found no evidence of compensatory drug use following naloxone/overdose training among two groups of heroin users. These findings support the acceptance and expansion of naloxone distribution to at-risk populations and may assist in allaying concerns about the potential for unintended negative consequences on drug use.

Topics: Drug Overdose; Follow-Up Studies; Heroin Dependence; Humans; Naloxone; Narcotic Antagonists; Risk-Taking; Severity of Illness Index

Topics: Adolescent; Adult; Age Distribution; Aged; Analgesics, Opioid; Drug Overdose; Emergency Medical Services; Humans; Male; Middle Aged; Naloxone; Opioid-Related Disorders; Population Surveillance; Public Health; Rhode Island; Sex Distribution; Treatment Outcome; Young Adult

Opioid overdose deaths in Massachusetts increased 150% from 2012 to 2015 (1). The proportion of opioid overdose deaths in the state involving fentanyl, a synthetic, short-acting opioid with 50-100 times the potency of morphine, increased from 32% during 2013-2014 to 74% in the first half of 2016 (1-3). In April 2015, the Drug Enforcement Agency (DEA) and CDC reported an increase in law enforcement fentanyl seizures in Massachusetts, much of which was believed to be illicitly manufactured fentanyl (IMF) (4). To guide overdose prevention and response activities, in April 2016, the Massachusetts Department of Public Health and the Office of the Chief Medical Examiner collaborated with CDC to investigate the characteristics of fentanyl overdose in three Massachusetts counties with high opioid overdose death rates. In these counties, medical examiner charts of opioid overdose decedents who died during October 1, 2014-March 31, 2015 were reviewed, and during April 2016, interviews were conducted with persons who used illicit opioids and witnessed or experienced an opioid overdose. Approximately two thirds of opioid overdose decedents tested positive for fentanyl on postmortem toxicology. Evidence for rapid progression of fentanyl overdose was common among both fatal and nonfatal overdoses. A majority of interview respondents reported successfully using multiple doses of naloxone, the antidote to opioid overdose, to reverse suspected fentanyl overdoses. Expanding and enhancing existing opioid overdose education and prevention programs to include fentanyl-specific messaging and practices could help public health authorities mitigate adverse effects associated with overdoses, especially in communities affected by IMF.

Topics: Adolescent; Adult; Age Distribution; Analgesics, Opioid; Drug Overdose; Ethnicity; Female; Fentanyl; Humans; Illicit Drugs; Male; Massachusetts; Middle Aged; Naloxone; Risk Factors; Sex Distribution; White People; Young Adult

Topics: Drug Overdose; Heroin; Humans; Naloxone

Topics: Adolescent; Drug Overdose; Epidemics; Heroin; Heroin Dependence; Humans; Naloxone; Opioid-Related Disorders; United States; Young Adult

Describe surveillance data from three existing surveillance systems during an unexpected fentanyl outbreak in a large metropolitan area.. We performed a retrospective analysis of three data sets: Chicago Fire Department EMS, Cook County Medical Examiner, and Illinois Poison Center. Each included data from January 1, 2015 through December 31, 2015. EMS data included all EMS responses in Chicago, Illinois, for suspected opioid overdose in which naloxone was administered and EMS personnel documented other criteria indicative of opioid overdose. Medical Examiner data included all deaths in Cook County, Illinois, related to heroin, fentanyl or both. Illinois Poison Center data included all calls in Chicago, Illinois, related to fentanyl, heroin, and other prescription opioids. Descriptive statistics using Microsoft Excel® were used to analyze the data and create figures.. We identified a spike in opioid-related EMS responses during an 11-day period from September 30-October 10, 2015. Medical Examiner data showed an increase in both fentanyl and mixed fentanyl/heroin related deaths during the months of September and October, 2015 (375% and 550% above the median, respectively.) Illinois Poison Center data showed no significant increase in heroin, fentanyl, or other opioid-related calls during September and October 2015.. Our data suggests that EMS data is an effective real-time surveillance mechanism for changes in the rate of opioid overdoses. Medical Examiner's data was found to be valuable for confirmation of EMS surveillance data and identification of specific intoxicants. Poison Center data did not correlate with EMS or Medical Examiner data.

Topics: Chicago; Coroners and Medical Examiners; Cross-Sectional Studies; Databases, Factual; Disease Outbreaks; Drug Contamination; Drug Overdose; Emergency Medical Services; Fentanyl; Heroin; Humans; Illinois; Naloxone; Narcotic Antagonists; Narcotics; Poison Control Centers; Retrospective Studies

Pharmaceutical opioid overdose rates have increased in recent years. The current study aimed to compare rates per 1000 injections of non-fatal overdose after heroin or oxycodone injection, and their comparative clinical severity.. Analysis of prospectively collected data from the Sydney Medically Supervised Injecting Centre (MSIC). Severity of overdose was measured using the Glasgow Coma Scale, oxygen saturation levels, and the administration of naloxone.. Heroin overdoses occurred at three times the rate of oxycodone overdoses (12.7 v 4.1 per 1000 injections). Heroin overdoses appeared to be more severe than oxycodone overdoses, with higher levels of compromised consciousness (31 v 18%) and severe respiratory depression (67 v 48%), but there were no differences in naloxone doses (20 v 17%). Concurrent use of other depressants at the time of overdose was also associated with compromised consciousness, and the need for naloxone.. Heroin overdoses occurred at a greater rate than oxycodone overdoses, and had more severe clinical indicators.

Topics: Adult; Drug Overdose; Female; Humans; Male; Naloxone; Narcotic Antagonists; Needle-Exchange Programs; New South Wales; Opioid-Related Disorders; Prospective Studies; Trauma Severity Indices; Young Adult

Overdose is a major cause of death among PWID, and for opioid overdoses naloxone administration can reduce harm. However, globally there is limited national level data on the extent of non-fatal overdose and naloxone uptake. The first national level data on the extent of self-reported overdose and self-reported receipt of naloxone among UK PWID, providing a baseline to monitor the impact of the recent policy change regarding naloxone availability, is presented.. Data on self-reported overdose and receipt of naloxone during the preceding year for 2013-2014 from a national survey of PWID was analysed. Participants who reported injecting during the preceding year were included.. Participants (3850) were predominantly male (75%); mean age was 36 years. The most commonly injected drugs were: heroin (91%), crack (45%) and amphetamine (29%). 15% (591) reported overdosing during the preceding year. There were no differences in the proportion reporting overdose by age or gender, but overdose was more common among those who: injected multiple drugs; recently ceased addiction treatment; injected with used needles/syringes; ever had transactional sex; had used a sexual health clinic or emergency department and lived in Wales or Northern Ireland. Among those reporting an overdose during the preceding year, a third reported two to four overdoses and 7.5% five or more overdoses; half reported receiving naloxone. Those reporting naloxone receipt in the preceding year were more likely to: live in Wales or Northern Ireland; ever received used needles/syringes; ever been imprisoned; and less likely to have injected two drug types.. These data provide a baseline for monitoring the impact of the 2015 UK policy change to improve take-home naloxone access. Interventions tackling overdose should promote naloxone awareness and access, and target those who; are poly-drug injectors, have ceased treatment, share needles/syringes and whose drug use links to sexual activity.

Topics: Adult; Drug Overdose; England; Female; Harm Reduction; Humans; Male; Naloxone; Narcotic Antagonists; Needle Sharing; Northern Ireland; Opioid-Related Disorders; Risk Factors; Risk-Taking; Self Report; Substance Abuse, Intravenous; Substance-Related Disorders; Surveys and Questionnaires; Wales

Topics: Baltimore; Drug Overdose; Harm Reduction; Humans; Naloxone; Students

Topics: Baltimore; Drug Overdose; Harm Reduction; Humans; Naloxone; Narcotic Antagonists; Students

Take home naloxone (THN) programs reduce mortality by training bystanders to respond to opioid overdoses. Clinical observation by the health care team at the Inner City Youth (ICY) program indicated that young adults appeared to enthusiastically participate in the THN program and developed improved relationships with staff after THN training. However, we found a dearth of literature exploring the experiences of young adults with THN programs. This study set out to address this gap and identify suggestions from the young adults for program improvement. The primary research question was "How do street-involved young people experience the THN Program in Vancouver, BC?". The study was undertaken at the ICY Program. Two peer researchers with lived experience of THN were recruited from ICY and were involved in all phases of the study. The peer researchers and a graduate student facilitated two focus groups and five individual interviews with ICY program participants using a semi-structured interview guide. Audio recordings were transcribed verbatim. The cut-up-and-put-in-folders approach was used to identify emerging themes.. The themes that emerged were perceptions of risk, altruism, strengthening relationship with staff, access to training, empowerment, and confidence in ability to respond, and suggestions for youth-friendly training. These themes were then situated within the framework of the health belief model to provide additional context. Participants viewed themselves as vulnerable to overdose and spoke of the importance of expanding access to THN training. Following training, participants reported an increase in internal locus of control, an improved sense of safety among the community of people who use drugs, improved self-esteem, and strengthened relationships with ICY staff. Overall, participants found THN training engaging, which appeared to enhance participation in other ICY programming.. Young people perceived THN training as a positive experience that improved relationships with staff. Participant recommendations for quality improvement were implemented within the provincial program.

Topics: Altruism; British Columbia; Community-Based Participatory Research; Drug Overdose; Female; Harm Reduction; Heroin; Humans; Ill-Housed Persons; Male; Naloxone; Narcotic Antagonists; Narcotics; Patient Care Team; Young Adult

Emergency Medical Services (EMS) data may provide insight into opioid overdose incidence, clinical characteristics, and medical response. This analysis describes patient characteristics, clinical features, and EMS response to opioid overdoses, comparing heroin and pharmaceutical opioid (PO) overdoses, using a structured opioid overdose case criteria definition.. A case series study was conducted. EMS medical staff screened cases for possible overdoses and study staff categorized the likelihood of opioid overdose. Medical form data were abstracted. Patient characteristics, clinical presentation, and medical response to heroin and PO-involved overdoses were compared with bi-variate test statistics.. We identified 229 definite or probable opioid overdose cases over six months: heroin in 98 (43%) cases (10 also involved PO), PO without heroin in 85 (37%) cases, and 46 (20%) that could not be categorized and were excluded from analyses. Heroin overdose patients were younger than PO (median age 33 v 41 (p<0.05)), more often male (80% v 61% (p=<0.01)), intubated less (8% v 22%, p<0.01) and more likely to be administered naloxone (72% v 51%, p<0.01). No significant differences were found between heroin and PO overdoses for initial respiratory rate, Glasgow Coma Scale score, or co-ingestants, but heroin users were more likely to have miotic pupils (p<0.01).. While heroin and PO events presented similarly, heroin-involved cases were more likely to receive naloxone and less likely to be intubated. Standardized case definitions and data documentation could aid opioid overdose surveillance as well as provide data for measuring the impact of professional and lay interventions.

Topics: Adult; Age Factors; Analgesics, Opioid; Drug Overdose; Emergency Medical Services; Female; Heroin; Humans; Incidence; Male; Middle Aged; Naloxone; Narcotic Antagonists; Sex Factors; Washington; Young Adult

High mortality rates have been reported for methadone in both adults and children. We aimed to determine the pattern of toxicity, possible underlying diseases and treatment challenges in patients referred to our centre with early diagnosis of methadone toxicity and who later died. Medical files of all methadone-poisoned patients who had been admitted to a referral centre of toxicology between March 2011 and March 2016, died during the hospital stay and sent for autopsy to Legal Medicine Organization were retrospectively evaluated. In a total of 94 patients, autopsy findings and laboratory evaluations showed that cause of death was pure methadone toxicity in 57 (60.6%). Other causes of death were ischaemic heart disease in ten, co-ingestions (toxicities including methadone) in eight, brain haemorrhage, multi-organ failure and pneumosepsis (each in four), meningitis/encephalitis in three and head trauma and other toxicities (other than methadone but including an opioid, each in two) patients. Time of cardiopulmonary arrest was significantly different between those with pure methadone toxicity and those who died due to other causes (p = 0.01). Patients who had died due to co-ingestions and other toxicities were younger (p = 0.029) and took more bolus doses of naloxone (p = 0.042). In methadone users, especially in older ages and those with trivial response to naloxone administration, loss of consciousness should not be strictly attributed to methadone toxicity. In such patients, thorough evaluation for other possible causes of loss of consciousness is mandatory.

