Naloxone Distribution Research Articles

Characterizing Individuals Who Elect and Decline Opioid Overdose Education and Naloxone Distribution to Tailor Programs and Expand Impact

Characterizing Individuals Who Elect and Decline Opioid Overdose Education and Naloxone Distribution to Tailor Programs and Expand Impact

Clinical Decision Support to Increase Emergency Department Naloxone Coprescribing: Implementation Report

Abstract Background Coprescribing naloxone with opioid analgesics is a Centers for Disease Control and Prevention (CDC) best practice to mitigate the risk of fatal opioid overdose, yet coprescription by emergency medicine clinicians is rare, occurring less than 5% of the time it is indicated. Clinical decision support (CDS) has been associated with increased naloxone prescribing; however, key CDS design characteristics and pragmatic outcome measures necessary to understand replicability and effectiveness have not been reported. Objective This study aimed to rigorously evaluate and quantify the impact of CDS designed to improve emergency department (ED) naloxone coprescribing. We hypothesized CDS would increase naloxone coprescribing and the number of naloxone prescriptions filled by patients discharged from EDs in a large health care system. Methods Following user-centered design principles, we designed and implemented a fully automated, interruptive, electronic health record–based CDS to nudge clinicians to coprescribe naloxone with high-risk opioid prescriptions. “High-risk” opioid prescriptions were defined as any opioid analgesic prescription ≥90 total morphine milligram equivalents per day or for patients with a prior diagnosis of opioid use disorder or opioid overdose. The Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework was used to evaluate pragmatic CDS outcomes of reach, effectiveness, adoption, implementation, and maintenance. Effectiveness was the primary outcome of interest and was assessed by (1) constructing a Bayesian structural time-series model of the number of ED visits with naloxone coprescriptions before and after CDS implementation and (2) calculating the percentage of naloxone prescriptions associated with CDS that were filled at an outpatient pharmacy. Mann-Kendall tests were used to evaluate longitudinal trends in CDS adoption. All outcomes were analyzed in R (version 4.2.2; R Core Team). Implementation (Results) Between November 2019 and July 2023, there were 1,994,994 ED visits. CDS reached clinicians in 0.83% (16,566/1,994,994) of all visits and 15.99% (16,566/103,606) of ED visits where an opioid was prescribed at discharge. Clinicians adopted CDS, coprescribing naloxone in 34.36% (6613/19,246) of alerts. CDS was effective, increasing naloxone coprescribing from baseline by 18.1 (95% CI 17.9‐18.3) coprescriptions per week or 2,327% (95% CI 3390‐3490). Patients filled 43.80% (1989/4541) of naloxone coprescriptions. The CDS was implemented simultaneously at every ED and no adaptations were made to CDS postimplementation. CDS was maintained beyond the study period and maintained its effect, with adoption increasing over time (τ=0.454; P<.001). Conclusions Our findings advance the evidence that electronic health record–based CDS increases the number of naloxone coprescriptions and improves the distribution of naloxone. Our time series analysis controls for secular trends and strongly suggests that minimally interruptive CDS significantly improves process outcomes.

An interrupted time series analysis of fentanyl, naloxone, and opioid-involved deaths in five counties in Eastern Missouri

