Willingness to use a wearable device capable of detecting and reversing overdose among people who use opioids in Philadelphia.

BACKGROUND: The incidence of opioid-related overdose deaths has been rising for 30 years and has been further exacerbated amidst the COVID-19 pandemic. Naloxone can reverse opioid overdose, lower death rates, and enable a transition to medication for opioid use disorder. Though current formulations for community use of naloxone have been shown to be safe and effective public health interventions, they rely on bystander presence. We sought to understand the preferences and minimum necessary conditions for wearing a device capable of sensing and reversing opioid overdose among people who regularly use opioids. METHODS: We conducted a combined cross-sectional survey and semi-structured interview at a respite center, shelter, and syringe exchange drop-in program in Philadelphia, Pennsylvania, USA, during the COVID-19 pandemic in August and September 2020. The primary aim was to explore the proportion of participants who would use a wearable device to detect and reverse overdose. Preferences regarding designs and functionalities were collected via a questionnaire with items having Likert-based response options and a semi-structured interview intended to elicit feedback on prototype designs. Independent variables included demographics, opioid use habits, and previous experience with overdose. RESULTS: A total of 97 adults with an opioid use history of at least 3 months were interviewed. A majority of survey participants (76%) reported a willingness to use a device capable of detecting an overdose and automatically administering a reversal agent upon initial survey. When reflecting on the prototype, most respondents (75.5%) reported that they would wear the device always or most of the time. Respondents indicated discreetness and comfort as important factors that increased their chance of uptake. Respondents suggested that people experiencing homelessness and those with low tolerance for opioids would be in greatest need of the device. CONCLUSIONS: The majority of people sampled with a history of opioid use in an urban setting were interested in having access to a device capable of detecting and reversing an opioid overdose. Participants emphasized privacy and comfort as the most important factors influencing their willingness to use such a device. TRIAL REGISTRATION: NCT04530591.

Hostility, compassion and role reversal in West Virginia's long opioid overdose emergency.

BACKGROUND: West Virginia is a largely rural state with strong ties of kinship, mutual systems of support and charitable giving. At the same time, wealth inequalities are extreme and the state's drug overdose fatality rate stands above all others in the USA at 51.5/100,000 in 2018, largely opioid-related. In recent years, harm reduction services have been active in the state but in 2018 Charleston's needle and syringe program was forced to close. This paper considers the risk environment in which the state's drug-related loss of life, and those attempting to prevent it, exist. METHODS: This rapid ethnographic study involved semi-structured interviews (n = 21), observation and video recordings of injection sequences (n = 5), initially recruiting people who inject heroin/fentanyl (PWIH) at the Charleston needle and syringe program. Snowball sampling led the research team to surrounding towns in southern West Virginia. Telephone interviews (n = 2) with individuals involved in service provision were also carried out. RESULTS: PWIH in southern West Virginia described an often unsupportive, at times hostile risk environment that may increase the risk of overdose fatalities. Negative experiences, including from some emergency responders, and fears of punitive legal consequences from calling these services may deter PWIH from seeking essential help. Compassion fatigue and burnout may play a part in this, along with resentment regarding high demands placed by the overdose crisis on impoverished state resources. We also found low levels of knowledge about safe injection practices among PWIH. CONCLUSIONS: Hostility faced by PWIH may increase their risk of overdose fatalities, injection-related injury and the risk of HIV and hepatitis C transmission by deterring help-seeking and limiting the range of harm reduction services provided locally. Greater provision of overdose prevention education and naloxone for peer distribution could help PWIH to reverse overdoses while alleviating the burden on emergency services. Although essential for reducing mortality, measures that address drug use alone are not enough to safeguard longer-term public health. The new wave of psychostimulant-related deaths underline the urgency of addressing the deeper causes that feed high-risk patterns of drug use beyond drugs and drug use.

All-cause mortality among males living with and without HIV initiating long-term opioid therapy, and its association with opioid dose, opioid interruption and other factors.

