Engagement in a National Naloxone Programme among people who inject drugs

A study protocol for a European, mixed methods, prospective, cohort study of the effectiveness of naloxone administration by community members, in reversing opioid overdose: NalPORS

BACKGROUND

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.

METHODS

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.

DISCUSSION

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.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05072249. Date of Registration: 8.10.2021.

Sweden's first Take-Home Naloxone program: participant characteristics, dose endpoints and predictors for overdose reversals

BACKGROUND

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.

METHODS

This was a prospective open inclusion cohort study conducted between January 24^th 2018 and March 31^st 2022 at the Stockholm NSP. Participants received THN, free of charge, after a training session and provided data regarding drug use and overdose experiences. During refill visits, participants reported if the naloxone was used for overdose reversal and, if so, responded to a ten-item questionnaire which included stating whether the naloxone recipient was the participant themselves or somebody else. Questionnaire data was combined with NSP database demographic data. Zero-inflated Poisson regression was applied to analyse predictors for number of reported overdose reversals.

RESULTS

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).

CONCLUSIONS

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.

Take-Home Naloxone and the Prevention of Deaths from Heroin Overdose: Pursuing Strong Science, Fuller Understanding, Greater Impact

BACKGROUND AND CONTEXT

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.

KEY MESSAGES

"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.

Take-Home Naloxone Kits: Attitudes and Likelihood-Of-Use Outcomes from a European Survey of Potential Overdose Witnesses

BACKGROUND

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.

OBJECTIVES

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.

METHOD

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.

RESULTS

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).

CONCLUSION

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.

A systematic review and meta-analysis of the prevalence of take-home naloxone (THN) ownership and carriage

BACKGROUND

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).

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Rethinking 'carriage' of take-home naloxone

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).

Rural and small metro area naloxone-dispensing pharmacists' attitudes, experiences, and support for a frontline public health pharmacy role to increase naloxone uptake in New York State, 2019

INTRODUCTION

The purpose of this study is to assess community pharmacists' attitudes and experiences related to naloxone dispensation and counseling in non-urban areas in New York State to better understand individual and structural factors that influence pharmacy provision of naloxone.

MATERIALS AND METHODS

The study conducted interviewer-administered semistructured surveys among community pharmacists in retail, independent, and supermarket pharmacies between October 2019 and December 2019. The 29-item survey ascertained pharmacists' demographic and practice characteristics; experiences and beliefs related to naloxone dispensation; and attitudes toward expansion of pharmacy services to include on-site public health services for persons who use opioids. The study used Chi square tests to determine associations between each characteristic and self-reported naloxone dispensation (any vs. none).

RESULTS

A total of 60 of the 80 community pharmacists that the study team had approached agreed to participate. A majority were supportive of expanding pharmacy-based access to vaccinations (93.3%), on-site HIV testing, or referrals (75% and 96.7%, respectively), providing information on safe syringe use (93.3%) and disposal (98.3%), and referrals to medical/social services (88.3%), specifically substance use treatment (90%). A majority of pharmacist respondents denied negative impacts on business with over half reporting active naloxone dispensation (58.3%). Pharmacists dispensing naloxone were more likely to be multilingual (p < 0.03), and to specifically support on-site HIV testing (p < 0.02) than those who were not dispensing naloxone.

DISCUSSION

Community pharmacists were highly favorable of naloxone dispensation in rural and small metro area pharmacies in NY, and those fluent in additional language(s) and supportive of on-site HIV testing were associated with active naloxone dispensation. While active naloxone dispensation was low, pharmacists appear supportive of a "frontline public health provider" model, which could facilitate naloxone uptake and warrants large-scale investigation.

CONCLUSION

Rural and small metro area pharmacists are generally favorable of naloxone dispensation.

A scoping review of factors that influence opioid overdose prevention for justice-involved populations

Background

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.

Methods

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.

Results

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.

Conclusion

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.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13011-021-00346-1.

