Naloxone Rescue Research Articles

A novel preclinical model of fentanyl-induced cardiorespiratory collapse to investigate resuscitation outcomes

Introduction: Opioid-related morbidities have become a critical public health concern, with ultrapotent synthetic opioids (UPSO) such as fentanyl contributing to the rise in opioid-related fatalities. Respiratory depression is the cardinal trait of fentanyl overdose, leading to systemic hypoxia and subsequent cardiorespiratory collapse (CRC). There is growing recognition that fentanyl induced CRC (fiCRC) is unique from other forms of sudden CRC. Yet, the consequences of fiCRC and its reversal remain poorly understood. This is due in part to the limited preclinical studies investigating rescue from fiCRC. Objective: using a novel model of fiCRC and subsequent reversal, this ongoing study aims to define the impact of UPSO and naloxone rescue on in vivo survival outcomes. Methods and Results: Male and female C57BL/6J mice were used. UPSO fentanyl i.v. administration (30 to 500 mcg/kg) suppressed breathing and subsequently led to fiCRC. The return of spontaneous circulation (ROSC) was achieved by performing manual chest compressions in combination of epinephrine administration after 8 minutes of fiCRC. In subset of mice, naloxone was administered post ROSC. Outcomes after 72 hours were accessed. The latency of fiCRC (mean arterial pressure at 40 mmHg) exhibited a negative correlation with the doses of fentanyl administered. Resuscitation from fiCRC was unreliable across the dose spectrum, while naloxone consistently rescued the majority of fiCRC animals. Naloxone increased ROSC rate from 54% to 86% when the dose of fentanyl was 30 mcg/Kg (n=22). With naloxone rescue, we compared fiCRC with non-opioid-induced cardiac arrest followed by potassium chloride injection (0.8 mg/g). Both models showed severe lung edema as evidenced by Evans Blue staining. However, the lung wet/dry weight ratio was higher in fiCRC group than in the non-opioid treatment group (5.50±0.05 vs. 6.60±0.60, n=4, p<0.05). Survival in fiCRC group was significantly worse than in non-opioid treatment group (survival rate: 25% vs. 83%, n=17, p<0.05). Conclusions: Our study highlights two important findings. First, the reliable resuscitation of fiCRC necessitates the use of naloxone. Second, the likelihood of injury is significant following successful rescue from fiCRC by naloxone. Our continued work using this fiCRC model will lead to insights that can be leveraged for strategies to mitigate injury and improve survival following fentanyl overdose. R01 HL163965 & R01 DA057767. This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

Opioid Misuse Harm Reduction.

The misuse of opioids by the public is a major health issue. Prescription opioids and nonprescription opioids, such as heroin and opium, are misused in epidemic proportions. When opioids are used incorrectly or illegally, they can lead to drug dependence, addiction, morbidity, and mortality. This program is in collaboration with the Jolt Foundation that provides resources to prevent opioid overdose deaths. This program involves community education on the dangers of opioid use and training on the use of naloxone rescue procedures to prevent overdose deaths. A pretest-posttest design was employed to determine if participants gained knowledge regarding the naloxone administration procedures. The researcher presented 10 community naloxone trainings that included staff from 20 different social service agencies, two schools, and three local churches. Each agency received at least one naloxone kit. The outcomes were met and included educating 137 participants on the risk factors and signs and symptoms of opioid overdose and the proper procedure to administer naloxone. One hundred twenty-eight posttests were returned and showed that the objectives for the project were met. The overall mean score for the pretests was 65.00 ( n = 126) with a standard deviation of 19.01, and the overall mean for the posttests was 86.64 ( n = 128) with a standard deviation of 14.60. Community social service agency staff were successfully educated to respond appropriately to overdose situations in a group training setting as evidenced by significant posttest scores.

Changes to opioid overdose deaths and community naloxone access among Black, Hispanic and White people from 2016 to 2021 with the onset of the COVID-19 pandemic: An interrupted time-series analysis in Massachusetts, USA.

