Evaluation of an overdose prevention and response training programme for injection drug users in the Skid Row area of Los Angeles,CA

BackgroundFatal opioid overdose is a significant cause of mortality among injection drug users (IDUs).MethodsWe evaluated an overdose prevention and response training programme for IDUs run by a community-based organisation in Los Angeles, CA. During a 1-h training session participants learned skills to prevent, recognise, and respond to opioid overdoses, including: calling for emergency services, performing rescue breathing, and administering an intramuscular injection of naloxone (an opioid antagonist). Between September 2006 and January 2008, 93 IDUs were trained. Of those, 66 (71%) enrolled in the evaluation study and 47 participants (71%) completed an interview at baseline and 3-month follow-up.ResultsTwenty-one percent of participants were female, 42% were white, 29% African American, and 18% Latino. Most were homeless or lived in temporary accommodation (73%). We found significant increases in knowledge about overdose, in particular about the use of naloxone. Twenty-two participants responded to 35 overdoses during the follow-up period. Twenty-six overdose victims recovered, four died, and the outcome of five cases was unknown. Response techniques included: staying with the victim (85%), administering naloxone (80%), providing rescue breathing (66%), and calling emergency services (60%). The average number of appropriate response techniques used by participants increased significantly from baseline to follow-up (p < 0.05). Half (53%) of programme participants reported decreased drug use at follow-up.ConclusionOverdose prevention and response training programmes may be associated with improved overdose response behaviour, with few adverse consequences and some unforeseen benefits, such as reductions in personal drug use.     

Overdoses among friends: drug users are willing to administer naloxone to others

The distribution of naloxone to heroin users is a suggested intervention to reduce overdose and death rates. However, the level of willingness of drug users to administer this medication to others is unclear. Drug users recruited from the community between January 2002 and January 2004 completed a structured interview that assessed topics including drug use, overdose history, and attitudes toward using overdose remedies to assist others. Of the 329 drug users, 82% had used heroin and 64.3% reported that they had injected drugs. Nearly two thirds (64.6%) said that they had witnessed a drug overdose and more than one third (34.6%) had experienced an accidental drug overdose. Most participants (88.5%) said that they would be willing to administer a medication to another drug user in the event of an overdose. Participants who had used heroin (p = .024), had injected drugs (p = .022), had witnessed a drug overdose (p = .001), or had a history of one or more accidental drug overdoses (p = .009) were significantly more willing to treat a companion who had overdosed. Drug users were willing to use naloxone in the event of a friend's overdose. Specific drug use and overdose histories were associated with the greatest willingness to administer naloxone.     

Responsible management and use of a personal take-home naloxone supply: A pilot project

Aims: To assess if Scottish drug users, their family and friends could be trained in critical incident management and the safe and effective administration of naloxone. The project also sought to monitor whether drug users can manage their own personal take-home naloxone (THN) supply and use it appropriately in an emergency opiate overdose situation.

Methods: Twenty-three clients were trained alongside 18 ‘buddies’ and 19 clients were issued with naloxone packs following successful completion of training.

Findings: Three overdoses were witnessed by three participant clients during the pilot with two reported ‘saves’; pilot training procedure was followed on both occasions. Each reported overdose was validated by police and ambulance service records. Eighty-nine percent (n = 17) were followed up at 2 months; 94% (n = 16) of these claimed to still have their THN; 89% (n = 17) followed up at 6 months; 100% (n = 17) of these claimed to still have their THN.

Results: This data suggests that Scottish drug users can be trained to identify and respond to an opiate overdose utilizing basic life support and naloxone administration skills similar to their counterparts from other parts of the world. Moreover these results suggest that a majority of opiate users can responsibly manage their own personal THN supply when trained appropriately.     

