Effectiveness of Scotland's National Naloxone Programme for reducing opioid-related deaths: a before (2006-10) versus after (2011-13) comparison

Effectiveness of naloxone distribution in community settings to reduce opioid overdose deaths among people who use drugs: a systematic review and meta-analysis

BACKGROUND

It is estimated that over 111,000 people in the U.S. died from a drug overdose in the twelve-month period ending in July 2023. More than three-quarters of those deaths were attributed to opioids. Naloxone has long been available in healthcare facilities to reverse opioid overdose rapidly and safely but is not universally accessible for use in community settings where overdoses occur. We conducted a systematic literature review and meta-analysis to assess the effectiveness of overdose education and naloxone distribution (OEND) programs in three types of community settings to reduce overdose deaths among people who use opioids nonmedically.

METHODS

We systematically searched electronic databases, including Medline (OVID), Embase (OVID), Psycinfo (OVID), and Global Health (OVID), for peer-reviewed studies of OEND programs published during 2003-2018 (Group 1) that reported overdose outcomes individual level survivals or deaths immediately following naloxone administration. The PRISMA checklist guided screening, quality assessment, and data abstraction. We later identified studies published during 2018-2022 (Group 2), when drug usage and fentanyl-related overdose deaths notably increased, differed from earlier ones. We conducted meta-analyses on both Groups using random effects models to estimate summary survival proportions.

RESULTS

Among the 44 Group 1 studies published during 2003-2018, survival did not differ by time (year), location, naloxone dose, or route of administration, but studies of OEND programs serving people who use drugs reported 98.3% (95% CI: 97.5-98.8) survival; those serving family of people who use drugs or other community members reported 95.0% (95% CI: 91.4-97.1) survival; and those for police reported 92.4% (95% CI: 88.9-94.8) survival (p < 0.01). Five Group 2 studies (2018-2022) yielded similar results.

CONCLUSIONS

Community-based naloxone distribution programs can be effective in preventing opioid overdose deaths. The paper demonstrates that in the face of increasing overdose deaths over time, survival after naloxone administration has been sustained. The very high survival rates provide clear evidence for public health to continue efforts to expand channels for naloxone distribution in community settings.

National consensus statement on opioid agonist treatment in custodial settings

INTRODUCTION

Opioid use and dependence are prevalent among incarcerated people, contributing to elevated rates of overdose and other harms in this population. Opioid agonist treatment (OAT) has been shown to be an effective intervention to mitigate these risks. However, challenges to health care implementation in the custodial sector result in suboptimal and variable access to OAT in prisons nationally.

MAIN RECOMMENDATIONS

Among a national multidisciplinary expert panel, we conducted a modified Delphi study that yielded 19 recommendations to government, relevant health authorities and custodial health services. These recommendations cover five core domains: induction or continuation of OAT, OAT options and administration, transition of care to the community, special populations, and organisational support. Key recommendations include prompt recognition and treatment of opioid withdrawal, active linkage to community-based OAT providers upon release, and ensuring appropriate organisational support through local protocols, adequate funding, and monitoring of key program indicators.

CHANGES IN MANAGEMENT AS A RESULT OF THIS STATEMENT

This consensus statement addresses a significant gap in national policy on OAT in Australian prisons. The recommendations, finalised in July 2024, set forth best practice standards grounded in evidence and expert consensus. We expect that implementing these recommendations will enhance the quality, consistency and continuity of OAT both within prison and upon release. Optimising OAT provision is crucial for improving health outcomes and addressing the risk of overdose, which is the leading cause of death among people released from prison.

Increasing take-home naloxone kit distribution to patients with substance use disorder before hospital discharge: a quality improvement project

The ongoing drug toxicity crisis is a growing public health challenge in many countries across the world. Despite the WHO's recommendation of take-home naloxone (THN) kits as a cost-effective harm reduction strategy to prevent drug toxicity deaths, the Addiction Medicine Consult Team (AMCT) at Burnaby Hospital found that only 51% of their eligible patients were receiving a kit before discharge. In response, the AMCT created a quality improvement (QI) team with the aim of increasing their THN kit distribution rate on two hospital wards from 51% to over 80% within 10 months.Change ideas were implemented with the aim of targeting various components of the THN kit distribution process. Changes included adjusting THN kit inventory on wards, hosting education sessions for nurses, creating just-in-time training using nursing station whiteboards, streamlining the documentation process for nurses and standardising the ordering process for providers. The QI team collaborated with hospital interest holders including senior executives, nursing and pharmacy groups to facilitate change ideas. The project culminated with 4 months of sustained THN kit provision above 80%.The QI team is currently in talks with hospital operations to ensure that an effective documentation system will be integrated into the new electronic medical record system when the hospital transitions away from paper charting in 2025.

Could Flumazenil Be Used Pre-hospital by Intramuscular Injection for Coma due to Mixed Drug Overdose Not Responding to Naloxone?: A Systematic Review of the Evidence

BACKGROUND/RATIONALE

Benzodiazepine-involved overdose deaths are increasing. Flumazenil is rarely used due to fear of seizures; however, the risk benefit may favour its use. Flumazenil is licensed for intravenous (IV) use, but intramuscular (IM) treatment would be required pre-hospital.

OBJECTIVE

To identify and synthesise pre-clinical and clinical data on the parenteral IM flumazenil safety and efficacy.

METHODS

PubMed, Google Scholar, Cochrane and Scopus searches without any language restriction. Adverse effect studies were limited to systematic reviews and large cohort studies (n > 100), IM administration efficacy to studies in large animal (mammalian, excluding reptiles and birds) and humans.

RESULTS

Two systematic reviews reported adverse effects from IV or IM flumazenil in clinical use and combined retrospective/prospective patient cohort. Seizures were uncommon (< 2%) including mixed overdoses. Seven studies (four animal, three human) reported on IM flumazenil. Animal studies indicated IM flumazenil efficacy. In a canine cross-over study, IM flumazenil reversed midazolam sedation moderately slower than IV. Two clinical observational studies reported sedation reversal with IM flumazenil, whereas a cross-over study found no IM flumazenil response at 15 min.

CONCLUSION

IM flumazenil data are sparse, but it may be effective and safe. Clinical research is urgently needed to determine whether pre-hospital IM flumazenil can prevent benzodiazepine-involved overdose deaths.

Description of implementing a mail-based overdose education and naloxone distribution program in community supervision settings during COVID-19

INTRODUCTION

This study uses the Exploration, Preparation, Implementation, and Sustainment (EPIS) model to retrospectively describe the mail-based overdose education and naloxone distribution (OEND) program developed in collaboration with the Kentucky Department of Corrections (DOC) for use in the HEALing Communities Study in Kentucky (HCS-KY) and details the reach of this innovative delivery model.

METHODS

HCS-KY is a community-engaged cluster-randomized trial assessing the effects of implementing evidence-based practices, including OEND, on overdose death reduction across 16 communities highly impacted by the opioid epidemic in Kentucky.6 The study launch coincided with the COVID-19 pandemic. All coalitions in the 16 HCS-KY counties selected OEND implementation in community supervision offices; however, pandemic limitations on in-person reporting made face-to-face OEND unfeasible. This study uses the EPIS phases to understand how the unique inner and outer contextual factors of the pandemic drove innovation, including five implementation strategies to promote the mail-based OEND program. Internal study management trackers data measured implementation reach.

RESULTS

Implementation occurred in all 16 counties. All promotional strategies used in the first 8 counties (Wave 1) were carried over to the second 8 counties (Wave 2), except letters were not sent to community supervision clients in Wave 2 counties. Across both waves, 1759 people accessed the Typeform™ website to receive overdose education, complete a brief demographic survey, and 1696 had naloxone shipped to their homes. Greater reach occurred in Wave 1 and in rural counties. Of the participants, 81.13 % were white, 61.17 % were female, 51.79 % were between the ages of 35-54, 18.82 % had previously experienced an overdose, and 69.07 % had witnessed an overdose. Sites sustained three of the five implementation strategies for publicizing the OEND website at the study's end but not letters and texting.

CONCLUSIONS

Mail-based OEND programs are an appropriate delivery method for ensuring access to life-saving medication for people on community supervision and may encourage treatment. Strategies to promote the OEND program that were high-effort for agency and study staff, such as letters, or high-cost, such as texting, were not sustainable. Implications for OEND best practices, including innovative technology use within community supervision settings are addressed.

"Before medically advised" hospital discharge and the risk of subsequent drug overdose: A case-crossover analysis

BACKGROUND

Patient-initiated or "before medically advised" (BMA) hospital discharge is more common among people who use drugs. Transitions of care can be destabilizing and might increase the risk of subsequent illicit drug overdose.

OBJECTIVES

This study sought to evaluate whether BMA discharge is associated with an increased risk of subsequent drug overdose (primary objective) and whether physician-advised discharge is associated with an increased risk of subsequent drug overdose (secondary objective).

METHODS

We performed a case-crossover analysis of population-based linked administrative health data for individuals experiencing an overdose between 2016 and 2019 in British Columbia, Canada. Using conditional logistic regression, we compared the likelihood of hospital discharge in the 28 days before overdose (the "pre-overdose interval") to the likelihood of hospital discharge in two self-matched 28-day control intervals ending 26 and 52 weeks before overdose.

