Provision Of Naloxone Research Articles

A 3-year retrospective review of hospital admissions involving opioid toxicity in South Australia.

This article aims to characterise hospital admissions involving opioid toxicity across South Australia to guide future implementation and evaluation of risk mitigation strategies. International Classification of Diseases, 10th Edition codes (T40.0-T40.4) were used to identify admissions involving pre-hospital opioid toxicity in public hospitals across South Australia from 1 June 2017 to 30 August 2020. Demographic and episode of care data were extracted and summarised using descriptive statistics. Admission cost estimates were calculated using Independent Hospital Pricing Authority data. A total of 2046 cases met the criteria for inclusion; over half (56%) were female and median age on admission was 44 years (interquartile range 27 years). Where opioid toxicity was the primary diagnosis, 70% of admissions did not specify the responsible opioid and 23% were related to heroin use. One-fifth of admissions occurred outside of metropolitan Adelaide. Individuals living in an area of relative socio-economic disadvantage were over-represented. Over half of admissions required a stay >24 h; 19% were admitted for ≥5 days, 22% required intensive care and ~10% required mechanical ventilation. The total estimated cost of admissions involving opioid toxicity in South Australia over the 3-year period was $18,230,546.50, equating to $5.6 million per annum. These findings highlight the significant personal, fiscal, and systemic impacts of opioid toxicity-related hospital admissions in South Australia and provide a baseline to evaluate the effectiveness of initiatives to reduce opioid-related harm, including real-time prescription monitoring and take-home naloxone supply.

Correlates of stocking naloxone: a cross-sectional survey of community pharmacists.

Provision of take-home naloxone (THN) and overdose education reduces opioid-related mortality. In Australia, from July 2022, all Australian community pharmacies were eligible to supply naloxone for free through the nationalTHN Program. This study aimed to identify naloxone stocking rates and correlates of stocking naloxone across Australian pharmacies. Data were collected from a representative sample of Australian pharmacists in Victoria, New South Wales, Queensland and Western Australia via an online survey. Data collected included pharmacy and pharmacist characteristics and services offered within the pharmacy, including needle and syringe programs, opioid agonist treatment (OAT) and stocking naloxone. Binary probit regression analysis was used to identify correlates of stocking naloxone after controlling for key covariates. Data from 530 pharmacists were analysed. In total, 321 pharmacies (60.6%) reported stocking naloxone. Chain pharmacies and pharmacies that provided OAT had a greater probability of stocking naloxone (B = 0.307, 95%CI: [0.057, 0.556], and B = 0.543, 95%CI: [0.308, 0.777] respectively). Most (61.7%) pharmacists felt comfortable discussing overdose prevention with patients who use prescription opioids, and this comfort was associated with a higher probability of stocking naloxone (B = 0.392, 95%CI: 0.128, 0.655). Comfort discussing overdose prevention with people who use illicit opioids was lower (49.4%) and was not associated with stocking naloxone. There is scope to increase stocking of naloxone and comfort with overdose prevention, particularly through addressing comfort working with higher risk groups such as people who use illicit opioids.

Community pharmacists’ attitudes toward and practice of pharmacy-based harm reduction services in Pittsburgh, PA: a descriptive survey

BackgroundIn Pittsburgh, PA, legal changes in recent decades have set the stage for an expanded role for community pharmacists to provide harm reduction services, including distributing naloxone and non-prescription syringes (NPS). In the wake of the syndemics of the COVID-19 pandemic and worsening overdose deaths from synthetic opioids, we examine knowledge, attitudes, and practices of harm reduction services among community pharmacists in Pittsburgh and identify potential barriers of expanded pharmacy-based harm reduction services.MethodsWe provided flyers to 83 community pharmacies within a 5-mile radius of the University of Pittsburgh Medical Center to recruit practicing community pharmacists to participate in an anonymous electronic survey. We used a 53-question Qualtrics survey consisting of multiple-choice, 5 or 6 point-Likert scale, and open-ended questions adapted from 5 existing survey instruments. Survey measures included demographics, knowledge, attitudes, and practices of harm reduction services (specifically naloxone and NPS provision), and explored self-reported barriers to future implementation. Data was collected July–August 2022. We conducted descriptive analysis using frequencies and proportions reported for categorical variables as well as means and standard deviations (SD) for continuous variables. We analyzed open-ended responses using inductive content analysis.ResultsEighty-eight community pharmacists responded to the survey. 90% of participants agreed pharmacists had a role in overdose prevention efforts, and 92% of participants had previously distributed naloxone. Although no pharmacists reported ever refusing to distribute naloxone, only 29% always provided overdose prevention counseling with each naloxone distributed. In contrast, while 87% of participants had positive attitudes toward the usefulness of NPS for reducing disease, only 73% of participants ever distributed NPS, and 54% had refused NPS to a customer. Participants endorsed a lack of time and concerns over clientele who used drugs as the most significant barriers to offering more comprehensive harm reduction services.ConclusionsOur findings highlight that while most community pharmacists have embraced naloxone provision, pharmacy policies and individual pharmacists continue to limit accessibility of NPS. Future expansion efforts for pharmacy-based harm reduction services should not only address the time and labor constraints identified by community pharmacists, but also fear-based policy and stigma toward people who inject drugs and harm reduction more broadly.

