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.

Overdose prevention centres as spaces of safety, trust and inclusion: A causal pathway based on a realist review.

ISSUES: Overdose prevention centres (OPC) are non-residential spaces where people can use illicit drugs (that they have obtained elsewhere) in the presence of staff who can intervene to prevent and manage any overdoses that occur. Many reviews of OPCs exist but they do not explain how OPCs work. APPROACH: We carried out a realist review, using the RAMESES reporting standards. We systematically searched for and then thematically analysed 391 documents that provide information on the contexts, mechanisms and outcomes of OPCs. KEY FINDINGS: Our retroductive analysis identified a causal pathway that highlights the feeling of safety - and the immediate outcome of not dying - as conditions of possibility for the people who use OPCs to build trust and experience social inclusion. The combination of safety, trust and social inclusion that is triggered by OPCs can - depending on the contexts in which they operate - generate other positive outcomes, which may include less risky drug use practices, reductions in blood borne viruses and injection-related infections and wounds, and access to housing. These outcomes are contingent on relevant contexts, including political and legal environments, which differ for women and people from racialised minorities. CONCLUSIONS: OPCs can enable people who live with structural violence and vulnerability to develop feelings of safety and trust that help them stay alive and to build longer term trajectories of social inclusion, with potential to improve other aspects of their health and living conditions.

Trends in drug overdose deaths among adults 65 years of age and older in Canada (2000-2022).

Background: Although young adults and middle-aged adults have borne the brunt of the drug overdose crisis in Canada, older adults are also at an increased risk of harms. We examined trends in drug overdose deaths and opioid overdose deaths among adults 65 years of age and older. Methods: Age-standardized rates of drug overdose deaths in Canada (2000-2022) and of opioid overdose deaths in Ontario (2003-2021) were computed. Drug overdose deaths were based on vital statistics registries, while opioid overdose deaths were based on toxicologic testing. Trends were characterized using joinpoint regression. Results: Drug overdose deaths among adults 65 years of age and older in Canada rose from 4.3 to 9.9 deaths per million in the entire population between 2000 and 2022 (Average Annual Percentage Change [AAPC; 95 % CI]: 3.1 % [2.6 %-3.6 %]). Increases were observed in males (AAPC [95 % CI]: 4.0 % [3.1 %-4.9 %]), females (2.1 % [1.0 %-3.2 %]) and unintentional deaths (6.0 % [1.0 %-11.3 %]) after stratification by sex and manner of death. Opioid overdose deaths among adults 65 years of age and older in Ontario increased from 1.5 to 5.2 deaths per million in the entire population between 2003 and 2021 (AAPC [95 % CI]: 7.5 % [4.5 %-10.5 %]). Conclusions: Drug overdose deaths more than doubled in Canada and opioid overdose deaths more than tripled in Ontario among adults 65 years of age and older during the past two decades. These findings indicate a need for education of patients, prioritization of harm reduction interventions, screening, intervention and treatment and adherence to prescribing guidelines.

Benefits and challenges of geographic information systems (GIS) for data-driven outreach in black communities experiencing overdose disparities: results of a stakeholder focus group.

BACKGROUND: Black individuals in the U.S. face increasing racial disparities in drug overdose related to social determinants of health, including place-based features. Mobile outreach efforts work to mitigate social determinants by servicing geographic areas with low drug treatment and overdose prevention access but are often limited by convenience-based targets. Geographic information systems (GIS) are often used to characterize and visualize the overdose crisis and could be translated to community to guide mobile outreach services. The current study examines the initial acceptability and appropriateness of GIS to facilitate data-driven outreach for reducing overdose inequities facing Black individuals. METHODS: We convened a focus group of stakeholders (N = 8) in leadership roles at organizations conducting mobile outreach in predominantly Black neighborhoods of St. Louis, MO. Organizations represented provided adult mental health and substance use treatment or harm reduction services. Participants were prompted to discuss current outreach strategies and provided feedback on preliminary GIS-derived maps displaying regional overdose epidemiology. A reflexive approach to thematic analysis was used to extract themes. RESULTS: Four themes were identified that contextualize the acceptability and utility of an overdose visualization tool to mobile service providers in Black communities. They were: 1) importance of considering broader community context; 2) potential for awareness, engagement, and community collaboration; 3) ensuring data relevance to the affected community; and 4) data manipulation and validity concerns. CONCLUSIONS: There are several perceived benefits of using GIS to map overdose among mobile providers serving Black communities that are overburdened by the overdose crisis but under resourced. Perceived potential benefits included informing location-based targets for services as well as improving awareness of the overdose crisis and facilitating collaboration, advocacy, and resource allocation. However, as GIS-enabled visualization of drug overdose grows in science, public health, and community settings, stakeholders must consider concerns undermining community trust and benefits, particularly for Black communities facing historical inequities and ongoing disparities.