Stakeholders' Perceptions of Factors Influencing the Use of Take-Home-Naloxone

Background and Aims: Opioid associated death and overdose is a growing burden in societies all over the world. In recent years, legislative changes have increased access to naloxone in the take-home setting for use by patients with a substance use disorder and bystanders, to prevent opioid overdose deaths. However, few studies have explored the factors influencing the uptake by its multiple stakeholders. The aim of this scoping review was to explore the factors influencing the use of take-home naloxone from the perspectives of different stakeholders. Methods: A scoping review methodology was adopted with a systematic search of databases EMBASE, MEDLINE and PubMed. A variation of the search words “naloxone”, “opioid” and “overdose” were used in each database. The articles were screened according to the predetermined inclusion/exclusion criteria and categorized based on their key perspective or target population. Results: The initial database search yielded a total of 1483 articles. After a series of screening processes, 51 articles were included for analysis. Two key stakeholder perspectives emerged: patients and bystanders (n = 36), and healthcare professionals (n = 15). Within the patient and bystander group, a strong consensus arose that there were positive outcomes from increased access to take-home naloxone and relevant training programs. Despite these positive outcomes, some healthcare professionals were concerned that take-home naloxone would encourage high-risk opioid use. Conclusion: Take-home naloxone is slowly being introduced into community practice, with a sense of enthusiasm from patients and bystanders. There are still a number of barriers that need to be addressed from healthcare professionals’ perspective. Future research should be aimed at emergency care professionals outside of the US, who are most experienced with naloxone and its potential impact on the community.

Protocol for a multi-site study of the effects of overdose prevention education with naloxone distribution program in Skåne County, Sweden

BACKGROUND

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.

METHODS

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.

DISCUSSION

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.

TRIAL REGISTRATION

Naloxone Treatment in Skåne County - Effect on Drug-related Mortality and Overdose-related Complications, NCT03570099, registered on 26 June 2018.

Access and Barriers to Take-Home Naloxone Use among Emergency Department Patients with Opioid Misuse in Baltimore, Maryland, USA

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. Objective: Characterizing the access and barrier to NK use among at-risk ED patients. Methods: We enrolled a convenience sample of ED patients with active opioid misuse from May 21-July 31, 2018. We administered a survey to collect patients' demographic data, substance use history, and access to and use of NK. The primary outcome was NK access (prior receipt of a kit or prescription); secondary outcomes were knowledge and use of NK, and barriers to obtaining and using it. Results: Of 165 respondents, 71.5% knew of THN programs and 57.6% (n = 95) had access to THN by either having received a NK (n = 90) or a prescription (n = 5); 34 respondents received both. Among 39 (23.6%) who received a naloxone prescription, 25 (64.1%) filled it. 60.0% (n = 99) reported knowing how to administer naloxone; lack of training was the primary reason (n = 63/66, 96.9%) for their unfamiliarity. Patients who presented after an opioid overdose (25.5%; n = 42) were less likely to have knowledge of THN programs (57.1% vs. 76.4%), and to have received a NK (35.7% vs. 61.0%). Conclusion: Awareness of THN programs was high among our cohort. But approximately 60% the respondents received a NK or knew how to use it. Despite efforts to expand THN access, gaps in knowledge, access, and use exist.

Designing, implementing and evaluating the overdose response with take-home naloxone model of care: An evaluation of client outcomes and perspectives

INTRODUCTION AND DESIGNS

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.

DESIGN AND METHODS

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.

RESULTS

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).

DISCUSSION AND CONCLUSIONS

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.

Naloxone distribution and possession following a large-scale naloxone programme

AIMS

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.

DESIGN

(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.

SETTING

Seven Norwegian cities.

PARTICIPANTS

A total of 497 recruited users of illegal opioids and/or central stimulants.

MEASUREMENTS

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).

FINDINGS

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).

CONCLUSIONS

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.

"Once I'd done it once it was like writing your name": Lived experience of take-home naloxone administration by people who inject drugs

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Knowledge and possession of take-home naloxone kits among street-involved youth in a Canadian setting: a cohort study

BACKGROUND

The distribution of take-home naloxone (THN) kits has been an important strategy in reducing overdose fatalities among people who use drugs. However, little is known about the use of THN among youth who are street-involved. The present study explores knowledge and possession of THN among street-involved youth in a Canadian setting.

METHODS

Data were derived from the At-Risk Youth Study (ARYS), a prospective cohort of street-involved youth age 14-28 at enrollment in Vancouver, Canada. Participants completed a standardized questionnaire, which included items related to knowledge and possession of THN, sociodemographic characteristics, and substance use-related factors. Multivariable logistic regression models were used to identify factors independently associated with knowledge and possession of THN.

RESULTS

Between December 2014 and November 2016, 177 youth were interviewed, including 68 females (38.4%). While 126 (71.2%) participants reported knowledge of THN, only 40 (22.6%) possessed a THN kit. Caucasian/white ethnicity was found to be positively associated with both knowledge and possession of THN (both p < 0.05). Public injection drug use in the last 6 months was found to be positively associated with knowledge of THN, while daily heroin use and daily methamphetamine use were associated with possession of THN (all p < 0.05). Male gender was negatively associated with possession of THN (p < 0.05).