A theoretical explanation of naloxone provision among primary care physicians and community pharmacists in Tennessee

BackgroundIncreasing access to naloxone reduces opioid-related morbidity and mortality. Primary care and community pharmacy settings are critical access points, yet limited theoretical research has examined naloxone prescribing and dispensing behaviors. ObjectivesTo determine if the theory of planned behavior (TPB) combined with theoretical constructs from communication science explains intentions to co-prescribe and discuss co-dispensing naloxone among primary care physicians and community pharmacists, respectively. MethodsThis cross-sectional study surveyed cohorts of licensed primary care physicians and community pharmacists in Tennessee in 2017. Intentions were measured using profession-specific case vignettes, whereby they were asked given 10 similar patients, how many times (0–10) would they co-prescribe or discuss co-dispensing naloxone. Bivariate and multivariable analyses were used. ResultsThe analytic sample included 295 physicians (response rate = 15.6 %) and 423 pharmacists (response rate = 19.4 %). Approximately 65 % of physicians reported never intending to co-prescribe naloxone (0 out of 10 patients), while 47 % of pharmacists reported never intending to discuss co-dispensing. All TPB constructs—attitudes (AOR = 1.32, CI = 1.16–1.50), subjective norms (AOR = 1.17, CI = 1.06–1.30), and perceived behavioral control (AOR 1.16, CI = 1.02–1.33)—were associated with an increased likelihood of pharmacists always (versus never) discussing co-dispensing. Similarly, two TPB constructs—attitudes (AOR = 1.41, CI = 1.19–1.68) and subjective norms (AOR = 1.22, CI = 1.08–1.39)—were associated with an increased likelihood of physicians always co-prescribing. Among physicians only, one communication construct—self-perceived communication competence (AOR = 1.19, CI = 1.01–1.41)—was associated with an increased likelihood of always co-prescribing. ConclusionFindings support the value of theory, particularly TPB, in explaining primary care physician intentions to co-prescribe and community pharmacist intentions to discuss co-dispensing naloxone.

Implementation and Evaluation of a Bystander Naloxone Training Course.

Bystander provision of naloxone is a key modality to reduce opioid overdose-related death. Naloxone training courses are available, but no standardized program exists. As part of a bystander empowerment course, we created and evaluated a brief naloxone training module. This was a retrospective evaluation of a naloxone training course, which was paired with Stop the Bleed training for hemorrhage control and was offered to administrative staff in an office building. Participants worked in an organization related to healthcare, but none were clinicians. The curriculum included the following topics: 1)background about the opioid epidemic; 2)how to recognize the signs of an opioid overdose; 3)actions not to take when encountering an overdose victim; 4)the correct steps to take when encountering an overdose victim; 5)an overview of naloxone products; and 6)Good Samaritan protection laws. The 20-minute didactic section was followed by a hands-on session with nasal naloxone kits and a simulation mannequin. The course was evaluated with the Opioid Overdose Knowledge (OOKS) and Opioid Overdose Attitudes (OOAS) scales for take-home naloxone training evaluation. We used the paired Wilcoxon signed-rank test to compare scores pre- and post-course. Twenty-eight participants completed the course. The OOKS, measuring objective knowledge about opioid overdose and naloxone, had improved scores from a median of 73.2% (interquartile range [IQR] 68.3%-79.9%) to 91.5% (IQR 85.4%-95.1%), P < 0.001. The three domains on the OOAS score also showed statistically significant results. Competency to manage an overdose improved on a five-point scale from a median of 2.5 (IQR 2.4-2.9) to a median of 3.7 (IQR 3.5-4.1), P < 0.001. Concerns about managing an overdose decreased (improved) from a median of 2.3 (IQR 1.9-2.6) to median 1.8 (IQR 1.5-2.1), P < 0.001. Readiness to intervene in an opioid overdose improved from a median of 4 (IQR 3.8-4.2) to a median of 4.2 (IQR 4-4.2), P < 0.001. A brief course designed to teach bystanders about opioid overdose and naloxone was feasible and effective. We encourage hospitals and other organizations to use and promulgate this model. Furthermore, we suggest the convening of a national consortium to achieve consensus on program content and delivery.