Topics: Adolescent; Adult; Age Factors; Aged; Aged, 80 and over; Analgesics, Opioid; Autopsy; Blood Gas Analysis; Cause of Death; Child; Child, Preschool; Drug Overdose; Female; Hospitals; Humans; Infant; Italy; Male; Methadone; Middle Aged; Naloxone; Narcotic Antagonists; Retrospective Studies; Sex Factors; Treatment Outcome; Young Adult

Topics: Administration, Intranasal; Analgesics, Opioid; Dose-Response Relationship, Drug; Drug Overdose; Emergency Medical Services; Humans; Naloxone; Narcotic Antagonists; Nasal Sprays; Treatment Outcome

Little is known about the engagement of young people who use drugs (PWUD) in harm reduction programs (HRPs), and few studies have included non-opioid users and non-injectors. While HRPs have effectively engaged PWUD, young people are under-represented in their services.. The Injection Drug Users Health Alliance Citywide Study (IDUCS) is the largest community-based study of PWUD in HRPs in the US. From 2014-2015, 2421 HRP participants across New York City (NYC) completed a cross-sectional survey. We investigated differences in socio-demographics, service utilization, and risk behaviors between young (aged 18-30) and older participants and examined factors associated with overdose among young participants.. The study included 257 young participants. They were significantly more likely than older participants to be white, educated, uninsured, unstably housed or homeless, and have a history of incarceration and residential drug treatment. They were more likely to report recent overdose but less likely to report knowledge of naloxone. Young participants also had higher rates of alcohol, marijuana, benzodiazepine, and injection drug use, and related risk behaviors such as public injection. Factors associated with past year overdose among young participants included experiencing symptoms of psychological distress (AOR=9.71), being unstably housed or homeless (AOR=4.39), and utilizing detox (AOR=4.20).. Young PWUD who access services at HRPs in NYC differ significantly from their older counterparts. New York City and other urban centers that attract young PWUD should consider implementing harm reduction oriented services tailored to the unique needs of young people.

Topics: Cross-Sectional Studies; Drug Overdose; Drug Users; Harm Reduction; Humans; Naloxone; New York City; Risk; Risk-Taking; Substance Abuse, Intravenous

Topics: Analgesics, Opioid; Drug Overdose; Emergency Medicine; Health Policy; Health Services Accessibility; Humans; Naloxone; Narcotic Antagonists; Societies, Medical

Opioid medication to treat acutely injured patients is usual care in trauma settings. A higher prevalence of alcohol and other substance misuse in this population compared to the general population increases the vulnerability of such patients to both misuse of their prescribed opioids, and also unintentional opioid overdose. The primary purpose of this study was to assess the prevalence of substance use and unintentional opioid overdose risk among acutely injured trauma patients, and to examine the frequency and predictors of high opioid dose at discharge.. A retrospective electronic medical record (EMR) review of three-months of data from two Level 1 trauma centers. We assessed the prevalence of substance misuse, unintentional opioid overdose risk, and presence of documentation of clinical strategies to mitigate these risks, such as co-prescription of the opioid agonist naloxone.. In total, 352 patient EMRs were examined. Over 40% of the patients reviewed had at least one indication of substance misuse (42.5% [95%CI: 37.3, 47.7]); at least 1 unintentional opioid overdose risk factor was identified in 240 EMR reviewed (68.2% [95%CI: 63.3, 73.1]). Dose of opioid medication was not significantly different for patients with substance misuse versus those without. There was no co-prescription of naloxone for any of the discharged patients.. Our results indicate that despite the high rates of substance misuse, the potential for misuse, dependence and unintentional overdose risk from prescribed opioid medications are prevalent among acutely injured trauma patients. Prescribing after acute trauma care should address these risk factors.

Topics: Adolescent; Adult; Aged; Aged, 80 and over; Analgesics, Opioid; Drug Overdose; Drug Prescriptions; Electronic Health Records; Female; Humans; Male; Middle Aged; Naloxone; Patient Discharge; Retrospective Studies; Risk Factors; Substance-Related Disorders; Trauma Centers; Young Adult

Community-based overdose prevention programs first emerged in the 1990's and are now the leading public health intervention for overdose. Key elements of these programs are overdose education and naloxone distribution to people who use opioids and their social networks. We review the evolution of naloxone programming through the heroin overdose era of the 1990's, the prescription opioid era of the 2000's, and the current overdose crisis stemming from the synthetic opioid era of illicitly manufactured fentanyl and its analogues in the 2010's. We present current challenges arising in this new era of synthetic opioids, including variable potency of illicit drugs due to erratic adulteration of the drug supply with synthetic opioids, potentially changing efficacy of standard naloxone formulations for overdose rescue, potentially shorter overdose response time, and reports of fentanyl exposure among people who use drugs but are opioid naïve. Future directions for adapting naloxone programming to the dynamic opioid epidemic are proposed, including scale-up to new venues and social networks, new standards for post-overdose care, expansion of supervised drug consumption services, and integration of novel technologies to detect overdose and deliver naloxone.

Topics: Analgesics, Opioid; Community Health Services; Drug Overdose; Fentanyl; Heroin; Heroin Dependence; Humans; Illicit Drugs; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Substance-Related Disorders

In 2014, the US Food and Drug Administration limited the production of prescription acetaminophen-opioid combination products to 325 mg per dose unit. The goal of this mandate was to decrease the likelihood of unintentional acetaminophen hepatotoxicity. This study was designed to determine if this federal regulation has succeeded in reducing unintentional acetaminophen-induced hepatotoxicity from opioid combination products.. Using data from the National Poison Data System (NPDS), we analyzed all calls to US Poison Control Centers in the years 2013 and 2015 for acetaminophen-opioid combination product exposures. We then excluded cases that were classified as intentional and those aged 12 years and younger. We used a primary endpoint of N-acetylcysteine administration; secondary endpoints included evidence of hepatotoxicity as aspartate aminotransferase elevation, opioid antagonist administration and severity of overall medical outcome.. A total of 18,259 calls between the two yearlong periods met inclusion criteria. 5.16 and 5.01% of calls resulted in N-acetylcysteine administration in 2013 and 2015, respectively. 3.63 and 4.02% received naloxone in 2013 and 2015, respectively, and 0.9% in each year developed hepatotoxicity. Rates of N-acetylcysteine administration, naloxone administration, and hepatotoxicity did not differ significantly between 2013 and 2015. Severity of medical outcome was worse in 2015 as compared to 2013 with more cases being categorized as "major effect" and fewer cases being categorized as "no effect.". The Food and Drug Administration limitation on acetaminophen content per dose unit in opioid combination products did not reduce the occurrence of unintentional acetaminophen-induced hepatotoxicity or N-acetylcysteine administration as reported to NPDS.

Topics: Acetaminophen; Acetylcysteine; Adolescent; Adult; Analgesics, Non-Narcotic; Chemical and Drug Induced Liver Injury; Databases, Factual; Drug and Narcotic Control; Drug Approval; Drug Combinations; Drug Compounding; Drug Overdose; Female; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Poison Control Centers; Policy Making; Pregnancy; Prescription Drugs; Program Evaluation; Protective Factors; Risk Factors; Time Factors; United States; United States Food and Drug Administration; Young Adult

Overdose Education and Naloxone Distribution (OEND) training for persons who inject drugs (PWID) underlines the importance of summoning emergency medical services (EMS). To encourage PWID to do so, Colorado enacted a Good Samaritan law providing limited immunity from prosecution for possession of a controlled substance and/or drug paraphernalia to the overdose victim and the witnesses who in good faith provide emergency assistance. This paper examines the law's influence by describing OEND trained PWIDs' experience reversing overdoses and their decision about calling for EMS support.. Findings from two complementary studies, a qualitative study based on semi-structured interviews with OEND trained PWID who had reversed one or more overdoses, and an on-going fieldwork-based project examining PWIDs' self-identified health concerns were triangulated to describe and explain participants' decision to call for EMS.. In most overdose reversals described, no EMS call was made. Participants reported several reasons for not doing so. Most frequent was the fear that despite the Good Samaritan law, a police response would result in arrest of the victim and/or witness for outstanding warrants, or sentence violations. Fears were based on individual and collective experience, and reinforced by the city of Denver's aggressive approach to managing homelessness through increased enforcement of misdemeanors and the imposition of more recent ordinances, including a camping ban, to control space. The city's homeless crisis was reflected as well in the concern expressed by housed PWID that an EMS intervention would jeopardize their public housing.. Results suggest that the immunity provided by the Good Samaritan law does not address PWIDs' fear that their current legal status as well as the victim's will result in arrest and incarceration. As currently conceived, the Good Samaritan law does not provide immunity for PWIDs' already enmeshed in the criminal justice system, or PWID fearful of losing their housing.

Topics: Adult; Colorado; Crime; Drug Overdose; Emergency Medical Services; Fear; Female; Health Education; Humans; Interviews as Topic; Law Enforcement; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

Providing naloxone to laypersons who are likely to witness an opioid overdose is now a widespread public health response to the national opioid overdose epidemic. Estimating the proportion of individuals who use naloxone can define its potential impact to reduce overdose deaths at a population level. We determined the proportion of study participants who used naloxone within 12 months following training and factors associated with witnessing overdose and naloxone use.. We conducted a prospective, observational study of individuals completing overdose prevention training (OPT) between June and September 2013. Participants were recruited from New York City's six largest overdose prevention programs, all operated by syringe exchange programs. Questionnaires were administered at four time points over 12 months. Main outcomes were witnessing or experiencing overdose, and naloxone administration.. Of 675 individuals completing OPT, 429 (64%) were approached and 351 (52%) were enrolled. Overall, 299 (85%) study participants completed at least one follow-up survey; 128 (36%) witnessed at least one overdose. Of 312 witnessed opioid overdoses, naloxone was administered in 241 events (77%); 188 (60%) by the OPT study participant. Eighty-six (25%) study participants administered naloxone at least once. Over one third of study participants (30, 35%) used naloxone 6 or more months after training.. Witnessing an overdose and naloxone use was common among this study cohort of OPT trainees. Training individuals at high risk for witnessing overdoses may reduce opioid overdose mortality at a population level if sufficient numbers of potential responders are equipped with naloxone.

Topics: Analgesics, Opioid; Drug Overdose; Humans; Longitudinal Studies; Naloxone; Narcotic Antagonists; Needle-Exchange Programs; New York City; Prospective Studies

Psychotropic drugs are medications that are indicated for treatment of psychiatric disorders. Attempted suicide is the major reason for intoxication but inadvertent overdosing may also occur. Other psychotropic agents are taken because of their stimulating and hallucinogenic effects and many have a high addictive potential. Poisoning is usually due to accidental overdosing. For treatment of benzodiazepine and opioid intoxication, flumazenil and naloxone, respectively, are used as specific antagonists. For intoxication by tricyclic antidepressants, sodium bicarbonate is the treatment of choice. It can also be administered for poisoning caused by selective serotonin re-uptake inhibitors and neuroleptics, in cases of cardiotoxicity. Torsades de pointes can be terminated with defibrillation and intravenous magnesium. Symptomatic treatment is performed for intoxications caused by analeptics or hallucinogens. Beta blockers must be avoided in cocaine and amphetamine poisoning.