IntroductionRates of opioid overdose deaths (OOD) have increased since the introduction of illicitly manufactured fentanyl in the U.S. drug supply. Though community-based naloxone distribution efforts have been found to effectively reduce OOD, no studies to date have examined their effects during the fentanyl era, nor in the epicenter of a state's overdose crisis. Thus, the current study assessed the impacts of both fentanyl and of subsequent grant-funded community-based naloxone distribution on OOD across Missouri's St. Louis region. MethodsMedical examiner data includes individuals who died within one of the five study counties (St. Louis City, St. Louis County, and Franklin, Jefferson, St. Charles counties [combined as “Collar Counties”]) between 2011 and 2022 due to an opioid overdose (N = 6799). Naloxone distribution date and location data came from Missouri's university-based naloxone distribution team. We conducted a controlled interrupted time series using an autoregressive model via proc. ARIMA to examine changes over time in the rate of OOD associated with the introduction of fentanyl (defined to be present in 25 % of opioid overdose deaths; June 2015) and the start of naloxone distribution for each location (August 2017, October 2017, and January 2018, respectively). ResultsThe introduction of fentanyl into the drug supply of St. Louis City was associated with an increased rate of OOD over time (p < .001). Naloxone distribution in the City was associated with an immediate decrease in OOD (p < .001) followed by a slowed increase in OOD (p < .001). These findings were not replicated in St. Louis County nor the Collar Counties. ConclusionsThe effects of fentanyl and naloxone on OOD varied by region in Eastern Missouri. Specifically, fentanyl and naloxone effects were only found in a high-need urban area with existing harm reduction and street outreach programs, but not in surrounding suburban or rural areas. State-level naloxone distribution decision-makers should prioritize funding harm reduction services in both urban and non-urban settings to help increase targeted naloxone distribution to those actively using drugs. Additionally, interventions tailored for people who engage in solitary drug use - such as safe consumption spaces and overdose detection technologies - should receive increased investment and implementation, particularly in rural areas where harm reduction infrastructure is more scarce.

A Holistic Harm Reduction Center Model: A Commentary

Substance addiction is a chronic, relapsing disorder characterized by compulsive drug seeking, loss of control over consumption, and a negative emotional state when access to the drug is restricted. Substance Use Disorders (SUDs) are associated with severe health issues including suicide and co-occurring diseases like HIV and hepatitis C, and mental health problems. Although the present SUD treatment models prioritize abstinence, achieving abstinence during a treatment episode is challenging as majority of individuals with SUDs continue using drugs during treatment. To address this challenge in the current SUD treatment model, harm reduction has emerged as a strategy that focuses on interventions such as naloxone distribution, syringe services, safe drug use education and other strategies that reduce harmful outcomes such as substance-related overdose death and disease transmission while improving quality of life. This commentary proposes a Holistic Harm Reduction Model that can be incorporated by harm reduction centers aimed at reducing risky drug use behavior and overdose deaths, and ultimately improving public health outcomes in the community. The proposed holistic model includes new components such as trauma-informed care and referral and a brief mindfulness intervention along with the already existing harm reduction approaches such as Licensed Practical Nurses (LPNs) and harm reduction managers to provide comprehensive healthcare services, distribution of supplies; education; referral and linkage to other services, including medications for substance use disorder; and participant data collection and analysis.

Use and perceptions of involuntary civil commitment among post-overdose outreach staff in Massachusetts, United States: A mixed-methods study.

Involuntary civil commitment (ICC) is a legal process by which people are compulsorily admitted to substance use treatment. This study explored views about and promotion of ICC procedures for substance use disorders among public health-public safety post-overdose outreach programs and their outreach team members in Massachusetts, USA. In this mixed-methods study, survey data were collected from post-overdose outreach programs in 2019, and semi-structured interviews were conducted with outreach team members in 2019 and 2020. Massachusetts, USA. We received 138 survey responses and conducted 38 interviews with post-overdose outreach team members (law enforcement officers, recovery coaches, social workers and harm reductionists) who were majority male (57%) and white (66%). We used the survey instrument to categorize programs as more (discussed ICC at 50% or more of outreach encounters) or less ICC focused (discussed ICC at less than 50% of outreach encounters) and to identify program characteristics that corresponded with each categorization. Semi-structured interviews explored staff perceptions of ICC effectiveness. Among 138 programs, 36% (n = 50) discussed ICC at 50% or more of outreach encounters. Discussing ICC at a majority of visits was positively associated with abstinence-only program philosophies (36% v. 6%, P < 0.001) and collaborating with drug courts (60% v. 30%, P < 0.001), but negatively associated with naloxone distribution (48% v. 75%, P < 0.001) and referring to syringe service programs (26% v. 65%, P < 0.001). Qualitative interviews identified three themes: 1) some programs viewed ICC as a first line tool to engage overdose survivors in treatment; 2) other programs considered ICC a last resort, skeptical of its benefits and concerned about potential harms; 3) families commonly initiated discussions about ICC, reportedly out of desperation. Promotion of involuntary civil commitment (ICC) appears to vary widely across post-overdose outreach programs in Massachusetts, USA, with approaches ranging from seeing it as a first step to treatment to being a tool of last resort. Demand for ICC among family members may relate to inadequate access to voluntary treatment. Family interest in ICC appears to be driven by inadequate availability of treatment and other services. ICC at post-overdose outreach visits should be limited, if used at all.