Analytically Confirmed Intentional Overdose of the Antidepressant Vortioxetine.

INTRODUCTION: Vortioxetine is an antidepressant with a multimodal mechanism of action. It is used as a treatment option for patients with major depressive episodes. There have only been two previously reported non-fatal overdoses of vortioxetine; neither of these were analytically confirmed There has also been one case of serotonin syndrome potentially related to vortioxetine and two deaths where vortioxetine was detected. We report here a non-fatal analytically confirmed case of vortioxetine overdose. CASE REPORT: A 32-year-old male presented to the emergency department (ED) 12-13 h after oral ingestion of 1,260 mg of vortioxetine and 350 mg of diazepam. A family member reported that he had been drowsy after the overdose, but his level of consciousness and observations (heart rate, blood pressure and temperature) were normal on review by the pre-hospital emergency services and on arrival to the ED. During a period of observation, he did not develop any features of serotonin syndrome or any other significant toxicity. Toxicological analysis of a blood sample taken in the ED detected vortioxetine (plasma concentration 457 ng/mL 10 h after ingestion) and sub-therapeutic concentrations of diazepam and pregabalin. DISCUSSION: Despite having a plasma vortioxetine concentration nearly 15-times therapeutic vortioxetine concentrations, this patient did not develop any significant toxicity. In particular he did not develop any clinical or biochemical features of serotonin toxicity that would be expected with this class of antidepressant. Additional reporting of analytically confirmed vortioxetine overdoses will allow clinicians and licensing authorities to further understand the safety of this medication in overdose.

Trends in toxicological findings in unintentional opioid or stimulant toxicity deaths in Québec, Canada, 2012-2021: Has Québec entered a new era of drug-related deaths?

INTRODUCTION: We aimed to describe rates and toxicological findings of unintentional opioid and stimulant toxicity deaths, 2012-2021. METHODS: The dataset included accidental deaths determined by the Coroner to be due to opioids or stimulants. We calculated annual crude mortality rates and described combinations of drugs identified in toxicological examinations of these deaths. We described temporal trends in the detection of specific opioids, stimulants, benzodiazepines (including novel benzodiazepines), gabapentinoids and z-drugs in deaths due to opioids and stimulants. RESULTS: Mortality rates increased over time, reaching their peak in 2020 and remaining high in 2021. In deaths due to opioids, there was a decline in the proportion of deaths involving pharmaceutical opioids after 2019, and a corresponding increase in the proportion of deaths with fentanyl detected. Benzodiazepines were often present in deaths due to opioids, with novel benzodiazepines increasing rapidly from 2019 onwards. Cocaine was the most frequently detected drug in deaths due to stimulants, but amphetamine/methamphetamine was detected in around half of all stimulant deaths from 2016 onwards. DISCUSSION AND CONCLUSIONS: Despite availability of a multitude of overdose prevention interventions, mortality rates due to drug toxicity have increased in Québec. Toxicological findings of these deaths suggest concerning shifts in the illicit drug market, with Québec potentially having entered a new era of elevated overdose mortality. Intervention scale-up is essential, but unlikely to be sufficient, to reduce drug-related mortality. Policy reform to address the root causes of drug toxicity deaths, including an unpredictable drug supply, strained health systems and socio-economic precarity, is essential.

Loperamide-Induced Torsades de Pointes.

Loperamide is a readily available, over-the-counter medication used to treat diarrhea. At therapeutic doses, loperamide exerts its effects mainly on the intestinal opioid receptors with minimal psychoactive effects; however, at supratherapeutic doses, it reaches central opioid receptors. With tighter regulations on opioid prescriptions, loperamide has emerged as a popular drug of abuse among opioid users. At supratherapeutic doses, loperamide can cause severe cardiac toxicity, resulting in wide QRS rhythms, severe bradycardia, prolonged QTc, polymorphic ventricular tachycardia, and cardiac arrest. We present the case of a 27-year-old female with a history of heroin abuse who suffered torsades de pointes resulting in cardiac arrest in the setting of a loperamide overdose.

Midlife and Older Age Methamphetamine Poisoning Deaths in Hawai'i.

