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.

Opioid Overdose Prevention Programs Providing Naloxone to Laypersons - United States, 2014.

Drug overdose deaths in the United States have more than doubled since 1999. During 2013, 43,982 drug overdose deaths (unintentional, intentional [suicide or homicide], or undetermined intent) were reported. Among these, 16,235 (37%) were associated with prescription opioid analgesics (e.g., oxycodone and hydrocodone) and 8,257 (19%) with heroin. For many years, community-based programs have offered opioid overdose prevention services to laypersons who might witness an overdose, including persons who use drugs, their families and friends, and service providers. Since 1996, an increasing number of programs provide laypersons with training and kits containing the opioid antagonist naloxone hydrochloride (naloxone) to reverse the potentially fatal respiratory depression caused by heroin and other opioids. In July 2014, the Harm Reduction Coalition (HRC), a national advocacy and capacity-building organization, surveyed 140 managers of organizations in the United States known to provide naloxone kits to laypersons. Managers at 136 organizations completed the survey, reporting on the amount of naloxone distributed, overdose reversals by bystanders, and other program data for 644 sites that were providing naloxone kits to laypersons as of June 2014. From 1996 through June 2014, surveyed organizations provided naloxone kits to 152,283 laypersons and received reports of 26,463 overdose reversals. Providing opioid overdose training and naloxone kits to laypersons who might witness an opioid overdose can help reduce opioid overdose mortality.

Hepatitis B vaccination in six STD clinics in the United States committed to integrating viral hepatitis prevention services.

OBJECTIVES: Hepatitis B vaccination is recommended for clients of sexually transmitted disease (STD) clinics. The Healthy People 2010 goal is for 90% of STD clinics to offer hepatitis B vaccine to all unprotected clients. This report describes hepatitis B vaccination trends in six STD clinics in the United States and discusses implications for policy and practice. METHODS: We conducted a retrospective study in six STD clinics to evaluate hepatitis B vaccination. We collected data on client visits and hepatitis B vaccinations for the period 1997-2005. To compare clinics, we calculated vaccination rates per 100 client visits. We interviewed staff to explore factors associated with hepatitis B vaccination trends. RESULTS: STD clinic client visits ranged from 2,883 to 23,109 per year. The median rate of hepatitis B vaccination was 28 per 100 client visits. Vaccination rates declined in all six clinics in later years, which was associated with eligibility restrictions caused by fiscal problems and increasing levels of prior vaccination. The median rate of vaccine series completion was 30%. Staff cited multiple provider- and client-level barriers to series completion. CONCLUSIONS: This study shows that STD clinics can implement hepatitis B vaccination and reach large numbers of high-risk adults. Adequate funding and vaccine supply are needed to implement current federal recommendations to offer hepatitis B vaccine to adults seen in STD clinics and to achieve the Healthy People 2010 objective.

Establishing a viral hepatitis prevention and control program: Florida's experience.

In 1999, the Florida State Legislature established and funded the statewide Hepatitis Prevention Program (HPP) to address growing concern about hepatitis C virus (HCV) and its potential public health burden. HPP supports county health departments' (CHDs') provision of viral hepatitis prevention services to at-risk adults through free hepatitis A and B vaccine in most CHDs and hepatitis serologic testing and statewide viral hepatitis-related education, consultation, and referral services. Some CHDs are directly funded by HPP. In 2001-2005, HPP support helped CHDs provide 59,228 hepatitis A and 74,039 hepatitis B vaccinations statewide. In 2005, HPP supported almost 17,000 hepatitis B and C tests. From January to June 2005, 1,603 positive HCV tests were reported, a 9.5% seropositivity rate. With $24 million from the Florida State Legislature through 2006, HPP has helped CHDs statewide provide substantial viral hepatitis prevention services to at-risk adults.

The costs and impacts of testing for hepatitis C virus antibody in public STD clinics.

OBJECTIVES: To estimate the cost and cost-effectiveness of testing sexually transmitted disease (STD) clinic subgroups for antibodies to hepatitis C virus (HCV). METHODS: HCV counseling, testing, and referral (CTR) costs were estimated using data from two STD clinics and the literature, and are reported in 2006 dollars. Effectiveness of HCV CTR was defined as the estimated percentage of clinic clients in subgroups targeted for HCV antibody (anti-HCV) testing who had a true positive test and returned for their test results. We estimated the cost per true positive injection drug user (IDU) who returned for anti-HCV test results and the cost-effectiveness of expanding HCV CTR to non-IDU subgroups. RESULTS: The estimated cost per true positive IDU who returned for test results was $54. The cost-effectiveness of expanding HCV CTR to non-IDU subgroups ranged from $179 to $2,986. Our estimates were most sensitive to variations in HCV prevalence, the cost of testing, and the rate of client return. CONCLUSIONS: Based on national data, testing IDUs in the STD clinic setting is highly cost-effective. Some clinics may find that it is cost-effective to expand testing to non-IDU men older than 40 who report more than 100 lifetime sex partners. STD clinics can use study estimates to assess the feasibility and desirability of expanding HCV CTR beyond IDUs.

