Nonfatal Opioid Overdose Research Articles

Evaluating the temporal association between the recency of prescribed controlled substance acquisition and fatal and non-fatal opioid overdose.

Previous studies have explored psychosocial effects as possible triggers of opioid overdose (OOD). However, little is known about the temporal association between OOD and prescribed controlled substance (CS) acquisition. The objective of this study was to evaluate the temporal relationship between OOD and acquiring prescribed CSs prior to OOD. This study is an exploratory descriptive analysis using Arkansas Prescription Drug Monitoring Program (AR-PDMP) data linked to death certificate and statewide inpatient discharge records. All persons with ≥1 AR-PDMP prescription fill(s) between 1 January 2014 and 31 December 2017 were included (n= 1,946,686). For persons that experienced OOD and had ≥1 PDMP record(s), the difference in days between OOD and the most recent AR-PDMP prescription filled prior to an OOD was recorded. To account for censoring, a sensitivity analysis was conducted restricting the study group to "New AR-PDMP Entrants" that had at least a 180-day gap between consecutive AR-PDMP fill dates. 28,998,307 AR-PDMP records were analyzed for 1,946,686 individuals. 7195 persons experienced 9223 OODs and 414 (4.49%) of those were fatal. Of these, 6236 experienced ≥1 OOD and acquired prescribed CSs prior to or on the day of the first OOD. Of those that experienced ≥1 OOD(s), 2201 (30.59%) had an AR-PDMP record in the 0- to 5-day period prior to their overdose and 497 (6.91%) had an AR-PDMP record the day prior to their overdose. Among New AR-PDMP Entrants that experienced ≥1 OOD(s), 408 (27.38%) had an AR-PDMP record in the 0- to 5-day period prior to their overdose. Though the vast majority of persons accessing CSs in Arkansas did not experience an OOD, a sizable proportion of persons that experience an OOD(s) obtained prescribed CSs immediately prior.

Fatal and nonfatal opioid overdose risk following release from prison: A retrospective cohort study using linked administrative data

IntroductionAmong individuals who are released from prison, opioid overdose is a leading cause of death with a risk more than ten-fold the general population. Although the epidemiology of opioid-related fatalities has been described, few studies have characterized both fatal and nonfatal opioid-related poisonings. The objective of this study was to estimate risk of fatal and nonfatal opioid overdose among adults released from prison. MethodsThe study estimated fatal and nonfatal opioid overdose rates using linked corrections, Medicaid, hospital discharge, and vital statistics from the state of Oregon from 2014 to 2018. Multivariable proportional hazards models identified demographic and prison-related factors associated with overdose. ResultsBetween 2014 and 2017, 18,258 individuals were released from prison. A majority of individuals were male (87 %) and ages 26 to 64 (83 %). Two-thirds had a documented substance use disorder treatment need and 20 % demonstrated mental health treatment need. Following prison release, 579 opioid overdose events occurred; 65 (11 %) were fatal. The rate of opioid overdose was 1085.7 per 100,000 person-years (PY). Rates were highest in the first two weeks (2286.7 per 100,000 PY), among women (1582.9 per 100,000 PY), and those with mental health (1624.3 per 100,000 PY) or substance use disorder treatment needs (1382.6 per 100,100 PY). Only mental health (adjusted hazard ratio [aHR] 1.54, 95 % CI 1.24 to 1.90) and substance use need (aHR 2.59; 95 % CI 2.01 to 3.34) remained significant in multivariable models. ConclusionsThe rate of opioid overdose is markedly elevated after prison release, particularly in the first two weeks. In women, the higher rate of opioid overdose is mediated by a greater mental health burden.

