Promoting opioid overdose prevention and recovery: An exploratory study of an innovative intervention model to address opioid abuse

BackgroundFatal opioid overdose is a national public health concern in the United States and a critical problem confronting New Jersey’s addiction treatment system. New Jersey developed an innovative program, the Opioid Overdose Recovery Program (OORP), to address the epidemic and the issue of low treatment admissions following a non-fatal overdose. The OORP utilizes an intervention model with peer recovery specialists (RSs) and patient navigators (PNs) to engage individuals within emergency departments (EDs) immediately following an opioid overdose reversal. The purpose of this exploratory s/tudy was to examine the process through which the OORP was implemented in its first year and determine facilitators and barriers to implementation.MethodsData were collected in 2016–2017, through 17 telephone interviews and focus groups with 39 participants. Participants were OORP staff and stakeholders selected through purposeful, non-random sampling. Standardized, open-ended interview guides were used. Thematic analysis was conducted to identify, analyze, and report overall patterns.ResultsParticipants detailed stories from the field and policymakers illuminated the process of implementation. Findings revealed logistical barriers to treatment including patients’ lack of insurance and cell phones, lack of immediately available detox beds, and program ineligibility for some patients due to medical conditions. The model using peers as first responders had a positive impact as their experiences with addiction enabled them to more successfully engage patients. The PNs were critical in addressing high needs for case management and referral and external partners were also important for implementation.ConclusionsResults underscore the effort needed to integrate this important model within EDs as part of a multi-level approach to address opioid misuse. The identified challenges led to statewide strategic planning and areas for further development. OORP is a promising intervention that might increase the number of individuals suffering with opioid disorders linked to peer support, treatment and recovery.     

Developing interagency collaboration to address the opioid epidemic: A scoping review of joint criminal justice and healthcare initiatives

BackgroundWith the current opioid epidemic impacting well over half of all counties across the United States, initiatives that encourage interagency collaboration between first responder organizations appear necessary to comprehensively address this crisis. Police, fire, and emergency medical services (EMS) are in a unique position to identify substance users and provide necessary resources to initiate treatment, yet there is not sufficient evidence of joint collaborative programs between law enforcement/first responders and healthcare providers.MethodsIn this scoping review we examine the current state of joint criminal justice and healthcare interventions, specifically, opioid and substance use pre-arrest initiatives via emergency first responders and police officers. We relied on data from the last 10 years across three major databases to assess the extent of criminal justice (CJ) and healthcare collaborations as a response to individuals with opioid use disorder (OUD). We specifically focused on interventional programs between criminal justice first responders (pre-arrest) and healthcare providers where specific outcomes were documented.ResultsWe identified only a small number (6) of studies involving interventions that met this criteria, suggesting very limited study of joint interagency collaboration between law enforcement first responders and healthcare providers. Most had small samples, none were in the southern states, and all but one were initiated within the last 5 years.ConclusionsAlthough studies describing joint efforts of early intercept criminal justice responses and healthcare interventions were few, existing studies suggest that such programs were effective at improving treatment referral and retention outcomes. Greater resources are needed to encourage criminal justice and healthcare collaboration and policies, making it easier to share data, refer patients, and coordinate care for individuals with OUD.     

Restrictive opioid prescribing policies and evolving risk environments: A qualitative study of the perspectives of patients who experienced an accidental opioid overdose

BackgroundDespite policy efforts to prevent overdose, accidental overdoses among individuals prescribed opioids continue to occur. Guided by Rhodes’ Risk Environment Framework, we examined the unintended consequences of restrictive policies by identifying macro policy and micro-level contextual factors that patients prescribed opioids for pain identified as contributing to overdose events.MethodsSemi-structured interviews were conducted with 31 patients prescribed opioids who experienced an accidental opioid overdose between April 2017 and June 2019 in two health systems.ResultsWe identified three interrelated factors that emerged within an evolving risk environment and may have increased patients’ vulnerability for an accidental opioid overdose: desperation from persistent pain and comorbidities; limited knowledge about opioid medication safety and effectiveness; and restrictive opioid prescribing policies that exacerbated stigma, fear and mistrust and prevented open patient-clinician communication. When experiencing persistent pain, patients took matters into their own hands by taking more medications or in different intervals than prescribed, mixing them with other substances, or using illicitly obtained opioids.ConclusionFor some patients, macro-level policies and guidelines designed to reduce opioid overdoses by restricting opioid supply may have paradoxically created a micro-level risk environment that contributed to overdose events in a subset of patients.     

