Barriers to implementation of opioid overdose prevention programs in Ohio

Reducing perceived barriers to scaling up overdose education and naloxone distribution and medications for opioid use disorder in the United States in the HEALing (helping end addiction long-term®) communities study

BACKGROUND

Scaling up overdose education and naloxone distribution (OEND) and medications for opioid use disorder (MOUD) is needed to reduce opioid overdose deaths, but barriers are pervasive. This study examines whether the Communities That HEAL (CTH) intervention reduced perceived barriers to expanding OEND and MOUD in healthcare/behavioral health, criminal-legal, and other/non-traditional venues.

METHODS

The HEALing (Helping End Addiction Long-Term®) Communities Study is a parallel, wait-list, cluster randomized trial testing the CTH intervention in 67 communities in the United States. Surveys administered to coalition members and key stakeholders measured the magnitude of perceived barriers to scaling up OEND and MOUD in November 2019-January 2020, May-June 2021, and May-June 2022. Multilevel linear mixed models compared Wave 1 (intervention) and Wave 2 (wait-list control) respondents. Interactions by rural/urban status and research site were tested.

RESULTS

Wave 1 respondents reported significantly greater reductions in mean scores for three outcomes: perceived barriers to scaling up OEND in Healthcare/Behavioral Health Venues (-0.26, 95% confidence interval, CI: -0.48, -0.05, p = 0.015), OEND in Other/Non-traditional Venues (-0.53, 95% CI: - 0.84, -0.22, p = 0.001) and MOUD in Other/Non-traditional Venues (-0.34, 95% CI: -0.62, -0.05, p = 0.020). There were significant interactions by research site for perceived barriers to scaling up OEND and MOUD in Criminal-Legal Venues. There were no significant interactions by rural/urban status.

DISCUSSION

The CTH Intervention reduced perceived barriers to scaling up OEND and MOUD in certain venues, with no difference in effectiveness between rural and urban communities. More research is needed to understand facilitators and barriers in different venues.

High-risk Individuals and Naloxone Use: Implications for THN Programs in Rural Appalachian Communities

Introduction

Take-home naloxone (THN) is being made available across rural Appalachia to curb opioid overdose fatalities. Despite this initiative, some opioid users do not possess naloxone, and if they do, do not administer it to others.

Purpose

Research findings on risk factors that contribute to opioid overdose are presented. These factors, identified in a sample of 16 overdose cases, are (1) early onset age of opioid use; (2) progressive opioid use; (3) a transition from pain medication to heroin and fentanyl; (4) fears of being arrested at a naloxone intervention if first responders are contacted, and (5) limited knowledge of Good Samaritan Laws.

Methods

The findings are based on a subsample 16 overdose victims who were identified during a one-year (2018) qualitative study on the decline of overdose fatalities in four rural counties in Western Pennsylvania. They were recruited from a larger sample of 50 current and former substance users and were interviewed a second time using a semi-structured interview guide about their overdose experiences. All interview data were analyzed using thematic analysis via NVivo.

Results

Findings reveal that risk factors contribute to a severe opioid dependence that interferes with naloxone use. These factors also hinder adherence to proper naloxone protocol, designed to place overdose victims in contact with treatment providers.

Implications

Recommendations are made for additional research and for pursuing measures to increase efficacy of naloxone interventions. They include developing naloxone campaigns aimed at high-risk individuals, improving their knowledge of Good Samaritan Laws, increasing adherence to THN protocols that improve the possibility of treatment, and using community harm reduction specialists for community outreach.

Scaling up overdose education and naloxone distribution in Kentucky: adoption and reach achieved through a "hub with many spokes" model

BACKGROUND

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).

METHODS

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.

RESULTS

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.

CONCLUSIONS

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 .

Effectiveness of take ACTION online naloxone training for law enforcement officers

BACKGROUND

Training law enforcement officers (LEOs) to administer naloxone is a recommended strategy to reduce overdose deaths in the United States. To achieve this, an evidence-based and scalable naloxone training curriculum that is easy to use and readily scalable is needed. Convenient web-based training is a flexible method for delivering educational interventions particularly for LEOs who have irregular or shifting schedules. This study examined the effectiveness of a comprehensive web-based naloxone training that was created in partnership with LEOs on their knowledge, confidence, and attitudes regarding naloxone.

METHODS

From May 2019 to September 2020, five law enforcement departments from Michigan participated in web-based naloxone training. A total of 182 LEOs (77% male) were in the final sample based on matching pre-and post-test surveys. LEOs were assessed on knowledge, confidence, and attitudes towards naloxone. Negative binomial and Poisson regression was conducted to assess associations between knowledge, confidence, and attitudes towards naloxone before and after training.