Topics: Antipsychotic Agents; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Psychotropic Drugs; Substance-Related Disorders

Topics: Analgesics, Opioid; Drug Overdose; Fentanyl; Health Knowledge, Attitudes, Practice; Hospital Rapid Response Team; Humans; Law Enforcement; Naloxone; Narcotic Antagonists; North America; Opioid-Related Disorders; Pharmacovigilance; Police; Prescription Drug Misuse

On August 15, 2016, the Mayor's Office of Drug Control Policy in Huntington, West Virginia, notified the Cabell-Huntington Health Department (CHHD) of multiple calls regarding opioid overdose received by the emergency medical system (EMS) during 3 p.m.-8 p.m. that day. A public health investigation and response conducted by the West Virginia Bureau for Public Health (BPH) and CHHD identified 20 opioid overdose cases within a 53-hour period in Cabell County; all cases included emergency department (ED) encounters. EMS personnel, other first responders, and ED providers administered the opioid antidote naloxone to 16 (80%) patients, six of whom were administered multiple doses, suggesting exposure to a highly potent opioid. No patients received referral for recovery support services. In addition to the public health investigation, a public safety investigation was conducted; comprehensive opioid toxicology testing of clinical specimens identified the synthetic opioid fentanyl* and novel fentanyl analogs, including carfentanil,

Topics: Adolescent; Adult; Analgesics, Opioid; Designer Drugs; Disease Outbreaks; Drug Overdose; Emergency Medical Services; Female; Fentanyl; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; West Virginia; Young Adult

Topics: Aged; Cardiopulmonary Resuscitation; Drug Overdose; Heroin; Heroin Dependence; Humans; Male; Naloxone; Narcotic Antagonists; Narcotics; Pneumoperitoneum; Radiography, Thoracic; Respiratory Insufficiency; Stomach; Tomography, X-Ray Computed

Topics: Analgesics, Opioid; Drug Overdose; Female; Fentanyl; Humans; Male; Naloxone; Narcotic Antagonists; Nurse-Patient Relations; Opioid-Related Disorders

The adulteration of heroin with non-pharmaceutical fentanyl and other high-potency opioids is one of the factors contributing to striking increases in overdose deaths. To fully understand the magnitude of this problem, accurate detection methods for fentanyl and other novel opioid adulterant exposures are urgently required. The objective of this work was to compare the detection of fentanyl in oral fluid and urine specimens using liquid chromatography quadrupole time-of-flight mass spectrometry (LC-QTOF-MS) in a population of heroin users presenting to the Emergency Department after overdose.. This was a prospective observational study of adult Emergency Department patients who presented after a reported heroin overdose requiring naloxone administration. Participants provided paired oral fluid and urine specimens, which were prepared, extracted, and analyzed using a dual LC-QTOF-MS workflow for the identification of traditional and emerging drugs of abuse. Analytical instrumentation included SCIEX TripleTOF® 5600+ and Waters Xevo® G2-S QTOF systems.. Thirty participants (N = 30) were enrolled during the study period. Twenty-nine participants had fentanyl detected in their urine, while 27 had fentanyl identified in their oral fluid (overall agreement 93.3%, positive percent agreement 93.1%). Cohen's Kappa (k) was calculated and demonstrated moderately, significant agreement (k = 0.47; p value 0.002) in fentanyl detection between oral fluid and urine using this LC-QTOF-MS methodology. Additional novel opioids and metabolites, including norfentanyl, acetylfentanyl, and U-47700, were detected during this study.. In this study of individuals presenting to the ED after reported heroin overdose, a strikingly high proportion had a detectable fentanyl exposure. Using LC-QTOF-MS, the agreement between paired oral fluid and urine testing for fentanyl detection indicates a role for oral fluid testing in surveillance for nonpharmaceutical fentanyl. Additionally, the use of LC-QTOF-MS allowed for the detection of other clandestine opioids (acetylfentanyl and U-47700) in oral fluid.

Topics: Adolescent; Analgesics, Opioid; Chromatography, Liquid; Drug Contamination; Drug Overdose; Emergency Service, Hospital; Female; Fentanyl; Heroin Dependence; Humans; Male; Mass Spectrometry; Naloxone; Narcotic Antagonists; Predictive Value of Tests; Prospective Studies; Reproducibility of Results; Saliva; Substance Abuse Detection; Urinalysis; Young Adult

This study describes the implementation and evaluation of revised opioid overdose prevention and education of naloxone training for law enforcement officers (LEOs) that added: (1) a recovery testimony and (2) the process for deputy-initiated referrals postnaloxone administration.. Evaluation regarding the naloxone training included a pre- and postopioid overdose knowledge surveys (N = 114) and subsequent 1-year postnaloxone training outcomes.. Pre- and posttest scores for all knowledge outcome measures were statistically significant (p < .001) with favorable comments pertaining to the recovery testimony. Out of 31 individuals who received naloxone, 6 individuals (19.4%) continue to be in treatment or received some treatment services. The most common symptoms reported were unconsciousness/unresponsiveness (40.5%), abnormal breathing patterns (24.3%), and blue lips (16.2%). The majority of the calls (65.6%) were to a residential area, and the time for naloxone revival ranged <1-10 min (M = 3.48; SD = 2.27).. As nearly 20% of individuals sought treatment after a LEO-initiated referral, it is recommended that other agencies consider the referral process into the training. Future research will investigate the impact of the recovery testimony in reducing the stigma of addiction.

Topics: Adult; Analgesics, Opioid; Drug Overdose; Female; Follow-Up Studies; Health Knowledge, Attitudes, Practice; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Police; Program Development; Program Evaluation; Surveys and Questionnaires; Young Adult

Opioid prescribing for chronic pain significantly contributes to opioid overdose deaths in the United States. Naloxone as a take-home antidote to opioid overdose is underutilized and has not been evaluated in the high-risk chronic pain population. The objective was to increase overdose education and naloxone distribution (OEND) to high-risk patients on long-term opioid therapy for pain by utilizing group visits in primary care.. Quality improvement intervention among two primary care clinics.. A large, academic facility within the Veterans Health Administration.. Patients prescribed ≥100 mg morphine-equivalent daily dose or coprescribed opioids and benzodiazepines.. One clinic provided usual care with respect to OEND; another clinic encouraged attendance at an OEND group visit to all of its high-risk patients.. We used attendance at group visits, prescriptions of naloxone issued, and patient satisfaction scores to evaluate this format of OEND.. Group OEND visits resulted in significantly more naloxone prescriptions than usual care. At these group visits, patients were engaged, valued the experience, and all requested a prescription for the naloxone kit.. This quality improvement pilot study suggests that OEND group visits are a promising model of care.

Topics: Analgesics, Opioid; Chronic Pain; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Patient Education as Topic; Patient Satisfaction; Pilot Projects; Primary Health Care; Quality Improvement

The United States is experiencing an epidemic of opioid-related deaths. Naloxone, the drug of choice for reversing acute opioid overdose, is not routinely prescribed for outpatient use. The aims of this project were to improve naloxone awareness, increase naloxone prescribing, and prevent opioid overdoses.. A naloxone counseling intervention was implemented in three family health centers by an interprofessional team of providers including family medicine physicians, clinical pharmacists, and social workers. An outreach letter was designed with provider input, an electronic order set was developed to facilitate prescribing, and intranasal naloxone kits were assembled for free dispensing. Providers and staff received education about opioid overdose and naloxone prescribing. Faculty and resident physicians were surveyed before and after the intervention to assess their attitudes. Patients who received naloxone kits were surveyed to assess their attitudes and use of opioids and naloxone.. Over 16 months, 71 outreach letters were distributed and 97 naloxone kits were dispensed. The majority of kits were prescribed for illicit opioid use. Faculty and resident physician surveys indicated improved knowledge about naloxone prescribing, and increased professional satisfaction caring for patients requesting opioids. Surveyed patients endorsed high levels of comfort discussing opioid use with their primary care physician. Five successful opioid overdose reversals were reported.. An interprofessional naloxone counseling intervention engaged patients in opioid use discussions, increased provider satisfaction, and reversed overdoses. Improving naloxone access is an essential component of comprehensive overdose prevention programs that encourage responsible opioid prescribing and use.

Topics: Analgesics, Opioid; Counseling; Drug Overdose; Harm Reduction; Health Knowledge, Attitudes, Practice; Humans; Naloxone; Narcotic Antagonists; Patient Care Team; Patient Participation; Physicians, Primary Care; Practice Patterns, Physicians'; United States

Topics: Analgesics, Opioid; Drug Overdose; Fentanyl; Heroin Dependence; Humans; Illicit Drugs; Mortality; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; United States

The objectives were to analyze the knowledge about overdose prevention, the use of naloxone, and the number of fatal overdoses after the implementation of Systematic Training in Overdose Prevention (STOOP) program. We conducted a quasi-experimental study, and held face-to-face interviews before (n = 725) and after (n = 722) implementation of systematic training in two different samples of people who injected opioids attending harm reduction centers. We asked participants to list the main causes of overdose and the main actions that should be taken when witnessing an overdose. We created two dependent variables, the number of (a) correct and (b) incorrect answers. The main independent variable was Study Group: Intervention Group (IG), Comparison Group (CG), Pre-Intervention Group With Sporadic Training in Overdose Prevention (PREIGS), or Pre-Intervention Group Without Training in Overdose Prevention (PREIGW). The relationship between the dependent and independent variables was assessed using a multivariate Poisson regression analysis. Finally, we conducted an interrupted time series analysis of monthly fatal overdoses before and after the implementation of systematic program during the period 2006-2015. Knowledge of overdose prevention increased after implementing systematic training program. Compared to the PREIGW, the IG gave more correct answers (IRR = 1.40;95%CI:1.33-1.47), and fewer incorrect answers (IRR = 0.33;95%CI:0.25-0.44). Forty percent of people who injected opioids who received a naloxone kit had used the kit in response to an overdose they witnessed. These courses increase knowledge of overdose prevention in people who use opioids, give them the necessary skills to use naloxone, and slightly diminish the number of fatal opioid overdoses in the city of Barcelona.

Topics: Adult; Analgesics, Opioid; Drug Overdose; Female; Harm Reduction; Health Education; Health Knowledge, Attitudes, Practice; Humans; Interviews as Topic; Male; Multivariate Analysis; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Program Evaluation; Regression Analysis; Risk Factors; Spain

Topics: Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Primary Health Care; Quality Improvement

Alberta is a prairie province located in western Canada, with a population of approximately 4.3 million. In 2016, 363 Albertans died from apparent drug overdoses related to fentanyl, an opioid 50-100 times more toxic than morphine. This surpassed the number of deaths from motor vehicle collisions and homicides combined.. Naloxone is a safe, effective, opioid antagonist that may quickly reverse an opioid overdose. In July 2015, a committee of community-based harm reduction programs in Alberta implemented a geographically restricted take-home naloxone (THN) program. The successes and limitations of this program demonstrated the need for an expanded, multi-sectoral, multi-jurisdictional response. The provincial health authority, Alberta Health Services (AHS), used previously established incident command system processes to coordinate implementation of a provincial THN program.. Alberta's provincial THN program was implemented on December 23, 2015. This collaborative program resulted in a coordinated response across jurisdictional levels with wide geographical reach. Between December 2015 and December 2016, 953 locations, including many community pharmacies, registered to dispense THN kits, 9572 kits were distributed, and 472 reversals were reported. The provincial supply of THN kits more than tripled from 3000 to 10 000.. Alberta was uniquely poised to deliver a large, province-wide, multi-sectoral and multi-jurisdictional THN program as part of a comprehensive response to increasing opioid-related morbidity and mortality. The speed at which AHS was able to roll out the program was made possible by work done previously and the willingness of multiple jurisdictions to work together to build on and expand the program.

