Provision Of Naloxone Research Articles

Opioid-related deaths in Europe: Strategies for a comprehensive approach to address a major public health concern

Use of illicit opioids and misuse of prescription opioids are the main causes of drug-related deaths across the world, and the continuing rise in opioid-related mortality, especially affecting North America, Australia and Europe, is a public health challenge. Strategies that may help to decrease the high levels of opioid-related mortality and morbidity and improve care across Europe include risk assessment and interventions to improve the use of opioid analgesics, e.g. prescription drug-monitoring programmes, education on pain management to reduce opioid prescribing, and the implementation of evidence-based primary prevention programmes to reduce the demand for opioids. For patients who develop opioid use disorder (a chronic and relapsing problematic use of opioids that causes clinical impairment or distress), treatment combining opiate receptor full or partial agonist medications for opioid-use disorder (MOUD) with psychosocial interventions is essential.However, in Europe a substantial proportion of the 1.3 million high-risk opioid users (defined as injecting drug use or regular use of opioids, mainly heroin) remain outside of dedicated treatment programmes. More widespread and easier access to MOUD could reduce mortality levels; via approaches such as primary care-led treatment models, and efforts to improve patient retention and adherence to treatment programmes. Other harm-reduction strategies, such as the use of MOUD at optimal doses, the provision of take-home naloxone, the introduction of supervised drug-consumption facilities, and patient education to reduce the risk of overdose may also be beneficial.

Designing, implementing and evaluating the overdose response with take‐home naloxone model of care: An evaluation of client outcomes and perspectives

Take-home naloxone (THN) interventions are an effective response to preventing overdose deaths, however uptake across Australia remains limited. This project designed, implemented and evaluated a model of care targeting opioid users attending alcohol and other drug (AOD) treatment, needle and syringe programs (NSP) and related health services targeting people who inject drugs. Service providers, consumers and regulators collaboratively designed a THN brief intervention (ORTHN, Overdose Response with Take-Home Naloxone) involving client education and supply of naloxone in pre-filled syringes, delivered by nursing, allied health and NSP workers. ORTHN interventions were implemented in over 15 services across New South Wales, Australia. The evaluation included client knowledge, attitudes, substance use and overdose experiences immediately before and 3 months after ORTHN intervention in a subsample of participants. Six hundred and sixteen interventions were delivered, with 145 participants recruited to the research subsample, of whom 95 completed the three-month follow up. Overdose-related attitudes amongst participants improved following ORTHN, with no evidence of increased substance use or failure to implement other 'first responses' (e.g. calling an ambulance). Nine participants (10%) reversed an overdose using THN in the follow-up period. Participants identified a willingness to access THN from a range of services. While a minority (16%) indicated they were unwilling to pay for THN, the median price that participants were willing to pay was $AUD20 (IQR $10.40). The ORTHN model of care for THN appears an effective way to disseminate THN to people who use opioids attending AOD, NSP and related health-care settings.

Rurality and differences in pharmacy characteristics and community factors associated with provision of naloxone in the pharmacy

BackgroundPharmacies are the most accessible healthcare settings across urban, suburban, and rural areas of the United States and, thus a key venue in the overdose risk environment. Pharmacy dispensing of naloxone is part of the public health response to the opioid overdose crisis, yet little is known about the pharmacy- and community-level characteristics with which naloxone provision is associated. MethodsWe conducted a longitudinal analysis of pharmacy-level quarterly naloxone dispensed from one large US community pharmacy chain from the 1st quarter of 2013 to the 2nd quarter of 2017, examining associations between naloxone provision and pharmacy-level characteristics and community factors in two US states, Rhode Island and Massachusetts. Rurality was defined using the rural urban commuting area (RUCA) scale scores, calculated based on US 2010 Census variables. Pharmacy-level characteristics (e.g., 24 h store, average daily volumes of total prescriptions, nonprescription syringe sales, buprenorphine prescriptions) derived from the pharmacy chain; community factors (e.g., RUCA score, ZIP-code level age, race distributions, and median household income) were obtained from the decennial census files. The linear mixed effects methods modeled dispensing history and the number of naloxone doses dispensed through binomial and negative binomial distributions respectively, accounting for trend and covariates. ResultsAdjusted analyses of dispensing data from 449 pharmacies in two states indicated that more rural pharmacies (i.e., stores in areas with higher RUCA scores), pharmacies with higher volumes of all prescriptions and of buprenorphine, that sell more nonprescription syringes, that have drive-throughs and longer weekend hours, and that are located in communities with younger age distributions were associated with increased likelihood of ever dispensing naloxone and a greater number of naloxone doses dispensed (all p<.05). ConclusionPharmacies are a key evolving element in the overdose risk environment, striving to develop reputations as sources of wellness, prevention, and harm reduction supplies, like naloxone. Pharmacy naloxone dispensing may be an especially effective strategy to alter the overdose risk environment in rural communities.

