Take-home Naloxone Programs Research Articles

Patient characteristics associated with being offered take home naloxone in a busy, urban emergency department: a retrospective chart review

BackgroundOverdose deaths can be prevented by distributing take home naloxone (THN) kits. The emergency department (ED) is an opportune setting for overdose prevention, as people who use opioids frequently present for emergency care, and those who have overdosed are at high risk for future overdose death. We evaluated the implementation of an ED-based THN program by measuring the extent to which THN was offered to patients presenting with opioid overdose. We analyzed whether some patients were less likely to be offered THN than others, to identify areas for program improvement.MethodsWe retrospectively reviewed medical records from all ED visits between April 2016 and May 2017 with a primary diagnosis of opioid overdose at a large, urban tertiary hospital located in Alberta, Canada. A wide array of patient data was collected, including demographics, opioid intoxicants, prescription history, overdose severity, and whether a naloxone kit was offered and accepted. Multivariable analyses were used to identify patient characteristics and situational variables associated with being offered THN.ResultsAmong the 342 ED visits for opioid overdose, THN was offered in 49% (n = 168) of cases. Patients were more likely to be offered THN if they had been found unconscious (Adjusted Odds Ratio 3.70; 95% Confidence Interval [1.63, 8.37]), or if they had smoked or injected an illegal opioid (AOR 6.05 [2.15,17.0] and AOR 3.78 [1.32,10.9], respectively). In contrast, patients were less likely to be offered THN if they had a current prescription for opioids (AOR 0.41 [0.19, 0.88]), if they were admitted to the hospital (AOR 0.46 [0.22,0.97], or if they unexpectedly left the ED without treatment or before completing treatment (AOR 0.16 [0.22, 0.97).ConclusionsIn this real-world evaluation of an ED-based THN program, we observed that only half of patients with opioid overdose were offered THN. ED staff readily identify patients who use illegal opioids or experience a severe overdose as potentially benefitting from THN, but may miss others at high risk for future overdose. We recommend that hospital EDs provide additional guidance to staff to ensure that all eligible patients at risk of overdose have access to THN.

Implementing an Opioid Risk Reduction Program in the Acute Comprehensive Inpatient Rehabilitation Setting

ObjectiveTo describe the implementation and evaluation of an interdisciplinary quality improvement (QI) project to increase prescription of take-home naloxone (THN) to reduce risks associated with opioids for patients admitted to an acute inpatient rehabilitation unit. DesignProspective cohort quality improvement project. SettingEighteen-bed acute comprehensive inpatient rehabilitation (ACIR) unit at a large academic institution. ParticipantsPatients admitted to ACIR between December 2015-November 2016 (N=788). InterventionsAn interdisciplinary QI model comprised of planning, education, implementation, and maintenance was used to implement a THN and opioid risk-reduction program involving provider and patient education. Analyses consisted of comparisons between baseline, early, and late phases of the project. Main Outcome Measures(1) The proportion of eligible patients who received a prescription for naloxone upon discharge from ACIR; (2) the proportion of patients originally admitted to ACIR on opioids that were weaned off upon discharge. ResultsThe adjusted odds of eligible patients being discharged from ACIR with a naloxone prescription during the late QI period were 7 (95% confidence interval [CI]: 3-21) times higher than during the early QI period (late QI period: 43%, 95% CI: 25%-63%; early QI period: 10%, 95% CI: 3%-28%; P<.001). For patients admitted on opioids, the adjusted odds of being weaned off opioids during the late QI period were 10 (95% CI: 4-25) times higher than during baseline (late QI period: 29%, 95% CI: 17%-45%; baseline: 4%, 95% CI: 1%-10%; P<.001). ConclusionsImplementation of a THN and opioid risk reduction QI project in an inpatient rehabilitation setting led to significantly more eligible patients receiving naloxone and more patients weaned off schedule II opioids.