Psychiatrists can save lives with naloxone.

Naloxone is an effective medication used to reverse opioid overdoses. Distributing naloxone directly to those at risk, therefore, reduces the risk of opioid-related deaths. New legislation in Australia means a prescription is no longer required to access naloxone. Whilst acknowledging the benefits of increased access, we aim to evaluate the impact psychiatrists can have on naloxone provision due to their unique position as doctors often working with those who may be at risk. Data was recorded on those accessing naloxone from a co-located addiction and mental health service. Descriptive statistics were generated to establish the cohort characteristics, prior knowledge of naloxone and outcome of previously supplied naloxone. Naloxone was dispensed 488 times from 2021 to 2023. 267 people had previously been prescribed naloxone from these sites where 137 (51.3%) were reportedly used in an opioid reversal. Our findings highlight the importance of community access to naloxone in reducing opioid-related harm. Whilst removing the need for a prescription makes naloxone more accessible, it remains vital that doctors remain involved in this process to broaden the reach of supply to those at risk.

Barriers and motivational factors for engaging in novel opioid and medication disposal-related services in community pharmacies

ObjectiveThis study aimed to explore and identify motivational factors and barriers for pharmacy personnel participation in specific opioid mitigation programs, using the Theory of Planned Behavior (TPB) as an investigational framework. MethodsA naturalistic inquiry method was employed involving semi-structured interviews with pharmacy personnel to assess their intentions, attitudes, normative beliefs, and behaviors towards participating in naloxone dispensing and provision of at-home drug disposal solutions. Purposive sampling was utilized to recruit participants, with saturation achieved after 12 interviews. Interviews were transcribed and coded to identify recurring themes. ResultsFour primary themes emerged: 1) the value and benefits of helping others, emphasizing societal, patient, and environmental benefits; 2) limits and barriers to participation, including financial concerns, management support, and time constraints; 3) pharmacists’ intrinsic motivators, highlighting personal motivations and differentiation between programs for specific patient types; and 4) program implementation challenges and strategies. ConclusionThe findings underscore the applicability of the TPB in understanding pharmacy engagement in opioid abatement programs. Despite facing barriers such as financial considerations and time constraints, the overall positive attitudes towards the programs indicate a strong motivation to contribute to public health efforts. Addressing identified barriers and leveraging motivators could enhance participation, potentially mitigating the opioid crisis. Future research should incorporate patient perspectives to fully understand the impact and effectiveness of pharmacy-led interventions, such as naloxone dispensing and disposal solutions, in opioid misuse prevention.

Nurses Supporting Harm Reduction: How Take-Home Naloxone is Conceived in the Context of Neoliberalism

Introduction – Individuals must be personally invested in their own recovery journey; however, the neoliberal perspective absolves the state of responsibility of this work and makes promotion of health merely an individual action. Naloxone distribution, as a harm reduction strategy, is presented herein as one practice engaged by nurses that demonstrates philosophical tension between neoliberalism and harm reduction.&#x0D; Background Literature – The research literature supporting the provision of take-home naloxone (THN), non-medically administered, is significant and broad.&#x0D; Discussion – The problem with neoliberal discourses of constrained healthcare resources in this case is that without broad availability of naloxone, drug poisonings will continue unchecked. There is an ethical call to nurses to support broad distribution of naloxone regardless of the costs involved.&#x0D; Conclusion – THN is not only a best practice to reduce the harms of substance use, but it is also a political and philosophical act to hand over the control of public health resources to the public.