RESULTS

Significant improvements in overdose knowledge and confidence were revealed across all departments with median (IQR) total composite scores for knowledge increasing from 35 (32, 37) to 40 (39, 42) (p < 0.01) and confidence increasing from 18.5 (15, 20) to 20 (20, 25) (p < 0.01). Median (IQR) attitude scores did not change.

CONCLUSION

Our web-based naloxone training was effective in improving knowledge and confidence for LEOs but did not significantly improve LEOs attitudes towards naloxone across most departments. The web-based format is readily scalable and quickly disseminated and meets the immediate need for LEO overdose training. Additional intervention is needed to address the negative attitudes of LEOs regarding naloxone.

Feasibility and acceptability of online opioid overdose education and naloxone distribution: Study protocol and preliminary results from a randomized pilot clinical trial

Drug overdose is the leading cause of accidental death in the United States, with over 70% of drug related fatalities resulting from the use of opioids. Federal agencies have responded to this crisis with various recommendations including enhancing harm reduction approaches such as training laypersons to administer naloxone through Opioid Overdose Education and Naloxone Distribution (OEND) programs. Several studies have demonstrated that OEND programs effectively reduce opioid overdose mortality and are both safe and cost-effective, however, they are typically implemented in urban areas as part of large medical center research programs, needle exchanges, or drug treatment programs. Individuals living in areas without these programs or services lack access to critical and life-saving OEND. The current study examined the acceptability and feasibility of online recruitment, online opioid overdose education, and remote distribution of naloxone kits. Persons who illicitly use opioids and are at risk for overdose were recruited through online media and completed an opioid use questionnaire. If interested in receiving opioid overdose and naloxone administration training, participants completed pre- and post-intervention knowledge questionnaires, engaged in audiovisual training, and were randomized to either receive a naloxone kit or be given information on where they could obtain one. Preliminary results indicate feasibility and acceptability as evidenced by strong recruitment and retention, as well as high participant satisfaction ratings. Successful implementation of remote OEND through this project supports future employment of similar remote programs to expand this critical harm reduction strategy to high-risk individuals in areas lacking traditional OEND programs.

Trial Registration #

Clinitaltrials.gov- NCT04303000.

How do contextual factors influence naloxone distribution from syringe service programs in the USA: a cross-sectional study

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Opioid-involved overdose trainings delivered using remote learning modalities

AIM

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.

DESIGN

This pre-post study examined learning outcomes among 17 nursing students.

METHODS

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.

RESULTS

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.

CONCLUSIONS

These hypothesis generating results illustrate the utility of remote learning approaches to deliver trainings, while maintaining social distance during the ongoing COVID-19 pandemic.

Knowledge, attitudes, and behaviors related to the fentanyl-adulterated drug supply among people who use drugs in Oregon

INTRODUCTION

Nonpharmaceutical fentanyl has reconfigured the U.S. illicit drug market, contributing to a drastic increase in overdose drug deaths. While illicit fentanyl has subsumed the drug supply in the Northeast and Midwest, it has more recently reached the West. For this study, we explored knowledge, attitudes, and behaviors among people who use drugs in Oregon in the context of the emergence of fentanyl in the drug supply.

METHODS

We conducted in-depth interviews by phone with 34 people who use drugs in Oregon from May to June 2021. We used thematic analysis to analyze transcripts and construct themes.

RESULTS

People who use drugs knew about fentanyl, expressed doubt that fentanyl could be found in methamphetamine; believed those who were younger or less experienced were at higher risk for harm; and received information about fentanyl from drug dealers, syringe service programs, or peers (other people who use drugs). Preference for fentanyl's presence in drugs like heroin or methamphetamine was mixed. Some felt that their preference was irrelevant since fentanyl was unavoidable. Participants reported engaging in harm reduction practices, including communicating about fentanyl with dealers and peers, testing for fentanyl, using smaller quantities of drugs, switching from injecting to smoking, and using naloxone.

CONCLUSION

People who use drugs are responding to the rise of fentanyl on the West Coast and are concerned about the increasing uncertainty and hazards of the drug supply. They are willing and motivated to adopt harm reduction behaviors. Harm reduction promotion from syringe service programs and public health agencies is essential to reduce injury and death from nonpharmaceutical fentanyl.

Technology-assisted opioid education for out-of-treatment adults with opioid use disorder

OBJECTIVE

To evaluate the feasibility and potential efficacy of a technology-assisted education program in teaching adults at a high risk of opioid overdose about opioids; opioid overdose; and opioid use disorder medications.

METHOD

A within-subject, repeated-measures design was used to evaluate effects of the novel technology-assisted education program. Participants (N = 40) were out-of-treatment adults with opioid use disorder, recruited in Baltimore, Maryland from May 2019 to January 2020. The education program was self-paced and contained three courses. Each course presented information and required answers to multiple-choice questions. The education program was evaluated using a 50-item test, delivered before and after participants completed each course. Tests were divided into three subtests that contained questions from each course. We measured accuracy on each subtest before and after completion of each course and used a mixed-effects model to analyze changes in accuracy across tests.