A latent class analysis of drug and substance use patterns among patients treated in emergency departments for suspected drug overdose

IntroductionPolysubstance use and misuse can increase risks for nonfatal and fatal drug overdose. To categorize drugs used in combination in nonfatal overdoses, we analyzed data from emergency department (ED) overdose-related visits in 18 states funded by CDC’s Enhanced State Opioid Overdose Surveillance (ESOOS) program. MethodsFrom 2017 to 2018, 120,706 ED visits included at least one hospital discharge code indicating acute drug poisoning for opioids, stimulants, hallucinogens, cannabis, anti-depressants, sedatives, alcohol, benzodiazepines, or other psychotropic drugs. Latent class analyses were conducted to determine the groupings of drug combinations in overdose visits. ResultsLatent class analyses indicated a model of 5 classes – mostly heroin overdose (42.5% of visits); mostly non-heroin opioid overdose/use (27.3%); opioid, polysubstance (11.0%); female, younger (<25 years), other non-opioid drugs (10.5%); female, older (>55 years), benzodiazepine (8.0%). Findings indicated that heroin continues to be a large burden to EDs, yet EDs are also seeing overdose survivors with polydrug toxicity. ConclusionsMedication-assisted treatment could be initiated in the emergency department following overdose for patients with opioid use disorder, and post-overdose protocols, such as naloxone provision and linkage to treatment and harm reduction services, have the potential to prevent future overdose for those at risk.

161 The Impact of Statewide Emergency Department Opioid Overdose Treatment Standards on Naloxone Distribution, Behavioral Counseling, and Referral to Treatment

Determine the impact of Rhode Island (RI)’s emergency department (ED) opioid use disorder (OUD) treatment standards, the Levels of Care for Rhode Island EDs and Hospitals for Treating Overdose and OUD (Levels of Care), on ED provision of take-home naloxone, behavioral counseling, and referral to treatment after certification of level of care policy implementation. Data from the Rhode Island Department of Health’s 48-hour ED opioid overdose reporting system were analyzed from 2016 to 2018 to determine changes in services provision after hospital level of care certification for patients 18 years of age and older discharged from a RI ED after being treated for a non-fatal opioid overdose. The primary outcomes were offering and provision of: 1) take-home naloxone; 2) ED behavioral counseling; 3) referral to OUD treatment. Changes in services provision before and after hospital certification were compared using a chi-square test and using predicted probabilities from a multivariable GEE model with a binomial outcome, logit link, and variance clustered within hospitals. Sub-analyses were conducted looking at changes after certification at facilities certified as Level 3, the minimum standard of care, and those certified as Level 1, which provide the minimum standard of care as well as access to comprehensive addiction treatment services and medication for addiction treatment. There were 2,049 ED opioid overdose visits before hospital level of care certification and 1,338 after. Six hospitals were certified as Level 1; four were certified as Level 3. The majority of patients were male (71%), 25-44 years old (61%), and white (78%). After hospital certification, patients were more likely to be offered (60% vs 82%, p<0.001) and given (41% vs 51%, p<0.001) take-home naloxone. Overall, counseling offers increased (58% vs 85%, p<0.001), but receipt of counseling did not change (35% vs 33%, p=0.137). After adjusting for age, sex, naloxone administration prior to ED arrival, previous overdose ED visit in the past year, calendar time, season, and within-hospital clustering, there was no significant change in offering or receipt of take-home naloxone after hospital certification. In adjusted estimates, more patients were offered counseling after certification at Level 3 (24% vs. 77%, p<0.001) hospitals, but there was no significant change at Level 1 hospitals (42% vs. 72%, p=0.139). There was no significant change in receiving counseling; however, there was an increase in referral to treatment for both Level 1 (15% vs. 21%, p=0.044) and Level 3 (27% vs. 43%, p=0.004) hospitals after certification. The RI Levels of Care are the first state-wide adopted treatment standards for opioid overdose and OUD. Hospital certification is associated with increased provision of take-home naloxone, offering of counseling at Level 3 hospitals, and referral to treatment at all hospitals. Future investigations are needed to better characterize implementation barriers and evaluate policy impact on patient outcomes.

