Best practices for community-based overdose education and naloxone distribution programs: results from using the Delphi approach.

BACKGROUND: Opioid-related overdose deaths have surged in the USA over the last two decades. Overdose fatalities are preventable with the timely administration of naloxone. Syringe service programs (SSP) have pioneered community-based naloxone distribution through overdose prevention and naloxone distribution (OEND) programs. There is a dearth of information with regards to best practices for community-based OEND. METHODS: We utilized a modified Delphi approach to develop a set of best practices for OEND delivery. Starting with an initial list of best practices, we engaged 27 experts, in the field of OEND programming who reviewed, made recommendations for changes, and assigned a priority to each best practice. RESULTS: Two rounds of input resulted in a final list of 20 best practices organized into four categories. The mean priority scores ranged from 1.17 to 2.17 (range 1 to 3). The top 5 ranked best practices were ensuring that SSP participants have low barrier, consistent, needs-based access to naloxone and that there is ample naloxone available within communities. While the remaining fifteen best practices were deemed important, they had more to do with organizational culture and implementation climate. CONCLUSIONS: Increasing community-based OEND delivery is essential to reduce opioid overdose deaths; however, it will be insufficient to add programs without an eye toward quality of implementation and fidelity to the model upon which the evidence is based. This list of best practices summarizes the consensus among OEND experts and can serve as a tool for SSPs providing OEND programming to improve services.

Estimating naloxone need in the USA across fentanyl, heroin, and prescription opioid epidemics: a modelling study.

BACKGROUND: The US overdose crisis is driven by fentanyl, heroin, and prescription opioids. One evidence-based policy response has been to broaden naloxone distribution, but how much naloxone a community would need to reduce the incidence of fatal overdose is unclear. We aimed to estimate state-level US naloxone need in 2017 across three main naloxone access points (community-based programmes, provider prescription, and pharmacy-initiated distribution) and by dominant opioid epidemic type (fentanyl, heroin, and prescription opioid). METHODS: In this modelling study, we developed, parameterised, and applied a mechanistic model of risk of opioid overdose and used it to estimate the expected reduction in opioid overdose mortality after deployment of a given number of two-dose naloxone kits. We performed a literature review and used a modified-Delphi panel to inform parameter definitions. We refined an established model of the population at risk of overdose by incorporating changes in the toxicity of the illicit drug supply and in the naloxone access point, then calibrated the model to 2017 using data obtained from proprietary data sources, state health departments, and national surveys for 12 US states that were representative of each epidemic type. We used counterfactual modelling to project the effect of increased naloxone distribution on the estimated number of opioid overdose deaths averted with naloxone and the number of naloxone kits needed to be available for at least 80% of witnessed opioid overdoses, by US state and access point. FINDINGS: Need for naloxone differed by epidemic type, with fentanyl epidemics having the consistently highest probability of naloxone use during witnessed overdose events (range 58-76% across the three modelled states in this category) and prescription opioid-dominated epidemics having the lowest (range 0-20%). Overall, in 2017, community-based and pharmacy-initiated naloxone access points had higher probability of naloxone use in witnessed overdose and higher numbers of deaths averted per 100 000 people in state-specific results with these two access points than with provider-prescribed access only. To achieve a target of naloxone use in 80% of witnessed overdoses, need varied from no additional kits (estimated as sufficient) to 1270 kits needed per 100 000 population across the 12 modelled states annually. In 2017, only Arizona had sufficient kits to meet this target. INTERPRETATION: Opioid epidemic type and how naloxone is accessed have large effects on the number of naloxone kits that need to be distributed, the probability of naloxone use, and the number of deaths due to overdose averted. The extent of naloxone distribution, especially through community-based programmes and pharmacy-initiated access points, warrants substantial expansion in nearly every US state. FUNDING: National Institute of Health, National Institute on Drug Abuse.

Results from a mobile drug checking pilot program using three technologies in Chicago, IL, USA.