Study protocol for a multisite randomized controlled trial of a peer navigator intervention for emergency department patients with nonfatal opioid overdose

BackgroundPatients presenting to emergency departments (EDs) after a nonfatal opioid-involved overdose are at high risk for future overdose and death. Responding to this risk, the New York City (NYC) Department of Health and Mental Hygiene operates the Relay initiative, which dispatches trained peer “Wellness Advocates” to meet patients in the ED after a suspected opioid-involved overdose and follow them for up to 90 days to provide support, education, referrals to treatment, and other resources using a harm reduction framework. MethodsIn this article, we describe the protocol for a multisite randomized controlled trial of Relay. Study participants are recruited from four NYC EDs and are randomized to receive the Relay intervention or site-directed care (the control arm). Outcomes are assessed through survey questionnaires conducted at 1-, 3-, and 6-months after the baseline visit, as well as through administrative health data. The primary outcome is the number of opioid-related adverse events, including any opioid-involved overdose or any other substance use-related ED visit, in the 12 months post-baseline. Secondary and exploratory outcomes will also be analyzed, as well as hypothesized mediators and moderators of Relay program effectiveness. ConclusionWe present the protocol for a multisite randomized controlled trial of a peer-delivered OD prevention intervention in EDs. We describe how the study was designed to minimize disruption to routine ED operations, and how the study was implemented and adapted during the COVID-19 pandemic. This trial is registered with ClinicalTrials.gov [NCT04317053].

Opioid Overdose Risk Following Hospital Discharge Among Individuals Prescribed Long-Term Opioid Therapy: a Risk Interval Analysis.

Individuals prescribed long-term opioid therapy (LTOT) have increased risk of readmission and death after hospital discharge. The risk of opioid overdose during the immediate post-discharge time period is unknown. To examine the association between time since hospital discharge and opioid overdose among individuals prescribed LTOT. Self-controlled risk interval analysis. Adults prescribed LTOT with at least one hospital discharge at a safety-net health system and a non-profit healthcare organization in Colorado. We identified individuals prescribed LTOT who were discharged from January 2006 through June 2019. The outcome was a composite of fatal and non-fatal opioid overdoses during a 90-day post-discharge observation period, identified using electronic health record (EHR) and vital statistics data. Risk intervals included days 0-6 after index and subsequent hospital discharges. Control intervals ranged from days 7 to 89 after index discharge and included all other time during the observation period that did not fall within a risk interval or time readmitted during a subsequent hospitalization, which was excluded. Poisson regression was used to estimate incidence rate ratios (IRR) and 95% confidence intervals (CI) for overdose events during risk in comparison to control intervals. We identified 7695 adults (63.3% over 55 years, 59.4% female, 20.3% Hispanic) who experienced 9499 total discharges during the study period. Twenty-one overdoses occurred during their observation periods (1174 per 100,000 person-years [9 in risk, 12 in control]). Overdose risk was significantly higher during the risk interval in comparison to the control interval (IRR 6.92; 95% CI 2.92-16.43). During the first 7 days after hospital discharge, individuals prescribed LTOT appear to be at elevated risk for opioid overdose. Clarifying mechanisms of overdose risk may help inform in-hospital and post-discharge prevention strategies.

The salience of social context, opioid antagonist use, and prior opioid exposure as determinants of fatal and non-fatal opioid overdoses.

This study examines the salience of social context for opioid overdoses in Boston from 2014 to 2019. Longitudinal negative binomial models with random effects indicated that higher levels of concentrated disadvantage, residential instability, and illicit drug activity increased annual block group counts of opioid overdoses. Logistic hierarchical and cross-classified random effects models indicated that the use of Narcan and greater exposure to drugs through previous opioid overdose and contextual lillicit drug crime activity reduced the odds of fatal opioid overdose relative to non-fatal opioid overdose. The findings suggest that the accurate tracking of both fatal and non-fatal overdoses, and a consideration of the broader social context, can facilitate effective public health resource allocation to reduce opioid overdoses.