An evaluation of Take Home Naloxone program implementation in British Columbian correctional facilities

PurposeTo understand how the Take Home Naloxone (THN) program is implemented in two pilot correctional facilities in British Columbia (BC), Canada, in order to identify areas for program improvement and inform the expansion of the program to other Canadian correctional facilities The paper aims to discuss these issues.Design/methodology/approachTwo focus groups and one interview were conducted with healthcare staff at two pilot correctional facilities. Sessions were audio recorded, transcribed verbatim and divergent and convergent experiences within and between the facilities were explored in an iterative process. Key themes and lessons learned were identified and later validated by focus group participants.FindingsKey themes that emerged included: challenges and importance of the train-the-trainer program for healthcare staff conducting participant training sessions; potential for improved prison population engagement and awareness of the program; tailoring program resources to the unique needs of an incarcerated population; challenges connecting participants to community harm reduction resources following release; and clarifying and enhancing the role of correctional officers to support the program.Research limitations/implicationsThe correctional setting presents unique challenges and opportunities for the THN program that must be considered for program effectiveness.Originality/valueThis evaluation was conducted to inform program expansion amidst a historic opioid overdose epidemic in BC, and adds to the limited yet growing body of literature on the implementation and evaluation of this program in correctional settings globally.

Take-home naloxone program is a priority in Iran.

Take-home naloxone program is a priority in Iran.

Challenges with take-home naloxone in reducing heroin mortality: a review of fatal heroin overdose cases in Victoria, Australia

Aim: Take-home naloxone (THN) programs have been implemented in order to reduce the number of heroin-overdose deaths. Because of recent legislative changes in Australia, there is a provision for a greater distribution of naloxone in the community, however, the potential impact of these changes for reduced heroin mortality remains unclear. The aim of this study was to examine the characteristics of the entire cohort of fatal heroin overdose cases and assess whether there was an opportunity for bystander intervention had naloxone been available at the location and time of each of the fatal overdose events to potentially avert the fatal outcome in these cases.Methods: The circumstances related to the fatal overdose event for the cohort of heroin-overdose deaths in the state of Victoria, Australia between 1 January 2012 and 31 December 2013 were investigated. Coronial data were investigated for all cases and data linkage was performed to additionally investigate the Emergency Medical Services information about the circumstances of the fatal heroin overdose event for each of the decedents.Results and Discussion: There were 235 fatal heroin overdose cases identified over the study period. Data revealed that the majority of fatal heroin overdose cases occurred at a private residence (n = 186, 79%) and where the decedent was also alone at the time of the fatal overdose event (n = 192, 83%). There were only 38 cases (17%) where the decedent was with someone else or there was a witness to the overdose event, and in half of these cases the witness was significantly impaired, incapacitated or asleep at the time of the fatal heroin overdose. There were 19 fatal heroin overdose cases (8%) identified where there was the potential for appropriate and timely intervention by a bystander or witness.Conclusion: This study demonstrated that THN introduction alone could have led to a very modest reduction in the number of fatal heroin overdose cases over the study period. A lack of supervision or a witness to provide meaningful and timely intervention was evident in most of the fatal heroin overdose cases.

Adoption and Utilization of an Emergency Department Naloxone Distribution and Peer Recovery Coach Consultation Program.

Rising rates of opioid overdose deaths require innovative programs to prevent and reduce opioid-related morbidity and mortality. This study evaluates adoption, utilization, and maintenance of an emergency department (ED) take-home naloxone and peer recovery coach consultation program for ED patients at risk of opioid overdose. Using a Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework, we conducted a retrospective provider survey and electronic medical record (EMR) review to evaluate implementation of a naloxone distribution and peer recovery coach consultation program at two EDs. Provider adoption was measured by self-report using a novel survey instrument. EMRs of discharged ED patients at risk for opioid overdose were reviewed in three time periods: preimplementation, postimplementation, and maintenance. Primary study outcomes were take-home naloxone provision and recovery coach consultation. Secondary study outcome was referral to treatment. Chi-square analysis was used for study period comparisons. Logistic regression was conducted to examine utilization moderators. Poisson regression modeled utilization changes over time. Most providers reported utilization (72.8%, 83/114): 95.2% (79/83) provided take-home naloxone and 85.5% (71/83) consulted a recovery coach. There were 555 unique patients treated and discharged during the study periods: 131 preimplementation, 376 postimplementation, and 48 maintenance. Postimplementation provision of take-home naloxone increased from none to more than one-third (35.4%, p<0.001), one-third received consultation with a recovery coach (33.1%, 45/136), and discharge with referral to treatment increased from 9.16% to 20.74% (p=0.003). Take-home naloxone provision and recovery coach consultation did not depreciate over time. ED naloxone distribution and consultation of a community-based peer recovery coach are feasible and acceptable and can be maintained over time.

