Use of fentanyl test strips by people who inject drugs: Baseline findings from the South Atlantic Fentanyl Test Strip Study (SAFTSS).

BACKGROUND: Research published during the early fentanyl period exposed a growing concern of unwitting fentanyl exposure and a general willingness to use fentanyl test strips (FTS). A paucity of FTS studies over the last several years has restricted our ability to understand FTS use in the late fentanyl era. The South Atlantic FTS Study (SAFTSS) was established to investigate contemporaneous changes in FTS use and drug use behavior among a rural cohort of PWID. METHODS: Between June 2021 and March 2022, a total of 541 PWID completed an in-person survey. Baseline survey questions included demographics, socioeconomic characteristics, and drugs used. FTS questions covered lifetime use, past 6-months, and past 30-day use and included reasons for using FTS, levels of access, and confidence testing illicit opioids and stimulants. Multivariable analyses examined significant baseline correlates of lifetime and 30-day FTS use. RESULTS: Overall, more than half (58%; N=315) used FTS in their lifetime. Among lifetime FTS users, almost half (47%) used FTS in the past 6 months and 30% in the past 30 days, with an average of 13 months from last FTS use and the baseline survey. The most common reason for not using FTS was "not having them with me when I use drugs." Less frequent reasons were "I already know it's fentanyl" followed by "FTS take too much time to use." Among past 30-day FTS users, 74% used FTS on heroin, 55% on methamphetamine, and 33% on fentanyl. Consumer confidence using FTS was higher with illicit opioids (66%) but lower for methamphetamine (43%). In both the lifetime and past 30-day models, PWID with FTS use were more likely than non-users to have witnessed an overdose in the past six months (lifetime aOR = 2.85, p<.001; 30-day aOR=2.57, p<.01). Virtually no differences in drug use behaviors were found when comparing past 30-days FTS use to no FTS use. Women (aOR=1.68, p<.05) and non-white PWID (aOR=2.43, p<.05) were more likely than men and white PWID to have used FTS. CONCLUSIONS: Declines in FTS use are consistent with what syringe services programs have been signaling for years. Needs assessments to gauge interest in FTS before scaling up can help ensure funding better spent on naloxone and syringes is not allocated to idle FTS. Increased FTS among women and racial minorities presents opportunities for tailored interventions. Recognizing trauma associated with witnessing overdoses as a growing component of the opioid epidemic is a critical first step toward addressing the full spectrum of drug-related harm.

Increasing Access to Naloxone in Veterans Receiving Opioids Through Community Care.

The United States is battling an opioid overdose epidemic, and Veterans are at almost double the risk compared to the general population. Veterans Health Administration (VHA) recognizes the critical role naloxone plays as a risk mitigation strategy in opioid prescribing; however, there was not a standardized process within the Kansas City VA Medical Center's (KCVAMC) community care program. This quality improvement project included Veterans that received opioids through community care from 2022 to 2023. The Stratification Tool for Opioid Risk Mitigation and chart review were used along with descriptive statistics. Results found 11% (22 of 206) of Veterans were dispensed naloxone within one year prior to receiving their opioid prescription. This data indicated the importance of expanding access to naloxone in Veterans receiving opioids from community care providers. As a result of this data, the KCVAMC implemented an outpatient pharmacy protocol to dispense naloxone to appropriate Veterans that receive an opioid through the community care program. The protocol was initiated on March 29, 2023. From the end of March through 2023, naloxone dispensing for these Veterans increased from 11% to 67%.

Overdose Detection Among High-Risk Opioid Users Via a Wearable Chest Sensor in a Supervised Injecting Facility: Protocol for an Observational Study.

