Cost-Effectiveness of Take-Home Naloxone for the Prevention of Overdose Fatalities among Heroin Users in the United Kingdom

Background: Heroin overdose is a major cause of premature death. Naloxone is an opioid antagonist that is effective for the reversal of heroin overdose in emergency situations and can be used by nonmedical responders. Objective: Our aim was to assess the cost-effectiveness of distributing naloxone to adults at risk of heroin overdose for use by nonmedical responders compared with no naloxone distribution in a European healthcare setting (United Kingdom). Methods: A Markov model with an integrated decision tree was developed based on an existing model, using UK data where available. We evaluated an intramuscular naloxone distribution reaching 30% of heroin users. Costs and effects were evaluated over a lifetime and discounted at 3.5%. The results were assessed using deterministic and probabilistic sensitivity analyses. Results: The model estimated that distribution of intramuscular naloxone, would decrease overdose deaths by around 6.6%. In a population of 200,000 heroin users this equates to the prevention of 2,500 premature deaths at an incremental cost per quality-adjusted life year (QALY) gained of £899. The sensitivity analyses confirmed the robustness of the results. Conclusions: Our evaluation suggests that the distribution of take-home naloxone decreased overdose deaths by around 6.6% and was cost-effective with an incremental cost per QALY gained well below a £20,000 willingness-to-pay threshold set by UK decision-makers. The model code has been made available to aid future research. Further study is warranted on the impact of different formulations of naloxone on cost-effectiveness and the impact take-home naloxone has on the wider society.     

The need to prioritize research,policy, and practice to address the overdose epidemic in smaller settings in Canada

The majority of research and policy directives targeting opioid use and overdose prevention are based in larger urban settings and not easily adaptable to smaller Canadian settings (i.e., small- to mid-sized cities and rural areas). We identify a variety of research and policy gaps in smaller settings, including limited access to supervised consumption services, safer supply and novel opioid agonist therapy programs, as well as housing-based services and supports. Additionally, we identify the need for novel strategies to improve healthcare access and health outcomes in a more equitable way for people who use drugs, including virtual opioid agonist therapy clinics, episodic overdose prevention services, and housing-based harm reduction programs that are better suited for smaller settings. These programs should be coupled with rigorous evaluation, in order to understand the unique factors that shape overdose risk, opioid use, and service uptake in smaller Canadian settings.     

Attitudes of emergency medical service providers toward naloxone distribution programs

Training and distributing naloxone to drug users is a promising method for reducing deaths associated with heroin overdose. Emergency Medical Service (EMS) providers have experience responding to overdose, administering naloxone, and performing clinical management of the patient. Little is known about the attitudes of EMS providers toward training drug users to use naloxone. We conducted an anonymous survey of 327 EMS providers to assess their attitudes toward a pilot naloxone program. Of 176 who completed the survey, the majority were male (79%) and Caucasian (75%). The average number of years working as an EMS provider was 7 (SD=6). Overall attitudes toward training drug users to administer naloxone were negative with 56% responding that this training would not be effective in reducing overdose deaths. Differences in attitudes did not vary by gender, level of training, or age. Providers with greater number of years working in EMS were more likely to view naloxone trainings as effective in reducing overdose death. Provider concerns included drug users’ inability to properly administer the drug, program condoning and promoting drug use, and unsafe disposal of used needles. Incorporating information about substance abuse and harm reduction approaches in continuing education classes may improve the attitudes of provider toward naloxone training programs.     

Naloxone distribution and cardiopulmonary resuscitation training for injection drug users to prevent heroin overdose death: A pilot intervention study

Fatal heroin overdose has become a leading cause of death among injection drug users (IDUs). Several recent feasibility studies have concluded that naloxone distribution programs for heroin injectors should be implemented to decrease heroin overdose deaths, but there have been no prospective trials of such programs in North America. This pilot study was undertaken to investigate the safety and feasibility of training injection drug using partners to perform cardiopulmonary resuscitation (CPR) and administer naloxone in the event of heroin overdose. During May and June 2001, 24 IDUs (12 pairs of injection partners) were recruited from street settings in San Francisco. Participants took part in 8-hour training in heroin overdose prevention, CPR, and the use of naloxone. Following the intervention, participants were prospectively followed for 6 months to determine the number and outcomes of witnessed heroin overdoses, outcomes of participant interventions, and changes in participants’ knowledge of overdose and drug use behavior. Study participants witnessed 20 heroin overdose events during 6 months follow-up. They performed CPR in 16 (80%) events, administered naloxone in 15 (75%) and did one or the other in 19 (95%). All overdose victims survived. Knowledge about heroin overdose management increased, whereas heroin use decreased. IDUs can be trained to respond to heroin overdose emergencies by performing CPR and administering naloxone. Future research is needed to evaluate the effectiveness of this peer intervention to prevent fatal heroin overdose.     

