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Patel SV, Wenger LD, Kral AH, Sherr K, Wagner AD, Davidson PJ, Lambdin BH. Optimizing naloxone distribution to prevent opioid overdose fatalities: results from piloting the Systems Analysis and Improvement Approach within syringe service programs. BMC Health Serv Res 2023; 23:278. [PMID: 36949494 PMCID: PMC10035142 DOI: 10.1186/s12913-023-09289-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Accepted: 03/13/2023] [Indexed: 03/24/2023] Open
Abstract
BACKGROUND Opioid overdose fatalities are preventable with timely administration of naloxone, an opioid antagonist, during an opioid overdose event. Syringe service programs have pioneered naloxone distribution for potential bystanders of opioid overdose. The objective of this study was to pilot test a multi-component implementation strategy-the systems analysis and improvement approach for naloxone (SAIA-Naloxone)-with the goal of improving naloxone distribution by syringe service programs. METHODS Two syringe service programs participated in a 6-month pilot of SAIA-Naloxone, which included (1) analyzing program data to identify gaps in the naloxone delivery cascade, (2) flow mapping to identify causes of attrition and brainstorm programmatic changes for improvement, and (3) conducting continuous quality improvement to test and assess whether modifications improve the cascade. We conducted an interrupted time series analysis using 52 weeks of data before and 26 weeks of data after initiating SAIA-Naloxone. Poisson regression was used to evaluate the association between SAIA-Naloxone and the weekly number of participants receiving naloxone and number of naloxone doses distributed. RESULTS Over the course of the study, 11,107 doses of naloxone were distributed to 6,071 participants. Through SAIA-Naloxone, syringe service programs prioritized testing programmatic modifications to improve data collection procedures, proactively screen and identify naloxone-naïve participants, streamline naloxone refill systems, and allow for secondary naloxone distribution. SAIA-Naloxone was associated with statistically significant increases in the average number of people receiving naloxone per week (37% more SPP participants; 95% CI, 12% to 67%) and average number of naloxone doses distributed per week (105% more naloxone doses; 95% CI, 79% to 136%) beyond the underlying pre-SAIA-Naloxone levels. These initial increases were extended by ongoing positive changes over time (1.6% more SSP participants received naloxone and 0.3% more naloxone doses were distributed in each subsequent week compared to the weekly trend in the pre-SAIA Naloxone period). CONCLUSIONS SAIA-Naloxone has strong potential for improving naloxone distribution from syringe service programs. These findings are encouraging in the face of the worsening opioid overdose crisis in the United States and support testing SAIA-Naloxone in a large-scale randomized trial within syringe service programs.
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Affiliation(s)
- Sheila V Patel
- Center for Behavioral Health Epidemiology, Implementation, and Evaluation Research, Community Health Research Division, RTI International, 3040 E. Cornwallis Rd, Research Triangle Park, NC, 27709, USA.
| | - Lynn D Wenger
- Center for Behavioral Health Epidemiology, Implementation, and Evaluation Research, Community Health Research Division, RTI International, 3040 E. Cornwallis Rd, Research Triangle Park, NC, 27709, USA
| | - Alex H Kral
- Center for Behavioral Health Epidemiology, Implementation, and Evaluation Research, Community Health Research Division, RTI International, 3040 E. Cornwallis Rd, Research Triangle Park, NC, 27709, USA
| | - Kenneth Sherr
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
- Department of Industrial & Systems Engineering, University of Washington, Seattle, WA, USA
| | - Anjuli D Wagner
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Peter J Davidson
- Department of Medicine, Division Global Public Health, Herbert Wertheim School of Public Health and Human Longevity Science, University of California San Diego, San Diego, CA, USA
| | - Barrot H Lambdin
- Center for Behavioral Health Epidemiology, Implementation, and Evaluation Research, Community Health Research Division, RTI International, 3040 E. Cornwallis Rd, Research Triangle Park, NC, 27709, USA
- Department of Global Health, University of Washington, Seattle, WA, USA
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, CA, USA
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Modeling of overdose and naloxone distribution in the setting of fentanyl compared to heroin. Drug Alcohol Depend 2022; 236:109478. [PMID: 35588609 PMCID: PMC9235402 DOI: 10.1016/j.drugalcdep.2022.109478] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 04/22/2022] [Accepted: 04/25/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Fentanyl has replaced most other non-prescribed opioids in much of North America. There is controversy over whether a hypothetical reduced efficacy of naloxone in reversing fentanyl is a major contributor to the coincident rising overdose mortality. METHODS We modified an existing Markov decision analytic model of heroin overdose and naloxone distribution to account for known risks of fentanyl by adjusting overdose risk, the likelihood of death in the event of overdose, and the proportion of cases in which available naloxone was administered in time to prevent death. We assumed near-universal survival when naloxone was administered promptly for heroin or fentanyl overdose, but allowed that to decline in sensitivity analyses for fentanyl. We varied the proportion of use that was fentanyl and adjusted the modified parameters accordingly to estimate mortality as the dominant opioid shifted. RESULTS Absent naloxone, the annual overdose death rate was 1.0% and 4.1% for heroin and fentanyl, respectively. With naloxone reaching 80% of those at risk, the overdose death rate was 0.7% and 3.6% for heroin and fentanyl, respectively, representing reductions of 26.4% and 12.0%. Monte Carlo simulations resulted in overdose mortality with fentanyl of 3.3-5.2% without naloxone and 2.6-4.9% with naloxone, with 95% certainty. Positing reduced efficacy for naloxone in reversing fentanyl resulted in 3.6% of fentanyl overdose deaths being prevented by naloxone. CONCLUSIONS Heightened risk for overdose and subsequent death, alongside the time-sensitive need for naloxone administration, fully account for increased mortality when fentanyl replaces heroin, assuming optimal pharmacologic efficacy of naloxone.
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Cherrier N, Kearon J, Tetreault R, Garasia S, Guindon E. Community Distribution of Naloxone: A Systematic Review of Economic Evaluations. PHARMACOECONOMICS - OPEN 2022; 6:329-342. [PMID: 34762276 PMCID: PMC8581604 DOI: 10.1007/s41669-021-00309-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/06/2021] [Indexed: 05/05/2023]
Abstract
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.
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Affiliation(s)
- Nelda Cherrier
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Joanne Kearon
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada.
| | - Robin Tetreault
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
| | - Sophiya Garasia
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada
| | - Emmanuel Guindon
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, Canada
- Centre for Health Economics and Policy Analysis, McMaster University, Hamilton, ON, Canada
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Strang J. Take-Home Naloxone and the Prevention of Deaths from Heroin Overdose: Pursuing Strong Science, Fuller Understanding, Greater Impact. Eur Addict Res 2022; 28:161-175. [PMID: 34963112 DOI: 10.1159/000519939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 09/07/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND CONTEXT Realization of the life-saving potential of "take-home naloxone" has been a personal journey, but it has also been a collective journey. It has been a story of individual exploration and growth, and also a story of changes at a societal level. "Take-home naloxone" has matured since its first conceptualization a quarter of a century ago. It required recognition of the enormous burden of deaths from drug overdose (particularly heroin and other opioids), and also realization of critical clusterings (such as post-release from prison). It also required realization that, since many overdose deaths are witnessed, we can potentially prevent many deaths by mobilizing drug users themselves, their families, and the wider caring community to act as intervention workforce to give life-saving interim emergency care. Summary of Scope: This article explores 5 areas (many illustrations UK-based where the author works): firstly, the need for strong science; secondly, our improved understanding of opioid overdose and deaths; thirdly, the search for greater impact from our policies and interventions; fourthly, developing better forms of naloxone; and fifthly, examining the challenges still to be addressed. KEY MESSAGES "Take-home naloxone" is an exemplar of harm reduction with potential global impact - drug policy and practice for the public good. However, "having the potential" is not good enough - there needs to be actual implementation. This will be easier once the component parts of "take-home naloxone" are improved (better naloxone products, better training aids, revised legislation, and explicit funding support). Many improvements are already possible, but we hesitate about implementation. It is our responsibility to drive progress faster. With "take-home naloxone," we can be proud of what we have achieved, but we must also be humble about how much more we still need to do.