RESULTS

The technology-assisted education program required a median time of 91 min of activity to complete. Most participants completed the program in a single day. Accuracy on each subtest increased only after completion of the course that corresponded to that subtest, and learning comparisons were significant at the p < .001 level for all subtests. Accuracy on each subtest was unchanged before completion of the relevant course, and increases in accuracy were retained across subsequent tests. Learning occurred similarly independent of participant education, employment, and poverty.

CONCLUSIONS

Technology-assisted education programs can provide at-risk adults with access to effective education on opioids, opioid overdose, and opioid use disorder medications. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Who is using take-home naloxone? An examination of supersavers

Background

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.

Methods

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.

Results

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).

Conclusions

THN programs should continue to emphasize and prioritize THN for people actively using drugs, particularly those who have witnessed overdoses previously.

Costs of opioid overdose education and naloxone distribution in New York City

Background: Naloxone is an opioid antagonist medication that can be administered by lay people or medical professionals to reverse opioid overdoses and reduce overdose mortality. Cost was identified as a potential barrier to providing expanded overdose education and naloxone distribution (OEND) in New York City (NYC) in 2017. We estimated the cost of delivering OEND for different types of opioid overdose prevention programs (OOPPs) in NYC. Methods: We interviewed naloxone coordinators at 11 syringe service programs (SSPs) and 10 purposively sampled non-SSPs in NYC from December 2017 to September 2019. The samples included diverse non-SSP program types, program sizes, and OEND funding sources. We calculated one-time start up costs and ongoing operating costs using micro-costing methods to estimate the cost of personnel time and materials for OEND activities from the program perspective, but excluding naloxone kit costs. Results: Implementing an OEND program required a one-time median startup cost of $874 for SSPs and $2,548 for other programs excluding overhead, with 80% of those costs attributed to time and travel for training staff. SSPs spent a median of $90 per staff member trained and non-SSPs spent $150 per staff member. The median monthly cost of OEND program activities excluding overhead was $1,579 for SSPs and $2,529 for non-SSPs. The costs for non-SSPs varied by size, with larger, multi-site programs having higher median costs compared to single-site programs. The estimated median cost per kit dispensed excluding and including overhead was $19 versus $25 per kit for SSPs, and $36 versus $43 per kit for non-SSPs, respectively. Conclusions: OEND operating costs vary by program type and number of sites. Funders should consider that providing free naloxone to OEND programs does not cover full operating costs. Further exploration of cost-effectiveness and program efficiency should be considered across different types of OEND settings.

UNDERSTANDING PREFERENCES FOR TYPE OF TAKE-HOME NALOXONE DEVICE: INTERNATIONAL QUALITATIVE ANALYSIS OF THE VIEWS OF PEOPLE WHO USE OPIOIDS

Background

Take-home naloxone (THN) is provided to non-medically trained people to reverse potential opioid overdoses. There is an increasing range of effective intramuscular (IM) and intranasal (IN) naloxone devices and this paper explores the types preferred by people who use opioids, using consumer behaviour literature to interpret the findings.

Methods

Data derive from two unconnected qualitative studies involving audio-recorded semi-structured interviews. Study 1 was conducted in the United States (n=21 users of non-medical/illicit opioids). Study 2 was conducted in Australia (n=42 users of non-medical/illicit or prescribed opioids).

Findings

Most participants preferred IN naloxone. Preferences were based on the ease, speed, safety and comfort of each device and underpinned by accounts of overdose revivals as being very rushed and frightening situations. Preferences related to complex interactions between the naloxone device ('product'); the knowledge, skills, experience and attitudes of the lay responder ('consumer'), and when, where and how naloxone was to be used ('usage situation').

Conclusions

THN programs should offer choice of device when possible and nasal naloxone if resources permit. Asking people which devices they prefer and why and treating them as valued consumers of naloxone products can generate insights that improve future naloxone technology and increase THN uptake and usage.

Bridging institutional logics: Implementing naloxone distribution for people exiting jail in three California counties

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.

Beyond effectiveness of the Strengthening Families Program (10-14): a scoping RE-AIM-based review

A scoping review, based on the RE-AIM framework, was conducted to analyze evidence of reach, effectiveness, adoption, implementation, and maintenance of the Strengthening Families Program (10-14), a preventive family-based substance abuse program for adolescents. Sixty-five articles were included. The results disclosed that effectiveness, implementation, and maintenance at the individual-level were the most evaluated aspects, while reach, maintenance at the setting-level, and adoption were the least investigated aspects. Positive effects on drug abuse prevention and protective parenting factors were found in the U.S. studies. Likewise, Latin American studies have shown the improvement of parenting practices. However, European studies have produced mixed results, with predominantly null effects on substance abuse. The implementation quality was high. There is no available evidence of adoption and maintenance at the setting-level by the organizations that implemented it. New studies must examine the reach, adoption, and sustainability of the program to lay foundations for its future use as an instrument of public policies.

