"I wanted to close the chapter completely … and I feel like that [carrying naloxone] would keep it open a little bit": Refusal to carry naloxone among newly-abstinent opioid users and 12-step identity

An interrupted time series analysis of fentanyl, naloxone, and opioid-involved deaths in five counties in Eastern Missouri

INTRODUCTION

Rates of opioid overdose deaths (OOD) have increased since the introduction of illicitly manufactured fentanyl in the U.S. drug supply. Though community-based naloxone distribution efforts have been found to effectively reduce OOD, no studies to date have examined their effects during the fentanyl era, nor in the epicenter of a state's overdose crisis. Thus, the current study assessed the impacts of both fentanyl and of subsequent grant-funded community-based naloxone distribution on OOD across Missouri's St. Louis region.

METHODS

Medical examiner data includes individuals who died within one of the five study counties (St. Louis City, St. Louis County, and Franklin, Jefferson, St. Charles counties [combined as "Collar Counties"]) between 2011 and 2022 due to an opioid overdose (N = 6,799). Naloxone distribution date and location data came from Missouri's university-based naloxone distribution team. We conducted a controlled interrupted time series using an autoregressive model via proc ARIMA to examine changes over time in the rate of OOD associated with the introduction of fentanyl (defined to be present in 25% of opioid overdose deaths; June 2015) and the start of naloxone distribution for each location (August 2017, October 2017, and January 2018, respectively).

RESULTS

The introduction of fentanyl into the drug supply of St. Louis City was associated with an increased rate of OOD over time (p < .001). Naloxone distribution in the City was associated with an immediate decrease in OOD (p < .001) followed by a slowed increase in OOD (p < .001). These findings were not replicated in St. Louis County nor the Collar Counties.

CONCLUSIONS

The effects of fentanyl and naloxone on OOD varied by region in Eastern Missouri. Specifically, fentanyl and naloxone effects were only found in a high-need urban area with existing harm reduction and street outreach programs, but not in surrounding suburban or rural areas. State-level naloxone distribution decision-makers should prioritize funding harm reduction services in both urban and non-urban settings to help increase targeted naloxone distribution to those actively using drugs. Additionally, interventions tailored for people who engage in solitary drug use - such as safe consumption spaces and overdose detection technologies - should receive increased investment and implementation, particularly in rural areas where harm reduction infrastructure is more scarce.

Agent-Based Model of Combined Community- and Jail-Based Take-Home Naloxone Distribution

Importance

Opioid-related overdose accounts for almost 80 000 deaths annually across the US. People who use drugs leaving jails are at particularly high risk for opioid-related overdose and may benefit from take-home naloxone (THN) distribution.

Objective

To estimate the population impact of THN distribution at jail release to reverse opioid-related overdose among people with opioid use disorders.

Design, Setting, and Participants

This study developed the agent-based Justice-Community Circulation Model (JCCM) to model a synthetic population of individuals with and without a history of opioid use. Epidemiological data from 2014 to 2020 for Cook County, Illinois, were used to identify parameters pertinent to the synthetic population. Twenty-seven experimental scenarios were examined to capture diverse strategies of THN distribution and use. Sensitivity analysis was performed to identify critical mediating and moderating variables associated with population impact and a proxy metric for cost-effectiveness (ie, the direct costs of THN kits distributed per death averted). Data were analyzed between February 2022 and March 2024.

Intervention

Modeled interventions included 3 THN distribution channels: community facilities and practitioners; jail, at release; and social network or peers of persons released from jail.

Main Outcomes and Measures

The primary outcome was the percentage of opioid-related overdose deaths averted with THN in the modeled population relative to a baseline scenario with no intervention.

Results

Take-home naloxone distribution at jail release had the highest median (IQR) percentage of averted deaths at 11.70% (6.57%-15.75%). The probability of bystander presence at an opioid overdose showed the greatest proportional contribution (27.15%) to the variance in deaths averted in persons released from jail. The estimated costs of distributed THN kits were less than $15 000 per averted death in all 27 scenarios.

Conclusions and Relevance

This study found that THN distribution at jail release is an economical and feasible approach to substantially reducing opioid-related overdose mortality. Training and preparation of proficient and willing bystanders are central factors in reaching the full potential of this intervention.

Remaking the 'angry Narcanned subject': Affording new subject positions through take-home naloxone training

Naloxone is a medication used to reverse opioid overdose. Alongside its lifesaving effects, it also has a reputation for producing distress, aggression and occasionally violence upon administration. This article analyses how take-home naloxone (THN) training initiatives address naloxone's reputation for producing aggression and conflict, and how new subject positions emerge in the context of this training. While the role of naloxone in producing aggression has been discussed in a range of research, this work emphasises that such conflict is neither inevitable nor even likely because it is contingent on several other issues such as administration practices. Building on this scholarship, we work with Bruno Latour's theorisation of technological 'affordances' to analyse THN as a socially co-produced technology that, rather than either determining or neutrally communicating actions and effects, 'affords' possibilities, capacities and subjects. Analysing data drawn from observations of THN training in Victoria, Australia, and in-depth interviews with training participants, we argue that the issue of conflict upon revival affords a subject position we term the 'angry Narcanned subject'. This subject, we note, has come to hold a powerful position in understandings of naloxone, not least because it tends to accord with stereotypes of antisocial drug users. From here, we argue that a much of THN training is focused on challenging and reframing naloxone's reputation for conflict and questioning related subject positions, especially that of the angry Narcanned subject. We argue that this process of challenging and reframing affords two new subject positions for consumers: the 'capable administrator' and the 'calmer revivee'. We conclude that while THN training affords multiple, potentially positive, subject positions, unless these initiatives are accompanied by broader interventions such as decriminalisation campaigns, they may inadvertently responsibilise people who consume opioids for addressing overdose and erase the role of prohibition, criminalisation and stigmatisation in producing overdose events.