Improving racial/ethnic health equity and naloxone access among people at risk for opioid overdose: A simulation modeling analysis of community-based naloxone distribution strategies in Massachusetts, United States.

During the COVID-19 pandemic, there was a surge in opioid overdose deaths (OODs) in Massachusetts, USA, particularly among Black and Hispanic/Latinx populations. Despite the increasing racial and ethnic disparities in OODs, there was no compensatory increase in naloxone distributed to these groups. We aimed to evaluate two community-based naloxone expansion strategies, with the objective of identifying approaches that could mitigate mortality and racial and ethnic disparities in OODs. Individual-based simulation model. We measured naloxone availability using naloxone kits per OOD and evaluated scenarios of achieving higher benchmarks for naloxone availability (i.e. 40, 60 and 80 kits per OOD) from 2022 levels (overall: 26.0, White: 28.8, Black: 17.3, Hispanic/Latinx: 18.9). We compared two naloxone distribution strategies: (1) proportional distribution: achieving the benchmark ratio at the overall population level while distributing additional kits proportional to the 2022 level for each racial/ethnic group (at 40 kits per OOD benchmark: overall: 40, White: 44.3, Black: 26.6, Hispanic/Latinx: 29.1), and (2) equity-focused distribution: achieving the benchmark ratio among each racial/ethnic group (at 40 kits per OOD benchmark: 40 for all groups). Massachusetts, United States. People at risk of OOD. Annual number and rate of OODs, total healthcare costs of increasing naloxone availability. Both naloxone distribution strategies yielded comparable predicted reductions in total OODs in 2025 and incurred similar incremental costs. However, the relative reduction in the rate of OODs differed across groups. For achieving an 80 kits per OOD benchmark, proportional distribution resulted in a projected 6.7%, 6.5% and 7.1% reduction in annual OODs in 2025 among White, Black and Hispanic/Latinx populations, respectively. In contrast, equity-focused distribution achieved a reduction of 5.7%, 11.3% and 10.2% in the respective groups. In all scenarios, the cost per OOD averted was lower than the generally accepted thresholds for cost per life saved. An equity-focused naloxone distribution strategy designed to reduce racial and ethnic disparities in naloxone availability could improve health equity among racial and ethnic groups while potentially improving overall population health at lower healthcare costs per opioid overdose death averted than a proportional distribution strategy.

Naloxone Distribution Models in the United States: A Scoping Review.

Increasing naloxone distribution is a high priority means to mitigating opioid overdose rates in the United States. Since a variety of naloxone distribution models exist, with differences in infrastructure and funding between states and health-systems, it is important to review their differences and understand the strengths and barriers to widespread implementation of each model. The following 4 databases were searched for articles reporting on naloxone distribution models: (1) PubMed/Medline (National Library of Medicine), (2) Embase (Elsevier), (3) Scopus (Elsevier), and (4) the Cochrane library. Reports from all years written in English that discussed naloxone distribution models in the United States were included, as were all study designs. Of 5825 articles initially identified, 173 were selected for full text review. Of these, 49 met full criteria and were included for data extraction and analysis. Most distribution models occurred in community-based opioid education and naloxone distribution programs and in community pharmacies via a standing order/statewide protocol. Most programs reported strengths related to feasibility, but frequently reported cost as a limitation. Fewer studies described distribution models in ambulatory care or hospital settings, though these studies also highlighted strengths related to feasibility, particularly with support from working partners, and when utilizing an interprofessional care approach. Few studies reported health/economic outcomes data associated with naloxone distribution, such as changes in the number of patient/layperson access, the number of opioid overdose reversals, or cost-savings. This review outlines the many ways in which naloxone is distributed in the United States and emphasizes a need for improved outcomes data collecting/reporting in the various settings where naloxone is distributed. This would allow for future studies to evaluate which distribution model factors are associated with improvements in health outcomes, such as increased layperson access, and lower opioid overdose/mortality rates.