BACKGROUND: Opioid overdose deaths in the United States continue to rise, with the majority of deaths involving fentanyl. Drug checking has been used in Europe and Canada to assess adulteration of the illegal drug supply, but faces legal barriers in the United States. We are presenting information from a pilot mobile program offering drug checking services to participants of a harm reduction program in Chicago, Illinois, USA. METHODS: Drug checking services were provided at five mobile outreach and one fixed-point drop-in location in Chicago, IL, between March 2019 and August 2020. Three technologies were used: a Fourier transform infrared spectroscopy (FTIR) spectrometer, a handheld high-pressure mass spectrometer (HPMS), and immunoassay fentanyl test strips (FTS). We report on results generated by this combination of technology during the study period. RESULTS: During the study period, 422 total samples were tested, the majority of which were sold as dope/heroin (66.7 %). Of the 282 samples sold as dope/heroin, 12.8 % matched to fentanyl on the FTIR, 47.5 % had fentanyl identified on the HPMS, and 57.8 % produced a positive FTS. CONCLUSIONS: This pilot program demonstrated the feasibility of using three technologies to assess for the presence of fentanyl in user-submitted samples, revealed discordant results from the technologies, and provided information on the local drug market.

Amount of naloxone used to reverse opioid overdoses outside of medical practice in a city with increasing illicitly manufactured fentanyl in illicit drug supply.

Background: Illicitly manufactured fentanyl (IMF) prevalence has increased. However, there is uncertainty about naloxone dose(s) used by nonmedical bystanders to reverse opioid overdoses in the context of increasing IMF. Methods: We used community naloxone distribution program data about naloxone doses and fatal opioid overdoses from the Allegheny County Medical Examiner. From January 2013 to December 2016, staff interviewed participants who administered naloxone in response to 1072 overdoses. We calculated frequencies, percentages, and conducted a 1-way analysis of variance (ANOVA). Results: Despite increases in fentanyl-contributed deaths, there were no statistically significant differences between any of the 4 years (2013-2016) on average number of naloxone doses used by participants to reverse an overdose (F = 0.88; P = .449). Conclusion: Even though IMF is more potent than heroin and is a rapidly increasing contributor to drug overdose deaths in Allegheny County, the average dose of naloxone administered has not changed. Our findings differ from studies in different areas also experiencing increasing IMF prevalence. Additional investigations are needed to clarify the amount of naloxone needed to reverse opioid overdoses in the community caused by new synthetic opioids.

From Peers to Lay Bystanders: Findings from a Decade of Naloxone Distribution in Pittsburgh, PA.

Distribution of the opioid overdose reversal drug naloxone has been central to efforts to combat the ongoing opioid epidemic in the United States. This report presents data from Prevention Point Pittsburgh (PPP), a public health advocacy and direct service organization that has operated an overdose prevention program (OPP) with naloxone distribution since 2005. The program initially provided naloxone training and distribution only to people who use opioids (PWUO). In 2015, a change to state law enabled PPP to provide naloxone to anyone in a position to respond to an opioid-related overdose. This report examines the characteristics and naloxone-related experiences of 1330 PWUO trained in overdose prevention and naloxone administration by PPP between January 1, 2006, and December 31, 2015, and compares rates of return for a naloxone refill by PWUO and the 619 non-users trained between January 1, 2015, and December 31, 2015. While larger numbers of individuals obtained naloxone after state law changed, PWUO-especially heroin users-were significantly more likely to reverse an overdose and return to PPP for a naloxone refill. Based on these findings, we recommend that resource-limited, community-based organizations prioritize the distribution of naloxone to PWUO.

Medication-assisted treatment for substance use disorders within a national community health center research network.

