Using RE-AIM Framework to Evaluate Recovery Opioid Overdose Team Plus: A Peer-Led Post-overdose Quick Response Team.

Peer recovery coaches utilize their lived experiences to support overdose survivors, a role gaining prominence across communities. A convergent mixed methods design, informed by the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) framework, was used to evaluate the Recovery Opioid Overdose Team Plus (ROOT +), through an iterative evaluation using web-based surveys and qualitative interviews. Reach: Over 27 months, ROOT + responded to 83% of suspected overdose referrals (n = 607) and engaged with 41% of survivors (n = 217) and 7% of survivors' family/friends (n = 38). Effectiveness: Among those initially engaged with ROOT +, 36% of survivors remained engaged, entered treatment, or were in recovery at 90 days post-overdose (n = 77). Adoption: First responders completed 77% of ROOT + referrals (n = 468). Implementation: Barriers included lack of awareness of ROOT + , working phones, and access to treatment from community partner interviews (n = 15). Maintenance: Adaptations to ROOT + were made to facilitate implementation. Peer-led teams are promising models to engage with overdose survivors.

Naloxone and Buprenorphine Prescribing Following US Emergency Department Visits for Suspected Opioid Overdose: August 2019 to April 2021.

STUDY OBJECTIVE: Nonfatal emergency department (ED) visits for opioid overdose are important opportunities to prescribe naloxone and buprenorphine, both of which can prevent future overdose-related mortality. We assessed the rate of this prescribing using national data from August 2019 to April 2021, a period during which US opioid overdose deaths reached record levels. METHODS: We conducted a retrospective cohort analysis using Symphony Health's Integrated Dataverse, which includes data from 5,800 hospitals and 70,000 pharmacies. Of ED visits for opioid overdose between August 4, 2019, and April 3, 2021, we calculated the proportion with at least 1 naloxone prescription within 30 days and repeated this analysis for buprenorphine. To contextualize the naloxone prescribing rate, we calculated the proportion of ED visits for anaphylaxis with at least 1 prescription for epinephrine-another life-saving rescue medication-within 30 days. RESULTS: Analyses included 148,966 ED visits for opioid overdose. Mean weekly visits increased 23.6% during the period between April 26, 2020 and October 3, 2020 compared with the period between August 4, 2019 to April 25, 2020. Visits declined to prepandemic levels between October 4, 2020 and March 13, 2021, after which visits began to rise. Naloxone and buprenorphine were prescribed within 30 days at 7.4% and 8.5% of the 148,966 visits, respectively. The naloxone prescribing rate (7.4%) was substantially lower than the epinephrine prescribing rate (48.9%) after ED visits for anaphylaxis. CONCLUSION: Between August 4, 2019, and April 3, 2021, naloxone and buprenorphine were only prescribed after 1 in 13 and 1 in 12 ED visits for opioid overdose, respectively. Findings suggest that clinicians are missing critical opportunities to prevent opioid overdose-related mortality.

Factors associated with naloxone availability and dispensing through Michigan's pharmacy standing order.

Background: Pharmacy standing order policies allow pharmacists to dispense naloxone, thereby increasing access to naloxone. Objectives: To describe pharmacy standing order participation and associations of pharmacy and community characteristics that predict naloxone availability and dispensing across eight counties in Michigan. Methods: We conducted a telephone survey of 662 standing order pharmacies with a response rate of 81% (n = 539). Pharmacies were linked with census tract-level demographics, overdose fatality rates, and dispensing data. County maps were created to visualize pharmacy locations relative to fatality rates. Regression models analyzed associations between pharmacy type, neighborhood characteristics, fatality rates, and these outcomes: naloxone availability, having ever dispensed naloxone, and counts of naloxone dispensed. Results: The prevalence of standing order pharmacies was 54% (n = 662/1231). Maps revealed areas with higher fatality rates had fewer pharmacies participating in the standing order or lacked any pharmacy access. Among standing order pharmacies surveyed, 85% (n = 458/539) had naloxone available and 82% had ever dispensed (n = 333/406). The mean out-of-pocket cost of Narcan® was $127.77 (SD: 23.93). National chains were more likely than regional chains to stock naloxone (AOR = 3.75, 95%CI = 1.77, 7.93) and to have ever dispensed naloxone (AOR 3.02, 95%CI = 1.21,7.57). Higher volume of naloxone dispensed was associated in neighborhoods with greater proportions of public health insurance (IRR = 1.38, 95%CI = 1.21, 1.58) and populations under 44 years old (IRR = 1.24, 95%CI = 1.04, 1.48). There was no association with neighborhood overdose fatality rates or race in regression models. Conclusion: As deaths from the opioid epidemic continue to escalate, efforts to expand naloxone access through greater standing order pharmacy participation are warranted.