The Lookout Project: A Student-Run Mail-Based Overdose Response Kit Distribution Program Through Social Media During COVID-19.

Naloxone distribution and overdose education are key preventive strategies to reduce opioid overdose deaths. This paper describes the development and evaluation of The Lookout Project (TLP), a 501(c)(3) organization led by college students and based in Ann Arbor, Michigan. This research aimed to examine the outreach of TLP with hopes of creating a reproducible mail-based kit distribution program for college student-run organizations to replicate. TLP used a targeted social media advertising campaign to ask participants 7 multiple-choice questions concerning their demographics, previous incarcerations, experiences with intranasal naloxone (IN), and if they had watched the optional informational video in the opioid overdose response kit (OORK) order form. TLP's team distributed over 900 OORKs from August 3, 2020, to January 4, 2022, first by word of mouth and then through social media advertising that began on February 13, 2021. Of the 657 respondents who agreed to participate in research, the majority identified as white (76.0%, n = 400), did not identify with any specified ethnicity group (60.2%, n = 318), were female (60.8%, n = 356), were between the ages of 18 and 22 (35.4%, n = 209), had not been previously incarcerated (95.6%, n = 564), and did watch the hyperlinked video detailing how to respond to an overdose (74.7%, n = 438). Additionally, several kit recipients (2.8%, n = 19) responded to a follow-up survey. Of those, 7 people reported using the IN provided by TLP to reverse an overdose (36.8%, n = 7). TLP, a nonprofit organization founded by college students, shows potential for informing other student-run organizations about naloxone distribution programs using social media advertising.

Communities That HEAL Intervention and Mortality Including Polysubstance Overdose Deaths

The HEALing Communities Study (HCS) evaluated the effectiveness of the Communities That HEAL (CTH) intervention in preventing fatal overdoses amidst the US opioid epidemic. To evaluate the impact of the CTH intervention on total drug overdose deaths and overdose deaths involving combinations of opioids with psychostimulants or benzodiazepines. This randomized clinical trial was a parallel-arm, multisite, community-randomized, open, and waitlisted controlled comparison trial of communities in 4 US states between 2020 and 2023. Eligible communities were those reporting high opioid overdose fatality rates in Kentucky, Massachusetts, New York, and Ohio. Covariate constrained randomization stratified by state allocated communities to the intervention or control group. Trial groups were balanced by urban or rural classification, 2016-2017 fatal opioid overdose rate, and community population. Data analysis was completed by December 2023. Increased overdose education and naloxone distribution, treatment with medications for opioid use disorder, safer opioid prescribing practices, and communication campaigns to mitigate stigma and drive demand for evidence-based interventions. The primary outcome was the number of drug overdose deaths among adults (aged 18 years or older), with secondary outcomes of overdose deaths involving specific opioid-involved drug combinations from death certificates. Rates of overdose deaths per 100 000 adult community residents in intervention and control communities from July 2021 to June 2022 were compared with analyses performed in 2023. In 67 participating communities (34 in the intervention group, 33 in the control group) and including 8 211 506 participants (4 251 903 female [51.8%]; 1 273 394 Black [15.5%], 603 983 Hispanic [7.4%], 5 979 602 White [72.8%], 354 527 other [4.3%]), the average rate of overdose deaths involving all substances was 57.6 per 100 000 population in the intervention group and 61.2 per 100 000 population in the control group. This was not a statistically significant difference (adjusted rate ratio [aRR], 0.92; 95% CI, 0.78-1.07; P = .26). There was a statistically significant 37% reduction (aRR, 0.63; 95% CI, 0.44-0.91; P = .02) in death rates involving an opioid and psychostimulants (other than cocaine), and nonsignificant reductions in overdose deaths for an opioid with cocaine (6%) and an opioid with benzodiazepine (1%). In this clinical trial of the CTH intervention, death rates involving an opioid and noncocaine psychostimulant were reduced; total deaths did not differ statistically. Community-focused data-driven interventions that scale up evidence-based practices with communications campaigns may effectively reduce some opioid-involved polysubstance overdose deaths. ClinicalTrials.gov Identifier: NCT04111939.