BACKGROUND: The Affordable Care Act increases access to treatment services for people who suffer from substance use disorders (SUDs), including alcohol use disorders (AUDs) and opioid use disorders (OUDs). This increased access to treatment has broad implications for delivering health services and creates a dramatic need for transformation in clinical care, service lines, and collaborative care models. Medication-assisted treatments (MAT) are effective for helping SUD patients reach better outcomes. This article uses electronic health record (EHR) data to examine the prevalence of EHR-documented SUDs, patient characteristics, and patterns of MAT prescribing and screening for patients within the Community Health Applied Research Network (CHARN), a national network of 17 community health centers that facilitates patient-centered outcomes research among underserved populations. METHODS: Hierarchical generalized linear models examined patient characteristics, SUD occurrence rates, MAT prescription, and human immunodeficiency virus (HIV) and hepatitis virus C screening for patients with AUDs or OUDs. Results: Among 572,582 CHARN adult patients, 16,947 (3.0%) had a documented AUD diagnosis and 6,080 (1.1%) an OUD diagnosis. Alcohol MAT prescriptions were documented for 547 AUD patients (3.2%) and opioid MAT for 1,764 OUD patients (29.0%). Among OUD patients, opioid MAT was significantly associated with HIV screening (odds ratio [OR] = 1.31, P < .001) in OUD patients, as was alcohol MAT among AUD patients (OR = 1.30, P = .013). CONCLUSIONS: These findings suggest that effective opioid and alcohol MAT may be substantially underprescribed among safety-net patients identified as having OUDs or AUDs.

Overdose rescues by trained and untrained participants and change in opioid use among substance-using participants in overdose education and naloxone distribution programs: a retrospective cohort study.

BACKGROUND: One approach to preventing opioid overdose, a leading cause of premature, preventable mortality, is to provide overdose education and naloxone distribution (OEND). Two outstanding issues for OEND implementation include 1) the dissemination of OEND training from trained to untrained community members; and 2) the concern that OEND provides active substance users with a false sense of security resulting in increased opioid use. METHODS: To compare overdose rescue behaviors between trained and untrained rescuers among people reporting naloxone rescue kit use; and determine whether heroin use changed after OEND, we conducted a retrospective cohort study among substance users in the Massachusetts OEND program from 2006 to 2010. We used chi square and t-test statistics to compare the differences in overdose management characteristics among overdoses managed by trained versus untrained participants. We employed Wilcoxon signed rank test to compare median difference among two repeated measures of substance use among participants with drug use information collected more than once. RESULTS: Among 4,926 substance-using participants, 295 trained and 78 untrained participants reported one or more rescues, resulting in 599 rescue reports. We found no statistically significant differences in help-seeking (p = 0.41), rescue breathing (p = 0.54), staying with the victim (p = 0.84) or in the success of naloxone administration (p = 0.69) by trained versus untrained rescuers. We identified 325 OEND participants who had drug use information collected more than once. We found no significant overall change in the number of days using heroin in past 30 days (decreased 38%, increased 35%, did not change 27%, p = 0.52). CONCLUSION: Among 4926 substance users who participated in OEND, 373(7.6%) reported administering naloxone during an overdose rescue. We found few differences in behavior between trained and untrained overdose rescuers. Prospective studies will be needed to determine the optimal level of training and whether naloxone rescue kits can meet an over-the-counter standard. With no clear evidence of increased heroin use, this concern should not impede expansion of OEND programs or policies that support them.

Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis.