Recent Incarceration, Substance Use, Overdose, and Service Use Among People Who Use Drugs in Rural Communities

Drug use and incarceration have a substantial impact on rural communities, but factors associated with the incarceration of rural people who use drugs (PWUD) have not been thoroughly investigated. To characterize associations between recent incarceration, overdose, and substance use disorder (SUD) treatment access among rural PWUD. For this cross-sectional study, the Rural Opioid Initiative research consortium conducted a survey in geographically diverse rural counties with high rates of overdose across 10 US states (Illinois, Wisconsin, North Carolina, Oregon, Kentucky, West Virginia, Ohio, Massachusetts, New Hampshire, and Vermont) between January 25, 2018, and March 17, 2020, asking PWUD about their substance use, substance use treatment, and interactions with the criminal legal system. Participants were recruited through respondent-driven sampling in 8 rural US regions. Respondents who were willing to recruit additional respondents from their personal networks were enrolled at syringe service programs, community support organizations, and through direct community outreach; these so-called seed respondents then recruited others. Of 3044 respondents, 2935 included participants who resided in rural communities and reported past-30-day injection of any drug or use of opioids nonmedically via any route. Data were analyzed from February 8, 2022, to September 15, 2023. Recent incarceration was the exposure of interest, defined as a report of incarceration in jail or prison for at least 1 day in the past 6 months. The associations between PWUD who were recently incarcerated and main outcomes of treatment use and overdose were examined using logistic regression. Of 2935 participants, 1662 (56.6%) were male, 2496 (85.0%) were White; the mean (SD) age was 36 (10) years; and in the past 30 days, 2507 (85.4%) reported opioid use and 1663 (56.7%) reported injecting drugs daily. A total of 1224 participants (41.7%) reported recent incarceration, with a median (IQR) incarceration of 15 (3-60) days in the past 6 months. Recent incarceration was associated with past-6-month overdose (adjusted odds ratio [AOR], 1.38; 95% CI, 1.12-1.70) and recent SUD treatment (AOR, 1.62; 95% CI, 1.36-1.93) but not recent medication for opioid use disorder (MOUD; AOR, 1.03; 95% CI, 0.82-1.28) or currently carrying naloxone (AOR, 1.02; 95% CI, 0.86-1.21). In this cross-sectional study of PWUD in rural areas, participants commonly experienced recent incarceration, which was not associated with MOUD, an effective and lifesaving treatment. The criminal legal system should implement effective SUD treatment in rural areas, including MOUD and provision of naloxone, to fully align with evidence-based SUD health care policies.

Pharmacy staff-reported adaptations to naloxone provision and over-the-counter (OTC) syringe sales during the COVID-19 pandemic: Experiences across multiple states and 2 pharmacy chains

BackgroundAccess to harm reduction materials was greatly disrupted during coronavirus disease 2019 (COVID-19). Community pharmacies often continued provision of harm reduction materials as part of their usual operations during the pandemic, but little is known about what, if any, adaptations were made and the perceived impact of these actions from the perspective of pharmacy staff. ObjectivesWe explored how pharmacy staff across 4 states in 2 major pharmacy chains adapted to the COVID-19 pandemic for ongoing naloxone and over-the-counter (OTC) syringe access and how staff perceived the pandemic affected drug use in the community they served and their pharmacy’s volume of syringe sales and naloxone provision. MethodsWe analyzed 134 pharmacy staff responses to a 12-month follow-up assessment for an educational intervention conducted in 2 pharmacy chains in Oregon, Washington, Massachusetts, and New Hampshire. Respondents answered closed- and open-ended questions collected online from July 2020 to February 2022. Questions measured prevalence of adaptations and perceived uptake of naloxone and OTC syringe services. Descriptive statistics summarized adaptations and perceived impact and chi-square tests explored differences by state and pharmacy chain. Open-ended responses were reviewed and analyzed to identify summary points and themes. ResultsWith few differences by state or pharmacy chain detected, pharmacy staff reported more naloxone mailing, requests by phone, streamlined counseling, and drive-thru provision adaptations to OTC syringe sales and naloxone provision during the pandemic. Most staff perceived adaptations as increasing or maintaining naloxone provision and OTC syringe sales. Respondents described specific aspects of the pharmacy that contributed to successful adaptations, including tailoring to specific product demand, inventory levels, drive-thru access, and a perception of extraordinary public health need at a time of and in places affected by the opioid crisis. ConclusionsPharmacy OTC syringe and naloxone access continued during the COVID-19 pandemic through streamlining workflows and innovating no-contact harm reduction services, reinforcing pharmacy’s public health role.

Moving Naloxone Over the Counter Is Necessary but Not Sufficient.