Community pharmacists in Virginia dispensing naloxone under a standing order: A qualitative study

BACKGROUND

In 2016, the Virginia Health Commissioner signed a standing order into law allowing licensed pharmacists to dispense opioid receptor antagonists (ORAs) for overdose reversal.

OBJECTIVES

Using the theory of planned behavior as an initial guide to study development, the aim of this qualitative study was to explore community pharmacists' attitudes, subjective norm, perceived behavioral control, and behavioral intention toward dispensing ORAs under a standing order in Virginia.

METHODS

Semi-structured interviews were conducted with community pharmacists across the Commonwealth between June 2018 and October 2019. Interviews were recorded, transcribed verbatim, and thematically analyzed.

RESULTS

Twenty-one community pharmacists were interviewed. Pharmacists were confused about the specifics and the processes involved with dispensing naloxone under the standing order. Furthermore, many recognized the underuse of the standing order. Positive attitudes focused on the life-saving action of ORAs. Negative attitudes included encouraging risky behaviors by patients, negatively affecting the patient-pharmacist relationship, offending or contributing to stigmatizing patrons, and having liability issues to the pharmacy. Subjective norms regarding dispensing of ORAs under the standing order were perceived to be favorable among peer pharmacists and primary care and emergency department physicians but may be seen as profit-seeking by patients. Barriers to service provision included lack of guidance from corporate offices (in chain pharmacies), inadequate training, patient out-of-pocket costs, reimbursement issues, inadequate staffing and time, and stigma. Facilitators comprised the existence of practice site-specific protocols, the REVIVE! training, technician support, increased community awareness, physician collaboration, pharmacist training, and employer guidance. Whereas some pharmacists intended to become more familiarized with the standing order, others did not intend to actively identify patients who were at risk of an opioid overdose.

CONCLUSION

Pharmacists expressed mixed behavioral intention toward dispensing ORAs under the standing order. Future research should focus on quantifying the uptake of the standing order at the state level.

Opioid Treatment Deserts: Concept development and application in a US Midwestern urban county

Objectives

An Opioid Treatment Desert is an area with limited accessibility to medication-assisted treatment and recovery facilities for Opioid Use Disorder. We explored the concept of Opioid Treatment Deserts including racial differences in potential spatial accessibility and applied it to one Midwestern urban county using high resolution spatiotemporal data.

Methods

We obtained individual-level data from one Emergency Medical Services (EMS) agency (Columbus Fire Department) in Franklin County, Ohio. Opioid overdose events were based on EMS runs where naloxone was administered from 1/1/2013 to 12/31/2017. Potential spatial accessibility was measured as the time (in minutes) it would take an individual, who may decide to seek treatment after an opioid overdose, to travel from where they had the overdose event, which was a proxy measure of their residential location, to the nearest opioid use disorder (OUD) treatment provider that provided medically-assisted treatment (MAT). We estimated accessibility measures overall, by race and by four types of treatment providers (any type of MAT for OUD, Buprenorphine, Methadone, or Naltrexone). Areas were classified as an Opioid Treatment Desert if the estimate travel time to treatment provider (any type of MAT for OUD) was greater than a given threshold. We performed sensitivity analysis using a range of threshold values based on multiple modes of transportation (car and public transit) and using only EMS runs to home/residential location types.

Results

A total of 6,929 geocoded opioid overdose events based on data from EMS agencies were used in the final analysis. Most events occurred among 26–35 years old (34%), identified as White adults (56%) and male (62%). Median travel times and interquartile range (IQR) to closest treatment provider by car and public transit was 2 minutes (IQR: 3 minutes) and 17 minutes (IQR: 17 minutes), respectively. Several neighborhoods in the study area had limited accessibility to OUD treatment facilities and were classified as Opioid Treatment Deserts. Travel time by public transit for most treatment provider types and by car for Methadone-based treatment was significantly different between individuals who were identified as Black adults and White adults based on their race.

Conclusions

Disparities in access to opioid treatment exist at the sub-county level in specific neighborhoods and across racial groups in Columbus, Ohio and can be quantified and visualized using local public safety data (e.g., EMS runs). Identification of Opioid Treatment Deserts can aid multiple stakeholders better plan and allocate resources for more equitable access to MAT for OUD and, therefore, reduce the burden of the opioid epidemic while making better use of real-time public safety data to address a public health epidemic that has turned into a public safety crisis.

