Association of drug overdoses and user characteristics of Canada's national mobile/virtual overdose response hotline: the National Overdose Response Service (NORS)

Perspectives of Canadian Healthcare and Harm Reduction Workers on Mobile Overdose Response Services: A Qualitative Study

BACKGROUND

Supervised consumption sites (SCS) are an evidence-based intervention proven effective for preventing drug overdose deaths. Obstacles to accessing SCS include stigma, limited hours of operation, concerns about policing, and limited geographic availability. Mobile overdose response services (MORS) are novel technologies that provide virtual supervised consumption to help reduce the risk of fatal overdoses, especially for those who use alone. MORS can take various forms, such as phone-based hotlines and mobile apps. The aim of this article is to assess the perceptions of MORS among healthcare and harm reduction staff to determine if they would be comfortable educating clients about these services.

METHODS

Twenty-two healthcare and harm reduction staff were recruited from Canada using convenience, snowball, and purposive sampling techniques to complete semistructured interviews. Inductive thematic analysis informed by grounded theory was used to identify main themes and subthemes.

RESULTS

Four themes were identified: (1) increasing MORS awareness among healthcare providers was seen as useful; (2) MORS might lessen the burden of drug overdoses on the healthcare system but could also increase ambulance callouts; (3) MORS would benefit from certain improvements such as providing harm reduction resources and other supports; and (4) MORS are viewed as supplements for harm reduction, but SCS were preferred.

CONCLUSIONS

This research provides valuable perspectives from healthcare and harm reduction workers to understand their perception of MORS and identifies key areas of potential improvement. Practical initiatives to improve MORS implementation outcomes exist.

Preference for hotline versus mobile application/countdown-based mobile overdose response services: a qualitative study

BACKGROUND

In response to the exacerbated rates of morbidity and mortality associated with the overlapping overdose and COVID-19 epidemics, novel strategies have been developed, implemented, operationalized and scaled to reduce the harms resulting from this crisis. Since the emergence of mobile overdose response services (MORS), two strategies have aimed to help reduce the mortality associated with acute overdose including staffed hotline-based services and unstaffed timer-based services. In this article, we aim to gather the perspectives of various key interest groups on these technologies to determine which might best support service users.

METHODS

Forty-seven participants from various interested groups including people who use substances who have and have not used MORS, healthcare workers, family members, harm reduction employees and MORS operators participated in semi-structured interviews. Transcripts were coded and analyzed using a thematic analysis approach.

RESULTS

Four major themes emerged regarding participant perspectives on the differences between services, namely differences in connection, perceived safety, privacy and accessibility, alongside features that are recommended for MORS in the future.

CONCLUSIONS

Overall, participants noted that individuals who use substances vary in their desire for connection during a substance use session offered by hotline and timer-based service modalities. Participants perceived hotline-based approaches to be more reliable and thus potentially safer than their timer-based counterparts but noted that access to technology is a limitation of both approaches.

Perspectives of healthcare workers on the integration of overdose detection technologies in acute care settings

BACKGROUND

People who use drugs (PWUD) face disproportionately high rates of hospitalizations and patient-initiated discharge (leaving against medical advice), explained by a combination of stigma, withdrawal, judgment, blame, and improper pain management. In addition, evidence has shown that despite abstinence-based policies within healthcare settings, PWUD continue to use their substances in healthcare environments often hidden away from hospital staff, resulting in fatalities. Various novel overdose detection technologies (ODTs) have been developed with early adoption in a few settings to reduce the morbidity and mortality from risky substance use patterns within healthcare environments. Our study aimed to gain the perspectives of healthcare workers across Canada on implementing ODTs within these settings.

METHOD

We used purposive and snowball sampling to recruit 16 healthcare professionals to participate in semi-structured interviews completed by two evaluators. Interview transcripts were analyzed using thematic analysis to identify key themes and subthemes.