Brief overdose education can significantly increase accurate recognition of opioid overdose among heroin users

BackgroundIn an effort to increase effective intervention following opioid overdose, the New York State Department of Health (NYSDOH) has implemented programs where bystanders are given brief education in recognizing the signs of opioid overdose and how to provide intervention, including the use of naloxone. The current study sought to assess the ability of NYSDOH training to increase accurate identification of opioid and non-opioid overdose, and naloxone use among heroin users.MethodsEighty-four participants completed a test on overdose knowledge comprised of 16 putative overdose scenarios. Forty-four individuals completed the questionnaire immediately prior to and following standard overdose prevention training. A control group (n = 40), who opted out of training, completed the questionnaire just once.ResultsOverdose training significantly increased participants’ ability to accurately identify opioid overdose (p < 0.05), and scenarios where naloxone administration was indicated (p < 0.05). Training did not alter recognition of non-opioid overdose or non-overdose situations where naloxone should not be administered.ConclusionsThe data indicate that overdose prevention training improves participants’ knowledge of opioid overdose and naloxone use, but naloxone may be administered in some situations where it is not warranted. Training curriculum could be improved by teaching individuals to recognize symptoms of non-opioid drug over-intoxication.     

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.     

Using a group approach to preventing heroin overdose in North London

Aims: This study used group psycho-education methods to assist injecting heroin users in preventing, and responding to overdose. Methods: An ‘OD Prevention’ group was advertised in a London prescribing service and associated primary care unit. The intervention took place in a small group over one afternoon (3.5 hours), and trained participants in recognizing, and responding to heroin overdoses (defining overdose, discussing known risk factors and on-site instruction in cardio-pulmonary resuscitation (CPR). Participants were all injecting heroin users in service contact with the primary care unit, drug dependence unit, or hostels for the homeless in central London. Participants self-referred, or were referred by key workers. Participants completed pre- and post-group questionnaires concerning their personal experience of overdose, the witnessing of others’ overdoses and fatalities, their current response in overdose situations, and their overall confidence in helping others who have overdosed. Findings: In total 107 people attended the group. Of these, 42% had witnessed others’ overdose, and 29% had witnessed one or more deaths as a result of overdose. Following the group intervention more participants reported feeling ‘quite or very confident’ in managing an OD situation, confident in undertaking CPR with someone who had overdosed, and were less likely to pursue ‘folklore’ remedies to overdose. Conclusions: Using psycho-educational group approaches can be an effective tool in attempts to prevent and respond to heroin overdoses, and is seen as useful by users.     

Stigma and drug use settings as correlates of self-reported,non-fatal overdose among people who use drugs in Baltimore,Maryland

BackgroundFatalities from opioid overdose quadrupled during the last 15 years as illicit opioid use increased. This study assesses how stigma and drug use settings are associated with non-fatal overdose to identify targets for overdose risk reduction interventions and inform overdose education and naloxone distribution programs.MethodsWe surveyed 444 people who used drugs in Baltimore, Maryland, USA, from 2009 to 2013 as part of a randomized clinical trial of a harm reduction intervention. Participants reported demographic characteristics, drug use, overdose history, use of a local syringe services program, involvement in the local drug economy, and whether they experienced discrimination from others (i.e., enacted stigma) or stigmatized themselves (i.e., internalized stigma) related to their drug use. We used multinomial logistic regression models to identify correlates of experiencing a non-fatal overdose within the past year or >1 year ago relative to participants who never experienced an overdose.ResultsStigma was positively associated with experiencing a non-fatal overdose in the past year (adjusted Odds Ratio [aOR]: 1.7, 95% Confidence Interval [CI]: 1.1–2.7) and >1 year ago (aOR [95% CI]: 1.5 [1.1–2.0]) after adjustment for demographic and substance use characteristics. The association of stigma with overdose was stronger for enacted versus internalized stigma. The number of public settings (shooting gallery, crack house, abandoned building, public bathroom, outside) where participants used drugs was also positively associated with experiencing an overdose.ConclusionsStigma related to drug use and using drugs in more settings may increase overdose risk. The effectiveness of overdose prevention and naloxone training may be improved by reducing discrimination against people who use drugs in community and medical settings and diversifying the settings in which overdose prevention trainings are delivered. These efforts may be enhanced by use of peer outreach approaches in which people who use drugs diffuse prevention messages through their social networks and within settings of drug consumption outside the medical setting.     