RESULTS

Over the 3.5-year study interval, 235 of 27,584 (0.9%) pre-overdose intervals and 189 of 55,168 (0.3%) control intervals included a BMA discharge, suggesting that BMA discharge was associated with a twofold increase in the risk of subsequent drug overdose (adjusted odds ratio [aOR], 2.08; 95% confidence interval [95% CI], 1.68-2.58; p < 0.001). Physician-advised hospital discharge was also a risk factor for subsequent overdose, occurring in 1350 of 27,584 (4.9%) pre-overdose intervals and 1625 of 55,168 (2.9%) control intervals (aOR, 1.39; 95% CI, 1.27-1.52; p < 0.001).

CONCLUSIONS

Both BMA and physician-advised hospital discharge are independently associated with transient increases in the risk of subsequent illicit drug overdose. Better in-hospital treatment of substance use disorder and novel means of post-discharge outreach should be deployed to reduce this risk.

Increasing Naloxone Access and Prescribing for Patients on High-Dose Opioids From a Managed Care Pharmacy Health Plan Perspective

Background: Opioid overdoses decrease when communities have access to naloxone. Clinicians play a key role in offering naloxone to high-risk chronic opioid patients. Managed care pharmacists within our health plan noted disproportionate processing for claims of opioid utilizers compared to claims of naloxone prescriptions. Objective: To increase naloxone access and prescribing to members who classify at a dosage with a higher risk for opioid overdose, defined as over 90 morphine milligram equivalents (MME). Methods: Multiple system-wide initiatives were implemented to improve naloxone access. A claims file was pulled monthly to identify members on opioids meeting MME criteria >90 MME per day excluding members with cancer, sickle cell disease, or on hospice. A separate report was then matched to naloxone claims and prescribing percentages calculated. Results: 12 444 utilizing members on opioids were identified from June 2019 prescription claims data. Of these, 131 were on opioids exceeding 90 MME per day, or 1.05% of utilizers, and the percentage of members exceeding 90 MME per day prescribed naloxone was 6.87%. By May 2023, the percentage of opioid utilizers exceeding 90 MME per day decreased to 0.58%. Naloxone prescribing increased to 41.18%. Conclusion: A multi-pronged approach to improve access to naloxone and continued educational efforts by our health plan increased naloxone prescribing in members on opioids exceeding 90 MME per day.

Evaluating Quality of Life Changes over 12 Months Among Opiate Users from Romania and Associated Worsening Factors

This study aimed to evaluate the changes in quality of life (QoL) over a 12-month period among opiate users in Romania, identifying factors that contribute to a worsening of their condition. By examining these dynamics, the research intended to inform targeted interventions and support mechanisms to mitigate the negative outcomes associated with opiate use. Conducted as a longitudinal cohort analysis, this study enrolled 74 participants diagnosed with opioid use disorders from multiple healthcare settings in Romania. The WHOQOL-BREF instrument was utilized to assess QoL, with data collection spanning from 1 January 2023 to 31 December 2023. Ethical compliance with the Declaration of Helsinki was maintained, and participants provided informed consent. Statistical analysis was performed using SPSS, focusing on the impact of demographic and behavioral variables on QoL. Over the 12-month period, significant improvements were observed in all QoL domains: physical (51.68 to 58.39, p < 0.001), psychological (49.34 to 55.32, p < 0.001), social (46.21 to 53.66, p < 0.001), and environmental (47.85 to 54.17, p < 0.001). Methadone compliance significantly influenced positive outcomes across all domains. Compliant participants exhibited higher mean scores compared to non-compliant users, with respective increases in the physical domain from 52.47 to 60.21 (p < 0.001), psychological from 50.93 to 58.32 (p < 0.001), social from 48.36 to 57.14 (p < 0.001), and environmental from 47.82 to 55.79 (p < 0.001). Additionally, education showed a protective effect, particularly enhancing environmental QoL (estimate = 0.33, p = 0.013). Methadone compliance and higher education levels were identified as significant predictors of improved QoL among opiate users, demonstrating the critical importance of adherence to treatment protocols and the supportive role of education in enhancing life quality. These findings highlight the necessity for integrated treatment programs and educational interventions to improve the well-being of individuals battling opioid addiction, advocating for policy enhancements and supportive measures tailored to this demographic.

Interventions to reduce harms related to drug use among people who experience incarceration: systematic review and meta-analysis

BACKGROUND

Mortality, suicide, self-harm, and substance use are elevated among people who are incarcerated. There is a wide range of heterogeneous interventions aimed at reducing these harms in this population. Previous reviews have focused on specific interventions or limited their findings to drug use and recidivism and have not explored interventions delivered after release from prison. Our aim is to examine the effect of interventions delivered to people who use drugs during incarceration or after release from incarceration, on a wide range of outcomes.

METHODS

In this systematic review and meta-analysis, we searched Embase, MEDLINE, and PsycINFO databases up until Sept 12, 2023 for studies published from Jan 1, 1980 onwards. All studies evaluating the effectiveness of any intervention on drug use, recidivism outcomes, sexual or injecting risk behaviours, or mortality among people who use psychoactive drugs and who were currently or recently incarcerated were included. Studies without a comparator or measuring only alcohol use were excluded. Data extracted from each study included demographic characteristics, interventions, and comparisons. Pooled odds ratios and risk ratios were calculated using random-effects meta-analyses.

FINDINGS

We identified 126 eligible studies (47 randomised controlled trials and 79 observational studies) encompassing 18 interventions; receiving opioid-agonist treatment (OAT) in prison reduced the risk of death in prison (one study; hazard ratio 0·25; 95% CI 0·13-0·48), whereas receiving OAT in the first 4 weeks following release reduced risk of death in the community (two studies; relative risk 0·24; 95% CI 0·15-0·37). Therapeutic community interventions reduced re-arrest at 6-12 months (six studies; odds ratio [OR] 0·72; 95% CI 0·55-0·95) and reincarceration at 24 months (two studies; OR 0·66; 95% CI 0·48-0·96). There was scarce evidence that OAT and syringe service provision are effective in reducing injecting risk behaviours and needle and syringe sharing.

INTERPRETATION

There are effective interventions to reduce mortality and recidivism for people who use drugs who have been incarcerated. Nonetheless, there are also substantial gaps in the research examining the effect of interventions on risk behaviours and mortality during incarceration and a need for randomised designs examining outcomes for people who use drugs after release.

FUNDING

Australian National Health and Medical Research Council.

National increase in the community supply of take-home naloxone associated with a mass media campaign in Scotland: a segmented time series analysis

BACKGROUND

Take-home naloxone (THN) programmes have been associated with reductions in opioid-related mortality. In response to high rates of drug-related deaths in Scotland, the Scottish Government commissioned the 'How to save a life' (HTSAL) mass media campaign to: (1) increase awareness of drug-related deaths and how to respond to an overdose, and (2) increase the supply of THN. The aim of this study was to assess the effect of the campaign on the supply of THN.

METHODS

We used an interrupted time series design to assess the effect of the HTSAL mass media campaign on the national community supply of THN. The study time period was August 2020-December 2021. We modelled two key dates: the start of the campaign (week beginning (w/b) 30th of August 2021) and after the end of the main campaign (w/b 25th of October 2021).

RESULTS

The total number of THN kits distributed in the community in Scotland during the study period was 27,064. The mean number of THN kits distributed per week (relative to the pre-campaign period), increased by 126% during the campaign and 57% post-campaign. In segmented regression analyses, the pre-campaign trend in the number of THN kits supplied was increasing by an average of 1% each week (RR=1.01, 95% CI 1.01 to 1.01, p<0.001). Once the campaign started, a significant change in level was observed, and the number of kits increased by 75% (RR=1.75, 95% CI 1.29 to 2.40, p<0.001). The trend during the campaign was stable (i.e. not increasing or decreasing) but a significant change in level was observed when the campaign ended, and the number of THN kits supplied decreased by 32% (RR=0.68, 95% CI 0.46 to 0.98, p = 0.042). The trend during the post-campaign period was stable.

CONCLUSIONS

The HTSAL campaign had a short term, but large and significant impact, on the community supply of THN in Scotland. Mass media campaigns could be combined with other interventions and strategies to maintain the increased uptake of THN outside of campaign periods.