119 Opioid Use Disorder Management in Canadian Emergency Departments: A Cross-Sectional Survey

Emergency department (ED) visits for opioid use disorders (OUD) have seen a four- to ten- fold increase in the last five years across Canada. In comparison, there has been a 30% increase of OUD-related ED visits in the United States from 2016 to 2017, with limited access to treatment. There is a growing body of evidence for improving ED-based symptomatic treatment of acute opioid withdrawal, medication-assisted treatment of OUD on discharge from the ED, and the transition to outpatient services. This cross-sectional study aims to understand current management of OUD across Canadian EDs, establish a baseline understanding of OUD amongst emergency physicians, complete a needs-assessment of EDs to increase utilization of best practice guidelines, and optimize the OUD response in EDs. We completed a cross-sectional study of emergency physicians across Canada using a self-administered 16-question survey circulated through SurveyMonkey via the Canadian Association for Emergency Physicians (CAEP) survey deployment service. We used a modified Dillman methodology to develop the survey tool consisting of multiple choice, likert-scale, and open-ended questions. Descriptive statistics were used to calculate rates and averages. Surveys were fully completed by 179 physicians, or 9.7% of eligible CAEP members. Approximately half of respondents (45%) worked in community settings and half (55%) in academic settings. Most were attending physicians (83%) working in high volume EDs (81%). The majority saw patients presenting with OUD at least 1-5 times a week (43%) or more than 6 times per week (32%). Over half (54.6%) of the participants felt dissatisfied with the care their patients receive for OUDs in the ED. The most commonly reported interventions for patients with OUD included: provision of a take-home naloxone (54.1%), referral to a methadone/buprenorphine clinic (60.7%), referral to an addiction clinic (73.2%), and/or instructions to see their family physician (74.3%). Most physicians never or rarely provided buprenorphine in the ED (74%) or via outpatient script (78%). Most (89%) never or rarely provided a prescription for other medications to prevent withdrawal symptoms. Physicians identified pre-printed order sets (91%), phone (92%) or on-site (88%) access to addiction specialists, on-site case managers (93%), and rapid access to addictions clinics (73%) as useful supports. Respondents identified written protocols as the most useful educational tool, followed by in-person presentations (75%) and brief online learning modules (75%). Clinical guidelines now strongly recommend buprenorphine as first line treatment for OUD, and ED-initiated and ED-prescribed buprenorphine have been found to be both feasible and effective. However, buprenorphine for OUD is currently underutilized in Canadian EDs, and only half of physicians surveyed routinely offer take-home naloxone. The reasons for this are likely multifactorial and systemic, and naloxone and buprenorphine may not always be available in EDs. Uptake of evidence-based recommendations may work to improve ED provider satisfaction in caring for patients with OUD. We will seek options to rapidly disseminate the simple interventions identified in this study, including pre-printed order sets and protocols.