Naloxone is an opioid antagonist that is available in numerous formulations and can be easily administered to avert death from opioid overdose. Amid a historic overdose crisis in the United States, naloxone has a crucial role in stemming the loss of life. However, it remains largely inaccessible to the public. Recently, the U.S. Food and Drug Administration announced the approval of the first over-the-counter formulation of naloxone. Although this historic change provides an important opportunity to increase distribution of naloxone, we must take careful steps during this transition so that it does not paradoxically threaten overall access to this life-saving medication. Specifically, we must ensure that a larger supply of naloxone will meet the newly increased demand at a sustainable price for consumers who are most in need. We must also continue to prioritize comprehensive methods of distribution, such as overdose education and naloxone distribution programs, that serve as important tools to reach the most vulnerable populations. In addition, simultaneous investment in harm-reduction strategies, such as supervised consumption spaces, is critical to ensure that naloxone is available in settings where its life-saving potential can be most fully realized.

Impact of a Didactic-Experiential Naloxone Learning Model to Improve Student Pharmacist Skills and Patient Care

ObjectiveTo assess the impact of an integrated didactic-experiential learning model on student pharmacists’ knowledge, confidence, comfort, and intention regarding provision of naloxone for patients receiving opioid therapy. MethodsAn integrated didactic-experiential learning model was developed to bridge learning in the classroom and laboratory with application in the experiential setting. Student knowledge, confidence, comfort, and intentions regarding provision of naloxone services were measured via online survey at predidactic, postdidactic, and postexperiential time points, and analyzed using Friedman’s analysis of variance. ResultsA total of 280 first-year student pharmacists completed the baseline survey. The learning model increased student knowledge, confidence, comfort, and intention regarding naloxone services implementation. Specifically, students reported an increase in mean (SD) knowledge score from 60.85% (17.40%) in the predidactic to 81.47% (13.57%) in the postdidactic period. Similarly, mean (SD) confidence (2.49 [0.75] to 3.56 [0.45]), comfort (2.06 [0.74] to 3.57 [0.45]), and intention (3.46 [0.70] to 3.66 [0.44]) increased from pre- to postdidactic period, and these changes were maintained from postdidactic to postexperiential period. ConclusionThe didactic-experiential learning model increased student knowledge, confidence, comfort, and intentions regarding naloxone services implementation. We believe that the model fills gaps in student pharmacist education and is the first step in enhancing and sustaining community pharmacy–based naloxone services. Although this study was limited to a single college, it shows the effectiveness of linking didactic and experiential training in improving students’ knowledge and skills.

Evaluation of a Primary Care-Based Multidisciplinary Transition Clinic for Patients Newly Initiated on Buprenorphine in the Emergency Department.

Care transitions represent vulnerable events for patients newly initiating medications for opioid use disorder (MOUD). Multidisciplinary primary care-based transition clinics may improve care linkage and retention in MOUD treatment. Additionally, these interventions may help primary care clinicians (PCPs) overcome barriers to adopting MOUD into practice. In this evaluation, we assessed the impact of a primary care-based transition clinic for patients newly initiating buprenorphine for opioid use disorder (OUD) in the emergency department. We conducted a retrospective program evaluation within a single academic health system involving adults who newly initiated buprenorphine for OUD through an emergency department-based program and were referred to follow up in either a dedicated multidisciplinary primary care-based transition clinic (SPARC) vs referral to usual primary care (UPC). We performed descriptive analyses comparing patient demographics, referral volume, linkage to care, treatment retention, and markers of high-quality care between the 2 groups. A log-rank test was used to determine the difference in probabilities of retention between SPARC and UPC over 6 months. Over 12 months, the number of referrals to SPARC was greater than to UPC (N = 64 vs N = 26). About 58% of patients referred to SPARC attended an initial visit vs 38% referred to UPC. Treatment retention was consistently greater in SPARC than UPC (1 m: 90% vs 60%; 3 m: 76% vs 40%; 6 m: 60% vs 30%). Markers of care quality including naloxone provision (100% vs 80%) and infectious screening (81% vs 40%) were greater in SPARC clinic. SPARC was associated with a statistically significant increased probability of retention in treatment as compared to UPC (P < .01). In this observational evaluation, a primary care-based multidisciplinary transition clinic for patients initiating buprenorphine MOUD was associated with expanded access to longitudinal OUD treatment and superior linkage to care, retention in care, and quality of care compared to referral to usual primary care. Further research using a more rigorous research design is required to further evaluate these findings.

