Prevent Overdose Deaths Research Articles

Women\u2019s multiple uses of an overdose prevention technology to mitigate risks and harms within a supportive housing environment: a qualitative study

BackgroundNorth America is amidst an opioid overdose epidemic. In many settings, particularly Canada, the majority of overdose deaths occur indoors and impact structurally vulnerable people who use drugs alone, making targeted housing-based interventions a priority. Mobile applications have been developed that allow individuals to solicit help to prevent overdose death. We examine the experiences of women residents utilizing an overdose response button technology within a supportive housing environment.MethodsIn October 2019, we conducted semi-structured qualitative interviews with 14 residents of a women-only supportive housing building in an urban setting where the overdose response button technology was installed. Data was analyzed thematically and framed by theories of structural vulnerability.ResultsWhile participants described the utility and disadvantages of the technology for overdose response, most participants, unexpectedly described alternate adoptions of the technology. Participants used the technology for other emergency situations (e.g., gender-based violence), rather than its intended purpose of overdose response.ConclusionsOur findings highlight the limitations of current technologies while also demonstrating the clear need for housing-based emergency response interventions that address not just overdose risk but also gender-based violence. These need to be implemented alongside larger strategies to address structural vulnerabilities and provide greater agency to marginalized women who use drugs.

Having a voice and saving lives: a qualitative survey on employment impacts of people with lived experience of drug use working in harm reduction

BackgroundOngoing legal and social discrimination, and stigmatization of people with lived experience of drug use (PWLE) continues to contribute to overdose-related deaths in Canada. The involvement of PWLE working in harm reduction services has proven effective in decreasing drug-related harms among PWLE; however, there exist unintended negative impacts. PWLE working in harm reduction services risk overextending themselves beyond employment parameters (e.g., emotional labor) with few systems in place (e.g., employment advocacy) for support. While meaningful participation of PWLE in harm reduction programs is critical to addressing the overdose crisis, their labor in Canada’s overdose response commands further investigation and recognition. This paper examines some of the benefits and negative aspects of working in harm reduction among PWLE.MethodsFifty qualitative surveys were completed by PWLE working in harm reduction services from across Canada at the National 2018 Stimulus conference held in Edmonton, Alberta. The surveys focused on the benefits and negatives of ‘peer’ employment and recommendations for organizational transformation through short answer written sections. Surveys were analyzed thematically using NVivo, informed by critical perspectives on substance use, with attention to key re-occurring themes on employment equity.ResultsWhile participants described multiple benefits of working in harm reduction services, such as the valuing of their expertise by fellow ‘peers,’ growing skill sets, countering stigma, and preventing overdose deaths, issues of workplace equity were significantly identified. Stigma, tokenism, workplace discrimination, including power and pay inequities, as well as lack of worker compensation and benefits were identified as key factors persisting in the everyday experiences of participants.ConclusionContinued exposure to stigma, workplace discrimination, and/or power imbalances, combined with the impact of high stakes employment (e.g., dealing with overdose deaths), can have significant consequences for PWLE working in harm reduction, including burn out. Policy recommendations include large-scale structural changes that address inequities of hierarchical ‘peer’ employment for PWLE, including increased leadership roles for diverse PWLE, pay equity and benefits, unionization, as well as more supportive working environments attentive to the intersecting social-structural factors (poverty, criminalization, racism, gendered violence) impacting the everyday lives of PWLE working in harm reduction.