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.

Challenges and Facilitators of Implementing a Physician-approved Naloxone Protocol: A Mixed-methods Study

OBJECTIVES

In 2015, the State of Ohio passed legislation to allow pharmacists to dispense naloxone under a physician-approved protocol. The legislation allows all individuals authorized under a physician-approved protocol to personally furnish naloxone without requiring clients to be seen by a licensed prescriber, thus expanding the capacity of Ohio's community distribution programs. We aimed to evaluate the implementation of legislation allowing for a physician-approved protocol in pharmacies and other naloxone distribution sites in Ohio, and to compare barriers and facilitators of implementing the law changes among sites that implemented a physician-approved protocol versus sites that did not.

METHODS

The study used a convergent parallel mixed-method design. Random samples from all pharmacies registered with the State of Ohio Board of Pharmacy and community naloxone distribution sites were selected. Quantitative data were collected via survey (n = 168) and qualitative data were collected via semi-structured interviews (n = 17).

RESULTS

Most survey respondents agreed that the policy has expanded access to naloxone at their site for individuals who want or need the medication. Both pharmacies and other naloxone distribution sites identified that leadership and organizational support facilitated protocol implementation and cost, stigma, and lack of naloxone demand challenged protocol implementation.

CONCLUSIONS

The study identified barriers and facilitators to the implementation of a physician-approved protocol within Ohio. The majority of respondents stated they could implement a protocol. However, barriers of cost, lack of public awareness of naloxone availability, and stigma remain for pharmacies and other naloxone distribution sites.

Community Case Study of Naloxone Distribution by Hospital-Based Harm Reduction Program for People Who Use Drugs in New York City

Background: In 2017, The Respectful and Equitable Access to Comprehensive Healthcare (REACH) Program at Mount Sinai Hospital became a registered Opioid Overdose Prevention Program (OOPP) and received funding from the New York City Department of Health and Mental Hygiene to develop a program to provide overdose education and naloxone distribution (OEND) training to at risk population and bystanders. We report on the programmatic quality improvement initiatives conducted. Methods: From April 2017 to December 2020, the REACH OOPP conducted 290 opioid overdose reversal trainings, throughout the Mount Sinai Health System and in multiple other community settings. OEND training was at times offered alone and in other settings alongside Hepatitis C Virus point of care testing. Additionally, a "train the trainer" model was implemented whereby medical students and nurses at outpatient clinics were trained to train others. Results: There were 4235 naloxone kits distributed to 3,906 participants. The training venues included hospital settings (patients and medical staff), public events, substance use programs, educational facilities, homeless prevention programs, faith-based organizations, alternative to incarceration programs, and community-based organizations. We implemented two types of training. During outreach sessions, we utilized one-on-one personalized sessions to train bystanders. When training clinic staff in the "train the trainer" model we utilized a standardized didactic presentation with slides. The two top reasons participants reported for being trained were "Just in case I see someone overdose" (59.3%) and "I'm worried that someone I know will overdose OR that I will overdose" (20.2%). Conclusion: The REACH program at Mount Sinai Hospital developed an effective model to train community bystanders and health care staff by leveraging administrative support and building on broader programmatic initiatives to promote drug user health and stigma-free care for people who use drugs. Hospitals do not currently mandate staff training or keeping naloxone stocked at inpatient units or outpatients clinics posing a challenge when implementing an OEND program in this setting. A recommended policy change needed to decrease overdose deaths is for hospitals to be required to implement systematic naloxone education and access for all health care personal and at risk patients.

Using the behaviour change wheel to understand and address barriers to pharmacy naloxone supply in Australia

BACKGROUND

There has been low community pharmacy-based naloxone supply in Australia despite its over-the-counter status. The Behaviour Change Wheel (BCW) is a method used to understand individual and system-level barriers and facilitators to a particular behaviour to inform program implementation. The BCW is focused on three essential conditions of behaviour change (capability, opportunity, and motivation (termed the COM-B)) which we use to assess pharmacists perceptions and experiences of naloxone provision with the aim of using informing targets for interventions to improve naloxone distribution.

METHOD

Qualitative interviews with community pharmacists (n = 37) from four Australian jurisdictions explored naloxone knowledge, expectations and experiences dispensing the medicine. Audio-recorded interviews were transcribed verbatim and coded against the a priori domains in the COM-B (capability, opportunity, and motivation). Results were analysed to identify key barriers and facilitators to naloxone provision within each domain. Finally, we mapped our analysis against the intervention functions and policy-level strategies provided in the BCW to identify example intervention strategies.