Estimated Reductions in Opioid Overdose Deaths With Sustainment of Public Health Interventions in 4 US States

In 2021, more than 80 000 US residents died from an opioid overdose. Public health intervention initiatives, such as the Helping to End Addiction Long-term (HEALing) Communities Study (HCS), are being launched with the goal of reducing opioid-related overdose deaths (OODs). To estimate the change in the projected number of OODs under different scenarios of the duration of sustainment of interventions, compared with the status quo. This decision analytical model simulated the opioid epidemic in the 4 states participating in the HCS (ie, Kentucky, Massachusetts, New York, and Ohio) from 2020 to 2026. Participants were a simulated population transitioning from opioid misuse to opioid use disorder (OUD), overdose, treatment, and relapse. The model was calibrated using 2015 to 2020 data from the National Survey on Drug Use and Health, the US Centers for Disease Control and Prevention, and other sources for each state. The model accounts for reduced initiation of medications for OUD (MOUDs) and increased OODs during the COVID-19 pandemic. Increasing MOUD initiation by 2- or 5-fold, improving MOUD retention to the rates achieved in clinical trial settings, increasing naloxone distribution efforts, and furthering safe opioid prescribing. An initial 2-year duration of interventions was simulated, with potential sustainment for up to 3 additional years. Projected reduction in number of OODs under different combinations and durations of sustainment of interventions. Compared with the status quo, the estimated annual reduction in OODs at the end of the second year of interventions was 13% to 17% in Kentucky, 17% to 27% in Massachusetts, 15% to 22% in New York, and 15% to 22% in Ohio. Sustaining all interventions for an additional 3 years was estimated to reduce the annual number of OODs at the end of the fifth year by 18% to 27% in Kentucky, 28% to 46% in Massachusetts, 22% to 34% in New York, and 25% to 41% in Ohio. The longer the interventions were sustained, the better the outcomes; however, these positive gains would be washed out if interventions were not sustained. In this decision analytical model study of the opioid epidemic in 4 US states, sustained implementation of interventions, including increased delivery of MOUDs and naloxone supply, was found to be needed to reduce OODs and prevent deaths from increasing again.

Use of nonstigmatizing language is associated with improved outcomes in hospitalized people who inject drugs.

Stigma surrounding opioid use disorder (OUD) is a barrier to treatment. The use of stigmatizing language may be evidence of negative views toward patients. We aimed to identify associations between language and clinical outcomes in patients admitted for infectious complications of OUD. We performed a retrospective medical record review. Four U.S. academic health systems. Participantswere patients with OUD admitted for infectious complications of injection opioid use from January 1, 2018, to December 31, 2018, identified through international classification of diseases, 10th revisioncodes consistent with OUD and acute bacterial/fungal infection. Discharge summaries were reviewed for language, specifically: abuse, addiction, dependence, misuse, use disorder, intravenous drug use, and others. Binary outcomes including medication for OUD, planned discharge, naloxone provision, and an OUD treatment plan were evaluated using logistic regressions and admission duration was evaluated using Gamma regression. A total of 1285 records were reviewed and 328 met inclusion criteria. Of those, 191 (58%) were male, with a median age of 38 years. The most common term was "abuse" (219, 67%), whereas "use disorder" was recorded in 75 (23%) records. Having "use disorder" in the discharge summary was associated with increased odds of having a documented plan for ongoing OUD treatment (adjusted odds ratio[AOR]: 4.11, 95% confidence interval [CI]: 1.89-8.93) and having a documented plan for addiction-specific follow-up care (AOR: 2.31, 95% CI: 1.30-4.09). Stigmatizing language was common in this study of patients hospitalized for infectious complications of OUD. Best-practice language was uncommon, but when used was associated with increased odds of addiction treatment and specialty care referrals.

