Naloxone Distribution Programs Research Articles

Expanding access to naloxone for family members: The Massachusetts experience.

The Massachusetts Department of Public Health Overdose Education and Naloxone Distribution Program provides overdose education and naloxone rescue kits to people at risk for overdose and bystanders, including family members. Using Massachusetts Department of Public Health data, the aims are to: (i) describe characteristics of family members who receive naloxone; (ii) identify where family members obtain naloxone; and (iii) describe characteristics of rescues by family members. We conducted a retrospective review using program enrollee information collected on a standardised form between 2008 and 2015. We calculated descriptive statistics, including demographics, current substance use, enrolment location, history of witnessed overdoses and rescue attempt characteristics. We conducted a stratified analysis comparing family members who used drugs with those who did not. Family members were 27% of total program enrollees (n=10883/40801). Family members who reported substance use (n=4679) were 35.6years (mean), 50.6% female, 76.3% non-Hispanic white, 75.6% had witnessed an overdose, and they obtained naloxone most frequently at HIV prevention programs. Family members who did not report substance use (n=6148) were 49.2years (mean), 73.8% female, 87.9% non-Hispanic white, 35.3% had witnessed an overdose, and they obtained naloxone most frequently at community meetings. Family members were responsible for 20% (n=860/4373) of the total rescue attempts. The Massachusetts experience demonstrates that family members can be active participants in responding to the overdose epidemic by rescuing family members and others. Targeted intervention strategies for families should be included in efforts to expand overdose education and naloxone in Massachusetts.

Addressing excess risk of overdose among recently incarcerated people in the USA: harm reduction interventions in correctional settings

PurposeThe purpose of this paper is to discuss overdose among those with criminal justice experience and recommend harm reduction strategies to lessen overdose risk among this vulnerable population.Design/methodology/approachStrategies are needed to reduce overdose deaths among those with recent incarceration. Jails and prisons are at the epicenter of the opioid epidemic but are a largely untapped setting for implementing overdose education, risk assessment, medication assisted treatment, and naloxone distribution programs. Federal, state, and local plans commonly lack corrections as an ingredient in combating overdose. Harm reduction strategies are vital for reducing the risk of overdose in the post-release community.FindingsTherefore, the authors recommend that the following be implemented in correctional settings: expansion of overdose education and naloxone programs; establishment of comprehensive medication assisted treatment programs as standard of care; development of corrections-specific overdose risk assessment tools; and increased collaboration between corrections entities and community-based organizations.Originality/valueIn this policy brief the authors provide recommendations for implementing harm reduction approaches in criminal justice settings. Adoption of these strategies could reduce the number of overdoses among those with recent criminal justice involvement.

Opioid overdose education and naloxone distribution: Development of the Veterans Health Administration’s national program

ObjectivesTo prevent opioid-related mortality, the Veterans Health Administration (VHA) developed a national Opioid Overdose Education and Naloxone Distribution (OEND) program. SettingVHA’s OEND program sought national implementation of OEND across all medical facilities (n = 142). Practice descriptionThis paper describes VHA’s efforts to facilitate nationwide health care system–based OEND implementation, including the critical roles of VHA’s national pharmacy services and academic detailing services. Practice innovationVHA is the first large health care system in the United States to implement OEND nationwide. Launching the national program required VHA to translate a primarily community-based public health approach to OEND into a health care system–based approach that distributed naloxone to patients with opioid use disorders as well as to patients prescribed opioid analgesics. Key innovations included developing steps to implement OEND, pharmacy developing standard naloxone rescue kits, adding those kits to the VHA National Formulary, centralizing kit distribution, developing clinical guidance for issuing naloxone kits, and supporting OEND as a focal campaign of academic detailing. Other innovations included the development of patient and provider education resources (e.g., brochures, videos, accredited training) and implementation and evaluation resources (e.g., technical assistance, clinical decision support tools). EvaluationClinical decision support tools that leverage VHA national data are available to clinical staff with appropriate permissions. These tools allow staff and leaders to evaluate OEND implementation and provide actionable next steps to help them identify patients who could benefit from OEND. ResultsThrough fiscal year 2016, VHA dispensed 45,178 naloxone prescriptions written by 5693 prescribers to 39,328 patients who were primarily prescribed opioids or had opioid use disorder. As of February 2, 2016, there were 172 spontaneously reported opioid overdose reversals with the use of VHA naloxone prescriptions. ConclusionVHA has successfully translated community-based OEND into health care system–based OEND targeting 2 patient populations. There is a tremendous amount that can be learned from VHA’s experience implementing this novel health care innovation nationwide.

