Personal social network factors associated with overdose prevention training participation

Overdose education and naloxone distribution program design informed by people who use drugs and naloxone distributors

People who use drugs (PWUD) are the most directly affected by the overdose epidemic. However, they are not often targets of overdose education and naloxone distribution (OEND) programs. Instead, these programs target friends or family members of people prescribed opioids or general community members. This study aimed to understand the perspectives of PWUD and community naloxone distributors on OEND program design. We used a community-based participatory research model to elucidate participant perspectives on what OEND programs should look like in the context of each individual's specific risk environment. We conducted semi-structured in-depth interviews with PWUD and naloxone distributors (n = 30) in New Brunswick and Newark, New Jersey between February and November of 2022. We analyzed interviews using thematic analysis and identified the following themes: increasing naloxone knowledge, peer-based naloxone access, increasing PWUD-informed OEND program design, and desired broader OEND program scope. All Participants knew what naloxone was and emphasized that naloxone needed to be ubiquitous in the community. Participants prioritized peer-based distribution, integrating distribution into community organizations, and addressing psychosocial issues related to naloxone administration and drug use. In summary, PWUD and community naloxone distributors emphasized peer-led community naloxone distribution that prioritized novel ways for PWUD to access naloxone. OEND program design should prioritize PWUD's perspectives and direct community naloxone distribution.

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

Background

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

Methods

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

Results

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

Conclusions

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

Health risk associated with residential relocation among people who inject drugs in Los Angeles and San Francisco, CA: a cross sectional study

Background

Given the housing instability and frequent residential relocation (both volitional and hegemonic) of people who inject drugs, we sought to determine whether residential relocation (defined as sleeping in a different place in the past 30 days) is associated with health outcomes in a sample of people who inject drugs (PWID).

Methods

We recruited 601 PWID using targeted sampling and interviewed them between 2016 and 2018 in San Francisco and Los Angeles, CA about housing, drug use practices, and service utilization. We then developed multivariable regression models to investigate how residential relocation is associated with violence, health outcomes, and social service access. We analyzed our data between June 2018 and October 2019.

Results

Participants who relocated in the past 30 days had lower odds of being in substance use treatment (Adjusted Odds Ratio [AOR] = 0.62, 95% Confidence Interval [CI] = 0.42, 0.89) and higher odds of nonfatal overdose (AOR = 2.50, CI = 1.28, 4.90), receptive syringe sharing (AOR = 2.26, CI = 1.18, 4.32), severe food insecurity (AOR = 1.69, CI = 1.14, 2.50), having belongings stolen (AOR = 2.14, CI = 1.42, 3.21), experiencing physical assault (AOR = 1.58, CI = 1.03, 2.43), arrest (AOR = 1.64, CI = 1.02, 2.65), and jail (AOR = 1.90, CI = 1.16, 3.13) in the past 6 months when compared to those who did not relocate.

Conclusions

PWID who have relocated in the past 30 days have higher odds of experiencing violence and life- threatening adverse outcomes, and policies that disrupt living circumstances of PWID should be ended in favor of those that support housing stability.

Legacies of the war on drugs: Next of kin of persons who died of opioid overdose and harm reduction interventions in Philadelphia

BACKGROUND

Between the years 2017-2019 in Philadelphia, more than 70% of all deaths from opioid overdose occurred in a private residence. To learn more about home-based opioid use and overdose, researchers conducted qualitative interviews with next of kin of overdose victims to learn their perceptions about the decedent's drug use and their opinions about city-led harm reduction efforts, specifically naloxone administration and collaborative efforts to open an overdose prevention site.

METHODS

In 2019, researchers conducted 35 qualitative interviews with next of kin of persons who died of opioid overdose in Philadelphia in 2017. Data were coded and analyzed using NVivo software.

RESULTS

Data reveal that while persons who use drugs may benefit from enhanced harm reduction interventions that target their family members and caregivers including naloxone education and public health messaging about overdose prevention, these efforts may be up against other realities that Philadelphia families navigate-in particular structural inequalities exacerbated by decades of "War on Drugs" policies.

CONCLUSION

Existing health disparities and structural barriers to care increase vulnerability to overdose and highlight the urgency to collaborate with impacted families and communities to design relevant harm reduction interventions. Without efforts to redress the consequences of war on drug policies, however, harm reduction interventions will not reach their full potential.

"You've got to care to carry this stuff" Community implications from take-home naloxone use: A qualitative study

BACKGROUND

In New Mexico, drug overdose rates have been among the highest in the nation for the past two decades, with 332 overdose deaths involving opioids in 2017. While interventions aimed at enhancing distribution and uptake of take-home naloxone (THN) have identified people who use opioids as viable candidates, there exists a gap in applying these findings to underserved, ethnic minority women.

METHODS

We conducted qualitative interviews with participants recruited from a parent study which recruited 395 women diagnosed with OUD who participated in a two year study (April 2016-May 2018) during which they received opioid overdose education and two free THN kits for their use.

RESULTS

Findings characterize the social dynamics of persistent opioid exposure, accidental overdose, and take home naloxone use to reverse overdose, and we identified three overarching themes: 1) Crisis management and community responsibility; 2) Complex social networks as informal channels for family to family and peer to peer naloxone distribution and education; and 3) Participant preferences and strategies for THN distribution and education.

CONCLUSIONS

Participants in the ASAP program demonstrated an unquestionable willingness to distribute naloxone when they had access to it, and the ability to replace it. Further research is warranted to apply these findings in interventional contexts to refine strategies toward prioritizing distribution of THN, enhance training tools and optimize community locations for engagement.