BACKGROUND: While the relationship between long-term opioid therapy (LTOT) dose and overdose is well-established, LTOT's association with all-cause mortality is less understood, especially among people living with HIV (PLWH). There is also limited information regarding the association of LTOT cessation or interruption with mortality. METHODS: Among PLWH and matched uninfected male veterans in care, we identified those who initiated LTOT. Using time-updated cox regression, we examined the association between all-cause mortality, unnatural death, and overdose, and opioid use categorized as 1-20 (reference group), 21-50, 51-90, and ≥ 91 mg morphine equivalent daily dose (MEDD). RESULTS: There were 22,996 patients on LTOT, 6,578 (29 %) PLWH and 16,418 (71 %) uninfected. Among 5,222 (23 %) deaths, 12 % were unnatural deaths and 6 % overdoses. MEDD was associated with risk of all 3 outcomes; compared to patients on 1-20 mg MEDD, adjusted risk for all-cause mortality monotonically increased (Hazard Ratios (HR) [95 % CI] for 21-50 mg MEDD = 1.36 [1.21, 1.52], 51-90 mg MEDD = 2.06 [1.82, 2.35], and ≥ 91 mg MEDD = 3.03 [2.71, 3.39]). Similar results were seen in models stratified by HIV. LTOT interruption was also associated with all-cause, unnatural, and overdose mortality (HR [95 % CI] 2.30 [2.09, 2.53], 1.47 [1.13, 1.91] and 1.52 [1.04, 2.23], respectively). CONCLUSIONS: Among PLWH and uninfected patients on LTOT we observed a strong dose-response relationship with all 3 mortality outcomes. Opioid risk mitigation approaches should be expanded to address the potential effects of higher dose on all-cause mortality in addition to unnatural and overdose fatalities.

Evaluation of a personally-tailored opioid overdose prevention education and naloxone distribution intervention to promote harm reduction and treatment readiness in individuals actively using illicit opioids.

BACKGROUND: Opioid overdose prevention education and naloxone distribution (OEND) programs include information on general risk factors, overdose recognition, and naloxone utilization. This study evaluated a personally-tailored OEND (PTOEND) intervention designed to promote harm reduction and treatment readiness for illicit opioid users by also including education about personal overdose-risk factors and medication for opioid use disorder (MOUD). METHOD: A secondary analysis of a randomized controlled trial testing a Peer recovery support service (PRSS) intervention, relative to Control, in adult illicit opioid users reporting treatment for an overdose in the prior 6 months. PTOEND, a 30-minute computer-guided intervention, was administered by a research assistant at the randomization visit to all participants (N = 80). Participants completed a telephone visit 3 weeks post-randomization (n = 74) to assess changes in opioid overdose/MOUD knowledge and treatment readiness. Participants completed in-person visits at 3 (n = 66), 6 (n = 58), and 12 (n = 44) months post-randomization to assess illicit opioid use and naloxone utilization (all time points) and overdose-risk behaviors (12 months). We conducted pre-post analyses of the impact of PTOEND controlling for the PRSS effect. RESULTS: PTOEND increased knowledge of overdose (79.8% to 81.5%, p < 0.05) and MOUD (66.9% to 75.0%, p < 0.01) and decreased perceived treatment barriers (2.1 to 1.9, p < 0.01); desire to quit all substances increased (7.2 to 7.8, p = 0.05). Self-reported opioid use was significantly decreased at each follow-up (all p < 0.01). Self-reported overdose-risk behaviors decreased significantly (6.2 to 2.4, p < 0.01). A majority of participants (65 %) reported naloxone utilization. CONCLUSIONS: PTOEND may be effective for promoting harm reduction and treatment readiness.

Knowledge, preparedness, and compassion fatigue among law enforcement officers who respond to opioid overdose.