BACKGROUND: Opioid overdose is a global health crisis, affecting over 27 million individuals worldwide, with more than 100,000 drug overdose deaths in the United States in 2022-2023. This protocol outlines the development of the PneumoWave chest biosensor, a wearable device being designed to detect respiratory depression in real time through chest motion measurement, intending to enhance early intervention and thereby reduce fatalities. OBJECTIVE: The study aims to (1) differentiate opioid-induced respiratory depression (OIRD) from nonfatal opioid use patterns to develop and refine an overdose detection algorithm and (2) examine participants' acceptability of the chest biosensor. METHODS: The study adopts an observational design over a 6-month period. The biosensor, a small device, will be worn by consenting participants during injecting events to capture chest motion data. Safe injecting facilities (SIF) in Melbourne, Victoria (site 1), and Sydney, New South Wales (site 2), which are legally sanctioned spaces where individuals can use preobtained illicit drugs under medical supervision. Each site is anticipated to recruit up to 100 participants who inject opioids and attend the SIF. Participants will wear the biosensor during supervised injecting events at both sites. The biosensor will attempt to capture data on an anticipated 40 adverse drug events. The biosensor's ability to detect OIRD will be compared to the staff-identified events that use standard protocols for managing overdoses. Measurements will include (1) chest wall movement measured by the biosensor, securely streamed to a cloud, and analyzed to refine an overdose detection algorithm and (2) acute events or potential overdose identified by site staff. Acceptability will be measured by a feedback questionnaire as many times as the participant is willing to throughout the study. RESULTS: As of April 2024, a total of 47 participants have been enrolled and data from 1145 injecting events have already been collected, including 10 overdose events. This consists of 17 females and 30 males with an average age of 45 years. Data analysis is ongoing. CONCLUSIONS: This protocol establishes a foundation for advancing wearable technology in opioid overdose prevention within SIFs. The study will provide chest wall movement data and associated overdose data that will be used to train an algorithm that allows the biosensor to detect an overdose. The study will contribute crucial insights into OIRD, emphasizing the biosensor's potential step forward in real-time intervention strategies. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/57367.

Time Course of Reversal of Fentanyl-Induced Respiratory Depression in Healthy Subjects by Intramuscular Nalmefene and Intramuscular and Intranasal Naloxone.

The increase in opioid overdose deaths, particularly involving potent, long-acting synthetic opioids, has led to calls for stronger, longer-acting opioid-overdose-reversal agents. Using an opioid-induced respiratory depression model, we investigated the onset and time course of action of naloxone and a long-acting opioid antagonist, nalmefene, in reversing the effects of an ongoing intravenous fentanyl infusion over a period of up to 100 min. Healthy, moderately experienced opioid users received intramuscular (IM) nalmefene 1 mg, IM naloxone 2 mg, or intranasal (IN) naloxone 4 mg after fentanyl-induced respiratory depression was established based on reduction in respiratory minute volume (MV). Each participant received each opioid antagonist twice per a randomized crossover schedule. Reversal of respiratory depression, pharmacokinetics, and safety were investigated. Participants showed rapid increases in plasma opioid antagonist concentrations, and meaningful reversal of depressed MV tended to occur earlier with IM nalmefene and IM naloxone than with IN naloxone. Compared to naloxone, nalmefene provided extended exposure, and mean MV was maintained at a higher level. All participants experienced treatment-related adverse events, but none were severe, serious, or led to study drug discontinuation. This study provides evidence that IM nalmefene 1 mg achieves reversal of fentanyl-induced respiratory depression similar to or better than that achieved with standard-of-care naloxone treatments. No new safety concerns were raised for IM nalmefene at the tested dose. The pharmacokinetic and pharmacodynamic properties of IM nalmefene position it as an important treatment option in opioid overdose reversal, particularly given the increasing prevalence of overdoses involving potent, long-acting synthetic opioids.

Incidence, Timing and Social Correlates of the Development of Opioid Use Disorder Among Clients Seeking Treatment for an Alcohol Use Problem: Changes Over the Three Waves of the Opioid Epidemic.

Introduction: Opioid use disorder (OUD) and opioid overdose (OD) have shown to be strongly associated with alcohol use disorder (AUD). As a potential target population for secondary prevention, we examined the incidence and timing of OUD/OD among clients seeking treatment for alcohol problems and how this has changed over the three waves of the opioid epidemic corresponding to the primary opioid involved in fatal ODs, prescription painkillers (2007-2009), heroin (2010-2012), and fentanyl (2013-2016). We also examined social determinants of health as predictors of OUD/OD. Methods: Clients (N = 59,186) presenting for a first treatment for alcohol use problems were extracted from the Client Data System (CDS) of the New York State Office of Addiction Services and Support (OASAS) and New York State (NYS) Medicaid Data Warehouse. Using this cohort, we employed the Kaplan-Meier method to determine the survival probabilities for patients admitted in each of the three waves of the epidemic. Results: Patients in Cohort 3 (2013-2016) were diagnosed with OUD/OD more rapidly than patients in Cohort 1 (2007-2009) or Cohort 2 (2010-2012), although the overall estimated OUD/OD rate was comparable across the three cohorts. Discussion: These findings provide a useful estimate of the incidence and the expected time frame of an opioid use disorder in clients with an alcohol use problem. Moreover, it suggests that as the opioid epidemic progressed, OUD/OD developed more rapidly but the overall prevalence did not increase.

