Distinguishing signs of opioid overdose and indication for naloxone: an evaluation of six overdose training and naloxone distribution programs in the United States

AIMS: This study assessed overdose and naloxone administration knowledge among current or former opioid abusers trained and untrained in overdose-response in the United States. DESIGN AND PARTICIPANTS: Ten individuals, divided equally between those trained or not trained in overdose recognition and response, were recruited from each of six sites (n = 62). SETTING: US-based overdose training and naloxone distribution programs in Baltimore, San Francisco, Chicago, New York and New Mexico. MEASUREMENTS: Participants completed a brief questionnaire on overdose knowledge that included the task of rating 16 putative overdose scenarios for: (i) whether an overdose was occurring and (ii) if naloxone was indicated. Bivariate and multivariable analyses compared results for those trained to untrained. Responses were also compared to those of 11 medical experts using weighted and unweighted kappa statistics. FINDINGS: Respondents were primarily male (72.6%); 45.8% had experienced an overdose and 72% had ever witnessed an overdose. Trained participants recognized more opioid overdose scenarios accurately (t(60) = 3.76, P < 0.001) and instances where naloxone was indicated (t(59) = 2.2, P < 0.05) than did untrained participants. Receipt of training and higher perceived competency in recognizing signs of an opioid overdose were associated independently with higher overdose recognition scores. Trained respondents were as skilled as medical experts in recognizing opioid overdose situations (weighted kappa = 0.85) and when naloxone was indicated (kappa = 1.0). CONCLUSIONS: Results suggest that naloxone training programs in the United States improve participants' ability to recognize and respond to opioid overdoses in the community. Drug users with overdose training and confidence in their abilities to respond may effectively prevent overdose mortality.     

Overdose training and take-home naloxone for opiate users: prospective cohort study of impact on knowledge and attitudes and subsequent management of overdoses

Aim To examine the impact of training in overdose management and naloxone provision on the knowledge and confidence of current opiate users; and to record subsequent management of overdoses that occur during a 3‐month follow‐up period. Design Repeated‐measures design to examine changes in knowledge and confidence immediately after overdose management training; retention of knowledge and confidence at 3 months; and prospective cohort study design to document actual interventions applied at post‐training overdose situations. Method A total of 239 opiate users in treatment completed a pre‐training questionnaire on overdose management and naloxone administration and were re‐assessed immediately post‐training, at which point they were provided with the take‐home emergency supply of naloxone. Three months later they were re‐interviewed. Results Significant improvements were seen in knowledge of risks of overdose, characteristics of overdose and appropriate actions to be taken; and in confidence in the administration of naloxone. A 78% follow‐up rate was achieved (186 of 239) among whom knowledge of both the risks and physical/behavioural characteristics of overdose and also of recommended management actions was well retained. Eighteen overdoses (either experienced or witnessed) had occurred during the 3 months between the training and the follow‐up. Naloxone was used on 12 occasions (a trained client's own supply on 10 occasions). One death occurred in one of the six overdoses where naloxone was not used. Where naloxone was used, all 12 resulted in successful reversal. Conclusions With overdose management training, opiate users can be trained to execute appropriate actions to assist the successful reversal of potentially fatal overdose. Wider provision may reduce drug‐related deaths further. Future studies should examine whether public policy of wider overdose management training and naloxone provision could reduce the extent of opiate overdose fatalities, particularly at times of recognized increased risk.     

Transient changes in behaviour lead to heroin overdose: results from a case-crossover study of non-fatal overdose

BACKGROUND AND AIMS: Heroin overdose is a serious consequence of heroin use and one of the leading causes of premature death and illness in Australia. Despite considerable research effort little is known about the effects of transient changes in heroin user behaviour and the links to overdose. This research is the first to use a suitable methodology to allow such ephemeral changes and their effects on non-fatal heroin overdose to be examined. METHODS: A case-crossover design was used in which non-fatal heroin overdose survivors' recall of risk behaviours in the 12 hours prior to overdose (hazard period) was compared to their recall of risk behaviours in the 12 hours prior to a selected non-overdose heroin injection (control period). RESULTS: A total of 155 participants were able to provide valid details of hazard and control periods. A dose-response relationship was observed between the self-reported amount of heroin used and likelihood of overdose (e.g. > AUD50, OR 12.97, 95% CI 2.54-66.31). The use of benzodiazepines (OR 28, 95% CI 3.81-205.79) or alcohol (OR 2.88, 95% CI 1.29-6.43), during the hazard period was related to overdose risk, but the effect of alcohol was attenuated by the effect of benzodiazepines. Shifting from private to public locations between control and hazard periods was also related to increased risk of overdose (OR 3.63, 95% CI 1.66-7.93). CONCLUSIONS: We demonstrate the value of a new methodology to explore heroin overdose, as well as discussing its limitations and ways to overcome them in future. In terms of our findings, overdose prevention messages need to highlight the impact of these transient changes in behaviour and to emphasize the risks of using higher doses of heroin as well as continuing to emphasize the risks of combining heroin with other central nervous system (CNS) depressants. Safer environments for heroin use, such as injecting rooms, may also reduce the chances of overdose.