Implementing an overdose education and naloxone distribution program in a health system

ObjectiveTo design and implement a health system–wide program increasing provision of take-home naloxone in patients at risk for opioid overdose, with the downstream aim of reducing fatalities. The program includes health care professional education and guidelines, development, and dissemination of patient education materials, electronic health record changes to promote naloxone prescriptions, and availability of naloxone in pharmacies. SettingAcademic health system, San Diego, California. Practice descriptionUniversity of California, San Diego Health (UCSDH), offers both inpatient and outpatient primary care and specialty services with 563 beds spanning 2 hospitals and 6 pharmacies. UCSDH is part of the University of California health system, and it serves as the county’s safety net hospital. Practice innovationIn January 2016, a multisite academic health system initiated a system-wide overdose education and naloxone distribution program to prevent opioid overdose and opioid overdose–related deaths. An interdisciplinary, interdepartmental team came together to develop and implement the program. To strengthen institutional support, naloxone prescribing guidelines were developed and approved for the health system. Education on naloxone for physicians, pharmacists, and nurses was provided through departmental trainings, bulletins, and e-mail notifications. Alerts in the electronic health record and preset naloxone orders facilitated co-prescribing of naloxone with opioid prescriptions. EvaluationElectronic health record reports captured naloxone prescriptions ordered. Summary reports on the electronic health record measured naloxone reminder alerts and response rates. ResultsSince the start of the program, the health system has trained 252 physicians, pharmacists, and nurses in overdose education and take-home naloxone. There has been an increase in the number of prescriptions for naloxone from a baseline of 4.5 per month to an average of 46 per month during the 3 months following full implementation of the program including implementation of electronic health record alerts. ConclusionInitiating and implementing an overdose education and naloxone distribution program is feasible in an academic health system.

Development and applications of the Veterans Health Administration’s Stratification Tool for Opioid Risk Mitigation (STORM) to improve opioid safety and prevent overdose and suicide.

Concerns about opioid-related adverse events, including overdose, prompted the Veterans Health Administration (VHA) to launch an Opioid Safety Initiative and Overdose Education and Naloxone Distribution program. To mitigate risks associated with opioid prescribing, a holistic approach that takes into consideration both risk factors (e.g., dose, substance use disorders) and risk mitigation interventions (e.g., urine drug screening, psychosocial treatment) is needed. This article describes the Stratification Tool for Opioid Risk Mitigation (STORM), a tool developed in VHA that reflects this holistic approach and facilitates patient identification and monitoring. STORM prioritizes patients for review and intervention according to their modeled risk for overdose/suicide-related events and displays risk factors and risk mitigation interventions obtained from VHA electronic medical record (EMR)-data extracts. Patients' estimated risk is based on a predictive risk model developed using fiscal year 2010 (FY2010: 10/1/2009-9/30/2010) EMR-data extracts and mortality data among 1,135,601 VHA patients prescribed opioid analgesics to predict risk for an overdose/suicide-related event in FY2011 (2.1% experienced an event). Cross-validation was used to validate the model, with receiver operating characteristic curves for the training and test data sets performing well (>.80 area under the curve). The predictive risk model distinguished patients based on risk for overdose/suicide-related adverse events, allowing for identification of high-risk patients and enrichment of target populations of patients with greater safety concerns for proactive monitoring and application of risk mitigation interventions. Results suggest that clinical informatics can leverage EMR-extracted data to identify patients at-risk for overdose/suicide-related events and provide clinicians with actionable information to mitigate risk. (PsycINFO Database Record

Rapid widespread distribution of intranasal naloxone for overdose prevention

BackgroundTake home naloxone programs have been successful internationally in training bystanders to reverse an opioid overdose with naloxone, an opioid antagonist. A multi-site naloxone distribution program began in Norway in 2014 as part of a national overdose prevention strategy. The aim of this study was to a) describe the program, and b) present findings from the government-supported intervention. MethodsFrom July 2014 to December 2015, staff from multiple low-threshold facilities trained clients on how to use intranasal naloxone. Distribution occurred without an individual prescription or physician present. Questionnaires from initial and refill trainings were obtained, and distribution rates were monitored. ResultsThere were 2056 naloxone sprays distributed from one of the 20 participating facilities, with 277 reports of successful reversals. Participants exhibited known risks for overdosing, with injecting (p=0.02, OR=2.4, 95% CI=1.14, 5.00) and concomitant benzodiazepine use (p=0.01, OR=2.6, 95% CI=1.31, 5.23) being significant predictors for having had high rates of previous overdoses. Suggested target coverage for large-scale programs was met, with an annual naloxone distribution rate of 144 per 100,000 population, as well as 12 times the cities mean annual number of opioid-related deaths. ConclusionA government-supported multisite naloxone initiative appears to achieve rapid, high volume distribution of naloxone to an at-risk population.