The onset of the coronavirus disease 2019 (COVID-19) pandemic was associated with a surge in opioid overdose deaths in Massachusetts, particularly affecting racial and ethnic minority communities. We aimed to compare the impact of the pandemic on opioid overdose fatalities and naloxone distribution from community-based programs across racial and ethnic groups in Massachusetts. Interrupted time-series. Opioid overdose deaths (OODs) among non-Hispanic White, non-Hispanic Black, Hispanic and non-Hispanic other race people in Massachusetts, USA (January 2016 to June 2021). Rate of OODs per 100 000 people, rate of naloxone kits distributed per 100 000 people and ratio of naloxone kits per opioid overdose death as a measure of naloxone availability. We applied five imputation strategies using complete data in different periods to account for missingness of race and ethnicity for naloxone data. Before COVID-19 (January 2016 to February 2020), the rate of OODs declined among non-Hispanic White people [0.2% monthly reduction (95% confidence interval = 0.0-0.4%)], yet was relatively constant among all other population groups. The rate of naloxone kits increased across all groups (0.8-1.2% monthly increase) and the ratio of naloxone kits per OOD death among non-Hispanic White was 1.1% (0.8-1.4%) and among Hispanic people was 1.0% (0.2-1.8%). After the onset of the pandemic (March 2020+), non-Hispanic Black people experienced an immediate increase in the rate of OODs [63.6% (16.4-130%)], whereas rates among other groups remained similar. Trends in naloxone rescue kit distribution did not substantively change among any groups, and the ratio of naloxone kits per OOD death for non-Hispanic Black people did not compensate for the surge in OODs deaths in this group. With the onset of the COVID-19 pandemic, there was a surge in opioid overdose deaths among non-Hispanic Black people in Massachusetts, USA with no compensatory increase in naloxone rescue kit distribution. For non-Hispanic White and Hispanic people, opioid overdose deaths remained stable and naloxone kit distribution continued to increase.

Point-of-Care Naloxone Distribution in the ED Increases Provider Prescription Rate

Background: Distribution of naloxone rescue kits has been found to be safe, reduce death rate from overdose, and be associated with a decrease in high-risk opioid use A rural emergency department (ED) developed an intervention to increase provision of naloxone rescue kits to patients at risk of opioid overdose. Methods: Naloxone rescue kits were stocked in the ED Omnicell. An order set was created in the electronic medical record (EMR) consolidating order for rescue kit and referral to substance abuse treatment center. ED providers were given an educational session to demonstrate the effectiveness of naloxone rescue kits and the new care plan. A retrospective review of 12-month periods pre- and post-intervention was completed. Patients at risk of opioid overdose were identified by diagnosis or provider judgement. Primary outcome was order for rescue kit provision at time of discharge. Secondary outcomes included buprenorphine order in ED, referral to substance abuse treatment center, and attendance of 7-day post-discharge follow-up encounter. Analysis performed with chi-square test and a p value of <0.05 was considered significant. Results: Rate of naloxone rescue kit order rose from 1.6% to 10.4% ( p = 0.0025). Rate of buprenorphine ordering rose from 14.2% to 31.3% ( p = 0.0007). Referrals to outpatient treatment did not differ (12.6% versus 19.6%; p = 0.1). Attendance of 7-day follow-up encounter decreased (24.5% versus 46.5%; p = 0.0001). Conclusions: This intervention modestly increased the provision of naloxone rescue kits in one ED. Future work should focus on care coordination with outpatient clinics to improve the follow-up rate.

Assessment of the acute‐ and long‐term application of naloxone training on a simulated overdose response