The role of take-home naloxone in the epidemic of opioid overdose involving illicitly manufactured fentanyl and its analogs

Introduction: There has been an exponential increase in overdose fatalities as illicitly manufactured fentanyl and its analogs (IMF) are becoming more prevalent in the illicit drug supply. In response, overdose education and naloxone distribution (OEND) programs have been implemented throughout the United States as a harm reduction strategy. However, there are increasing reports that higher naloxone doses or repeat administration might be required for overdose victims involving IMF.

Areas covered: In this article, we provide a comprehensive review of the epidemiology, public health impact, and pharmacologic properties of IMF. The pharmacokinetic properties of currently available take-home naloxone (THN) kits, the role of THN as a harm reduction strategy and available data on its clinical use are discussed. Implications of occupational IMF exposure for first responders are also described.

Expert opinion: THN administration by a bystander is an effective harm reduction intervention. However, there is growing evidence that higher dose or multiple administrations of naloxone are required to fully reverse IMF related toxicity. Recently, the US Food and Drug Administration approved THN kits with a concentrated naloxone dose that produce high bioavailability. However, limited presence of OEND programs and cost of these new devices impede their accessibility to the general public.     

High occurrence of witnessing an opioid overdose in a sample of women who use heroin in Tanzania: Implications for overdose prevention

BackgroundOpioid overdose is preventable and reversible. To target overdose prevention training and naloxone distribution, it is important to understand characteristics of those people who use drugs most likely to witness an overdose. In this paper we report the proportion and characteristics of women who use heroin that have witnessed an opioid overdose in Dar es Salaam, Tanzania.MethodsWe conducted a cross-sectional survey with 200 women who use heroin. We fitted unadjusted and adjusted logistic regression models with witnessing an opioid overdose as the dependent variable and sociodemographic and drug use-related variables as independent variables.ResultsThe majority of participants (85%) reported having ever witnessed an opioid overdose. Age (adjusted Odds Ratio [aOR] = 1.09; 95% CI: 1.02–1.12), having ever attempted to stop heroin use (aOR = 11.27; 95% CI: 2.25–56.46), history of arrest (aOR = 3.75; 95% CI: 1.32–10.63), and spending time daily in places where people use drugs (aOR = 3.72; 95% CI: 1.43–9.64) were found to be independently associated with ever witnessing an overdose.ConclusionsFindings suggest the need for expanded access to naloxone to lay people and community and peer-based overdose prevention training in Tanzania, including the distribution of naloxone in settings with high drug use.     

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

BackgroundRates 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.MethodsWe 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.ResultsFrom 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.ConclusionsWe 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 training for healthcare professionals on how to manage an opioid overdose with naloxone: effective, but dissemination is challenging

Background

Opioid overdose has a high mortality, but is often reversible with appropriate overdose management and naloxone (opioid antagonist). Training in these skills has been successfully trialled internationally with opioid users themselves. Healthcare professionals working in substance misuse are in a prime position to deliver overdose prevention training to drug users and may themselves witness opioid overdoses. The best method of training dissemination has not been identified. The study assessed post-training change in clinician knowledge for managing an opioid overdose and administering naloxone, evaluated the ‘cascade method’ for disseminating training, and identified barriers to implementation.

Methods

A repeated-measures design evaluated knowledge pre-and-post training. A sub-set of clinicians were interviewed to identify barriers to implementation. Clinicians from addiction services across England received training. Participants self-completed a structured questionnaire recording overdose knowledge, confidence and barriers to implementation.

Results

One hundred clinicians were trained initially, who trained a further 119 clinicians (n = 219) and thereafter trained 239 drug users. The mean composite score for opioid overdose risk signs and actions to be taken was 18.3/26 (±3.8) which increased to 21.2/26 (±4.1) after training, demonstrating a significant improvement in knowledge (Z = 9.2, p < 0.001). The proportion of clinicians willing to use naloxone in an opioid overdose rose from 77% to 99% after training. Barriers to implementing training were clinician time and confidence, service resources, client willingness and naloxone formulation.

Conclusions

Training clinicians how to manage an opioid overdose and administer naloxone was effective. However the ‘cascade method’ was only modestly successful for disseminating training to a large clinician workforce, with a range of clinician and service perceived obstacles. Drug policy changes and improvements to educational programmes for drug services would be important to ensure successful implementation of overdose training internationally.     

Evaluation of intraarticular opioid analgesia for the relief of articular pain in the domestic fowl.