RESULTS

Underlying all pharmacists' descriptions of naloxone were structural impediments to dispensing including poor communication regarding pharmacists' role and disrupted supply chains. Mapped across the three COM-B domains, we find two divergent groups of pharmacists. Pharmacists' capability and motivation to supply naloxone was higher amongst those who did not problematize people who inject drugs and who worked in pharmacies already supplying harm reduction services. Pharmacists were less likely to discuss capabilities and opportunities for naloxone dispensing when harm reduction was not normalised in their workplace and/or they described people who inject drugs using negative and stigmatising language.

CONCLUSIONS

Analysis using the COM-B framework reveals key areas where implementation and policy strategies are needed to increase naloxone supply. Individual- and structural-level supports are needed to improve pharmacists' knowledge of naloxone and address other logistical and cultural barriers that limit naloxone provision in pharmacy settings.

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.

Facilitators, barriers and lessons learnt from the first state-wide naloxone distribution conducted in West Virginia

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Factors associated with withdrawal symptoms and anger among people resuscitated from an opioid overdose by take-home naloxone: Exploratory mixed methods analysis

INTRODUCTION

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.

AIM

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Recognition and stigma of prescription drug abuse disorder: personal and community determinants

BACKGROUND

Prescription drug abuse (PDA) disorders continue to contribute to the current American opioid crisis. Within this context, our study seeks to improve understanding about stigma associated with, and symptom recognition of, prescription drug abuse.

AIMS

Model the stigma and symptom recognition of PDA in the general population.

METHODS

A randomized, nation-wide, online, vignette-focused survey of the general public (N = 631) was implemented with an oversample for rural counties. Logit estimation was used for analysis, with regional and county-level sociodemographic variables as controls.

RESULTS

Individual respondents that self-identify as having or having had "a prescription drug abuse issue" were less likely to correctly identify the condition and were 4 times more likely to exhibit stigma. Male respondents were approximately half as likely to correctly identify PDA as female respondents while older respondents (55+) were more likely to correctly identify PDA, relative to those aged 35-54. Being both male and younger was associated with slightly more stigma, in that they were less likely to disagree with the stigma statement.

CONCLUSIONS

In light of the continued risks that individuals with PDA behaviors face in potentially transitioning to illicit opioid use, the findings of this survey suggested a continued need for public education and outreach. Of particular note is the perspective of those who have self-identified with the condition, as this population faces the largest risks of adverse health outcomes from illicit drug use within the survey respondents.

The Bell Tolls for Thee & Thine: Compassion Fatigue & the Overdose Epidemic

Non-fatal and fatal overdoses are traumatic events that have been increasing over the past 20 years and disproportionately impacting rural communities in the United States. The human suffering caused by the opioid epidemic is rarely described in the empirical literature. The purpose of this article is to 1) define individual- and community-level overdose-related compassion fatigue (OCF), 2) review measurement of compassion fatigue (CF) and interventions to reduce CF, 3) discuss strategies that may reduce OCF and 4) briefly discuss policy implications. OCF is distress resulting from knowledge of or exposure to overdose-related harms, which at the community-level may prohibit collaboration and adaptive agency to effectively respond. When OCF occurs at a community-level, it could have negative consequences by eroding support for evidence-based services and fueling stigma-driven policies that blame people who use drugs. Empathy underlies both OCF and vicarious resilience by allowing one to understand the suffering caused by overdose deaths and to witness the joy of addiction recovery. Using the risk environment framework, OCF at the micro- and macro-levels of the social environment, may increase rural communities' vulnerability to harm by emphasizing individual responsibility for reducing overdoses rather than community-level infrastructure and resource management. Additional research is needed to develop a measure of OCF and to confirm whether OCF is associated with increased stigma and decreased support for harm reduction in rural areas.

Barriers to and recommendations for take-home naloxone distribution: perspectives from opioid treatment programs in New Mexico

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Variations in the California Emergency Medical Services Response to Opioid Use Disorder

Introduction

Opioids contributed to over 300,000 deaths in the United States in the past 10 years. Most research on drug use occurs in clinics or hospitals; few studies have evaluated the impact of opioid use on emergency medical services (EMS) or the EMS response to opioid use disorder (OUD). This study describes the perceived burden of disease, data collection, and interventions in California local EMS agencies (LEMSA).

Methods

We surveyed medical directors of all 33 California LEMSAs with 25 multiple-choice and free-answer questions. Results were collected in RedCap and downloaded into Excel (Microsoft Corporation, Redmond WA). This study was exempt from review by the Alameda Health System - Highland Hospital Institutional Review Board.