Effects of Online Naloxone Training for Laypersons: An Extended-Baseline Assessment

Background: While laypersons can play a crucial role in administering naloxone in opioid overdoses, they must be recruited and trained to effectively manage overdose events as good Samaritans. This study aimed to examine the effectiveness of a technology-based intervention that recruited and trained laypersons to administer naloxone. Methods: Opioid Rapid Response System (ORRS) was an online recruitment and training intervention which capitalized on social cognitive theory and a digital media engagement model to mobilize laypersons to administer intranasal naloxone. ORRS was developed based on a randomized waitlisted controlled trial (N = 220). This secondary analysis is a within-group, extended-baseline assessment of the waitlisted group (n = 106), considering that they served as their own control prior to receiving the training. ORRS was conducted in five counties of Indiana with adults who did not self-identify as a certified first responder. Five indices were generated from 23 variables: knowledge of overdose signs, knowledge of overdose management, self-efficacy in responding, concerns about responding, and intent to respond. Paired t-test compared changes between 3 timepoints. Results: Three indices had significantly greater increases associated with training compared to extended baseline: recognizing opioid overdose signs (difference = 0.08; 95%CI = 0.02, 0.15; t = 2.48; p = 0.01); knowledge of overdose management (difference = 0.27; 95%CI = 0.18, 0.35; t = 5.99; p < 0.01); and self-efficacy in overdose management (difference = 0.68; 95%CI = 0.45, 0.91; t = 5.78; p < 0.01). Concerns related to overdose management significantly decreased as expected (difference = -1.53; 95%CI = -1.86, -1.21; t = -9.27; p < 0.01). Conclusions: ORRS provided strong support for self-efficacy, concerns, and knowledge related to overdose management, and the digital modality accelerates largescale dissemination.

Community pharmacists' attitudes toward and practice of pharmacy-based harm reduction services in Pittsburgh, PA: a descriptive survey

BACKGROUND

In Pittsburgh, PA, legal changes in recent decades have set the stage for an expanded role for community pharmacists to provide harm reduction services, including distributing naloxone and non-prescription syringes (NPS). In the wake of the syndemics of the COVID-19 pandemic and worsening overdose deaths from synthetic opioids, we examine knowledge, attitudes, and practices of harm reduction services among community pharmacists in Pittsburgh and identify potential barriers of expanded pharmacy-based harm reduction services.

METHODS

We provided flyers to 83 community pharmacies within a 5-mile radius of the University of Pittsburgh Medical Center to recruit practicing community pharmacists to participate in an anonymous electronic survey. We used a 53-question Qualtrics survey consisting of multiple-choice, 5 or 6 point-Likert scale, and open-ended questions adapted from 5 existing survey instruments. Survey measures included demographics, knowledge, attitudes, and practices of harm reduction services (specifically naloxone and NPS provision), and explored self-reported barriers to future implementation. Data was collected July-August 2022. We conducted descriptive analysis using frequencies and proportions reported for categorical variables as well as means and standard deviations (SD) for continuous variables. We analyzed open-ended responses using inductive content analysis.

RESULTS

Eighty-eight community pharmacists responded to the survey. 90% of participants agreed pharmacists had a role in overdose prevention efforts, and 92% of participants had previously distributed naloxone. Although no pharmacists reported ever refusing to distribute naloxone, only 29% always provided overdose prevention counseling with each naloxone distributed. In contrast, while 87% of participants had positive attitudes toward the usefulness of NPS for reducing disease, only 73% of participants ever distributed NPS, and 54% had refused NPS to a customer. Participants endorsed a lack of time and concerns over clientele who used drugs as the most significant barriers to offering more comprehensive harm reduction services.

CONCLUSIONS

Our findings highlight that while most community pharmacists have embraced naloxone provision, pharmacy policies and individual pharmacists continue to limit accessibility of NPS. Future expansion efforts for pharmacy-based harm reduction services should not only address the time and labor constraints identified by community pharmacists, but also fear-based policy and stigma toward people who inject drugs and harm reduction more broadly.

Harm Reduction in the Field: First Responders' Perceptions of Opioid Overdose Interventions

Introduction

Recent policy changes in Washington State presented a unique opportunity to pair evidence-based interventions with first responder services to combat increasing opioid overdoses. However, little is known about how these interventions should be implemented. In partnership with the Research with Expert Advisors on Drug Use team, a group of academically trained and community-trained researchers with lived and living experience of substance use, we examined facilitators and barriers to adopting leave-behind naloxone, field-based buprenorphine initiation, and HIV and hepatitis C virus (HCV) testing for first responder programs.

Methods

Our team completed semi-structured, qualitative interviews with 32 first responders, mobile integrated health staff, and emergency medical services (EMS) leaders in King County, Washington, from February-May 2022. Semi-structured interviews were recorded, transcribed, and coded using an integrated deductive and inductive thematic analysis approach grounded in community-engaged research principles. We collected data until saturation was achieved. Data collection and analysis were informed by the Consolidated Framework for Implementation Research. Two investigators coded independently until 100% consensus was reached.

Results

Our thematic analysis revealed several perceived facilitators (ie, tension for change, relative advantage, and compatibility) and barriers (ie, limited adaptability, lack of evidence strength and quality, and prohibitive cost) to the adoption of these evidence-based clinical interventions for first responder systems. There was widespread support for the distribution of leave-behind naloxone, although funding was identified as a barrier. Many believed field-based initiation of buprenorphine treatment could provide a more effective response to overdose management, but there were significant concerns that this intervention could run counter to the rapid care model. Lastly, participants worried that HIV and HCV testing was inappropriate for first responders to conduct but recommended that this service be provided by mobile integrated health staff.

Conclusion

These results have informed local EMS strategic planning, which will inform roll out of process improvements in King County, Washington. Future work should evaluate the impact of these interventions on the health of overdose survivors.

Community-led approaches to making naloxone available in public settings: Implementation experiences in the HEALing communities study

BACKGROUND

Expanding public naloxone access is a key strategy to reduce opioid overdose fatalities. We describe tailored community-engaged, data-driven approaches to install and maintain naloxone housing units (naloxone boxes) in New York State and estimate the cost of these approaches.

METHODS

Guided by the Consolidated Framework for Implementation Research, we collected data from administrative records and key informant interviews that documented the unique processes employed by four counties enrolled in the HEALing Communities Study to install and maintain naloxone housing units. We conducted a prospective micro-costing analysis to estimate the cost of each naloxone housing unit strategy from the community perspective.

RESULTS

While all counties used a coalition to guide action planning for naloxone distribution, we identified unique approaches to implementing naloxone housing units: 1) County-led with technology expansion; 2) County-led grassroots; 3) Small-scale rural opioid overdose prevention program (OOPP) contract and 4) Comprehensive OOPP contract including overdose education and naloxone distribution (OEND) to individuals. The first two county-led approaches had lower cost per naloxone dose disbursed ($28-$38) compared to outsourcing to an OOPP ($183-$266); costs depended on services added to installing and maintaining units, such as OEND. Barriers included competing demands on public health resources (i.e., COVID-19) and stigma toward naloxone and opioid use disorder. Geographic access was a barrier in rural areas whereas existing infrastructure was a facilitator in urban counties. The policy landscape in New York State, which provides free naloxone kits and financial support to OOPPs, facilitated implementation in all counties.

CONCLUSIONS

If a community has the resources, installing and maintaining naloxone housing units in-house can be less expensive than contracting with an outside partner. However, contracts that include OEND may be more effective at reaching target populations. Financial support from health departments and legislative authorization are important facilitators to making naloxone available in public settings.

Naloxone Accessibility by Standing Order in North Carolina Community Pharmacies

BACKGROUND

According to a standing order in North Carolina (NC), naloxone can be purchased without a provider prescription.

OBJECTIVE

The objective of this study is to examine whether same-day naloxone accessibility and cost vary by pharmacy type and rurality in NC.

METHODS

A cross-sectional telephone audit of 202 NC community pharmacies stratified by pharmacy type and county of origin was conducted in March and April 2023. Trained "secret shoppers" enacted a standardized script and recorded whether naloxone was available and its cost. We examined the relationship between out-of-pocket naloxone cost, pharmacy type, and rurality.

RESULTS

Naloxone could be purchased in 53% of the pharmacies contacted; 26% incorrectly noting that naloxone could be filled only with a provider prescription and 21% did not sell naloxone. Naloxone availability by standing order was statistically different by pharmacy type (chain/independent) (χ2 = 20.58, df = 4, P value < 0.001), with a higher frequency of willingness to dispense according to the standing order by chain pharmacies in comparison to independent pharmacies. The average quoted cost for naloxone nasal spray at chain pharmacies was $84.69; the cost was significantly more ($113.54; P < 0.001) at independent pharmacies. Naloxone cost did not significantly differ by pharmacy rurality (F2,136 = 2.38, P = 0.10).

CONCLUSION

Approximately half of NC community pharmacies audited dispense naloxone according to the statewide standing order, limiting same-day access to this life-saving medication. Costs were higher at independent pharmacies, which could be due to store-level policies. Future studies should further investigate these cost differences, especially as intranasal naloxone transitions from a prescription only to over-the-counter product.

Psychosocial factors associated with overdose subsequent to Illicit Drug use: a systematic review and narrative synthesis

BACKGROUND AND AIMS

Psychological and social status, and environmental context, may mediate the likelihood of experiencing overdose subsequent to illicit drug use. The aim of this systematic review was to identify and synthesise psychosocial factors associated with overdose among people who use drugs.

METHODS

This review was registered on Prospero (CRD42021242495). Systematic record searches were undertaken in databases of peer-reviewed literature (Medline, Embase, PsycINFO, and Cinahl) and grey literature sources (Google Scholar) for work published up to and including 14 February 2023. Reference lists of selected full-text papers were searched for additional records. Studies were eligible if they included people who use drugs with a focus on relationships between psychosocial factors and overdose subsequent to illicit drug use. Results were tabulated and narratively synthesised.