Acceptability of prison-based take-home naloxone programmes among a cohort of incarcerated men with a history of regular injecting drug use

BackgroundTake-home naloxone (THN) programmes are an evidence-based opioid overdose prevention initiative. Elevated opioid overdose risk following prison release means release from custody provides an ideal opportunity for THN initiatives. However, whether Australian prisoners would utilise such programmes is unknown. We examined the acceptability of THN in a cohort of male prisoners with histories of regular injecting drug use (IDU) in Victoria, Australia.MethodsThe sample comprised 380 men from the Prison and Transition Health (PATH) Cohort Study; all of whom reported regular IDU in the 6 months prior to incarceration. We asked four questions regarding THN during the pre-release baseline interview, including whether participants would be willing to participate in prison-based THN. We describe responses to these questions along with relationships between before- and during-incarceration factors and willingness to participate in THN training prior to release from prison.ResultsMost participants (81%) reported willingness to undertake THN training prior to release. Most were willing to resuscitate a friend using THN if they were trained (94%) and to be revived by a trained peer (91%) using THN. More than 10 years since first injection (adjusted odds ratio [AOR] 2.22, 95%CI 1.03–4.77), having witnessed an opioid overdose in the last 5 years (AOR 2.53, 95%CI 1.32–4.82), having ever received alcohol or other drug treatment in prison (AOR 2.41, 95%CI 1.14–5.07) and injecting drugs during the current prison sentence (AOR 4.45, 95%CI 1.73–11.43) were significantly associated with increased odds of willingness to participate in a prison THN programme. Not specifying whether they had injected during their prison sentence (AOR 0.37, 95%CI 0.18–0.77) was associated with decreased odds of willingness to participate in a prison THN training.ConclusionOur findings suggest that male prisoners in Victoria with a history of regular IDU are overwhelmingly willing to participate in THN training prior to release. Factors associated with willingness to participate in prison THN programmes offer insights to help support the implementation and uptake of THN programmes to reduce opioid-overdose deaths in the post-release period.

390 Increasing Utilization of Take-Home Naloxone Program for At-Risk Emergency Department Patients Using Computerized Clinical Decision Support

We examine the effects of implementation of a computerized clinical decision support on take-home naloxone prescribing from emergency departments across emergency departments (EDs) in a large hospital system. We performed a retrospective chart review of number of take-home naloxone (THN) kits prescribed by physicians from 15 emergency departments in a hospital system over the 3-month periods before and after implementation of a computerized clinical decision support (CCDS) was implemented into the electronic health record (EHR). We analyzed de-identified medical records of discharged ED patients with a chief complaint related to opioids in the 3-month period prior to CCDS through the 3-month period post CCDS implementation and compared them to ED pharmacy THN dispensing records. The CCDS that was implemented prompted a pop-up notification in the EMR when discharge orders were placed to advise physicians to prescribe THN, based on an initial nurse triage entry related to opioid-use disorder (OUD). All THN kits were purchased in advance by the institution and stocked in the ED to be offered at no cost to patients, and ED staff were made aware of the THN kits and trained in how to dispense prior to initiation of the 6-month period of study analysis. In the 3 months prior to implementation of the CCDS, the 15 EDs in the system saw a total of 827 patients identified as having a visit related to OUD, and during this period 108 THN kits were prescribed. In the 3 months following implementation of the CCDS 851 patients were identified as having an ED visit related to OUD, and during this period 192 THN kits were prescribed. This represent a 77.8% increase in THN kits prescribed, with less than a 3% increase in patient visits for OUD, and an increase from 13% of patients receiving THN at time of ED discharge to 22.6% of patients. This is the first attempt to describe a CCDS for THN prescribing across EDs in a large hospital system, and findings support implementation of CCDS to increase ED prescribing of THN.

The Emergency Department as an Opportunity for Naloxone Distribution.