Factors Associated with Take Home Naloxone Refusal among Emergency Department Patients Participating in an Opioid Overdose Prevention Program.

BACKGROUND: Increasing the equitable distribution of take home naloxone (THN) may result in reduced deaths from opioid overdose (OD). OBJECTIVES: The primary study objective is to describe the demographic and clinical characteristics of emergency department (ED) patients who decline THN. The findings of this descriptive study may generate new hypotheses for successful THN distribution. METHODS: Retrospective chart review using prospectively collected program evaluation data from a single urban EDs Health Education THN database and electronic health record. Characteristics of participants who refused versus accepted THN were compared using Chi-square testing for categorical variables and t-tests for continuous variables. A multivariate model was built to assess associations of statistical and clinically relevant characteristics with THN refusal. RESULTS: A total of 711 ED patients were offered THN of which 334 (46%) declined. In unadjusted analysis, with the independent variable being refusal of the THN offer, being currently on medication for opioid use disorder (MOUD) was associated with a greater odds of refusal (OR 1.9, 95%CI 1.3-2.6) while any drug related overdose (OR 0.6, 95%CI 0.4-0.8) or being given a prescription for buprenorphine in the ED (OR 0.2, 95%CI 0.1-0.9) were both associated with a lower odds of refusal. CONCLUSIONS: Demographic characteristics did not differ between those who accept versus refuse THN. Patients already receiving MOUD were more likely to refuse THN while those starting MOUD in the ED were less likely to refuse THN. Further studies are needed to determine the root causes of patients' declination of THN and develop targeted interventions to address these causes.

Perceptions of a naloxone leave behind program among emergency medical services personnel in Michigan, USA.

Introduction: In 2020, Michigan implemented its first Naloxone Leave-Behind Program for Emergency Medical Service (EMS) field providers. Under the program, EMS field providers leave naloxone kits to individuals aged 15 or older they encounter in the field who have overdosed, who indicate they have a substance use disorder, or exhibit signs of opioid use and/or to bystanders, friends, or family that are present at the encounter. Methods: Survey of EMS field providers and administrators to assess perspectives on the Michigan NLB program. Comparisons of perspectives between field providers and administrators working in EMS agencies operating in medical control authorities (MCAs) participating in the NLB program (i.e., participating agencies) with field providers and administrators working for EMS agencies serving non-participating MCAs. Results: Most EMS field providers and administrators supported the Michigan NLB program. However, some were concerned about the unintended consequences of leaving behind naloxone, including the potential for recipients to use more drugs or be less likely to seek treatment. Perspectives of NLB program effectiveness were similar between EMS administrators and field providers. Participating administrators' top-cited barrier to implementation was convincing field providers to leave behind naloxone, while non-participating administrators were concerned with stocking naloxone kits. Conclusions: Additional engagement and training to address concerns by EMS field providers and administrators about the benefits of the NLB program are needed to expand program participation intensity. Streamlining naloxone procurement and increasing messaging about free access to naloxone for participating in the program may help increase adoption.

Effects of Online Naloxone Training for Laypersons: An Extended-Baseline Assessment.

Background: While laypersons can play a crucial role in administering naloxone in opioid overdoses, they must be recruited and trained to effectively manage overdose events as good Samaritans. This study aimed to examine the effectiveness of a technology-based intervention that recruited and trained laypersons to administer naloxone. Methods: Opioid Rapid Response System (ORRS) was an online recruitment and training intervention which capitalized on social cognitive theory and a digital media engagement model to mobilize laypersons to administer intranasal naloxone. ORRS was developed based on a randomized waitlisted controlled trial (N = 220). This secondary analysis is a within-group, extended-baseline assessment of the waitlisted group (n = 106), considering that they served as their own control prior to receiving the training. ORRS was conducted in five counties of Indiana with adults who did not self-identify as a certified first responder. Five indices were generated from 23 variables: knowledge of overdose signs, knowledge of overdose management, self-efficacy in responding, concerns about responding, and intent to respond. Paired t-test compared changes between 3 timepoints. Results: Three indices had significantly greater increases associated with training compared to extended baseline: recognizing opioid overdose signs (difference = 0.08; 95%CI = 0.02, 0.15; t = 2.48; p = 0.01); knowledge of overdose management (difference = 0.27; 95%CI = 0.18, 0.35; t = 5.99; p < 0.01); and self-efficacy in overdose management (difference = 0.68; 95%CI = 0.45, 0.91; t = 5.78; p < 0.01). Concerns related to overdose management significantly decreased as expected (difference = -1.53; 95%CI = -1.86, -1.21; t = -9.27; p < 0.01). Conclusions: ORRS provided strong support for self-efficacy, concerns, and knowledge related to overdose management, and the digital modality accelerates largescale dissemination.