AbstractIntroductionPharmacist training on naloxone is often assessed within a year of initial instruction, however, the retention of the skills necessary in a naloxone rescue beyond this time frame has not been well established.ObjectiveThe aim of this study was to determine the acute‐ vs long‐term application of naloxone training on a simulated overdose response.MethodsPharmacy students in their first professional year (P1) were provided asynchronous training on naloxone information and use 2 days prior to a required skills lab. During the lab, students completed an overdose simulation with naloxone response. Students in their third professional year (P3) had a required skills lab focused on substance use disorders at the same time as the P1 lab. These students, who received the same training as the current P1's 2 years prior, completed the same overdose simulation with naloxone response during their scheduled lab time. A checklist from previously published work was used to evaluate student performance during each simulation. Results of the P1 and P3 simulations were compared.ResultsOne hundred percent of P1 students (n = 65) and 97% of P3 students (n = 65) consented to have their data used as part of the study. The median scores for the simulation were 82% (interquartile range [IQR] = 9) for the P1 students and 73% (IQR = 9) for the P3 students (p = 0.58). A significant difference between the groups existed for two items on the checklist: assess the scene is safe (P1 = 52%, P3 = 26%, p = 0.002), and determine if the patient is breathing (P1 = 18%, P3 = 34%, p = 0.04).ConclusionStudents who received initial instruction on naloxone use 2 years prior to a simulated naloxone rescue demonstrated similar results to those who received initial instruction 2 days prior to the same simulation.

The Massachusetts Department of Public Health Post Overdose Support Team Initiative: A Public Health-Centered Co-Response Model for Post-Overdose Outreach.

Context:Post–overdose outreach programs have emerged in response to surging overdose deaths amid fentanyl contamination of the illicit opioid supply. Predominantly centered in police departments in collaboration with public health providers, these programs conduct home-based outreach with survivors and their social networks following an overdose.Approach:We describe implementation of the Post Overdose Support Team (POST) initiative, an ongoing public health funded and centered approach. Post Overdose Support Team is a person-centered model led by harm reductionists in health and human services agencies in collaboration with municipal first responders. The goal of POST is to engage overdose survivors and their social network to improve general health, connect people to services (including access to treatment, if desired), and reduce risk of subsequent overdose.Implementation:Nine agencies in Massachusetts that are part of the state's overdose education and naloxone distribution network implemented POST programs, covering 28 municipalities. The POST teams conduct home-based outreach with individuals who experienced an opioid-related overdose to provide a menu of services, including naloxone rescue kits, overdose response and risk reduction planning, referral to treatment for substance use disorders, including medication for opioid use disorder, and referral to recovery and family supports.Evaluation:From October 2017 to October 2021, the POST teams attempted to reach 5634 overdose survivors via 10 536 outreach visits. Teams successfully engaged 3014 survivors, either directly or through contact with their social network (53.5% success rate). Using data from a real-time encounter-level database, monthly peer-sharing calls with program sites, and annual site visits, we describe the implementation of the POST initiative and provide practice-based recommendations and lessons learned.Discussion:Early evidence suggests that the POST initiative is meeting its goal to engage overdose survivors, improve general health, and reduce subsequent overdose risk. Future evaluations should examine long-term outcomes among participants, including service linkages and incremental behavior change.

Prescribe to Save Lives: Improving Buprenorphine Prescribing Among HIV Clinicians.

HIV clinicians are uniquely positioned to treat their patients with opioid use disorder using buprenorphine to prevent overdose death. The Prescribe to Save Lives (PtSL) study aimed to increase HIV clinicians' buprenorphine prescribing via an overdose prevention intervention. The quasi-experimental stepped-wedge study enrolled 22 Ryan White-funded HIV clinics and delivered a peer-to-peer training to clinicians with follow-up academic detailing that included overdose prevention education and introduced buprenorphine prescribing. Site-aggregated electronic medical record (EMR) data measured with the change in X-waivered clinicians and patients prescribed buprenorphine. Clinicians completed surveys preintervention and at 6- and 12-month postintervention that assessed buprenorphine training, prescribing, and attitudes. Analyses applied generalized estimating equation models, adjusting for time and clustering of repeated measures among individuals and sites. Nineteen sites provided EMR prescribing data, and 122 clinicians returned surveys. Of the total patients with HIV across all sites, EMR data showed 0.38% were prescribed buprenorphine pre-intervention and 0.52% were prescribed buprenorphine postintervention. The intervention increased completion of a buprenorphine training course (adjusted odds ratio 2.54, 95% confidence interval: 1.38 to 4.68, P = 0.003) and obtaining an X-waiver (adjusted odds ratio 2.11, 95% confidence interval: 1.12 to 3.95, P = 0.02). There were nonsignificant increases at the clinic level, as well. Although the PtSL intervention resulted in increases in buprenorphine training and prescriber certification, there was no meaningful increase in buprenorphine prescribing. Engaging and teaching HIV clinicians about overdose and naloxone rescue may facilitate training in buprenorphine prescribing but will not result in more treatment with buprenorphine without additional interventions.