IntroductionSubstance use disorders, including opioid use disorders, are a major public health concern in the United States. Between 2005 and 2014, the rate of opioid-related emergency department (ED) visits nearly doubled, from 89.1 per 100,000 persons in 2005 to 177.7 per 100,000 persons in 2014. Thus, the ED presents a distinctive opportunity for harm-reduction strategies such as distribution of naloxone to patients who are at risk for an opioid overdose.MethodsWe conducted a systematic review of all existing literature related to naloxone distribution from the ED. We included only those articles published in peer-reviewed journals that described results relating to naloxone distribution from the ED.ResultsOf the 2,286 articles we identified from the search, five met the inclusion criteria and had direct relevance to naloxone distribution from the ED setting. Across the studies, we found variation in the methods of implementation and evaluation of take-home naloxone programs in the ED. In the three studies that attempted patient follow-up, success was low, limiting the evidence for the programs’ effectiveness. Overall, in the included studies there is evidence that distributing take-home naloxone from the ED has the potential for harm reduction; however, the uptake of the practice remained low. Barriers to implementation included time allocated for training hospital staff and the burden on workflow.ConclusionThis systematic review of the best evidence available supports the ED as a potential setting for naloxone distribution for overdose reversal in the community. The variability of the implementation methods across the studies highlights the need for future research to determine the most effective practices.

Naloxone Effectiveness: A Systematic Review.

Opioid abuse and overdose is a public health concern as it relates to increased morbidity and mortality. This systematic review focuses on the application of take-home naloxone programs and its association with decreased mortality among those who abuse opioids. Take-home naloxone programs consist of distributed naloxone kits and corresponding education of overdose recognition. The purpose of this systematic review was to determine if programs that supply take-home naloxone are effective in preventing fatal overdoses among those who abuse opioids. A systematic search was conducted in Academic Search Complete, CINHAL, MEDLINE, PsychINFO, and SocINDEX. The key words searched were "programs," "take-home kits," "Narcan," "Naloxone," and "mortality." On the basis of the predefined inclusion and exclusion criteria, nine studies were found for inclusion. Study results were then synthesized, qualitatively, and within the current research, there is overwhelming support of take-home naloxone programs being effective in preventing fatal opioid overdoses. A significant limitation of this systematic review is the lack of randomized controlled trials as it is viewed as unethical withholding a known lifesaving medication from an at-risk population. On the basis of the most current evidence, there is overwhelming support of take-home naloxone programs associated with decreased mortality among those who abuse opioids. As a result, there is an implication for a practice change that take-home naloxone programs should be more widely implemented throughout communities as a method of decreasing mortality associated with opioid overdoses. It is recommended that further research is done examining the cost-effectiveness of these programs.

Journal Digest

Journal Digest

At-a-glance - Lessons learned from launching the Manitoba Take-Home Naloxone Program.

The Government of Manitoba launched the provincial Take-Home Naloxone Program in January 2017. By the end of September 2017, there were over 60 sites operating in Manitoba. These sites distributed 765 kits to people at risk of opioid overdose, and 93 of these kits were replacement kits used in overdose events. Most of these events occurred among males (60.2%) and in a private residence (72.0%). Fentanyl and carfentanil were the most common substances reported during overdose events. Take-Home Naloxone Program data provide important information about the unique context of the opioid crisis in Manitoba.

An overview of take-home naloxone programs in Australia.

Take-home naloxone (THN) programs commenced in Australia in 2012 in the Australian Capital Territory and programs now operate in five Australian jurisdictions. The purpose of this paper is to record the progress of THN programs in Australia, to provide a resource for others wanting to start THN projects, and provide a tool for policy makers and others considering expansion of THN programs in this country and elsewhere. Key stakeholders with principal responsibility for identified THN programs operating in Australia provided descriptions of program development, implementation and characteristics. Short summaries of known THN programs from each jurisdiction are provided along with a table detailing program characteristics and outcomes. Data collected across current Australian THN programs suggest that to date over 2500 Australians at risk of overdose have been trained and provided naloxone. Evaluation data from four programs recorded 146 overdose reversals involving naloxone that was given by THN participants. Peer drug user groups currently play a central role in the development, delivery and scale-up of THN in Australia. Health professionals who work with people who use illicit opioids are increasingly taking part as alcohol and other drug-related health agencies have recognised the opportunity for THN provision through interactions with their clients. Australia has made rapid progress in removing regulatory barriers to naloxone since the initiation of the first THN program in 2012. However, logistical and economic barriers remain and further work is needed to expand access to this life-saving medication.