RESULTS

Twenty-six studies were included in the review, with 150,625 participants: of those 3,383-4072 (3%) experienced overdose. Twenty-one (81%) studies were conducted in North America and 23 (89%) reported polydrug use. Psychosocial factors associated with risk of overdose (n = 103) were identified and thematically organised into ten groups. These were: income; housing instability; incarceration; traumatic experiences; overdose risk perception and past experience; healthcare experiences; perception of own drug use and injecting skills; injecting setting; conditions with physical environment; and social network traits.

CONCLUSIONS

Global rates of overdose continue to increase, and many guidelines recommend psychosocial interventions for dependent drug use. The factors identified here provide useful targets for practitioners to focus on at the individual level, but many identified will require wider policy changes to affect positive change. Future research should seek to develop and trial interventions targeting factors identified, whilst advocacy for key policy reforms to reduce harm must continue.

An economic evaluation of community pharmacy-dispensed naloxone in Canada

Aims

To determine the cost-effectiveness of pharmacy-based intranasal (IN) and intramuscular (IM) naloxone distribution in Canada.

Methods

We developed a state-transition model for pharmacy-based naloxone distribution, every 3 years, to illicit, prescription, opioid-agonist therapy and nonopioid use populations compared to no naloxone distribution. We used a monthly cycle length, lifetime horizon and a Canadian provincial Ministry of Health perspective. Transition probabilities, cost and utility data were retrieved from the literature. Costs (2020) and quality-adjusted life years (QALY) were discounted 1.5% annually. Microsimulation, 1-way and probabilistic sensitivity analyses were conducted.

Results

Distribution of naloxone to all Canadians compared to no distribution prevented 151 additional overdose deaths per 10,000 persons, with an incremental cost-effectiveness ratio (ICER) of $50,984 per QALY for IM naloxone and an ICER of $126,060 per QALY for IN naloxone. Distribution of any naloxone to only illicit opioid users was the most cost-effective. One-way sensitivity analysis showed that survival rates for illicit opioid users were most influenced by the availability of either emergency medical services or naloxone.

Conclusion

Distribution of IM and IN naloxone to all Canadians every 3 years is likely cost-effective at a willingness-to-pay threshold of $140,000 Canadian dollars/QALY (~3 × gross domestic product from the World Health Organization). Distribution to people who use illicit opioids was most cost-effective and prevented the most deaths. This is important, as more overdose deaths could be prevented through nationwide public funding of IN naloxone kits through pharmacies, since individuals report a preference for IN naloxone and these formulations are easier to use, save lives and are cost-effective. Can Pharm J (Ott) 2024;157:xx-xx.

Organize and mobilize for implementation effectiveness to improve overdose education and naloxone distribution from syringe services programs: a randomized controlled trial

BACKGROUND

The United States (US) continues to face decades-long increases in opioid overdose fatalities. As an opioid overdose reversal medication, naloxone can dramatically reduce opioid overdose mortality rates when distributed to people likely to experience or witness an opioid overdose and packaged with education on its use, known as overdose education and naloxone distribution (OEND). Syringe services programs (SSPs) are ideal venues for OEND with staff who are culturally competent in providing services for people who are at risk of experiencing or observing an opioid overdose. We carried out a randomized controlled trial of SSPs to understand the effectiveness of the organize and mobilize for implementation effectiveness (OMIE) approach at improving OEND implementation effectiveness within SSPs.

METHODS

Using simple randomization, 105 SSPs were enrolled into the trial and assigned to one of two study arms - (1) dissemination of OEND best practice recommendations (Control SSPs) or the OMIE approach along with dissemination of the OEND best practice recommendations (i.e., OMIE SSPs). OMIE SSPs could participate in 60-min OMIE sessions once a month for up to 12 months. At 12-month post-baseline, 102 of 105 SSPs (97%) responded to the follow-up survey.

RESULTS

The median number of sessions completed by OMIE SSPs was 10. Comparing OMIE SSPs to control SSPs, we observed significant increases in the number of participants receiving naloxone (incidence rate ratio: 2.15; 95% CI: 1.42, 3.25; p < 0.01) and the rate of naloxone doses distributed per SSP participant (adjusted incidence rate ratio: 1.97; 95% CI: 1.18, 3.30; p = 0.01). We observed no statistically significant difference in the number of adopted best practices between conditions (difference in means 0.2, 95% CI: - 0.7, 1.0; p = 0.68). We also observed a threshold effect where SSPs receiving a higher OMIE dose had greater effect sizes with regard to the number of people given naloxone and the number of naloxone doses distributed.

CONCLUSIONS

In conclusion, the multifaceted OMIE approach was effective at increasing naloxone distribution from SSPs, despite substantial external shocks during the trial. These findings have major implications for addressing the overdose crisis, which has continued unabated for decades.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT03924505 . Registered 19 April 2019.

Impact of harm minimization interventions on reducing blood-borne infection transmission and some injecting behaviors among people who inject drugs: an overview and evidence gap mapping

BACKGROUND

This study aimed to synthetize the evidence on the effectiveness of harm minimization interventions on reducing blood-borne infection transmission and injecting behaviors among people who inject drugs (PWID) through a comprehensive overview of systematic reviews and evidence gap mapping.

METHODS

A systematic review was conducted with searches in PubMed and Scopus to identify systematic reviews assessing the impact of interventions aimed at reducing the harms associated with injectable drug use. The overall characteristics of the studies were extracted and their methodological quality was assessed using AMSTAR-2. An evidence gap map was constructed, highlighting the most frequently reported outcomes by intervention (CRD42023387713).

RESULTS

Thirty-three systematic reviews were included. Of these, 14 (42.2%) assessed the impact of needle/syringe exchange programs (NSEP) and 11 (33.3%) examined opioid agonist therapy (OAT). These interventions are likely to be associated with reductions of HIV/HCV incidence (10-40% risk reduction for NSEP; 50-60% for OAT) and sharing injecting paraphernalia (50% for NSEP, 25-85% for OAT), particularly when combined (moderate evidence). Behavioral/educational interventions were assessed in 12 reviews (36.4%) with most authors in favor/partially in favor of the use of these approaches (moderate evidence). Take-home naloxone programs and supervised-injection facilities were each assessed in two studies (6.1%), which reported inconclusive results (limited/inconsistent evidence). Most authors reported high levels of heterogeneity and risk of bias. Other interventions and outcomes were inadequately reported. Most systematic reviews presented low or critically low quality.

CONCLUSION

The evidence is sufficient to support the effectiveness of OAT, NSEP and their combination in reducing blood-borne infection transmission and certain injecting behaviors among PWID. However, evidence of other harm minimizations interventions in different settings and for some outcomes remain insufficient.

Distribution of intranasal naloxone to potential opioid overdose bystanders in Sweden: effects on overdose mortality in a full region-wide study

OBJECTIVES

Distribution of take-home naloxone is suggested to reduce opioid-related fatalities, but few studies have examined the effects on overdose deaths in the general population of an entire community. This study aimed to assess the effects on overdose deaths of a large-scale take-home naloxone programme starting in June 2018, using an observational design with a historic control period.

DESIGN

From the national causes of death register, deaths diagnosed as X42 or Y12 (International Classification of Diseases, 10th revision, ICD-10) were registered as overdoses. Numbers of overdoses were calculated per 100 000 inhabitants in the general population, and controlled for data including only individuals with a prior substance use disorder in national patient registers, to focus on effects within the primary target population of the programme. The full intervention period (2019-2021) was compared with a historic control period (2013-2017).

SETTING

Skåne county, Sweden.

PARTICIPANTS

General population.

INTERVENTIONS

Large-scale take-home naloxone distribution to individuals at risk of overdose.

PRIMARY AND SECONDARY OUTCOME MEASURES

Decrease in overdose deaths per 100 000 inhabitants, in total and within the population with substance use disorder diagnosis.

RESULTS

Annual average number of overdose deaths decreased significantly from 3.9 to 2.8 per 100 000 inhabitants from the control period to the intervention period (a significant decrease in men, from 6.7 to 4.3, but not in women, from 1.2 to 1.3). Significant changes remained when examining only prior substance use disorder patients, and decreases in overdose deaths could not be attributed to a change in treatment needs for opioid use disorders in healthcare and social services.

CONCLUSIONS

The present study, involving 3 years of take-home naloxone distribution, demonstrated a decreased overdose mortality in the population, however, only in men. The findings call for further implementation of naloxone programmes, and for further studies of potential effects and barriers in women.

TRIAL REGISTRATION NUMBER

NCT03570099.

Opioid-related deaths and their counterpart by occurrence era, age group and coimplicated drugs: Scotland vs. England and Wales

AIMS

Compare by occurrence era and age group how opioid-related deaths (ORDs) and their counterpart evolved in Scotland vs. England and Wales during 2006-2020. For Scotland, compare coimplication rates between ORDs and non-ORDs for any benzodiazepine, cocaine or gabapentin/pregabalin, and consider whether coimplication in ORDs depended on opioid-specificity.