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Affiliation(s)
- John Strang
- National Addiction Centre, Kings College London, London, United Kingdom
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Behrends CN, Gutkind S, Winkelstein E, Wright M, Dolatshahi J, Welch A, Paone D, Kunins HV, Schackman BR. Costs of opioid overdose education and naloxone distribution in New York City. Subst Abus 2022; 43:692-698. [PMID: 34666633 PMCID: PMC9048167 DOI: 10.1080/08897077.2021.1986877] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background: Naloxone is an opioid antagonist medication that can be administered by lay people or medical professionals to reverse opioid overdoses and reduce overdose mortality. Cost was identified as a potential barrier to providing expanded overdose education and naloxone distribution (OEND) in New York City (NYC) in 2017. We estimated the cost of delivering OEND for different types of opioid overdose prevention programs (OOPPs) in NYC. Methods: We interviewed naloxone coordinators at 11 syringe service programs (SSPs) and 10 purposively sampled non-SSPs in NYC from December 2017 to September 2019. The samples included diverse non-SSP program types, program sizes, and OEND funding sources. We calculated one-time start up costs and ongoing operating costs using micro-costing methods to estimate the cost of personnel time and materials for OEND activities from the program perspective, but excluding naloxone kit costs. Results: Implementing an OEND program required a one-time median startup cost of $874 for SSPs and $2,548 for other programs excluding overhead, with 80% of those costs attributed to time and travel for training staff. SSPs spent a median of $90 per staff member trained and non-SSPs spent $150 per staff member. The median monthly cost of OEND program activities excluding overhead was $1,579 for SSPs and $2,529 for non-SSPs. The costs for non-SSPs varied by size, with larger, multi-site programs having higher median costs compared to single-site programs. The estimated median cost per kit dispensed excluding and including overhead was $19 versus $25 per kit for SSPs, and $36 versus $43 per kit for non-SSPs, respectively. Conclusions: OEND operating costs vary by program type and number of sites. Funders should consider that providing free naloxone to OEND programs does not cover full operating costs. Further exploration of cost-effectiveness and program efficiency should be considered across different types of OEND settings.
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Affiliation(s)
- Czarina N. Behrends
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY
| | - Sarah Gutkind
- Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY
| | - Emily Winkelstein
- Bureau of Alcohol and Drug Use Prevention, Care and Treatment, New York City Department of Health and Mental Hygiene, Queens, New York
| | - Monique Wright
- Bureau of Alcohol and Drug Use Prevention, Care and Treatment, New York City Department of Health and Mental Hygiene, Queens, New York
| | - Jennifer Dolatshahi
- Bureau of Alcohol and Drug Use Prevention, Care and Treatment, New York City Department of Health and Mental Hygiene, Queens, New York
| | - Alice Welch
- Bureau of Alcohol and Drug Use Prevention, Care and Treatment, New York City Department of Health and Mental Hygiene, Queens, New York
| | - Denise Paone
- Bureau of Alcohol and Drug Use Prevention, Care and Treatment, New York City Department of Health and Mental Hygiene, Queens, New York
| | - Hillary V. Kunins
- Bureau of Alcohol and Drug Use Prevention, Care and Treatment, New York City Department of Health and Mental Hygiene, Queens, New York
| | - Bruce R. Schackman
- Department of Population Health Sciences, Weill Cornell Medical College, New York, NY
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Cerdá M, Jalali MS, Hamilton AD, DiGennaro C, Hyder A, Santaella-Tenorio J, Kaur N, Wang C, Keyes KM. A Systematic Review of Simulation Models to Track and Address the Opioid Crisis. Epidemiol Rev 2021; 43:147-165. [PMID: 34791110 DOI: 10.1093/epirev/mxab013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 10/20/2021] [Accepted: 11/04/2021] [Indexed: 01/04/2023] Open
Abstract
The opioid overdose crisis is driven by an intersecting set of social, structural, and economic forces. Simulation models offer a tool to help us understand and address this complex, dynamic, and nonlinear social phenomenon. We conducted a systematic review of the literature on simulation models of opioid use and overdose up to September 2019. We extracted modeling types, target populations, interventions, and findings. Further, we created a database of model parameters used for model calibration, and evaluated study transparency and reproducibility. Of the 1,398 articles screened, we identified 88 eligible articles. The most frequent types of models were compartmental (36%), Markov (20%), system dynamics (16%), and Agent-Based models (16%). Over a third evaluated intervention cost-effectiveness (40%), and another third (39%) focused on treatment and harm reduction services for people with opioid use disorder (OUD). More than half (61%) discussed calibrating their models to empirical data, and 31% discussed validation approaches used in their modeling process. From the 63 studies that provided model parameters, we extracted the data sources on opioid use, OUD, OUD treatment, cessation/relapse, emergency medical services, and mortality parameters. This database offers a tool that future modelers can use to identify potential model inputs and evaluate comparability of their models to prior work. Future applications of simulation models to this field should actively tackle key methodological challenges, including the potential for bias in the choice of parameter inputs, investment in model calibration and validation, and transparency in the assumptions and mechanics of simulation models to facilitate reproducibility.
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Affiliation(s)
- Magdalena Cerdá
- Center for Opioid Epidemiology and Policy, Division of Epidemiology, Department of Population Health, New York University School of Medicine, New York, New York
| | | | - Ava D Hamilton
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | | | - Ayaz Hyder
- Division of Environmental Health Sciences, College of Public Health, and Translational Data Analytics Institute, The Ohio State University, Columbus, Ohio
| | - Julian Santaella-Tenorio
- Center for Opioid Epidemiology and Policy, Division of Epidemiology, Department of Population Health, New York University School of Medicine, New York, New York
| | - Navdep Kaur
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Christina Wang
- Center for Opioid Epidemiology and Policy, Division of Epidemiology, Department of Population Health, New York University School of Medicine, New York, New York
| | - Katherine M Keyes
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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7
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Razaghizad A, Windle SB, Filion KB, Gore G, Kudrina I, Paraskevopoulos E, Kimmelman J, Martel MO, Eisenberg MJ. The Effect of Overdose Education and Naloxone Distribution: An Umbrella Review of Systematic Reviews. Am J Public Health 2021; 111:e1-e12. [PMID: 34214412 PMCID: PMC8489614 DOI: 10.2105/ajph.2021.306306] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/24/2021] [Indexed: 11/04/2022]
Abstract
Background. Opioids contribute to more than 60 000 deaths annually in North America. While the expansion of overdose education and naloxone distribution (OEND) programs has been recommended in response to the opioid crisis, their effectiveness remains unclear. Objectives. To conduct an umbrella review of systematic reviews to provide a broad-based conceptual scheme of the effect and feasibility of OEND and to identify areas for possible optimization. Search Methods. We conducted the umbrella review of systematic reviews by searching PubMed, Embase, PsycINFO, Epistemonikos, the Cochrane Database of Systematic Reviews, and the reference lists of relevant articles. Briefly, an academic librarian used a 2-concept search, which included opioid subject headings and relevant keywords with a modified PubMed systematic review filter. Selection Criteria. Eligible systematic reviews described comprehensive search strategies and inclusion and exclusion criteria, evaluated the quality or risk of bias of included studies, were published in English or French, and reported data relevant to either the safety or effectiveness of OEND programs, or optimal strategies for the management of opioid overdose with naloxone in out-of-hospital settings. Data Collection and Analysis. Two reviewers independently extracted study characteristics and the quality of included reviews was assessed in duplicate with AMSTAR-2, a critical appraisal tool for systematic reviews. Review quality was rated critically low, low, moderate, or high based on 7 domains: protocol registration, literature search adequacy, exclusion criteria, risk of bias assessment, meta-analytical methods, result interpretation, and presence of publication bias. Summary tables were constructed, and confidence ratings were provided for each outcome by using a previously modified version of the Royal College of General Practitioners' clinical guidelines. Main Results. Six systematic reviews containing 87 unique studies were included. We found that OEND programs produce long-term knowledge improvement regarding opioid overdose, improve participants' attitudes toward naloxone, provide sufficient training for participants to safely and effectively manage overdoses, and effectively reduce opioid-related mortality. High-concentration intranasal naloxone (> 2 mg/mL) was as effective as intramuscular naloxone at the same dose, whereas lower-concentration intranasal naloxone was less effective. Evidence was limited for other naloxone formulations, as well as the need for hospital transport after overdose reversal. The preponderance of evidence pertained persons who use heroin. Author's Conclusions. Evidence suggests that OEND programs are effective for reducing opioid-related mortality; however, additional high-quality research is required to optimize program delivery. Public Health Implications. Community-based OEND programs should be implemented widely in high-risk populations.