Risk Factors for Nonfatal Overdose at Seattle-Area Syringe Exchanges

Opioid-involved overdose deaths are on the rise, both nationwide and in the state of Washington. In a survey of 443 participants at syringe exchanges in Seattle, Washington, 16% had overdosed in the last year. Several factors were significantly associated in bivariate analysis: lack of permanent housing; incarceration of five or more days in the past year; gender of sex partners; sharing of syringes and other injection paraphernalia; use of speedballs (cocaine and heroin together), goofballs (methamphetamine and heroin together), buprenorphine; injection use of crack cocaine and sedatives; and use of opioids with sedatives. Adjusting for other variables in multivariate logistic regression analyses, only recent incarceration and sharing of injection materials were still significantly associated with overdose. Correctional facilities, syringe exchange programs, and other agencies serving opioid injectors should include overdose prevention components in release planning and services.     

Expanded Access to Naloxone Among Firefighters,Police Officers,and Emergency Medical Technicians in Massachusetts

Naloxone is a medication that reverses respiratory depression from opioid overdose if given in time. Paramedics routinely administer naloxone to opioid overdose victims in the prehospital setting, and many states are moving to increase access to the medication. Several jurisdictions have expanded naloxone administration authority to nonparamedic first responders, and others are considering that step. We report here on policy change in Massachusetts, where several communities have equipped emergency medical technicians, law enforcement officers, and firefighters with naloxone.Fatal poisonings, more than 90% of which are drug overdoses, have increased by nearly 600% in the past 3 decades to become the leading cause of injury death in the United States.1This rise has been driven largely by opioid analgesic medications, which now account for more overdose deaths than heroin and cocaine combined.2 Although first responders are not always contacted in time to reverse overdose, emergency department encounters associated with opioids and other sedatives have increased markedly over the past decade.3To address this epidemic, many states are moving to increase community access to the opioid antagonist naloxone, which can reverse opioid overdose if administered in time.4,5 Nearly 200 community-based overdose prevention programs dispensed naloxone as of 2010, and participants reported reversing more than 10 000 overdoses.6 In Massachusetts, communities participating in a community naloxone access program had lower opioid overdose death rates than those that did not, strongly suggesting that increased access to naloxone can reduce fatal opioid overdose.7Naloxone is the standard medication for reversing opioid overdose, and is routinely administered by paramedics for that purpose. Although paramedics typically administer naloxone intramuscularly (IM) or intraveneously (IV), it can also be administered intranasally (IN) via a needleless atomizer. IN administration of naloxone has been shown to be similarly effective as IV administration in the prehospital setting,8–10 and in one study, IN naloxone administration was faster, better accepted, and perceived to be safer than IV administration.11In many areas, the first emergency personnel to respond to overdose calls are not paramedics but law enforcement officers, firefighters, and emergency medical technicians (EMTs; medical first responders who have a lower level of training than paramedics). The National Drug Control Strategy has called for equipping first responders to recognize and manage overdoses since 2010, and the Office of National Drug Control Policy has stated that naloxone “should be in the patrol cars of every law enforcement professional across the nation.”12 Although these first responders in most states are not authorized to administer naloxone, this is rapidly changing; in 2013, 5 states changed law or policy to permit EMTs to administer naloxone, bringing the total up to 13 states.13 Access to emergency prehospital care, including the provision of naloxone, may be an important piece in the overdose prevention puzzle. Nationwide, EMTs outnumber paramedics by approximately 3-to-1, and law enforcement officers are even more numerous.14 In rural areas, EMTs may be the only medical first responders, and hospital transport times can be long.15 A study in one large county demonstrated that EMT nasal naloxone administration could reduce time to naloxone delivery by between 5.7 and 10.2 minutes.16 In tiered EMS departments with high overdose call volume, efficiencies may be created by dispatching EMTs instead of paramedics to overdose calls, reducing response time, and making paramedics available to respond to emergencies that require a higher level of skill and training.16,17We provide an overview of policy change in 3 communities in Massachusetts that expanded naloxone access to firefighters, EMTs, and police officers, and offer some brief thoughts on what this change might mean for other jurisdictions.     