Social mixing and correlates of injection frequency among opioid use partnerships

BackgroundAs resources are deployed to address the opioid overdose epidemic in the USA, it is essential that we understand the correlates of more frequent opioid injections—which has been associated not only with HIV and HCV transmission, but also with overdose risk—to inform the development and targeting of effective intervention strategies like overdose prevention and naloxone distribution programs. However, no studies have explored how characteristics of opioid use partnerships may be associated within injection frequency with opioid partnerships. MethodsUsing baseline data from a trial of a behavioural intervention to reduce overdose among opioid users in San Francisco, CA, we calculated assortativity among opioid use partnerships by race, gender, participant-reported HIV- and HCV-status, and opioids used using Newman’s assortativity coefficient (NC). Multivariable generalized estimating equations linear regression was used to examine associations between individual- and partnership-level characteristics and injection frequency within opioid use partnerships. ResultsOpioid use partnerships (n=134) reported by study participants (n=55) were assortative by race (NC=0.42, 95%CI=0.33–0.50) and participant-reported HCV-status (NC=0.42, 95%CI=0.31–0.52). In multivariable analyses, there were more monthly injections among sexual/romantic partnerships (β=114.4, 95%CI=60.2–168.7, p<0.001), racially concordant partnerships reported by white study participants (β=71.4, 95%CI=0.3–142.5, p=0.049), racially discordant partnerships reported by African American study participants (β=105.7, 95%CI=1.0–210.5, p=0.048), and partnerships in which either member had witnessed the other experience an overdose (β=81.8, 95%CI=38.9–124.6, p<0.001). ConclusionSocial segregation by race and HCV-status should potentially be considered in efforts to reach networks of opioid users. Due to higher injection frequency and greater likelihood of witnessing their partners experience an overdose, individuals in sexual/romantic opioid use partnerships, white individuals in racially homogenous partnerships, and African American individuals in heterogeneous partnerships may warrant focused attention as part of peer- and network-based overdose prevention efforts, as well as broader HIV/HCV prevention strategies. Developing and targeting overdose prevention education programs that provide information on risk factors and ways to identify overdose, as well as effective responses, including naloxone use and rescue breathing, for more frequently injecting networks may help reduce opioid morbidity and mortality in these most at risk groups.

Trends in naloxone prescriptions prescribed after implementation of a National Academic Detailing Service in the Veterans Health Administration: A preliminary analysis

ObjectivesTo evaluate the effects of the U.S. Veterans Health Administration (VA) National Academic Detailing Service alongside the Opioid Overdose Education and Naloxone Distribution (OEND) program on naloxone prescriptions prescribed from October 2014 to September 2016. MethodsA retrospective, repeated measures cohort study was conducted to evaluate the effectiveness of a real-world application of academic detailing (AD) alongside OEND on providers’ outpatient naloxone prescribing from October 2014 to September 2016. Outcome was the number of naloxone prescriptions prescribed per month per provider. During the study period, VA providers were aware of OEND, but may not have been exposed to academic detailing. Therefore, providers were categorized as exposed when the first OEND-specific academic detailing session was provided during the study period. Generalized estimating equations were used to estimate the association between exposure to academic detailing and monthly naloxone prescriptions prescribed while taking into account the correlation within each provider. Incident rate ratios with 95% CIs were reported. ResultsSeven hundred fifty (22.6%) of 3313 providers received at least 1 OEND-specific academic detailing visit. At 1 year, the average number of naloxone prescriptions per month was 3-times greater in AD-exposed providers compared with AD-unexposed providers (95% CI 2.0-5.3); and at 2 years, the average number of naloxone prescriptions was 7-times greater (95% CI 3.0-17.9). Moreover, the average difference in naloxone prescribing from baseline to 2 years was 7.1% greater in AD-exposed providers compared with AD-unexposed providers (95% CI 2.0%-12.5%). ConclusionsThis preliminary analysis provides the first evidence that academic detailing influenced naloxone prescribing rates in a large, integrated health care system at 1 and 2 years. In addition, AD-exposed providers had a higher average difference in naloxone prescribing rate compared with AD-unexposed providers after 2 years of follow-up.