Services for perinatal patients with opioid use disorder: a comprehensive Baltimore City-wide 2023 assessment

BackgroundOverdose is a leading cause of maternal mortality; in response, maternal mortality review committees have recommended expanding substance use disorder (SUD) screening, improving collaboration between obstetric and SUD treatment providers, and reducing fragmentation in systems of care. We undertook an analysis of the perinatal SUD treatment landscape in Baltimore, Maryland in order to identify barriers to treatment engagement during pregnancy and the postpartum period and guide system improvement efforts.MethodsWe conducted a survey of seven birthing hospitals, 31 prenatal care practices, and 108 SUD treatment providers in Baltimore from April-June 2023. Organizations were asked to quantify care for perinatal patients with opioid use disorder (OUD) as well as about screening, service availability, referral practices, and support needed to improve care.Results61% of the 145 contacted organizations responded. Birthing hospitals reported caring for pregnant persons with OUD with greater frequency than prenatal care practices or SUD treatment programs. Most birthing hospitals and prenatal care practices reported screening for OUD at intake, but the minority reported using validated tools. Service availability varied by type of organization and type of service. In general, prenatal care practices offered the fewest number of SUD-related services. Most SUD treatment programs that offered buprenorphine or methadone to the general population also offered these medications to pregnant patients. Withdrawal management for comorbid alcohol/benzodiazepine use disorders during pregnancy was more limited. The majority of birthing hospitals and prenatal care practices reported offering neither direct naloxone distribution nor prescriptions. Few SUD treatment programs offered tailored services for perinatal patients or for parents of young children, and many programs do not permit children onsite. Respondents reported high levels of interest in education and consultative support on SUD treatment in pregnancy within obstetric settings and on pregnancy-related medical concerns within SUD programs.ConclusionsThis project provides a comprehensive picture of services available for treatment of perinatal OUD in a major US city. Results have served as a guide for ongoing citywide system improvement efforts by our project team and offer a model for other jurisdictions hoping to strengthen services for perinatal OUD and reduce maternal mortality.

Layperson-Administered Naloxone Trends Reported in Emergency Medical Service Activations, 2020-2022

Layperson-administered naloxone (LAN) is a powerful but incompletely characterized intervention to prevent opioid-related overdose mortality. LAN trends are relevant to policy and strategic planning in naloxone distribution initiatives. To assess the 2-year LAN trend for persons in the United States receiving naloxone during emergency medical services (EMS) activations. This retrospective cross-sectional study was conducted in the United States from June 2020 to June 2022 among 65 621 195 EMS activations from 911 responses, EMS standbys, or when EMS crews functioned in an ambulance intercept role or during mutual aid to another ambulance response. Activations within health care settings and interfacility or medical transports were excluded. Data are from the National Emergency Medical Services Information System (NEMSIS), the national EMS patient care record database. From June 2020 to June 2022, NEMSIS included more than 96 million EMS activations from nearly 14 000 agencies across 54 states and territories. EMS clinician-reported LAN. The primary outcome was the trend of receiving LAN, measured by EMS clinician documentation. From June 2020 to June 2022, EMS reported 744 078 patients receiving naloxone, with 24 990 (3.4%) involving LAN. Patients were predominantly male (17 331 [69.4%]) and had a median (IQR) age of 42 (31-56) years, with the majority treated in urban homes or residences (21 692 [86.8%] urban; 13 223 [52.9%] in-home or residence). Of the total naloxone recipients, 243 985 patients (32.8%) had suspected drug overdose documentation as either the primary or secondary impression. Overall, the percentage change in naloxone administration rates decreased 6.1% over the study period (from 1140.1 [95% CI, 1135.1-1145.1] per 100 000 EMS activations to 1070.1 [95% CI, 1064.9-1075.3] per 100 000 EMS activations), while the percentage change of persons receiving LAN increased 43.5% (from 30.0 [95% CI, 29.2-30.8] per 100 000 EMS activations to 43.1 [95% CI, 42.0-44.1] per 100 000 EMS activations). In this cross-sectional study, the LAN rate increased from June 2020 to June 2022 as reported in the national EMS database. These findings help inform policies and practices aimed at mitigating the devastating impacts of the opioid epidemic and saving lives. Novel public health strategies are needed to measure the effects of this intervention nationally, evaluate approaches to expand naloxone distribution, and address naloxone usage barriers.