Unintentional and undetermined intent drug overdose fatality records from the State Unintentional Drug Overdose Reporting System (SUDORS) for Hawai'i from July 1, 2020, to December 31, 2021 revealed that 58.2% of decedents were aged 50-75. The main substance associated with cause of death for those aged 50-75 years was methamphetamine, followed by a combination of mixed drugs. Of those aged 50 and older, 25.5% died from cardiovascular or neurological complications which were likely to be associated with chronic, long-term methamphetamine use. Based on death investigator narrative reports, 76.5% of the older decedents had a history of substance abuse, suggesting possible long-term substance use starting at a young age. The trajectory of substance use over the life course is often influenced by life events and transitions, which can be stressors. Hawai'i kupuna (older adults) should be screened for substance use and dependence to ensure that there is treatment if needed, for the entirety of this use trajectory.Also, barriers to kupuna seeking treatment, such as stigma towards drug use should be addressed.

An individual-based dynamic model to assess interventions to mitigate opioid overdose risk.

BACKGROUND: Illicit opioid overdose continues to rise in North America and is a leading cause of death. Mathematical modeling is a valuable tool to investigate the epidemiology of this public health issue, as it can characterize key features of population outcomes and quantify the broader effect of structural and interventional changes on overdose mortality. The aim of this study is to quantify and predict the impact of key harm reduction strategies at differing levels of scale-up on fatal and nonfatal overdose among a population of people engaging in unregulated opioid use in Toronto. METHODS: An individual-based model for opioid overdose was built featuring demographic and behavioural variation among members of the population. Key individual attributes known to scale the risk of fatal and nonfatal overdose were identified and incorporated into a dynamic modeling framework, wherein every member of the simulated population encompasses a set of distinct characteristics that govern demographics, intervention usage, and overdose incidence. The model was parametrized to fatal and nonfatal overdose events reported in Toronto in 2019. The interventions considered were opioid agonist therapy (OAT), supervised consumption sites (SCS), take-home naloxone (THN), drug-checking, and reducing fentanyl in the drug supply. Harm reduction scenarios were explored relative to a baseline model to examine the impact of each intervention being scaled from 0% use to 100% use on overdose events. RESULTS: Model simulations resulted in 3690.6 nonfatal and 295.4 fatal overdoses, coinciding with 2019 data from Toronto. From this baseline, at full scale-up, 290 deaths were averted by THN, 248 from eliminating fentanyl from the drug supply, 124 from SCS use, 173 from OAT, and 100 by drug-checking services. Drug-checking and reducing fentanyl in the drug supply were the only harm reduction strategies that reduced the number of nonfatal overdoses. CONCLUSIONS: Within a multi-faceted harm reduction approach, scaling up take-home naloxone, and reducing fentanyl in the drug supply led to the largest reduction in opioid overdose fatality in Toronto. Detailed model simulation studies provide an additional tool to assess and inform public health policy on harm reduction.

Interaction of a caffeine overdose with clinical doses of contraceptive ethinyl estradiol in a young woman.

Aim: The overdose of caffeine, a cytochrome P450 1A2 probe, in young women has become a problem. The aim of this study was to evaluate possible drug interactions between intentionally overdosed caffeine (12 g) and oral contraceptive doses of ethinyl estradiol prescribed to a young woman in a suicide attempt. Methods: The serum concentrations of caffeine in the patient and the time-dependent ethinyl estradiol inhibition of caffeine oxidation in vitro were evaluated. Results: The serum concentration of caffeine 4 h after overdose was 136 µg/mL; from the data obtained between 4 and 28 h after overdose, the half-life was estimated to be 33 h, which is many times larger than the normal value. Prescribed ethinyl estradiol prolonged caffeine elimination in vivo and inhibited paraxanthine formation, as evidenced by the low serum concentrations. In human liver microsomes, ethinyl estradiol (50 nM) inhibited half of caffeine N 3 -demethylation. Pre-incubation of human liver microsomes with ethinyl estradiol resulted in a powerful time-dependent inhibitory effect on caffeine N 3 -demethylation in human liver microsomes. Conclusion: These results suggest that a prescription history of contraceptives at clinical doses may have a strong effect on the pharmacokinetics of overdosed caffeine in young women, resulting in dangerous drug interactions.

A case study of the DULF compassion club and fulfillment centre-A logical step forward in harm reduction.