Choosing Opioid Policies Our Patients Can Live With.

In 1997, the American Academy of Pain Medicine and the American Pain Society jointly issued recommendations regarding the care of patients with chronic pain.(1) Several years later, the Joint Commission on Accreditation of Healthcare Organizations issued pain management standards "recommending" that hospitals identify patients with pain upon initial screening and collect data to monitor the effectiveness of pain management.(2) Nearly two decades later, we find ourselves in the midst of a opioid epidemic triggered, in part, by excessive utilization of opioid pain medications.(3) We now find ourselves playing "catch up," as we try to undo some of the practices of the past, and change the culture to better balance benefit and risk. This article is protected by copyright. All rights reserved.This article is protected by copyright. All rights reserved. Language: en

P071: Emergency physician attitudes and perceived barriers to take-home naloxone programs in Canadian emergency departments

Introduction: Unintentional overdose is the leading cause of injurious death among Americans aged 25-64 years. A similar epidemic is underway in Canada. Community-based opioid overdose education and naloxone distribution (OOEND) programs distribute take-home naloxone kits to people at risk of overdose in several cities across Canada. Due to the high rate of drug-related visits, recurrent opioid prescribing, and routine encounters with opioid overdose, Emergency Departments (ED) may represent an under-utilized setting to deliver naloxone to people at risk of opioid overdose or likely to witness overdose. The goal of this study was to identify Canadian emergency physician attitudes and perceived barriers to the implementation of take-home naloxone programs. Methods: This was an anonymous web-based survey of physician and trainee members of the Canadian Association of Emergency Physicians. Survey questions were developed by the research team and piloted for face validity and clarity. Two reminder emails were sent to non-responders at 2-week intervals, per the modified Dillman method. Respondent demographics were collected and Likert scales used to assess attitudes and barriers to the prescription of naloxone from the ED. Results: A total of 347/1658 CAEP members responded (20.9%). Of the respondents, 62.1% were male and residents made up 15.6%. The majority (48.2%) worked in Ontario and 55.7% worked in an urban tertiary centre. Overall attitudes to OOEND were strongly positive: 86.6% of respondents identified a willingness to prescribe naloxone from the ED. Perceived barriers included allied health support for patient education (56.4%), access to follow-up (40.3%), and inadequate time in the clinical encounter (37.7%). In addition to people at risk of overdose, 78% of respondents identified that friends and family members may benefit from OOEND programs. Conclusion: Canadian emergency physicians are willing to prescribe take-home naloxone to at-risk patients, but better systems and tools are required to facilitate opioid overdose education and naloxone distribution implementation. This data will inform the development of these programs, with emphasis on allied health support, training and education.

Utilizing a train-the-trainer model for multi-site naloxone distribution programs

BackgroundIn order to have a substantial impact on overdose prevention, the expansion and scaling-up of overdose prevention with naloxone distribution (OPEND) programs are needed. However, limited literature exists on the best method to train the large number of trainers needed to implement such initiatives. MethodsAs part of a national overdose prevention strategy, widespread OPEND was implemented throughout multiple low-threshold facilities in Norway. Following a two-hour ‘train-the trainer course’ staff were able to distribute naloxone in their facility. The course was open to all staff, regardless of educational background. To measure the effectiveness of the course, a questionnaire was given to participants immediately before and after the session, assessing knowledge on overdoses and naloxone, as well as attitudes towards the training session and distributing naloxone. ResultsIn total, 511 staff were trained during 41 trainer sessions. During a two-month survey period, 54 staff participated in a questionnaire study. Knowledge scores significantly improved in all areas following the training (p<0.001). Attitude scores improved, and the majority of staff found the training useful and intended to distribute naloxone to their clients. ConclusionLarge-scale naloxone distribution programs are likely to continue growing, and will require competent trainers to carry out training sessions. The train-the-trainer model appears to be effective in efficiently training a high volume of trainers, improving trainers’ knowledge and intentions to distribute naloxone. Further research is needed to assess the long term effects of the training session, staffs’ subsequent involvement following the trainer session, and knowledge transferred to the clients.