OBJECTIVE: To evaluate the impact of state supported overdose education and nasal naloxone distribution (OEND) programs on rates of opioid related death from overdose and acute care utilization in Massachusetts. DESIGN: Interrupted time series analysis of opioid related overdose death and acute care utilization rates from 2002 to 2009 comparing community-year strata with high and low rates of OEND implementation to those with no implementation. SETTING: 19 Massachusetts communities (geographically distinct cities and towns) with at least five fatal opioid overdoses in each of the years 2004 to 2006. PARTICIPANTS: OEND was implemented among opioid users at risk for overdose, social service agency staff, family, and friends of opioid users. INTERVENTION: OEND programs equipped people at risk for overdose and bystanders with nasal naloxone rescue kits and trained them how to prevent, recognize, and respond to an overdose by engaging emergency medical services, providing rescue breathing, and delivering naloxone. MAIN OUTCOME MEASURES: Adjusted rate ratios for annual deaths related to opioid overdose and utilization of acute care hospitals. RESULTS: Among these communities, OEND programs trained 2912 potential bystanders who reported 327 rescues. Both community-year strata with 1-100 enrollments per 100,000 population (adjusted rate ratio 0.73, 95% confidence interval 0.57 to 0.91) and community-year strata with greater than 100 enrollments per 100,000 population (0.54, 0.39 to 0.76) had significantly reduced adjusted rate ratios compared with communities with no implementation. Differences in rates of acute care hospital utilization were not significant. CONCLUSIONS: Opioid overdose death rates were reduced in communities where OEND was implemented. This study provides observational evidence that by training potential bystanders to prevent, recognize, and respond to opioid overdoses, OEND is an effective intervention.

Opioid overdose prevention with intranasal naloxone among people who take methadone.

Overdose education and naloxone distribution (OEND) is an intervention that addresses overdose, but has not been studied among people who take methadone, a drug involved in increasing numbers of overdoses. This study describes the implementation of OEND among people taking methadone in the previous 30 days in various settings in Massachusetts. From 2008 to 2010, 1553 participants received OEND who had taken methadone in the past 30 days. Settings included inpatient detoxification (47%), HIV prevention programs (25%), methadone maintenance treatment programs (MMTP) (17%), and other settings (11%). Previous overdose, recent inpatient detoxification and incarceration, and polysubstance use were overdose risks factors common among all groups. Participants reported 92 overdose rescues. OEND programs are public health interventions that address overdose risk among people who take methadone and their social networks. OEND programs can be implemented in MMTPs, detoxification programs, and HIV prevention programs.

Saved by the nose: bystander-administered intranasal naloxone hydrochloride for opioid overdose.

Administering naloxone hydrochloride (naloxone) during an opioid overdose reverses the overdose and can prevent death. Although typically delivered via intramuscular or intravenous injection, naloxone may be delivered via intranasal spray device. In August 2006, the Boston Public Health Commission passed a public health regulation that authorized an opioid overdose prevention program that included intranasal naloxone education and distribution of the spray to potential bystanders. Participants were taught by trained nonmedical needle exchange staff. After 15 months, the program provided training and intranasal naloxone to 385 participants who reported 74 successful overdose reversals. Problems with intranasal naloxone were uncommon. Overdose prevention education with distribution of intranasal naloxone is a feasible public health intervention to address opioid overdose.

A report of a midwifery model for training traditional midwives in Guatemala.

OBJECTIVE: to describe the specific characteristics of one model of training traditional birth attendants (TBAs) in Guatemala. DESIGN: participant observation, unstructured and semi-structured interviews undertaken between 1997 and 2003 to gather the data to report on the characteristics of this training programme as it is evolving in the field. SETTING: the birth centre site of Ixmucane in Antigua, Guatemala, as well as community sites in the Departments of Saquetepequez, Chimaltenango, and Quetzaltenango in the western highlands of Guatemala. PARTICIPANTS: traditional midwives, certified nurse-midwives and certified professional midwives, as well as many allied health professionals and volunteers. INTERVENTION: training philosophy, participant selection, curriculum content, intensity, and planned follow-up are the key components of the training programme described. MEASUREMENT AND FINDINGS: 93 TBAs have received training through the development of a 150 hrs contact course for self-selected TBAs in the Midwives for Midwives Program. Formal evaluation of this training is underway but results are not yet available. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: the value of incorporating midwifery philosophy and praxis in TBA training has received scant attention in the TBA literature. This report suggests that TBA training programme characteristics are important considerations in any evaluation of training efficacy of TBAs to improve maternal-child health.