Chronic pain and accidental acute toxicity deaths in Canada, 2016-2017. / Recherche quantitative originale La douleur chronique et les décès par intoxication aiguë accidentelle au Canada, 2016-2017.

INTRODUCTION: Multiple Canadian jurisdictions have reported a pattern of chronic pain among people who died from substance-related acute toxicity. This study examined the prevalence and characteristics of those with chronic pain using data from a national study of people who died of accidental acute toxicity. METHODS: A cross-sectional analysis of accidental substance-related acute toxicity deaths that occurred in Canada between 1 January 2016 and 31 December 2017 was conducted. The prevalence of pain and pain-related conditions were summarized as counts and percentages of the overall sample. Subgroups of people with and without a documented history of chronic pain were compared across sociodemographic characteristics, health history, contextual factors and substances involved. RESULTS: From the overall sample (n = 7902), 1056 (13%) people had a history of chronic pain while 6366 (81%) had no documented history. Those with chronic pain tended to be older (40 years and older), unemployed, retired and/or receiving disability supports around the time of death. History of mental health conditions, trauma and surgery or injury was significantly more prevalent among people with chronic pain. Of the substances that most frequently contributed to death, opioids typically prescribed for pain (hydromorphone and oxycodone) were detected in toxicology more often among those with chronic pain than those without. CONCLUSION: Findings underscore the cross-cutting role of multiple comorbidities and unmanaged pain, which could compound the risk of acute toxicity death. Continued prioritization of harm reduction and regular patient engagement to assess ongoing needs are among the various opportunities for intervention.

Quantifying the Burden of Opioid Use Disorder and Non-fatal Opioid Overdose in American Indian and Alaskan Native Populations Using the Cerner Real-World Data™ Database.

OBJECTIVE: This study evaluated the prevalence and incidence of opioid use disorder (OUD), rates of opioid overdose (OD), and rates of non-fatal (NF) OD in American Indian/Alaskan Native (AI/AN) populations. METHODS: We used de-identified patient data from Oracle Cerner Real-World Data™. Rates were estimated over time, and stratified by sex, age, marital status, insurance, and region. Mann-Kendall trend tests and Theil-Sen slopes assessed changes over time for each group while autoregressive modeling assessed differences between groups. RESULTS: The study identified trends in OUD and OD among 700,225 AI/AN patients aged 12 and above. Between 2012 and 2022, there was a significant upward trend in both OUD and OD rates (p < 0.05) , with OUD diagnosed in 1.75% and OD in 0.38% of the population. The Western region of the US exhibited the highest rates of OUD and OD. The 35-49 age group showed the highest rates of OUD, while the 12-34 age group had the highest rates of OD. Marital status analysis revealed higher rates of OUD and OD among separated, widowed, or single patients. Additionally, individuals with Medicare or Medicaid insurance demonstrated the highest rates of OUD and OD. CONCLUSION: Results show that rates of OUD, OD, and NF OD continue to rise among AI/AN individuals, with some regional and demographic variation. Our study provides foundational estimates of key AI/AN populations bearing greater burdens of opioid-related morbidity that federal, state, and tribal organizations can use to direct and develop targeted resources that can improve the health and well-being of AI/AN communities.

Improving Naloxone Co-prescribing Through Clinical Decision Support.