Book Reviews

Aim: To assess (a) carers’ experiences of witnessing overdose; (b) their training needs; and (c) their interest in receiving training in overdose management.

Design: Postal questionnaire distributed through consenting participating local carer group co-ordinators in England.

Sample: 147 carers attending local support groups for friends and families of drug users.

Findings: Carers were usually parents (80%); 89% were currently caring for a heroin user of whom 49% had already had an overdose (93% involving opiates). One third had witnessed heroin being used, and 31 had witnessed an overdose. For eight carers, there had already been a death from drug overdose. There was poor knowledge of how to manage an overdose. Only a quarter had received advice on overdose management (26%) and only one third knew of the opiate antagonist naloxone (33%). The majority (88%) wanted training in overdose management, especially in emergency naloxone administration (88%). Interest in training did not differ according to carer type nor previous overdose experience.

Conclusion: We found evidence of an extensively overlooked carer population, many of whom have already been faced with an overdose situation and yet have received minimal training. We also found high levels of interest in receiving overdose training, in particular, in emergency naloxone administration.     

The impact of take-home naloxone distribution and training on opiate overdose knowledge and response: An evaluation of the THN Project in Wales

Aims: To determine the impact of naloxone training on knowledge of opiate overdose and confidence and willingness to take appropriate action and to examine the use of naloxone and other harm-reduction actions at the time of overdose events. Methods: The evaluation was based on a repeated-measure design, whereby clients were tested before and after training. In total, 521 opiate users and four non-opiate users, drawn from five community sites (362) and three prison locations (163), completed pre- and post-test self-completed questionnaires. Actions taken at the time of overdose events by the naloxone group and a comparison group were compared using forms completed by agency staff. Findings: Knowledge about how to recognise and respond to overdose events increased among trainees across all measures. So too did perceived confidence in responding to them and willingness to carry out the recommended procedures. Over the course of the evaluation, there were 28 recorded uses of naloxone, resulting in 27 recoveries and one fatality. Conclusions: The study has shown that training in overdose management and the use of naloxone can bring about significant improvements in knowledge and willingness to take action. THN trainees also demonstrated that they were able to use naloxone successfully in overdose events.     

A qualitative evaluation of a peer-implemented overdose response pilot project in Gejiu, China

Background

A harm reduction NGO in southern Yunnan operating an emergency overdose response hotline service successfully reversed 76 overdoses through the administration of naloxone in one of the first interventions of its kind in China.

Method

To explore local understandings of risk factors related to overdose, assess ongoing barriers to overdose response, and solicit client input on how to further reduce opiate overdose mortality in Gejiu, the authors conducted qualitative interviews with 30 clients, including 15 individuals who received naloxone injections to reverse an overdose and 15 individuals who called the hotline in response to the overdose of a peer.

Results

Participants pointed to a number of local structural shifts in heroin use including the ageing of the opiate using population and drug mixing practises that contribute to the city's overdose toll. Concerns over medical professionals’ willingness to treat drug users, protection of confidentiality, and financial costs associated with treatment frequently cause drug users to avoid contact with the city's emergency service providers. Participants suggest directly distributing naloxone to clients as one strategy to further reduce overdose mortality.

Conclusion

The authors explore possible strategies, including targeted trainings and new partnerships with local hospitals, to further reduce opiate overdose mortality in this resource-poor setting.     