Results

Of the 33 California LEMSAs, 100% responded, all indicating that OUD significantly affects their patients. Most (91%) had specific protocols directing care of those patients and repeat naloxone dosing. After naloxone administration, none permitted release to law enforcement custody, 6% permitted patient refusal of care, and 45% directed base hospital contact for refusal of care. Few protocols directed screening or treatment of OUD or withdrawal symptoms. Regular data collection occurred in 76% of LEMSAs, with only 48% linking EMS data with hospital or coroner outcomes. In only 30% did the medical director oversee regular quality improvement meetings. Of respondents, 64% were aware of public health agency-based outreach programs and 42% were aware of emergency department BRIDGE programs (Medication Assisted Treatment and immediate referral). Only 9% oversaw naloxone kit distribution (all under the medical director), and 6% had EMS-based outreach programs. In almost all (94%), law enforcement officers carried naloxone and administered it anywhere from a few times a year to greater than 200 in one LEMSA.

Conclusion

This study represents an important description of EMS medical directors’ approaches to the impact of OUD as well as trends in protocols and interventions to treat and prevent overdoses. Through this study, we can better understand the variable response to patients with OUD across California.

Understanding Naloxone Uptake from an Emergency Department Distribution Program Using a Low-Energy Bluetooth Real-time Location System

INTRODUCTION

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Endogenous opiates and behavior: 2017

This paper is the fortieth consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2017 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

Take-Home Naloxone for the Emergency Interim Management of Opioid Overdose: The Public Health Application of an Emergency Medicine

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.

Barriers to naloxone use and acceptance among opioid users, first responders, and emergency department providers in New Hampshire, USA

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Opioid Overdose Knowledge among College Students in a High Overdose Death State

PURPOSE

The goal of this study was to investigate university students' knowledge about identification of opioid overdose and actions to take in an overdose emergency.

METHODS

A cross-sectional, anonymous, 36-item survey was developed and administered to West Virginia University (WVU) students. Overdose knowledge was assessed using the Opioid Overdose Knowledge Scale (OOKS). Demographic information, health insurance coverage status, previously receiving an opioid prescription, and knowledge about West Virginia Good Samaritan laws were also collected. Online survey responses were collected via REDCap.

RESULTS

The study sample (n=214) was 90% white, 72.5% female, had a mean age of 24.8 years, and over half previously received a prescription opioid (51.9%). Additionally, 6.5% reported witnessing an overdose in the past year, and 15.9% previously received naloxone training. Overall, our participants had an average score of 30.9 out of 45 on the OOKS. Participants who previously received naloxone training scored higher overall on the OOKS than participants who did not (p<0.001). Similarly, participants who previously received a prescription for an opioid also scored higher than participants who had never had a previous prescription for an opioid (p<0.001).

CONCLUSIONS

University students' knowledge suggests that previous exposure to opioid prescriptions and naloxone training increase a student's knowledge about opioid overdose. This information is not surprising; however, this does make the case that students may benefit from brief overdose education programs that could be implemented across university health education curricula. However, a larger effort may need to be implemented to encourage students to participate in such programs.

A Dissemination and Implementation Science Approach to the Epidemic of Opioid Use Disorder in the United States

PURPOSE OF REVIEW

This review aims to (1) conceptualize the complexity of the opioid use disorder epidemic using a conceptual model grounded in the disease continuum and corresponding levels of prevention and (2) summarize a select set of interventions for the prevention and treatment of opioid use disorder.

RECENT FINDINGS

Epidemiologic data indicate non-medical prescription and illicit opioid use have reached unprecedented levels, fueling an opioid use disorder epidemic in the USA. A problem of this magnitude is rooted in multiple supply- and demand-side drivers, the combined effect of which outweighs current prevention and treatment efforts. Multiple primary, secondary, and tertiary prevention interventions, both evidence-informed and evidence-based, are available to address each point along the disease continuum-non-use, initiation, dependence, addiction, and death. If interventions grounded in the best available evidence are disseminated and implemented across the disease continuum in a coordinated and collaborative manner, public health systems could be increasingly effective in responding to the epidemic.

How competent are people who use opioids at responding to overdoses? Qualitative analyses of actions and decisions taken during overdose emergencies

BACKGROUND AND AIMS

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.

DESIGN

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.

SETTING

New York City, USA.

PARTICIPANTS

Thirty-nine people who used opioids (32 men, 7 women; aged 22-58 years).

INTERVENTION

Trial participants received brief or extended overdose training and injectable or nasal naloxone.

MEASUREMENTS

The systematic coding frame comprised deductive codes based on the topic guide and more inductive codes emerging from the data.

FINDINGS

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.

CONCLUSIONS

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).

The relationship between parental heavy drinking and non-fatal overdose among people who inject drugs in Vancouver, Canada

BACKGROUND

Despite the acute drug-related and behavioural risk factors for experiencing a drug overdose, few remote childhood experiences have been examined as risk factors for subsequent later life overdose risk. Parental heavy drinking has been associated with some later life negative outcomes, but little is known regarding the impact on drug overdoses, especially among people who inject drugs. Given the current overdose crisis in North America, we sought to evaluate the impact of parental heavy drinking on later life non-fatal overdose among people who inject drugs in Vancouver, Canada.