Nonfatal opioid-related overdoses treated by emergency medical services in Florida, before and during the COVID-19 pandemic

Previous studies have found increases in nonfatal opioid overdoses during the COVID-19 pandemic, which created difficult conditions for people with substance use disorders. We assessed changes in nonfatal opioid-related overdoses in Florida during the onset of the COVID-19 pandemic. Emergency medical service data was obtained from the Florida Department of Health. Naloxone administration with documented improvement was used as a proxy for nonfatal opioid-related overdoses. Age-adjusted rates were estimated per 100,000 population for April-September 2020 (n = 9,377) and compared to the same time period during 2019 (n = 6,765) using rate ratios. Age-adjusted rates were estimated by sex, race/ethnicity, and metro/nonmetro county classification, as well as county-level measures of medications for opioid use disorder (MOUD) availability, rates of COVID-19 deaths, and unemployment during 2020. The age-adjusted rate of nonfatal opioid-related overdoses increased from 32.41 (95 % CL: 31.64–33.19) during 2019 to 45.35 (95 % CL: 44.42–46.27) during 2020 (RR = 1.40; 95 % CL: 1.36–1.44). The rate for males increased most in metro counties (RR = 1.47, 95 % CL: 1.41–1.53); the rate for females increased most in nonmetro counties (RR = 1.51, 95 % CL: 1.10–2.06). The largest increases were observed among Hispanics (males: RR = 1.56, 95 % CL: 1.37–1.78; females: RR = 1.44, 95 % CL: 1.14–1.81), counties with no MOUD treatment options (RR = 1.66, 95 % CL: 1.14–2.44) and counties with the lowest rates of buprenorphine prescribers (RR = 1.70, 95 % CL: 1.29–2.22). Nonfatal opioid-related overdoses increased in Florida during the first six months of the COVID-19 pandemic. Expanding access to services that support treatment and recovery is critical to addressing the ongoing opioid crisis in Florida.

1399. Dramatic Increase in Invasive Group A Streptococcal Infection in Persons Who Inject Drugs in an Urban Philadelphia Hospital

Abstract Background Invasive infection from Group A streptococcus (iGAS) is rising nationally, and we report a significant increase in incidence at an urban, quaternary care health center, which serves the Kensington neighborhood, the epicenter of the opioid crisis in Philadelphia, PA. We examined iGAS infection in the Temple University Health System catchment area Methods iGAS was defined as an of streptococcus pyogenes cultured from a previously sterile site. Injection drug use (IDU) is a known risk factor for bacterial infection, including iGAS infection. All blood, sterile fluid, and/or tissue cultures that yielded S. pyogenes were identified using the laboratory information system at Temple University Hospital – Main Campus. Two cohorts were compared: January 1, 2021, to December 31, 2021, and January 1, 2019, to December 31, 2019. Electronic health records were reviewed and data pertaining to age, gender, and injection drug use were abstracted. Descriptive statistics were used to summarize findings. Results 155 cases of iGAS were identified in 2021 (105 of which involved bacteremia) compared to 69 in 2019 (42 of which involved bacteremia), representing a 224% increase overall. Of the cases in 2021, 130 (84%) were Persons Who Inject Drugs (PWID) compared to only 39 (57%) in 2019. PWID with iGAS were younger (median age 35 vs 54 in 2019, 39 vs 53 in 2021) and more likely to be male (57% vs 43% in 2019, 68% vs 32% in 2021). Male patients also had a higher incidence of PWID than female patients (56% vs 44% in 2019 and 64% vs 36% in 2021). Conclusion During this same time period, the COVID-19 pandemic added to the ongoing opioid crisis in Philadelphia. The city of Philadelphia publicly reports opioid data, which shows that hospitalizations related to non-fatal opioid overdose have exponentially risen in the past two decades. This also coincides with an increase in the presence of xylazine, an adulterant in the Philadelphia fentanyl supply. Xylazine has been implicated in worsening wounds. Our data supports a concerning association between iGAS and PWID. Disclosures All Authors: No reported disclosures.

National dashboard to track nonfatal opioid ODs

Last week, the White House Office of National Drug Control Policy (ONDCP), in partnership with the National Highway Traffic Safety Administration (NHTSA), launched a national data dashboard of nonfatal opioid overdoses across the country. A person who is rescued from an opioid overdose is more than twice as likely to die from an opioid overdose in the future, said ONDCP Director Rahul Gupta, M.D., in announcing the dashboard Dec. 7.