Evaluation of the Overdose Education and Naloxone Distribution Program of the Baltimore Student Harm Reduction Coalition.

Although historically the majority of overdose education and naloxone distribution (OEND) programs have targeted opioid users, states are increasingly passing laws that enable third-party prescriptions of naloxone to individuals who may be able to respond to an overdose, including friends and family members of individuals who use opioids. In this report, we discuss the Baltimore Student Harm Reduction Coalition (BSHRC) OEND program, Maryland's first community-based, state-authorized training program under a new law allowing third-party naloxone prescription. In an 8-month pilot period, 250 free naloxone kits were distributed, and 3 overdose reversals were reported to BSHRC. Trainings were effective in increasing self-efficacy surrounding overdose prevention and response, which appears to persist at up to 12 months following the training.

Patient perspectives on an opioid overdose education and naloxone distribution program in the U.S. Department of Veterans Affairs

ABSTRACTBackground: In an effort to prevent opioid overdose mortality among Veterans, Department of Veterans Affairs (VA) facilities began implementing opioid overdose education and naloxone distribution (OEND) in 2013 and a national program began in 2014. VA is the first national health care system to implement OEND. The goal of this study is to examine patient perceptions of OEND training and naloxone kits. Methods: Four focus groups were conducted between December 2014 and February 2015 with 21 patients trained in OEND. Participants were recruited from a VA residential facility in California with a substance use disorder treatment program (mandatory OEND training) and a homeless program (optional OEND training). Data were analyzed using matrices and open and closed coding approaches to identify participants' perspectives on OEND training including benefits, concerns, differing opinions, and suggestions for improvement. Results: Veterans thought OEND training was interesting, novel, and empowering, and that naloxone kits will save lives. Some veterans expressed concern about using syringes in the kits. A few patients who never used opioids were not interested in receiving kits. Veterans had differing opinions about legal and liability issues, whether naloxone kits might contribute to relapse, and whether and how to involve family in training. Some veterans expressed uncertainty about the effects of naloxone. Suggested improvements included active learning approaches, enhanced training materials, and increased advertisement. Conclusions: OEND training was generally well received among study participants, including those with no indication for a naloxone kit. Patients described a need for OEND and believed it could save lives. Patient feedback on OEND training benefits, concerns, opinions, and suggestions provides important insights to inform future OEND training programs both within VA and in other health care settings. Training is critical to maximizing the potential for OEND to save lives, and this study includes specific suggestions for improving the effectiveness and acceptability of training.

Capsule Commentary on Binswanger et al., Overdose Education and Naloxone for Patients Prescribed Opioids in Primary Care: A Qualitative Study of Primary Care Staff.

M ore people in the US die from overdose due to prescription opioids than from street drugs. The rise in mortality rates has paralleled increased opiate use over the last decade. There have been a number of responses, locally and nationally. BSafe^ opiate prescribing includes screening patients for opiate risk, keeping opiate doses as low as possible, not combining them with benzodiazepines, requiring patients to sign opiate consent agreements, and performing regular urine monitoring. Most states have prescription drug monitoring programs. Several opiates have been reformulated to make them harder to misuse, and some formularies have dropped higher-risk opiates. Emergency responders have long used naloxone in patients at risk for overdose. Naloxone distribution programs exist in several countries; the US has 52 such programs in 17 states. These largely target users of illicit drugs, and hence would not help the majority of overdose victims. The VA has begun to issue naloxone kits to veterans felt to be at risk for opiate overdose. To date, there have been eight reports of patient overdose successfully reversed by family members using these kits. In their qualitative study of focus groups involving 56 providers discussing naloxone rescue kits, Biswinger found several important themes. First, providers are not prepared or trained to help their patients understand how and when to use naloxone, or even to identify patients at risk. Second, there are logistical barriers such as how and whom to train in naloxone rescue use, since the patient is likely to be incapacitated. Finally, there are concerns about cost, particularly if identifying a subgroup at high risk is not possible. With over 200 million opiate prescriptions in the US in 2013, this is a potentially enormous target group to receive naloxone kits. While the ethics of rigorously studying interventions such as Bsafe^ prescriber practice or issuing naloxone rescue kits may be difficult, it is important to note that there is no clear evidence of effectiveness for any of these interventions. In the absence of hard evidence, I personally catch my breath every time I write a prescription for chronic opiates.