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Affiliation(s)
- Amir Razaghizad
- Amir Razaghizad, Sarah B. Windle, Kristian B. Filion, and Mark J. Eisenberg are with the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada. Genevieve Gore is with the Schulich Library of Physical Sciences, Life Sciences, and Engineering, McGill University, Montreal. Irina Kudrina is with the Department of Family Medicine, Faculty of Medicine, McGill University. Elena Paraskevopoulos is with the Department of Anesthesia, Faculty of Medicine, McGill University. Jonathan Kimmelman is with the Studies of Translation, Ethics, and Medicine Biomedical Ethics Unit, McGill University. Marc O. Martel is with the Faculty of Dentistry, McGill University
| | - Sarah B Windle
- Amir Razaghizad, Sarah B. Windle, Kristian B. Filion, and Mark J. Eisenberg are with the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada. Genevieve Gore is with the Schulich Library of Physical Sciences, Life Sciences, and Engineering, McGill University, Montreal. Irina Kudrina is with the Department of Family Medicine, Faculty of Medicine, McGill University. Elena Paraskevopoulos is with the Department of Anesthesia, Faculty of Medicine, McGill University. Jonathan Kimmelman is with the Studies of Translation, Ethics, and Medicine Biomedical Ethics Unit, McGill University. Marc O. Martel is with the Faculty of Dentistry, McGill University
| | - Kristian B Filion
- Amir Razaghizad, Sarah B. Windle, Kristian B. Filion, and Mark J. Eisenberg are with the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada. Genevieve Gore is with the Schulich Library of Physical Sciences, Life Sciences, and Engineering, McGill University, Montreal. Irina Kudrina is with the Department of Family Medicine, Faculty of Medicine, McGill University. Elena Paraskevopoulos is with the Department of Anesthesia, Faculty of Medicine, McGill University. Jonathan Kimmelman is with the Studies of Translation, Ethics, and Medicine Biomedical Ethics Unit, McGill University. Marc O. Martel is with the Faculty of Dentistry, McGill University
| | - Genevieve Gore
- Amir Razaghizad, Sarah B. Windle, Kristian B. Filion, and Mark J. Eisenberg are with the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada. Genevieve Gore is with the Schulich Library of Physical Sciences, Life Sciences, and Engineering, McGill University, Montreal. Irina Kudrina is with the Department of Family Medicine, Faculty of Medicine, McGill University. Elena Paraskevopoulos is with the Department of Anesthesia, Faculty of Medicine, McGill University. Jonathan Kimmelman is with the Studies of Translation, Ethics, and Medicine Biomedical Ethics Unit, McGill University. Marc O. Martel is with the Faculty of Dentistry, McGill University
| | - Irina Kudrina
- Amir Razaghizad, Sarah B. Windle, Kristian B. Filion, and Mark J. Eisenberg are with the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada. Genevieve Gore is with the Schulich Library of Physical Sciences, Life Sciences, and Engineering, McGill University, Montreal. Irina Kudrina is with the Department of Family Medicine, Faculty of Medicine, McGill University. Elena Paraskevopoulos is with the Department of Anesthesia, Faculty of Medicine, McGill University. Jonathan Kimmelman is with the Studies of Translation, Ethics, and Medicine Biomedical Ethics Unit, McGill University. Marc O. Martel is with the Faculty of Dentistry, McGill University
| | - Elena Paraskevopoulos
- Amir Razaghizad, Sarah B. Windle, Kristian B. Filion, and Mark J. Eisenberg are with the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada. Genevieve Gore is with the Schulich Library of Physical Sciences, Life Sciences, and Engineering, McGill University, Montreal. Irina Kudrina is with the Department of Family Medicine, Faculty of Medicine, McGill University. Elena Paraskevopoulos is with the Department of Anesthesia, Faculty of Medicine, McGill University. Jonathan Kimmelman is with the Studies of Translation, Ethics, and Medicine Biomedical Ethics Unit, McGill University. Marc O. Martel is with the Faculty of Dentistry, McGill University
| | - Jonathan Kimmelman
- Amir Razaghizad, Sarah B. Windle, Kristian B. Filion, and Mark J. Eisenberg are with the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada. Genevieve Gore is with the Schulich Library of Physical Sciences, Life Sciences, and Engineering, McGill University, Montreal. Irina Kudrina is with the Department of Family Medicine, Faculty of Medicine, McGill University. Elena Paraskevopoulos is with the Department of Anesthesia, Faculty of Medicine, McGill University. Jonathan Kimmelman is with the Studies of Translation, Ethics, and Medicine Biomedical Ethics Unit, McGill University. Marc O. Martel is with the Faculty of Dentistry, McGill University
| | - Marc O Martel
- Amir Razaghizad, Sarah B. Windle, Kristian B. Filion, and Mark J. Eisenberg are with the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada. Genevieve Gore is with the Schulich Library of Physical Sciences, Life Sciences, and Engineering, McGill University, Montreal. Irina Kudrina is with the Department of Family Medicine, Faculty of Medicine, McGill University. Elena Paraskevopoulos is with the Department of Anesthesia, Faculty of Medicine, McGill University. Jonathan Kimmelman is with the Studies of Translation, Ethics, and Medicine Biomedical Ethics Unit, McGill University. Marc O. Martel is with the Faculty of Dentistry, McGill University
| | - Mark J Eisenberg
- Amir Razaghizad, Sarah B. Windle, Kristian B. Filion, and Mark J. Eisenberg are with the Lady Davis Institute for Medical Research, Jewish General Hospital, Montreal, QC, Canada. Genevieve Gore is with the Schulich Library of Physical Sciences, Life Sciences, and Engineering, McGill University, Montreal. Irina Kudrina is with the Department of Family Medicine, Faculty of Medicine, McGill University. Elena Paraskevopoulos is with the Department of Anesthesia, Faculty of Medicine, McGill University. Jonathan Kimmelman is with the Studies of Translation, Ethics, and Medicine Biomedical Ethics Unit, McGill University. Marc O. Martel is with the Faculty of Dentistry, McGill University
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Thakarar K, Nenninger K, Agmas W. Harm Reduction Services to Prevent and Treat Infectious Diseases in People Who Use Drugs. Infect Dis Clin North Am 2021; 34:605-620. [PMID: 32782104 DOI: 10.1016/j.idc.2020.06.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
This article reviews the principles of harm reduction, evidence-based harm reduction strategies such as syringe service programs and supervised injection facilities, and provides approaches to integrating a harm reduction approach into clinical practice. As providers strive to increase capacity to treat underlying substance use disorder, we must also recognize that some people may continue to use drugs. In this setting, providers can still deliver nonjudgmental, individualized care, and advocate for the health and safety of people who inject drugs.
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Affiliation(s)
- Kinna Thakarar
- Infectious Disease and Addiction Medicine, Maine Medical Center/Tufts University School of Medicine, 50 Foden Road, South Portland, ME 04106, USA.
| | - Katherine Nenninger
- Preventive Medicine, Maine Medical Center/Tufts University School of Medicine, 22 Bramhall Street, Portland, ME 04102, USA
| | - Wollelaw Agmas
- Infectious Disease, Maine Medical Center/Tufts University School of Medicine, 22 Bramhall Street, Portland, ME 04102, USA
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9
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Thylstrup B, Hesse M, Jørgensen M, Thiesen H. One opioid user saving another: the first study of an opioid overdose-reversal and naloxone distribution program addressing hard-to-reach drug scenes in Denmark. Harm Reduct J 2019; 16:66. [PMID: 31805969 PMCID: PMC6896775 DOI: 10.1186/s12954-019-0328-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 09/06/2019] [Indexed: 02/06/2023] Open
Abstract
Background Overdose education and naloxone distribution programs decrease opioid overdose deaths. However, no studies of such programs have been carried out in Denmark. The aim of this study was to evaluate the feasibility and the effect of a broader “training-the-trainers” model in low-threshold settings after participation in the “Danish Save Lives” [SL] program. Methods Between May 2013 and November 2015, 552 participants from four municipalities took part in the SL program. The program is built on the train-the-trainers model where a central trainer trains others (trainers), who in turn train others (helpers). Participants were 30 police officers (5%), 188 people who use opioids (34%), 23 significant others (4%), and 217 social workers (39%). Ninety-four participants could not be classified (17%). At follow-up, participants were interviewed to determine the number and outcomes of opioid overdoses. Logistic regression was used to assess predictors of treating an overdose. Results In all, 37 (7%) participants had intervened in 45 opioid overdose events (two trainers and 35 helpers). Detailed descriptions of the overdose event were available from 32 follow-up interviews (70%). In 16 cases, the person who intervened was already present at the site when the overdose occurred, and in 17 cases, the overdose victim recovered without complications. All overdose victims survived except one. People who used opioids were more likely to have treated an overdose than other participants (adjusted odds ratio [AOR] = 8.50, p = 0.001), and the likelihood of treating and overdose declined over time AOR = 0.37 (0.13, 0.93), p = 0.034). Conclusions Prevention programs that target people who use opioids are more likely to be effective than programs that target professionals, especially in high-risk settings that can be hard for paramedics to reach. A future goal is to explore how prevention programs can be adapted to new user groups. Trial registration The Danish Data Protection Agency, 2015-57-0002, Aarhus University, 2016-051-000001, 184, retrospectively registered
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Affiliation(s)
- Birgitte Thylstrup
- Centre for Alcohol and Drug Research, Bartholins Allé 10, 8000, Aarhus C, Denmark.