Characteristics of Nonfatal Opioid Overdose in Emergency Department Patients Surviving to Discharge or Hospital Admission.

Emergency department (ED) presentations for opioid overdose have risen significantly over the past decade. Many of these visits result in hospital admission with substantial public health and economic consequences. Much is unknown about the patient and hospital characteristics associated with discharge versus inpatient admission for these patients. We investigated patient and hospital characteristics associated with nonfatal ED visits for opioid overdose associated with hospital admission. Using 2016 data from the Nationwide Emergency Department Sample (NEDS), we performed a cross sectional analysis and identified a weighted estimate of adult patients presenting to EDs across the U.S. with ICD-10 diagnoses consistent with opioid overdose. Disposition, sex, age, expected payer, income quartile, geographic region, type of opioid ingested, co-ingestions, urban/ rural designation and teaching status of hospital were examined. Logistic regression (proc surveylogistic) was used to identify predictors of hospital admission for overdose. Odds ratios and their associated 95% confidence intervals are reported. In 2016 there were 263,621 adult ED presentations for opioid overdose, and 25.5% of them were admitted to the hospital. Although rates of overdose (per 100,000) were higher in the Northeast (110.6) and Midwest (106.4), admission rates were higher in the South (29.4%) and West (30.7%). Factors associated with hospital admission included female sex, older age, having any type of insurance, non-heroin overdoses and benzodiazepine co-ingestions. Understanding the characteristics associated with inpatient admission of patients presenting to the ED with opioid overdose represents an important area for ongoing and future public health intervention.

Analysis of trends and usage of ICD-10-CM discharge diagnosis codes for poisonings by fentanyl, tramadol, and other synthetic narcotics in emergency department data

Synthetic opioids, including illicitly manufactured fentanyls, are driving recent increases in US overdose deaths. Beginning October 2020, the International Classification of Diseases, 10th revision, Clinical Modification (ICD-10-CM) code for poisonings involving synthetic narcotics (T40.4X) was split into three codes: fentanyl (T40.41), tramadol (T40.42), and other synthetic narcotics (T40.49). Emergency department data from October 2019–September 2021 in the Centers for Disease Control and Prevention’s National Syndromic Surveillance Program BioSense platform were queried for synthetic opioid codes in the chief complaint and discharge diagnosis fields. Trend analyses assessed average monthly percent change overall and by sex and age. Emergency department visits for overdoses involving synthetic narcotics increased on average 3.2 % each month before the code split and 4.8 % after. Visits with fentanyl codes drove this increase after the split, accounting for most visits among males, females, and every age group except ≥ 65 years. The average monthly percent increase for ED visits for fentanyl-involved overdoses was greater than for all synthetic narcotics combined (i.e., T40.41, T40.42, and/or T40.49), suggesting that the old code (T40.4X) masked the full extent of the increase in ED visits for fentanyl overdoses. Usage of these new codes can improve tracking of non-fatal synthetic opioid overdose trends.

Prescribing Characteristics Associated With Opioid Overdose Following Buprenorphine Taper