Implementation of nasal naloxone across health-care settings: a case report from Ohio

Drug overdose is now the leading cause of injury death in the United States, surpassing deaths from motor vehicle accidents in 2008 [1]. Naloxone, a short-acting mu opioid receptor antagonist, can reverse an opioid overdose and prevent fatality [2]. Opioid overdose prevention programs (OOPPs) provide education on overdose prevention and some have begun to distribute naloxone. As of June 2010, there were an estimated 188 OOPPs operating in the United States [3]; despite the fact that Ohio has one of the highest overdose fatality rates, there were no OOPPs at that time. The purpose of this study is to: 1) describe overdose prevention education and/or naloxone distribution programs in Ohio across various health-care settings; and 2) identify implementation barriers. A two-page survey was emailed to known Ohio OOPPs and snowball sampling was used to identify other programs. OOPP staff were contacted by phone to confirm their interest in study participation, and 19 of 21 programs completed the survey and are included in this analysis. As of October 2014 these 19 OOPPs were operating in 14 Ohio cities. The primary funding sources were: 1) Ohio Department of Health; 2) Interact for Health (a foundation serving southwest Ohio); and 3) other local public and private agencies. Overall, these programs have distributed 1935 naloxone kits and reported 152 confirmed overdose reversals. There was significant expansion of OOPPs in Ohio after the passage of House Bill 170 in 2014, which removed criminal and civil penalties for clinicians that prescribe naloxone and bystanders that administer naloxone. Identified barriers to OOPPs include: 1) cost in terms of both the provision of naloxone kits and the operational costs associated with prescribing naloxone; 2) stigma of addiction and perceptions of naloxone as a harm reduction strategy that would enable continued drug use; 3) legal/administrative concerns related to possession and distribution of naloxone; and 4) lack of standardized protocols or models that would facilitate operational integration of OOPPs into existing programming. In conclusion, OOPPs have recently expanded significantly in Ohio. Additional research is needed to determine whether this expansion is associated with a decrease in overdose fatalities. Language: en

A systematic review of community opioid overdose prevention and naloxone distribution programs.

Community-based opioid overdose prevention programs (OOPPs) that include the distribution of naloxone have increased in response to alarmingly high overdose rates in recent years. This systematic review describes the current state of the literature on OOPPs, with particular focus on the effectiveness of these programs. We used systematic search criteria to identify relevant articles, which we abstracted and assigned a quality assessment score. Nineteen articles evaluating OOPPs met the search criteria for this systematic review. Principal findings included participant demographics, the number of naloxone administrations, percentage of survival in overdose victims receiving naloxone, post-naloxone administration outcome measures, OOPP characteristics, changes in knowledge pertaining to overdose responses, and barriers to naloxone administration during overdose responses. The current evidence from nonrandomized studies suggests that bystanders (mostly opioid users) can and will use naloxone to reverse opioid overdoses when properly trained, and that this training can be done successfully through OOPPs.

Overdose rescues by trained and untrained participants and change in opioid use among substance-using participants in overdose education and naloxone distribution programs: a retrospective cohort study.

BackgroundOne approach to preventing opioid overdose, a leading cause of premature, preventable mortality, is to provide overdose education and naloxone distribution (OEND). Two outstanding issues for OEND implementation include 1) the dissemination of OEND training from trained to untrained community members; and 2) the concern that OEND provides active substance users with a false sense of security resulting in increased opioid use.MethodsTo compare overdose rescue behaviors between trained and untrained rescuers among people reporting naloxone rescue kit use; and determine whether heroin use changed after OEND, we conducted a retrospective cohort study among substance users in the Massachusetts OEND program from 2006 to 2010. We used chi square and t-test statistics to compare the differences in overdose management characteristics among overdoses managed by trained versus untrained participants. We employed Wilcoxon signed rank test to compare median difference among two repeated measures of substance use among participants with drug use information collected more than once.ResultsAmong 4,926 substance-using participants, 295 trained and 78 untrained participants reported one or more rescues, resulting in 599 rescue reports. We found no statistically significant differences in help-seeking (p = 0.41), rescue breathing (p = 0.54), staying with the victim (p = 0.84) or in the success of naloxone administration (p = 0.69) by trained versus untrained rescuers. We identified 325 OEND participants who had drug use information collected more than once. We found no significant overall change in the number of days using heroin in past 30 days (decreased 38%, increased 35%, did not change 27%, p = 0.52).ConclusionAmong 4926 substance users who participated in OEND, 373(7.6%) reported administering naloxone during an overdose rescue. We found few differences in behavior between trained and untrained overdose rescuers. Prospective studies will be needed to determine the optimal level of training and whether naloxone rescue kits can meet an over-the-counter standard. With no clear evidence of increased heroin use, this concern should not impede expansion of OEND programs or policies that support them.