Provincial Overdose Cohort: Population Data Linkage During an Overdose Crisis

IntroductionIn 2016, the Provincial Overdose Cohort (ODC) was created following the declaration of the public health emergency in British Columbia (BC), Canada. The ODC is a set of longitudinal and linked administrative data which identifies illicit drug-related overdose events, including death, ambulance, emergency room, hospital, physician, and prescription drug records.
 Objectives and ApproachThe ODC was developed to better understand factors associated with overdose in order to support response activities, prevent overdose deaths, and identify trends and opportunities for interventions. Person-level linkages were conducted using provincial health insurance and health history data; socio-economic information, mental and physical illness diagnoses, and corrections history were also appended. The ODC currently includes people who have had a drug-related overdose between January 1 st 2015 and December 31 st 2017 as well as a 20% random sample of the general population.
 ResultsThe ODC contains 36,576 overdose episodes and 23,161 people who have a drug-related overdose between January 1 st , 2015 and December 31 st 2017. Of the 23,161 people, 3,604 (15.6%) had a fatal overdose and 19,557 (84.4%) had a non-fatal overdose. 49.9% of people in BC who had an overdose were 20-39 years of age and 67.4% were males. From 2015 to 2017, the proportion of people experiencing 3 or more overdoses a year increased from 3.6% to 8.7%, respectively. There were an increasing number of fatal and non-fatal drug-related overdoses in BC during this time period.
 Conclusion / ImplicationsLarge population data linkages can be invaluable tools during a public health emergency. Collaborative partnerships and a shared data governance across jurisdictions was central in building the ODC and understanding how various social determinants of health impact risk of overdose among people who use drugs.

The HEALing (Helping to End Addiction Long-term SM) Communities Study: Protocol for a cluster randomized trial at the community level to reduce opioid overdose deaths through implementation of an integrated set of evidence-based practices

BackgroundOpioid overdose deaths remain high in the U.S. Despite having effective interventions to prevent overdose deaths, there are numerous barriers that impede their adoption. The primary aim of the HEALing Communities Study (HCS) is to determine the impact of an intervention consisting of community-engaged, data-driven selection, and implementation of an integrated set of evidence-based practices (EBPs) on reducing opioid overdose deaths. MethodsThe HCS is a four year multi-site, parallel-group, cluster randomized wait-list controlled trial. Communities (n = 67) in Kentucky, Massachusetts, New York and Ohio are randomized to active intervention (Wave 1), which starts the intervention in Year 1 or the wait-list control (Wave 2), which starts the intervention in Year 3. The HCS will test a conceptually driven framework to assist communities in selecting and adopting EBPs with three components: 1) a community engagement strategy with local coalitions to guide and implement the intervention; 2) a compendium of EBPs coupled with technical assistance; and 3) a series of communication campaigns to increase awareness and demand for EBPs and reduce stigma. An implementation science framework guides the intervention and allows for examination of the multilevel contexts that promote or impede adoption and expansion of EBPs. The primary outcome, number of opioid overdose deaths, will be compared between Wave 1 and Wave 2 communities during Year 2 of the intervention for Wave 1. Numerous secondary outcomes will be examined. DiscussionThe HCS is the largest community-based implementation study in the field of addiction with an ambitious goal of significantly reducing fatal opioid overdoses.

Promoting Safe Injection Practices, Substance Use Reduction, Hepatitis C Testing, and Overdose Prevention Among Syringe Service Program Clients Using a Computer-Tailored Intervention: Pilot Randomized Controlled Trial.