317 Sustainable Naloxone Education and Distribution From an Urban Emergency Department

The opioid epidemic was declared a national emergency in 2017. Naloxone can rapidly reverse fatal overdose and evidence shows reduced mortality when naloxone is available in the community. The optimal naloxone distribution methods are yet to be established. We aim to determine the feasibility and sustainability of instituting a program which provides naloxone in hand to at-risk patients in a high-volume, urban emergency department (ED). Secondary objectives are to describe patient receptiveness to receiving naloxone at ED discharge, medication cost and 30 day follow up. Our study included a convenience sample of patients who presented to the ED between October 2018 and May 2019 who exhibited improvement in mental status after administration of naloxone, either in the ED or via emergency medical services, and who were anticipated to be discharged home from the ED. Enrollment was limited to the outpatient pharmacy work hours: Monday to Friday 7am to 6pm. Eligible patients were identified by ED personnel and were engaged by the ED naloxone educator 1-2 hours prior to anticipated discharge. Patients were asked if they were interested in receiving the naloxone and the administration instructions. If the patient was agreeable to others receiving education with them, others were invited to participate. If no one was available, teach back occurred to ensure the patient could teach others after discharge. The outpatient pharmacy delivered a 2-dose package of 4mg naloxone nasal spray as prescribed by the ED provider prior to discharge. Uninsured patients had medication cost covered by the ED medical needs fund. The pharmacy provided additional financial assistance for those with copays. The ED naloxone educator provided the naloxone administration education along with an informational packet on community resources and follow-up care. Patients were called in follow-up at least 30 days after the date of visit. A total of 30 patients were approached between October 2018 and May 2019, and 27 (90%) patients were successfully enrolled in the study. The cohort was predominantly African American (75%) with a median age of 54 years and male sex (74%). 24/27 (89%) of patients were insured and 20/24 (83%) insured patients had zero copay for naloxone nasal spray. One of 18 (6%) eligible patients for 30 day follow up was successfully contacted. 4/18 (22%) patients who were agreeable to receive naloxone declined to give contact information for 30-day follow-up. The study was initiated as a 1-month pilot and was continued after ED administration noted minimal interference to ED workflow. Utilization of existing ED systems can allow for a sustainable model of naloxone provision and administration instruction. Most patients in the study had zero copay and were receptive to education. Follow-up in this patient population was relatively unsuccessful. Identifying patients nearing the end of an observation period with an anticipated discharge home can allow for naloxone distribution to cause minimal disruption to workflow in a busy ED. This model of naloxone provision can be sustainable without external funding and provides a method to receive prescribed medications while in the ED. Further studies are needed to demonstrate sustainable naloxone distribution.

Attitudes and perceptions of naloxone dispensing among a sample of Massachusetts community pharmacy technicians

ObjectivesThere is limited research on the attitudes of pharmacy technicians toward pharmacy naloxone provision, despite their widespread role in the pharmacy. We examined attitudes and perceptions of pharmacy technicians in the provision of naloxone in a sample of Massachusetts pharmacies. DesignThirty-nine community retail pharmacies from 1 U.S. chain were purposely sampled in 13 municipalities across Massachusetts. Pharmacies were divided into high-risk municipalities (HRMs) versus low-risk municipalities (LRMs) based on the state average opioid-related death rate from 2011 to 2015. Setting and participantsA pharmacy technician working in each pharmacy was administered an in-person survey. Survey topics included technician beliefs about current naloxone provision practices; patient groups at greater risk of overdose; whether individuals filling prescriptions would benefit from naloxone; and whether individuals purchasing syringes would benefit from naloxone. Outcome measuresClosed-ended responses were analyzed by Mann-Whitney U, Fisher exact, and chi-square tests. Open-ended responses were summarized for themes and then contrasted by municipality risk status. ResultsTechnician participation was 100% (n = 39). Technicians in both groups believed they could identify patient groups at risk of overdose in their practice, but HRM technicians recognized the need for naloxone for more of their at-risk patients (81% in HRM vs. 33% in LRM believed > 25% of patients need naloxone, P < 0.01). A willingness to provide naloxone was high (> 89%) in both groups. Open-ended responses revealed commonalities between groups, including the belief that patients need lower-cost naloxone, and a lack of patient and technician awareness that naloxone could prevent overdose in individuals at risk through use of prescription opioids not just through use of illicit drugs. ConclusionPharmacy technicians would benefit from overdose prevention training and are well positioned to recognize overdose risk and offer preventive interventions, such as naloxone. Among technicians, there is a high willingness to be involved in implementing broader naloxone access in pharmacies.