Risk factors for opioid toxicity requiring naloxone rescue in adults: a case-control study.

Opioid-induced sedation and respiratory depression (OSRD) is a potentially life-threatening side effect of opioid analgesia. However, little is known about the individual and clinical-related factors associated with OSRD in the New Zealand context. To identify risk factors for OSRD in patients admitted to a large regional health board in New Zealand-Auckland District Health Board (ADHB). A retrospective matched case-control study design was undertaken among adults who were admitted to ADHB and prescribed opioids in hospital between August 2015 and April 2020. Those who were prescribed opioids and received naloxone for OSRD were defined as cases, whereas those who received opioids but did not experience OSRD were identified as controls. Cases and controls were matched on a1:1 basis by age (± 10 years). Data were retrieved from the electronic medical records of ADHB. A conditional logistic regression model was used to identify the risk factors for OSRD. We identified 51 cases, and these were matched with 51 control patients. The odds of experiencing OSRD were four times higher among opioid-naïve patients compared to those exposed to opioids prior to hospital admission (OR 4.113; 95% CI 1.14-14.89). Increased risk of OSRD was also associated with higher serum creatinine level prior to OSRD episode (OR 1.015; 95% CI 1.01-1.03) and a higher oral morphine milligram equivalent (OME) (OR 1.023; 95% CI 1.01-1.04). Increased risk of OSRD was associated with a higher OME, a higher serum creatinine level prior to OSRD episode, and opioid naivety. Our findings can inform policies that aim to prevent serious adverse effects related to opioids.

Patient Controlled Analgesia and an Alternative Protocol: A Comparison of Outcomes After Thoracic and Lumbar Surgery.

IntroductionPatient controlled analgesia (PCA) is a common form of pain management after spine surgeries, in which patients get custom control of their opioid dose. PCA has been demonstrated as a safe form of analgesia; however, use of PCA comes with risks that can be mitigated by opting for alternative pain management. This study aimed to compare the outcomes of patients using PCA to those with an alternative analgesia protocol that does not involve PCA.MethodsA retrospective chart review from January 2017 to July 2018 was conducted. Patients included in this study were those 18 or older who were admitted to a large midwestern tertiary medical center in Wichita, Kansas, and underwent thoracic or lumbar spinal surgery from a single spine surgeon. Data from patient demographics, comorbidities, and type of procedure were collected and compared to control for possible confounding variables. Patients were divided into two groups: patients receiving a PCA pain protocol post-operatively and those receiving a non-PCA protocol. Statistical analyses were performed and all tests with p < 0.05 were considered significant.ResultsThis study found patients in the PCA protocol had similar outcomes to those in the alternative analgesia protocol. This was true for both primary and secondary outcomes. The primary outcome was patient length of stay after the operation. Secondary outcomes included readmission rates, frequency of naloxone rescue, transfers to higher levels of care, and total opioid consumption.ConclusionsThis study supported that a non-PCA protocol for post-operative pain management yields similar outcomes to a PCA protocol in the setting of thoracic and lumbar surgery.

Piloting a statewide emergency department take-home naloxone program: Improving the quality of care for patients at risk of opioid overdose.