| | - Morten Hesse
- Centre for Alcohol and Drug Research, Bartholins Allé 10, 8000, Aarhus C, Denmark
| | - Marian Jørgensen
- HealthTeam for Homeless, Save Lives Program, Sundholmsvej 18, 2300, København S, Denmark
| | - Henrik Thiesen
- HealthTeam for Homeless, Save Lives Program, Sundholmsvej 18, 2300, København S, Denmark
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10
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The prevalence of non-fatal overdose among people who inject drugs: A multi-stage systematic review and meta-analysis. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2019; 73:172-184. [DOI: 10.1016/j.drugpo.2019.07.030] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 07/15/2019] [Accepted: 07/15/2019] [Indexed: 12/13/2022]
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11
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Wenger LD, Showalter D, Lambdin B, Leiva D, Wheeler E, Davidson PJ, Coffin PO, Binswanger IA, Kral AH. Overdose Education and Naloxone Distribution in the San Francisco County Jail. JOURNAL OF CORRECTIONAL HEALTH CARE 2019; 25:394-404. [DOI: 10.1177/1078345819882771] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - David Showalter
- Sociology Department, University of California, Berkeley, CA, USA
| | | | - David Leiva
- San Francisco Department of Public Health, Jail Health Services, CA, USA
| | | | | | - Phillip O. Coffin
- Population Health Division, San Francisco Department of Public Health, Community Health Equity & Promotion Branch, San Francisco, CA, USA
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12
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Weinand J, Huckaby A, Chavez O, Sharma R, Lara J, Leija L, Morriss C, Rowland S, Norris D, de Ramirez MM, Adame-Zambrano S, Andazola J, De La Rosa I. Addressing the Opioid Crisis: Community Partnerships in Primary Care. PRIMER (LEAWOOD, KAN.) 2019; 3:20. [PMID: 32537591 PMCID: PMC7205132 DOI: 10.22454/primer.2019.649767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
INTRODUCTION New Mexico is currently ranked 17th in the United States for drug overdose death rates. Our project seeks to decrease opioid overdose deaths in a community by increasing the number of patients with naloxone in a local family medicine residency clinic. METHODS We developed a protocol wherein providers asked patients at risk of opioid overdose about naloxone access. Free naloxone was distributed in partner with the county health department, accompanied by teaching of use. We reviewed patient encounters during a 45-day control and study period to measure naloxone possession among patients at risk. RESULTS Nearly two-thirds of patients at risk of opioid overdose had no naloxone. A standardized protocol implemented to distribute an opioid reversal agent doubled naloxone prescribed by providers at visits (10.3%) compared to a control period (4.3%), but lacked statistical significance. CONCLUSION Patients in a family medicine residency clinic who were at risk of opioid overdose overwhelmingly did not have naloxone, and a standardized protocol with a community-based partnership increased access to naloxone. Further project data will have implications for ongoing naloxone distribution programs in primary care.
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Affiliation(s)
- Jamie Weinand
- Memorial Medical Center, Southern New Mexico Family Medicine Residency Program, Las Cruces, NM
| | - Athena Huckaby
- Doña Ana County Health and Human Services, Las Cruces, NM
| | - Olivia Chavez
- Memorial Medical Center, Southern New Mexico Family Medicine Residency Program, Las Cruces, NM
| | - Ramona Sharma
- Memorial Medical Center, Southern New Mexico Family Medicine Residency Program, Las Cruces, NM
| | - Jeanette Lara
- Memorial Medical Center, Southern New Mexico Family Medicine Residency Program, Las Cruces, NM
| | - Laura Leija
- Memorial Medical Center, Southern New Mexico Family Medicine Residency Program, Las Cruces, NM
| | - Christopher Morriss
- Memorial Medical Center, Southern New Mexico Family Medicine Residency Program, Las Cruces, NM
| | - Shawn Rowland
- Memorial Medical Center, Southern New Mexico Family Medicine Residency Program, Las Cruces, NM
| | - Davena Norris
- Memorial Medical Center, Southern New Mexico Family Medicine Residency Program, Las Cruces, NM
| | | | - Salvador Adame-Zambrano
- Memorial Medical Center, Southern New Mexico Family Medicine Residency Program, Las Cruces, NM
| | - John Andazola
- Memorial Medical Center, Southern New Mexico Family Medicine Residency Program, Las Cruces, NM
| | - Ivan De La Rosa
- Memorial Medical Center, Southern New Mexico Family Medicine Residency Program, Las Cruces, NM | and New Mexico State University, School of Social Work, Las Cruces, NM
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Zschoche JH, Nesbit S, Murtaza U, Sowell A, Waldfogel JM, Arwood N, Rush J, McNamara L, Swarthout M, Nesbit T, Ortmann M. Development and implementation of procedures for outpatient naloxone prescribing at a large academic medical center. Am J Health Syst Pharm 2018; 75:1812-1820. [DOI: 10.2146/ajhp170759] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Affiliation(s)
| | - Suzanne Nesbit
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD
| | - Umbreen Murtaza
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD
| | - Amanda Sowell
- Department of Pharmacy, Palmetto Health Richland Hospital, Columbia, SC
| | | | - Nicole Arwood
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD
| | - Jordan Rush
- Department of Pharmacy, University of North Carolina Hospitals, Chapel Hill, NC
| | - LeAnn McNamara
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD
| | | | - Todd Nesbit
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD
| | - Melinda Ortmann
- Department of Pharmacy, Johns Hopkins Hospital, Baltimore, MD
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14
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Dwyer R, Olsen A, Fowlie C, Gough C, van Beek I, Jauncey M, Lintzeris N, Oh G, Dicka J, Fry CL, Hayllar J, Lenton S. An overview of take-home naloxone programs in Australia. Drug Alcohol Rev 2018; 37:440-449. [PMID: 29744980 DOI: 10.1111/dar.12812] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 04/06/2018] [Accepted: 04/12/2018] [Indexed: 11/29/2022]
Abstract
INTRODUCTION AND AIMS Take-home naloxone (THN) programs commenced in Australia in 2012 in the Australian Capital Territory and programs now operate in five Australian jurisdictions. The purpose of this paper is to record the progress of THN programs in Australia, to provide a resource for others wanting to start THN projects, and provide a tool for policy makers and others considering expansion of THN programs in this country and elsewhere. DESIGN AND METHODS Key stakeholders with principal responsibility for identified THN programs operating in Australia provided descriptions of program development, implementation and characteristics. Short summaries of known THN programs from each jurisdiction are provided along with a table detailing program characteristics and outcomes. RESULTS Data collected across current Australian THN programs suggest that to date over 2500 Australians at risk of overdose have been trained and provided naloxone. Evaluation data from four programs recorded 146 overdose reversals involving naloxone that was given by THN participants. DISCUSSION AND CONCLUSIONS Peer drug user groups currently play a central role in the development, delivery and scale-up of THN in Australia. Health professionals who work with people who use illicit opioids are increasingly taking part as alcohol and other drug-related health agencies have recognised the opportunity for THN provision through interactions with their clients. Australia has made rapid progress in removing regulatory barriers to naloxone since the initiation of the first THN program in 2012. However, logistical and economic barriers remain and further work is needed to expand access to this life-saving medication.
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Affiliation(s)
- Robyn Dwyer
- Centre for Alcohol Policy Research, School of Psychology and Public Health, La Trobe University, Melbourne, Australia.,Centre for Cultural Diversity and Wellbeing, Victoria University, Melbourne, Australia.,National Drug Research Institute, Curtin University, Melbourne, Australia
| | - Anna Olsen
- Research School of Population Health, ANU College of Medicine, Biology and Environment, The Australian National University, Canberra, Australia
| | - Carrie Fowlie
- Alcohol, Tobacco and Other Drug Association ACT, Canberra, Australia
| | - Chris Gough
- Canberra Alliance for Harm Minimisation and Advocacy, Canberra, Australia
| | | | | | - Nicholas Lintzeris
- Drug and Alcohol Services, South East Sydney Local Health District, NSW Health, Sydney, Australia
| | - Grace Oh
- Alcohol and Other Drug and Prevention Services - WA Mental Health Commission, Perth, Australia
| | - Jane Dicka
- Harm Reduction Victoria, Melbourne, Australia
| | - Craig L Fry
- College of Health and Biomedicine, Victoria University, Melbourne, Australia
| | - Jeremy Hayllar
- Metro North Hospital and Health Service Alcohol and Drug Service, Queensland Health, Brisbane, Australia
| | - Simon Lenton
- National Drug Research Institute, Curtin University, Melbourne, Australia
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15
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Cipriano LE, Zaric GS. Cost-effectiveness of naloxone kits in secondary schools. Drug Alcohol Depend 2018; 192:352-361. [PMID: 30321745 DOI: 10.1016/j.drugalcdep.2018.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 08/02/2018] [Accepted: 08/04/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND We seek to identify conditions under which a plan by the Toronto District School Board (TDSB) to equip high schools with naloxone kits would be cost-effective. METHODS We developed a decision-analytic model to evaluate the costs, benefits, and cost-effectiveness of a school-based naloxone program. We estimated model inputs from the medical literature and used Toronto-specific sources whenever available. We present our results varying both the expected total number of opioid overdoses per year across all 112 TDSB high schools and the effectiveness of a school-based naloxone program in reducing mortality. RESULTS A school naloxone program likely costs less than CAD$50,000 per quality-adjusted life-year gained if the overdose frequency is at least once each year and it reduces opioid poisoning mortality by at least 40% (from 10% to <6.0%) or if the overdose frequency is at least two per year and the program reduces mortality by at least 20% (from 10% to <8.0%). The results are sensitive to the intensity and cost of staff training, the lifetime costs and life-expectancy of overdose survivors, and the probability of an overdose being fatal in the absence of a school naloxone program. CONCLUSIONS School naloxone programs are relatively inexpensive, but that does not ensure that they are a cost-effective use of resources. While potentially cost-effective, if the risk of an overdose in a Toronto high school is low, then other programs aimed at improving the health and wellbeing of students may be better use of limited resources.