Take-Home Naloxone for the Emergency Interim Management of Opioid Overdose: The Public Health Application of an Emergency Medicine

Naloxone is a well-established essential medicine for the treatment of life-threatening heroin/opioid overdose in emergency medicine. Over two decades, the concept of ‘take-home naloxone’ has evolved, comprising pre-provision of an emergency supply to laypersons likely to witness an opioid overdose (e.g. peers and family members of people who use opioids as well as non-medical personnel), with the recommendation to administer the naloxone to the overdose victim as interim care while awaiting an ambulance. There is an urgent need for more widespread naloxone access considering the growing problem of opioid overdose deaths, accounting for more than 100,000 deaths worldwide annually. Rises in mortality are particularly sharp in North America, where the ongoing prescription opioid problem is now overlaid with a rapid growth in overdose deaths from heroin and illicit fentanyl. Using opioids alone is dangerous, and the mortality risk is clustered at certain times and contexts, including on prison release and discharge from hospital and residential care. The provision of take-home naloxone has required the introduction of new legislation and new naloxone products. These include pre-filled syringes and auto-injectors and, crucially, new concentrated nasal sprays (four formulations recently approved in different countries) with speed of onset comparable to intramuscular naloxone and relative bioavailability of approximately 40–50%. Choosing the right naloxone dose in the fentanyl era is a matter of ongoing debate, but the safety margin of the approved nasal sprays is superior to improvised nasal kits. New legislation in different countries permits over-the-counter sales or other prescription-free methods of provision. However, access remains uneven with take-home naloxone still not provided in many countries and communities, and with ongoing barriers contributing to implementation inertia. Take-home naloxone is an important component of the response to the global overdose problem, but greater commitment to implementation will be essential, alongside improved affordable products, if a greater impact is to be achieved.

One single large intramuscular dose of naloxone is effective and safe in suspected heroin poisoning.

Naloxone is an established antidote for the treatment of heroin poisoning; however, dosing regimens vary widely, with a current trend towards small titrated intravenous dosing. This study aims to characterise naloxone use in the treatment of patients presenting with suspected heroin poisoning. This was a retrospective review of poisoned patients presenting to a clinical toxicology unit in Brisbane from January 2015 to December 2017. Patient demographics, clinical effects, naloxone dosing, observation periods and complications were extracted from the patient's medical records. There were 117 presentations accounted for by 108 patients. Prehospital naloxone was provided to 57 (49%) patients, 46 of which received a standardised 1.6 mg i.m. dose. The remaining 60 (51%) patients received their first naloxone in hospital, with 58 (97%) receiving this by titrated i.v. doses. A subsequent naloxone infusion was required significantly more often in those treated with i.v. titrated naloxone compared to i.m. dose (27/69 [39%] vs 5/48 [10%], P = 0.0006). The need for parenteral sedation to manage acute behavioural disturbance following naloxone provision was rare (3/117 [3%]). In this retrospective observational study, a single large i.m. dose of naloxone reversed the toxicity of suspected heroin overdose in the majority of patients. In addition, patients were less likely to require repeated intermittent doses or naloxone infusion than those treated solely with i.v. naloxone. Further comparison in a prospective study is warranted to validate these observations in confirmed heroin overdose. Requirement for sedation secondary to acute behavioural disturbance was rare regardless of the route.

Availability and Cost of Naloxone Nasal Spray at Pharmacies in Philadelphia, Pennsylvania, 2017

Despite the increasingly important role of pharmacies in the implementation of naloxone access laws, there is limited information on the impact of such laws at the local level. To evaluate the availability (with or without a prescription) and cost of naloxone nasal spray at pharmacies in Philadelphia, Pennsylvania, following a statewide standing order enacted in Pennsylvania in August 2015 to allow pharmacies to dispense naloxone without a prescription. A survey study was conducted by telephone of all pharmacies in Philadelphia between February and August 2017. Pharmacies were geocoded and linked with the American Community Survey (2011-2015) to obtain information on the demographic characteristics of census tracts and the Medical Examiner's Office of the Philadelphia Department of Public Health to derive information on the number of opioid overdose deaths per 100 000 people for each planning district. Data were analyzed from March 2018 to February 2019. Availability and out-of-pocket cost of naloxone nasal spray (with or without a prescription) at Philadelphia pharmacies overall and by pharmacy and neighborhood characteristics. Of 454 eligible pharmacies, 418 were surveyed (92.1% response rate). One in 3 pharmacies (34.2%) had naloxone nasal spray in stock; of these, 61.5% indicated it was available without a prescription. There were significant differences in the availability of naloxone by pharmacy type and neighborhood characteristics. Naloxone was both more likely to be in stock (45.9% vs 27.8%; difference, 18.0%; 95% CI, 8.3%-27.8%; P < .001) and available without a prescription (80.6% vs 42.2%; difference, 38.4%; 95% CI, 23.0%-53.8%; P < .001) in chain stores than in independent stores. Naloxone was also less likely to be available in planning districts with very elevated rates of opioid overdose death (≥50 per 100 000 people) compared with those with lower rates (31.1% vs 38.5%). The median (interquartile range) out-of-pocket cost among pharmacies offering naloxone without a prescription was $145 ($119-$150); costs were greatest in independent pharmacies and planning districts with elevated rates of opioid overdose death. Despite the implementation of a statewide standing order in Pennsylvania more than 3 years prior to this study, only one-third of Philadelphia pharmacies carried naloxone nasal spray and many also required a physician's prescription. Efforts to strengthen the implementation of naloxone access laws and better ensure naloxone supply at local pharmacies are warranted, especially in localities with the highest rates of overdose death.