Community syringe collection and disposal policies in 16 states.

OBJECTIVE: To review laws, regulations, and guidelines that affect the collection and disposal of hypodermic needles, syringes, and lancets used outside of professional health care settings (hereafter referred to as "community syringes"). DESIGN: Law and policy analysis. SETTING: Alabama, California, Florida, Georgia, Hawaii, Massachusetts, Michigan, Minnesota, New Jersey, New York, Ohio, Oregon, Rhode Island, South Carolina, Washington, and Wisconsin. INTERVENTION: Information on syringe collection and disposal in the community was gathered from federal and state records and state agency personnel. MAIN OUTCOME MEASURES: Legally permissible means of syringe collection and disposal available to persons in the community injecting medical treatments and injection drug users. RESULTS: Laws, regulations, or guidelines in 13 states allowed community syringes to be legally discarded in household trash; guidelines for in-trash disposal varied among the states. Only 6 states had laws or regulations that specifically addressed community syringe collection. In 10 states, infectious waste laws and regulations that apply to medical facilities such as clinics would also apply to community syringe collection sites. CONCLUSION: In the 16 states studied, laws, regulations, and guidelines relating to community syringe collection and disposal were somewhat inconsistent and confusing and presented potential barriers to safe disposal. States should consider amending laws, regulations, and guidelines to promote community syringe collection programs. A national effort is needed to achieve consistent community syringe collection and disposal laws and guidelines for all states. Pharmacists can aid in safe syringe disposal by counseling their patients about safe disposal, providing or selling sharps containers, and accepting used syringes for safe disposal. Pharmacists can join other interested groups in advocating clarification of disposal laws and regulations that favor community programs designed to keep syringes out of the trash so that they can be disposed of as infectious waste.

Pharmacy student knowledge, attitudes, and beliefs about selling syringes to injection drug users.

OBJECTIVE: To explore pharmacy school education and pharmacy students' knowledge, attitudes, and beliefs about human immunodeficiency virus (HIV) and acquired immunodeficiency syndrome (AIDS), drug use, and syringe sales to injection drug users (IDUs). DESIGN: Qualitative study of a convenience sample of pharmacy school students. SETTING: A pharmacy school in the southeastern United States. INTERVENTION: Two focus groups and nine in-depth interviews were conducted about HIV/AIDS education and counseling, syringe sales to possible IDUs, and related pharmacy school education. PARTICIPANTS: 19 Doctor of Pharmacy students, including 88 students in their third professional year and 11 in their fourth professional year. RESULTS: Most participants believed that they would benefit from more class time on HIV/AIDS topics, including AIDS treatment medications and HIV prevention. Most participants believed that the laws and regulations governing syringe sales in their state were vague, leaving syringe sale decisions to pharmacists' discretion. Nine study participants supported selling syringes to possible IDUs, five opposed it, and five were undecided or ambivalent. Classroom education focused on addiction to prescription drugs, with limited attention to illicit drug use. CONCLUSION: Pharmacy students have divided opinions about selling syringes to IDUs. To prepare students for helping their patients with drug-use problems, pharmacy schools should increase training about HIV/AIDS and addiction. Policy makers should consider changing laws and regulations of syringe sales to recognize prevention of blood-borne infections as a legitimate medical purpose for selling syringes to IDUs.

Individual and structural influences shaping pharmacists' decisions to sell syringes to injection drug users in Atlanta, Georgia.

OBJECTIVE: To better understand the individual (e.g., attitudes and beliefs) and structural (e.g., laws and regulations) factors that influence and shape pharmacists' decisions about selling syringes to injection drug users (IDUs). DESIGN: Qualitative research. SETTING: Metropolitan Atlanta. PARICIPANTS: 20 practicing pharmacists who work in or near areas of high drug use in Atlanta, and nine pharmacists who are considered leaders in their profession in Georgia. INTERVENTIONS: Semistructured, in-depth interviews. MAIN OUTCOME MEASURES: Individual and structural factors that influence pharmacists' decisions about selling syringes to IDUs. RESULTS: Pharmacists reported that they use their professional discretion in making syringe sale decisions and that these decisions are influenced by individuals factors such as their personal attitudes and beliefs about the nature and causes of drug use, and by structural factors such as the Georgia Board of Pharmacy regulation stating that syringes cannot be sold if they will be used for an "unlawful purpose." CONCLUSIONS: IDUs' access to sterile syringes from pharmacies in Atlanta, would likely be increased by (1) providing practicing pharmacists with professional education programs that describe the broad professional support for IDU access to sterile syringes and why blood-borne infection prevention is a legitimate medical purpose for selling syringes and (2) removing or modifying the restrictive Board of Pharmacy regulation governing syringe sales.