Considerations for the design of overdose education and naloxone distribution interventions: results of a multi-stakeholder workshop

IntroductionOpioid overdose epidemic is a public health crisis that is impacting communities around the world. Overdose education and naloxone distribution programs equip and train lay people to respond in the event of an overdose. We aimed to understand factors to consider for the design of naloxone distribution programs in point-of-care settings from the point of view of community stakeholders.MethodsWe hosted a multi-stakeholder co-design workshop to elicit suggestions for a naloxone distribution program. We recruited people with lived experience of opioid overdose, community representatives, and other stakeholders from family practice, emergency medicine, addictions medicine, and public health to participate in a full-day facilitated co-design discussion wherein large and small group discussions were audio-recorded, transcribed and analysed using thematic approaches.ResultsA total of twenty-four participants participated in the multi-stakeholder workshop from five stakeholder groups including geographic and setting diversity. Collaborative dialogue and shared storytelling revealed seven considerations for the design of naloxone distribution programs specific to training needs and the provision of naloxone, these are: recognizing overdose, how much naloxone, impact of stigma, legal risk of responding, position as conventional first aid, friends and family as responders, support to call 911.ConclusionTo create an naloxone distribution program in emergency departments, family practice and substance use treatment services, stigma is a central design consideration for training and naloxone kits. Design choices that reference the iconography, type, and form of materials associated with first aid have the potential to satisfy the need to de-stigmatize overdose response.

The Opioid Crisis

The opioid crisis has become one of the most pressing public health issues in recent times, with devastating consequences for individuals, families, and communities. As per the Center for Disease Control and Prevention (CDC), nearly 500,000 people in the United States have died from opioid overdose between 1999 and 2019 [1]. The current opioid epidemic is a multifaceted problem that demands comprehensive and integrated strategies to address it effectively.&#x0D; One of the key approaches to address the opioid crisis is harm reduction, which involves reducing the negative consequences of drug use for individuals, families, and communities. Harm reduction strategies include the provision of naloxone to reverse overdoses, access to clean syringes, and testing for infectious diseases such as HIV and hepatitis C. However, harm reduction approaches are often criticized for being permissive and promoting drug use. Still, evidence suggests that harm reduction strategies can be effective in reducing harm and improving health outcomes.&#x0D; Another critical strategy to address the opioid crisis is promoting recovery, which involves supporting individuals in their journey towards sobriety and wellness. Recovery-oriented systems of care aim to provide comprehensive, person-centered, and evidence-based interventions to support individuals with substance use disorders. This includes medication-assisted treatment, counseling, peer support, and community-based resources. Promoting recovery requires a long-term commitment and a collaborative effort from healthcare providers, policymakers, and communities to ensure that individuals receive the support they need to achieve their recovery goals [2].&#x0D; In conclusion, addressing the opioid crisis requires a multi-pronged approach that integrates harm reduction and recovery-oriented strategies. While preventing opioid misuse and addiction is a key priority, it is equally important to ensure that individuals who are already struggling with substance use disorders receive the necessary support to recover and rebuild their lives. Through collaborative efforts and evidence-based interventions, we can work towards reducing harm, promoting recovery, and improving the overall health and well-being of our communities.

Sweden’s first Take-Home Naloxone program: participant characteristics, dose endpoints and predictors for overdose reversals

BackgroundOpioid overdoses are a growing concern, particularly among people who inject drugs. Sweden, with a comparatively high proportion of drug-related mortality, introduced its first Take-Home Naloxone (THN) program in 2018, at the Stockholm needle and syringe program (NSP). In this study we compare THN participant characteristics regarding refills and overdose reversals as well as investigate predictors associated with number of reversals. We also investigate interventions performed in overdose situations and endpoints for naloxone doses.MethodsThis was a prospective open inclusion cohort study conducted between January 24th 2018 and March 31st 2022 at the Stockholm NSP. Participants received THN, free of charge, after a training session and provided data regarding drug use and overdose experiences. During refill visits, participants reported if the naloxone was used for overdose reversal and, if so, responded to a ten-item questionnaire which included stating whether the naloxone recipient was the participant themselves or somebody else. Questionnaire data was combined with NSP database demographic data. Zero-inflated Poisson regression was applied to analyse predictors for number of reported overdose reversals.ResultsAmong study participants (n = 1,295), 66.5% stated opioids as their primary drug, and 61.4% and 81.0% had previous experience of a personal or witnessed overdose, respectively. Overall, 44.0% of participants reported a total of 1,625 overdose reversals and the victim was known to have survived in 95.6% of cases. Stimulant use (aIRR 1.26; 95% CI 1.01, 1.58), benzodiazepine use (aIRR 1.75; 95% CI 1.1, 2.78) and homelessness (aIRR 1.35; 95% CI 1.06, 1.73) were predictors associated with an increased number of reported overdose reversals. Mortality was higher among those who reported at least one overdose reversal (HR 3.4; 95% CI 2.2, 5.2).ConclusionsAn NSP’s existent framework can be utilised to effectively implement a THN program, provide basic training and reach numerous high-risk individuals. During the four-year study, THN participants reversed a sizeable number of potentially fatal overdoses, of which many were reported by participants whose primary drug was not opioids. Naloxone refill rate was high, indicating that participants were motivated to maintain a supply of naloxone in case of future overdose events.