BackgroundSyringe service programs (SSPs) are safe, highly effective programs for promoting health among people who inject drugs. However, resource limitations prevent the delivery of a full package of prevention services to many clients in need. Computer-tailored interventions may represent a promising approach for providing prevention information to people who inject drugs in resource-constrained settings.ObjectiveThe aim of this paper is to assess the effect of a computer-tailored behavioral intervention, called Hep-Net, on safe injection practices, substance use reduction, overdose prevention, and hepatitis C virus (HCV) testing among SSP clients.MethodsUsing a social network–based recruitment strategy, we recruited clients of an established SSP in Wisconsin and peers from their social networks. Participants completed a computerized baseline survey and were then randomly assigned to receive the Hep-Net intervention. Components of the intervention included an overall risk synthesis, participants’ selection of a behavioral goal, and an individualized risk reduction exercise. Individuals were followed up 3 months later to assess their behavior change. The effect of Hep-Net on receiving an HCV screening test, undergoing Narcan training, reducing the frequency of drug use, and sharing drug equipment was assessed. The individual’s readiness to change each behavior was also examined.ResultsFrom 2014 to 2015, a total of 235 people who injected drugs enrolled into the Hep-Net study. Of these, 64.3% (151/235) completed the follow-up survey 3-6 months postenrollment. Compared with the control group, individuals who received the Hep-Net intervention were more likely to undergo HCV testing (odds ratio [OR] 2.23, 95% CI 1.05-4.74; P=.04) and receive Narcan training (OR 2.25, 95% CI 0.83-6.06; P=.11), and they shared drug equipment less frequently (OR 0.06, 95% CI 0.55-0.65; P<.001). Similarly, individuals who received the intervention were more likely to advance in their stage of readiness to change these 3 behaviors. However, intervention participants did not appear to reduce the frequency of drug use or increase their readiness to reduce drug use more than control participants, despite the fact that the majority of the intervention participants selected this as the primary goal to focus on after participation in the baseline survey.ConclusionsImplementing computer-based risk reduction interventions in SSPs may reduce harms associated with the sharing of injection equipment and prevent overdose deaths; however, brief computerized interventions may not be robust enough to overcome the challenges associated with reducing and ceasing drug use when implemented in settings centered on the delivery of prevention services.Trial RegistrationClinicalTrials.gov NCT02474043; https://clinicaltrials.gov/ct2/show/NCT02474043International Registered Report Identifier (IRRID)RR2-10.2196/resprot.4830

Drug overdose mortality is associated with employment status and occupation in the National Longitudinal Mortality Study

ABSTRACT Background Since 1999, over 702,000 people in the US have died of a drug overdose, and the drug overdose death rate has increased from 6.2 to 21.8 per 100,000. Employment status and occupation may be important social determinants of overdose deaths. Objectives Estimate the risk of drug overdose death by employment status and occupation, controlling for other social and demographic factors known to be associated with overdose deaths. Methods Proportional hazard models were used to study US adults in the National Longitudinal Mortality Study with baseline measurements taken in the early 2000s and up to 6 years of follow-up (n = 438,739, 53% female, 47% male). Comparisons were made between adults with different employment statuses (employed, unemployed, disabled, etc.) and occupations (sales, construction, service occupations, etc.). Models were adjusted for age, sex, race/ethnicity, education, income and marital status. Results Adults who were disabled (hazard ratio (HR) = 6.96 (95% CI = 6.81–7.12)), unemployed (HR = 4.20, 95% CI = 4.09–4.32) and retired (HR = 2.94, 95% CI = 2.87–3.00) were at higher risk of overdose death relative to those who were employed. By occupation, those working in service (HR = 2.05, 95% CI = 1.97–2.13); construction and extraction (HR = 1.69, 95% CI = 1.64–1.76); management, business and financial (HR = 1.39, 95% CI = 1.33–1.44); and installation, maintenance and repair (HR = 1.32, 95% CI = 1.25–1.40) occupations displayed higher risk relative to professional occupations. Conclusions In a large national cohort followed prospectively for up to 6 years, several employment statuses and occupations are associated with overdose deaths, independent of a range of other factors. Efforts to prevent overdose deaths may benefit from focusing on these high-risk groups.

A Low-Barrier and Comprehensive Community-Based Harm-Reduction Site in Vancouver, Canada.

"The Molson" is a low-barrier, peer-staffed, supervised consumption site located in Vancouver, Canada. In addition to overdose response, this site offers drug checking and a colocated injectable hydromorphone treatment program, and it distributes tablet and liquid hydromorphone to service users at high risk of overdose. Our evaluation suggests benefits of this program in creating service continuums and preventing overdose deaths. From September 2017 to August 2019, the site had 128 944 visits, reversed 770 overdoses, and had no overdose deaths.

Knowledge of Good Samaritan Laws and Beliefs About Arrests Among Persons Who Inject Drugs a Year After Policy Change in Baltimore, Maryland.