METHODS

Cross-tabulations of drug misuse deaths (DMDs) obtained by 3 yearly occurrence era (2006-2008 to 2018-2020) and age group (under 25, 25-34, 35-44, 45-54, 55+ years) for England and Wales and subdivided by whether at least 1 opiate was mentioned on death certificate (DMD-Os or not); and of Scotland's opioid-related deaths (ORDs vs. non-ORDs) together with (i) coimplication by any benzodiazepine, cocaine or gabapentin/pregabalin; and (ii) opioid-specificity of ORDs. ORD is defined by heroin/morphine, methadone or buprenorphine being implicated in DMD.

RESULTS

Per era between 2012-2014 and 2018-2020, Scotland's ORDs increased by 54% and non-ORDs by 34%. Increase in DMD-Os in England and Wales was more modest. Cocaine was implicated in 83% of Scotland's 2690 non-ORDs during 2006-2020; and any benzodiazepine in 53% of 8409 ORDs. However, in 2018-2020, coimplication rates in 2926 ORDs (880 non-ORDs) were 81% (33%) for any benzodiazepine, 30% (74%) for cocaine and 38% (22%) for gabapentin/pregabalin. Coimplication rate in 2018-2020 for any benzodiazepine was lowest at 70% (616/877) for heroin/morphine ORDs; and, by age group, at 66% (160/241) for ORDs aged 55+ years.

CONCLUSIONS

Drug testing to inform users, shared intelligence between police and public health for earlier detection of changes in supply and monitoring of prescribed daily-dose of methadone are urgent.

Assessing the reach and engagement with the 'How To Save A Life' mass media campaign on drug-related death prevention in Scotland

'How To Save A Life' (HTSAL) was a mass media campaign on drug-related death prevention which ran in Scotland from August 2021 to January 2022. It aimed to increase awareness of how to respond to an opioid overdose, and the uptake of take-home naloxone (THN). The objective of this study was to determine the reach and engagement with the campaign. Methods included a descriptive analysis of data from media sources, the campaign website, and an online naloxone training course. A quantitative content analysis was conducted on media articles. The campaign generated 57,402,850 non-unique impressions (the total number of times the campaign was seen or heard), and unique reach (the number of people who were exposed to the campaign) figures of 2,621,450. Engagement with the campaign was positive, and 96% of print/digital media articles had a positive view of the campaign. There were 40,714 visits to the campaign website, leading to 8,107 clicks to the free naloxone training course, and 3,141 clicks to order a free naloxone kit. This study showed that mass media campaigns on drug policy topics can achieve high levels of reach and engagement. There was a clear progression from viewing campaign materials, to visiting the campaign website, to completing naloxone training. Our research suggests that mass media campaigns can be used to disseminate harm reduction messages to the general public.

[Take-home naloxone: a building block of drug emergency prophylaxis in Germany]

Naloxone is an opioid antagonist that reverses the (respiratory-paralyzing) effects of opioids in the body within minutes. Naloxone can therefore reduce opioid overdose deaths. Take-home naloxone (THN) is an intervention recommended by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) and the World Health Organization (WHO). It involves training opioid users and their relatives or friends in the use of naloxone and providing them with the drug in case of emergency.So far, THN has been implemented in Germany mainly by individual addiction support facilities. In order to fully exploit the potential of THN, it is necessary to establish the measure nationwide. In particular, THN can be included in the services offered in (low-threshold) addiction support facilities, in psychiatric facilities, in the context of opioid substitution treatment, and in the correctional system.This discussion article reviews the development of THN in Germany since 1998, highlights the difficulties and obstacles to its widespread implementation, and outlines how THN can succeed as an effective public health intervention in Germany. This is particularly relevant in view of the increasing number of drug-related deaths over the past 10 years.

Experiences Administering Naloxone Among People in Different Social Roles: People Who Use Opioids and Family Members and Friends

Unintentional drug overdose deaths continue to be a critical public health issue. Naloxone, a nonscheduled, safe, and effective drug that reverses opioid-involved overdoses is available to non-medically trained individuals ("lay people"), but there is scant information about how people in different social roles experience naloxone administration. We conducted 24 in-depth interviews with people who use opioids (PWUO; n = 15) and family members and friends of people who use opioids (FF; n = 9) who had administered naloxone in response to an opioid overdose. Compared with PWUO, members of the FF group were less reticent to administer naloxone in response to an overdose. PWUO and FF had different perspectives of law enforcement and demonstrated varied knowledge of the Good Samaritan Law. While PWUO found that having and administering naloxone was empowering, FF took a more pragmatic approach, reporting the need for naloxone as an unfortunate reality of their loved one's drug use.

Implementing a decentralized opioid overdose prevention strategy in Mexico, a pending public policy issue

The public health crisis due to opioid overdose is worsening in Mexico's northern region due to the introduction of illicitly manufactured fentanyl into the local drug supply. Though there is an increase in overdose deaths, there is no accurate report of overdoses by Mexican government agencies and no comprehensive opioid overdose prevention strategy. There is currently only an anti-drug marketing strategy which is likely insufficient to mitigate the growing epidemic. In order to address the growing opioid overdose crisis in the country, it is necessary to create and implement a decentralized prevention strategy, that includes naloxone distribution, expanded treatment services in regions most in need, and create active dialogue with community organisations already implementing harm reduction actions. Decisive action must be taken by the Mexican government to ensure the health and wellbeing of the Mexican citizens, especially those at high risk for opioid overdose.

Preliminary effectiveness of online opioid overdose and naloxone administration training and impact of naloxone possession on opioid use

BACKGROUND

Despite the demonstrated value of opioid overdose education and naloxone distribution (OEND) programs, uptake and utilization remains low. Accessibility to OEND is limited and traditional programs may not reach many high-risk individuals. This study evaluated the effectiveness of online opioid overdose and naloxone administration education and the impact of naloxone possession.

METHODS

Individuals with self-reported illicit use of opioids were recruited via Craigslist advertisements and completed all assessments and education online via REDCap. Participants watched a 20-minute video outlining signs of opioid overdose and how to administer naloxone. They were then randomized to either receive a naloxone kit or be given instructions on where to obtain a kit. Effectiveness of training was measured with pre- and post-training knowledge questionnaires. Naloxone kit possession, overdoses, opioid use frequency, and treatment interest were self-reported on monthly follow-up assessments.

RESULTS

Mean knowledge scores significantly increased from 6.82/9.00 to 8.22 after training (t(194)=6.85, p <0.001, 95% CI[1.00, 1.81], Cohen's d=0.85). Difference in naloxone possession between randomized groups was significant with a large effect size (p <0.001, diff=0.60, 95% CI[0.47, 0.73]). A bidirectional relationship was found between naloxone possession and frequency of opioid use. Overdoses and treatment interest were similar across possession status.

CONCLUSIONS

Overdose education is effective in online video format. Disparity in naloxone possession across groups indicates barriers to obtaining naloxone from pharmacies. Naloxone possession did not influence risky opioid use or treatment interest and its impact on frequency of use warrants further investigation.

TRIAL REGISTRATION

Clinitaltrials.gov-NCT04303000.

Estimated Reductions in Opioid Overdose Deaths With Sustainment of Public Health Interventions in 4 US States

Importance

In 2021, more than 80 000 US residents died from an opioid overdose. Public health intervention initiatives, such as the Helping to End Addiction Long-term (HEALing) Communities Study (HCS), are being launched with the goal of reducing opioid-related overdose deaths (OODs).

Objective

To estimate the change in the projected number of OODs under different scenarios of the duration of sustainment of interventions, compared with the status quo.

Design, Setting, and Participants

This decision analytical model simulated the opioid epidemic in the 4 states participating in the HCS (ie, Kentucky, Massachusetts, New York, and Ohio) from 2020 to 2026. Participants were a simulated population transitioning from opioid misuse to opioid use disorder (OUD), overdose, treatment, and relapse. The model was calibrated using 2015 to 2020 data from the National Survey on Drug Use and Health, the US Centers for Disease Control and Prevention, and other sources for each state. The model accounts for reduced initiation of medications for OUD (MOUDs) and increased OODs during the COVID-19 pandemic.

Exposure

Increasing MOUD initiation by 2- or 5-fold, improving MOUD retention to the rates achieved in clinical trial settings, increasing naloxone distribution efforts, and furthering safe opioid prescribing. An initial 2-year duration of interventions was simulated, with potential sustainment for up to 3 additional years.

Main Outcomes and Measures

Projected reduction in number of OODs under different combinations and durations of sustainment of interventions.

Results

Compared with the status quo, the estimated annual reduction in OODs at the end of the second year of interventions was 13% to 17% in Kentucky, 17% to 27% in Massachusetts, 15% to 22% in New York, and 15% to 22% in Ohio. Sustaining all interventions for an additional 3 years was estimated to reduce the annual number of OODs at the end of the fifth year by 18% to 27% in Kentucky, 28% to 46% in Massachusetts, 22% to 34% in New York, and 25% to 41% in Ohio. The longer the interventions were sustained, the better the outcomes; however, these positive gains would be washed out if interventions were not sustained.

Conclusions and Relevance

In this decision analytical model study of the opioid epidemic in 4 US states, sustained implementation of interventions, including increased delivery of MOUDs and naloxone supply, was found to be needed to reduce OODs and prevent deaths from increasing again.