BACKGROUND: Rates of fatal overdose (OD) from synthetic opioids rose nearly 60 % from 2016 to 2018. 911 Good Samaritan Laws (GSLs) are an evidenced-based strategy for preventing OD fatality. This study describes patrol officers' knowledge of their state's GSL, experience with OD response, and their perspectives on strategies to prevent and respond to opioid OD. METHODS: An electronic survey assessed officers' knowledge of state GSLs and experiences responding to OD. Descriptive statistics and hierarchical linear modeling were generated to examine differences in knowledge, preparedness, and endorsement of OD response efforts by experience with OD response. RESULTS: 2,829 officers responded to the survey. Among those who had responded to an OD call in the past six months (n = 1,946), 37 % reported administering naloxone on scene and 36 % reported making an arrest. Most (91 %) correctly reported whether their state had a GSL in effect. Only 26 % correctly reported whether that law provides limited immunity from arrest. Fifteen percent of officers who had responded to an OD work in departments that do not carry naloxone. Compared with officers who had not responded to any OD calls, those who reported responding OD calls at least monthly and at least weekly, were significantly less likely to endorse OD response efforts. CONCLUSION: Officers who respond to OD calls are generally receiving training and naloxone supplies to respond, but knowledge gaps and additional training needs persist. Additional training and strategies to relieve compassion fatigue among those who have more experience with OD response efforts may be indicated.

A brief telephone-delivered peer intervention to encourage enrollment in medication for opioid use disorder in individuals surviving an opioid overdose: Results from a randomized pilot trial.

BACKGROUND: Medication for opioid use disorder (MOUD) can decrease the risk of opioid overdose (OOD) in individuals with opioid use disorder. Peer recovery support services (PRSS) are increasingly used to promote MOUD engagement but evidence of their efficacy is limited. This study's objective was to evaluate a single 20-minute telephone-delivered PRSS intervention for increasing MOUD enrollment and decreasing recurring OODs. METHOD: This single-site, randomized controlled pilot trial enrolled adults, primarily recruited from a syringe service program, with an opioid-positive urine drug screen (UDS) reporting having been treated for an OOD within the past 6 months. Participants (N = 80) were randomized to PRSS (n = 40) or Control (n = 40) condition with all participants receiving personally-tailored OOD education and naloxone. Outcome measures obtained at 3 (n = 66), 6 (n = 58), and 12 (n = 44) months post-randomization included verified MOUD enrollment (primary), self-reported OOD, and opioid use assessed by self-report and UDS. RESULTS: Through 12-month follow-up, 32.5 % of PRSS, compared to 17.5 % of Control participants enrolled in MOUD (X2 = 2.4, p = 0.12; odds ratio = 2.27 (0.79-6.49)). PRSS participants were significantly less likely to have experienced an OOD through 12-month follow-up (12.5 % of PRSS participants, 32.5 % of Control, p = 0.03). No significant treatment effect was found for opioid use through 12-month follow-up as measured by either opioid-positive UDSs or self-reported past month opioid use days. Based on self-report, PRSS had good acceptability for both the interventionists and participants. CONCLUSIONS: The results suggest that further development and testing of this PRSS telephone intervention to encourage MOUD enrollment and reduce OOD may be warranted.

Links between suicidal intent, polysubstance use, and medical treatment after non-fatal opioid overdose.

BACKGROUND: Suicidal thinking during non-fatal overdose may elevate risk for future completed suicide or intentional overdose. Long-term outcomes following an intentional non-fatal overdose may be improved through specific intervention and prevention responses beyond those designed for unintentional overdoses, yet little research has assessed suicidal intent during overdoses or defined characteristics that differentiate these events from unintentional overdoses. METHODS: Patients with a history of opioid overdose (n = 274) receiving residential addiction treatment in the Midwestern United States completed self-report surveys to classify their most recent opioid overdose as unintentional, actively suicidal (wanted to die), or passively suicidal (didn't care about the risks). We characterized correlates of intent using descriptive statistics and prevalence ratios. We also examined how intent related to thoughts of self-harm at the time of addiction treatment. RESULTS: Of opioid overdoses, 51 % involved suicidal intent (44 % passive and 7 % active). Active suicidal intent was positively associated with hospitalization. Active/passive intent (vs. no intent, aPR: 2.2, 95 % CI: 1.4-3.5) and use of ≥5 substances (vs. 1 substance, aPR: 3.6, 95 % CI: 1.2-10.6) at the last opioid overdose were associated with having thoughts of self-harm or suicide in the 2 weeks before survey completion in adjusted models. Participants who reported active/passive intent more commonly used cocaine or crack (27 %) with opioids during their last overdose relative to unintentional overdoses (16 %). CONCLUSIONS: Over half of opioid overdoses among individuals in addiction treatment involved some degree of suicidal thinking. Identifying patients most at risk will facilitate better targeting of suicide prevention and monitoring services.