Emergency department (ED) patients with nonfatal opioid overdose are at high risk for subsequent fatal overdose, yet ED programs aimed at reducing harm from opioid use remain underdeveloped. The objective was to pilot a statewide ED take-home naloxone program and improve the care of patients with opioid use disorder (OUD) and risky drug use through training and interprofessional network building. Nine hospital EDs with pharmacy, nurse, and physician champions were recruited, surveyed, and trained. Take-home naloxone rescue kits were developed, disseminated, and tracked. Two overdose prevention summits were convened prior to the COVID pandemic, and two X-waiver training courses aimed at emergency physicians and advanced practice providers were arranged, both in person and virtual. A total of 872 naloxone rescue kits were distributed to ED patients at risk of opioid overdose during the first phase of this project, and more than 140 providers were trained in the use of medications for OUD in acute care settings. A statewide ED take-home naloxone program was shown to be feasible across a range of different hospitals with varying maturity in preexisting OUD resources and capabilities. Future work will be aimed at both expanding and measuring the effectiveness of this work.

“Narcan encounters:” overdose and naloxone rescue experiences among people who use opioids

Background Communities across the United States are confronting the precipitous rise in opioid overdose fatalities that has occurred over the past decade. Naloxone, an opioid antagonist, is a safe rescue medication that laypeople can administer to reverse an overdose. Community naloxone training programs have been well-documented. Less is known about overdose survivors’ subjective experiences with naloxone reversal and its impacts on drug use behavior. Methods: Semi-structured interviews were conducted with 35 community-dwelling adults who had been reversed at least once with naloxone. Inductive thematic content analysis incorporating Atlas.ti software was used to identify themes. Results: Four broad thematic categories were identified. (1) Overdose experience and memory: Most participants remembered taking the drugs one minute and waking up the next—sometimes in different surroundings; (2) Naloxone rescue—waking up: Participants described acute withdrawal symptoms, disorientation, and volatile emotions; (3) Reasons for overdose: Polypharmacy; changes in opioid tolerance, or presence of fentanyl were the most common explanations. (4) Impacts of naloxone rescue: A variety of contextual factors influenced participants’ responses to naloxone rescue, especially acute withdrawal symptoms. While some participants altered or tempered their opioid use, others resumed opioid use—especially to mitigate withdrawal. Participants overwhelmingly emphasized that naloxone saved their lives. Conclusion: Results suggest that a naloxone rescue may not be a wake-up call for many people who use opioids, but access to naloxone is an effective overdose harm reduction option, supporting its widespread implementation. The study findings underscore the importance of ongoing community overdose prevention and harm reduction initiatives, including take-home naloxone (THN) and medication assisted treatment in the Emergency Department.

Drug Overdose Deaths Reach Grim Milestone During Pandemic

Drug Overdose Deaths Reach Grim Milestone During Pandemic

Targeting community-based naloxone distribution using opioid overdose death rates: A descriptive analysis of naloxone rescue kits and opioid overdose deaths in Massachusetts and Rhode Island.

Rates of fatal opioid overdose in Massachusetts (MA) and Rhode Island (RI) far exceed the national average. Community-based opioid education and naloxone distribution (OEND) programs are effective public health interventions to prevent overdose deaths. We compared naloxone distribution and opioid overdose death rates in MA and RI to identify priority communities for expanded OEND. We compared spatial patterns of opioid overdose fatalities and naloxone distribution through OEND programs in MA and RI during 2016 to 2019 using public health department data. The county-level ratio of naloxone kits distributed through OEND programs per opioid overdose death was estimated and mapped to identify potential gaps in naloxone availability across geographic regions and over time. From 2016 to 2019, the statewide community-based naloxone distribution to opioid overdose death ratio improved in both states, although more rapidly in RI (from 11.8 in 2016 to 35.6 in 2019) than in MA (from 12.3 to 17.2), driven primarily by elevated and increasing rates of naloxone distribution in RI. We identified some urban/non-urban differences, with higher naloxone distribution relative to opioid overdose deaths in more urban counties, and we observed some counties with high rates of overdose deaths but low rates of naloxone kits distributed through OEND programs. We identified variations in spatial patterns of opioid overdose fatalities and naloxone availability, and these disparities appeared to be widening in some areas over time. Data on the spatial distribution of naloxone distribution and opioid overdose deaths can inform targeted, community-based naloxone distribution strategies that optimize resources to prevent opioid overdose fatalities.