Record linkage studies of drug-related deaths among adults who were released from prison to the community: a scoping review

BACKGROUND

There are public health concerns about an increased risk of mortality after release from prison. The objectives of this scoping review were to investigate, map and summarise evidence from record linkage studies about drug-related deaths among former adult prisoners.

METHODS

MEDLINE, EMBASE, PsychINFO and Web of Science were searched for studies (January 2011- September 2021) using keywords/index headings. Two authors independently screened all titles and abstracts using inclusion and exclusion criteria and subsequently screened full publications. Discrepancies were discussed with a third author. One author extracted data from all included publications using a data charting form. A second author independently extracted data from approximately one-third of the publications. Data were entered into Microsoft Excel sheets and cleaned for analysis. Standardised mortality ratios (SMRs) were pooled (where possible) using a random-effects DerSimonian-Laird model in STATA.

RESULTS

A total of 3680 publications were screened by title and abstract, and 109 publications were fully screened; 45 publications were included. The pooled drug-related SMR was 27.07 (95%CI 13.32- 55.02; I 2 = 93.99%) for the first two weeks (4 studies), 10.17 (95%CI 3.74-27.66; I 2 = 83.83%) for the first 3-4 weeks (3 studies) and 15.58 (95%CI 7.05-34.40; I 2 = 97.99%) for the first 1 year after release (3 studies) and 6.99 (95%CI 4.13-11.83; I 2 = 99.14%) for any time after release (5 studies). However, the estimates varied markedly between studies. There was considerable heterogeneity in terms of study design, study size, location, methodology and findings. Only four studies reported the use of a quality assessment checklist/technique.

CONCLUSIONS

This scoping review found an increased risk of drug-related death after release from prison, particularly during the first two weeks after release, though drug-related mortality risk remained elevated for the first year among former prisoners. Evidence synthesis was limited as only a small number of studies were suitable for pooled analyses for SMRs due to inconsistencies in study design and methodology.

Opioid-related emergency department visits and deaths after a harm-reduction intervention: a retrospective observational cohort time series analysis

BACKGROUND

To date, there has been little research on the effect of safe consumption site and community-based naloxone programs on regional opioid-related emergency department visits and deaths. We sought to determine the impact of these interventions on regional opioid-related emergency department visit and death rates in the province of Alberta.

METHODS

We used a retrospective observational design, via interrupted time series analysis, to assess municipal opioid-related emergency department visit volume and opioid-related deaths (defined by poisoning and opioid use disorder). We compared rates before and after program implementation in individual Alberta municipalities and province-wide after safe consumption site (March 2018 to October 2018) and community-based naloxone (January 2016) program implementation.

RESULTS

A total of 24 107 emergency department visits and 2413 deaths were included in the study. After safe consumption site opening, we saw decreased opioid-related emergency department visits in Calgary (level change -22.7 [-20%] visits per month, 95% confidence interval [CI] -29.7 to -15.8) and Lethbridge (level change -8.8 [-50%] visits per month, 95% CI -11.7 to -5.9), and decreased deaths in Edmonton (level change -5.9 [-55%] deaths per month, 95% CI -8.9 to -2.9). We observed increased emergency department visits after community-based naloxone program implementation in urban Alberta (level change 38.9 [46%] visits, 95% CI 33.3 to 44.4). We also observed an increase in urban opioid-related deaths (level change 9.1 [40%] deaths, 95% CI 6.7 to 11.5).

INTERPRETATION

The results of this study suggest differences exist between municipalities employing similar interventions. Our results also suggest contextual variation; for example, illicit drug supply toxicity may modify the ability of a community-based naloxone program to prevent opioid overdose without a thorough public health response.

The Impact of Naloxone Coprescribing Mandates on Opioid-Involved Overdose Deaths

INTRODUCTION

Since 2017, a total of 10 states have mandated naloxone coprescribing intended to prevent fatal opioid overdoses. This study aims to assess the association between naloxone coprescribing/offering mandates and opioid-involved overdose deaths on the basis of the opioid type.

METHODS

Data on overdose deaths from 1999 to 2020 came from the National Center for Health Statistics CDC WONDER Online Database. This study examined deaths stratified by illicit/synthetic opioids and prescription/treatment opioids. Difference-in-difference negative binomial regression models estimated average marginal effects and 95% CIs. Covariates included opioid dispensing rate, Good Samaritan law, pharmacy-based naloxone access law, mandatory use of prescription drug monitoring program, and recreational cannabis dispensaries. Data collection and analysis were conducted in 2022.

RESULTS

Ten states implemented naloxone coprescribing/offering mandates during the period. Coprescribing/offering mandates significantly reduced the number of prescription/treatment overdose deaths by 8.61 per state per quarter (95% CI= -15.13, -2.09), a 16% reduction from the counterfactual estimates. Coprescribing/offering mandates did not significantly impact illicit/synthetic overdose deaths (average marginal effect=0.32; 95% CI= -18.27, 18.91).

CONCLUSIONS

Coprescribing/offering mandates prevent overdose deaths for its target population, individuals using prescription/treatment opioids. These mandates do not appear to impact populations using illicit/synthetic opioids; thus, expanded efforts are needed to reach these individuals.

Fatal and nonfatal opioid overdose risk following release from prison: A retrospective cohort study using linked administrative data

INTRODUCTION

Among individuals who are released from prison, opioid overdose is a leading cause of death with a risk more than ten-fold the general population. Although the epidemiology of opioid-related fatalities has been described, few studies have characterized both fatal and nonfatal opioid-related poisonings. The objective of this study was to estimate risk of fatal and nonfatal opioid overdose among adults released from prison.

METHODS

The study estimated fatal and nonfatal opioid overdose rates using linked corrections, Medicaid, hospital discharge, and vital statistics from the state of Oregon from 2014 to 2018. Multivariable proportional hazards models identified demographic and prison-related factors associated with overdose.

RESULTS

Between 2014 and 2017, 18,258 individuals were released from prison. A majority of individuals were male (87 %) and ages 26 to 64 (83 %). Two-thirds had a documented substance use disorder treatment need and 20 % demonstrated mental health treatment need. Following prison release, 579 opioid overdose events occurred; 65 (11 %) were fatal. The rate of opioid overdose was 1085.7 per 100,000 person-years (PY). Rates were highest in the first two weeks (2286.7 per 100,000 PY), among women (1582.9 per 100,000 PY), and those with mental health (1624.3 per 100,000 PY) or substance use disorder treatment needs (1382.6 per 100,100 PY). Only mental health (adjusted hazard ratio [aHR] 1.54, 95 % CI 1.24 to 1.90) and substance use need (aHR 2.59; 95 % CI 2.01 to 3.34) remained significant in multivariable models.

CONCLUSIONS

The rate of opioid overdose is markedly elevated after prison release, particularly in the first two weeks. In women, the higher rate of opioid overdose is mediated by a greater mental health burden.

Fatal opioid overdoses geospatially cluster with level 1 trauma centers in Ohio

OBJECTIVE

Ohio is consistently ranked as one of the worst states for opioid overdose deaths. Traumatic injury has been linked to opioid overdose deaths, yet the location of trauma centers has not been explored. We examined whether geospatial clustering occurred between county-level opioid overdose deaths (OODs) and trauma center levels.

METHODS

We obtained 2019 county-level data from the Ohio Department of Health for fatal overdoses from prescription opioids. We obtained the total number of opioid doses prescribed in 2019 per county from the Ohio Automated Rx Reporting System and American College of Surgeons designated trauma center locations within Ohio from their website. We used geospatial analysis to assess if clustering occurred between trauma center level and prescription opioid overdose deaths at a county level.

RESULTS

There were 42 trauma centers located within 21 counties: 7 counties had level 1, and 14 counties had only level 2/level 3. There was no difference in rates of opioid doses prescribed per 100,000 people between counties with level 1 trauma centers and only level 2/level 3. However, prescription OODs rates were significantly higher in counties with level 1 trauma centers (37.6 vs 20, P = .02). Geospatial clustering was observed between level 1 trauma centers and prescription opioid overdose deaths at the county level (P < .01).

CONCLUSION

Geospatial clustering exists between prescription OODs and level 1 trauma center locations in Ohio. Improved at-risk patient identification and targeted community outreach represent opportunities for trauma providers to tackle the opioid epidemic.

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.

'I'm not going to leave someone to die': carriage of naloxone by police in Scotland within a public health framework: a qualitative study of acceptability and experiences

BACKGROUND

Scotland has one of the highest rates of drug-related deaths (DRDs) per capita in Europe, the majority of which involve opioids. Naloxone is a medication used to reverse opioid-related overdoses. In efforts to tackle escalating DRDs in many countries, naloxone is increasingly being provided to people who are likely first responders in overdose situations. This includes non-healthcare professionals, such as police officers. A pilot exercise to test the carriage and administration of naloxone by police officers was conducted in selected areas of Scotland between March and October 2021. The aim of the study was to explore the acceptability and experiences of naloxone carriage and administration by police in Scotland.

METHODS

The study comprised of two stages. Stage 1 involved in-depth one-to-one qualitative interviews with 19 community stakeholders (people with lived experience, family members, support workers). Stage 2 involved a mixture of in-depth one-to-one interviews and focus groups with 41 police officers. Data were analysed thematically, and the findings from the two stages were triangulated to develop overarching themes and subthemes.