Recovery opioid overdose team (ROOT) pilot program evaluation: A community-wide post-overdose response strategy.

Background: Effective interventions for overdose survivors are needed in the emergency departments (EDs). One promising model is the use of peer recovery coaches to engage with survivors in EDs, followed by partnering with community case management navigators to connect survivors to recovery support and treatment services. This paper describes the evaluation of a pilot program, the Recovery Opioid Overdose Team (ROOT), a warm hand-off system that links survivors to treatment services post-ED discharge. Methods: The ROOT program is composed of a peer recovery coach who is in long-term recovery, and a case management navigator who specializes in mental health care and provides guidance for accessing community services. After an overdose reversal, law enforcement contacts a county 24/7 Crisis Team, who then notifies ROOT. The peer recovery coach engages with the survivor in the ED, and then follow up continues with the case management navigator and the peer recovery coach for up to 90 days post-ED discharge. Retrospective chart reviews were conducted to evaluate ROOT in two Midwest EDs from September 2017 through March 2019. Results: Of the 122 referrals, 77.0% (n = 94) of the survivors initially engaged with ROOT in the ED or in the community. The remaining 23.0% (n = 28) left the ED against medical advice or were unengaged. The majority of overdose survivors were male (63.9%; n = 78), White (43.4%; n = 53), had housing (80.2%; n = 48), and access to transportation (48.4%; n = 59). From the 122 referrals, 33.6% (n = 41) received ongoing treatment services (n = 20 outpatient, n = 17 residential, n = 2 detoxification facility, n = 1 recovery housing, n = 1 medication treatment for opioid use disorder), 2.5% (n = 3) were incarcerated, 2.5% (n = 3) died, and 61.5% (n = 75) declined services. Conclusions: The ROOT, a community-wide coordinated program in the EDs, shows promise in linking overdose survivors to recovery support and treatment services post-overdose.

Beyond rescue: Implementation and evaluation of revised naloxone training for law enforcement officers.

OBJECTIVE: This study describes the implementation and evaluation of revised opioid overdose prevention and education of naloxone training for law enforcement officers (LEOs) that added: (1) a recovery testimony and (2) the process for deputy-initiated referrals postnaloxone administration. DESIGN AND SAMPLE: Evaluation regarding the naloxone training included a pre- and postopioid overdose knowledge surveys (N = 114) and subsequent 1-year postnaloxone training outcomes. RESULTS: Pre- and posttest scores for all knowledge outcome measures were statistically significant (p < .001) with favorable comments pertaining to the recovery testimony. Out of 31 individuals who received naloxone, 6 individuals (19.4%) continue to be in treatment or received some treatment services. The most common symptoms reported were unconsciousness/unresponsiveness (40.5%), abnormal breathing patterns (24.3%), and blue lips (16.2%). The majority of the calls (65.6%) were to a residential area, and the time for naloxone revival ranged <1-10 min (M = 3.48; SD = 2.27). CONCLUSION: As nearly 20% of individuals sought treatment after a LEO-initiated referral, it is recommended that other agencies consider the referral process into the training. Future research will investigate the impact of the recovery testimony in reducing the stigma of addiction.