Delivering and receiving prompt medical care during an overdose are imperative to ensure survival. Good Samaritan laws encourage people to call 911 during an overdose by providing immunity from selected drug arrests (eg, low-level possession). However, it is unclear whether persons who inject drugs (PWID) are aware of and understand these laws and their implications. We examined awareness among PWID of the 2015 Good Samaritan law in Maryland and their beliefs about whether they could be arrested for calling 911 or having an overdose. We surveyed 298 PWID in Baltimore, Maryland. We estimated the proportion who knew what the Good Samaritan law addressed and who believed they could be arrested for calling 911 or overdosing. We used a multivariate model to assess the association between harm-reduction services and knowledge of the Good Samaritan law or beliefs about getting arrested for calling 911 or overdosing. Of PWID, 56 of 298 (18.8%) knew what the Good Samaritan law addressed, 43 of 267 (16.1%) believed they could be arrested for calling 911, and 32 of 272 (11.8%) believed they could be arrested for having an overdose. After adjusting for demographic characteristics, accessing the syringe services program was associated with accurate knowledge and the belief that PWID could be arrested for calling 911; however, training in overdose reversal was not associated. Most PWID were unaware of the Good Samaritan law; this lack of awareness is a barrier to preventing overdose deaths. Educating PWID about Good Samaritan laws is essential, and such education should include police to ensure that law enforcement is congruent with Good Samaritan laws and does not perpetuate mistrust between police and PWID.

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.

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.

2.6 IMPACT: IMPROVING AWARENESS AND KNOWLEDGE IN MEDICAL STUDENTS REGARDING OPIOID USE DISORDERS IN ADOLESCENTS

Despite the availability of effective treatment strategies for opioid use disorders (OUD), physicians in training are not prepared to deal with patients with substance use disorders. With the emerging opioid epidemic, there is a serious need to focus on prevention and effective management of OUD to prevent overdose deaths in adolescents and young adults. This project aims to develop a standardized, effective curriculum to improve the awareness, knowledge, and skills among third-year medical students of managing OUD in adolescents. CorrectionJournal of the American Academy of Child & Adolescent PsychiatryVol. 59Issue 2PreviewIn New Research Poster 2.6, “IMPACT: Improving Awareness and Knowledge in Medical Students Regarding Opioid Use Disorders in Adolescents,” published in the October 2019 Scientific Proceedings supplement issue of the Journal of the American Academy of Child and Adolescent Psychiatry, (2019;58:S172), Patricia Wright, PhD, MPH, RN, was omitted from the author list. The author list should have appeared as follows: Srinivasa Gokarakonda, MD, MPH, Nihit Kumar, MD, Michael Mancino, MD, Patricia Wright, PhD, MPH, RN, Alison Oliveto, PhD. Full-Text PDF

Optimization of Linkage between North Carolina EMS and ED Data: EMS Naloxone Cases

Optimization of Linkage between North Carolina EMS and ED Data: EMS Naloxone Cases

The implementation of overdose prevention sites as a novel and nimble response during an illegal drug overdose public health emergency

BackgroundDrug-related overdoses were declared a public health emergency in British Columbia, Canada in April, 2016 facilitating the scale-up of responses including rapid sanctioning and implementation of overdose prevention sites (OPSs). OPSs are a health service providing supervised injection and immediate overdose response. In BC, OPSs were operational within weeks of sanctioning. In the first year of operation over 20 OPSs were established with approximately 550,000 visits and no overdose deaths at any site. In this paper, we examine the implementation of OPSs as a novel and nimble response to prevent overdose deaths as a result of injection drug use. MethodsA multiple case study design was used with the Consolidated Framework for Implementation (CFIR) informing the analysis. Three sites in a single city were included with each site constituting a case. In this paper, we focus on qualitative interviews with 15 staff and their perceptions of the implementation of the OPSs as well as provincial and local documents. ResultsThe legislative process to implement OPSs was unprecedented as it sanctioned supervised injection services as an extraordinary measure under a declared public health emergency. Innovative and inclusionary practices were possible within state-sanctioned OPSs, as the sites were government-directed yet community-developed, with PWUD centred in service design, implementation and delivery. OPSs lack permanency and may be limited to the duration of the public health emergency. ConclusionThe rapid implementation of OPSs provides an international example of an alternative to lengthy and often onerous sanctioning processes for supervised consumption services (SCSs). Overdose prevention sites provide an example of a novel service design and nimble implementation process that combines the benefits of state-sanctioned injection services with community-driven implementation. Such evidence questions the continued acceptability of governments’ restrictive sanctioning processes, which have limited expansion of SCSs internationally and the implementation of services that are not necessarily aligned with the needs of PWUD.