BACKGROUND: Despite national guidelines recommending naloxone co-prescription with high-risk medications, rates remain low nationally. This was reflected at our institution with remarkably low naloxone prescribing rates. We sought to determine if a clinical decision support (CDS) tool could increase rates of naloxone co-prescribing with high-risk prescriptions. METHODS:  An alert in the electronic health record was triggered upon signing an order for a high-risk opioid medication without a naloxone co-prescription. We examined all opioid prescriptions written by family and general internal medicine practitioners at the University of Iowa Hospitals and Clinics in outpatient encounters between November 30, 2020, and February 28, 2022. Once triggered by a high-risk prescription, the CDS tool had the option to choose an order set with an automatically selected co-prescription for naloxone along with patient instructions automatically added to the patient's after-visit summary (AVS). We examined the monthly percentage of patients receiving Schedule II opioid prescriptions ≥90 morphine milliequivalents (MME)/day who received concurrent naloxone prescriptions in the 12 months before the CDS went live and the three months following go-live. RESULTS:  Concurrent naloxone prescriptions increased from 1.1% in the 12 months prior to implementation in November 2021 to 9.4% (p<0.001) during the post-intervention period across eight family medicine and internal medicine clinics. DISCUSSION:  This single-center quality improvement project with retrospective analysis demonstrates the potential efficacy of a single CDS tool in increasing the rate of naloxone prescription. The impact of such prescribing on overall mortality requires further research. CONCLUSIONS: The CDS tool was easy to implement and improved rates of appropriate naloxone co-prescribing.

Prevalence of fentanyl in the pediatric postmortem population from 2019 to 2023.

For the past decade, illicitly manufactured fentanyl has been a primary contributor in drug overdose deaths regardless of age. The pediatric population is particularly vulnerable to fentanyl exposure, yet there are limited case reports involving this population. Postmortem cases from 2019 to 2023 were retrospectively analyzed to determine the prevalence of fentanyl in decedents between 0 and 12 years of age. Over this time frame, the fentanyl positivity rate increased from 2.6 to 6.2% (n = 632). The most commonly reported age group was 0-4 years, with a peak around 1 year of age for toddlers. Fentanyl concentrations in blood (n = 573) ranged from 0.19 to 360 ng/mL (mean 18 ng/mL, median 6.9 ng/mL). Polydrug use was present in 428 cases; midazolam (n = 96) and methamphetamine (n = 66) were the most common drugs found concurrently in blood with fentanyl, followed by markers of illicitly manufactured fentanyl, such as xylazine (n = 23), para-fluorofentanyl (n = 18), and acetyl fentanyl (n = 17). This report contrasts the differences in postmortem pediatric fentanyl toxicology results for three groups of case histories: likely medical intervention (n = 113), pregnancy/birth related (n = 136), and inadvertent/intentional exposure (n = 196). Overall, this study provides a retrospective review of postmortem pediatric fentanyl concentrations in a variety of biological matrices and highlights the need for comprehensive toxicology testing in postmortem pediatric casework.

Understanding Clinician Knowledge, Attitudes, and Practices Relating to Nonpharmaceutical Fentanyl and Harm Reduction.

BACKGROUND: Nonpharmaceutical fentanyl (NPF) is driving the national epidemic of opioid overdose deaths. Clinicians can play a role in fostering awareness of this growing risk and delivering interventions to reduce mortality. However, there is limited research assessing clinician knowledge, attitudes, and practices relating to NPF and harm reduction strategies. METHODS: A 34-question survey was designed to assess knowledge, attitudes, and practices related to NPF and harm reduction strategies of adult and pediatric hospital-based and emergency clinicians at a single academic medical center. Results were summarized using descriptive statistics. Chi square and Fishers exact tests were used to compare groups. RESULTS: There were 136 survey responses. The majority (88%) of respondents correctly answered a question on NPF potency. Most respondents were aware that NPF exposure was very (84%) or somewhat likely (10%) for someone using illicit opioids and very (44%) or somewhat likely (46%) for nonopioid drugs. Respondents viewed overdose prevention as highly important for patients using illicit opioids (93%) and nonopioid drugs (86%) but few (21%) were very/extremely familiar with overdose prevention strategies and just over half (57%) were comfortable/very comfortable counseling about overdose prevention. There was wide variability in utilization of harm reduction/treatment strategies (7.3% frequently providing fentanyl test kits to 70% frequently prescribing naloxone). Higher levels of comfort and familiarity with overdose prevention were associated with more frequent counseling on harm reduction strategies. Pediatric-only clinicians had less familiarity (5% very/extremely familiar) and comfort (35% comfortable/very comfortable) with overdose prevention, and limited use of harm reduction strategies (0%-31% using each strategy frequently). CONCLUSIONS: While clinicians had knowledge and awareness of NPF and rated overdose prevention as highly important, utilization of harm reduction and treatment strategies was variable. This study highlights opportunities for education and system-based support to improve clinician-driven harm reduction practices for patients at risk of overdose.