Examining antenatal health literacy in Ghana.

PURPOSE: To explore Ghanaian pregnant women's understanding and recognition of danger signs in pregnancy, birth preparedness and complication readiness, and their understanding of newborn care. DESIGN: An exploratory, qualitative study design was used. METHODS: Data were gathered through six focus group discussions with 68 pregnant women attending antenatal care at a busy urban hospital in Ghana. Qualitative and descriptive data were analyzed using SPSS version 21. Health literacy was used as the guiding framework to analyze the qualitative data. Data were analyzed in the content domains of (a) understanding and recognition of danger signs in pregnancy, (b) preparedness for childbirth, (c) understanding and recognition of danger signs in the newborn, and (d) appropriate and timely referral. FINDINGS: Women in this study identified danger signs of pregnancy and in the newborn, but had difficulty interpreting and operationalizing information they received during antenatal care visits, indicating that health education did not translate to appropriate health behaviors. Cultural beliefs in alternative medicine, lack of understanding, and prior negative encounters with healthcare professionals may have led to underutilization of professional midwives for delivery and health services. CONCLUSIONS: Women in this study exhibited low health literacy by incorrectly interpreting and operationalizing health education received during antenatal care. With limited health literacy, pregnant women cannot fully comprehend the scope of services that a health system can provide for them and their families. CLINICAL RELEVANCE: Achieving the greatest impact with limited time in antenatal care is a challenge. Since antenatal care is widely available to pregnant women in Ghana, it is vital to reexamine the way antenatal education is delivered. Pregnant women must receive health information that is accurate and easy to understand in order to make informed health choices that will improve maternal and child health.

Scholarly productivity for nursing clinical track faculty.

Recent years have yielded substantial advancement by clinical track faculty in cohort expansion and collective contributions to the discipline of nursing. As a result, standards for progression and promotion for clinical faculty need to be more fully developed, articulated, and disseminated. Our school formed a task force to examine benchmarks for the progression and promotion of clinical faculty across schools of nursing, with the goal of guiding faculty, reviewers, and decision makers about what constitutes excellence in scholarly productivity. Results from analyses of curriculum vitae of clinical professors or associate professors at six universities with high research activity revealed a variety of productivity among clinical track members, which included notable diversity in the types of scholarly products. Findings from this project help quantify types of scholarship for clinical faculty at the time of promotion. This work provides a springboard for greater understanding of the contributions of clinical track faculty to nursing practice.

The Lookout Project: A Student-Run Mail-Based Overdose Response Kit Distribution Program Through Social Media During COVID-19.

BACKGROUND: Naloxone distribution and overdose education are key preventive strategies to reduce opioid overdose deaths. This paper describes the development and evaluation of The Lookout Project (TLP), a 501(c)(3) organization led by college students and based in Ann Arbor, Michigan. This research aimed to examine the outreach of TLP with hopes of creating a reproducible mail-based kit distribution program for college student-run organizations to replicate. METHODS: TLP used a targeted social media advertising campaign to ask participants 7 multiple-choice questions concerning their demographics, previous incarcerations, experiences with intranasal naloxone (IN), and if they had watched the optional informational video in the opioid overdose response kit (OORK) order form. RESULTS: TLP's team distributed over 900 OORKs from August 3, 2020, to January 4, 2022, first by word of mouth and then through social media advertising that began on February 13, 2021. Of the 657 respondents who agreed to participate in research, the majority identified as white (76.0%, n = 400), did not identify with any specified ethnicity group (60.2%, n = 318), were female (60.8%, n = 356), were between the ages of 18 and 22 (35.4%, n = 209), had not been previously incarcerated (95.6%, n = 564), and did watch the hyperlinked video detailing how to respond to an overdose (74.7%, n = 438). Additionally, several kit recipients (2.8%, n = 19) responded to a follow-up survey. Of those, 7 people reported using the IN provided by TLP to reverse an overdose (36.8%, n = 7). CONCLUSION: TLP, a nonprofit organization founded by college students, shows potential for informing other student-run organizations about naloxone distribution programs using social media advertising.