Transformation of identity in substance use as a pathway to recovery and the potential of treatment for hepatitis C: a systematic review

BACKGROUND AND AIM

People who inject drugs are at high risk of contracting hepatitis C (HCV). The introduction of direct acting antiviral (DAA) drugs to treat HCV has the potential to transform care; however, uptake of DAAs has been slower than anticipated. The strong link between HCV and injecting drug use frames HCV as a shameful, stigmatising disease, reinforcing an 'addict' identity. Linking HCV care to a recovery journey, 'clean' identity and social redemption may provide compelling encouragement for people to engage with treatment and re-evaluate risk and behaviours, reducing the incidence of HCV re-infection. The aim of this review was to identify actions, interventions and treatments that provide an opportunity for a change in identity and support a recovery journey and the implications for HCV care.

METHODS

Databases (MEDLINE, EMBASE, PsycINFO, ProQuest Public Health, ProQuest Sociological Abstracts, CINAHL and Web of Science) were searched following our published strategy and a grey literature search conducted. A narrative synthesis was undertaken to collate themes and identify common threads and provide an explanation of the findings.

RESULTS

Thirty-two studies fulfilled the inclusion criteria. The narrative synthesis of the studies identified five over-arching analytical themes: social factors in substance use and recovery, therapeutic communities, community treatment, online communities, and finally women and youth subsets. The change from an 'addict' identity to a 'recovery' identity is described as a key aspect of a recovery journey, and this process can be supported through social support and turning point opportunities.

CONCLUSIONS

Recovery from addiction is a socially mediated process. Actions, interventions and treatments that support a recovery journey provide social connections, a recovery identity and citizenship (reclaiming a place in society). There is a gap in current literature describing how pathways of care with direct acting antivirals can be designed to promote recovery, as part of hepatitis C care.

Individual and social network correlates of responding to multiple overdoses among a cohort of people who use drugs

Background

The purpose of this study was to identify characteristics of people who respond to two or more overdoses (i.e., multiple overdose responders; MOR) compared to those who respond to zero or one, and the association between MOR status and changes in network size.

Methods

Secondary analysis of data from a randomized trial among 199 PWUD in Baltimore, MD (2016-2019). We used cross-tabulation, 𝜒 ² , and ANOVA models to identify cross-sectional associations between overdose response and demographic, drug use, and network size; and ANCOVA models to examine the relationship between baseline MOR status and change in network size.

Results

From the cohort of 199, 185 people provided data on overdose response at baseline; 197 provided data at 6-month follow-up. At baseline, 27.6% of participants were classified as MORs (ever). Correlates of MOR status included homelessness; age; injecting drug use; quality of interactions with police (respectful vs. not); and use of powder cocaine, prescription opioids, and heroin. MORs had larger networks and their network size decreased more over time, but the association was not statistically significant. At follow-up, 16% were classified as MORs (past 6 months); correlates of follow-up MOR status were similar to those at baseline.

Conclusions

Overdose prevention interventions rely on PWUD to respond to overdoses. Identifying factors associated with MOR status could increase intervention efficiency and providing MORs with support could increase sustainability. Our findings suggest that PWUD experiencing homelessness, using cocaine and heroin, and demonstrating increased salience of overdose in their lives would benefit from targeted programs.

Individual and County-Level Disparities in Drug and Opioid Overdose Mortality for Hispanic Men in Massachusetts and the Northeast United States

BACKGROUND

This study aimed to identify individual- and county-level inequalities that may underlie disparities in drug overdose mortality for Hispanic men in Massachusetts and the broader Northeast region.

METHODS

The study first used data from the State Unintentional Drug Overdose Reporting System to compare the 635 Hispanic and 3593 Non-Hispanic (NH) White men who died of unintentional/undetermined opioid-related overdoses in Massachusetts in 2016-2018. Next, the study used 2015-2019 data from the Multiple Cause of Death online platform to: a) compare rates of drug overdose mortality in Hispanic versus NH White men in 54 counties in the Northeast United States; and b) examine associations with inequalities in poverty, educational attainment, unemployment, and uninsurance (from 2015-2019 American Community Survey data).

RESULTS

At the individual level, in Massachusetts, Hispanic and NH White men who died of opioid-related overdose differed in terms of educational attainment, birthplace, urbanicity, substance use disorder treatment history, and specific drugs involved in death. At the county level, in the Northeast region, each one-standard deviation increase in the ratio of the Hispanic to NH White poverty rate was associated with a 27% increase in the ratio of Hispanic to NH White male overdose mortality; each one-standard deviation increase in the ratio of the Hispanic to NH White unemployment rate was associated with a 43% increase in the ratio of Hispanic to NH White male overdose mortality.

CONCLUSIONS

Findings underscore the importance of equitable interventions and efforts to address inequalities in social determinants of health for Hispanic populations in the Northeast.