Rescue Kits Research Articles

Abuse potential of fentanyl and fentanyl analogues

Introduction: In this perspective review, we evaluated the clinical management of fatal fentanyl overdose in several routes of administration, concentrating on both legally prescribed and illegally produced formulations. Methods: A literature search was conducted on Web of Science, PubMed, and Google Scholar databases, using the following keywords: fentanyl, illicit fentanyl, deaths, misuse, abuse, and naloxone. We included only articles whose abstracts were available in English. All articles were screened using their abstracts to determine their relevance to the current review. Results: The gold standard for treating both acute and chronic pain is fentanyl, but abuse of the drug has exploded globally since the late 2000s. Fentanyl abuse has been shown to frequently result in serious harm and even death. Conclusions: By educating patients and physicians, making rescue kits easily accessible, developing vaccines to prevent opioid addiction, and perhaps even creating new tamper-resistant fentanyl formulations, it may be possible to prevent fentanyl misuse, therapeutic errors, and the repercussions that follow.

Retrieval of a fractured implant abutment using a modified cover screw removal instrument: A clinical report

Implant abutment fractures are an uncommon mechanical complication, and the removal of the abutment fragment and replacement with a new prosthesis is the best solution. However, successful retrieval of the fractured abutment fragment from the implant is challenging, and effective rescue kits are lacking. This clinical report describes the retrieval of a fractured implant abutment in a conical connection implant using a modified manufacturer-specific instrument.

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

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

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

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

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

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

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

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

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

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

Facilitators, barriers and lessons learnt from the first state-wide naloxone distribution conducted in West Virginia

BackgroundOverdose education and naloxone distribution programmes are known to reduce opioid-related deaths. A state-wide naloxone distribution effort of 8250 rescue kits was undertaken by government, community and university partners in...

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

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

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

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

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

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

Take -home naloxone rescue kits following heroin overdose in the emergency department to prevent opioid overdose related repeat emergency department visits, hospitalization and death- a pilot study

BackgroundOpioid overdoses are at an epidemic in the United States causing the deaths of thousands each year. Project DAWN (Deaths Avoided with Naloxone) is an opioid overdose education and naloxone distribution program in Ohio that distributes naloxone rescue kits at clinics and in the emergency departments of a single hospital system.MethodsWe performed a retrospective analytic cohort study comparing heroin overdose survivors who presented to the emergency department and were subsequently discharged. We compared those who received a naloxone rescue kit at discharge with those who did not. Our composite outcome was repeat opioid overdose related emergency department visit(s), hospitalization and death at 0–3 months and at 3–6 months following emergency department overdose. Heroin overdose encounters were identified by ICD- 9 or 10 codes and data was abstracted from the electronic medical record for emergency department patients who presented for heroin overdose and were discharged over a 31- month period between 2013 and 2016. Patients were excluded for previous naloxone access, incarceration, suicidal ideation, admission to the hospital or death from acute overdose on initial emergency department presentation. Data was analyzed with the Chi- square statistical test.ResultsWe identified 291emergency department heroin overdose encounters by ICD-9 or 10 codes and were analyzed. A total of 71% of heroin overdose survivors received a naloxone rescue kit at emergency department discharge. Between the patients who did not receive a naloxone rescue kit at discharge, no overdose deaths occurred and 10.8% reached the composite outcome. Of the patients who received a naloxone rescue kit, 14.4% reached the composite endpoint and 7 opioid overdose deaths occurred in this cohort. No difference in mortality at 3 or 6 months was detected, p = 0.15 and 0.36 respectively. No difference in the composite outcome was detected at 3 or 6 months either, p = 0.9 and 0.99 respectively.ConclusionsOf our emergency department patients receiving a naloxone rescue kit we did not find a benefit in the reduction of repeat emergency department visits hospitalizations, or deaths following a non-fatal heroin overdose.

Structural Refinement of Glucagon for Therapeutic Use.

Glucagon counters insulin's effects on glucose metabolism and serves as a rescue medicine in the treatment of hypoglycemia. Acute hypoglycemia, a common occurrence in insulin-dependent diabetes, is the central obstacle to correcting high blood glucose, a primary cause of long-term microvascular complications. As a result, there has been a resurgence of interest in improved glucagon therapy, including nonconventional liquid formulations, alternative routes of administration, and novel analogs with optimized biophysical properties. These options collectively minimize the complexity of glucagon delivery and enable its application in ways not feasible with conventional emergency rescue kits. These advances have indirectly promoted the integrated use of glucagon agonism with other hormones in a manner that runs counter to the long-standing pursuit of glucagon antagonism. This review summarizes novel approaches to glucagon optimization, methods with potential application to the broader family of therapeutic peptides, where biophysical challenges may be encountered.

Tools for Community-Based Pharmacist Patient Care Services to Support Optimal Opioid Use

Tools for Community-Based Pharmacist Patient Care Services to Support Optimal Opioid Use

The opioid crisis: Origins, trends, policies, and the roles of pharmacists.