Delivering Opioid Overdose Prevention in Bars and Nightclubs: A Public Awareness Pilot in New York City.

Drug seizure data indicate the presence of fentanyl in the cocaine supplies nationally and in New York City (NYC). In NYC, 39% of cocaine-only involved overdose deaths in 2017 also involved fentanyl, suggesting that fentanyl in the cocaine supply is associated with overdose deaths. To raise awareness of fentanyl overdose risk among people who use cocaine, the NYC Department of Health and Mental Hygiene pilot tested an awareness campaign in 23 NYC nightlife venues. Although 87% of venue owners/managers were aware of fentanyl, no participating venues had naloxone on premises prior to the intervention. The campaign's rapid dissemination reached people at potential risk of opioid overdose in a short period of time following the identification of fentanyl in the cocaine supply. Public health authorities in states with high rates of opioid-involved overdose death should consider similar campaigns to deliver overdose prevention education in the context of a drug supply containing fentanyl.

Risk and protective factors for repeated overdose after opioid overdose survival.

BACKGROUND: Nonfatal opioid overdose (OD) is an opportunity to identify patients who may benefit from interventions to reduce repeated overdose (rOD). In this study, we sought to determine risk and protective factors associated with rOD. METHODS: In this retrospective cohort study of 4,155 patients aged 18-64 who presented to one of 16 emergency departments in a single Western Pennsylvania health system between July 2015 and January 2018 for index opioid overdose (iOD) and survived to discharge, we identified demographic and clinical factors association with rOD within one-year. Relative risk of repeated opioid overdose was estimated using adjusted Cox proportional hazard ratios (aHRs). RESULTS: 14.9 % of patients (95 % CI 13.9-16.1) had a rOD, with 29 % occurring within 30 days from iOD. The adjusted hazard of opioid overdose was increased for male patients (aHR = 1.19; 95 % CI 1.01, 1.41), those with pre-iOD diagnoses of anxiety (aHR = 1.41; 95 % CI1.13, 1.77), depression (aHR = 1.44; 95 % CI 1.17, 1.78), substance use disorders (aHR = 1.30; 95 % CI 1.09, 1.55), and alcohol use disorder (aHR = 1.52; 95 % CI 1.02, 2.25). The hazard was lower for individuals prescribed an opioid in the 90 days prior to iOD (aHR = 0.59; 95 % CI 0.37, 0.97) and those admitted to the hospital for iOD (aHR = 0.56; 95 % CI 0.37, 0.86). CONCLUSION: We found that, among ED patients who survive an initial OD, mental health and substance use diagnoses are associated with a higher hazard of repeated overdoses whereas opioids prescriptions and admission are associated with lower hazards.

Chronic non-cancer pain among adults with substance use disorders: Prevalence, characteristics, and association with opioid overdose and healthcare utilization.