Topics: Alberta; Community Health Services; Drug Overdose; Fentanyl; Harm Reduction; Humans; Naloxone; Narcotic Antagonists; Program Evaluation

Prison inmates face a ten times increased risk of experiencing a fatal drug overdose during their first 2 weeks upon release than their non-incarcerated counterparts. Naloxone, the antidote to an opioid overdose, has been shown to be feasible and effective when administered by bystanders. Given the particular risk that newly released inmates face, it is vital to assess their knowledge about opioid overdoses, as well as the impact of brief overdose prevention training conducted inside prisons.. Prison inmates nearing release (within 6 months) in Oslo, Norway, voluntarily underwent a brief naloxone training. Using a questionnaire, inmates were assessed immediately prior to and following a naloxone training. Descriptive statistics were performed for main outcome variables, and the Wilcoxon signed-rank test was used to compare the participants' two questionnaire scores from pre-and post-training.. Participating inmates (n = 31) were found to have a high baseline knowledge of risk factors, symptoms, and care regarding opioid overdoses. Nonetheless, a brief naloxone training session prior to release significantly improved knowledge scores in all areas assessed (p < 0.001). The training appears to be most beneficial in improving knowledge regarding the naloxone, including its use, effect, administration, and aftercare procedures.. Given the high risk of overdosing that prison inmates face upon release, the need for prevention programs is critical. Naloxone training in the prison setting may be an effective means of improving opioid overdose response knowledge for this particularly vulnerable group. Naloxone training provided in the prison setting may improve the ability of inmates to recognize and manage opioid overdoses after their release; however, further studies on a larger scale are needed.

Topics: Adult; Drug Overdose; Educational Measurement; Female; Humans; Knowledge; Male; Naloxone; Narcotic Antagonists; Norway; Prisoners; Prisons; Program Evaluation; Risk Factors; Surveys and Questionnaires

Topics: Adult; Analgesics, Opioid; Drug Overdose; Fentanyl; Heroin; Heroin Dependence; Humans; Hypoxia; Lung; Male; Naloxone; Narcotic Antagonists; Pulmonary Edema; Radiography, Thoracic; Substance Abuse, Intravenous

North America is currently experiencing an overdose epidemic due to a significant increase of fentanyl-adulterated opioids and related analogs. Multiple jurisdictions have declared a public health emergency given the increasing number of overdose deaths. In the province of British Columbia (BC) in Canada, people who use drugs and who are unstably housed are disproportionately affected by a rising overdose crisis, with close to 90% of overdose deaths occurring indoors. Despite this alarming number, overdose prevention and response interventions have yet to be widely implemented in a range of housing settings.. There are few examples of overdose prevention interventions in housing environments. In BC, for example, there are peer-led naloxone training and distribution programs targeted at some housing environments. There are also "supervised" spaces such as overdose prevention sites (similar to supervised consumption sites (SCS)) located in some housing environments; however, their coverage remains limited and the impacts of these programs are unclear due to the lack of evaluation work undertaken to date. A small number of SCS exist globally in housing environments (e.g., Germany), but like overdose prevention sites in BC, little is known about the design or effectiveness, as they remain under-evaluated.. Implementing SCS and other overdose prevention interventions across a range of housing sites provides multiple opportunities to address overdose risk and drug-related harms for marginalized people who use drugs. Given the current overdose crisis rising across North America, and the growing evidence of the relationship between housing and overdose, the continued implementation and evaluation of novel overdose prevention interventions in housing environments should be a public health priority. A failure to do so will simply perpetuate what has proven to be a devastating epidemic of preventable death.

Topics: British Columbia; Drug Overdose; Harm Reduction; Housing; Humans; Naloxone; Narcotic Antagonists; Needle-Exchange Programs

Topics: Drug Overdose; Emergency Medical Services; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; United States

As awareness of the opioid epidemic in this country has grown, so has the number of efforts to respond to it. This article reviews national and state efforts involving the medical community. It also reports on new funding coming to Minnesota with passage of the 21 st Century Cures Act, and it calls for increased involvement at the health system level. The hope is that with greater awareness of these efforts, health care providers will be better equipped to address the full spectrum of the epidemic.

Topics: Cross-Sectional Studies; Drug Overdose; Epidemics; General Practice; Humans; Minnesota; Naloxone; Opioid-Related Disorders; United States

The opioid epidemic has included use of traditional drugs and recently newer synthetics. It is critically important to recognize and identify these new drugs both clinically and through appropriately designed toxicology testing. There is little available information on a synthetic gaining popularity, U-47700.. A 23-year-old female presented after using "U4" by nasal insufflation and injection. She was cyanotic with respiratory depression and responded to naloxone in the field. She was found to have non cardiogenic pulmonary edema and hemoptysis which improved with BiPAP. Urine and serum samples were analyzed using mass spectrometry, confirming 3,4-dichloro-N-[(1R,2R)-2-(dimethylamino)cyclohexyl]-N-methylbenzamide or U-47700. The sample was further analyzed elucidating metabolism specifics. Drug and metabolite concentrations were subsequently measured in both serum and urine. The parent compound of U-47700 was detected at 394 ng/mL and 228 ng/mL in serum and urine, respectively. Metabolites detected in appreciable amounts included the desmethyl (1964 ng/mL in urine), bisdesmethyl (618 ng/mL), desmethyl hydroxy (447 ng/mL), and bisdesmethyl hydroxy forms (247 ng/mL) of U-47700.. U-47700 is a potent μ-opioid receptor agonist and has recently been used recreationally, contributing to hospitalizations and likely deaths in the community. This is a case report describing an exposure to U-47700 with subsequent laboratory analysis. Based upon this one case, parent U-47700 appear to be an appropriate marker of use in a serum sample. However, demethylated metabolites appear dominant as urinary markers of U-47700 use.

Topics: Analgesics, Opioid; Benzamides; Designer Drugs; Drug Overdose; Female; Humans; Naloxone; Narcotic Antagonists; Substance Abuse Detection; Young Adult

The increased use of opioids for chronic treatment of pain and the resulting epidemic of opioid overdoses have created a major public health challenge. Parenteral naloxone has been used since the 1970's to treat opioid overdose. Recently, a novel naloxone auto-injector device (EVZIO, kaleo, Inc., Richmond, VA) was approved by the Food and Drug Administration. In this article, we review the Human Factors Engineering (HFE) process used in the development and testing of this novel naloxone auto-injector currently used in nonmedical settings for the emergency treatment of known or suspected opioid overdose. HFE methods were employed throughout the product development process for the naloxone auto-injector including formative and summative studies in order to optimize the auto-injector's user interface, mitigate use-related hazards and increase reliability during an opioid emergency use scenario. HFE was also used to optimize the product's design and user interface in order to reduce or prevent user confusion and misuse. The naloxone auto-injector went through a rigorous HFE process that included perceptual, cognitive, and physical action analysis; formative usability evaluations; use error analysis and summative design validation studies. Applying HFE resulted in the development of a product that is safe, fast, easy and predictably reliable to deliver a potentially life-saving dose of naloxone during an opioid overdose emergency. The naloxone auto-injector may be considered as a universal precaution option for at-risk patients prescribed opioids or those who are at increased risk for an opioid overdose emergency.

Topics: Analgesics, Opioid; Drug Delivery Systems; Drug Overdose; Equipment Design; Ergonomics; Humans; Injections; Naloxone; Narcotic Antagonists

It has been suggested that distributing naloxone to people who inject drugs (PWID) will lead to fewer attendances by emergency medical services at opioid-related overdose incidents if peer administration of naloxone was perceived to have resuscitated the overdose victim successfully. This study evaluated the impact of a national naloxone programme (NNP) on ambulance attendance at opioid-related overdose incidents throughout Scotland. Specifically, we aimed to answer the following research questions: is there evidence of an association between ambulance call-outs to opioid-related overdose incidents and the cumulative number of 'take-home naloxone' (THN) kits in issue; and is there evidence of an association between ambulance call-outs to opioid-related overdose incidents in early adopter (pilot) or later adopting (non-pilot) regions and the cumulative number of THN kits issued in those areas?. Controlled time-series analysis.. Scotland, UK, 2008-15.. Pre-NNP implementation period for the evaluation was defined as 1 April 2008 to 31 March 2011 and the post-implementation period as 1 April 2011 to 31 March 2015. In total, 3721 ambulance attendances at opioid-related overdose were recorded for the pre-NNP implementation period across 158 weeks (mean 23.6 attendances per week) and 5258 attendances across 212 weeks in the post-implementation period (mean 24.8 attendances per week).. Scotland's NNP; formally implemented on 1 April 2011.. Primary outcome measure was weekly incidence (counts) of call-outs to opioid-related overdoses at national and regional Health Board level. Data were acquired from the Scottish Ambulance Service (SAS). Models were adjusted for opioid replacement therapy using data acquired from the Information Services Division on monthly sums of all dispensed methadone and buprenorphine in the study period. Models were adjusted further for a control group: weekly incidence (counts) of call-outs to heroin-related overdose in the London Borough area acquired from the London Ambulance Service.. There was no significant association between SAS call-outs to opioid-related overdose incidents and THN kits in issue for Scotland as a whole (coefficient 0.009, 95% confidence intervals = -0.01, 0.03, P = 0.39). In addition, the magnitude of association between THN kits and SAS call-outs did not differ significantly between pilot and non-pilot regions (interaction test, P = 0.62).. The supply of take-home naloxone kits through a National Naloxone Programme in Scotland was not associated clearly with a decrease in ambulance attendance at opioid-related overdose incidents in the 4-year period after it was implemented in April 2011.

Topics: Ambulances; Drug Overdose; Emergency Medical Services; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Scotland; Substance Abuse, Intravenous

Topics: Adult; Confusion; Direct-to-Consumer Advertising; Drug Overdose; GABA Agonists; gamma-Aminobutyric Acid; Glasgow Coma Scale; Humans; Internet; Male; Naloxone; Narcotic Antagonists; Stupor

Although the World Health Organization recommends take-home naloxone to address the increasing global burden of opioid-related deaths, few emergency departments (EDs) offer a take-home naloxone program. We seek to determine the take-home naloxone acceptance rate among ED patients at high risk of opioid overdose and to examine factors associated with acceptance.. At a single urban ED, consecutive eligible patients at risk of opioid overdose were invited to complete a survey about opioid use, overdose experience, and take-home naloxone awareness, and then offered take-home naloxone. The primary outcome was acceptance of take-home naloxone, including the kit and standardized patient training. Univariate and multivariable logistic analyses were used to evaluate factors associated with acceptance.. Of 241 eligible patients approached, 201 (83.4%) completed the questionnaire. Three-quarters of respondents used injection drugs, 37% were women, and 26% identified as "Indigenous." Of 201 respondents, 137 (68.2%; 95% confidence interval [CI] 61.7% to 74.7%) accepted take-home naloxone. Multivariable analysis revealed that factors associated with take-home naloxone acceptance included witnessing overdose in others (odds ratio [OR] 4.77; 95% CI 2.25 to 10.09), concern about own overdose death (OR 3.71; 95% CI 1.34 to 10.23), female sex (OR 2.50; 95% CI 1.21 to 5.17), and injection drug use (OR 2.22; 95% CI 1.06 to 4.67).. A two-thirds ED take-home naloxone acceptance rate in patients using opioids should encourage all EDs to dispense take-home naloxone. ED-based take-home naloxone programs have the potential to improve access to take-home naloxone and awareness in individuals most vulnerable to overdoses.