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Affiliation(s)
- Lauren E Cipriano
- Ivey Business School, Western University, London, ON, N6G 0N1, Canada; Department of Biostatistics and Epidemiology, Schulich School of Medicine and Dentistry, Western University, London, ON, N6A 5C1, Canada.
| | - Gregory S Zaric
- Ivey Business School, Western University, London, ON, N6G 0N1, Canada; Department of Biostatistics and Epidemiology, Schulich School of Medicine and Dentistry, Western University, London, ON, N6A 5C1, Canada
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16
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Cepeda JA, Eritsyan K, Vickerman P, Lyubimova A, Shegay M, Odinokova V, Beletsky L, Borquez A, Hickman M, Beyrer C, Martin NK. Potential impact of implementing and scaling up harm reduction and antiretroviral therapy on HIV prevalence and mortality and overdose deaths among people who inject drugs in two Russian cities: a modelling study. Lancet HIV 2018; 5:e578-e587. [PMID: 30033374 PMCID: PMC6188805 DOI: 10.1016/s2352-3018(18)30168-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 06/22/2018] [Accepted: 06/25/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Most new HIV infections among people who inject drugs (PWID) in eastern Europe and central Asia occur in Russia, where PWID have a high risk of overdose. In Russia, use of opioid agonist therapy (OAT) is prohibited, and coverage of needle and syringe programmes (NSPs) and antiretroviral therapy (ART) is poor. We aimed to assess the effects that scaling up harm reduction (ie, use of OAT and coverage of NSPs) and use of ART might have on HIV incidence and the frequency of fatal overdoses among PWID in two cities in the Ural Federal District and Siberian Federal District, where the prevalence of HIV is high or increasing in PWID. METHODS In this modelling study, we developed a dynamic deterministic model that simulated transmission of HIV through injection drug use and sex among PWID. We calibrated this model to HIV prevalence data among PWID in two Russian cities: Omsk (which has high but increasing prevalence of HIV among PWID) and Ekaterinburg (which has very high but stable prevalence of HIV). The source data were from research studies supported by the Global Fund to Fight AIDS, Tuberculosis, and Malaria and US Centers for Disease Control and Prevention and surveillance studies from WHO and regional AIDS centres. We modelled the effects of no intervention scale-up (no use of harm reduction measures and 30% of HIV-positive PWID receiving ART) versus combinations of scaling up of OAT, receipt of high coverage of NSPs, and use of ART on the incidence of HIV infections, mortality from HIV, and the frequency of fatal overdoses from 2018 to 2028. FINDINGS Without intervention, HIV prevalence among PWID in Omsk could increase from 30% in 2018 to 36% (2·5-97·5 percentile interval 22-52) in 2028 and remain high in Ekaterinburg, estimated at 60% (57-67) in 2028. Scaling up OAT to 50% coverage for a duration of 2 years could prevent 35% of HIV infections and 19% of deaths associated with HIV in Omsk and 20% (11-29) of HIV infections and 10% (4-14) of deaths associated with HIV in Ekaterinburg. Further, this scaling up could prevent 33% of overdose deaths over the next 10 years. Scaling up of NSPs and OAT to 50% coverage and tripling recruitment to ART (reaching about 65% of HIV-positive PWID) could prevent 58% (46-69) of HIV infections and 45% (36-54) of deaths associated with HIV in Omsk and 38% (26-50) of HIV infections and 32% (23-41) of deaths associated with HIV in Ekaterinburg by 2028. INTERPRETATION Legalisation of OAT and increased use of ART and NSPs for PWID are urgently needed to prevent HIV and fatal overdose among PWID in Russia. FUNDING National Institutes of Health and Elton John AIDS Foundation.
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Affiliation(s)
- Javier A Cepeda
- Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, CA, USA.
| | - Ksenia Eritsyan
- NGO Stellit, Saint Petersburg, Russia; Department of Sociology, National Research University Higher School of Economics, Saint Petersburg, Russia
| | - Peter Vickerman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | | | | | | | - Leo Beletsky
- Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, CA, USA; School of Law and Bouvé College of Health Sciences, Northeastern University, Boston, MA, USA
| | - Annick Borquez
- Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, CA, USA
| | - Matthew Hickman
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Chris Beyrer
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Natasha K Martin
- Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, CA, USA; Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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17
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Ladapo JA, Larochelle MR, Chen A, Villalon MM, Vassar S, Huang DYC, Mafi JN. Physician Prescribing of Opioids to Patients at Increased Risk of Overdose From Benzodiazepine Use in the United States. JAMA Psychiatry 2018; 75:623-630. [PMID: 29710086 PMCID: PMC6137520 DOI: 10.1001/jamapsychiatry.2018.0544] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 02/18/2018] [Indexed: 12/20/2022]
Abstract
Importance Recent increases in US opioid-related deaths underscore the need to understand drivers of fatal overdose. The initial prescription of opioids represents a critical juncture because it increases the risk of future opioid use disorder and is preventable. Objective To examine new opioid prescribing patterns in US patients at increased risk of overdose from benzodiazepine use. Design, Setting, and Participants This study used publicly available data from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey from January 1, 2005, through December 31, 2015, to identify adults 20 years or older receiving new opioid prescriptions and concurrently using a benzodiazepine. Main Outcomes and Measures Population-based rates of new opioid prescriptions stratified by use of benzodiazepines. Results This study analyzed 13 146 visits, representing 214 million visits nationally, with a new opioid prescription. Rates of new opioid prescriptions among adults using a benzodiazepine increased from 189 to 351 per 1000 persons between 2005 and 2010 (rate difference, 162; 95% CI, 29-295; P = .02) and decreased to 172 per 1000 persons by 2015 (rate difference, -179; 95% CI, -310 to -48; P = .008). New opioid prescriptions in the general population not using benzodiazepines increased nonsignificantly from 78 to 93 per 1000 US persons between 2005 and 2010 (rate difference, 15; 95% CI, -3 to 33; P = .10) and decreased nonsignificantly to 79 per 1000 persons by 2015 (rate difference, -14; 95% CI, -38 to 11; P = .28). The likelihood of receiving a new opioid prescription during an ambulatory visit remained higher for patients concurrently using benzodiazepines compared with the general population after adjusting for demographic characteristics, comorbidities, and diagnoses associated with pain (adjusted relative risk, 1.83; 95% CI, 1.56-2.15; P < .001). Naloxone was coprescribed in less than 1% of visits when a patient concurrently used a benzodiazepine. Conclusions and Relevance In 2010, new opioid prescriptions for US adults stopped increasing and began to decrease among higher-risk patients who used benzodiazepines. These patterns suggest that the recent increase in opioid-related deaths may be associated with factors other than physicians writing new opioid prescriptions. Nevertheless, prescribing among higher-risk patients still occurred at rates higher than rates in the general population, representing an important opportunity to improve quality of care for patients experiencing pain.
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Affiliation(s)
- Joseph A. Ladapo
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles
| | - Marc R. Larochelle
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston Medical Center, Boston, Massachusetts
- Boston University School of Medicine, Boston, Massachusetts
| | - Alexander Chen
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles
| | - Melissa M. Villalon
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles
| | - Stefanie Vassar
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles
| | - David Y. C. Huang
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles
| | - John N. Mafi
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at University of California, Los Angeles
- RAND Corporation, Santa Monica, California
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18
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Langham S, Wright A, Kenworthy J, Grieve R, Dunlop WCN. Cost-Effectiveness of Take-Home Naloxone for the Prevention of Overdose Fatalities among Heroin Users in the United Kingdom. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2018; 21:407-415. [PMID: 29680097 DOI: 10.1016/j.jval.2017.07.014] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Revised: 07/12/2017] [Accepted: 07/14/2017] [Indexed: 05/22/2023]
Abstract
BACKGROUND Heroin overdose is a major cause of premature death. Naloxone is an opioid antagonist that is effective for the reversal of heroin overdose in emergency situations and can be used by nonmedical responders. OBJECTIVE Our aim was to assess the cost-effectiveness of distributing naloxone to adults at risk of heroin overdose for use by nonmedical responders compared with no naloxone distribution in a European healthcare setting (United Kingdom). METHODS A Markov model with an integrated decision tree was developed based on an existing model, using UK data where available. We evaluated an intramuscular naloxone distribution reaching 30% of heroin users. Costs and effects were evaluated over a lifetime and discounted at 3.5%. The results were assessed using deterministic and probabilistic sensitivity analyses. RESULTS The model estimated that distribution of intramuscular naloxone, would decrease overdose deaths by around 6.6%. In a population of 200,000 heroin users this equates to the prevention of 2,500 premature deaths at an incremental cost per quality-adjusted life year (QALY) gained of £899. The sensitivity analyses confirmed the robustness of the results. CONCLUSIONS Our evaluation suggests that the distribution of take-home naloxone decreased overdose deaths by around 6.6% and was cost-effective with an incremental cost per QALY gained well below a £20,000 willingness-to-pay threshold set by UK decision-makers. The model code has been made available to aid future research. Further study is warranted on the impact of different formulations of naloxone on cost-effectiveness and the impact take-home naloxone has on the wider society.