In 2022, the Drug User Liberation Front's Compassion Club and Fulfillment Centre emerged as a groundbreaking initiative and research endeavor aimed at addressing the alarming rise in overdose deaths within Vancouver's Downtown Eastside. As the first of its kind, this pioneering model operated as a non-profit, low-barrier, and non-medicalized approach to regulating the volatility of the content of the illicit drug market in order to prevent overdose deaths. Going beyond traditional overdose prevention methods, the Drug User Liberation Front's Compassion Club and Fulfillment Centre not only provided supervised consumption services, but also supplied rigorously tested cocaine, heroin, and methamphetamine at cost to club members. This intrinsic case study offers a unique perspective on the operation of Drug User Liberation Front's Compassion Club and Fulfillment Centre, delving into its inception, development, implementation, and the challenges it faced in its operation. Ultimately, the insights garnered from the Drug User Liberation Front's Compassion Club and Fulfillment Centre hold significant value for others interested in establishing similar programs or exploring de-medicalized approaches regulating substances in order to prevent overdose deaths.

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.

Comparative effectiveness of extended-release naltrexone and sublingual buprenorphine for treatment of opioid use disorder among Medicaid patients.

BACKGROUND AND AIMS: Extended-release naltrexone (XR-NTX) and sublingual buprenorphine (SL-BUP) are both approved for opioid use disorder (OUD) treatment in any medical setting. We aimed to compare the real-world effectiveness of XR-NTX and SL-BUP. DESIGN AND SETTING: This was an observational active comparator, new user cohort study of Medicaid claims records for patients in New Jersey and California, USA, 2016-19. PARTICIPANTS/CASES: The participants were adult Medicaid patients aged 18-64 years who initiated XR-NTX or SL-BUP for maintenance treatment of OUD and did not use medications for OUD in the 90 days before initiation. Our cohort included 1755 XR-NTX and 9886 SL-BUP patients. MEASUREMENTS: We examined two outcomes up to 180 days after medication initiation: (1) composite of medication discontinuation and death and (2) composite of overdose and death. FINDINGS: In adjusted analyses, treatment with XR-NTX was more likely to result in discontinuation or death by the end of follow-up than treatment with SL-BUP: cumulative risk 75.9% [95% confidence interval (CI) = 73.9%, 77.9%] versus 62.2% (95% CI = 61.2%, 63.2%), respectively (risk difference = 13.7 percentage points, 95% CI = 11.4, 16.0). There was minimal difference in the cumulative risk of overdose or death by the end of follow-up: XR-NTX 3.9% (95% CI = 3.0%, 4.8%) versus SL-BUP 3.3% (95% CI = 2.9%, 3.7%); risk difference = 0.5 percentage points, 95% CI = -0.4, 1.5. Results were consistent across sensitivity analyses. CONCLUSIONS: Medicaid patients in California and New Jersey, USA, receiving treatment for opioid use disorder stayed in treatment longer on sublingual buprenorphine than on extended-release naltrexone, but the risk of overdose was similar. Most patients in this study discontinued medication within 6 months, regardless of which medication was initiated.

Diphenhydramine Intoxication With Blood Extended Half-Life and a False Positive Result for Tricyclic Antidepressants.

Diphenhydramine is a first-generation antihistamine medication. Acute intoxication with diphenhydramine can be severe and potentially fatal. The current case is of a 13-year-old girl who presented with central nervous system depression after voluntary intake of unknown drugs. Serum concentration analysis showed diphenhydramine intoxication, blood half-life extension, and a false positive result for tricyclic antidepressants (TCAs) in urine examination. To our knowledge, this is the first reported case of confirmed diphenhydramine overdose with a false positive result for TCAs and measurement of the serum level in a child. Considering the similarities between the clinical symptoms of diphenhydramine and TCA intoxication, this case illustrates that all physicians should consider the possibility of cross-reactivity during the diagnosis of patients with unknown acute drug intoxication who test positive for TCAs.

Tricyclic Antidepressant and Antipsychotic Toxicity: Clomipramine and Ziprasidone Overdose.

This case report details an intentional overdose attempt utilizing tricyclic antidepressants (TCAs) and atypical antipsychotics with significant neurologic, pulmonary, and cardiac toxicity. In conjunction with the local poison control center, progression of the clinical toxidrome was anticipated, aggressively managed, and successfully treated. This case highlights the dangers of significant TCA toxicity, peak onset of toxicity within six hours, and the amplification of clinical toxidromes with co-ingestions.

Maternal mental health as a major contributor to maternal mortality.