Retention in buprenorphine therapy is associated with a lower risk of opioid overdose. Nevertheless, many patients discontinue treatment, and there is limited evidence to guide buprenorphine tapering. To understand what prescribing characteristics are associated with opioid overdose following buprenorphine taper. This is a population-based, retrospective, cohort study of adults who were maintained on buprenorphine for at least 60 days and underwent a buprenorphine taper. The study was conducted in the Canadian province of Ontario, using linked administrative health data. New buprenorphine treatment episodes were accrued between January 1, 2013, and January 1, 2019, and the maximum follow-up was April 30, 2020. Data analysis was performed from December 2020 to August 2022. The primary exposure of interest was time to taper initiation (≤1 year vs >1 year). Secondary exposures included mean rate of taper, percentage days during which the dose was decreasing, and taper duration. The primary outcome measure was time to fatal or nonfatal opioid overdose within 18 months following treatment discontinuation. Among 5774 individuals, the median (IQR) age at index date was 34 (28-44) years, and 3462 individuals (60.0%) were male. Time to taper initiation longer than 1 year vs 1 year or less (6.73 vs 10.35 overdoses per 100 person-years; adjusted hazard ratio [aHR], 0.69; 95% CI, 0.48-0.997), a lower mean rate of taper (≤2 mg per month, 6.95 overdoses per 100 person-years; >2 to ≤4 mg per month, 11.48 overdoses per 100 person-years; >4 mg per month, 17.27 overdoses per 100 person-years; ≤2 mg per month vs >4 mg per month, aHR, 0.65; 95% CI, 0.46-0.91; >2 to ≤4 mg per month vs >4 mg per month, aHR, 0.69; 95% CI, 0.51-0.93), and dose decreases in 1.75% or less of days vs more than 3.50% of days during the taper period (5.87 vs 13.87 overdoses per 100 person-years; aHR, 0.64; 95% CI, 0.43-0.93) were associated with reduced risk of opioid overdose; however, taper duration was not. In this retrospective cohort study, buprenorphine tapers undertaken after at least 1 year of therapy, a slower rate of taper, and a lower percentage of days during which the dose was decreasing were associated with a significantly lower risk of opioid overdose, regardless of taper duration. These findings underscore the importance of a carefully planned taper and could contribute to reduction in opioid-related overdose death.

Implementation of a multidisciplinary inpatient opioid overdose education and naloxone distribution program at a large academic medical center.

Opioid overdose-related deaths continue to rise. Despite public health efforts, there is still variability in obtainment of naloxone, a lifesaving antidote. We share our experience in the implementation of a novel opioid overdose education and naloxone distribution (OEND) program at a large academic medical center. Collaborative efforts made by pharmacists, pharmacy students, physicians, nurses, and recovery coaches were employed in the design of the program. The service was available Monday through Friday, 9 am to 6 pm, and primarily carried out by pharmacy students on a rotating basis. Services offered included bedside delivery of naloxone and education prior to the day of discharge. In preparation for their role, the pharmacy students were required to complete a series of trainings and competency assessments. A total of 40 patients were included in the program evaluation. Of the completed consults 96.7% (n = 30) of patients received both counseling and naloxone delivery. Eighty percent of patients had a history of nonfatal opioid overdose, but only 37.5% had naloxone listed as a home medication. OEND services were provided to 66% of individuals with patient-directed discharges. Implementation of an inpatient OEND program by mobilizing trained student pharmacists is feasible and expands naloxone access to patients during transitions of care. A similar model could be considered in the future for the delivery of harm reduction supplies to this patient population.

Patient-Level and County-Level Trends in Nonfatal Opioid-Involved Overdose Emergency Medical Services Encounters - 491 Counties, United States, January 2018-March 2022.

The number of nonfatal opioid-involved overdoses treated by health care providers has risen in the United States; the median number of emergency department (ED) visits for these overdoses was significantly higher during 2020 than during 2019 (1). ED visit data can underestimate nonfatal opioid-involved overdose incidence because, increasingly, persons experiencing a nonfatal opioid overdose are refusing transport to EDs by emergency medical services (EMS) (2). A study in Kentucky found that during a 6-month period, 19.8% of persons treated by EMS for an opioid overdose refused transport to an ED (2). Thus, EMS encounter data involving suspected nonfatal opioid-involved overdoses complement ED data and also allow for near real-time analysis (3). This report describes trends in rates of EMS encounters for nonfatal opioid-involved overdoses per 10,000 total EMS encounters (rates) by selected patient- and county-level characteristics during January 2018–March 2022 in 491 counties from 21 states using data from biospatial, Inc.* During this period, the nonfatal opioid-involved overdose rate increased, on average, 4.0% quarterly. Rates increased for both sexes and for most age groups. Rates were highest among non-Hispanic White (White) and non-Hispanic Native Hawaiian or other Pacific Islander (NH/OPI) persons, and increases were largest among non-Hispanic Black (Black), followed by Hispanic or Latino (Hispanic) persons. Rates increased in both urban and rural counties and for all quartiles of county-level characteristics (i.e., unemployment, education, and uninsured), except in counties with the lowest percentage of uninsured persons. Rates were highest and rate increases were largest in urban counties and counties with higher unemployment rates. This analysis of nonfatal opioid-involved overdose trends in EMS data highlights the utility of these data and the importance of addressing inequities that contribute to disproportionate overdose risk, such as through focused outreach to racial and ethnic minority groups, who disproportionately experience these inequities, and communities with higher levels of unemployment. EMS providers are in a unique position to engage in postoverdose response protocols and promote evidence-based overdose education and facilitate linkage to care and harm reduction services.†,§