RESULTS

Participants recognized ODTs as a potentially feasible solution for increasing the safety of PWUD in healthcare settings. Our results suggest the mixed ability of these services to decrease stigma and build rapport with PWUD. Participants further highlighted barriers to implementing these services, including pre-established policies, legal recourse, and coordination of emergency responses to suspected overdoses. Lastly, participants highlight that ODTs should only be one part of a multifaceted approach to reducing harm in healthcare settings and could currently be integrated into discharge planning.

CONCLUSION

Healthcare professionals from across Canada found ODTs to be an acceptable intervention, but only as part of a larger suite of harm reduction interventions to reduce the harms associated with illicit drug use in healthcare settings. In contrast, participants noted institutional policies, stigma on behalf of healthcare workers and leadership would present significant challenges to their uptake and dissemination.

Virtual overdose monitoring services/mobile overdose response services: estimated number of potentially averted drug poisoning fatality events by various telephone and digital-based overdose prevention/harm reduction services in North America

Background

Virtual overdose monitoring services or Mobile Overdose Response Services (MORS) are novel virtual harm reduction tools which have gained popularity as an adjunct public health intervention especially for those who cannot access harm reduction resources through traditional means. At this time, relatively little is known about their ability to reach their goals of reducing overdose mortality. Our study aims to summarize the potential effectiveness of various MORS collectively to avoid potential mortality from a drug poisoning event/drug overdose.

Methods

Utilizing publicly available data from various MORS alongside some usage data provided by these services for this study, we model the impact of these services on fatal drug poisoning/overdose. In order to calculate the number of deaths averted, a Monte Carlo simulation was used to calculate point estimates with 95% confidence for fatal drug poisonings/drug overdose potentially averted through the utilization of various MORS.

Results

From the earliest mention of MORS in current literature (2019), a total of 299 drug poisoning/overdose events occurred across these services. Noting the broad range of mortality statistics available in current literature, these technologies have potentially prevented between 33 to 243 deaths. Our Monte Carlo estimates 135 potentially fatal drug poisonings/overdose were overall averted by the various MORS.

Conclusions

While there is yet to be a robust data set proving the effectiveness of these services, conservative estimates show that MORS can reduce mortality associated with substance use and therefore should be considered as a viable harm-reduction strategy but as an adjunct to more established harm reduction services such as supervised consumption sites and supervised injection facilities. While more research is needed, clinicians and practitioners should consider the suggestion of these tools for patients who use drugs.

A cost benefit analysis of a virtual overdose monitoring service/mobile overdose response service: the national overdose response service

BACKGROUND

The overdose crisis continues across Canada which calls for novel harm reduction strategies. Previous research indicates that a majority of eHealth solutions are cost-effective however current literature on the cost-benefit of eHealth for harm reduction is sparse. The National Overdose Response Service (NORS) is a Canada-wide telephone-based harm reduction service. Service users can call the phone number and connect to a peer who can virtually monitor the substance use session and dispatch appropriate interventions in the case of overdose.

OBJECTIVES OF THE RESEARCH/PROJECT

We aim to assess the cost-benefit of NORS by comparing the estimated cost-savings from prevented overdose mortality to the operating costs of the program, alongside healthcare costs associated with its operation.

METHODS

Data around systems costs and operational costs were gathered for our calculations. Our primary outcome was cost-benefit ratios, derived from estimates and models of mortality rates in current literature and value of life lost. We presented our main results across a range of values for costs and the probability of death following an unwitnessed overdose. These values were utilized to calculate cost-benefit ratios and value per dollar spent on service provision by NORS over the length of the program's operation (December 2020-2022).

RESULTS

Over the total funded lifespan of the program, and using a Monte Carlo estimate, the benefit-to-cost ratio of the NORS program was 8.59 (1.53-15.28) per dollar spent, depending on estimated mortality rates following unwitnessed overdose and program operation costs. Further, we conservatively estimate that early community-based naloxone intervention results in healthcare system savings of $4470.82 per overdose response.

CONCLUSIONS

We found the NORS program to have a positive benefit-to-cost ratio when the probability of death following an unwitnessed overdose was greater than 5%. NORS and potentially other virtual overdose monitoring services have the potential to be cost-effective solutions for managing the drug poisoning crisis.