Perinatal mental health conditions affect up to 20 % of pregnant or postpartum individuals, and nearly 15 % of pregnant individuals meet criteria for substance use disorder (SUD). All providers taking care of pregnant or postpartum individuals will encounter patients in these scenarios. Maternal Mortality Review Committees (MMRCs) have determined maternal mental health conditions, including SUD, to be the leading cause of preventable maternal death during pregnancy or in the first year postpartum. Lessons learned from MMRCs to prevent these deaths include the recommendation that screening and identification of mental health conditions need to be linked with evidence-based, patient-centered, and accessible treatments. Obstetricians and gynecologists, midwives, family medicine providers, and pediatricians, are in unique positions not only to screen and diagnose, but also to treat individuals with mental health concerns, including SUD, during pregnancy and postpartum.

Drug Overdose Death Following Substance Use Disorder Treatment Termination in New York City: A Retrospective Longitudinal Cohort Study.

Drug overdose death rates are the highest recorded in New York City (NYC). Substance use disorder (SUD) treatment termination can confer increased risk of drug overdose death. Our objective was to determine the probability of, and factors associated with, drug overdose death following SUD treatment termination. Using a retrospective longitudinal cohort design, we identified those who had NYC-based SUD treatment terminated (01/2016-06/2019) using Chief Medical Examiner and SUD treatment data. Using survival analyses, we examined drug overdose deaths ≤ 14 and ≤ 90 days following SUD treatment termination, respectively. Of 51,171 patients with SUD treatment termination, 140 and 342 had a drug overdose death < 14 and ≤ 90 days, respectively. The crude drug overdose death rate was 26.7 per 1000 person-years at-risk in the ≤ 90-day period and was 71.6 per 1000 person-years at-risk in the ≤ 14-day period. In adjusted Cox proportional hazard model examining death ≤ 14 days, those unemployed (compared to employed) and those terminated from residential treatment (compared to medically supervised withdrawal, opioid treatment programs, and outpatient treatment) were more likely to have had a drug overdose death (all p-values < 0.01). In adjusted Cox proportional hazard model examining death ≤ 90 days, non-Hispanic White people (compared to non-Hispanic Black people), those not stably housed (compared to stably housed), those unemployed and those terminated from residential treatment were more likely to have had a drug overdose death (all p-values < 0.01). Strategies to improve retention including the reassessment of program treatment termination criteria along with strategies to promote ongoing OUD treatment, engagement in harm reduction, and distribution of naloxone are needed.

Methadone treatment utilization and overdose trends among Medicaid beneficiaries in New Jersey before and during the COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic disrupted the traditional mode of methadone maintenance treatment (MMT) delivery through the imposition of lockdowns and social distancing measures. In response, policy makers granted flexibilities to providers delivering MMT to change their practices to maintain patient participation while accommodating the measures imposed to prevent the spread of COVID-19. This study examines the utilization of MMT and overdoses of patients receiving MMT during the COVID-19 pandemic in one mid-Atlantic state. MATERIALS AND METHODS: We analyzed Medicaid claims data for 2018-2020, calculating weekly trends for starts, discontinuations, and medically-treated overdoses for beneficiaries receiving MMT who had been continuously enrolled in Medicaid for the previous 12 months, to account for changes in the composition of the Medicaid population following the COVID-19 public health emergency (PHE). We completed data analyses from January to June 2022. RESULTS: We observed countervailing trends in new starts, which experienced an immediate, non-significant dip of -22.47 per 100,000 Medicaid beneficiaries (95%CI, -50.99 to 6.04) at the outset of the pandemic followed by an increasing upward trend of 1.41 per 100,000 beneficiaries per week (95%CI, 0.37 to 2.46), and in discontinuations, which also experienced an immediate dip of -3.23 per 1000 MMT enrollees (95%CI, -4.49 to -1.97) followed by an increasing upward trend of 0.14 per 1000 MMT enrollees per week (95%CI, 0.09 to 0.19). The net result of these shifts was a stable, slowly increasing rate of MMT treatment of 0.02 % per week before and after the PHE. We also found no statistically significant association of the PHE with medically-treated overdoses among beneficiaries enrolled in MMT (trend change = 0.02 overdoses per 10,000 MMT enrollees, 95%CI, -0.05 to 0.09). CONCLUSIONS: New Jersey achieved overall stability in MMT treatment prevalence following the pandemic's onset, while some changes in treatment dynamics took place. This outcome may reflect that the extensive flexibilities granted to providers of MMT by the state and federal government successfully maintained access to MMT for Medicaid beneficiaries through the pandemic without increasing risk of medically-treated overdose. These findings should inform policy makers developing the post-COVID-19 legal and regulatory landscape.

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.