LO18: Access to take home naloxone in the Royal Alexandra Hospitals emergency department for patients at risk of an opioid overdose

Introduction: Take Home Naloxone (THN) programs prevent death from opioid poisoning by training laypersons to recognize an overdose and administer naloxone. Dispensing THN through the emergency department (ED) is particularly critical because an ED visit for opioid poisoning strongly predicts future mortality. Many EDs have implemented THN programs, yet almost no literature examines the reach of such initiatives. To address this gap, we conducted a chart review of all patients presenting for opioid poisoning to an urban tertiary hospital, with a large ED-based THN program. This exploratory study hypothesized that more than 50% of ED patients presenting for opioid poisoning would be offered a THN kit. Methods: Data on demographics, clinical characteristics, and THN kit dispensing were extracted and analyzed from the charts of all ED patients presenting with a primary diagnosis of opioid poisoning between April 1 2016 and April 30 2017. Logistic regression analyzed predictors of being offered a THN kit. Results: A total of 347 ED visits for 301 unique patients occurred during the study period. The mean age ± SD of patients was 38 ± 14 years, and 69% were male. In 49% of ED visits, a THN kit was offered; 73% of these episodes had a THN kit dispensation. Patients who were male (AOR=1.94; 95% CI 1.11 - 3.40), and reported that their overdose was unintentional (AOR=2.95; 95% CI 1.04 8.35) and caused by illegal opioids (AOR=4.73; 95% CI 2.63 8.52) were significantly more likely to be offered a THN kit. Conclusion: ED-based THN programs have the potential to reach significant proportions of patients at high risk of mortality. However, these programs may have differential reach within the target population. Further research is needed to examine barriers and facilitators to offering all eligible ED patients a THN kit.

Does training people to administer take-home naloxone increase their knowledge? Evidence from Australian programs.

Take-home naloxone (THN) programs have been operating in Australia since 2012 in a variety of settings. We examine whether THN programs were effective in increasing knowledge about opioid overdose and appropriate responses in program participants. Data were obtained from pre- and post-training questionnaires administered as part of the early evaluations of THN naloxone programs operated in Sydney (n = 67), Melbourne (n = 280), Perth (n = 153) and Canberra (n = 183). Pooled data from comparable items, analysed in the domains specified in previously-developed evaluation scales, were compared using repeated-measures analysis of variance and random effects logistic regression. Results pre- and post-training were compared as well as results across sites. High levels of knowledge about overdose risks and signs and appropriate actions to take were observed at baseline and this generally improved over time. No substantial differences were identified across cities. Knowledge also increased with participant age but the improvements over time were similar in each age group. There were small differences by participant gender with knowledge generally higher among females. THN programs are effective in improving knowledge related to overdose response. Major improvements in knowledge were limited to overdose recognition and effect of naloxone suggesting that education may best be focused on overdose signs and the use of naloxone among populations accessed through these programs. A focus on younger people also appears warranted. Further work is needed to understand the impact of training and knowledge on actual behaviours around overdose events.

Knowledge of naloxone and take-home naloxone programs among a sample of people who inject drugs in Australia: Variations across capital cities.

Take-home naloxone (THN) programs targeting people who inject drugs (PWID) have been running in some Australian states and territories since 2012. In this study, we aimed to determine the extent to which PWID in the capital cities of all Australian states and territories are aware of naloxone and THN programs, whether awareness of these programs has changed over time. Data were obtained from cross-sectional surveys of a total of 2088 PWID conducted annually as part of the Illicit Drug Reporting System from 2013 to 2015. Specific questions about THN added to the survey in 2013 allowed assessment of the extent to which sampled PWID were aware of naloxone and its function and THN programs in Australia and whether they had participated in a THN program. These main outcomes were examined over time and across states and territories using a mix of descriptive statistics and logistic regression. Over 80% of the sample reported having heard of naloxone across survey years. Less than half of the participants reported having heard of THN programs in 2013 (35%), but this increased to just over (52%) half in 2015 (P < 0.01). Changes over time differed across cities with increases in reports of having heard of THN occurring over time most clearly in those cities with operational THN programs. Around half of the PWID sampled for this study are aware of THN programs. Further work is needed to ensure widespread awareness of THN programs which should include implementing THN in all Australian states and territories.

