Naloxone distribution and possession following a large-scale naloxone programme.

AIMS: To examine uptake following a large-scale naloxone programme by estimating distribution rates since programme initiation and the proportion among a sample of high-risk individuals who had attended naloxone training, currently possessed or had used naloxone. We also estimated the likelihood of naloxone possession and use as a function of programme duration, individual descriptive and substance use indicators. DESIGN: (1) Distribution data (June 2014-August 2017) and date of implementation for each city and (2) a cross-sectional study among a sample of illicit substance users interviewed September 2017. SETTING: Seven Norwegian cities. PARTICIPANTS: A total of 497 recruited users of illegal opioids and/or central stimulants. MEASUREMENTS: Primary outcomes: naloxone possession and use. Random-intercepts logistic regression models (covariates: male, age, homelessness/shelter use, overdose, incarceration, opioid maintenance treatment, income sources, substance use indicators, programme duration). FINDINGS: Overall, 4631 naloxone nasal sprays were distributed in the two pilot cities, with a cumulative rate of 495 per 100 000 population. In the same two cities, among high-risk individuals, 44% and 62% reported current naloxone possession. The possession rates of naloxone corresponded well to the duration of each participating city's distribution programme. Overall, in the six distributing cities, 58% reported naloxone training, 43% current possession and 15% naloxone use. The significant indicators for possession were programme duration [adjusted odds ratios (aOR) = 1.44, 95% confidence interval (CI = 0.82-2.37], female gender (aOR = 1.97, 95% CI = 1.20-3.24) and drug-dealing (aOR = 2.36, 95% CI = 1.42-3.93). The significant indicators for naloxone use were programme duration (aOR = 1.49 95%, CI = 1.15-1.92), homelessness/shelter use (aOR = 2.06, 95% CI = 1.02-4.17), opioid maintenance treatment (OMT) (aOR = 2.07, 95% CI = 1.13-3.78), drug-dealing (aOR = 2.40, 95% CI = 1.27-4.54) and heroin injecting (aOR = 2.13, 95% CI = 1.04-4.38). CONCLUSIONS: A large-scale naloxone programme in seven Norwegian cities with a cumulative distribution rate of 495 per 100 000 population indicated good saturation in a sample of high-risk individuals, with programme duration in each city as an important indicator for naloxone possession and use.

Ambulance-attended opioid overdoses: An examination into overdose locations and the role of a safe injection facility.

Background: Although the United States and numerous other countries are amidst an opioid overdose crisis, access to safe injection facilities remains limited. Methods: We used prospective data from ambulance journals in Oslo, Norway, to describe the patterns, severity, and outcomes of opioid overdoses and compared these characteristics among various overdose locations. We also examined what role a safe injection facility may have had on these overdoses. Results: Based on 48,825 ambulance calls, 1054 were for opioid overdoses from 465 individuals during 2014 and 2015. The rate of calls for overdoses was 1 out of 48 of the total ambulance calls. Males made up the majority of the sample (n = 368, 79%), and the median age was 35 (range: 18-96). Overdoses occurred in public locations (n = 530, 50.3%), the safe injection facility (n = 353, 33.5%), in private homes (n = 83, 7.9%), and other locations (n = 88, 8.3%). Patients from the safe injection facility and private homes had similarly severe initial clinical symptoms (Glasgow Coma Scale median =3 and respiratory frequency median =4 breaths per minute) when compared with other locations, yet the majority from the safe injection facility did not require further ambulance transport to the hospital (n = 302, 85.6%). Those overdosed in public locations (odds ratio [OR] = 1.66, 95% confidence interval [CI] = 1.17-2.35), and when the safe injection facility was closed (OR =1.4, 95% CI =1.04-1.89), were more likely to receive transport for further treatment. Conclusions: Our findings suggest that the opening hours at the safe injection facility and the overdose location may impact the likelihood of ambulance transport for further treatment.

Overdose prevention training with naloxone distribution in a prison in Oslo, Norway: a preliminary study.

BACKGROUND: Prison inmates face a ten times increased risk of experiencing a fatal drug overdose during their first 2 weeks upon release than their non-incarcerated counterparts. Naloxone, the antidote to an opioid overdose, has been shown to be feasible and effective when administered by bystanders. Given the particular risk that newly released inmates face, it is vital to assess their knowledge about opioid overdoses, as well as the impact of brief overdose prevention training conducted inside prisons. METHODS: Prison inmates nearing release (within 6 months) in Oslo, Norway, voluntarily underwent a brief naloxone training. Using a questionnaire, inmates were assessed immediately prior to and following a naloxone training. Descriptive statistics were performed for main outcome variables, and the Wilcoxon signed-rank test was used to compare the participants' two questionnaire scores from pre-and post-training. RESULTS: Participating inmates (n = 31) were found to have a high baseline knowledge of risk factors, symptoms, and care regarding opioid overdoses. Nonetheless, a brief naloxone training session prior to release significantly improved knowledge scores in all areas assessed (p < 0.001). The training appears to be most beneficial in improving knowledge regarding the naloxone, including its use, effect, administration, and aftercare procedures. CONCLUSIONS: Given the high risk of overdosing that prison inmates face upon release, the need for prevention programs is critical. Naloxone training in the prison setting may be an effective means of improving opioid overdose response knowledge for this particularly vulnerable group. Naloxone training provided in the prison setting may improve the ability of inmates to recognize and manage opioid overdoses after their release; however, further studies on a larger scale are needed.

Intoxication with GHB/GBL: characteristics and trends from ambulance-attended overdoses.