CONCLUSIONS

These findings highlight important gaps between knowledge and possession of THN among youth and the need to increase participation in THN programs among specific populations including non-white and male youth. Further research is needed to gain a better understanding of the barriers that may prevent certain youth from acquiring THN kits.

Twenty years of take-home naloxone for the prevention of overdose deaths from heroin and other opioids-Conception and maturation

BACKGROUND

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.

METHOD

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

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.

CONCLUSIONS

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.

Awareness, Possession, and Use of Take-Home Naloxone Among Illicit Drug Users, Vancouver, British Columbia, 2014-2015

OBJECTIVES

Although take-home naloxone (THN) programs are integral in strategies to prevent overdose deaths among opioid users, the uptake of THN among people who use drugs (PWUD) (including non-opioid users) is unknown. The objectives of this study were to determine awareness, possession, and use of THN among PWUD in Vancouver, Canada, and identify barriers to adopting this strategy.

METHODS

From December 1, 2014, to May 29, 2015, participants in 2 prospective cohort studies of PWUD in Vancouver completed a standardized questionnaire, which asked about awareness, possession, and use of THN; sociodemographic characteristics; and drug use patterns. We conducted multivariable logistic regression analyses to determine factors independently associated with awareness and possession of THN.

RESULTS

Of 1137 PWUD, 727 (64%) reported at least 1 previous overdose ever, and 220 (19%) had witnessed an overdose in the previous 6 months. Although 769 (68%) participants overall reported awareness of THN, only 88 of 392 (22%) opioid users had a THN kit, 18 (20%) of whom had previously administered naloxone. Factors that were positively associated with awareness of THN included witnessing an overdose in the previous 6 months (adjusted odds ratio [aOR] = 2.23; 95% confidence interval [CI], 1.49-3.34; P < .001), possession of THN (aOR = 1.85; 95% CI, 1.11-3.06; P = .02), younger age (aOR = 1.02; 95% CI, 1.01-1.04; P = .003), white race (aOR = 1.67; 95% CI, 1.27-2.19; P < .001), hepatitis C infection (aOR = 1.63; 95% CI, 1.13-2.36; P = .01), residing in Vancouver's Downtown Eastside neighborhood (aOR = 1.93; 95% CI, 1.47-2.53; P < .001), and at least daily heroin injection (aOR = 1.69; 95% CI, 1.09-2.62; P < .02).

CONCLUSION

Efforts to improve knowledge of and participation in the THN program may contribute to reduced opioid overdose mortality in Vancouver.

The extent of and factors associated with self-reported overdose and self-reported receipt of naloxone among people who inject drugs (PWID) in England, Wales and Northern Ireland

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Scotland's national naloxone program: The prison experience

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.

Randomized controlled pilot trial of naloxone-on-release to prevent post-prison opioid overdose deaths

BACKGROUND AND AIMS

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.

DESIGN

Parallel-group randomized controlled pilot trial.

SETTING

English prisons.

PARTICIPANTS

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.

INTERVENTION

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.

MEASUREMENTS

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%).

FINDINGS

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.

CONCLUSIONS

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.

External data required timely response by the Trial Steering-Data Monitoring Committee for the NALoxone InVEstigation (N-ALIVE) pilot trial

The prison-based N-ALIVE pilot trial had undertaken to notify the Research Ethics Committee and participants if we had reason to believe that the N-ALIVE pilot trial would not proceed to the main trial. In this paper, we describe how external data for the third year of before/after evaluation from Scotland's National Naloxone Programme, a related public health policy, were anticipated by eliciting prior opinion about the Scottish results in the month prior to their release as official statistics. We summarise how deliberations by the N-ALIVE Trial Steering-Data Monitoring Committee (TS-DMC) on N-ALIVE's own interim data, together with those on naloxone-on-release (NOR) from Scotland, led to the decision to cease randomization in the N-ALIVE pilot trial and recommend to local Principal Investigators that NOR be offered to already-randomized prisoners who had not yet been released.

Evaluating the impact of a national naloxone programme on ambulance attendance at overdose incidents: a controlled time-series analysis

BACKGROUND AND AIMS

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?

DESIGN

Controlled time-series analysis.

SETTING

Scotland, UK, 2008-15.

PARTICIPANTS

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).

INTERVENTION

Scotland's NNP; formally implemented on 1 April 2011.

MEASUREMENTS

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.

FINDINGS

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).

CONCLUSIONS

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.