Topics: Adult; Drug Overdose; Emergency Service, Hospital; Female; Humans; Male; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Patient Acceptance of Health Care; Patient Education as Topic; Self Care

Topics: Cannabinoids; Designer Drugs; Drug Overdose; Humans; Illicit Drugs; Naloxone; Narcotic Antagonists

Naloxone co-prescription is recommended for patients on long-term opioids for pain, yet there are few data on the practice.. To explore naloxone co-prescribing acceptability among primary care providers for patients on long-term opioids.. We surveyed providers at six safety-net primary care clinics in San Francisco that had initiated naloxone co-prescribing. Providers were encouraged to offer naloxone to patients on long-term opioids or otherwise at risk of witnessing or experiencing an overdose. Surveys were administered electronically 4 to 11 months after co-prescribing began.. One hundred eleven providers (69 %) responded to the survey, among whom 41.4 % were residents; 40.5 % practiced internal medicine and 55.0 % practiced family medicine. Most (79.3 %) prescribed naloxone, to a mean of 7.7 patients; 99.1 % were likely to prescribe naloxone in the future. Providers reported they were likely to prescribe naloxone to most patients, including those on low doses, defined as <20 morphine equivalent mg daily (59.8 %), ≥65 years old (83.9 %), with no overdose history (80.7 %), and with no substance use disorder (73.6 %). Most providers felt that prescribing naloxone did not affect their opioid prescribing, 22.5 % felt that they might prescribe fewer opioids, and 3.6 % felt that they might prescribe more. Concerns about providing naloxone were largely administrative, relating to time and pharmacy or payer logistics. Internists (incidence rate ratio [IRR] = 0.49, 95 % CI = 0.26-0.93, p = 0.029), those licensed for 5-20 years (IRR = 2.10, 95 % CI = 1.35-3.25, p = 0.001), and those with more patients prescribed long-term opioids (IRR = 1.10, 95 % CI = 1.05-1.14, p <0.001) were independently more likely to prescribe a greater number of naloxone compared to participants without these exposures.. Naloxone co-prescription is considered acceptable among primary care providers. Barriers such as time and dispensing logistics may be alleviated by novel naloxone formulations intended for laypersons recently approved by the U.S. Food and Drug Administration.

Topics: Analgesics, Opioid; Attitude of Health Personnel; Chronic Pain; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Physicians, Primary Care; Practice Patterns, Physicians'; Surveys and Questionnaires

Take-home naloxone programs (THN) are harm reduction programs with the aim of reducing the number of deaths caused by opioid overdoses. A THN program in Montreal called the PROFAN project was implemented with the goal of reducing overdoses through the use of peer-trainers. Peer-trainers are people who are currently or have previously used drugs, who are trained in overdose prevention and are then responsible for delivering a training session to other individuals who use drugs. While studies on other peer-led programs have shown that peer-helpers gain numerous benefits from their role, little attention has been devoted to understanding this role in the context of overdose prevention. Additionally, to our knowledge, this is the first time that the impacts of the peer-trainer role are being studied and documented for a scientific journal.. This research represents a qualitative study using individual interviews with the six peer-trainers of the Montreal program to explore the benefits and challenges encountered in their role.. Interview results suggest that there are psychological benefits received through the peer-trainer role, such as empowerment and recovery. As well, there are a number of challenges associated with their role and suggestions to improve the program.. Knowledge about the impacts of the peer-trainer role will contribute to the development of THN programs. Additionally, the findings may also serve to demonstrate that THN programs are capable of not only reducing the number of deaths by opioid overdose, but that these programs may also have wider effects on a psychological level.

Topics: Adult; Drug Overdose; Female; Harm Reduction; Humans; Male; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Peer Group; Program Development; Program Evaluation; Quebec

Codeine containing analgesics are commonly taken in overdose, but the frequency of respiratory depression is unknown. We investigated whether paracetamol-codeine combination overdoses caused respiratory depression more than paracetamol alone.. We reviewed deliberate self-poisoning admissions with paracetamol (>2 g) and paracetamol-codeine combinations presenting to a tertiary toxicology unit (1987-2013). Demographic information, clinical effects, treatment (naloxone, length of stay [LOS], mechanical ventilation) were extracted from a prospective database. Primary outcome was naloxone requirement or ventilation for respiratory depression.. From 4488 presentations, 1376 admissions were included with paracetamol alone (929), paracetamol-codeine combinations (346) or paracetamol-codeine-doxylamine combinations (101) without co-ingestants. Median age was 23 years (12-89 years); 1002 (73%) were female. Median dose was 12 g (interquartile range [IQR]: 7.5-20 g). Median LOS was 16 h (IQR: 6.5-27 h) and 564 (41%) were given acetylcysteine. Significantly larger paracetamol doses were ingested and more acetylcysteine given in paracetamol alone versus paracetamol combination overdoses. Seven out of 1376 patients were intubated or received naloxone (0.5%; 95% CI: 0.2-1.1%), three intubated, three given naloxone and one both. Three out of 929 patients ingesting paracetamol alone (0.3%; 95% CI: 0.1-1%) required intubation or naloxone, compared to two out of 346 ingesting paracetamol-codeine combinations (0.6%; 95% CI: 0.1-2.3%; absolute difference, 0.26%; 95% CI: -0.7-1.2%; P = 0.62). Two out of 101 patients ingesting paracetamol-codeine-doxylamine combinations (2%; 95% CI: 0.3-8%) required intubation or naloxone. Four patients were intubated for reasons other than respiratory depression: hepatotoxicity (2), retrieval (1), no data (1). Two out of 929 (0.2%) paracetamol alone overdoses had a Glasgow coma score < 9 compared to three out of 346 (0.9%) in the paracetamol-codeine group.. Paracetamol-codeine combination overdoses are rarely associated with severe respiratory depression, with only two given naloxone and none intubated for respiratory depression.

Topics: Acetaminophen; Acetylcysteine; Adolescent; Adult; Aged; Aged, 80 and over; Antidotes; Child; Codeine; Critical Care; Drug Combinations; Drug Overdose; Female; Glasgow Coma Scale; Humans; Length of Stay; Male; Middle Aged; Naloxone; Narcotic Antagonists; Respiration, Artificial; Respiratory Insufficiency; Retrospective Studies; Suicide, Attempted; Treatment Outcome; Young Adult

Opioid overdose fatalities are a significant concern globally. Non-fatal overdoses have been described as a strong predictor for future overdoses, and are often attended by the ambulance services. This paper explores characteristics associated with non-fatal overdoses and aims to identify possible trends among these events in an urban area in Norway.. This is a retrospective analysis of non-fatal overdoses from Bergen ambulance services from 2012 to 2013. Demographic, temporal and geographic data were explored.. During the two years, 463 non-fatal opioid overdoses were attended by ambulance services. Ambulance call-outs occurred primarily during the late afternoon and evening hours of weekdays. Summer months had more overdoses than other seasons, with a peak in August. Overdoses were nearly twice as likely to occur in a public location in August (risk ratio 1.92, P = 0.042). Ambulance response times were more likely to be longer to private locations, and these victims were more likely to be treated and left at the scene. There was no difference in arrival time for drug-related and non-drug related dispatch.. The temporal patterns suggest that non-fatal overdoses occur during non-recreational time periods. The longer ambulance response time and disposition for private addresses indicate potential opportunities for peer interventions. Our analysis describes circumstances surrounding non-fatal overdoses and can be useful in guiding relevant, targeted prevention interventions. [Madah-Amiri D, Clausen T, Myrmel L, Brattebø G, Lobmaier P. Circumstances surrounding non-fatal opioid overdoses attended by ambulance services. Drug Alcohol Rev 2017;36:288-294].

Topics: Adolescent; Adult; Ambulances; Analgesics, Opioid; Drug Overdose; Emergency Medical Services; Female; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Norway; Retrospective Studies; Young Adult

Opioid abuse is a growing and significant public health concern in the United States. Naloxone is an opioid antagonist that can rapidly reverse the respiratory depression associated with opioid toxicity. Georgetown University's collegiate-based emergency medical services (EMS) agency recently adopted a protocol, allowing providers to administer intranasal naloxone for patients with suspected opioid overdose. While normally not within the scope of practice of basic life support prehospital agencies, the recognition of an increasing epidemic of opioid abuse has led many states, including the District of Columbia, to expand access to naloxone for prehospital providers of all levels of training. In particular, intranasal naloxone is a method of administering this medication that potentially avoids needlestick injuries among EMS providers. Universities with collegiate-based EMS agencies are well positioned to provide life-saving treatments for patients acutely ill from opioid overdose.

Topics: Administration, Intranasal; Analgesics, Opioid; Drug Overdose; Emergency Medical Services; Humans; Naloxone; Narcotic Antagonists; Students; Universities

Topics: Analgesics, Opioid; Drug Overdose; Emergency Medical Services; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders

There are limited reports of adult clonidine overdose. We aimed to describe the clinical effects and treatment of clonidine overdose in adults.. This was a retrospective review of a prospective cohort of poisoned patients who took clonidine overdoses (>200 μg). Demographic information, clinical effects, treatment, complications (central nervous system and cardiovascular effects) and length of stay (LOS) were extracted from a clinical database or medical records.. From 133 admissions for clonidine poisoning (1988-2015), no medical record was available in 14 and 11 took staggered ingestions. Of 108 acute clonidine overdoses (median age 27 years; 14-65 years; 68 females), 40 were clonidine alone ingestions and 68 were clonidine with co-ingestants. Median dose taken was 2100 μg (interquartile range [IQR]: 400-15,000 μg). Median LOS was 21h (IQR: 14-35 h) and there were no deaths. Glasgow coma score [GCS] <15 occurred in 73/108 (68%), and more patients taking co-ingestants (8/68; 12%) had coma (GCS <9) compared to clonidine alone (2/40; 5%). Miosis occurred in 31/108 (29%) cases. Median minimum HR was 48 bpm (IQR: 40-57 bpm), similar between clonidine alone and co-ingestant overdoses. There was a significant association between dose and minimum HR for clonidine alone overdoses (p = 0.02). 82/108 (76%) had bradycardia, median onset 2.5 h post-ingestion (IQR: 1.7-5.5 h) and median duration 20 h (2.5-83 h), similar for clonidine alone and co-ingestant overdoses. There were no arrhythmias. Three patients ingesting 8000-12,000 μg developed early hypertension. Median minimum systolic BP was 96 mmHg (IQR: 90-105 mmHg) and hypotension occurred in 26/108 (24%). 12/108 patients were intubated, but only 2 were clonidine alone cases. Treatments included activated charcoal (24), atropine (8) and naloxone (23). The median total naloxone dose was 2 mg (IQR: 1.2-2.4 mg), but only one patient given naloxone was documented to respond with partial improvement in GCS.. Clonidine causes persistent but not life-threatening clinical effects. Most patients develop mild central nervous system depression and bradycardia. Naloxone was not associated with improved outcomes.

Topics: Adolescent; Adult; Aged; Antidotes; Antihypertensive Agents; Atropine; Bradycardia; Central Nervous System Diseases; Clonidine; Drug Overdose; Female; Glasgow Coma Scale; Humans; Length of Stay; Male; Middle Aged; Naloxone; Retrospective Studies; Young Adult

Introduction Research suggests Emergency Medical Services (EMS) over-use in urban cities is partly due to substance users with limited access to medical/social services. Recent efforts to deliver brief, motivational messages to encourage these individuals to enter treatment have not considered EMS providers. Problem Little research has been done with EMS providers who serve substance-using patients. The EMS providers were interviewed about participating in a pilot program where they would be trained to screen their patients for substance abuse and encourage them to enter drug treatment.. Qualitative interviews were conducted with Baltimore City Fire Department (BCFD; Baltimore, Maryland USA) EMS providers (N=22). Topics included EMS misuse, work demands, and views on participating in the pilot program. Interviews were transcribed and analyzed using grounded theory and constant-comparison.. Participants were mostly white (68.1%); male (68.2%); with Advanced Life Skills training (90.9%). Mean age was 37.5 years. Providers described the "frequent flyer problem" (eg, EMS over-use by a few repeat non-emergent cases). Providers expressed disappointment with local health delivery due to resource limitations and being excluded from decision making within their administration, leading to reduced team morale and burnout. Nonetheless, providers acknowledged they are well-positioned to intervene with substance-using patients because they are in direct contact and have built rapport with them. They noted patients might be most receptive to motivational messages immediately after overdose revival, which several called "hitting their bottom." Several stated that involvement with the proposed study would be facilitated by direct incorporation into EMS providers' current workflow. Many recommended that research team members accompany EMS providers while on-call to observe their day-to-day work. Barriers identified by the providers included time constraints to intervene, limited knowledge of substance abuse treatment modalities, and fearing negative repercussions from supervisors and/or patients. Despite reservations, several EMS providers expressed inclination to deliver brief motivational messages to encourage substance-using patients to consider treatment, given adequate training and skill-building.. Emergency Medical Service providers may have many demands, including difficult case time/resource limitations. Even so, participants recognized their unique position as first responders to deliver motivational, harm-reduction messages to substance-using patients during transport. With incentivized training, implementing this program could be life- and cost-saving, improving emergency and behavioral health services. Findings will inform future efforts to connect substance users with drug treatment, potentially reducing EMS over-use in Baltimore. Maragh-Bass AC , Fields JC , McWilliams J , Knowlton AR . Challenges and opportunities to engaging Emergency Medical Service providers in substance use research: a qualitative study. Prehosp Disaster Med. 2017;32(2):148-155.