Web-Based Naloxone Training for Law Enforcement Officers: A Pilot Feasibility Study.

BACKGROUND: Training and equipping law enforcement officers (LEOs) with naloxone to reverse overdoses is one national preventive strategy to reduce overdose deaths. Web-based interventions can offer convenience, flexibility of use, and can be readily disseminated. OBJECTIVES: This paper describes our community-academic partnership in developing and evaluating a web-based naloxone training for LEOs. METHODS: Using a community-engaged approach, we created a web-based training (www.overdoseaction.org) and conducted a pilot feasibility test using surveys and individual interviews with ten LEOs. RESULTS: The median time to complete the web-based naloxone training, including the pre- and post-tests, was 45 minutes (range, 37-80 minutes). A significant difference in the pretest and post-test scores of overdose knowledge was observed. The LEOs found the training helpful in responding to overdoses and sustained their attention. CONCLUSIONS: This study demonstrates the feasibility of a web-based naloxone training for LEOs that can be easily disseminated and alternative to in-person trainings.

Effectiveness of take ACTION online naloxone training for law enforcement officers.

BACKGROUND: Training law enforcement officers (LEOs) to administer naloxone is a recommended strategy to reduce overdose deaths in the United States. To achieve this, an evidence-based and scalable naloxone training curriculum that is easy to use and readily scalable is needed. Convenient web-based training is a flexible method for delivering educational interventions particularly for LEOs who have irregular or shifting schedules. This study examined the effectiveness of a comprehensive web-based naloxone training that was created in partnership with LEOs on their knowledge, confidence, and attitudes regarding naloxone. METHODS: From May 2019 to September 2020, five law enforcement departments from Michigan participated in web-based naloxone training. A total of 182 LEOs (77% male) were in the final sample based on matching pre-and post-test surveys. LEOs were assessed on knowledge, confidence, and attitudes towards naloxone. Negative binomial and Poisson regression was conducted to assess associations between knowledge, confidence, and attitudes towards naloxone before and after training. RESULTS: Significant improvements in overdose knowledge and confidence were revealed across all departments with median (IQR) total composite scores for knowledge increasing from 35 (32, 37) to 40 (39, 42) (p < 0.01) and confidence increasing from 18.5 (15, 20) to 20 (20, 25) (p < 0.01). Median (IQR) attitude scores did not change. CONCLUSION: Our web-based naloxone training was effective in improving knowledge and confidence for LEOs but did not significantly improve LEOs attitudes towards naloxone across most departments. The web-based format is readily scalable and quickly disseminated and meets the immediate need for LEO overdose training. Additional intervention is needed to address the negative attitudes of LEOs regarding naloxone.

Law Enforcement Perceptions About Naloxone Training and Its Effects Post-Overdose Reversal.

BACKGROUND: Law enforcement officers (LEOs) often are the first responders to arrive at a scene of an opioid overdose. Thus, equipping LEOs as first responders with naloxone is necessary to prevent overdose deaths and a recommended strategy. However, little is known about how LEOs perceive naloxone training and their feelings after using naloxone to save a life. It is important to understand LEOs' experiences with naloxone so as to develop additional training materials that are relevant to the LEO experience. METHODS: A descriptive exploratory study was conducted to explore the perceptions of LEOs about using naloxone in the field and to identify areas that should be included in future naloxone trainings. Interview data were obtained through face-to-face interviews with LEOs (N = 14) and analyzed using manifest content analysis. RESULTS: LEOs changed their attitudes and beliefs toward naloxone after receiving training and experiencing a successful resuscitation. The change in attitudes was enhanced after saving a life. However, misconceptions about naloxone and lack of understanding about disease of addiction persisted even after training. CONCLUSION: Future naloxone curriculum could benefit from additional lessons on the stigma of addiction, the disease of addiction, misconceptions about the safety of naloxone, strategies for postoverdose responses, and the role naloxone, which might play in a hopeful recovery.