Effect of a peer-led emergency department behavioral intervention on non-fatal opioid overdose: 18-month outcome in the Navigator randomized controlled trial.

BACKGROUND AND AIMS: Emergency departments (EDs) provide an opportunity to identify people at risk of overdose and reduce the risk. We evaluated the effect of an ED behavioral intervention delivered by peer recovery support specialists (PRSSs) on non-fatal opioid overdose. DESIGN: Two-arm, randomized trial. SETTING: Two EDs in Rhode Island, USA. PARTICIPANTS: ED patients presenting with an opioid overdose, complications of opioid use disorder or a recent history of opioid overdose (November 2018-May 2021). Among 648 participants, the mean age was 36.9 years, 68.2% were male and 68.5% were White. INTERVENTION AND COMPARATOR: Participants were randomized to receive a behavioral intervention from a PRSS (n = 323) or a licensed clinical social worker (LICSW) (n = 325). PRSS and LICSW used evidence-based interviewing and intervention techniques, informed by their lived experience (PRSS) or clinical theory and practice (LICSW). MEASUREMENTS: We identified non-fatal opioid overdoses in the 18 months following the ED visit through linkage to statewide emergency medical services data using a validated case definition. The primary outcome was any non-fatal opioid overdose during the 18-month follow-up period. FINDINGS: Among 323 participants randomized to the PRSS arm, 81 (25.1%) had a non-fatal opioid overdose during follow-up, compared with 95 (29.2%) of 325 participants randomized to the LICSW arm (P = 0.24). There was no statistically significant difference in the effectiveness of randomization to the PRSS arm versus the LICSW arm on the risk of non-fatal opioid overdose, adjusting for the history of previous overdose (relative risk = 0.86, 95% confidence interval = 0.67-1.11). CONCLUSIONS: In Rhode Island, USA, over one-in-four emergency department patients at high risk of overdose experience a non-fatal opioid overdose in the 18 months post-discharge. We found no evidence that the risk of non-fatal opioid overdose differs for emergency department patients receiving a behavioral intervention from a peer recovery support specialist versus a licensed clinical social worker.

A theoretical explanation of naloxone provision among primary care physicians and community pharmacists in Tennessee.

BACKGROUND: Increasing access to naloxone reduces opioid-related morbidity and mortality. Primary care and community pharmacy settings are critical access points, yet limited theoretical research has examined naloxone prescribing and dispensing behaviors. OBJECTIVES: To determine if the theory of planned behavior (TPB) combined with theoretical constructs from communication science explains intentions to co-prescribe and discuss co-dispensing naloxone among primary care physicians and community pharmacists, respectively. METHODS: This cross-sectional study surveyed cohorts of licensed primary care physicians and community pharmacists in Tennessee in 2017. Intentions were measured using profession-specific case vignettes, whereby they were asked given 10 similar patients, how many times (0-10) would they co-prescribe or discuss co-dispensing naloxone. Bivariate and multivariable analyses were used. RESULTS: The analytic sample included 295 physicians (response rate = 15.6 %) and 423 pharmacists (response rate = 19.4 %). Approximately 65 % of physicians reported never intending to co-prescribe naloxone (0 out of 10 patients), while 47 % of pharmacists reported never intending to discuss co-dispensing. All TPB constructs-attitudes (AOR = 1.32, CI = 1.16-1.50), subjective norms (AOR = 1.17, CI = 1.06-1.30), and perceived behavioral control (AOR 1.16, CI = 1.02-1.33)-were associated with an increased likelihood of pharmacists always (versus never) discussing co-dispensing. Similarly, two TPB constructs-attitudes (AOR = 1.41, CI = 1.19-1.68) and subjective norms (AOR = 1.22, CI = 1.08-1.39)-were associated with an increased likelihood of physicians always co-prescribing. Among physicians only, one communication construct-self-perceived communication competence (AOR = 1.19, CI = 1.01-1.41)-was associated with an increased likelihood of always co-prescribing. CONCLUSION: Findings support the value of theory, particularly TPB, in explaining primary care physician intentions to co-prescribe and community pharmacist intentions to discuss co-dispensing naloxone.