High-dose buprenorphine in the ED could be safe for some patients

Doses of buprenorphine well above the established standards (>12 mg) administered in the emergency department are safe and well-tolerated in individuals experiencing opioid withdrawal symptoms, says a new case series published by Herring and colleagues in the July 2021 issue of JAMA. The authors’ findings suggest that a relatively high buprenorphine induction dose, in certain patient populations that do not respond to current recommended induction regimens, may allow for a paradigm shift in common opioid use disorder (OUD) treatment modalities. The clinical algorithm presented in the study’s design allows for a more rapid response to withdrawal symptoms while also removing barriers to short-term medication access. The authors hope that by rapidly achieving therapeutic levels of buprenorphine and extending buprenorphine’s duration of action, it will potentially improve patient engagement in longer-term addiction treatment programs. Herring and colleagues conducted a retrospective review of patient electronic health record data from Highland Hospital Emergency Department in Oakland, CA in 2018. The authors identified specific OUD patients who did not have their withdrawal symptoms relieved by current guideline-recommended buprenorphine induction therapy as outlined by the Substance Abuse and Mental Health Services Administration (SAMHSA). Patients who had a COWS score (Clinical Opioid Withdrawal Scale) of 8 or more after receiving 8 mg to 12 mg of buprenorphine in the ED could be escalated to what the authors refer to as the “high-dose induction pathway,” in which the patient could receive up to 32 mg of buprenorphine, provided they showed no clinical signs of sedation, respiratory depression, or other complicating factors. Additionally, the participating providers could discharge the patient with a prescription for 16 mg of buprenorphine daily until follow-up at an addiction treatment clinic. Of the 579 opioid withdrawal ED visits during the study’s timeframe, 366—or 63.2%—were escalated to the high-dose induction pathway. Additionally, of all the buprenorphine dose totals, nearly one-fourth of them were equal to 28 mg or more. The high-dose intervention appears to have been very well-tolerated, with only one case experiencing precipitated withdrawal symptoms after receiving 24 mg of buprenorphine. In fact, of the 5 total cases of precipitated withdrawal recorded, 4 of them occurred after 8 mg of buprenorphine, but resolved after their doses were escalated to 28 mg total. Overall, there were no serious adverse effects related to buprenorphine recorded during the study, including sedation, hypoxia, or naloxone rescue in the ED 24 hours after discharge. It has been well-established that allowing withdrawal treatment through EDs improves patient engagement in addiction treatment programs. However, according to buprenorphine (specifically SUBUTEX) drug label information from 2017, “in some studies, gradual induction over several days led to a high rate of drop-out of buprenorphine patients during the induction period.” The drug labeling recommends that an adequate treatment dose, titrated to clinical effectiveness, should be achieved as rapidly as possible. Currently, the 2021 Treatment Improvement Protocols—the official guidance document by SAMHSA—recommends buprenorphine 2 mg to 4 mg, followed by a second dose of 2 mg to 4 mg after approximately 2 hours, with a maximum of 8 mg to 12 mg on day 1 and 16 mg on day 2 via a referred addiction clinic. However, this guidance may be too uniform and not adequate for patients who require a higher dosing strategy. The authors imply that the current standard often prolongs the time for maximum saturation of μ-opioid receptors and reduction in cravings. Furthermore, they state that it assumes the patient has adequate access to a buprenorphine prescription for the second day, which is often not the case. The treatment algorithm presented by Herring and colleagues is a good step forward for redefining current recommendations with regard to opioid addiction treatment in the ED. While the study may be a retrospective case series at a single site, it represents a practical application (with a well-represented patient population) for adopting a relatively safe high-dose treatment algorithm into routine practice. This new treatment technique could help prevent the inadvertent prolongation of withdrawal symptoms that current guidance may yield and improve patient follow-up and retention with addiction centers.