Effective use of naloxone among people who inject drugs in Kyrgyzstan and Tajikistan using pharmacy- and community-based distribution approaches

BackgroundOpioid overdose (OD) is a major cause of mortality among people who inject drugs (PWID) in Central Asia, and distribution of naloxone, an opioid antagonist, can effectively prevent these deaths. However, little is known about the use and wastage of distributed naloxone ampoules. Having reliable data on wastage rates is critical for accurately calculating the health impact of naloxone distribution projects targeting PWID. MethodsIn 2011, Population Services International (PSI) launched two pilot naloxone distribution programs in Kyrgyzstan (pharmacy-based approach) and Tajikistan (community-based approach). PWID were trained on OD prevention and naloxone use. Upon returning for more ampoules, the PWID completed a brief survey on their OD experience and naloxone use. 158 respondents in Kyrgyzstan and 59 in Tajikistan completed the questionnaire. Usage and wastage rates were calculated based on responses. A four-year model wastage rate that takes into account the shelf life of naloxone for both countries was then calculated. Results51.3% of respondents in Kyrgyzstan and 91.5% in Tajikistan reported having ever experienced an OD. 82.9% of respondents in Kyrgyzstan and all respondents in Tajikistan had ever witnessed an OD. Out of these PWID who experienced or witnessed OD, 81.5% in Kyrgyzstan and 59.3% in Tajikistan reported having been injected with naloxone, and 83.2% in Kyrgyzstan and 50.9% in Tajikistan reported injecting another individual with naloxone. Of ampoules received, 46.5% in Kyrgyzstan and 78.1% in Tajikistan were used. In both countries, 3.1% of these ampoules were wasted. The four-year model wastage rates for Kyrgyzstan and Tajikistan were found to be 13.8% and 3.9% respectively. ConclusionFindings indicate that a high proportion of naloxone distributed to PWID is used in actual OD incidents, with low wastage rates in both countries. Expanding these distribution models can potentially create more positive health outcomes for PWID in Central Asia.

Board 339 - Research Abstract Patient Simulation for Assessment and Reinforcement of Layperson Management of Opioid Overdose with Intranasal Naloxone in a Recently Released Prison Inmate Cohort (Submission #66)

Introduction/Background Individuals who accidentally overdose (OD) with opioids, especially those recently released from prison, are at significant risk for death. Investigators initiated a program to assess, educate, equip and reassess at-risk, volunteering prison inmates in opiate OD prevention, recognition and naloxone administration for post-release exposure to OD situations. Methods Inmates expressing an interest in study participation after recruitment announcements, mailings and posters were approached for consent. Those agreeing to participate underwent a baseline assessment of OD-related knowledge, including recognition of opioid OD and awareness of naloxone. The study intervention was an educational DVD with standardized didactics; skills practice was not feasible during incarceration. Subjects were provided with an intra-nasal naloxone kit at time of release and scheduled for followup assessment. In order to evaluate subjects perception, acquisition, retention and delivery of layperson resuscitative skills for opioid OD at post-release followup, emergency medicine, simulation and substance abuse investigators developed an OD simulation script with accompanying 24 item assessment checklist for a low-fidelity full-body manikin. The scenario was designed to elicit, record and positively reinforce subjects performance of basic airway maneuvers, rescue breathing, naloxone administration, accessing of emergency services, avoidance of harmful actions and continued monitoring. Drug use props, distractor decoys (for common OD treatment errors) and ambient noise were provided. Investigators designed the simulation scenario for administration with video-recording as part of an assessment battery* that evaluated each subject soon after release. Pre-pilot sessions tested the scenario for feasibility and research utility. The study was IRB approved. *Assessments include the validated Brief Overdose Recognition and Response Assessment [BORR],1 questionnaires on OD risks, naloxone risks and perceptions of self-efficacy/confidence in pertinent knowledge and skills. Results One hundred sixty six inmates expressed an interest in study participation, of whom 99 (60%) consented to participate and completed the baseline assessment; 94 completed the study intervention training while incarcerated. Subject demographics were representative of the target population: average age 34.2 years; male 85%; race: white 81%, African American 7%, American Indian 5%, Hispanic/Latino 11%. 88 subjects received a naloxone kit. Six-month interim follow-up data were available for 40 subjects (43% of trained recruits) out of a projected cohort of 100 subjects. None of the follow-up subjects reported OD’s after release; 60% reported engaging in OD protective behaviors since release, including 3 naloxone administrations. At followup, subjects exhibited significant gains in OD recognition and response (naloxone administration) knowledge and self-efficacy scores as recorded by BORRA and questionnaires. Subjects scores on critical action checklists during simulation scenario at followup averaged 11.4±4.0 (range 3–22, out of 24 total correct actions). Average time to assemble the kit and administer intranasal naloxone was 55 seconds. Naloxone was administered IV, IM and without intra-nasal atomizer to the manikin by one participant each. Five participants incorrectly administered the naloxone (e.g., one nostril only or half the dose). Three participants stated they did not know how to put the naloxone together during the simulation; 5 individuals (12%) self-corrected themselves during the simulation. Additionally, potentially harmful interventions such as slapping, kicking or hitting the manikin were observed during 17 (46%) simulation sessions and unnecessary chest compressions were often performed. Conclusion Investigators developed and initiated an opioid OD prevention program for at-risk prison inmates, with a simulation component for hands-on demonstration of knowledge and assessment of skills at follow-up. The variation in in-simulation performance across subjects and relative to traditional assessment tools appears to support the utility of simulation as an evaluative methodology to assess layperson OD management skills. Reference 1. Green TC, Heimer R, Grau LE. Distinguishing signs of opioid overdose and indication for naloxone: an evaluation of six overdose training and naloxone distribution programs in the United States. Addiction, 2008; 103(6): 979–89. Disclosures Part-time employee of Inflexxion Inc. University Emergency Medicine Foundation (research grant 2009) intellectual property (copyrights; patent pending) on GLIDEPATH system.