Need for strategic communications and stakeholder engagement to advance acceptability of an overdose preventing vaccine targeting fentanyl.

BACKGROUND: Fentanyl is a synthetic opioid, exposure to which has led to hundreds of thousands of overdose deaths. Novel vaccines are being developed that might protect against fentanyl overdose. Proactive attention to strategic communications and stakeholder engagement may smooth uptake of a novel vaccine given known challenges around vaccine hesitancy and concern for stigma related to substance use. METHODS: Qualitative interviews (N = 74) with a purposive sample of adolescents/young adults with opioid use disorder (OUD), family members of persons with OUD, experts in substance use treatment and harm reduction, and community members were conducted and thematically analyzed to discern attitudes toward a fentanyl vaccine, and directions for communications and engagement. RESULTS: Major themes reflected personal concerns for biomedical risk and system-level concerns for alignment and integration of an overdose preventing vaccine with prevailing beliefs about addiction and associated frameworks and philosophies for treatment and response. CONCLUSION: Acceptability and implementation of a novel fentanyl vaccine targeting overdose will need precision communications that address biomedical, moral/spiritual, and structural perspectives about the nature of addiction. Education about the purpose and limits of a fentanyl vaccine, partnerships with diverse stakeholders from throughout the opioid response ecosystem and interweaving of a vaccine strategy into comprehensive prevention and treatment are recommended.

Spatial co-occurrence of firearm homicides and opioid overdose deaths in Chicago by level of COVID-19 mortality, 2017-2021.

BACKGROUND: Firearm homicide and opioid overdoses were already leading causes of death in the U.S. before both problems surged during the COVID-19 pandemic. Firearm violence, overdoses, and COVID-19 have all disproportionately harmed communities that are socially and economically marginalized, but the co-occurrence of these problems in the same communities has received little attention. To describe the co-occurrence of firearm homicides and opioid overdose deaths with COVID-19 mortality we used 2017-2021 medical examiner's data from Chicago, IL. Deaths were assigned to zip codes based on decedents' residence. We stratified zip codes into quartiles by COVID-19 mortality rate, then compared firearm homicide and fatal opioid overdose rates by COVID-19 quartile. FINDINGS: Throughout the study period, firearm homicide and opioid overdose rates were highest in the highest COVID-19 mortality quartile and lowest in the lowest COVID-19 mortality quartile. Increases in firearm homicide and opioid overdose were observed across all COVID-19 mortality quartiles. CONCLUSIONS: High co-occurrence of these deaths at the community level call for addressing the systemic forces which made them most vulnerable before the pandemic. Such strategies should consider the environments where people reside, not only where fatal injuries occur.

Sensitivity and specificity of International Classification of Diseases algorithms (ICD-9 and ICD-10) used to identify opioid-related overdose cases: A systematic review and an example of estimation using Bayesian latent class models in the absence of gold standards.

OBJECTIVES: This study aimed to summarize validity estimates of International Classification of Diseases (ICD) codes in identifying opioid overdose (OOD) among patient data from emergency rooms, emergency medical services, inpatient, outpatient, administrative, medical claims, and mortality, and estimate the sensitivity and specificity of the algorithms in the absence of a perfect reference standard. METHODS: We systematically reviewed studies published before December 8, 2023, and identified with Medline and Embase. Studies reporting sufficient details to recreate a 2 × 2 table comparing the ICD algorithms to a reference standard in diagnosing OOD-related events were included. We used Bayesian latent class models (BLCM) to estimate the posterior sensitivity and specificity distributions of five ICD-10 algorithms and of the imperfect coroner's report review (CRR) in detecting prescription opioid-related deaths (POD) using one included study. RESULTS: Of a total of 1990 studies reviewed, three were included. The reported sensitivity estimates of ICD algorithms for OOD were low (range from 25.0% to 56.8%) for ICD-9 in diagnosing non-fatal OOD-related events and moderate (72% to 89%) for ICD-10 in diagnosing POD. The last included study used ICD-9 for non-fatal and fatal and ICD-10 for fatal OOD-related events and showed high sensitivity (i.e. above 97%). The specificity estimates of ICD algorithms were good to excellent in the three included studies. The misclassification-adjusted ICD-10 algorithm sensitivity estimates for POD from BLCM were consistently higher than reported sensitivity estimates that assumed CRR was perfect. CONCLUSION: Evidence on the performance of ICD algorithms in detecting OOD events is scarce, and the absence of bias correction for imperfect tests leads to an underestimation of the sensitivity of ICD code estimates.