Evaluation of overdose prevention trainings in New York City: Knowledge and self-efficacy among participants 12 months after training

ABSTRACT

Background: Prevention of unintentional opioid overdose deaths is effective through overdose prevention trainings (OPTs), in which laypersons are taught overdose response through six actions. This longitudinal study examines trainee knowledge 12 months after OPT completion. Methods: Participants were enrolled following OPT at six sites. At the 12-month follow-up, participants were asked to name the drug overdoses that naloxone reverses and name overdose response actions. A 6-point scale was created and was comprised of the number of correct overdose response actions mentioned (check breathing; administer sternum rub; call 911; give rescue breathing; administer naloxone; put victim in recovery position). Mean knowledge was compared by participant sociodemographic characteristics, confidence, and site of OPT training (indoors versus outdoors). Results: Of 344 OPT participants, 273 were reached at 12 months. Nearly all (99%) participants identified that naloxone reverses heroin overdoes; 77% identified that naloxone reverses opioid analgesics overdoses; and 68% identified that naloxone reverses methadone overdoses. Overdose response actions most frequently mentioned were giving naloxone (86%) and calling 911 (76%). The remaining four actions were mentioned by less than 40% of participants. Overall mean knowledge score was 2.7 out of 6. Mean knowledge scores were higher for college graduates than those with less than college education (3.2 vs 2.6, P < 0.001), for those who felt very confident (mean score [ms] = 2.9), compared to somewhat confident (ms = 2.4) and a little or not at all confident (ms = 1.5) in their ability to reverse an overdose (P < .001), and for indoor-training recipients (3.0 vs 2.5, P = 0.02). There were no differences in mean knowledge scores for trainees by age, race, or gender. Conclusions: These findings suggest the need for several improvements in OPT curriculum, including emphasis on naloxone reversal of opioid analgesic and methadone overdoses, and all 6 rescue actions. Lower knowledge scores among outdoor-trained participants likely reflect session brevity, suggesting that outdoor trainings need to be enhanced.     

Social and structural aspects of the overdose risk environment in St. Petersburg, Russia

BackgroundWhile overdose is a common cause of mortality among opioid injectors worldwide, little information exists on opioid overdoses or how context may influence overdose risk in Russia. This study sought to uncover social and structural aspects contributing to fatal overdose risk in St. Petersburg and assess prevention intervention feasibility.MethodsTwenty-one key informant interviews were conducted with drug users, treatment providers, toxicologists, police, and ambulance staff. Thematic coding of interview content was conducted to elucidate elements of the overdose risk environment.ResultsSeveral factors within St. Petersburg's environment were identified as shaping illicit drug users’ risk behaviours and contributing to conditions of suboptimal response to overdose in the community. Most drug users live and experience overdoses at home, where family and home environment may mediate or moderate risk behaviours. The overdose risk environment is also worsened by inefficient emergency response infrastructure, insufficient cardiopulmonary or naloxone training resources, and the preponderance of abstinence-based treatment approaches to the exclusion of other treatment modalities. However, attitudes of drug users and law enforcement officials generally support overdose prevention intervention feasibility. Modifiable aspects of the risk environment suggest community-based and structural interventions, including overdose response training for drug users and professionals that encompasses naloxone distribution to the users and equipping more ambulances with naloxone.ConclusionLocal social and structural elements influence risk environments for overdose. Interventions at the community and structural levels to prevent and respond to opioid overdoses are needed for and integral to reducing overdose mortality in St. Petersburg.     

Naloxone access for Emergency Medical Technicians: An evaluation of a training program in rural communities

IntroductionOpioid-related overdose death rates in rural communities in the United States are much higher than their urban counterparts. However, basic life support (BLS) personnel, who are more common in rural areas, have much lower rates of naloxone administration than other levels of emergency medical services (EMS). Training and equipping basic level Emergency Medical Technician (EMTs) to administer naloxone for an opioid overdose could yield positive outcomes.MethodsFollowing a legislative change that allowed EMTs to administer naloxone in one rural state, we evaluated an EMT training program by examining EMTs' opioid overdose knowledge and attitudes before and after the training.ResultsOne-hundred-seventeen rural EMTs participated the training. They demonstrated statistically significant improvements on almost all of the knowledge questions after the training (p's = 0.0469 to <0.0001). The opioid overdose competency and concern scales showed statistically significant improvement (p < 0.0001) and reduction (p < 0.0001), respectively. Furthermore, statistically significant changes in knowledge and opinions of state law regarding naloxone administration were observed. Significantly more EMTs supported the idea of expanding naloxone to people at risk for overdose (p = 0.0026) after the training.ConclusionsAt a time when states are passing legislation to expand first responders' access to naloxone, this study provides evidence about authorizing EMTs to administer naloxone.     