Neighborhood-Level and Spatial Characteristics Associated with Lay Naloxone Reversal Events and Opioid Overdose Deaths

There were over 23,000 opioid overdose deaths in the USA in 2013, and opioid-related mortality is increasing. Increased access to naloxone, particularly through community-based lay naloxone distribution, is a widely supported strategy to reduce opioid overdose mortality; however, little is known about the ecological and spatial patterns of the distribution and utilization of lay naloxone. This study aims to investigate the neighborhood-level correlates and spatial relationships of lay naloxone distribution and utilization and opioid overdose deaths. We determined the locations of lay naloxone distribution sites and the number of unintentional opioid overdose deaths and reported reversal events in San Francisco census tracts (n = 195) from 2010 to 2012. We used Wilcoxon rank-sum tests to compare census tract characteristics across tracts adjacent and not adjacent to distribution sites and multivariable negative binomial regression models to assess the association between census tract characteristics, including distance to the nearest site, and counts of opioid overdose deaths and naloxone reversal events. Three hundred forty-two opioid overdose deaths and 316 overdose reversals with valid location data were included in our analysis. Census tracts including or adjacent to a distribution site had higher income inequality, lower percentage black or African American residents, more drug arrests, higher population density, more overdose deaths, and more reversal events (all p < 0.05). In multivariable analysis, greater distance to the nearest distribution site (up to a distance of 4000 m) was associated with a lower count of Naloxone reversals [incidence rate ratio (IRR) = 0.51 per 500 m increase, 95% CI 0.39–0.67, p < 0.001] but was not significantly associated with opioid overdose deaths. These findings affirm that locating lay naloxone distribution sites in areas with high levels of substance use and overdose risk facilitates reversals of opioid overdoses in those immediate areas but suggests that alternative delivery methods may be necessary to reach individuals in other areas with less concentrated risk.     

Opioid Agonist Treatments and Heroin Overdose Deaths in Baltimore,Maryland, 1995–2009

Objectives. We examined the association between the expansion of methadone and buprenorphine treatment and the prevalence of heroin overdose deaths in Baltimore, Maryland from 1995 to 2009.Methods. We conducted a longitudinal time series analysis of archival data using linear regression with the Newey–West method to correct SEs for heteroscedasticity and autocorrelation, adjusting for average heroin purity.Results. Overdose deaths attributed to heroin ranged from a high of 312 in 1999 to a low of 106 in 2008. While mean heroin purity rose sharply (1995–1999), the increasing number of patients treated with methadone was not associated with a change in the number of overdose deaths, but starting in 2000 expansion of opioid agonist treatment was associated with a decline in overdose deaths. Adjusting for heroin purity and the number of methadone patients, there was a statistically significant inverse relationship between heroin overdose deaths and patients treated with buprenorphine (P = .002).Conclusions. Increased access to opioid agonist treatment was associated with a reduction in heroin overdose deaths. Implementing policies that support evidence-based medication treatment of opiate dependence may decrease heroin overdose deaths.Heroin overdose death is a major public health problem throughout the world.1–4 Factors thought to be related to the prevalence of heroin overdose death include the availability and purity of heroin on the streets,5–8 periods of brief incarceration or detoxification that lower opioid tolerance,9–14 and the availability and penetration of opioid agonist treatment.1,15–17 Among public health treatment strategies to reduce opioid overdose deaths are increasing opioid agonist maintenance treatments, such as those involving methadone and buprenorphine; using depot naltrexone18; and distributing naloxone.19,20In Baltimore, Maryland, throughout the 1990s, heroin use and addiction were associated with an alarming number of overdose deaths, and from 1990 to 1997 drug overdose deaths increased by 426%, an increase that exceeded that of all the other 26 major US cities reporting to the federal Drug Abuse Warning Network during the same period.21 Starting in 1998, city and state leaders and local foundations renewed efforts to expand access to drug abuse treatment to reduce the impact of heroin and other drug addiction. The city obtained increased state and city funding for drug abuse treatment and reformed zoning laws to ease the opening of new drug abuse treatment programs. Through these efforts, the city’s methadone treatment capacity increased significantly over the next 6 years.With the passage of the Drug Abuse Treatment Act of 2000 and the Food and Drug Administration’s approval of buprenorphine for the treatment of opioid dependence,22 buprenorphine became available through private physician offices and in some community health centers in Baltimore. Maryland added buprenorphine to its Medicaid formulary in 2003 and organized efforts to enroll patients in Medicaid. In late 2006, the Baltimore City Health Department and the local substance abuse authority, the Baltimore Substance Abuse Systems, Inc., funded an initiative to expand access to buprenorphine treatment through formerly drug-free outpatient clinics and physicians’ offices by providing funding for Baltimore City physicians to obtain training and the necessary federal license to prescribe buprenorphine. This initiative integrated buprenorphine into the Baltimore Substance Abuse Systems, Inc.–funded network of drug-free outpatient clinics and created a system, overseen by the local nonprofit Baltimore Healthcare Access, to transfer stabilized buprenorphine patients to primary care physicians in community health centers and other primary care sites for ongoing care. From 2006 through 2009, the number of patients treated with buprenorphine in Baltimore City increased substantially.Through the efforts to expand methadone treatment in regulated opioid treatment programs and the increase in availability of buprenorphine treatment outside such programs, the number of patients treated with these evidence-based medications nearly quadrupled from 1995 through 2009. Meanwhile, heroin overdose deaths declined from a peak of 312 in 1999 to 118 in 2009. We examined the association between the increase in the number of patients treated with methadone and buprenorphine and the decline in heroin overdose deaths. We used archival data obtained from various public and private sources to examine the association between heroin overdose deaths and the increase in methadone and buprenorphine patients, controlling for the average purity of seized heroin in Baltimore City from 1995 through 2009.     