Knowledge and possession of take-home naloxone kits among street-involved youth in a Canadian setting: a cohort study

BackgroundThe distribution of take-home naloxone (THN) kits has been an important strategy in reducing overdose fatalities among people who use drugs. However, little is known about the use of THN among youth who are street-involved. The present study explores knowledge and possession of THN among street-involved youth in a Canadian setting.MethodsData were derived from the At-Risk Youth Study (ARYS), a prospective cohort of street-involved youth age 14–28 at enrollment in Vancouver, Canada. Participants completed a standardized questionnaire, which included items related to knowledge and possession of THN, sociodemographic characteristics, and substance use-related factors. Multivariable logistic regression models were used to identify factors independently associated with knowledge and possession of THN.ResultsBetween December 2014 and November 2016, 177 youth were interviewed, including 68 females (38.4%). While 126 (71.2%) participants reported knowledge of THN, only 40 (22.6%) possessed a THN kit. Caucasian/white ethnicity was found to be positively associated with both knowledge and possession of THN (both p < 0.05). Public injection drug use in the last 6 months was found to be positively associated with knowledge of THN, while daily heroin use and daily methamphetamine use were associated with possession of THN (all p < 0.05). Male gender was negatively associated with possession of THN (p < 0.05).ConclusionsThese findings highlight important gaps between knowledge and possession of THN among youth and the need to increase participation in THN programs among specific populations including non-white and male youth. Further research is needed to gain a better understanding of the barriers that may prevent certain youth from acquiring THN kits.

431 Facilitating an Emergency Department Take-Home Naloxone Program Through Involvement of Community-Based Harm Reductionists

Opioid overdose is a significant cause of morbidity and mortality in the United States. For decades, peer-led harm reduction organizations have prevented overdoses through provision of naloxone, an opioid antagonist, directly to those at highest risk of overdose after training them in overdose emergency response. More recently, some emergency departments (EDs) have started similar programs, but take-home naloxone from EDs has yet to become widespread. Common barriers to implementation include limited clinician time, lack of exposure to harm reduction, and uncertainty about liability. In this study we implemented a take-home naloxone program in a moderate-volume, suburban ED in which volunteer naloxone-certified medical students, who were experienced staff members at a local needle exchange, provided overdose prevention education to patients identified as being potentially high-risk for opioid overdose. The program aimed to determine whether involvement of community harm reductionists could initiate overdose prevention and naloxone distribution practices with minimal change or impact to ED throughput. Patients were screened by emergency physicians and needle exchange staff for risk of opioid overdose on the basis of their chief complaint, triage intake, and emergency physician impression. Those who met screening criteria were approached by needle exchange staff, who explained the program and inquired about opioid use. Eligible and consenting patients were then trained by the needle exchange staff in the recognition of opioid overdoses, basic emergency response, and naloxone usage. Upon completion of training, the treating physician prescribed naloxone which could be filled by the patient after discharge. Multiple attempts to contact patients were made at 3 months after discharge to identify any barriers to obtaining or using the prescribed naloxone. 71 patients met screening criteria. Of these, 24 (34%) were trained and prescribed naloxone. For the remaining 47 (66%), 17 (36%) denied opioid use, 11 (23%) declined participation, 2 (4%) already possessed naloxone, 1 (2%) clinically deteriorated, and 16 (34%) met enrollment criteria but the treating clinician refused to prescribe naloxone. All enrolled patients completed training without issues. At 3-month follow-up, 7 (29%) of patients given naloxone were successfully contacted. Of these, only 2 (29%) chose to fill their prescription. No patients reported obstacles to obtaining naloxone. Partnering with community harm reduction organizations can facilitate implementation of ED-based take-home naloxone programs. As this approach has minimal impact on the ED, this may be a useful low-threshold step towards incorporating more robust harm reduction practices in the ED. Obstacles include overcoming physician resistance to prescribing naloxone and inability to directly provide naloxone to patients on discharge. Future programs should consider engaging with physician concerns early and frequently to encourage participation in the program and discuss with pharmacy staff methods to provide patients with naloxone before discharge.