Effect of a Peer-Led Behavioral Intervention for Emergency Department Patients at High Risk of Fatal Opioid Overdose

Fatal and nonfatal opioid overdoses are at record levels, and emergency department (ED) visits may be an opportune time to intervene. Peer-led models of care are increasingly common; however, little is known about their effectiveness. To evaluate the effect of a peer-led behavioral intervention compared with the standard behavioral intervention delivered in the ED on engagement in substance use disorder (SUD) treatment within 30 days after the ED encounter. This randomized clinical trial recruited 648 patients from 2 EDs from November 15, 2018, to May 31, 2021. Patients were eligible to participate if they were in the ED for an opioid overdose, receiving treatment related to an opioid use disorder, or identified as having had a recent opioid overdose. Participants were randomly assigned to receive a behavioral intervention from a certified peer recovery specialist (n = 323) or a standard intervention delivered by a hospital-employed licensed clinical social worker (n = 325). A certified peer recovery specialist was someone with at least 2 years of recovery who completed a 45-hour training program and had 500 hours of supervised work experience. After the ED intervention, the certified peer recovery specialists offered continued contact with participants for up to 90 days. The primary outcome was receipt of SUD treatment within 30 days of enrollment, assessed with deterministic linkage of statewide administrative databases. Treatment engagement was defined as admission to a formal, publicly licensed SUD treatment program or receipt of office-based medication for opioid use disorder within 30 days of the initial ED visit. Among the 648 participants, the mean (SD) age was 36.9 (10.8) years, and most were male (442 [68.2%]) and White (444 [68.5%]). Receipt of SUD treatment occurred for 103 of 323 participants (32%) in the intervention group vs 98 of 325 participants (30%) in the usual care group within 30 days of the ED visit. Among all participants, the most accessed treatments were outpatient medication for opioid use disorder (buprenorphine, 119 [18.4%]; methadone, 44 [6.8%]) and residential treatment (44 [6.8%]). Overall, this study found that a substantial proportion of participants in both groups engaged in SUD treatment within 30 days of the ED visit. An ED-based behavioral intervention is likely effective in promoting treatment engagement, but who delivers the intervention may be less influential on short-term outcomes. Further study is required to determine the effects on longer-term engagement in SUD care and other health outcomes (eg, recurrent overdose). ClinicalTrials.gov Identifier: NCT03684681.

Detoxification, 12-step meeting attendance, and non-fatal opioid overdoses among a suburban/exurban population with opioid use disorder

Background Drug overdoses are the leading cause of injury death in the United States with an estimated 105,752 individuals dying from an overdose in the United States in a 12-month period ending October 2021. Given that people who have opioid use disorder (OUD) are at an increased risk of death, it is crucial to assess risk factors associated with opioid overdose to improve interventions. Objectives We examine factors associated with non-fatal overdose among a suburban/exurban population with OUD in Southern California. Methods Participants were recruited by convenience sampling (n = 355) and were interviewed between November 2017 to August 2018. Participants were eligible for the study if they had a history of pharmaceutical opioid use. Results A total of 198 (55.8%) participants reported at least one overdose in their lifetime. A total of 229 participants identified as male, 124 identified as female, and 2 identified as non-binary. When controlling for demographic factors, non-oral opioid administration at first opioid use (AOR 2.82, 95% CI 1.52-5.22), having a history of methadone detoxification, (AOR 2.23, 95% CI 1.27-3.91), history of buprenorphine detoxification (AOR 1.77, 95% CI 1.02-3.07), and history of 12 step attendance (AOR 1.89, 95% CI 1.12-3.20) were found to be independently and positively associated with lifetime opioid overdose. Conclusions Detoxification with buprenorphine and methadone was found to be associated with having a non-fatal opioid overdose. Buprenorphine and methadone should not be prescribed as a detoxification medication as long-term use of medication for OUD results in better outcomes than medication that is used short-term.