Topics: Adult; Drug Overdose; Emergency Medical Technicians; Female; Humans; Interviews as Topic; Male; Naloxone; Narcotic Antagonists; Pilot Projects; Research Design; Substance Abuse, Intravenous

For over 20 years, drug policy experts have been calling for the wider availability of naloxone, to enable lay overdose witnesses to respond to opioid overdose events. However, the 'evidence base' for peer-administered naloxone has become a key point of contention. This contention opens up critical questions about how knowledge ('evidence') is constituted and validated in drug policy processes, which voices may be heard, and how knowledge producers secure privileged positions of influence. Taking the debate surrounding peer-administered naloxone as a case study, and drawing on qualitative interviews with individuals (n = 19) involved in the development of naloxone policy in Australia, we examine how particular kinds of knowledge are rendered 'useful' in drug policy debates. Applying Bacchi's poststructuralist approach to policy analysis, we argue that taken-for-granted 'truths' implicit within evidence-based policy discourse privilege particular kinds of 'objective' and 'rational' knowledge and, in so doing, legitimate the voices of researchers and clinicians to the exclusion of others. What appears to be a simple requirement for methodological rigour in the evidence-based policy paradigm actually rests on deeper assumptions which place limits around not only what can be said (in terms of what kind of knowledge is relevant for policy debate) but also who may legitimately speak. However, the accounts offered by participants reveal the ways in which a larger number of ways of knowing are already co-habiting within drug policy. Despite these opportunities for re-problematisation and resistance, the continued mobilisation of 'evidence-based' discourse obscures these contesting positions and continues to privilege particular speakers.

Topics: Administrative Personnel; Attitude of Health Personnel; Australia; Decision Making; Drug Overdose; Evidence-Based Medicine; Health Policy; History, 21st Century; Humans; Interviews as Topic; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Peer Group; Policy Making; Qualitative Research

Investigators applied simulation to an experimental program that educated, trained, and assessed at-risk, volunteering prisoners on opioid overdose (OD) prevention, recognition, and layperson management with intranasal (IN) naloxone.. Consenting inmates were assessed for OD-related experience and knowledge then exposed on-site to standardized didactics and educational DVD (without simulation). Subjects were provided with IN naloxone kits at time of release and scheduled for postrelease assessment. At follow-up, the subjects were evaluated for their performance of layperson opioid OD resuscitative skills during video-recorded simulations. Two investigators independently scored each subject's resuscitative actions with a 21-item checklist; post hoc video reviews were separately completed to adjudicate subjects' interactions for overall benefit or harm.. One hundred three prisoners completed the baseline assessment and study intervention and then were prescribed IN naloxone kits. One-month follow-up and simulation data were available for 85 subjects (82.5% of trained recruits) who had been released and resided in the community. Subjects' simulation checklist median score was 12.0 (interquartile range, 11.0-15.0) of 21 total indicated actions. Forty-four participants (51.8%) correctly administered naloxone; 16 additional subjects (18.8%) suboptimally administered naloxone. Nonindicated actions, primarily chest compressions, were observed in 49.4% of simulations. Simulated resuscitative actions by 80 subjects (94.1%) were determined post hoc to be beneficial overall for patients overdosing on opioids.. As part of an opioid OD prevention research program for at-risk inmates, investigators applied simulation to 1-month follow-up assessments of knowledge retention and skills acquisition in postrelease participants. Simulation supplemented traditional research tools for investigation of layperson OD management.

Topics: Administration, Intranasal; Adult; Analgesics, Opioid; Drug Overdose; Female; Humans; Male; Naloxone; Narcotic Antagonists; Patient Simulation; Prisoners; Program Evaluation

On the evening of June 23, 2016, a white powder advertised as cocaine was purchased off the streets from multiple sources and used by an unknown number of persons in New Haven, Connecticut. During a period of less than 8 hours, 12 patients were brought to the emergency department (ED) at Yale New Haven Hospital, experiencing signs and symptoms consistent with opioid overdose. The route of intoxication was not known, but presumed to be insufflation ("snorting") in most cases. Some patients required doses of the opioid antidote naloxone exceeding 4 mg (usual initial dose = 0.1-0.2 mg intravenously), and several patients who were alert after receiving naloxone subsequently developed respiratory failure. Nine patients were admitted to the hospital, including four to the intensive care unit (ICU); three required endotracheal intubation, and one required continuous naloxone infusion. Three patients died. The white powder was determined to be fentanyl, a drug 50 times more potent than heroin, and it included trace amounts of cocaine. The episode triggered rapid notification of public health and law enforcement agencies, interviews of patients and their family members to trace and limit further use or distribution of the fentanyl, immediate naloxone resupply and augmentation for emergency medical services (EMS) crews, public health alerts, and plans to accelerate naloxone distribution to opioid users and their friends and families. Effective communication and timely, coordinated, collaborative actions of community partners reduced the harm caused by this event and prevented potential subsequent episodes.

Topics: Adult; Aged; Connecticut; Drug Overdose; Emergency Service, Hospital; Fatal Outcome; Female; Fentanyl; Humans; Male; Middle Aged; Naloxone

Take home naloxone programs have been successful internationally in training bystanders to reverse an opioid overdose with naloxone, an opioid antagonist. A multi-site naloxone distribution program began in Norway in 2014 as part of a national overdose prevention strategy. The aim of this study was to a) describe the program, and b) present findings from the government-supported intervention.. From July 2014 to December 2015, staff from multiple low-threshold facilities trained clients on how to use intranasal naloxone. Distribution occurred without an individual prescription or physician present. Questionnaires from initial and refill trainings were obtained, and distribution rates were monitored.. There were 2056 naloxone sprays distributed from one of the 20 participating facilities, with 277 reports of successful reversals. Participants exhibited known risks for overdosing, with injecting (p=0.02, OR=2.4, 95% CI=1.14, 5.00) and concomitant benzodiazepine use (p=0.01, OR=2.6, 95% CI=1.31, 5.23) being significant predictors for having had high rates of previous overdoses. Suggested target coverage for large-scale programs was met, with an annual naloxone distribution rate of 144 per 100,000 population, as well as 12 times the cities mean annual number of opioid-related deaths.. A government-supported multisite naloxone initiative appears to achieve rapid, high volume distribution of naloxone to an at-risk population.

Topics: Administration, Intranasal; Adult; Aged; Drug Overdose; Female; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Norway; Public Health; Surveys and Questionnaires; Young Adult

Topics: Analgesics, Opioid; Drug and Narcotic Control; Drug Overdose; Fentanyl; Humans; Illicit Drugs; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Public Health; United States

Opioid overdose deaths have become a major public health crisis. While efforts have focused mostly on helping opioid-addicted individuals directly, family members suffer also from the grave and enduring unpredictability associated with opioid addiction and often play a vital role in helping addicted loved ones access care. Little is known, however, about resources to help affected family members. Here we describe results from the first quantitative and qualitative investigation of a free and growing support organization for family members of addicted individuals ("Learn to Cope" [LTC]; www.learn2cope.org), organized around three key questions: 1. Who participates, how often, and in what ways? 2. What are the demographic and clinical histories of their addicted loved-ones? 3. How do participants benefit?. Survey with LTC members at meetings and online (N=509; 95% participation rate).. 1. Participants were primarily middle-aged mothers (77%) of opioid-addicted adult male children, attending LTC meetings several times per month, using LTC online resources several times a week, and meeting with LTC members between meetings. 2. Their addicted loved-ones were mostly male (73%), addicted to opioids (88%), with a criminal history (70%), with just under half (41%) having suffered at least one prior overdose. Almost three-quarters (71%), however, reported their loved one was "in recovery", with 30% having a year or more. 3. Benefits since beginning participation included gains in understanding and coping with addiction, feeling better able to help and communicate with their loved-one, and reductions in self-blame and stress. Of members trained in Narcan administration (66%), 86% had received training at LTC meetings; LTC members reported having deployed Narcan for over 44 overdose reversals.. The growing availability of LTC may provide a needed source of support and information for family members of opioid-addicted loved-ones and may help reduce overdose deaths through Narcan training and distribution.

Topics: Adaptation, Psychological; Adult; Aged; Aged, 80 and over; Communication; Drug Overdose; Family; Female; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Peer Group; Social Support; Surveys and Questionnaires; Young Adult

Administration of naloxone is a common treatment for opioid-dependent patients who present with respiratory depression. Although safe in opioid-naive patients, naloxone may cause severe and even life-threatening complications in opioid-dependent patients, including acute respiratory distress syndrome and myocardial infarction. It has been suggested that administration of buprenorphine, a partial μ-opioid receptor agonist, to an opioid-intoxicated patient may result in reversal of respiratory depression with less severe withdrawal signs and symptoms. In addition, the longer half-life of buprenorphine compared with naloxone may reduce the need for repetitive administration of antidote. We present a 20-year-old morphine-addicted man who presented with methadone-induced respiratory depression and responded safely and effectively to intravenous administration of buprenorphine. Buprenorphine may be a useful alternative opioid reversal agent for opioid-dependent patients.

Topics: Administration, Intravenous; Buprenorphine; Drug Overdose; Humans; Male; Methadone; Naloxone; Narcotic Antagonists; Respiratory Insufficiency; Treatment Outcome; Young Adult

Topics: Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Treatment Outcome

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.. To establish GPs' views and experiences of opiate addiction, overdose care, and naloxone provision.. An anonymous postal survey to GPs affiliated with the Department of Academic General Practice, University College Dublin, Ireland.. A total of 714 GPs were invited to complete an anonymous postal survey. Results were compared with a parallel GP trainee survey.. 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 (. 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.

Topics: Drug Overdose; Education, Medical, Graduate; General Practice; Health Knowledge, Attitudes, Practice; Humans; Ireland; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Practice Patterns, Physicians'; Preventive Health Services; Program Development; Program Evaluation

Topics: Cross-Sectional Studies; Drug Overdose; Emergency Service, Hospital; Fentanyl; Florida; Heroin; Humans; Naloxone; Narcotic Antagonists; Retrospective Studies

Topics: Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Outpatients; Practice Guidelines as Topic; United States

Topics: Analgesics, Opioid; Death; Drug Overdose; Humans; Naloxone

Topics: Analgesics, Opioid; Drug Overdose; Emergency Medical Services; Humans; Naloxone; Narcotic Antagonists

Topics: Drug Overdose; Emergency Medical Services; Emergency Treatment; Florida; Humans; Naloxone; Narcotic Antagonists; Practice Guidelines as Topic

Narcan, the nasal-spray form of naloxone, has been approved by the FDA as an easy-to-use version of a drug for saving lives of people who have overdosed on opioids--heroin or prescription painkillers. Communities across the US have been equipping first responders and police with the spray. Now, as the increase in overdose deaths has spread to hospitals, those facilities will have to decide whether their police/security officers should be equipped with. naloxone and trained in its use. In this article, the authors relate their health system's decision, how it was reached, and how it has been implemented.