BACKGROUND: Overdoses from so-called "club drugs" (GHB/GBL) have become a more frequent cause of overdoses attended by ambulance services. Given its availability, affordability, and lack of awareness of risks, there is a common misconception among users that the drug is relatively safe. METHODS: This study reviewed ambulance records in Bergen, Norway between 2009 and 2015 for cases of acute poisonings, particularly from suspected GHB/GBL intoxication. RESULTS: In total, 1112 cases of GHB and GBL poisoning were identified. GHB was suspected for 995 (89%) of the patients. Men made up the majority of the cases (n = 752, 67.6%) with a median age of 27 years old. Temporal trends for GHB/GBL overdoses displayed a late-night, weekend pattern. The most frequent initial symptoms reported were unconsciousness, or reduced consciousness. Most of the patients required further treatment and transport. During the period from 2009 to 2015, there was a nearly 50% decrease in GHB/GBL overdoses from 2013 to 2014. DISCUSSION: The characteristics of GHB/GBL overdose victims shed light on this patient group. The decrease in incidence over the years may be partly due to a legal ban on GBL in Norway, declared in 2010. It may also be due to an increase in the use of MDMA/ecstasy. CONCLUSION: The review of ambulance records on the prehospital treatment of overdoses can be beneficial in monitoring, preparing, and prevention efforts aimed to benefit this vulnerable group.

Rapid widespread distribution of intranasal naloxone for overdose prevention.

BACKGROUND: Take home naloxone programs have been successful internationally in training bystanders to reverse an opioid overdose with naloxone, an opioid antagonist. A multi-site naloxone distribution program began in Norway in 2014 as part of a national overdose prevention strategy. The aim of this study was to a) describe the program, and b) present findings from the government-supported intervention. METHODS: From July 2014 to December 2015, staff from multiple low-threshold facilities trained clients on how to use intranasal naloxone. Distribution occurred without an individual prescription or physician present. Questionnaires from initial and refill trainings were obtained, and distribution rates were monitored. RESULTS: There were 2056 naloxone sprays distributed from one of the 20 participating facilities, with 277 reports of successful reversals. Participants exhibited known risks for overdosing, with injecting (p=0.02, OR=2.4, 95% CI=1.14, 5.00) and concomitant benzodiazepine use (p=0.01, OR=2.6, 95% CI=1.31, 5.23) being significant predictors for having had high rates of previous overdoses. Suggested target coverage for large-scale programs was met, with an annual naloxone distribution rate of 144 per 100,000 population, as well as 12 times the cities mean annual number of opioid-related deaths. CONCLUSION: A government-supported multisite naloxone initiative appears to achieve rapid, high volume distribution of naloxone to an at-risk population.

Circumstances surrounding non-fatal opioid overdoses attended by ambulance services.

INTRODUCTION AND AIMS: Opioid overdose fatalities are a significant concern globally. Non-fatal overdoses have been described as a strong predictor for future overdoses, and are often attended by the ambulance services. This paper explores characteristics associated with non-fatal overdoses and aims to identify possible trends among these events in an urban area in Norway. DESIGN AND METHODS: This is a retrospective analysis of non-fatal overdoses from Bergen ambulance services from 2012 to 2013. Demographic, temporal and geographic data were explored. RESULTS: During the two years, 463 non-fatal opioid overdoses were attended by ambulance services. Ambulance call-outs occurred primarily during the late afternoon and evening hours of weekdays. Summer months had more overdoses than other seasons, with a peak in August. Overdoses were nearly twice as likely to occur in a public location in August (risk ratio 1.92, P = 0.042). Ambulance response times were more likely to be longer to private locations, and these victims were more likely to be treated and left at the scene. There was no difference in arrival time for drug-related and non-drug related dispatch. DISCUSSION AND CONCLUSIONS: The temporal patterns suggest that non-fatal overdoses occur during non-recreational time periods. The longer ambulance response time and disposition for private addresses indicate potential opportunities for peer interventions. Our analysis describes circumstances surrounding non-fatal overdoses and can be useful in guiding relevant, targeted prevention interventions. [Madah-Amiri D, Clausen T, Myrmel L, Brattebø G, Lobmaier P. Circumstances surrounding non-fatal opioid overdoses attended by ambulance services. Drug Alcohol Rev 2017;36:288-294].

Utilizing a train-the-trainer model for multi-site naloxone distribution programs.

BACKGROUND: In order to have a substantial impact on overdose prevention, the expansion and scaling-up of overdose prevention with naloxone distribution (OPEND) programs are needed. However, limited literature exists on the best method to train the large number of trainers needed to implement such initiatives. METHODS: As part of a national overdose prevention strategy, widespread OPEND was implemented throughout multiple low-threshold facilities in Norway. Following a two-hour 'train-the trainer course' staff were able to distribute naloxone in their facility. The course was open to all staff, regardless of educational background. To measure the effectiveness of the course, a questionnaire was given to participants immediately before and after the session, assessing knowledge on overdoses and naloxone, as well as attitudes towards the training session and distributing naloxone. RESULTS: In total, 511 staff were trained during 41 trainer sessions. During a two-month survey period, 54 staff participated in a questionnaire study. Knowledge scores significantly improved in all areas following the training (p<0.001). Attitude scores improved, and the majority of staff found the training useful and intended to distribute naloxone to their clients. CONCLUSION: Large-scale naloxone distribution programs are likely to continue growing, and will require competent trainers to carry out training sessions. The train-the-trainer model appears to be effective in efficiently training a high volume of trainers, improving trainers' knowledge and intentions to distribute naloxone. Further research is needed to assess the long term effects of the training session, staffs' subsequent involvement following the trainer session, and knowledge transferred to the clients.