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Affiliation(s)
| | | | | | - Richard Grieve
- London School of Hygiene and Tropical Medicine, London, UK
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19
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McDonald R, Campbell ND, Strang J. Twenty years of take-home naloxone for the prevention of overdose deaths from heroin and other opioids-Conception and maturation. Drug Alcohol Depend 2017; 178:176-187. [PMID: 28654870 DOI: 10.1016/j.drugalcdep.2017.05.001] [Citation(s) in RCA: 90] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Revised: 05/02/2017] [Accepted: 05/02/2017] [Indexed: 10/25/2022]
Abstract
BACKGROUND Opioid overdose is a major cause of mortality, but injury and fatal outcomes can be prevented by timely administration of the opioid antagonist naloxone. Pre-provision of naloxone to opioid users and family members (take-home naloxone, THN) was first proposed in 1996, and WHO Guidelines were issued in 2014. While widespread in some countries, THN is minimally available or absent elsewhere. This review traces the development of THN over twenty years, from speculative harm reduction proposal to public health strategy. METHOD Medline and PsycINFO were searched for peer-reviewed literature (1990-2016) using Boolean queries: 1) "naloxone OR Narcan"; 2) "(opioid OR opiate) AND overdose AND prevention". Grey literature and specialist websites were also searched. Data were extracted and synthesized as narrative review, with key events presented as chronological timeline. RESULTS Results are presented in 5-year intervals, starting with the original proposal and THN pilots from 1996 to 2001. Lack of familiarity with THN challenged early distribution schemes (2001-2006), leading to further testing, evaluation, and assessment of challenges and perceived medicolegal barriers. From 2006-2011, response to social and legal concerns led to the expansion of THN programs; followed by high-impact research and efforts to widen THN availability from 2011 to 2016. CONCLUSIONS Framed as a public health tool for harm reduction, THN has overcome social, clinical, and legal barriers in many jurisdictions. Nonetheless, the rising death toll of opioid overdose illustrates that current THN coverage is insufficient, and greater public investment in overdose prevention will be required if THN is to achieve its full potential impact.
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Affiliation(s)
- Rebecca McDonald
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, Addictions Sciences Building, 4 Windsor Walk, Denmark Hill, London, SE5 8BB, United Kingdom
| | - Nancy D Campbell
- Department of Science and Technology Studies, Sage Labs 5202, Rensselaer Polytechnic Institute, 110 Eighth Street Troy, NY, 12180, United States
| | - John Strang
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, Addictions Sciences Building, 4 Windsor Walk, Denmark Hill, London, SE5 8BB, United Kingdom.
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20
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Walley AY, Cheng DM, Quinn EK, Blokhina E, Gnatienko N, Chaisson CE, Krupitsky E, Coffin PO, Samet JH. Fatal and non-fatal overdose after narcology hospital discharge among Russians living with HIV/AIDS who inject drugs. THE INTERNATIONAL JOURNAL OF DRUG POLICY 2016; 39:114-120. [PMID: 27907848 DOI: 10.1016/j.drugpo.2016.10.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 09/16/2016] [Accepted: 10/29/2016] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Among Russians living with HIV/AIDS who inject drugs, we examined the incidence of fatal and non-fatal overdoses following discharge from a narcology hospital and the associations with more advanced HIV infection. DESIGN Prospective cohort study of data collected at baseline, 3 and 6 months from HIV-infected patients with a history of injection drug use who were not treated with anti-retroviral therapy. Participants were recruited between 2012-2014 from a narcology (addiction) hospital in St. Petersburg, Russia. METHODS Fatal overdose was determined based on contact reports to study staff in the year after discharge. Non-fatal overdose was self-reported at the 3- and 6-month assessments. The main independent variable for HIV severity was CD4 cell count at the baseline interview (<200cells/mm3≥200cells/mm3). Secondary analyses assessed time since HIV diagnosis and treated with anti-retroviral treatment (ART) prior to enrolment as independent variables. We fit Cox proportional hazards models to assess whether HIV severity is associated with either fatal or non-fatal overdose. RESULTS Among 349 narcology patients, 18 participants died from overdose within one year after discharge (8.7%, 95% CI 3.4-14.2 by Kaplan-Meier); an estimated 51% [95% CI 34-68%] reported at least one non-fatal overdose within 6 months of discharge. HIV severity, time since HIV diagnosis and ever ART were not significantly associated with either fatal or non-fatal overdose events. CONCLUSION Fatal and non-fatal overdose are common among Russians living with HIV/AIDS who inject drugs after narcology hospital discharge. Overdose prevention interventions are urgently warranted among Russian narcology patients with HIV infection.
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Affiliation(s)
- Alexander Y Walley
- Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston University School of Medicine & Boston Medical Center, 801 Massachusetts Avenue, Boston, USA.
| | - Debbie M Cheng
- Department of Biostatistics, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, USA
| | - Emily K Quinn
- Data Coordinating Center, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, USA
| | - Elena Blokhina
- First Pavlov State Medical University, St. Petersburg, Russian Federation
| | - Natalia Gnatienko
- Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston University School of Medicine & Boston Medical Center, 801 Massachusetts Avenue, Boston, USA
| | - Christine E Chaisson
- Department of Biostatistics, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, USA; Data Coordinating Center, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, USA
| | - Evgeny Krupitsky
- First Pavlov State Medical University, St. Petersburg, Russian Federation; Bekhterev Research Psychoneurological Institute, St.Petersburg, Russian Federation
| | - Philip O Coffin
- San Francisco Department of Public Health, San Francisco, CA 94102, USA; Division of HIV/AIDS, University of California San Francisco, San Francisco CA 94103, USA
| | - Jeffrey H Samet
- Department of Medicine, Section of General Internal Medicine, Clinical Addiction Research and Education Unit, Boston University School of Medicine & Boston Medical Center, 801 Massachusetts Avenue, Boston, USA; Department of Community Health Sciences, Boston University School of Public Health, 801 Massachusetts Avenue, Boston, MA, USA
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21
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McDonald R, Strang J. Are take-home naloxone programmes effective? Systematic review utilizing application of the Bradford Hill criteria. Addiction 2016; 111:1177-87. [PMID: 27028542 PMCID: PMC5071734 DOI: 10.1111/add.13326] [Citation(s) in RCA: 297] [Impact Index Per Article: 37.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 11/22/2015] [Accepted: 01/21/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND AND AIMS Fatal outcome of opioid overdose, once detected, is preventable through timely administration of the antidote naloxone. Take-home naloxone provision directly to opioid users for emergency use has been implemented recently in more than 15 countries worldwide, albeit mainly as pilot schemes and without formal evaluation. This systematic review assesses the effectiveness of take-home naloxone, with two specific aims: (1) to study the impact of take-home naloxone distribution on overdose-related mortality; and (2) to assess the safety of take-home naloxone in terms of adverse events. METHODS PubMed, MEDLINE and PsychINFO were searched for English-language peer-reviewed publications (randomized or observational trials) using the Boolean search query: (opioid OR opiate) AND overdose AND prevention. Evidence was evaluated using the nine Bradford Hill criteria for causation, devised to assess a potential causal relationship between public health interventions and clinical outcomes when only observational data are available. RESULTS A total of 1397 records (1164 after removal of duplicates) were retrieved, with 22 observational studies meeting eligibility criteria. Due to variability in size and quality of the included studies, meta-analysis was dismissed in favour of narrative synthesis. From eligible studies, we found take-home naloxone met all nine Bradford Hill criteria. The additional five World Health Organization criteria were all either met partially (two) or fully (three). Even with take-home naloxone administration, fatal outcome was reported in one in 123 overdose cases (0.8%; 95% confidence interval = 0.4, 1.2). CONCLUSIONS Take-home naloxone programmes are found to reduce overdose mortality among programme participants and in the community and have a low rate of adverse events.
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Affiliation(s)
- Rebecca McDonald
- National Addiction CentreInstitute of Psychiatry, Psychology and Neuroscience, King's College LondonLondonUK
| | - John Strang
- National Addiction CentreInstitute of Psychiatry, Psychology and Neuroscience, King's College LondonLondonUK
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22
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Thakarar K, Weinstein ZM, Walley AY. Optimising health and safety of people who inject drugs during transition from acute to outpatient care: narrative review with clinical checklist. Postgrad Med J 2016; 92:356-63. [PMID: 27004476 PMCID: PMC4967553 DOI: 10.1136/postgradmedj-2015-133720] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Accepted: 02/29/2016] [Indexed: 12/20/2022]
Abstract
The opioid epidemic in the USA continues to worsen. Medical providers are faced with the challenge of addressing complications from opioid use disorders and associated injection drug use. Unsafe injection practices among people who inject drugs (PWID) can lead to several complications requiring acute care encounters in the emergency department and inpatient hospital. Our objective is to provide a narrative review to help medical providers recognise and address key health issues in PWID, who are being released from the emergency department and inpatient hospital. In the midst of rises in overdose deaths and infections such as hepatitis C, we highlight several health issues for PWID, including overdose and infection prevention. We provide a clinical checklist of actions to help guide providers in the care of these complex patients. The clinical checklist includes strategies also applicable to low-resource settings, which may lack addiction treatment options. Our review and clinical checklist highlight key aspects of optimising the health and safety of PWID.