Impact of pharmacist contact via telephone vs letter on rate of acquisition of naloxone rescue kits by patients with opioid use disorder

Background: Limited data describes the effectiveness of strategies to optimize naloxone rescue kit distribution. Mental health clinical pharmacy specialists (CPS) at VA St. Louis HCS aimed to increase distribution of naloxone rescue kits to patients with Opioid Use Disorder (OUD). An informational letter detailing the purpose of rescue kits and how to obtain one were sent to patients with OUD who had no active order for a naloxone rescue kit within the previous year. Roughly half of these patients were targeted for follow-up education via telephone. Methods: A retrospective study was conducted comparing the effectiveness of these contact methods. Study groups included those contacted by letter alone and those contacted by both letter and phone call. The primary outcome was order placement for a rescue kit within 90 days of contact. Post-hoc analysis included a multivariate regression, case-control evaluation of variables potentially associated with kit distribution. Results: In total, 335 patients were included. Of 185 patients targeted for phone follow-up, 81 were reached (43.8%), and 254 received the letter alone. The primary outcome was achieved by 13 (5.1%) and 52 (64.2%) participants in the letter alone and letter plus phone contact groups, respectively (p < 0.001). In multivariate analysis, phone contact (OR 38.6; 95% CI 17.5–85.0), nonwhite race (OR 3.4; 95% CI 1.5–7.6), prior participation in the substance abuse rehabilitation treatment program (OR 3.2; 95% CI 1.3–8.0), and current active opioid prescription (OR 3.7; 95% CI 1.3–10.2) were independently associated with an order for a naloxone rescue kit. Conclusions: In patients with OUD, those contacted by phone in addition to receiving a letter were significantly more likely to receive a naloxone kit than those contacted via letter alone. In addition to contact by phone, nonwhite race, prior participation in rehabilitation and active opioid prescription were associated with a higher rate of kit obtainment.

Naloxone receipt and overdose prevention care among people with HIV on chronic opioid therapy.

This cross-sectional study describes naloxone rescue kit receipt among people with HIV (PWH) on chronic opioid therapy (COT) and HIV clinician opioid overdose prevention care in two clinics between 2015 and 2017. Naloxone rescue kit receipt was uncommon. History of overdose was associated with receiving naloxone but having a clinician who reported providing overdose prevention care was not. This study suggests that clinicians prescribing COT to PWH should improve overdose prevention care, including naloxone co-prescribing.

Reducing overdose after release from incarceration (ROAR): study protocol for an intervention to reduce risk of fatal and non-fatal opioid overdose among women after release from prison

BackgroundDrug overdose is the leading cause of death after release from prison, and this risk is significantly higher among women compared to men. Within the first 2 weeks after release, the risk of death from drug overdose is 12.7 times higher than the general population, with risk of death further elevated among females. Although female inmates have higher rates of opioid use disorder and post-release overdose fatality, justice-involved women are under-represented in studies of medications for opioid use disorder. The Reducing Overdose After Release from Incarceration (ROAR) pilot intervention and evaluation (recruitment June 2019 through December 2020) aims to reduce opioid overdose among women released to the community following incarceration in state prison. The evaluation further assesses induction, acceptance and effectiveness of extended release naltrexone in a female post-prison population.Methods/designIn the week prior to their release, female adults in custody with moderate to severe opioid use disorder start treatment with extended release naltrexone, an injectable opioid antagonist that blocks the effects of opioids for up to 1 month. All ROAR participants receive training to use naloxone rescue kits and are provided nasal naloxone at release. Ongoing support from a certified recovery mentor to facilitate sustained engagement with treatment for substance use disorders begins in the month prior to release from prison and continues for 6 months in community. We evaluate the association between ROAR participation and the primary outcome of opioid overdose.Using administrative data provided by the Oregon Department of Corrections and the Oregon Health Authority, we compare the odds of overdose among ROAR participants versus a comparison group of females released from prison during the study period. Evaluation activities in community includes survey and qualitative interviews for 6 months post release, as well as a review of clinic records to assess retention on medication among the pilot cohort (N = 100).DiscussionROAR is a collaboration between Oregon’s public health, criminal justice, and medical communities. The ROAR intervention and evaluation provide critical information on improving interventions to prevent opioid overdose and improve retention on treatment in community in an overlooked, high-risk population: incarcerated women re-entering the community.Trial registrationClinical Trials.gov TRN: NCT03902821.