Re-entry Needs Among a Population with Co-occurring Opioid Use and Mental Health Disorders in Massachusetts, USA Jails: Part of a National Plan to Address the Opioid Epidemic

Introduction. Studies show that the release from jail is a vulnerable transition for individuals with opioid use disorder re-entering their communities. Less is known about individuals with co-occurring mental health and opioid use disorders (COD), particularly their specific needs following release. Objectives. To describe the needs of people with COD within two weeks of release jail. Methods. Baseline data from 155 individuals with COD were collected within two weeks of release from jail across 9 counties in Massachusetts. Univariate analyses were conducted to determine baseline needs. Results. The majority of participants were male (78.7%), White (64.5%), and non-Hispanic (75.5%). The most relevant needs among participants were employment (88.4% were unemployed), opioid overdose prevention (67.7% had at least one non-fatal opioid overdose), mental health symptoms (participants reported anxiety or tension an average of 8.9 days in the past 30 days), and trauma support/treatment (71.6% reported at least one traumatic event in their lifetime). Conclusions. Individuals with COD re-entering their communities have critical needs that must be addressed upon release.

Expert views on state-level naloxone access laws: a qualitative analysis of an online modified-Delphi process.

BackgroundExpanding availability to naloxone is a core harm reduction strategy in efforts to address the opioid epidemic. In the US, state-level legislation is a prominent mechanism to expand naloxone availability through various venues, such as community pharmacies. This qualitative study aimed to identify and summarize the views of experts on state-level naloxone access laws.MethodsWe conducted a three-round modified-Delphi process using the online ExpertLens platform. Participants included 46 key stakeholders representing various groups (advocates, healthcare providers, human/social service practitioners, policymakers, and researchers) with expertise naloxone access laws. Participants commented on the effectiveness and implementability of 15 state-level naloxone access laws (NALs). We thematically analyzed participant comments to summarize views on NALs overall and specific types of NAL.ResultsParticipants commented that the effectiveness of NALs in reducing opioid-related mortality depends on their ability to make sustained, significant impacts on population-level naloxone availability. Participants generally believed that increased naloxone availability does not have appreciable negative impacts on the prevalence of opioid misuse, opioid use disorder (OUD), and non-fatal opioid overdoses. Implementation barriers include stigma among the general public, affordability of naloxone, and reliance on an inequitable healthcare system.ConclusionsExperts believe NALs that significantly increase naloxone access are associated with less overdose mortality without risking substantial unintended public health outcomes. To maximize impacts, high-value NALs should explicitly counter existing healthcare system inequities, address stigmatization of opioid use and naloxone, maintain reasonable prices for purchasing naloxone, and target settings beyond community pharmacies to distribute naloxone.

Concentrations of psychoactive substances in blood samples from non-fatal and fatal opioid overdoses.

AimThe primary aim was to compare concentrations of psychoactive substances in blood in non‐fatal and fatal opioid overdoses. The secondary aim was to assess the concentration levels of naloxone in blood in non‐fatal overdoses and the association between naloxone findings and concomitantly detected drugs.Method DesignCase‐control study.SettingNorway. Fatal overdoses from 2017 and non‐fatal overdoses from February 2018 to September 2019.CasesThirty‐one non‐fatal and 160 fatal opioid overdose cases. Data from the non‐fatal overdoses were collected from hospital records and blood samples, and data from the fatal overdoses were collected from autopsy reports. Concentrations of psychoactive substances (including ethanol) in blood samples were collected at the time of hospital admission for the non‐fatal overdoses and during autopsy for the fatal overdoses.ResultsThe median number of different substances detected was four for fatal and five for non‐fatal overdoses. The fatal overdoses had higher pooled concentrations of opioids (188 vs 57.2 ng/mL, P < .001), benzodiazepines (5467 vs 2051 ng/mL, P = .005) and amphetamines (581 vs 121 ng/mL, P < .001) than the non‐fatal overdoses. A linear relationship between naloxone and concomitant pooled opioid concentrations was found (95% confidence interval = 0.002‐0.135, P < .05).ConclusionThe total load of drug concentrations was associated with the fatal outcome of an overdose, while the number of drugs used, to a lesser extent, differentiated between those who survived and those who died from an overdose. Higher opioid concentrations were associated with treatment with higher naloxone doses.