Xylazine awareness and attitudes among people who use drugs in Ohio, 2023–2024

BackgroundThe prevalence of xylazine, a non-opioid tranquilizer not for human consumption, in illicitly manufactured fentanyl is increasing in the United States. However, little is known about xylazine awareness and attitudes among people who use drugs.MethodsA cross-sectional survey of people who use drugs in Ohio was conducted from November 2023 – May 2024 to identify xylazine awareness and attitudes in rural and urban counties across the state. Study participants were recruited from naloxone distribution sites, including health departments, syringe service programs, and community-based organizations.ResultsAmong 630 people who use drugs in Ohio, more than one-half (53.5%) were unaware of xylazine being in “street drugs,” regardless of urbanicity. Among individuals who were aware of xylazine, most (73.0%) indicated they did not want to use the drug and try to avoid it. In addition, 75.8% of this group felt it was “very” or “extremely” important to know if xylazine was in their drugs.DiscussionThis research found that many people who use drugs in Ohio are unaware of xylazine and its risks. An important finding of this study is that most individuals who had heard of xylazine did not want to use it and were concerned about knowing whether xylazine was in their drugs.

Effect of the Communities That HEAL Intervention on Overdose Education and Naloxone Distribution: A Cluster-Randomized, Wait-List Controlled Trial.

Objectives. To determine whether the Communities That HEAL (CTH) intervention is effective in increasing naloxone distribution compared with usual care. Methods. The HEALing (Helping to End Addiction Long-Term) Communities Study (HCS) is a cluster-randomized, parallel-arm, wait-list controlled implementation science trial testing the impact of the CTH intervention on increasing the use of evidence-based practices to lower opioid-related overdose deaths. Communities (n = 67) highly impacted by opioid overdose in Kentucky, Massachusetts, New York, and Ohio were allocated to CTH intervention (n = 34) or wait-list comparison (usual care; n = 33) arms. The primary outcome for this study was the number of naloxone units distributed in HCS communities during the comparison period (July 1, 2021‒June 30, 2022), examined using an intent-to-treat negative binomial regression model. Results. Naloxone distribution was 79% higher in the CTH intervention versus usual care arm (adjusted relative rate = 1.79; 95% confidence interval = 1.28, 2.51; P = .001; adjusted rates of naloxone distribution 3378 vs 1884 naloxone units per 100 000 residents), when controlling for urban‒rural status, state, baseline opioid-related overdose death rate, and baseline naloxone distribution rate. Conclusions. The CTH intervention increased naloxone distribution compared with usual care in communities highly impacted by the opioid crisis. Trial Registration. ClinicalTrials.gov identifier: NCT04111939. (Am J Public Health. Published online ahead of print October 10, 2024:e1-e12. https://doi.org/10.2105/AJPH.2024.307845).

Implementation of an EMS-based naloxone distribution program: A qualitative evaluation.

We evaluated a novel leave-behind naloxone (LBN) program that allows Emergency Medical Services (EMS) personnel to distribute naloxone after an opioid overdose. Our objective was to explore EMS engagement and experiences with the program, as well as interest in education on addiction and harm reduction. We also assessed the acceptability of LBN programs among people who use drugs (PWUD). We conducted telephone interviews with EMS personnel and residents of substance use recovery housing between February and September 2023. EMS personnel described their direct experiences with the LBN program and perceived facilitating factors and barriers to naloxone distribution. First responder interactions and support for LBN were explored with PWUD. A rapid assessment method was used to analyze the interview data. Eighteen of the 23 EMS participants had distributed LBN; most agreed EMS agencies should have an LBN program. Barriers included forgetting, patient acuity, patients declining, and perceived liability. Facilitators included having a clear protocol, accessible kits, and minimal documentation burden. The majority expressed interest in harm reduction education. Eight of the 11 PWUD participants reported recent involvement in an opioid overdose. The majority supported LBN and felt comfortable receiving naloxone training from EMS. In this qualitative evaluation, we found broad support for EMS-based naloxone distribution among EMS personnel and PWUD. We identified several modifiable barriers to the success of such programs, which should be the subject of future investigation. EMS and harm reduction communities should support the expansion of LBN programs across the United States.