RESULTS

By the end of the pilot, 808 police officers had been trained in the use of intranasal naloxone. Voluntary uptake of naloxone kits among police officers who completed training was 81%. There were 51 naloxone administration incidents recorded by police officers at suspected opioid-related overdose incidents during the pilot. Most officers shared positive experiences of naloxone administration. Naloxone as a first aid tool suited their role as first responders and their duty and desire to preserve life. Perceived barriers included concerns about police undertaking health-related work, potential legal liabilities and stigmatising attitudes. The majority of participants (and all community stakeholders) were supportive of the pilot and for it to be expanded across Scotland.

CONCLUSIONS

Police carriage of naloxone is an acceptable and potentially valuable harm reduction tool to help tackle the DRDs crisis in Scotland. However, it requires appropriate integration with existing health and social care systems. The intervention lies at the intersection between public health and policing and implies a more explicit public health approach to policing.

Prospective study of retention in opioid agonist treatment and contact with emergency healthcare following release from prisons in Victoria, Australia

BACKGROUND

People recently released from prison engage with emergency healthcare at greater rates than the general population. While retention in opioid agonist treatment (OAT) is associated with substantial reductions in the risk of opioid-related mortality postrelease, it is unknown how OAT affects contact with emergency healthcare. In a cohort of men who injected drugs regularly prior to imprisonment, we described rates of contact with ambulance services and EDs, and their associations with use of OAT, in the 3 months after release from prison.

METHODS

Self-report data from a prospective observational cohort of men who regularly injected drugs before a period of sentenced imprisonment, recruited between September 2014 and May 2016, were linked to state-wide ambulance and ED records over a 3-month postrelease period in Victoria, Australia. We used generalised linear models to estimate associations between OAT use (none/interrupted/retained) and contact with ambulance and EDs postrelease, adjusted for other covariates.

RESULTS

Among 265 participants, we observed 77 ambulance contacts and 123 ED contacts over a median of 98 days of observation (IQR 87-125 days). Participants who were retained in OAT between prison release and scheduled 3-month postrelease follow-up interviews had lower rates of contact with ambulance (adjusted incidence rate ratio (AIRR) 0.33, 95% CI 0.14 to 0.76) and ED (AIRR 0.43, 95% CI 0.22 to 0.83), compared with participants with no OAT use postrelease. Participants with interrupted OAT use did not differ from those with no OAT use in rates of contact with ambulance or ED.

CONCLUSION

We found lower rates of contact with emergency healthcare after release among people retained in OAT, but not among people reporting interrupted OAT use, underscoring the benefits of postrelease OAT retention. Strategies to improve accessibility and support OAT retention after leaving prison are important for men who inject drugs.

A Qualitative Analysis of Emergency Medical Services (EMS) Personnel Experiences and Perceptions Responding to Drug Overdoses in the United States (US) During the COVID-19 Pandemic

Summary

Background

The purpose of this work was to describe the experiences of EMS personnel in responding to drug overdose-related calls and the impact the pandemic has had to help better inform current response and treatment efforts.

Methods

Semi-structured interviews were conducted with 99 EMS personnel across 18 areas throughout the United States that were designated as Early Warning Network sentinel sites by the National Institute on Drug Abuse-funded National Drug Early Warning System. Participants were asked about topics including the potential burdens from the pandemic and the opioid crisis. We coded the interview responses and identified themes through qualitative analysis. Multiple cycles of descriptive coding, recoding, subcoding, pattern-coding, and thematic coding of responses were conducted.

Results

Responses were categorized into the following themes: 1) being over-worked from increased call volume; 2) increased risk for personal harm when responding to patients; 3) compassion fatigue due to long hours and repeat calls for the same people; 4) conflicting perceptions of the utility of naloxone; 5) the need for better treatment options to respond to opioid crisis on top of COVID-19.

Conclusions

The burden of the substance use disorder (SUD) crisis on EMS personnel has been compounded by the COVID-19 pandemic. These reports from EMS personnel throughout the US can help inform policy and procedures to better protect the mental health of EMS personnel and to ensure better care for patients with SUD. These experiences and recommendations may be of use for other countries as substance use and COVID-19 are global health issues.

The Effect of Naloxone Access Laws on Fatal Synthetic Opioid Overdose Fatality Rates

BACKGROUND

Increases in fatal synthetic opioid overdoses over the past 8 years have left states scrambling for effective means to curtail these deaths. Many states have implemented policies and increased service capacity to address this rise. To better understand the effectiveness of policy level interventions we estimated the impact of the presence of naloxone access laws (NALs) on synthetic opioid fatalities at the state level.

METHODS

A multivariable longitudinal linear mixed model with a random intercept was used to determine the relationship between the presence of NALs and synthetic opioid overdose death rates, while controlling for, Good Samaritan laws, opioid prescription rate, and capacity for medication for opioid use disorder (MOUD), utilizing a quadratic time trajectory. Data for the study was collected from the National Vital Statistics System using multiple cause-of-death mortality files linked to drug overdose deaths.

RESULTS

The presence of an NAL had a significant (univariate P-value = .013; multivariable p-value = .010) negative relationship to fentanyl overdose death rates. Other significant controlling variables were quadratic time (univariate and multivariable P-value < .001), MOUD (univariate P-value < .001; multivariable P-value = .009), and Good Samaritan Law (univariate P-value = .033; multivariable P-value = .018).

CONCLUSION

Naloxone standing orders are strongly related to fatal synthetic opioid overdose reduction. The effect of NALs, MOUD treatment capacity, and Good Samaritan laws all significantly influenced the synthetic opioid overdose death rate. The use of naloxone should be a central part of any state strategy to reduce overdose death rate.

Harm reduction: a public health approach to prison drug use

PURPOSE

As prison drug use continues to be a concern worldwide, harm reduction practices serve as an alternative approach to traditional abstinence-only or punishment-oriented methods to address substance use behind bars. The purpose of this study is to present a summary of research surrounding prison-based harm reduction programs.

DESIGN/METHODOLOGY/APPROACH

This narrative review of the international literature summarizes the harms associated with prison drug use followed by an overview of the literature surrounding three prison-based harm reduction practices: opioid agonist therapy, syringe exchange programs and naloxone distribution.

FINDINGS

A collection of international research has found that these three harm reduction programs are safe and feasible to implement in carceral settings. Additionally, these services can effectively reduce some of the harms associated with prison drug use (e.g. risky injection practices, needle sharing, fatal overdoses, etc.). However, these practices are underused in correctional settings in comparison to their use in the community.

ORIGINALITY/VALUE

Various policy recommendations are made based on the available literature, including addressing ethical concerns surrounding prison populations' rights to the same standard of health care and services available in the community. By taking a public health approach to prison drug use, harm reduction practices can provide a marginalized, high-risk population of incarcerated individuals with life-saving services rather than punitive, punishment-oriented measures.

The Significant Impact of Narcan Reversals on Overdose Mortality in Peoria County, IL

Objectives: Determine the impact of Narcan administrations in Peoria County, IL on the number of overdose deaths by testing the statistical significance of the association between monthly Narcan reversals and overdose mortality. As well as re-shedding the light on the opioid pandemic post-COVID.

Methods: We collected data on Narcan reversals from hospital emergency departments, Emergency Medical Services (EMS), the County Sheriff’s Office, local police departments, and other agencies that distributed and/or administered Narcan in Peoria County from January through December 2018. Data for the 2018 overdose mortality was collected through vital records at the Peoria City/County Health Department.

Results: Results from simple linear regression suggest that a significant proportion of the total variation in overdose mortality over 2018 was predicted by the Narcan reversals, F(1, 11) = 5.872, p< 0.05. Multiple R² indicates that approximately 30.7% of the variation in overdose mortality was predicted by the Narcan reversals. If there were 0 Narcan reversals, there would be 8.362 overdose deaths per month.

Conclusions: Narcan is known to save lives in cases of opioid overdose, and the need for increased administration campaigns is warranted to further battle the opioid epidemic. As this study has proven, Narcan administration has the potential to significantly decrease overdose mortality.

Study-design in pandemics: From surveillance and performance-evaluation to licensing and pharmacovigilance

Andy Grieve, the first pharmaceutical statistician to be President of the Royal Statistical Society, practiced in the regulated world of drug development. With reduction in drug development costs as his motivation, Grieve advanced Bayesian methods for developing predictive methods for efficacy and toxicity - to be used as early as possible in the drug development process; and his presidential address exhorted statisticians to weigh-in wherever data are used to make decisions. Diagnostic tests for infectious diseases are less regulated than drugs and vaccines unless the blood supply is at risk. Unlike in the HIV and HCV pandemics of the late 20th century, even well-designed surveys linked to a volunteered biological sample (to be tested for SARS-CoV-2 antigen or antibodies) have had modest or low consent rates. Record-linkage, statistical design and reporting standards have seen triumph and tragedy. Among the triumphs are: Liverpool's insistence on dual testing (lateral flow device; polymerase chain reaction [PCR]) of some 6000 asymptomatic citizens who attended for SARS-CoV-2-screening; two tricky randomized controlled public-policy trials on daily contact testing for close contacts of index cases of SARS-CoV-2 infection versus self-isolation (with or without initial PCR); and among already-consented participants in surveillance, over 80% secondary consent for linkage to their health records, including the Immunization Management Service. Before the next pandemic we need to entrench better regulation of diagnostic tests, better informed consent (not via weblinks), better feedback to participants, and transparency about basic safety data.