Insights from biosurveillance: non-fatal opioid overdoses in Rhode Island 2019-21.

Opioids biosurveillance is a new approach to public health surveillance of non-fatal overdoses that relies upon laboratory analysis of residual biospecimens from hospitals treating opioids overdoses. In Rhode Island (RI), USA, hospitals report suspected opioid overdoses to the Department of Health. Residual specimens associated with these overdoses are submitted to the State Health Laboratories for further characterization. This surveillance project aimed to characterize non-fatal overdoses through toxicological testing of urine specimens associated with non-fatal overdoses during the initial 2-year period of biosurveillance implementation in RI to assess the feasibility and public health utility of this approach. This study included individuals who presented for treatment for a suspected opioid overdose in 10 RI hospitals between July 2019 and June 2021. Urine samples were received for 1354 unique overdose encounters corresponding to reported overdoses. Some individuals experienced multiple overdoses during this time. Urine samples were extracted and then analyzed by liquid chromatography tandem mass spectrometry with a panel consisting of 1033 opiates, synthetic opioids, fentanyl analogs and select metabolites. Temporal and spatial trends were evaluated for the studied population. A total of 1354 samples were tested for the presence of opioids in urine collected from individuals who experienced a suspected overdose. Fentanyl (and/or norfentanyl) was present in 79% of all samples in which opioids were found (n = 1033). Fentanyl analogs varied in their contribution to these totals, with observations ranging as high as 35% of all opioid-containing samples in August 2019 and May 2021. Laboratory identification of opioids involved in suspected overdoses shows that fentanyl and its analogs are the main drivers of the opioids overdose epidemic in Rhode Island, USA. The biosurveillance approach is unique in its ability to quantify contributions of novel fentanyl analogs to the burden of overdoses.

The impact of opioid agonist treatment on fatal and non-fatal drug overdose among people with a history of opioid dependence in NSW, Australia, 2001–2018: Findings from the OATS retrospective linkage study

BackgroundThere are critical periods of mortality risk at onset and cessation of opioid agonist treatment. We aim to determine whether non-fatal overdose followed the same pattern as fatal overdose, comparing the first 4 weeks of treatment and treatment cessation and the remainder time off treatment, with the remainder treatment time, to determine intervention markers. MethodsRetrospective cohort study of people with a history of opioid agonist treatment using linked New South Wales data. The incidence of non-fatal overdose hospitalization; emergency department presentation; and fatal overdose from national death records were compared. Rates were calculated using generalized estimating equations adjusting for demographics, year, and recent health and incarceration events. ResultsThe remainder time in OAT had the lowest incidence of overdose for all outcomes and is the reference level for the adjusted incident rate ratios (aIRR). Fatal overdose was lowest in treatment and highest in the first four weeks out of treatment, aIRR of 12.83 (95% CI 10.0–16.4). Whereas the highest overdose rate for non-fatal opioid overdose was in the first four weeks in treatment, aIRR of 3.11 (95% CI 2.19–4.42). ConclusionsRetention on opioid agonist treatment is protective against drug related overdose. There is elevated risk of non-fatal overdose at treatment initiation that is not evident for fatal overdose, but the first month of treatment cessation is a critical period for both non-fatal and fatal overdose. These findings emphasize the importance of treatment retention and interventions for polysubstance overdose at cessation.