Is naloxone where it needs to be? Using spatial analytics to examine equitable distribution of community-based naloxone sites

BackgroundOne of the most effective harm reduction services for preventing opioid overdose deaths is naloxone. Given the ongoing opioid crisis, which has led to a surge in overdose deaths across the country, expanding access to naloxone is critical. Community-based naloxone distributions sites in Palm Beach County can increase access to naloxone. However, several rural and disadvantaged regions rarely have any type of access to naloxone. The purpose of this descriptive paper is to examine the spatial distribution of and evaluate equitable accessibility to community-based naloxone sites in Palm Beach County. MethodsWe examined health equity in the distribution of community-based naloxone sites using a mixed-methods approach with ArcGIS Pro version 3.0, which is a geographic information system (GIS) software used for mapping, spatial analysis, and data visualization. ResultsThe Belle Glade region was identified as the location most adversely affected with health inequities and limited accessibility to naloxone distribution sites, as it ranked in the 100 % percentile for all social vulnerability index (SVI) themes. The 30-minute drive-time area calculated a county service area of 1885.3 km2 (km2), which covers about 34 % of the 478.0 km2 land area of census tracts. Drive-time areas did not account for periods of heavier traffic such as during rush hour. Maximum distances during heavier traffic may be smaller, thus decreasing accessibility to naloxone distribution sites. ConclusionThere is a need for effective policy-led strategies tailored to expanding our understanding of the challenges that are experienced by the individuals in need of naloxone and encountered by the distribution sites themselves, as accessible naloxone is crucial for preventing nonfatal and fatal overdoses and ensuring timely emergency responses in vulnerable communities.

Examining naloxone access and interest in secondary naloxone distribution on an American Indian Reservation in the Northern Midwest of the United States

BackgroundIndigenous communities in the United States experience disproportionate rates of overdose morbidity and mortality due to a range of historical traumas and ongoing oppression. Limited health and harm reduction service access on some Tribal lands exacerbate these challenges. To date, little is known about naloxone access on tribal reservation lands. MethodsWe used cross-sectional survey data from community members on the reservation lands of a northern Midwest Tribe in the United States. We explored the prevalence and correlates of recent (past 6-month) naloxone receipt and interest in secondary naloxone distribution among all participants and people who used drugs (PWUD) recently. Correlates included sociodemographics, cultural identity and spirituality, witnessing overdoses, stigma, and drug use characteristics. ResultsAmong 227 Indigenous participants, the average age was 45, 62 % were women, 53 % were single, 29 % were not working, 29 % had experienced recent hunger, and 8 % considered themselves homeless. 91 % said that Indigenous spiritual values were important to them. Sixteen percent had witnessed a recent non-fatal overdose, and 6 % had witnessed a fatal one. Twenty-four percent of the overall sample had recently received naloxone, and 40 % of PWUD had received it. Witnessing both fatal (p<0.001) and nonfatal overdoses (p=0.001) were associated with receiving naloxone. Further, 63 % of participants were willing to distribute naloxone. ConclusionsInnovative strategies to expand naloxone access that are culturally relevant and responsive are needed in Indigenous communities. Cultural connectedness and shared identity are key strengths of Indigenous communities that can potentially be leveraged to implement secondary naloxone distribution programs.

184 Impact of Targeted Naloxone Distribution on Bystander Administration Prior to New Orleans EMS Calls

184 Impact of Targeted Naloxone Distribution on Bystander Administration Prior to New Orleans EMS Calls

Development of a Definition to Identify Severe Opioid Overdoses Treated in Emergency Departments, 2019-2022.