BACKGROUND: Chronic non-cancer pain (CNCP) among patients with substance use disorder (SUD) poses a risk for worse treatment outcomes. Understanding the association of CNCP with SUD is important for informing the need and potential benefits of pain assessment/management among those with SUDs. METHODS: We analyzed electronic health record data from 2013 to 2018 among adults aged ≥18 years (N = 951,533; mean age: 48.4 years; 57.4 % female) in a large academic healthcare system. Adjusted logistic regression models were conducted to estimate the association of CNCP conditions with opioid overdose, emergency department utilization, and inpatient hospitalization stratified by different SUD diagnoses and by gender. RESULTS: Among the total sample, the prevalence of CNCP was 46.6 % and any SUD was 11.2 %. The majority of patients with a SUD had CNCP (opioid: 74.7 %; sedative: 72.3 %; cannabis: 64.3 %; alcohol: 58.7 %; tobacco: 59.5 %). The prevalence of CNCP was greater in females vs. males for most SUD diagnoses. The presence of CNCP was associated with more mental health disorders and chronic medical conditions among each SUD group. CNCP was associated with significantly decreased odds of overdose among those with opioid use disorder but increased odds of overdose and healthcare utilization among other SUDs. CNCP was positively associated with overdose in females, but not males, with alcohol or non-opioid drug use disorders. CONCLUSIONS: The direction and magnitude of the association between CNCP and negative health indicators differed as a function of SUD type and gender, respectively. Greater awareness of potential unmet pain treatment need may have implications for improving SUD outcomes.

Acute stressors and clinical characteristics differentiate death by suicide, accident, or natural causes among illicit and prescription opiate users.

BACKGROUND: Opiate misuse has reached epidemic levels. Prevention efforts depend on distinguishing opiate users from abusers. The current study compared opioid users who died by natural cases, accidents, and suicide using psychological autopsy methods. Groups were compared on substance use characteristics, treatment history, experiences of negative life events, and circumstances at the time of death. METHODS: Substance use and suicide risk were evaluated using psychological autopsy methods in 63 decedents with positive toxicology for opiates at death divided into three groups: adults dying by suicide (n = 19), accident (n = 19), and natural causes (n = 25). Groups were compared on several dependent measures, using chi-square analyses to examine categorical variables and one-way analyses of variance (ANOVA) to examine continuous variables. RESULTS: Individuals who died by suicide were similar in many ways to adults who died by an accidental overdose. However, suicide completers were more likely to have struggled with severe depression, and previously attempted suicide, whereas the accidental overdose sample was more likely to display a chronic pattern of severe drug abuse. CONCLUSIONS: The current study helps to distinguish between opiate users who are at risk for death by an accidental or intentional overdose. In the ongoing opiate crisis, clinicians must understand the risk of overdose and the nuances of accidental behaviors compared to purposeful ones. Signs of suicidal planning, relevant psychopathology, and ongoing life stress may be useful points of intervention for stopping the increasing number of deaths among opiate users.

Opioid overdose prevention education for medical students: Adopting harm reduction into mandatory clerkship curricula.

Background: Opioid overdose deaths constitute a public health crisis in the United States. Strategies for reducing opioid-related harm are underutilized due in part to clinicians' low knowledge about harm reduction theory and limited preparedness to prescribe naloxone. Educational interventions are needed to improve knowledge and attitudes about, and preparedness to address, opioid overdoses among medical students. Methods: Informed by the Department of Veterans Affairs' Overdose Education and Naloxone Distribution (OEND) program and narrative medicine, we developed and led a mandatory workshop on harm reduction for clerkship medical students. Using validated scales, we assessed students' knowledge and attitudes about, and preparedness to address, opioid overdoses before the workshop and 6 weeks after. Results: Of 75 participating students from February through December 2017, 55 (73%) completed pre-workshop and 38 (51%) completed both pre- and post-workshop surveys. At baseline, 40 (73%) encountered patients with perceived at-risk opioid use in the previous 6 weeks, but only 11 (20%) recalled their teams prescribing naloxone for overdose prevention. Among those completing both surveys, knowledge about and preparedness to prevent overdose showed large improvement (Cohen's d = 0.85, P < .001; Cohen's d = 1.24, P < .001, respectively) and attitudes showed moderate improvement (Cohen's d = 0.32, P = .04). Discussion: Educational interventions grounded in harm reduction theory can increase students' knowledge and attitudes about, and preparedness to address, opioid overdoses.