RéSUMé: OBJECTIFS: Cette étude avait pour objectifs de recenser les estimations de la validité des codes de Classification Internationale des Maladies (CIM) à diagnostiquer les cas de surdose aux opioïdes (SDO) chez des patients en utilisant les données de salles d'urgence, services médicaux d'urgence, hospitalisations, soins ambulatoires, services administratifs, demandes de remboursement de frais médicaux, ainsi que de mortalité, et d'estimer la sensibilité et la spécificité d'algorithmes utilisant la CIM en l'absence d'un test de référence parfait. MéTHODES: Nous avons examiné systématiquement les études publiées avant le 8 décembre 2023, et identifiées dans Medline et Embase. Les études rapportant suffisamment de détails permettant de recréer un tableau 2 × 2 comparant les algorithmes de la CIM à un test de référence pour le diagnostic d'événements liés aux SDO ont été incluses. Les données d'une étude éligible ont été utilisées pour estimer, avec des modèles Bayésiens de classes latentes (MBCL), les distributions a posteriori de la sensibilité et de la spécificité de cinq algorithmes de la CIM-10 et du test imparfait de révision du rapport du coroner (RRC) dans la détection des décès liés aux opioïdes de prescription (DOP). RéSULTATS: Trois parmi les 1 990 études examinées ont été retenues. Les estimations rapportées de la sensibilité des codes CIM étaient faibles (variant de 25,0 % à 56,8 %) pour CIM-9 dans le diagnostic des événements liés aux SDO non-fatales dans une étude, et modérées (72 % à 89 %) pour CIM-10 dans le diagnostic des DOP dans une autre étude. La dernière étude incluse combinait des codes CIM-9 pour les cas non-fatals et fatals et CIM-10 pour les cas fatals et démontrait des estimations de sensibilité élevées (c.à.d. supérieures à 97 %). Les estimations de la spécificité étaient bonnes à excellentes dans les trois études. Les estimations de la sensibilité des algorithmes de la CIM-10 corrigées pour les erreurs de classification pour les décès liés aux opioïdes, obtenues à partir de nos MBCL, étaient systématiquement plus élevées que celles rapportées et qui supposaient que RRC était un test parfait. CONCLUSION: Les évidences sur la performance des algorithmes de la CIM dans la détection des cas de SDO sont rares, et l'absence de correction de biais pour des tests diagnostiques imparfaits conduit à une sous-estimation de la sensibilité des codes de la CIM.

Trends in recurrent overdose and treatment initiation following emergency department visits for opioid overdose between 2016 and 2021.

BACKGROUND: Overdose remains a pressing public health concern in the United States, particularly with the emergence of fentanyl and other potent synthetic opioids in the drug supply. We evaluated trends in recurrent overdose and opioid use disorder (OUD) treatment initiation following emergency department (ED) visits for opioid overdose to inform response efforts. METHODS: This retrospective cohort study used electronic health record and statewide administrative data from Rhode Island residents who visited EDs for opioid overdose between July 1, 2016, and June 30, 2021, a period with fentanyl predominance in the local drug supply. The primary outcome was recurrent overdose in the 365 days following the initial ED visit. OUD treatment initiation within 180 days following the initial ED visit was considered as a secondary outcome. Trends in study outcomes were summarized by year of the initial ED visit. RESULTS: Among 1745 patients attending EDs for opioid overdose, 20 % (n=352) experienced a recurrent overdose within 365 days, and this percentage was similar by year (p=0.12). Among patients who experienced any recurrent overdose, the median time to first recurrent overdose was 88 days (interquartile range=23-208), with 85 % (n=299/352) being non-fatal. Among patients not engaged in OUD treatment at their initial ED visit, 33 % (n=448/1370) initiated treatment within 180 days; this was similar by year (p=0.98). CONCLUSIONS: Following ED visits for opioid overdose in Rhode Island from 2016-2021, the one-year risk of recurrent overdose and six-month treatment initiation rate remained stable over time. Innovative prevention strategies and improved treatment access are needed.