Impact of a publicly funded pharmacy-dispensed naloxone program on fatal opioid overdose rates: A population-based study

BACKGROUND

Studies examining the impact of pharmacy-dispensed naloxone programs on fatal opioid overdose rates are lacking. We examined the impact of the publicly funded Ontario Naloxone Program for Pharmacies (ONPP), implemented in June 2016, on provincial rates of opioid overdose deaths.

METHODS

We conducted a population-based interrupted time-series study between July 1, 2012 and December 31, 2018. We considered a parsimonious model with terms for time, ONPP implementation, and time following the ONPP implementation. Models were adjusted for population characteristics, number of pharmacies and rate of naloxone distributed through non-pharmacy sites within provincial public health units.

RESULTS

In the parsimonious model, the ONPP was associated with a non-significant 9% reduction in the level of fatal opioid overdoses (rate ratio [RR] 0.91; 95% confidence interval [CI] 0.79-1.06), a finding that was most pronounced in regions in the lowest tertile of implementation (RR 0.75; 95% CI 0.62-0.91). Following multivariable adjustment, there was an increase in the level (RR 1.06; 95% CI 0.94-1.19) and slope change (RR 1.06; 95% CI 1.02-1.10) of fatal overdose rates.

CONCLUSION

The ONPP is insufficient as a single intervention to meaningfully reduce rates of fatal opioid overdoses during a period in which the cause of these deaths shifted from prescription opioids to highly potent fentanyl analogs. Access to additional harm reduction, treatment, and other interventions is necessary to prevent deaths and optimize the health of people who use drugs.

Community Distribution of Naloxone: A Systematic Review of Economic Evaluations

BACKGROUND

As a core component of harm-reduction strategies to address the opioid crisis, several countries have instituted publicly funded programs to distribute naloxone for lay administration in the community. The effectiveness in reducing mortality from opioid overdose has been demonstrated in multiple systematic reviews. However, the economic impact of community naloxone distribution programs is not fully understood.

OBJECTIVES

Our objective was to conduct a review of economic evaluations of community distribution of naloxone, assessing for quality and applicability to diverse contexts and settings.

DATA SOURCES

The search strategy was performed on MEDLINE, Embase, and EconLit databases.

STUDY ELIGIBILITY CRITERIA AND INTERVENTIONS

Search criteria were developed based on two themes: (1) papers involving naloxone or narcan and (2) any form of economic evaluation. A focused search of the grey literature was also conducted. Studies exploring the intervention of community distribution of naloxone were selected.

STUDY APPRAISAL AND SYNTHESIS METHODS

Data extraction was done using the British Medical Journal guidelines for economic submissions, assigning quality levels based on the impact of the missing or unclear components on the strength of the conclusions.

RESULTS

A total of nine articles matched our inclusion criteria: one cost-effectiveness analysis, eight cost-utility analyses, and one cost-benefit analysis. Overall, the quality of the studies was good (six of high quality, two of moderate quality, and one of low quality). All studies concluded that community distribution of naloxone was cost effective, with an incremental cost-utility ratio range of $US111-58,738 (year 2020 values) per quality-adjusted life-year gained.

LIMITATIONS

Our search strategy was developed iteratively, rather than following an a priori design. Additionally, our search was limited to English terms.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

Based on this review, community distribution of naloxone is a worthwhile investment and should be considered by other countries dealing with the opioid epidemic.

The Overdose Response with Take Home Naloxone (ORTHN) project: Evaluation of health worker training, attitudes and perceptions

INTRODUCTION

Naloxone is a life-saving medication that reverses opioid overdose; naloxone can be provided on a 'take-home' basis so naloxone can be administered outside of the health-care setting. The Overdose Response and Take Home Naloxone (ORTHN) project established a model of care for take-home naloxone (THN) interventions across alcohol and other drug and harm reduction services in NSW, Australia. This paper evaluates the staff training and credentialing program, and examines staff attitudes and perspectives regarding the provision of THN interventions in these settings.

METHODS

Staff across seven services were trained through a 'train-the-trainer' credentialing model to deliver ORTHN, including naloxone supply. Staff were surveyed regarding their experience, attitudes and knowledge on THN prior to and after training, and after 6 months. At the 6 months follow up, staff were asked about the interventions they provided, barriers and enablers to uptake, and opinions regarding future rollout.

RESULTS

A total of 204 staff were trained and credentialed to provide the ORTHN intervention. Most (60%) were nurses, followed by needle syringe program workers and allied health/counsellors (32%). Linear and logistic regression analyses indicated that the training program was associated with significant improvements in staff knowledge and attitudes towards overdose and THN; however, only attitudinal improvements were maintained over time. There were high rates of staff satisfaction with the ORTHN intervention and training.

DISCUSSION/CONCLUSIONS

The ORTHN program is 'fit for purpose' for broad implementation in these settings. A number of potential barriers (e.g. time, medication and staffing costs) and enablers (e.g. peer engagement, regulatory framework for naloxone supply) in implementing THN interventions were identified.

Characteristics of and Experience Among People Who Use Take-Home Naloxone in Skåne County, Sweden

Background

Opioid overdose related injury or death can be prevented by bystander naloxone administration. For naloxone to be present when and where overdoses occur, opioid prevention education and naloxone distribution (OPEND) must be established on a broad level. This is the 30-month follow-up of the first multi-site naloxone project in Sweden, implemented at 31 sites in the County of Skåne 2018.

Aim

To address participant characteristics and factors associated with returning for naloxone refill and with having used naloxone for overdose reversal. An additional aim was to describe self-reported reasons for naloxone refill and overdose experiences.

Methods

Data were collected during June 2018-December 2020 through questionnaires at baseline and upon naloxone refill of the initial and subsequent naloxone kit. Descriptive statistics was used to address participant characteristics, those returning for naloxone refill and reporting overdose reversal. Chi-2 test was used for variable comparison between groups. Factors associated with overdose reversals were examined by logistic regression analysis. Reasons for naloxone refill, overdose situation and management were presented descriptively.

Results

Among 1,079 study participants, 22% (n = 235) returned for naloxone refill, of which 60% (n = 140) reported a total of 229 overdose reversals. Reversals were more likely to be reported by participants trained at needle exchange programs (NEPs) [adjusted odds ratio (AOR) = 5.18, 95% Confidence interval (CI) = 3.38-7.95)], with previous experience of own (AOR = 1.63, 95% CI = 1.03-2.58) or witnessed (AOR = 2.12, 95% CI = 1.05-4.29) overdose, or who had used sedatives during the last 30 days before initial training (AOR = 1.56, 95% CI = 1.04-2.33). A majority of overdoses reportedly occurred in private settings (62%), where the victim was a friend (35%) or acquaintance (31%) of the rescuer.

Conclusion

Participants with own risk factors associated with overdose (e.g., injection use, concomitant use of benzodiazepines and previous experience of own overdose) were more likely to report administering naloxone for overdose reversal. Overdose management knowledge was high. The findings indicate that implementation of multi-site OPEND reaches individuals at particularly high risk of own overdose in settings with limited previous harm reduction strategies and favors a further scaling up of naloxone programs in similar settings.

Do naloxone access laws affect perceived risk of heroin use? Evidence from national US data

BACKGROUND AND AIMS

Whether expanded access to naloxone reduces perceptions of risk about opioid use has been subject to debate. Our aim was to assess how implementation of naloxone access laws shapes perceived risk of heroin use.

DESIGN

Using data from the restricted-access National Survey on Drug Use and Health, Prescription Drug Abuse Policy System and the US Census, we applied two-way fixed-effects models to determine whether naloxone access laws decreased perceived risk of any heroin use or regular heroin use. We used Bayes factors (BFs) to confirm evidence for null findings.

SETTING

United States.

PARTICIPANTS

A total of 884 800 respondents aged 12 and older from 2004 to 2016.

MEASUREMENTS

A binary indicator of whether a state implemented naloxone access laws was regressed on respondent-perceived risk of (1) any heroin use and (2) regular heroin use. Ratings of perceived risk were assessed on a scale of 1 (none) to 4 (great risk).

FINDINGS

In all instances, the BFs support evidence for the null hypothesis. Across models with three distinct specifications of naloxone access laws, we found no evidence of decreased risk perceptions, as confirmed by BFs ranging from 0.009 to 0.057. Across models of specific vulnerable subgroups, such as people who use opioids (BFs = 0.039-0.225) or young people (BFs = 0.009-0.158), we found no evidence of decreased risk perceptions. Across diverse subpopulations by gender (BFs = 0.011-0.083), socio-economic status (BFs = 0.015-0.168) or race/ethnicity (BFs = 0.016-0.094), we found no evidence of decreased risk perceptions.

CONCLUSIONS

There appears to be no empirical evidence that implementation of naloxone access laws has adversely affected perceptions of risk of heroin in the broader US population or within vulnerable subgroups or diverse subpopulations.