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Affiliation(s)
- Kinna Thakarar
- Department of Medicine/Infectious Diseases, Maine Medical Center, Portland, Maine, USA
| | - Zoe M Weinstein
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine/Boston Medical Center, Boston, Massachusetts, USA
| | - Alexander Y Walley
- Clinical Addiction Research and Education Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine/Boston Medical Center, Boston, Massachusetts, USA
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23
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Deonarine A, Amlani A, Ambrose G, Buxton JA. Qualitative assessment of take-home naloxone program participant and law enforcement interactions in British Columbia. Harm Reduct J 2016; 13:17. [PMID: 27206486 PMCID: PMC4875634 DOI: 10.1186/s12954-016-0106-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Accepted: 05/06/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The British Columbia take-home naloxone (BCTHN) program has been in operation since 2012 and has resulted in the successful reversal of over 581 opioid overdoses. The study aims to explore BCTHN program participant perspectives about the program, barriers to participants contacting emergency services (calling "911") during an overdose, and perspectives of law enforcement officials on naloxone administration by police officers. METHODS Two focus groups and four individual interviews were conducted with BCTHN program participants; interviews with two law enforcement officials were also conducted. Qualitative analysis of all transcripts was performed. RESULTS Positive themes about the BCTHN program from participants included easy to understand training, correcting misperceptions in the community, and positive interactions with emergency services. Potential barriers to contacting emergency services during an overdose include concerns about being arrested for outstanding warrants or for other illegal activities (such as drug possession) and confiscation of kits. Law enforcement officials noted that warrants were complex situational issues, kits would normally not be confiscated, and admitted arrests for drug possession or other activities may not serve the public good in an overdose situation. Law enforcement officials were concerned about legal liability and jurisdictional/authorization issues if naloxone administration privileges were expanded to police. CONCLUSIONS Program participants and law enforcement officials expressed differing perspectives about warrants, kit confiscation, and arrests. Facilitating communication between BCTHN program participants and other stakeholders may address some of the confusion and remove potential barriers to further improving program outcomes. Naloxone administration by law enforcement would require policies to address jurisdiction/authorization and liability issues.
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Affiliation(s)
- Andrew Deonarine
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Ashraf Amlani
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
| | - Graham Ambrose
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada
- BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada
| | - Jane A Buxton
- School of Population and Public Health, University of British Columbia, 2206 East Mall, Vancouver, BC, V6T 1Z3, Canada.
- BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC, V5Z 4R4, Canada.
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24
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Csete J, Kamarulzaman A, Kazatchkine M, Altice F, Balicki M, Buxton J, Cepeda J, Comfort M, Goosby E, Goulão J, Hart C, Kerr T, Lajous AM, Lewis S, Martin N, Mejía D, Camacho A, Mathieson D, Obot I, Ogunrombi A, Sherman S, Stone J, Vallath N, Vickerman P, Zábranský T, Beyrer C. Public health and international drug policy. Lancet 2016; 387:1427-1480. [PMID: 27021149 PMCID: PMC5042332 DOI: 10.1016/s0140-6736(16)00619-x] [Citation(s) in RCA: 297] [Impact Index Per Article: 37.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In September 2015, the member states of the United Nations endorsed sustainable development goals (SDG) for 2030 that aspire to human rights-centered approaches to ensuring the health and well-being of all people. The SDGs embody both the UN Charter values of rights and justice for all and the responsibility of states to rely on the best scientific evidence as they seek to better humankind. In April 2016, these same states will consider control of illicit drugs, an area of social policy that has been fraught with controversy, seen as inconsistent with human rights norms, and for which scientific evidence and public health approaches have arguably played too limited a role. The previous UN General Assembly Special Session (UNGASS) on drugs in 1998 – convened under the theme “a drug-free world, we can do it!” – endorsed drug control policies based on the goal of prohibiting all use, possession, production, and trafficking of illicit drugs. This goal is enshrined in national law in many countries. In pronouncing drugs a “grave threat to the health and well-being of all mankind,” the 1998 UNGASS echoed the foundational 1961 convention of the international drug control regime, which justified eliminating the “evil” of drugs in the name of “the health and welfare of mankind.” But neither of these international agreements refers to the ways in which pursuing drug prohibition itself might affect public health. The “war on drugs” and “zero-tolerance” policies that grew out of the prohibitionist consensus are now being challenged on multiple fronts, including their health, human rights, and development impact. The Johns Hopkins – Lancet Commission on Drug Policy and Health has sought to examine the emerging scientific evidence on public health issues arising from drug control policy and to inform and encourage a central focus on public health evidence and outcomes in drug policy debates, such as the important deliberations of the 2016 UNGASS on drugs. The Johns Hopkins-Lancet Commission is concerned that drug policies are often colored by ideas about drug use and drug dependence that are not scientifically grounded. The 1998 UNGASS declaration, for example, like the UN drug conventions and many national drug laws, does not distinguish between drug use and drug abuse. A 2015 report by the UN High Commissioner for Human Rights, by contrast, found it important to emphasize that “[d]rug use is neither a medical condition nor does it necessarily lead to drug dependence.” The idea that all drug use is dangerous and evil has led to enforcement-heavy policies and has made it difficult to see potentially dangerous drugs in the same light as potentially dangerous foods, tobacco, alcohol for which the goal of social policy is to reduce potential harms.
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Affiliation(s)
| | | | - Michel Kazatchkine
- UN Special Envoy, HIV in Eastern Europe and Central Asia, Geneva, Switzerland
| | | | | | | | - Javier Cepeda
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Eric Goosby
- University of California, San Francisco, San Francisco, CA, USA
| | | | - Carl Hart
- Columbia University, New York City, NY, USA
| | - Thomas Kerr
- University of British Columbia, Center of Excellence in HIV/AIDS, Vancouver, BC, Canada
| | | | | | | | | | | | | | | | | | - Susan Sherman
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Nandini Vallath
- Trivandrum Institute of Palliative Sciences, Trivandrum, India
| | | | | | - Chris Beyrer
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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Visconti AJ, Santos GM, Lemos NP, Burke C, Coffin PO. Opioid Overdose Deaths in the City and County of San Francisco: Prevalence, Distribution, and Disparities. J Urban Health 2015; 92:758-72. [PMID: 26077643 PMCID: PMC4524842 DOI: 10.1007/s11524-015-9967-y] [Citation(s) in RCA: 72] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Drug overdose is now the leading cause of unintentional death nationwide, driven by increased prescription opioid overdoses. To better understand urban opioid overdose deaths, this paper examines geographic, demographic, and clinical differences between heroin-related decedents and prescription opioid decedents in San Francisco from 2010 to 2012. During this time period, 331 individuals died from accidental overdose caused by opioids (310 involving prescription opioids and 31 involving heroin). Deaths most commonly involved methadone (45.9%), morphine (26.9%), and oxycodone (21.8%). Most deaths also involved other substances (74.9%), most commonly cocaine (35.3%), benzodiazepines (27.5%), antidepressants (22.7%), and alcohol (19.6%). Deaths were concentrated in a small, high-poverty, central area of San Francisco and disproportionately affected African-American individuals. Decedents in high-poverty areas were significantly more likely to die from methadone and cocaine, whereas individuals from more affluent areas were more likely die from oxycodone and benzodiazepines. Heroin decedents were more likely to be within a younger age demographic, die in public spaces, and have illicit substances rather than other prescription opioids. Overall, heroin overdose death, previously common in San Francisco, is now rare. Prescription opioid overdose has emerged as a significant concern, particularly among individuals in high-poverty areas. Deaths in poor and affluent regions involve different causative opioids and co-occurring substances.
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Affiliation(s)
- Adam J Visconti
- San Francisco Department of Public Health, 25 Van Ness Ave., San Francisco, CA, 94102, USA,
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26
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Green TC, Bowman S, Davis C, Los C, McHugh K, Friedmann PD. Discrepancies in addressing overdose prevention through prescription monitoring programs. Drug Alcohol Depend 2015; 153:355-8. [PMID: 26048640 DOI: 10.1016/j.drugalcdep.2015.05.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Revised: 04/07/2015] [Accepted: 05/05/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND State prescription monitoring programs (PMPs) purport to address the prescription opioid epidemic, but have evidenced limited effect on reducing opioid-related mortality. METHODS We systematically reviewed publicly available, PMP web-based materials from December, 2012 to October, 2013, to assess the degree to which overdose prevention was articulated in state PMP goals, mission statement, and accessible educational materials. The sites and available resources of 47 state PMPs with a web presence were reviewed by two independent coders for use of "overdose" and related terms. Website materials were further coded to capture five general thematic orientations: supply reduction-therapeutic, supply reduction-punitive, demand reduction, public health/research, and harm reduction oriented in content. RESULTS Twenty-nine of 47 (62%) PMPs did not address overdose or related terms in available online materials; six (12.8%) contained overdose-oriented messaging; and two included specific overdose prevention tools for providers. There were a median of three thematic orientations represented on the 18 state PMP websites mentioning only the term overdose, compared with a median of 4.5 thematic domains on the six PMP websites with overdose-oriented content. CONCLUSIONS A more comprehensive, public health orientation for PMPs that explicitly and publicly articulates their application and role in overdose prevention may increase PMP effectiveness and use.