"I Gotta Go With Modern Technology, So I'm Gonna Give 'em the Narcan": The Diffusion of Innovations and an Opioid Overdose Prevention Program

Fatal opioid overdoses can be prevented by opioid overdose prevention programs (OOPPs). The present study qualitatively examined the diffusion process of an OOPP among 30 persons who inject drugs (PWIDs) in an opioid-saturated community. Purposive sampling was used to recruit participants into three groups based on familiarity with the OOPP. Findings revealed that participants often adopted the OOPP, which was offered by a local harm reduction organization, if first exposed by staff hosting and implementing it. Barriers to adoption included belief that OOPP training was lengthy or unnecessary, lack of perceived relative advantage, nonengagement with the host organization, and trepidation of administering withdrawal-causing medication to fellow PWIDs. Participants outside of networks diffusing the OOPP were isolated from other PWIDs. Staff from the host organization were influential in encouraging OOPP adoption, which underscores their importance in the effort to reduce fatal overdoses.

Yes, not now, or never: an analysis of reasons for refusing or accepting emergency department-based take-home naloxone

OBJECTIVE

Take-home naloxone (THN) reduces deaths from opioid overdose. To increase THN distribution to at-risk emergency department (ED) patients, we explored reasons for patients' refusing or accepting THN.

METHODS

In an urban teaching hospital ED, we identified high opioid overdose risk patients according to pre-specified criteria. We offered eligible patients THN and participation in researcher-administered surveys, which inquired about reasons to refuse or accept THN and about THN dispensing location preferences. We analyzed refusal and acceptance reasons in open-ended responses, grouped reasons into categories (absolute versus conditional refusals,) then searched for associations between patient characteristics and reasons.

RESULTS

Of 247 patients offered THN, 193 (78.1%) provided reasons for their decision. Of those included, 69 (35.2%) were female, 91 (47.2%) were under age 40, 61 (31.6%) were homeless, 144 (74.6%) reported injection drug use (IDU), and 131 (67.9%) accepted THN. Of 62 patients refusing THN, 19 (30.7%) felt "not at risk" for overdose, while 28 (45.2%) gave conditional refusal reasons: "too sick," "in a rush," or preference to get THN elsewhere. Non-IDU was associated with stating "not at risk," while IDU, homelessness, and age under 40 were associated with conditional refusals. Among acceptances, 86 (65.7%) mentioned saving others as a reason. Most respondents preferred other dispensing locations beside the ED, whether or not they accepted ED THN.

CONCLUSION

ED patients refusing THN felt "not at risk" for overdose or felt their ED visit was not the right time or place for THN. Most accepting THN wanted to save others.

Association between non-fatal opioid overdose and encounters with healthcare and criminal justice systems: Identifying opportunities for intervention

BACKGROUND

Accidental overdose, driven largely by opioids, is a leading cause of death among people who inject drugs (PWIDs). We conducted secondary analysis of data from a cohort of PWIDs to identify venues where high-risk PWID could be targeted by overdose education/naloxone distribution (OEND) programs.

METHODS

573 PWIDs completed a quantitative survey between June, 2012 and January, 2014, which was analyzed using multivariable logistic regression. The dependent variable was a dichotomous indicator of experiencing a heroin/opioid-related overdose in the past six months. Independent variables included: demographics, drug use behavior, and encounters with two venues - the health care and criminal justice systems - that could serve as potential venues for OEND programs.

RESULTS

Almost half (41.5%) reported ever experiencing a heroin/opioid overdose, and 45 (7.9%) reported experiencing at least one heroin/opioid overdose in the past six months. In the final multivariable model, receiving care in a hospital in the past six months (Adjusted Odds Ratio [AdjOR] 4.08, 95% Confidence Interval [C.I.] 2.07, 8.04, p<0.001) and being arrested for drug possession in the past six months (AdjOR 5.17, 95% C.I. 2.37, 11.24, p<0.001) were associated with experiencing an opioid overdose in the past six months.

CONCLUSIONS

Identifying venues outside of those that traditionally target services to PWIDs (i.e., syringe exchange programs) will be critical to implementing OEND interventions at a scale sufficient to address the growing epidemic of heroin/opioid related deaths. Clinical settings, such as hospitals, and drug-related encounters with law enforcement officers are promising venues for the expansion of OEND programs.

"I felt like a superhero": the experience of responding to drug overdose among individuals trained in overdose prevention

BACKGROUND

Overdose prevention programs (OPPs) train people who inject drugs and other community members to prevent, recognise and respond to opioid overdose. However, little is known about the experience of taking up the role of an "overdose responder" for the participants.

METHODS

We present findings from qualitative interviews with 30 participants from two OPPs in Los Angeles, CA, USA from 2010 to 2011 who had responded to at least one overdose since being trained in overdose prevention and response.

RESULTS

Being trained by an OPP and responding to overdoses had both positive and negative effects for trained "responders". Positive effects include an increased sense of control and confidence, feelings of heroism and pride, and a recognition and appreciation of one's expertise. Negative effects include a sense of burden, regret, fear, and anger, which sometimes led to cutting social ties, but might also be mitigated by the increased empowerment associated with the positive effects.

CONCLUSION

Findings suggest that becoming an overdose responder can involve taking up a new social role that has positive effects, but also confers some stress that may require additional support. OPPs should provide flexible opportunities for social support to individuals making the transition to this new and critical social role. Equipping individuals with the skills, technology, and support they need to respond to drug overdose has the potential to confer both individual and community-wide benefits.