Why aren’t Australian pharmacists supplying naloxone? Findings from a qualitative study

BackgroundOpioid overdose is a significant public health issue among people who use pharmaceutical opioids and/or heroin. One response to reducing overdose deaths is to expand public access to naloxone. The Australian Therapeutic Goods Administration down-scheduled naloxone from prescription only (S4) to pharmacist only over-the-counter (OTC, schedule 3) in February 2016. There is little research examining pharmacists’ perspectives or experiences of this change. MethodsThirty-seven semi-structured interviews with Australian community pharmacists were conducted in 2016–2017 to investigate pharmacists’ attitudes to and experiences of OTC naloxone. Transcripts were thematically analysed, guided by a broad interest in facilitators and barriers to OTC supply. ResultsAround half of the pharmacists were aware of the down-scheduling and only two had provided OTC naloxone. Core barriers to pharmacist provision of OTC naloxone included limited understanding of opioid overdose, confusion about the role and responsibilities of pharmacists in providing OTC naloxone, concerns about business, stigma related to people who inject drugs (PWID) and system-level challenges. ConclusionPharmacy provision of OTC naloxone offers an important opportunity to reduce overdose mortality. Our study suggests this opportunity is yet to be realised and highlights several individual- and structural-level impediments hindering the expansion of public access to naloxone via community pharmacies. There is a need to develop strategies to improve pharmacists’ knowledge of OTC naloxone and opioid overdose as well as to address other logistical and cultural barriers that limit naloxone provision in pharmacy settings. These need to be addressed at the individual level (training) as well as the system level (information, regulation and supply).

The Global State of Harm Reduction in Prisons.

Despite the fact that a large portion of the prison population is made up of people who use and inject drugs, harm reduction continues to be extremely limited in prison settings. This article begins with a review of drug-related incarceration, drug use in prisons, and HIV and hepatitis C (HCV) prevalence among prisoners globally. It presents the scientific evidence, alongside legal and economic arguments supporting the provision of harm reduction to people who use drugs, both inside and outside of prisons. The article then provides a global overview of the availability, accessibility, and quality of harm reduction services in prisons-specifically needle and syringe programs; opioid substitution therapy; provision of the opioid agonist naloxone; and diagnosis, treatment, and care for HIV, HCV, and tuberculosis.

How prepared are pharmacists to provide over-the-counter naloxone? The role of previous education and new training opportunities.

and Aims: Opioid overdose can be reversed with timely administration of naloxone. In Australia, naloxone was rescheduled from prescription only (S4) to pharmacist only over-the-counter (OTC, S3) in February 2016, increasing access for the general public. A key barrier to naloxone supply by pharmacists is a lack of knowledge, highlighting the role of pharmacist education. Community pharmacists' education, experience, and training preferences related to naloxone provision, overdose, and substance use disorder were examined. Online survey data from a national sample of Australian pharmacists on their educational preferences regarding naloxone and overdose prevention, and prior training on substance use disorder (n = 595) was analyzed using bivariate and multivariate regression analysis. Data from qualitative semi-structured telephone interviews with pharmacists about OTC naloxone provision (n = 21) was analyzed using thematic analysis. Most pharmacists (81%, n = 479) were willing to be trained in opioid overdose prevention, with greater willingness to attend training associated with younger age, being female, fewer years of practice, not having attended previous education on substance use disorder, and higher confidence in issues relating to substance use disorder. Qualitative interviews confirmed community pharmacists' willingness to attend training but analysis revealed low awareness, knowledge, and confidence about naloxone and preventing opioid overdose. Most pharmacists preferred online training or webinars. Most community pharmacists in Australia are willing to attend training on providing naloxone and preventing opioid overdose. There are opportunities to develop and expand the online presence of training, guidelines, and education materials to facilitate the expanded supply of OTC naloxone.