Mobile supervised consumption services in Rural British Columbia: lessons learned

BackgroundIn 2016, a public health emergency was declared in British Columbia due to an unprecedented number of illicit drug overdose deaths. Injection drug use was implicated in approximately one third of overdose deaths. An innovative delivery model using mobile supervised consumption services (SCS) was piloted in a rural health authority in BC with the goals of preventing overdose deaths, reducing public drug use, and connecting clients to health services.MethodsTwo mobile SCS created from retrofitted recreational vehicles were used to serve the populations of two mid-sized cities: Kelowna and Kamloops. Service utilization was tracked, and surveys and interviews were completed to capture clients’, service providers’, and community stakeholders’ attitudes towards the mobile SCS.ResultsOver 90% of surveyed clients reported positive experiences in terms of access to services and physical safety of the mobile SCS. However, hours of operation met the needs of less than half of clients. Service providers were generally dissatisfied with the size of the space on the mobile SCS, noting constraints in the ability to respond to overdose events and meaningfully engage with clients in private conversations. Additional challenges included frequent operational interruptions as well as poor temperature control inside the mobile units. Winter weather conditions resulted in cancelled shifts and disrupted services. Among community members, there was variable support of the mobile SCS.ConclusionsOverall, the mobile SCS were a viable alternative to a permanent site but presented many challenges that undermined the continuity and quality of the service. A mobile site may be best suited to temporarily provide services while bridging towards a permanent location. A needs assessment should guide the stop locations, hours of operation, and scope of services provided. Finally, the importance of community engagement for successful implementation should not be overlooked.

Elements of a Comprehensive Public Health Response to the Opioid Crisis.

The Centers for Disease Control and Prevention's report of overdose deaths from prescription and illicit opioids underscores the need for urgent action to prevent overdose deaths, promote evidence-...

Opportunities to Prevent Overdose Deaths Involving Prescription and Illicit Opioids, 11 States, July 2016-June 2017.

In 2016, 63,632 drug overdose deaths occurred in the United States, 42,249 (66.4%) of which involved opioids (1). The development of prevention programs are hampered by a lack of timely data on specific substances contributing to and circumstances associated with fatal overdoses. This report describes opioid overdose deaths (referred to as opioid deaths) for decedents testing positive for prescription opioids (e.g., oxycodone and hydrocodone), illicit opioids (e.g., heroin, illicitly manufactured fentanyl, and fentanyl analogs), or both prescription and illicit opioids, and describes circumstances surrounding the overdoses, in 11 states participating in CDC’s Enhanced State Opioid Overdose Surveillance (ESOOS) program.* During July 2016–June 2017, among 11,884 opioid overdose deaths, 17.4% of decedents tested positive for prescription opioids only, 58.7% for illicit opioids only, and 18.5% for both prescription and illicit opioids (type of opioid could not be classified in 649 [5.5%] deaths). Approximately one in 10 decedents had been released from an institutional setting in the month preceding the fatal overdose. Bystanders were reportedly present in approximately 40% of deaths; however, naloxone was rarely administered by a layperson. Enhanced surveillance data from 11 states provided more complete information on the substances involved in and circumstances surrounding opioid overdose deaths. Consistent with other emerging evidence and recommendations,† these data suggest prevention efforts should prioritize naloxone distribution to persons misusing opioids or using high dosage prescription opioids and to their family members and friends. In addition, these data suggest a need to expand treatment and support for persons who have experienced a nonfatal overdose and to expand treatment in detention facilities and upon release.