Buprenorphine Field Initiation of ReScue Treatment by Emergency Medical Services (Bupe FIRST EMS): A Case Series

The opioid epidemic is currently a leading health crisis in the United States, and evidence supports Medication for Opioid Use Disorder (MOUD) as the most effective treatment (2). In our EMS system we are observing an ever increasing number of patients who, due to refusing transport after naloxone rescue, represent an access void at the point of overdose. We present a case series to illustrate a new treatment paradigm utilizing front line EMS paramedic units and high dose buprenorphine to treat withdrawal symptoms with next day bridge to long term care. The three patients described are exemplary cases, meant to represent overall characteristics of the intervention prior to complete data collection. Each patient was revived from opioid overdose with naloxone. Paramedics then treated each patient with 16 mg of buprenorphine to relieve and prevent withdrawal symptoms. Patients were provided with outpatient follow up irrespective of ED transport. To the best of our knowledge, this is the first EMS agency in the United States providing MOUD in the prehospital setting at the point of overdose. This innovative program provides EMS with education and tools to promote patient engagement. While still in its infancy, this approach utilizes existing EMS resources to bring MOUD to the prehospital setting, offering a new avenue to long term care. Keywords: Opioid, buprenorphine, emergency medical services, medication assisted therapy, naloxone, overdose

Understanding Naloxone Uptake from an Emergency Department Distribution Program Using a Low-Energy Bluetooth Real-time Location System.

Emergency department (ED)-based naloxone distribution programs are a widespread harm reduction strategy. However, data describing the community penetrance of naloxone distributed from these programs are lacking. This study gauges acceptance of naloxone use and monitoring technology among people who use drugs (PWUD), and explores the use of real-time location systems (RTLS) in monitoring naloxone movements. A prospective observational study was conducted on a convenience sample of individuals (N = 30) presenting to a tertiary-care academic medical center ED for an opioid-related complaint. A naloxone kit equipped with a low-energy Bluetooth (BLE) tracking system was employed to detect movement of naloxone off the hospital campus as a proxy for community penetrance, followed by a qualitative interview to gauge participant acceptance of naloxone use and monitoring technology. Detection of BLE signals verified transit of 24 distributed naloxone kits off our hospital campus. Three participants whose BLE signals were not captured reported taking their kits with them following discharge, suggesting technological errors occurred; another three participants were lost to follow-up. Qualitative interviews demonstrated that participants accepted ED-based naloxone distribution programs and passive tracking technologies, but revealed concerns regarding hypothetical continuous monitoring systems and problematic interactions with first responders and law enforcement personnel. Based on acquired BLE signals, 80% of dispensed naloxone kits left the hospital campus. Use of RTLS to passively geolocate naloxone rescue kits is feasible, but detection can be adversely affected by technological errors. PWUD are amenable to transient monitoring technologies but identified barriers to implementation.

Preventing opioid overdose with peer-administered naloxone: findings from a rural state

BackgroundIn response to the opioid epidemic, naloxone distribution programs aim to prevent overdose death by making naloxone available and training people to use it. Peers of individuals at risk of opioid overdose are well-positioned to administer naloxone and prevent overdose death.MethodsWe conducted key informant interviews with 18 individuals with past or current opioid and heroin drug use who had administered naloxone to a peer during an overdose emergency. Interviews explored individuals’ experiences with administration and their recommendations for program and policy improvement. Data were systematically coded and analyzed for themes.ResultsParticipants sought naloxone rescue kits because they perceived high risk of overdose. They described high satisfaction with training and felt prepared to administer naloxone during overdose incidents. Overwhelmingly, participants perceived naloxone to be effective and emphasized the need to make it widely available. Findings suggest that engagement in overdose prevention strategies other than naloxone differs by gender, with females more likely than males to use multiple different strategies. Participants described that overdose experiences do not have a lasting impact on drug use behaviors.ConclusionsFindings support the feasibility of naloxone distribution to peer opioid and heroin users and provide recommendations for policy improvement, including effective and well-advertised Good Samaritan laws and links to treatment for opioid use disorder.