Topics: Administration, Intranasal; Boston; Decision Making, Organizational; Drug Overdose; Hospitals, Urban; Humans; Inservice Training; Naloxone; Narcotic Antagonists; Narcotics; Nasal Sprays; Police

Topics: Drug Overdose; Health Services Needs and Demand; Humans; Naloxone; Narcotic Antagonists; Substance-Related Disorders; United States

Topics: Analgesics, Opioid; Drug Overdose; Emergency Medical Services; Humans; Information Dissemination; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Public Health; United States

To describe the development, implementation, and preliminary evaluation of Opioid Overdose Response Protocol using intranasal (IN) naloxone in a homeless shelter.. Opioid Overdose Response Protocol and training curriculum were developed using the Massachusetts Department of Public Health Opioid Overdose Education and Naloxone Distribution (OEND) flow chart, the American Heart Association (AHA) simplified adult basic life support algorithm, and resources through Harms Reduction Coalition.. Intranasal naloxone offers a safe and effective method for opioid reversal. To combat the rising incidence of opioid overdose, IN naloxone should be made available at homeless shelters and other facilities with high frequency of opioid overdose, including the training of appropriate staff. This project has demonstrated the effective training and implementation of an Opioid Overdose Response Protocol, based on feedback received from cardiopulmonary resuscitation (CPR) trained nonhealthcare staff. Nurse practitioners (NPs), with our focus on patient care, prevention, and education, are well suited to the deployment of this life-saving protocol.. NPs are in critical positions to integrate opioid overdose prevention education and provide naloxone rescue kits in clinical practices.

Topics: Administration, Intranasal; Ambulatory Care Facilities; Clinical Protocols; Drug Overdose; Humans; Ill-Housed Persons; Naloxone; Narcotics; Program Development; United States

Naloxone is commonly administered in emergency department (ED) to reverse opioid intoxication. Several naloxone dose recommendations exist for acute management of opioid intoxication based on limited published clinical data. A case series of ED patients with opioid-induced ventilatory depression that was reversed using a low-dose naloxone (0.04 mg with titration) is presented.. ED patients with opioid-induced ventilatory depression requiring naloxone administration were identified through medical toxicology consultation. Retrospective review of medical records was performed. Collected data included history, and pre- and post-naloxone data, including respiratory rate (RR), pulse oximetry (pulse ox), end-tidal CO2 level (ET-CO2), and Richmond Agitation Sedation Scale (RASS).. Fifteen ED patients with moderate to severe opioid-induced ventilatory depression (median RR, 6 breaths/min) who were managed using low-dose naloxone strategy were identified. Twelve of 15 patients reported ingestion of methadone (range, 30 to 180 mg). The median naloxone dose of 0.08 mg (range, 0.04 to 0.12 mg) reversed opioid-induced ventilatory and CNS depression. Two patients experienced acute opioid withdrawal after receiving 0.08 mg.. ED patients with moderate to severe opioid-induced ventilatory depression can be reversed using 0.04 mg IV naloxone with appropriate dose titration.

Topics: Adult; Analgesics, Opioid; Antidotes; Drug Overdose; Female; Humans; Lung; Male; Middle Aged; Naloxone; Narcotic Antagonists; Respiration; Respiratory Insufficiency; Retrospective Studies; Severity of Illness Index; Substance Withdrawal Syndrome; Treatment Outcome

Naloxone administration is an important component of resuscitation attempts by emergency medical services (EMS) for opioid drug overdoses. However, EMS providers must first recognize the possibility of opioid overdose in clinical encounters. As part of a public health response to an outbreak of opioid overdoses in Rhode Island, we examined missed opportunities for naloxone administration and factors potentially influencing EMS providers' decision to administer naloxone. We reviewed medical examiner files on all individuals who died of an opioid-related drug overdose in Rhode Island from January 1, 2012 through March 31, 2014, underwent attempted resuscitation by EMS providers, and had records available to assess for naloxone administration. We evaluated whether these individuals received naloxone as part of their resuscitation efforts and compared patient and scene characteristics of those who received naloxone to those who did not receive naloxone via chi-square, t-test, and logistic regression analyses. One hundred and twenty-four individuals who underwent attempted EMS resuscitation died due to opioid overdose. Naloxone was administered during EMS resuscitation attempts in 82 (66.1%) of cases. Females were nearly three-fold as likely not to receive naloxone as males (OR 2.9; 95% CI 1.2-7.0; p-value 0.02). Additionally, patients without signs of potential drug abuse also had a greater than three-fold odds of not receiving naloxone (OR 3.3; 95% CI 1.2-9.2; p-value 0.02). Older individuals, particularly those over age 50, were more likely not to receive naloxone than victims younger than age 30 (OR 4.8; 95% CI 1.3-17.4; p-value 0.02). Women, older individuals, and those patients without clear signs of illicit drug abuse, were less likely to receive naloxone in EMS resuscitation attempts. Heightened clinical suspicion for opioid overdose is important given the recent increase in overdoses among patients due to prescription opioids.

Topics: Adult; Cross-Sectional Studies; Drug Overdose; Emergency Medical Services; Female; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Resuscitation

The purpose of the current study was to assess the effect of opioid overdose prevention training on participants' knowledge about opioid overdose and confidence to recognize and respond to opioid overdose situations as a function of naloxone administration (i.e., injection vs. intranasal spray) and participant type (friend/family, provider, "other").. Opioid overdose prevention trainings were offered throughout a mid-sized metropolitan area in the northeast. Participants (n = 428) were trained to administer naloxone via intramuscular injection (n = 154) or intranasal spray (n = 274). All training participants were given pre-post assessments of knowledge about opioid overdose and confidence to recognize and respond to opioid overdose situations.. Participants' overall knowledge and confidence increased significantly from pre- to post-training (ps < .001). There was no significant association between knowledge and route of administration or participant type. Knowledge significantly increased from pre- to post-training in all participant types (ps < .001). Confidence improved significantly from pre- to post-training across both routes of administration (ps < .001). However, confidence was higher among those who were trained using the intranasal naloxone compared to those who were trained using the intramuscular injection naloxone at pre- (p = .011) and post-training (p < .001). Confidence increased from pre- to post-training in each of the participant types (ps < .001). Post-hoc tests revealed that confidence was higher among providers and friends/family members compared to "other" participants, such as first responders, only at post-training (p < .05).. Opioid overdose trainings are effective in increasing knowledge and confidence related to opioid overdose situations. Findings suggest that trainees are more confident administering naloxone via intranasal spray compared to injection. Future research should attempt to identify other factors that may increase the likelihood of trainees' effectively intervening in opioid overdose situations.

Topics: Administration, Intranasal; Analgesics, Opioid; Drug Overdose; Health Knowledge, Attitudes, Practice; Health Personnel; Humans; Injections, Intramuscular; Naloxone; Narcotic Antagonists; Program Evaluation

Topics: Analgesics, Opioid; Drug Overdose; Feasibility Studies; Humans; Inpatients; Internet; Naloxone; Program Evaluation

Rates of opioid overdose and opioid-related emergency department (ED) visits have increased dramatically. Naloxone is an effective antidote to potentially fatal opioid overdose, but little is known about naloxone administration in ED settings. We examined trends and correlates of naloxone administration in ED visits nationally from 2000 to 2011. Using data from the National Hospital Ambulatory Medical Care Survey, we examined ED visits involving (1) the administration of naloxone or (2) a diagnosis of opioid overdose, abuse, or dependence. We assessed patient characteristics in these visits, including concomitant administration of prescription opioid medications. We used logistic regression to identify correlates of naloxone administration. From 2000 to 2011, naloxone was administered in an estimated 1.7 million adult ED visits nationally; 19 % of these visits recorded a diagnosis of opioid overdose, abuse, or dependence. An estimated 2.9 million adult ED visits were related to opioid overdose, abuse, or dependence; 11 % of these visits involved naloxone administration. In multivariable logistic regression models, patient age, race, and insurance and non-rural facility location were independently associated with naloxone administration. An opioid medication was provided in 14 % of visits involving naloxone administration. Naloxone was administered in a minority of ED visits related to opioid overdose, abuse, or dependence. Among all ED visits involving naloxone administration, prescription opioids were also provided in one in seven visits. Further work should explore the provider decision-making in the management of opioid overdose in ED settings and examine patient outcomes following these visits.

Topics: Adolescent; Adult; Aged; Cross-Sectional Studies; Drug Overdose; Emergency Service, Hospital; Female; Health Care Surveys; Health Transition; Humans; Logistic Models; Male; Middle Aged; Multivariate Analysis; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Practice Patterns, Physicians'; Prescription Drug Overuse; Respiratory Insufficiency; United States; Workforce; Young Adult

In an effort to prevent opioid overdose mortality among Veterans, Department of Veterans Affairs (VA) facilities began implementing opioid overdose education and naloxone distribution (OEND) in 2013 and a national program began in 2014. VA is the first national health care system to implement OEND. The goal of this study is to examine patient perceptions of OEND training and naloxone kits.. Four focus groups were conducted between December 2014 and February 2015 with 21 patients trained in OEND. Participants were recruited from a VA residential facility in California with a substance use disorder treatment program (mandatory OEND training) and a homeless program (optional OEND training). Data were analyzed using matrices and open and closed coding approaches to identify participants' perspectives on OEND training including benefits, concerns, differing opinions, and suggestions for improvement.. Veterans thought OEND training was interesting, novel, and empowering, and that naloxone kits will save lives. Some veterans expressed concern about using syringes in the kits. A few patients who never used opioids were not interested in receiving kits. Veterans had differing opinions about legal and liability issues, whether naloxone kits might contribute to relapse, and whether and how to involve family in training. Some veterans expressed uncertainty about the effects of naloxone. Suggested improvements included active learning approaches, enhanced training materials, and increased advertisement.. OEND training was generally well received among study participants, including those with no indication for a naloxone kit. Patients described a need for OEND and believed it could save lives. Patient feedback on OEND training benefits, concerns, opinions, and suggestions provides important insights to inform future OEND training programs both within VA and in other health care settings. Training is critical to maximizing the potential for OEND to save lives, and this study includes specific suggestions for improving the effectiveness and acceptability of training.

Topics: Adult; Aged; Drug Overdose; Female; Focus Groups; Health Services Accessibility; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Patient Education as Topic; Patient Satisfaction; United States; United States Department of Veterans Affairs; Veterans; Young Adult

Nationally, overdose fatalities have reached epidemic proportions. Ohio has one of the highest overdose death rates in the country, as well as high rates of prescription opioid trafficking.. A cross-sectional self-report survey of opioid overdose prevention programs (OOPPs) in Ohio was conducted between August and October 2014 to characterize programs and ascertain barriers to successful implementation. A 91% response rate was achieved with 18 programs participating in the study.. The first Ohio OOPP opened in August 2012, a second program opened in 2013, and the remaining programs began in 2014. All of the programs distribute nasal naloxone and provide overdose prevention education, and 89% (n = 16) provide overdose kits for free. Six OOPPs are funded by the Ohio Department of Health, 3 programs are funded by a local health foundation, and several other public and private funding sources were reported. The OOPPs have funding to distribute a combined total of 8,670 overdose kits and had distributed 1998 kits by October 2014. The OOPPs reported 149 overdose reversals. Fifteen programs (83%) reported implementation barriers that were categorized as stigma-, cost-, staffing-, legal, regulatory, and client-related problems. Legislative changes aimed at removing some of the obstacles to distribution and lay administration of naloxone have recently been enacted in Ohio.. OOPPs have rapidly expanded in Ohio during the past 3 years. Although recent legislative changes have addressed some of the reported implementation barriers, stigma and the cost of naloxone remain significant problems.