Effects of naloxone distribution to likely bystanders: Results of an agent-based model

BackgroundOpioid overdose deaths in the US rose dramatically in the past 16 years, creating an urgent national health crisis with no signs of immediate relief. In 2017, the President of the US officially declared the opioid epidemic to be a national emergency and called for additional resources to respond to the crisis. Distributing naloxone to community laypersons and people at high risk for opioid overdose can prevent overdose death, but optimal distribution methods have not yet been pinpointed. MethodsWe conducted a sequential exploratory mixed methods design using qualitative data to inform an agent-based model to improve understanding of effective community-based naloxone distribution to laypersons to reverse opioid overdose. The individuals in the model were endowed with cognitive and behavioral variables and accessed naloxone via community sites such as pharmacies, hospitals, and urgent-care centers. We compared overdose deaths over a simulated 6-month period while varying the number of distribution sites (0, 1, and 10) and number of kits given to individuals per visit (1 versus 10). Specifically, we ran thirty simulations for each of thirteen distribution models and report average overdose deaths for each. The baseline comparator was no naloxone distribution. Our simulations explored the effects of distribution through syringe exchange sites with and without secondary distribution, which refers to distribution of naloxone kits by laypersons within their social networks and enables ten additional laypersons to administer naloxone to reverse opioid overdose. ResultsOur baseline model with no naloxone distribution predicted there would be 167.9 deaths in a six month period. A single distribution site, even with 10 kits picked up per visit, decreased overdose deaths by only 8.3% relative to baseline. However, adding secondary distribution through social networks to a single site resulted in 42.5% fewer overdose deaths relative to baseline. That is slightly higher than the 39.9% decrease associated with a tenfold increase in the number of sites, all distributing ten kits but with no secondary distribution. This suggests that, as long as multiple kits are picked up per visit, adding secondary distribution is at least as effective as increasing sites from one to ten. Combining the addition of secondary distribution with an increase in sites from one to ten resulted in a 61.1% drop in deaths relative to the baseline. Adding distribution through a syringe exchange site resulted in a drop of approximately 65% of deaths relative to baseline. In fact, when enabling distribution through a clean-syringe site, the secondary distribution through networks contributed no additional drops in deaths. ConclusionCommunity-based naloxone distribution to reverse opioid overdose may significantly reduce deaths. Optimal distribution methods may include secondary distribution so that the person who picks up naloxone kits can enable others in the community to administer naloxone, as well as targeting naloxone distribution to sites where individuals at high-risk for opioid overdose death are likely to visit, such as syringe-exchange programs. This study design, which paired exploratory qualitative data with agent-based modeling, can be used in other settings seeking to implement and improve naloxone distribution programs.

Prediction Model for Two-Year Risk of Opioid Overdose Among Patients Prescribed Chronic Opioid Therapy.

Naloxone is a life-saving opioid antagonist. Chronic pain guidelines recommend that physicians co-prescribe naloxone to patients at high risk for opioid overdose. However, clinical tools to efficiently identify patients who could benefit from naloxone are lacking. To develop and validate an overdose predictive model which could be used in primary care settings to assess the need for naloxone. Retrospective cohort. Derivation site was an integrated health system in Colorado; validation site was a safety-net health system in Colorado. We developed a predictive model in a cohort of 42,828 patients taking chronic opioid therapy and externally validated the model in 10,708 patients. Potential predictors and outcomes (nonfatal pharmaceutical and heroin overdoses) were extracted from electronic health records. Fatal overdose outcomes were identified from state vital records. To match the approximate shelf-life of naloxone, we used Cox proportional hazards regression to model the 2-year risk of overdose. Calibration and discrimination were assessed. A five-variable predictive model showed good calibration and discrimination (bootstrap-corrected c-statistic = 0.73, 95% confidence interval [CI] 0.69-0.78) in the derivation site, with sensitivity of 66.1% and specificity of 66.6%. In the validation site, the model showed good discrimination (c-statistic = 0.75, 95% CI 0.70-0.80) and less than ideal calibration, with sensitivity and specificity of 82.2% and 49.5%, respectively. Among patients on chronic opioid therapy, the predictive model identified 66-82% of all subsequent opioid overdoses. This model is an efficient screening tool to identify patients who could benefit from naloxone to prevent overdose deaths. Population differences across the two sites limited calibration in the validation site.