Will converting naloxone to over-the-counter status increase pharmacy sales?

ObjectiveTo estimate the own‐price elasticity of demand for naloxone, a prescription medication that can counter the effects of an opioid overdose, and predict the change in pharmacy sales following a conversion to over‐the‐counter status.Data Sources/Study SettingThe primary data source was a nationwide prescription claims dataset for 2010‐2017. The data cover 80 percent of US retail pharmacies and account for roughly 90 percent of prescriptions filled. Additional covariates were obtained from various secondary data sources.Study DesignWe estimated a longitudinal, simultaneous equation model of naloxone supply and demand. Our primary variables of interest were the quantity of naloxone sold, measured as total milligrams sold at pharmacies, and the out‐of‐pocket price paid per milligram, both measured per ZIP Code and quarter‐year.Data Collection/Extraction MethodsPrimary data came directly from payers and processors of prescription drug claims.Principal FindingsWe found that, on average, a 1 percent increase in the out‐of‐pocket price paid for naloxone would result in a 0.27 percent decrease in pharmacy sales. We predict that the total quantity of naloxone sold in pharmacies would increase 15 percent to 179 percent following conversion to over‐the‐counter status.ConclusionsNaloxone is own‐price inelastic, and conversion to over‐the‐counter status is likely to lead to a substantial increase in total pharmacy sales.

Beliefs Associated with Pharmacy-Based Naloxone: a Qualitative Study of Pharmacy-Based Naloxone Purchasers and People at Risk for Opioid Overdose.

Drug overdose is the leading cause of unintentional death in the USA and the majority of deaths involve an opioid. Pharmacies are playing an increasingly important role in getting naloxone-the antidote to an opioid overdose-into the community. The aim of the current study was to understand, from the perspective of those who had obtained naloxone at the pharmacy, whose drug using status and pain patient status was not known until the interviews were conducted, as well as those who had not obtained naloxone at the pharmacy but were at risk for overdose, factors that impact the likelihood of obtaining pharmacy-based naloxone (PBN). Fifty-two participants from two New England states were interviewed between August 2016 and April 2017. We used a phenomenological approach to investigate participants' beliefs about pharmacy-based naloxone. The social contextual model was chosen to structure the collection and analysis of the qualitative data as it takes into account individual, interpersonal, organizational (pharmacy), community, and societal influences on a specific health behavior. Of the 52 people interviewed, 24 participants had obtained naloxone from the pharmacy in the past year, of which 4% (n = 1) self-disclosed during the interview current illicit drug use and 29% (n = 7) mentioned using prescribed opioid pain medication. Of the 28 people who had not obtained naloxone from the pharmacy, 46% (n = 13) had obtained an over the counter syringe from a pharmacy in the past month and had used an opioid in the past month, and 54% (n = 15) had used a prescribed opioid pain medication in the past month but did not report a syringe purchase. Several main themes emerged from the interview data. Individual-level themes were as follows: helplessness and fear, naloxone as empowerment to help, and past experiences at the pharmacy. Interpersonal-level themes were as follows: concern for family and friends, and sources of harm reduction information. Themes associated with pharmacy-level influence were as follows: perceived stigma from pharmacists, confusion at the pharmacy counter, and receptivity to pharmacists' offer of naloxone; community-level themes were as follows: community caretaking and need for education and training. Finally, themes at the societal-level of influence were as follows: generational crisis, and frustration at lack of response to opioid crisis. Overall our findings reveal factors at multiple levels which may play a role in likelihood of obtaining naloxone at the pharmacy. These factors can be used to inform interventions seeking to increase provision of pharmacy-based naloxone.