Non-fatal opioid overdose,naloxone access,and naloxone training among people who recently used opioids or received opioid agonist treatment in Australia: The ETHOS Engage study

BackgroundOverdose is a major cause of morbidity and mortality among people who use opioids. Naloxone can reverse opioid overdoses and can be distributed and administered with minimal training. People with experience of overdose are a key population to target for overdose prevention strategies. This study aims to understand if factors associated with recent non-fatal opioid overdose are the same as factors associated with naloxone access and naloxone training in people who recently used opioids or received opioid agonist treatment (OAT).MethodsETHOS Engage is an observational study of people who inject drugs in Australia. Logistic regression models were used to estimate odds ratios for non-fatal opioid overdose, naloxone access and naloxone training.ResultsBetween May 2018-September 2019, 1280 participants who recently used opioids or received OAT were enrolled (62% aged >40 years; 35% female, 80% receiving OAT, 62% injected drugs in the preceding month). Recent opioid overdose (preceding 12 months) was reported by 7% of participants, lifetime naloxone access by 17%, and lifetime naloxone training by 14%. Compared to people receiving OAT with no additional opioid use, recent opioid, benzodiazepine (preceding six months), and hazardous alcohol use was associated with recent opioid overdose (aOR 3.91; 95%CI: 1.68–9.10) and lifetime naloxone access (aOR 2.12; 95%CI 1.29–3.48). Among 91 people who reported recent overdose, 65% had never received take-home naloxone or naloxone training.ConclusionsAmong people recently using opioids or receiving OAT, benzodiazepine and hazardous alcohol use is associated with non-fatal opioid overdose. Not all factors associated with non-fatal overdose correspond to factors associated with naloxone access. Naloxone access and training is low across all groups. Additional interventions are needed to scale up naloxone provision.     

Prevalence and correlates of opiate overdose among young injection drug users in a large U.S. city

OBJECTIVES: The current study examines the prevalence and correlates of witnessing and experiencing opiate overdoses among a sample of young, injection drug users (IDUs) and non-injection drug users (NIDUs) in Baltimore, MD. METHODS: Data were derived from a longitudinal study of 15-30 year old IDUs and NIDUs (N=309) who had initiated heroin, cocaine, and/or crack use within 5 years prior to study enrollment. Chi-square and Wilcoxon rank-sum tests were used in bivariate analyses of demographic and drug use variables with each of the two dependent variables. Multivariate logistic regression models were used to identify correlates of experiencing and witnessing overdose. RESULTS: Twenty-nine percent of participants reported having ever experienced an opiate overdose and 57% reported having ever witnessed an overdose. Having ever experienced an opiate overdose was independently associated with being White (Adjusted Odds Ratio [AOR]=3.2; 95% Confidence Interval [CI]: 1.6, 6.4) recent homelessness (AOR=2.9; 95%CI: 1.5, 5.7); and length of injection, 5.6-6.9 years versus <5.6 years (AOR=4.0; 95%CI: 1.8-8.9); injecting 7.0-7.9 years versus <5.6 years (AOR=2.5; 95%CI: 1.03-6.1); injecting >8 versus <5.6 years (AOR=4.7; 95%CI: 2.2-10.2). Having witnessed an opiate overdose was independently associated with being White (AOR=2.4; 95%CI: 1.4, 4.1) and injecting >8 years versus <5.6 years (AOR=2.2; 95%CI: 1.2, 4.0). CONCLUSIONS: This study documents the high prevalence of witnessing and experiencing opiate overdoses among young, newly initiated IDUs and NIDUs. The results could inform the growing number of overdose prevention efforts throughout the U.S.