Test of a workforce development intervention to expand opioid use disorder treatment pharmacotherapy prescribers: protocol for a cluster randomized trial

BackgroundOverdoses due to non-medical use of prescription opioids and other opiates have become the leading cause of accidental deaths in the USA. Buprenorphine and extended-release naltrexone are key evidence-based pharmacotherapies available to addiction treatment providers to address opioid use disorder (OUD) and prevent overdose deaths. Treatment organizations’ efforts to provide these pharmacotherapies have, however, been stymied by limited success in recruiting providers (physicians, nurse practitioners, and physician assistants) to prescribe these medications. Historically, the addiction treatment field has not attracted physicians, and many barriers to implementing OUD pharmacotherapy exist, ranging from lack of confidence in treating OUD patients to concerns regarding reimbursement. Throughout the USA, the prevalence of OUD far exceeds the capacity of the OUD pharmacotherapy treatment system. Poor access to OUD pharmacotherapy prescribers has become a workforce development need for the addiction treatment field and a significant health issue.MethodsThis cluster randomized controlled trial (RCT) is designed to increase buprenorphine and extended-release naltrexone treatment capacity for OUD. The implementation intervention to be tested is a bundle of OUD pharmacotherapy capacity building practices called the Prescriber Recruitment Bundle (PRB), which was developed and piloted in a previous statewide buprenorphine implementation study. For this cluster RCT, organizational sites will be recruited and then randomized into one of two arms: (1) control, with treatment as usual and access to a website with PRB resources, or (2) intervention, with organizations implementing the PRB using the Network for the Improvement of Addiction Treatment organizational change model over a 24-month intervention period and a 10-month sustainability period. The primary treatment outcomes for each organizational site are self-reported monthly counts of buprenorphine slots, extended-release naltrexone capacity, number of buprenorphine patients, and number of extended-release naltrexone patients.This trial will be conducted in Florida, Ohio, and Wisconsin, resulting in 35 sites in each arm, for a total sample size of 70 organizations.DiscussionThis study addresses three issues of substantial public health significance: (1) the pressing opioid misuse epidemic, (2) the low uptake of OUD treatment pharmacotherapies, and (3) the need to increase prescriber participation in the addiction treatment workforce.Trial registrationClinicalTrials.gov NCT02926482,

Characteristics of adherence to methadone maintenance treatment over a 15-year period among homeless adults experiencing mental illness

BackgroundMethadone maintenance treatment (MMT) has important protective effects related to reduced illicit opioid use, infectious disease transmission, and overdose mortality. Adherence to MMT has not been examined among homeless people. We measured MMT adherence and reported relevant characteristics among homeless adults experiencing mental illness in Vancouver, British Columbia, Canada. Material and methodsHomeless adults living with mental illness who had received MMT prior to the baseline interview of the Vancouver At Home study (n=78) were included in analyses. The medication possession ratio (MPR) was used to estimate MMT adherence from retrospective administrative pharmacy and public health insurance data collected across 15years. Independent sample t tests and one-way ANOVA were used to test for significant differences in MMT MPR by participant characteristics. ResultsMean MMT MPR was 0.47. A large proportion of participants reported blood-borne infectious disease, three or more chronic physical health conditions, and substance use. Being single and never married was associated with significantly lower MMT MPR (0.40 vs. 0.55, p=0.036), while living with schizophrenia, bipolar disorder, or a mood disorder with psychotic features was associated with significantly higher MMT MPR (0.54 vs. 0.37, p=0.022). Daily drug use (excluding alcohol) was associated with significantly lower MMT MPR (0.39 vs. 0.54, p=0.051). ConclusionsThe level of adherence to MMT was very low among homeless adults experiencing mental illness. Efforts are needed to improve adherence to MMT as a means of reducing illicit substance use, preventing overdose deaths, and attenuating infectious disease transmission.