An experimental paradigm, based on the microcrystalline sodium urate-induced arthritis pain model, was used to investigate the potential peripheral analgesic properties of a variety of opioid agonists. The response criteria were changes in behavioral profiles and pain-related behaviors over 60 min commencing 1 h after intraarticular injection. The testing system was used to determine the potential optimum dose of intraarticular application of morphine sulphate (1-3 mg), fentanyl citrate (0.5-3 mg), and buprenorphine hydrochloride (0.05-1 mg). None of the opioid analgesics used had any effect on pain behavior, and it was concluded that opioids with a high affinity for the mu receptor when injected intraarticularly were unlikely to be of use in the treatment or diagnosis of inflammatory arthritic pain in the strain of domestic fowl chosen.     

The role of mathematical modelling in aiding public health policy decision-making: A case study of the BC opioid overdose emergency

The province of British Columbia is currently experiencing the highest rate of apparent opioid-related deaths within Canada. This dramatic increase in overdose deaths has been primarily driven by the increase of fentanyl and fentanyl-analogues within the unregulated, highly unpredictable and toxic street drug supply. A public health emergency was declared in B.C. in April 2016. After the emergency was declared, overdose-related death rates continued to rise, reaching unprecedented levels. In the context of enhanced collaboration between government organizations and researchers, a series of mathematical studies improved the ability of government and service providers to understand the impact of scaled-up strategies, including harm reduction and treatment services. In this commentary we describe how government agencies collaborated with researchers and other experts to use modelling results, and describe lessons learned for enhancing these collaborations. Mathematical modelling provides a viable and timely approach to the generation of intelligence, combining disparate data to assess the on-going impact of a comprehensive package of interventions during a public health emergency, and enhancing accountability for investments.     

Ghrelin inhibits inflammatory pain in rats: involvement of the opioid system

This study examined the effects of intracerebroventricular (i.c.v.), intraperitoneal (i.p.) or intraplantar (i.pl.) administration of ghrelin, the endogenous ligand of the growth hormone secretagogue receptor, in the development of hyperalgesia and edema induced by intraplantar injection of carrageenan in rats. Central ghrelin (4 ng to 4 microg/rat) given 5 min before carrageenan produced a dose-related reversal of carrageenan-induced mechanical hyperalgesia measured by Randall-Selitto test with an ED50 of 81.7 ng/rat. Ghrelin at the dose of 4 microg/rat i.c.v. was also effective in inhibiting edema. When ghrelin (4 microg/rat i.c.v.) was administered 150 min after carrageenan, it failed to modify either hyperalgesia or the paw volume. Given i.p., 30 min before carrageenan, ghrelin (20-160 microg/kg) induced a significant dose-dependent inhibition of hyperalgesia with an ED50 of 77 microg/kg and a slight reduction of edema. Intraplantar ghrelin (40 ng to 12 microg/rat) did not significantly modify both the hyperalgesic and edematous activities of carrageenan. The anti-hyperalgesic and anti-edematous effects of ghrelin (4 microg/rat i.c.v.) were reversed by naloxone (10 microg/rat i.c.v.). Systemic administration of the peripheral selective opioid antagonist, naloxone methiodide (3 mg/kg s.c.), did not antagonize antinociception elicited by i.p. ghrelin. Overall these data indicate that ghrelin exerts an inhibitory role on inflammatory pain through an interaction with the central opioid system.     

Evaluation of the use of buprenorphine for opioid withdrawal in an emergency department

OBJECTIVES: To examine the use of buprenorphine for the treatment of opioid withdrawal (OW) in an emergency department (ED) setting. METHODS: The medical records of all adult patients who presented to the study ED during a 10 week period for OW were abstracted. Subjects were categorized as receiving buprenorphine, symptomatic treatment or no pharmacologic treatment for their OW. The three groups were compared by patient and service characteristics, withdrawal symptoms and outcomes. RESULTS: Of the 11,019 patients who presented to the ED during the 10 week study period, 158 (1.4%) were eligible. Subjects were more likely to receive buprenorphine (56%) compared to symptomatic treatment only (26%) or no pharmacologic treatment (18%). Subjects who received buprenorphine were more likely to have a history of suicide ideation (34% versus 12% p<0.05) compared to subjects who received symptomatic treatment(s) and were less likely to present with a gastrointestinal complaint (9% versus 25% p<0.05). Subjects who received buprenorphine were less likely to return to the same ED within 30 days for a drug-related visit (8%) compared to those who received symptomatic treatment (17%) (p<0.05). CONCLUSIONS: Buprenorphine was a common treatment for OW in this ED without any documented adverse outcomes. Given that it did not result in an increase in drug-related return ED visits and its proven efficacy in other settings, a prospective evaluation of its potential value to ED patients who present with OW is warranted.