Piloting a statewide emergency department take-home naloxone program: Improving the quality of care for patients at risk of opioid overdose.

BACKGROUND: Emergency department (ED) patients with nonfatal opioid overdose are at high risk for subsequent fatal overdose, yet ED programs aimed at reducing harm from opioid use remain underdeveloped. OBJECTIVES: The objective was to pilot a statewide ED take-home naloxone program and improve the care of patients with opioid use disorder (OUD) and risky drug use through training and interprofessional network building. METHODS: Nine hospital EDs with pharmacy, nurse, and physician champions were recruited, surveyed, and trained. Take-home naloxone rescue kits were developed, disseminated, and tracked. Two overdose prevention summits were convened prior to the COVID pandemic, and two X-waiver training courses aimed at emergency physicians and advanced practice providers were arranged, both in person and virtual. RESULTS: A total of 872 naloxone rescue kits were distributed to ED patients at risk of opioid overdose during the first phase of this project, and more than 140 providers were trained in the use of medications for OUD in acute care settings. CONCLUSIONS: A statewide ED take-home naloxone program was shown to be feasible across a range of different hospitals with varying maturity in preexisting OUD resources and capabilities. Future work will be aimed at both expanding and measuring the effectiveness of this work.

Prescription Opioid Misuse in Older Adult Surgical Patients: Epidemiology, Prevention, and Clinical Implications.

ABSTRACT: The United States and many other developed nations are in the midst of an opioid crisis, with consequent pressure on prescribers to limit opioid prescribing and reduce prescription opioid misuse. This review addresses prescription opioid misuse for older adult surgical populations. We outline the epidemiology and risk factors for persistent opioid use and misuse in older adults undergoing surgery. We also address screening tools and prescription opioid misuse prevention among vulnerable older adult surgical patients (e.g., older adults with a history of an opioid use disorder), followed by clinical management and patient education recommendations. A significant plurality of older adults engaged in prescription opioid misuse obtain opioid medication for misuse from health providers. Thus, nurses can play a critical role in identifying those older adults at a higher risk for misuse and deliver quality care while balancing the need for adequate pain management against the risk for prescription opioid misuse.

Emergency Department Visits by Patients with Substance Use Disorder in the United States.

INTRODUCTION: We aimed to characterize emergency department (ED) utilization and clinical characteristics of patients with substance use disorder (SUD) seeking emergency care for all reasons. METHODS: Using 2016-2017 ED data from the National Hospital Ambulatory Medical Care Survey, we investigated demographics, ED resource utilization, and clinical characteristics of patients with SUD vs those without SUD. RESULTS: Of all adult ED visits (N = 27,609) in the US in 2016-2017, 11.1% of patients had SUD. Among ED patients with SUD, they were mostly non-Hispanic White (62.5%) and were more likely to be male (adjusted odds ratio [aOR] 1.80 confidence interval [CI], 1.66-1.95). Emergency department patients with SUD were also more likely to return to the ED within 72 hours (aOR 1.32, CI, 1.09-1.61) and more likely to be admitted to the hospital (aOR 1.28, CI, 1.14-1.43) and intensive care unit (aOR 1.40, CI, 1.05-1.85). CONCLUSION: Patients with SUD have specific demographic, socioeconomic, and clinical characteristics associated with their ED visits. These findings highlight the importance of recognizing co-existing SUD as risk factors for increasing morbidity in acutely ill and injured patients, and the potential role of the ED as a site for interventions aimed at reducing harm from SUD.

Current state of screening high-ACE youth and emerging adults in primary care.