254 Rates of Naloxone Prescriptions Following Implementation of a Take-Home Naloxone Program from the Emergency Department

Opioid-related overdose death has more than quadrupled over the past three decades, mirroring trends in emergency department (ED) visits for opioid-related misuse and abuse. Recent studies have shown decreased mortality due to opioid overdose in communities with take-home naloxone (THN) programs. The methods of naloxone distribution vary across programs, with some programs providing naloxone directly to the patient and others providing naloxone prescriptions. The objective of this study was to determine the effectiveness of a THN program that utilizes naloxone prescriptions, with medication dispensing at a pharmacy, at two tertiary care EDs for patients presenting with a chief complaint related to opioid overdose. A multidisciplinary THN program was implemented at Harborview Medical Center and the University of Washington Medical Center in Seattle, WA. Eligible patients for THN (4mg/0.1ml nasal spray or 1mg/ml syringe) included those who were being discharged from the ED and met any inclusion criteria for risk of opioid overdose. Prior to discharge, patients received teaching, a naloxone prescription, and discharge instructions specific to heroin or pharmaceutical opioid overdose risk. Patients were then encouraged to fill the prescription at the hospital pharmacy, at no cost if needed, during available business hours (0900-1930) or through an after-hours pharmacy protocol where the naloxone was delivered to the ED. Pharmacists or ED staff, depending on pharmacy hours, dispensed the medication and provided teaching on naloxone. For this analysis, we reviewed data from October 1, 2015 to September 30, 2016 for patients who had a chief complaint consistent with opioid overdose, identified patients who received THN prescriptions, and then verified those who filled THN at one of our affiliated hospital pharmacies. A total of 744 patient encounters were identified to be at risk of opioid overdose between the two emergency departments over the study period. Take-home naloxone prescriptions were written for 83 encounters (11.1%) and 12 prescriptions (1.6%) were filled. Two patients were given and filled multiple prescriptions. Opioid overdose is a frequent presentation to the emergency department, but rates of naloxone prescription and filling through this THN program were marginal. True prescription fill rates may be underrepresented due to limitations in naloxone prescription tracking and a lack of outside pharmacy dispensing data. Additionally, it is unclear if patients were offered THN, but declined or were noted to already have THN. To further understand the impact of a THN program, EDs should consider prescription filling patterns, pharmacy access, and EHR data limitations. Identifying barriers to naloxone prescription and filling, unique to the emergency department, may improve naloxone distribution.

Emergency physicians' attitudes and perceived barriers to the implementation of take-home naloxone programs in Canadian emergency departments.

Rates of opioid-related deaths have reached the level of national public health crisis in Canada. Community-based opioid overdose education and naloxone distribution (OEND) programs distribute naloxone to people at risk, and the emergency department (ED) may be an underutilized setting to deliver naloxone to these people. The goal of this study was to identify Canadian emergency physicians' attitudes and perceived barriers to the implementation of take-home naloxone programs. This was an anonymous Web-based survey of members of the Canadian Association of Emergency Physicians. Survey questions were developed by the research team and piloted for face validity and clarity. Two reminder emails were sent to non-responders at 2-week intervals. Respondent demographics were collected, and Likert scales were used to assess attitudes and barriers to the prescription of naloxone from the ED. A total of 459 physicians responded. The majority of respondents were male (64%), worked in urban tertiary centres (58.3%), and lived in Ontario (50.6%). Overall, attitudes to OEND were strongly positive; 86% identified a willingness to prescribe naloxone from the ED. Perceived barriers included support for patient education (57%), access to follow-up (44%), and inadequate time (37%). In addition to people at risk of overdose, 77% of respondents identified that friends and family members may also benefit. Canadian emergency physicians are willing to distribute take-home naloxone, but thoughtful systems are required to facilitate opioid OEND implementation. These data will inform the development of these programs, with emphasis on multidisciplinary training and education.