Implementation Facilitation to Promote Emergency Department–Initiated Buprenorphine for Opioid Use Disorder

Emergency department (ED)-initiated buprenorphine for the treatment of opioid use disorder (OUD) is underused. To evaluate whether provision of ED-initiated buprenorphine with referral for OUD increased after implementation facilitation (IF), an educational and implementation strategy. This multisite hybrid type 3 effectiveness-implementation nonrandomized trial compared grand rounds with IF, with pre-post 12-month baseline and IF evaluation periods, at 4 academic EDs. The study was conducted from April 1, 2017, to November 30, 2020. Participants were ED and community clinicians treating patients with OUD and observational cohorts of ED patients with untreated OUD. Data were analyzed from July 16, 2021, to July 14, 2022. A 60-minute in-person grand rounds was compared with IF, a multicomponent facilitation strategy that engaged local champions, developed protocols, and provided learning collaboratives and performance feedback. The primary outcomes were the rate of patients in the observational cohorts who received ED-initiated buprenorphine with referral for OUD treatment (primary implementation outcome) and the rate of patients engaged in OUD treatment at 30 days after enrollment (effectiveness outcome). Additional implementation outcomes included the numbers of ED clinicians with an X-waiver to prescribe buprenorphine and ED visits with buprenorphine administered or prescribed and naloxone dispensed or prescribed. A total of 394 patients were enrolled during the baseline evaluation period and 362 patients were enrolled during the IF evaluation period across all sites, for a total of 756 patients (540 [71.4%] male; mean [SD] age, 39.3 [11.7] years), with 223 Black patients (29.5%) and 394 White patients (52.1%). The cohort included 420 patients (55.6%) who were unemployed, and 431 patients (57.0%) reported unstable housing. Two patients (0.5%) received ED-initiated buprenorphine during the baseline period, compared with 53 patients (14.6%) during the IF evaluation period (P < .001). Forty patients (10.2%) were engaged with OUD treatment during the baseline period, compared with 59 patients (16.3%) during the IF evaluation period (P = .01). Patients in the IF evaluation period who received ED-initiated buprenorphine were more likely to be in treatment at 30 days (19 of 53 patients [35.8%]) than those who did not 40 of 309 patients (12.9%; P < .001). Additionally, there were increases in the numbers of ED clinicians with an X-waiver (from 11 to 196 clinicians) and ED visits with provision of buprenorphine (from 259 to 1256 visits) and naloxone (from 535 to 1091 visits). In this multicenter effectiveness-implementation nonrandomized trial, rates of ED-initiated buprenorphine and engagement in OUD treatment were higher in the IF period, especially among patients who received ED-initiated buprenorphine. ClinicalTrials.gov Identifier: NCT03023930.

Public health detailing to increase naloxone access in NYC pharmacies

BackgroundDrug overdose is a public health crisis in the United States. Opioid overdose deaths are preventable using naloxone, an opioid antagonist that reverses the effect of an opioid and prevents fatal overdose. ObjectivesThis study aimed to evaluate changes in naloxone standing order status, attitudes, and practice behavior after an 8-week public health detailing campaign on increasing naloxone access conducted among pharmacists in independent pharmacies in New York City (NYC). MethodsCampaign recommendations were to (1) enroll in the NYC pharmacy naloxone standing order program, (2) offer naloxone to at-risk patients, and (3) educate patients on how to use naloxone. Evaluation was performed using initial and follow-up surveys administered to pharmacists during detailing visits and Department of Health and Mental Hygiene data on pharmacies in the standing order program. ResultsDetailing visits were completed with 1153 pharmacists; follow-up visits were completed with 457 (40%). Self-reported attitudes and practice behavior related to the 3 campaign recommendations improved (P < 0.01). After the campaign, 519 new pharmacies enrolled in the standing order program. ConclusionsThe detailing campaign substantially increased the number of pharmacies enrolled in the standing order program and was associated with improved attitudes and practice behavior related to naloxone provision to varying degrees. Other jurisdictions could consider detailing pharmacists as a strategy to increase naloxone access.