BACKGROUND AND PURPOSE: Trauma comes in many forms, including interpersonal, community, and institutional trauma. The adverse childhood event (ACE) studies demonstrated that adverse experiences in childhood can have a profound, cumulative impact on the course of health and development over a lifetime. It is critical for healthcare providers, such as nurse practitioners (NPs), working in primary care to screen adolescents and emerging adults for a history of ACEs and trauma. A review of current assessment tools used in assessing this population in health settings is needed to determine how screening for ACEs is being performed. CONCLUSIONS: Clinically efficient tools for screening and assessment of high-ACE youth in primary care settings are lacking.  Developing a process to assess ACEs, risk behaviors, and physical and mental health status that is efficient to use during a time limited clinical visit is an important step in providing holistic care to a challenging population. IMPLICATIONS FOR PRACTICE: Primary care NPs are in the perfect position to implement assessments of ACEs through trauma-informed nursing care. ACE assessment in clinical practice will provide vital information to guide the development of tailored interventions for reducing risk behaviors and mitigate the long-term impacts of ACEs.

Development and implementation of intranasal naloxone opioid overdose response protocol at a homeless health clinic.

PURPOSE: To describe the development, implementation, and preliminary evaluation of Opioid Overdose Response Protocol using intranasal (IN) naloxone in a homeless shelter. DATA SOURCES: Opioid Overdose Response Protocol and training curriculum were developed using the Massachusetts Department of Public Health Opioid Overdose Education and Naloxone Distribution (OEND) flow chart, the American Heart Association (AHA) simplified adult basic life support algorithm, and resources through Harms Reduction Coalition. CONCLUSIONS: Intranasal naloxone offers a safe and effective method for opioid reversal. To combat the rising incidence of opioid overdose, IN naloxone should be made available at homeless shelters and other facilities with high frequency of opioid overdose, including the training of appropriate staff. This project has demonstrated the effective training and implementation of an Opioid Overdose Response Protocol, based on feedback received from cardiopulmonary resuscitation (CPR) trained nonhealthcare staff. Nurse practitioners (NPs), with our focus on patient care, prevention, and education, are well suited to the deployment of this life-saving protocol. IMPLICATIONS FOR PRACTICE: NPs are in critical positions to integrate opioid overdose prevention education and provide naloxone rescue kits in clinical practices.

African American women and prenatal care: perceptions of patient-provider interaction.

Poor patient-provider interaction among racial/ethnic minorities is associated with disparities in health care. In this descriptive, cross-sectional study, we examine African American women's perspectives and experiences of patient-provider interaction (communication and perceived discrimination) during their initial prenatal visit and their influences on perceptions of care received and prenatal health behaviors. Pregnant African American women (n = 204) and their providers (n = 21) completed a pre- and postvisit questionnaire at the initial prenatal visit. Women were also interviewed face to face at the subsequent return visit. Women perceived high quality patient-provider communication (PPC) and perceived low discrimination in their interaction with providers. Multiple regression analyses showed that PPC had a positive effect on trust in provider (p < .001) and on prenatal care satisfaction (p < .001) but not on adherence to selected prenatal health behaviors. Findings suggest that quality PPC improves the prenatal care experience for African American women.

The Rapid Assessment for Adolescent Preventive Services (RAAPS): providers' assessment of its usefulness in their clinical practice settings.

INTRODUCTION: The purpose of this study was to evaluate health providers' use of the Rapid Assessment for Adolescent Preventive Services (RAAPS) screening tool to identify adolescent high-risk behaviors, its ease of use and efficiency, and its impact on provider/patient discussions of sensitive risk behaviors. METHOD: This mixed methods descriptive study used an online survey to assess providers' use of the RAAPS and their perspectives on its implementation and effect on adolescent-provider communication. The survey was completed by providers from a variety of settings across the United States (N = 201). RESULTS: Quantitative and qualitative analyses indicated that the RAAPS facilitated identification of risk behaviors and risk discussions and provided efficient and consistent assessments; 86% of providers believed that the RAAPS positively influenced their practice. DISCUSSION: Adoption of the RAAPS in practice settings could lead to more effective adolescent preventive services by giving providers a tool to systematically assess and identify adolescents at risk. Implementation of RAAPS offers health providers an efficient, consistent, and "adolescent friendly" way to identify risky behaviors and open the discussion needed to tailor interventions to meet their needs.