Vital Signs: Drug Overdose Deaths,by Selected Sociodemographic and Social Determinants of Health Characteristics — 25 States and the District of Columbia, 2019–2020

Introduction: Drug overdose deaths increased approximately 30% from 2019 to 2020 in the United States. Examining rates by demographic and social determinants of health characteristics can identify disproportionately affected populations and inform strategies to reduce drug overdose deaths.Methods: Data from the State Unintentional Drug Overdose Reporting System (SUDORS) were used to analyze overdose death rates from 2019 to 2020 in 25 states and the District of Columbia. Rates were examined by race and ethnicity and county-level social determinants of health (e.g., income inequality and treatment provider availability).Results: From 2019 to 2020, drug overdose death rates increased by 44% and 39% among non-Hispanic Black (Black) and non-Hispanic American Indian or Alaska Native (AI/AN) persons, respectively. Significant disparities were found across sex, age, and racial and ethnic subgroups. In particular, the rate in 2020 among Black males aged ≥65 years (52.6 per 100,000) was nearly seven times that of non-Hispanic White males aged ≥65 years (7.7). A history of substance use was frequently reported. Evidence of previous substance use treatment was lowest for Black persons (8.3%). Disparities in overdose deaths, particularly among Black persons, were larger in counties with greater income inequality. Opioid overdose rates in 2020 were higher in areas with more opioid treatment program availability compared with areas with lower opioid treatment availability, particularly among Black (34.3 versus 16.6) and AI/AN (33.4 versus 16.2) persons.Conclusions and Implications for Public Health Practice: Health disparities in overdose rates continue to worsen, particularly among Black and AI/AN persons; social determinants of health, such as income inequality, exacerbate these inequities. Implementation of available, evidence-based, culturally responsive overdose prevention and response efforts that address health disparities impacting disproportionately affected populations are urgently needed.     

A qualitative study of overdose responses among Chicago IDUs

Background  

Opioid overdose is a leading cause of death among injection drug users. Over half of injection drug users report at least one nonfatal overdose during their lifetime. Death from opioid overdose rarely occurs instantaneously, but rather over the course of one to three hours, allowing ample time for providing life-saving measures. In response to the prevalence of overdoses in the U.S., there are a growing number of overdose prevention and naloxone distribution programs targeting the injection drug using community.     

Attitudes about prescribing take-home naloxone to injection drug users for the management of heroin overdose: a survey of street-recruited injectors in the San Francisco Bay Area

Naloxone, an injectable opiate antagonist, can immediately reverse an opiate overdose and prevent overdose death. We sought to determine injection drug users’ (IDUs) attitudes about being prescribed take-home naloxone. During November 1999 to February 2000, we surveyed 82 street-recruited IDUs from the San Francisco Bay Area of California who had experienced one or more heroin overdose events. We used a questiomaire that included structured and open-ended questions. Most respondents (89%) had witnessed an overdose, and 90% reported initially attempting lay remedies in an effort to help companions survive. Only 51% reported soliciting emergency assistance (calling 911) for the last witnessed overdose, with most hesitating due to fear of police involvement. Of IDUs surveyed, 87% were strongly in favor of participating in an overdose management training program to receive take-home naloxone and training in resuscitation techniques. Nevertheless, respontdents expressed a variety of concerning attitudes. If provided naloxone, 35% predicted that they might feel comfortable using greater amounts of heroin, 62% might be less inclined to call 911 for an overdose, 30% might leave an overdose victim after naloxone resuscitation, and 46% might not be able to dissuade the victim from using heroin again to alleviate with drawal symptoms induced by naloxone. Prescribing take-home naloxone to IDUs with training in its use and in resuscitation techniques may represent a life-saving, peer-based adjunct to accessing emergency services. Nevertheless, strategies for overcoming potential risks associated with the use of take-home naloxone would need to be emphasized in an overdose management training program.