METHODS

Data were derived from two prospective cohort studies of community-recruited people who inject drugs in Vancouver between December 2012 and May 2016. We employed multivariable generalized estimating equations to examine the relationship between parental heavy drinking and non-fatal overdose in the past six months.

RESULTS

Among 327 eligible participants, 111 (33.9%) reported parental heavy drinking and 95 (29.1%) reported a non-fatal overdose at least once during the study period. In a multivariable analysis, experiencing parental heavy drinking remained independently associated with non-fatal overdose (adjusted odds ratio: 1.69; 95% confidence interval: 1.07-2.66) after adjustment for a range of socio-demographic and drug using confounders.

CONCLUSIONS

These findings suggest long-term negative impacts of parental heavy drinking, on subsequent risk taking or other mechanisms associated with overdose. Current overdose prevention efforts may benefit from the evaluation of life course vulnerabilities that may be amenable to earlier interventions.

Naloxone Distribution and Training for Patients with High-Risk Opioid Use in a Veterans Affairs Community-Based Primary Care Clinic

CONTEXT

Naloxone distribution has historically been implemented in a community-based, expanded public health model; however, there is now a need to further explore primary care clinic-based naloxone delivery to effectively address the nationwide opioid epidemic.

OBJECTIVE

To create a general medicine infrastructure to identify patients with high-risk opioid use and provide 25% of this population with naloxone autoinjector prescription and training within a 6-month period.

DESIGN

The quality improvement study was conducted at an outpatient clinic serving 1238 marginally housed veterans with high rates of comorbid substance use and mental health disorders. Patients at high risk of opioid-related adverse events were identified using the Stratification Tool for Opioid Risk Management and were contacted to participate in a one-on-one, 15-minute, hands-on naloxone training led by nursing staff.

MAIN OUTCOME MEASURES

The number of patients identified at high risk and rates of naloxone training/distribution.

RESULTS

There were 67 patients identified as having high-risk opioid use. None of these patients had been prescribed naloxone at baseline. At the end of the intervention, 61 patients (91%) had been trained in the use of naloxone. Naloxone was primarily distributed by licensed vocational nurses (42/61, 69%).

CONCLUSION

This study demonstrates the feasibility of high-risk patient identification and of a primary care-based and nursing-championed naloxone distribution model. This delivery model has the potential to provide access to naloxone to a population of patients with opioid use who may not be engaged in mental health or specialty care.

Polydrug use among heroin users in Cleveland, OH

BACKGROUND

Since 2000, heroin use patterns have shifted within the United States. How this change may relate to polydrug use among local heroin users is unknown. Although polydrug use has been studied, user perceptions of drug use in terms of health risks, arrest risk, availability, cost, liking, and dependence have not been considered.

METHODS

Data are presented from a brief, face-to-face survey conducted in 2016 of 200 non-in-treatment heroin users from Cleveland, OH. We assessed the use of and attitudes on alcohol, marijuana, methamphetamine, heroin, crack cocaine, powder cocaine, and prescription drugs. We estimated polydrug (concurrent past month) use with cluster analysis and latent profiles. Regression analysis estimated the strength of relationships between attitudes and frequency of use.

RESULTS

We identified five clusters: Cluster 1 used heroin concomitantly with alcohol and occasionally crack; Cluster 2 used heroin and crack cocaine daily; Cluster 3 used heroin daily and almost exclusively; Cluster 4 used heroin and marijuana daily; and Cluster 5 were part-time drug users. Drug use frequency was associated with liking and being anxious when drugs could not be obtained. High perceived availability of heroin and cocaine and low cost facilitated polydrug use.

CONCLUSIONS

Understanding polydrug use clusters among heroin users is important for addressing the larger opioid epidemic. Users' perceptions of a drug's availability and cost appeared to facilitate polydrug use and justify more detailed future research on drug access.

Naloxone laws facilitate the establishment of overdose education and naloxone distribution programs in the United States

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Dispensing Naloxone Without a Prescription: Survey Evaluation of Ohio Pharmacists

Background:

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.

Objectives:

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.

Methods:

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.

Results:

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.

Conclusion:

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.

Rapid widespread distribution of intranasal naloxone for overdose prevention

BACKGROUND

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.

METHODS

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.

RESULTS

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.

CONCLUSION

A government-supported multisite naloxone initiative appears to achieve rapid, high volume distribution of naloxone to an at-risk population.

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

OBJECTIVE

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

SETTING

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

PRACTICE DESCRIPTION

Not applicable.

PRACTICE POLICY INNOVATION

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

EVALUATION

Not applicable.

RESULTS

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

CONCLUSION

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