Existing surveillance systems monitor nonfatal and fatal opioid overdoses but do not monitor severe nonfatal overdoses that require intensive medical interventions. The Centers for Disease Control and Prevention's Drug Overdose Surveillance and Epidemiology system was used to query emergency department data from local syndromic systems and the National Syndromic Surveillance Program from January 2019 to August 2022. Opioid overdoses were classified as not severe or severe using a definition from the patient's chief complaint terms and discharge diagnosis codes. The percentage of opioid overdoses treated in emergency departments classified as severe was described by patient demographics, US Census region, and month. Among 503156 opioid overdoses in 29 states and Washington, DC, from January 2019 to August 2022, 17.4% were classified as severe. Common key terms found among severe opioid overdoses were hypoxia (34.8%), unresponsive (32.9%), and naloxone/Narcan (20.9%). The largest severity percentage was in the South Census region (19.6%). The trends of severe opioid overdoses remained stable during the study period. Based on the severe opioid overdose definition, there was minimal change in the severity of opioid overdoses during the study period. This definition can help monitor trends of severe opioid overdoses, guiding public health action such as focusing on naloxone and fentanyl test strip distribution to areas of need.

A call for compassionate opioid overdose response

High dose and long-acting opioid overdose reversal drugs can precipitate withdrawal in people who are opioid dependent. Products recently brought to market for community use in the United States (US) have drawn international concern because of their increased risk of withdrawal. At the March 18–19, 2024, Compassionate Overdose Response Summit & Naloxone Dosing Meeting, a panel of harm reduction experts issued the following call to action: 1) people who use drugs should be directly involved in decisions regarding the research, development, selection, and distribution of opioid overdose reversal products; 2) regulatory agencies and pharmaceutical manufacturers should carefully consider and communicate the risk and duration of withdrawal associated with higher dose and longer-acting opioid antagonists; 3) take-home naloxone kits should include at least two doses of an intramuscular (IM) product containing 0.4 mg or an intranasal (IN) product containing ≤4 mg; 4) At this time, high dose and long-acting opioid antagonists have no use in acute opioid overdose response; and, 5) overdose response educational materials, instructions on overdose response, and training should emphasize the restoration of breathing, avoiding withdrawal, and compassionate post-overdose support and care. High dose and long-acting opioid overdose reversal drugs were approved without testing for withdrawal and are often aggressively marketed despite decades of evidence from naloxone distribution programs worldwide that the ideal dose of naloxone is one that restores breathing without inducing withdrawal. Government agencies should direct resources to harm reduction programs to make standard dose take-home naloxone products widely available among people who use drugs. Lay bystanders, people who use drugs, their families, and professional first responders can learn and apply a compassionate approach to opioid overdose response.

Scaling up! Staff e-learning for a national take-home naloxone program.

A staff e-learning course was developed to prepare for scaling up a national take-home naloxone (THN) program in Norway. The aims of the study were to (a) describe participant characteristics for those that completed a THN e-learning course, (b) compare opioid overdose knowledge scores before and after e-learning course completion, and (c) to explore subsequent THN distribution by those trained. This was a quasi-experimental pre-test, post-test longitudinal cohort study of individuals completing a THN e-learning course from April 2021 to May 2022. Frequency analyses were performed for participant characteristics and subsequent naloxone distributions at 1-week and 1-month follow-up. The opioid overdose knowledge scale (OOKS) was used to measure pre-test-post-test knowledge among participants. Wilcoxon signed-rank test was performed for comparison between pre-test and post-test. Effect size was calculated using Cohen criteria. In total, 371 individuals were included in this study. Most were either nurses or social workers (n = 277, 75%). Participant knowledge increased by medium or large effect for all items measured. At 1-month follow-up, 15% reported naloxone distribution. During the study period, 94 naloxone kits were distributed. Major reasons for not distributing were "clients not interested", "workplace not distributing" and "workplace in process of distributing". Our findings suggest that an e-learning course is equally effective in terms of knowledge transfer as an in-person classroom setting, and may provide engagement in terms of naloxone distribution. However, our findings also emphasize the importance of clear implementation routines, including support from central coordinators to optimize the implementation process.