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Affiliation(s)
- Traci C Green
- Inflexxion, Inc., 320 Needham St. Suite 100, Newton, MA 02464, USA; Rhode Island Hospital, 793 Eddy St., Providence, RI 02903, USA.
| | - Sarah Bowman
- Inflexxion, Inc., 320 Needham St. Suite 100, Newton, MA 02464, USA
| | - Corey Davis
- Network for Public Health Law, 101 East Weaver Street, Suite G-7, Carrboro, NC 27510, USA.
| | - Cristina Los
- Inflexxion, Inc., 320 Needham St. Suite 100, Newton, MA 02464, USA.
| | - Kimberly McHugh
- Inflexxion, Inc., 320 Needham St. Suite 100, Newton, MA 02464, USA.
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Mueller SR, Walley AY, Calcaterra SL, Glanz JM, Binswanger IA. A Review of Opioid Overdose Prevention and Naloxone Prescribing: Implications for Translating Community Programming Into Clinical Practice. Subst Abus 2015; 36:240-53. [PMID: 25774771 DOI: 10.1080/08897077.2015.1010032] [Citation(s) in RCA: 114] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND As physicians have increased opioid prescribing, overdose deaths from pharmaceutical opioids have substantially increased in the United States. Naloxone hydrochloride (naloxone), an opioid antagonist, is the standard of care for treatment of opioid induced respiratory depression. Since 1996, community-based programs have offered overdose prevention education and distributed naloxone for bystander administration to people who use opioids, particularly heroin. There is growing interest in translating overdose education and naloxone distribution (OEND) into conventional medical settings for patients who are prescribed pharmaceutical opioids. For this review, we summarized and classified existing publications on overdose education and naloxone distribution to identify evidence of effectiveness and opportunities for translation into conventional medical settings. METHODS For this review, we searched English language PubMed for articles on naloxone based on primary data collection from humans, including feasibility studies, program evaluations, surveys, qualitative studies, and studies comparing the effectiveness of different routes of naloxone administration. We also included cost-effectiveness studies. RESULTS We identified 41 articles that represented 5 categories: evaluations of OEND programs, effects of OEND programs on experiences and attitudes of participants, willingness of medical providers to prescribe naloxone, comparisons of different routes of naloxone administration, and the cost-effectiveness of naloxone. CONCLUSIONS Existing research suggests that people who are at risk for overdose and other bystanders are willing and able to be trained to prevent overdoses and administer naloxone. Counseling patients about the risks of opioid overdose and prescribing naloxone is an emerging clinical practice that may reduce fatalities from overdose while enhancing the safe prescribing of opioids.
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Affiliation(s)
- Shane R Mueller
- a Division of General Internal Medicine , University of Colorado School of Medicine , Aurora , Colorado , USA
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Abstract
This paper is the thirty-sixth consecutive installment of the annual review of research concerning the endogenous opioid system. It summarizes papers published during 2013 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides, opioid receptors, opioid agonists and opioid antagonists. The particular topics that continue to be covered include the molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors related to behavior, and the roles of these opioid peptides and receptors in pain and analgesia; stress and social status; tolerance and dependence; learning and memory; eating and drinking; alcohol and drugs of abuse; sexual activity and hormones, pregnancy, development and endocrinology; mental illness and mood; seizures and neurologic disorders; electrical-related activity and neurophysiology; general activity and locomotion; gastrointestinal, renal and hepatic functions; cardiovascular responses; respiration and thermoregulation; and immunological responses.
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Affiliation(s)
- Richard J Bodnar
- Department of Psychology and Neuropsychology Doctoral Sub-Program, Queens College, City University of New York, Flushing, NY 11367, United States.
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29
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Lenton S, Dietze P, Olsen A, Wiggins N, McDonald D, Fowlie C. Working together: Expanding the availability of naloxone for peer administration to prevent opioid overdose deaths in the Australian Capital Territory and beyond. Drug Alcohol Rev 2014; 34:404-11. [PMID: 25272281 DOI: 10.1111/dar.12198] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 07/31/2014] [Indexed: 11/28/2022]
Abstract
ISSUE Since the mid-1990s, there have been calls to make naloxone, a prescription-only medicine in many countries, available to heroin and other opioid users and their peers and family members to prevent overdose deaths. CONTEXT In Australia there were calls for a trial of peer naloxone in 2000, yet at the end of that year, heroin availability and harm rapidly declined, and a trial did not proceed. In other countries, a number of peer naloxone programs have been successfully implemented. Although a controlled trial had not been conducted, evidence of program implementation demonstrated that trained injecting drug-using peers and others could successfully administer naloxone to reverse heroin overdose, with few, if any, adverse effects. APPROACH In 2009 Australian drug researchers advocated the broader availability of naloxone for peer administration in cases of opioid overdose. Industrious local advocacy and program development work by a number of stakeholders, notably by the Canberra Alliance for Harm Minimisation and Advocacy, a drug user organisation, contributed to the rollout of Australia's first prescription naloxone program in the Australian Capital Territory (ACT). Over the subsequent 18 months, prescription naloxone programs were commenced in four other Australian states. IMPLICATIONS The development of Australia's first take-home naloxone program in the ACT has been an 'ice-breaker' for development of other Australian programs. Issues to be addressed to facilitate future scale-up of naloxone programs concern scheduling and cost, legal protections for lay administration, prescribing as a barrier to scale-up; intranasal administration, administration by service providers and collaboration between stakeholders.
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Affiliation(s)
- Simon Lenton
- National Drug Research Institute, Faculty of Health Sciences, Curtin University, Perth, Australia
| | - Paul Dietze
- Centre for Population Health, Burnet Institute, Melbourne, Australia
| | - Anna Olsen
- Kirby Institute, University of NSW, Sydney, Australia
| | - Nicole Wiggins
- Canberra Alliance for Harm Minimisation and Advocacy, Canberra, Australia
| | - David McDonald
- National Centre for Epidemiology and Population Health, The Australian National University, Canberra, Australia
| | - Carrie Fowlie
- Alcohol Tobacco and Other Drug Association ACT, Canberra, Australia
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30
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Banjo O, Tzemis D, Al-Qutub D, Amlani A, Kesselring S, Buxton JA. A quantitative and qualitative evaluation of the British Columbia Take Home Naloxone program. CMAJ Open 2014; 2:E153-61. [PMID: 25295235 PMCID: PMC4183165 DOI: 10.9778/cmajo.20140008] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND In August 2012, the British Columbia Take Home Naloxone (BCTHN) program was introduced to help to reduce opioid overdose and its consequences. This study evaluates the BCTHN program, identifying the successes and challenges of implementing a provincial program in Canada. METHODS In this cross-sectional study, we reviewed the records of the BCTHN administrative program to report on program outcomes (participation and overdose reversals). Focus groups and individual interviews were conducted with 40 clients in Vancouver; 12 individual interviews were completed with service providers, police officers and parents of people who use opioids from both the Vancouver and Interior regions of British Columbia. Qualitative data were analyzed using content analysis and a qualitative descriptive approach. RESULTS As of March 13, 2014, the BCTHN program had been implemented at 40 sites, trained 1318 participants in overdose prevention, recognition and response, distributed 836 kits to clients and received reports of 85 overdose reversals. Stakeholders were supportive of the program, and clients reported greater confidence in response to overdose. Service providers found the program training materials easy to use and that training increased client engagement. Some of the challenges included difficulty in identifying physician willing to prescribe, recruitment of some at-risk populations (e.g., long-term opioid users and patients with chronic pain), and clients' reluctance to call 911. We also found that the police had some misconceptions about BCTHN. INTERPRETATION The BCTHN program was easy to implement, empowering for clients and was responsible for reversing 85 overdoses in its first 20 months. We suggest communities across Canada should consider implementing take-home naloxone programs and evaluate their findings.
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Affiliation(s)
- Oluwajenyo Banjo
- British Columbia Centre for Disease Control, Vancouver, BC
- Faculty of Health Sciences, Simon Fraser University, Burnaby, BC
| | - Despina Tzemis
- British Columbia Centre for Disease Control, Vancouver, BC
| | - Diana Al-Qutub
- British Columbia Centre for Disease Control, Vancouver, BC
- School of Population and Public Health, University of British Columbia, Vancouver, BC
| | - Ashraf Amlani
- British Columbia Centre for Disease Control, Vancouver, BC
| | - Sarah Kesselring
- British Columbia Centre for Disease Control, Vancouver, BC
- School of Population and Public Health, University of British Columbia, Vancouver, BC
| | - Jane A Buxton
- British Columbia Centre for Disease Control, Vancouver, BC
- School of Population and Public Health, University of British Columbia, Vancouver, BC
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