Topics: Analgesics, Opioid; Cross-Sectional Studies; Drug Overdose; Health Services Accessibility; Humans; Naloxone; Narcotic Antagonists; Ohio; Opioid-Related Disorders; Program Development; Program Evaluation

Topics: Administration, Intranasal; Drug Approval; Drug Labeling; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; United States

Fatal opioid overdose is a significant public health concern in the United States. One approach to reducing fatalities is expanding overdose response education to broader audiences. This study examined responses to a web-based overdose education tool.. The results of 422 anonymous surveys submitted on www.stopoverdose.org were analyzed for participant demographics, knowledge of opioid overdose recognition and response, and knowledge of Washington's Good Samaritan overdose law. Characteristics, knowledge, and planned behavior of respondents with professional versus personal interest in overdose education were compared.. Most respondents were age 35 or older (57%) and female (65%). The mean score on the knowledge quiz for overdose recognition and response items was 16.2 out of 18, and 1.5 out of 2 possible points for items concerning the law. Respondents indicating professional interest were significantly more likely to be 35 or older (p = .001) and to have received prior overdose education (p < .001), but less likely to know someone at risk for opioid overdose (p < .001) or report planning to obtain take-home naloxone (p < .001). No significant differences were found in overdose knowledge scores between groups.. Online training may be effective among individuals with professional and personal interest in overdose, as general knowledge scores of overdose response were high among both groups. Lower scores reflecting knowledge of the law suggest that the web-based training may not have adequately presented this information. Overall, results suggest that a web-based platform may be a promising approach to basic overdose education.

Topics: Adolescent; Adult; Analgesics, Opioid; Computer-Assisted Instruction; Drug Overdose; Female; Health Education; Health Knowledge, Attitudes, Practice; Humans; Internet; Law Enforcement; Legislation, Drug; Male; Middle Aged; Naloxone; Narcotic Antagonists; United States; Washington; Young Adult

Topics: Analgesics, Opioid; Drug Approval; Drug Overdose; Heroin; Humans; Naloxone; Narcotic Antagonists; Nasal Sprays; United States; United States Food and Drug Administration

Observers describe today's "epidemic" of pharmaceutical drug abuse as a recent phenomenon, but we argue that it is only the most recent of three waves stretching back more than a century. During each wave, policies have followed a similar pattern: voluntary educational campaigns, followed by supply-side policing and--sometimes--public health responses that would today be understood as "harm reduction." These experiences suggest that only broad-based application of all three approaches to users of all drugs (not just pharmaceutical drugs) can produce a reduction in drug-related harm rather than merely shifting it from one type of drug to another. This has rarely happened because policy has been shaped by the racially charged division of drug users into deserving and morally salvageable victims, or fearsome and morally repugnant criminals.

Topics: Drug Overdose; Epidemics; Harm Reduction; Humans; Naloxone; Opioid-Related Disorders; Prescription Drugs; Public Health Practice

There were over 23,000 opioid overdose deaths in the USA in 2013, and opioid-related mortality is increasing. Increased access to naloxone, particularly through community-based lay naloxone distribution, is a widely supported strategy to reduce opioid overdose mortality; however, little is known about the ecological and spatial patterns of the distribution and utilization of lay naloxone. This study aims to investigate the neighborhood-level correlates and spatial relationships of lay naloxone distribution and utilization and opioid overdose deaths. We determined the locations of lay naloxone distribution sites and the number of unintentional opioid overdose deaths and reported reversal events in San Francisco census tracts (n = 195) from 2010 to 2012. We used Wilcoxon rank-sum tests to compare census tract characteristics across tracts adjacent and not adjacent to distribution sites and multivariable negative binomial regression models to assess the association between census tract characteristics, including distance to the nearest site, and counts of opioid overdose deaths and naloxone reversal events. Three hundred forty-two opioid overdose deaths and 316 overdose reversals with valid location data were included in our analysis. Census tracts including or adjacent to a distribution site had higher income inequality, lower percentage black or African American residents, more drug arrests, higher population density, more overdose deaths, and more reversal events (all p < 0.05). In multivariable analysis, greater distance to the nearest distribution site (up to a distance of 4000 m) was associated with a lower count of Naloxone reversals [incidence rate ratio (IRR) = 0.51 per 500 m increase, 95% CI 0.39-0.67, p < 0.001] but was not significantly associated with opioid overdose deaths. These findings affirm that locating lay naloxone distribution sites in areas with high levels of substance use and overdose risk facilitates reversals of opioid overdoses in those immediate areas but suggests that alternative delivery methods may be necessary to reach individuals in other areas with less concentrated risk.

Topics: Analgesics, Opioid; Drug Overdose; Health Services Accessibility; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Residence Characteristics; San Francisco; Socioeconomic Factors; Spatial Analysis; Urban Health

Develop and internally validate a survey tool to assess emergency department (ED) physician attitudes, clinical practice, and willingness to perform opiate harm reduction (OHR) interventions and to identify barriers and facilitators in translating willingness to action.. This study was an anonymous, Web-based survey based on the Theory of Planned Behavior of ED physicians at three tertiary referral centers. Construction and internal validation of scaled questions was assessed through principal component and Cronbach's alpha analyses. Stepwise linear regression was conducted to measure impact of physician knowledge, attitudes, confidence, and self-efficacy on willingness to perform OHR interventions including opioid overdose education; naloxone prescribing; and referral to naloxone, methadone, and syringe access programs.. A total of 200 of 278 (71.9%) physicians completed the survey. Principal component analysis yielded five components: attitude, confidence, self-efficacy, professional impact factors, and personal impact factors. Overall, respondents were willing to perform OHR interventions, but few actually do. Willingness was correlated with attitude, confidence, and self-efficacy (R(2)  = 0.50); however, overall physicians lacked confidence (mean = 3.06 of 5, 95% confidence interval [CI] = 2.94 to 3.18]). Knowledge, time, training, and institutional support were all prohibitive barriers. Physicians reported that research evidence, professional organization recommendations, and opinions of ED leaders would strongly influence a change in their clinical practice to incorporate OHR interventions (mean = 4.25 of 5, 95% CI = 4.18 to 4.32).. Compared to prior studies, emergency medicine physicians had increased willingness to perform OHR interventions, but there remains a disparity between willingness and clinical practice. Influential factors that may move physicians from "willing" to "doing" include dissemination of supportive research evidence; professional organization endorsement; ED leadership opinion; and addressing time, knowledge, and institutional barriers.

Topics: Adult; Analgesics, Opioid; Attitude of Health Personnel; Drug Overdose; Emergency Service, Hospital; Female; Harm Reduction; Health Knowledge, Attitudes, Practice; Humans; Male; Middle Aged; Naloxone; Narcotic Antagonists; Patient Education as Topic; Physicians; Referral and Consultation; Self Efficacy; Surveys and Questionnaires

Topics: Analgesics, Opioid; Drug Overdose; Education, Medical; Humans; Naloxone; Opioid-Related Disorders; Pain; Risk Reduction Behavior; United States

Take-home naloxone is increasingly provided to prevent heroin overdose deaths. Naloxone 0.4-2.0 mg is licensed for use by injection. Some clinicians supply improvised nasal naloxone kits (outside licensed approval). Is this acceptable?. (1) To consider provision of improvised nasal naloxone in clinical practice and (2) to search for evidence for pharmacokinetics and effectiveness (versus injection).. (1) To document existing nasal naloxone schemes and published evidence of pharmacokinetics (systematic search of the CINAHL, Cochrane, EMBASE and MEDLINE databases and 18 records included in narrative synthesis). (2) To analyse ongoing studies investigating nasal naloxone (WHO International Clinical Trials Registry Platform and US NIH RePORT databases).. (1) Multiple studies report overdose reversals following administration of improvised intranasal naloxone. (2) Overdose reversal after nasal naloxone is frequent but may not always occur. (3) Until late 2015, the only commercially available naloxone concentrations were 0.4 mg/ml and 2 mg/2 ml. Nasal medications are typically 0.05-0.25 ml of fluid per nostril. The only published study of pharmacokinetics and bioavailability finds that nasal naloxone has poor bioavailability. QUESTIONS FOR DEBATE: (1) Why are pharmacokinetics and bioavailability data for nasal naloxone not available before incorporation into standard clinical practice? (2) Does nasal naloxone have the potential to become a reliable clinical formulation? (3) What pre-clinical and clinical studies should precede utilization of novel naloxone formulations as standard emergency medications?. The addictions treatment field has rushed prematurely into the use of improvised nasal naloxone kits. Evidence of adequate bioavailability and acceptable pharmacokinetic curves are vital preliminary steps, especially when effective approved formulations exist.

Topics: Administration, Intranasal; Drug Overdose; Health Policy; Heroin Dependence; Humans; Naloxone; Narcotic Antagonists; Self Care

The aim of the study was to assess potential barriers and challenges to the implementation of take-home naloxone (THN) across ten prisons in one region of England.. Qualitative interviews deploying a grounded theory approach were utilised over a 12- to 18-month period that included an on-going structured dialogue with strategic and operational prison staff from the ten prisons and other key stakeholders (n = 17). Prisoner perceptions were addressed through four purposive focus groups belonging to different establishments (n = 26). Document analysis also included report minutes and access to management information and local performance reports. The data were thematically interpreted using visual mapping techniques.. The distribution and implementation of THN in a prison setting was characterised by significant barriers and challenges. As a result, four main themes were identified: a wide range of negative and confused perceptions of THN amongst prison staff and prisoners; inherent difficulties with the identification and engagement of eligible prisoners; the need to focus on individual prison processes to enhance the effective distribution of THN; and the need for senior prison staff engagement.. The distribution of THN within a custodial setting requires consideration of a number of important factors which are discussed.

Topics: Adult; Attitude of Health Personnel; Drug Overdose; England; Female; Focus Groups; Health Education; Heroin; Humans; Male; Naloxone; Narcotic Antagonists; Narcotics; Prisoners; Prisons; Young Adult

As opioid overdose rates continue to pose a major public health crisis, the need for naloxone treatment by emergency first responders is critical. Little is known about the views of those who administer naloxone. The current study examines attitudes of health professionals on the social media platform Twitter to better understand their perceptions of opioid users, the role of naloxone, and potential training needs.. Public comments on Twitter regarding naloxone were collected for a period of 3 consecutive months. The occupations of individuals who posted tweets were identified through Twitter profiles or hashtags. Categories of emergency service first responders and medical personnel were created. Qualitative analysis using a grounded theory approach was used to produce thematic content. The relationships between occupation and each theme were analyzed using Pearson chi-square statistics and post hoc analyses.. A total of 368 individuals posted 467 naloxone-related tweets. Occupations consisted of professional first responders such as emergency medical technicians (EMTs), firefighters, and paramedics (n = 122); law enforcement officers (n = 70); nurses (n = 62); physicians (n = 48); other health professionals including pharmacists, pharmacy technicians, counselors, and social workers (n = 31); naloxone-trained individuals (n = 12); and students (n = 23). Primary themes included burnout, education and training, information seeking, news updates, optimism, policy and economics, stigma, and treatment. The highest levels of burnout, fatigue, and stigma regarding naloxone and opioid overdose were among nurses, EMTs, other health care providers, and physicians. In contrast, individuals who self-identified as "naloxone-trained" had the highest optimism and the lowest amount of burnout and stigma.. Provider training and refinement of naloxone administration procedures are needed to improve treatment outcomes and reduce provider stigma. Social networking sites such as Twitter may have potential for offering psychoeducation to health care providers.

Topics: Attitude of Health Personnel; Burnout, Professional; Drug Overdose; Emergency Responders; Evaluation Studies as Topic; Humans; Naloxone; Narcotic Antagonists; Opioid-Related Disorders; Social Media; Social Stigma