Efforts to Reduce Overdose Deaths

The recent article by Schwartz et al. addresses the intersection of two important public health issues: opiate substitution therapy and fatal heroin overdose.1 In the United States, drug overdose is responsible for more than 36 000 deaths annually2 and is the leading cause of death among illicit drug users. Baltimore, Maryland, has one of the highest per capita heroin addiction rates in the nation, with an estimated prevalence of heroin use in 10% of the population.3 Schwartz et al. conducted a 15-year ecological analysis in Baltimore and found that increases in buprenorphine and methadone treatment with concurrent decreases in overdose deaths, controlling for heroin purity. Along with previous research,4 this study demonstrates the far-reaching benefits of opiate agonist treatment. In Baltimore, an estimated 34% of 68 000 drug users were in drug treatment in 2011, with heroin being the primary drug of abuse.5 The magnitude of out-of-treatment drug users in Baltimore and in the United States underscores the need for overdose prevention efforts targeting this population. Furthermore, out-of-treatment, long-term injection drug users (IDUs) are at greatest risk for overdose.6,7 As Schwartz et al. noted, periods of abstinence resulting from recent incarceration or drug treatment are chief overdose risk factors, given associated decreases in tolerance.8,9 These facts speak to the importance of overdose prevention among active IDUs. Capital City Care, a medical marijuana dispensary, is shown in Washington, DC, on April 15, 2013, prior to the store's opening. Three years after Washington, DC, legalized medical marijuana, three stores are set to open, allowing patients with HIV/AIDS, ... As of 2012, there were an estimated 188 overdose prevention education and naloxone distribution programs (OPEND) in the United States.2 OPEND programs train peer drug users how to prevent overdoses and administer naloxone in the event of an overdose. Naloxone is a short-acting opiate antagonist that reverses the effects of respiratory depression commonly caused by opiate overdose.7 Since 2004, Baltimore’s OPEND program, Staying Alive, has reached 35 000 individuals including an estimated 10 000 IDUs, 1200 medical and drug treatment providers, and 8500 jail inmates. Staying Alive has distributed 4000 vials of naloxone, and 250 reversals have been reported. Between 2003 and 2009 (half of the study period examined in Schwartz et al.), Staying Alive distributed 1263 naloxone vials and 196 reversals were reported. We commend Schwartz et al. for their study, which highlighted important public health programs that appear to reduce overdose mortality. We believe that both OPEND and increased availability of opiate substitution therapy have contributed to decreases in overdose mortality in Baltimore. We think that both are necessary for a holistic approach to the issue of overdose.