Overdose mortality rates in Croatia and factors associated with self-reported drug overdose among persons who inject drugs in three Croatian cities

BackgroundDrug overdose is the major cause of morbidity and mortality among persons who inject drugs (PWID). We assessed factors associated with the non-fatal drug overdose among PWID in three Croatian cities and national trends of overdose-related mortality (OM), and rates of uptake of opioid agonist drug treatment (OAT). MethodsWe used a respondent-driven sampling method to recruit 830 PWID in Zagreb, Split and Rijeka in 2014/2015. Participants completed behavioural questionnaires that included questions about overdose history, and we used Poisson regression to assess factors associated with self-reported overdose. We used joinpoint regression to calculate national trends of OM from 2001 to 2015 and rates of uptake of drug treatment from 2005 to 2015. ResultsLifetime prevalence of self-reported drug overdose in our RDS sample was 45.2%, while 4.1% of PWID reported overdose in the past 12 months; PWID who injected more than one type of drug in the past 12 months (adjusted prevalence ratio [aPR] = 4.56, 95% confidence intervals [CI] = 1.35–15.38) compared to injecting only heroin, and those enrolled in OAT (aPR = 1.94, 95% CI = 1.01–3.74) were more likely to report overdose in the past 12 months. We observed an increase in annual percent change (APC) of the national OM rates from 2001 to 2007 (APC = 22.5%, 95% CI = 16.3–29.0) and a decline from 2007 to 2015 (APC = −8.0%, 95% CI = −5.3- −10.5). The national rates of drug treatment enrollment increased from 2005 to 2010 (APC = 12.0%, 95% CI = 10.3–13.8), mostly due to increase in provision of buprenorphine from 2005 to 2008 (APC = 130.4%, 95% CI = 102.1–162.7). ConclusionInjecting more than one type of drugs and enrollment in OAT while still injecting drugs was positively associated with non-fatal overdose in our sample. To further reduce OM in Croatia we suggest improvements in coverage and delivery of OAT and establishment of provision of naloxone for PWID.

1082. Meta-Analysis of Survival Outcomes in People Who Inject Drugs After Cardiac Surgery for Infective Endocarditis

BackgroundThe United States’ opioid epidemic has led to an increase in people who inject drugs (PWID) and opioid-associated infections, including infectious endocarditis (IE). Cardiac surgery is often indicated in IE to improve outcomes but is controversial in PWID due to the concerns about continued injection drug use leading to risk for reinfection and decreased survival. In response, we assessed the long-term survival after cardiac valve surgery in PWID compared with people who do not inject drugs (non-PWID) in the published literature.MethodsWe performed a systematic review and meta-analysis (MA) of studies that reported survival data after surgery for IE in PWID. We searched PUBMED up to April 2018. We extracted Kaplan–Meier (KM) curves from included studies. From the KM curves, we used an algorithm to estimate individual participant data (eIPD). In a one-step approach, we ran a Cox proportional hazards (CPH) model analysis of the eIPD with study random effects. In a two-step approach, we fitted CPH models by individual study; then, we ran a mixed-effects MA model of the log hazard ratios (HR) and standard errors.ResultsWe identified 11 retrospective studies. Of these, six reported comparisons of PWID vs. non-PWID, and five reported results for PWID only. Based on eIPD, we included 407 PWID and 1,877 non-PWID. Mean age for PWID was 36.7 years (95% CI 34.4–39.1) and for non-PWID was 52.0 years (95% CI 45.3–59.4). There were 144 deaths (35.3%) in PWID and 559 (29.8%) deaths in non-PWID. We present by study and by group KM curves of eIPD (Figures 1 and 2). In one-step MA (included all 11 studies), the HR for PWID was 1.13 (95% CI 0.92–1.39). In two-step MA (included six comparison studies), heterogeneity was high (I2 = 72%); and there was no significant between-group difference (HR 1.29, 95% CI 0.80–2.07) (Figure 3).ConclusionSurvival time post-surgery of PWID was similar to that of non-PWID. These estimates are concerning, as PWID on average are much younger than non-PWID with IE. Future studies should explore interventions to improve outcomes in PWID after surgery, including treatment of addiction during and after the index hospitalization and provision of naloxone at the time of discharge. Disclosures All authors: No reported disclosures.

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