The purpose of this review is to (1) provide information concerning the opioid crisis including origins, trends, and some important related laws/policies; and (2) summarize the current involvement and impact of pharmacists in helping to address the crisis, as well as examine practices in other healthcare disciplines from which pharmacists might derive guidance and strategies. Contributors to the opioid crisis included campaigns to treat pain as a fifth vital sign and to use opioids in treatment of non-cancer-related pain, as well as aggressive marketing of opioid analgesics by pharmaceutical companies. To address the crisis, numerous strategies have been implemented at the policy/legislative, health-system, and patient levels, such as prescription drug monitoring programs (PDMPs), increased regulation of pain clinics, and expanded use of naloxone. Pharmacists have a critical role to play in interventions to address opioid misuse and reduce harm resulting from misuse. Such interventions include patient screening and risk stratification, patient and community education and outreach concerning appropriate pain management, medication reviews/medication therapy management, education on safe storage and disposal, distribution of naloxone/opioid rescue kits and training on their proper use, and referral of patients to addiction treatment, among other strategies. Pharmacists have multiple, complex roles in addressing the opioid crisis. Outcomes of several studies provide substantial evidence that pharmacists can make an impact through appropriate pain management, use of PDMPs, opioid overdose prevention training, and medication reviews and counseling, among other interventions.

Digital Reformatting and Data Rescue with RADD and the PROUD and PRAVDA Kits

Despite the short remaining time to rescue unique cultural and personal materials stored on many twentieth- and early twenty-first-century audiovisual and digital storage media, realistic rescue options are starkly limited. Building a rescue apparatus in house, especially to archival standards, requires significant expertise and expense and is often of limited continuing use. Outsourcing digital capture of these materials overwhelms the resources of even well-funded academic libraries and archives, never mind public libraries, small archives, and local historical societies. To address this problem realistically, the University of Wisconsin-Madison Information School has built and documented an in-house rescue installation called RADD (Recover Analog and Digital Data) as well as two self-contained, portable, and shippable rescue kits: PROUD (Portable Recovery of Unique Data) for digital materials and PRAVDA (Portably Reformat Audio and Video to Digital from Analog) for audio and video. All three units are actively rescuing cultural heritage materials, as well as serving training and outreach functions.

Is Mini-Dose Glucagon the Answer to Preventing Exercise-Related Dysglycemia?

Hypoglycemia is a potentially fatal complication of insulin therapy. In normal physiology, glucagon acts as a counterregulatory hormone to raise circulating glucose, defending against hypoglycemia. This defense is lost early in type 1 diabetes (1,2). The absence of normal counterregulation in patients with type 1 diabetes, combined with the slow offset of subcutaneous insulin therapy, results in a significant risk of hypoglycemia in this population. Mild hypoglycemia can be treated with the ingestion of simple carbohydrates, but frequent treatments may lead to unwanted weight gain. Frequent hypoglycemic episodes also put a patient at risk for hypoglycemia unawareness, which significantly increases a person’s risk of severe hypoglycemia (3). For decades, the use of glucagon has been largely limited to a rescue treatment for severe hypoglycemia. The available rescue kits require the user to reconstitute glucagon from a lyophilized powder. After reconstitution into an aqueous solution, native glucagon quickly forms fibrils and degrades (4). For this reason, rescue glucagon kits are currently designed to be used immediately after reconstitution and then discarded. To address this …

Inadequate Use of Glucagon in Patients with T1D

Glucagon is an invaluable tool for patients with type 1 diabetes (T1D) who experience severe hypoglycemia, but little is known about the actual use of glucagon in this patient population. This study was undertaken among individuals with T1D or caregivers to assess the perceptions and/or past experiences using the currently available glucagon rescue kits, and factors that might increase its utility in the management of T1D. Survey responses from 264 adults with T1D (mean age 41.2 years [SD 15.5]) and 58 caregivers of a person with T1D (mean age 11.8 years [SD 3.7]) were included in the analyses. Overall the participants were highly educated, predominantly covered by private health insurance, and the majority were on insulin pumps. The survey revealed that the majority of the individuals with T1D had been prescribed glucagon; however, almost a third of the adult patients did not receive any education on its use, and a third of the adult patients did not have a current prescription. Caregivers reported higher percentages of receiving education on glucagon use and also having a current prescription. Of those with severe hypoglycemia who had glucagon available, half did not receive a glucagon injection. The majority of patients who had received glucagon injection reported various problems with the procedure; those who did not receive glucagon injection reported a number of barriers to its use. These data strongly suggest the need for 1) standards of practice that would increase prescribing of glucagon 2) initial and ongoing education on its use and administration 3) development of a glucagon rescue option that would eliminate the complexity relating to current formulations and packaging of rescue glucagon kits. Disclosure M.W. Haymond: Advisory Panel; Self; Zealand Pharma A/S. Other Relationship; Self; Xeris Pharmaceuticals, Inc.. J. Liu: None. J. Bispham: None. A. Hickey: None. A.H. McAuliffe-Fogarty: Advisory Panel; Self; Novo Nordisk Inc..

Overdose mortality rates following the introduction of naloxone rescue kits

Overdose mortality rates following the introduction of naloxone rescue kits

The American Society of Regional Anesthesia and Pain Medicine Checklist for Managing Local Anesthetic Systemic Toxicity: 2017 Version.

The American Society of Regional Anesthesia and Pain Medicine (ASRA) periodically revises and updates its checklist for the management of local anesthetic systemic toxicity. The 2017 update replaces the 2012 version and reflects new information contained in the third ASRA Practice Advisory on Local Anesthetic Systemic Toxicity. Electronic copies of the ASRA checklist can be downloaded from the ASRA Web site (www.asra.com) for inclusion in local anesthetic toxicity rescue kits or perioperative checklist repositories.