Linkage to Primary Care for Persons First Receiving Injectable Naltrexone During Inpatient Opioid Detoxification

HIGHLIGHTS

• XR-NTX begun during opioid detoxification can be continued in primary care settings.
• 55% of XR-NTX recipients link to primary care for continued treatment.
• We found no predictors of XR-NTX continuation in primary care.

INTRODUCTION:

Opioid use disorders commonly require ongoing medication-assisted treatment to reduce relapse following discharge from inpatient detoxification programs. Naltrexone, an opioid antagonist, is an increasingly popular treatment option in its once-monthly injectable form (XR-NTX). The aim of this study was to examine the follow-up rates of persons who received an initial injection during inpatient detoxification and scheduled for receipt of a first outpatient injection in the primary care setting.

METHODS:

We reviewed the electronic health records of 62 consecutive opioid dependent adults who received an initial injection of XR-NTX during extended inpatient detoxification at Stanley Street Treatment and Resources (SSTAR) in Fall River, Massachusetts, from March 2013 to August 2015, and were referred to the adjacent SSTAR primary care health center for their second injection 1month later. Demographic information, drug use and opioid treatment history, and aftercare planning were assessed.

RESULTS:

Participants averaged 32.4 (±7.8) years of age, 90.3% were non-Latino Caucasian, 35.5% were homeless, 21.3% reported a drug overdose in the last year, and 53.2% had been in detoxification within the last year. Of the 62 participants referred to primary care, 34 (54.8%) followed up to receive their second XR-NTX injection. Twenty of these persons received at least a third XR-NTX injection. No demographic, treatment history, substance use behaviors, or aftercare plan variables were associated with receipt of a second injection (p<.20).

CONCLUSION:

Predicting, and therefore improving, XR-NTX continuation during the transition from inpatient detoxification to primary care may be difficult in this population.

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By:  Stein MD1, Risi MM2, Bailey GL3, Anderson BJ2.

• 1General Medicine Research Unit, Butler Hospital, Providence, RI, 02906; Warren Alpert Medical School of Brown University, Providence, RI, 02912. Electronic address: michael_stein@brown.edu.
• 2General Medicine Research Unit, Butler Hospital, Providence, RI, 02906.
• 3Warren Alpert Medical School of Brown University, Providence, RI, 02912; Stanley Street Treatment and Resources, Inc., Fall River, Massachusetts, 02720. 
• J Subst Abuse Treat. 2016 May;64:44-6. doi: 10.1016/j.jsat.2016.01.007. Epub 2016 Feb 23.

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Lethality of Opioid Overdose in a Community Cohort of Young Heroin Users

BACKGROUND:

The aim of the study was to estimate the lethality of opioid overdose among young heroin users.

METHODS:

A prospective community cohort study was conducted in Barcelona and Madrid, Spain. Participants included 791 heroin users aged 18-30 years who were followed up between 2001 and 2006. Fatal overdoses were identified by record linkage of the cohort with the general mortality register, while non-fatal overdoses were self-reported at baseline and follow-up interviews. The person-years (py) at risk were computed for each participant. Fatal and non-fatal overdose rates were estimated by city. Transition towards injection shortly before the overdose could not be measured. Overdose lethality (rate of fatal overdose in proportion to total overdose) and its 95% CI was estimated using Bayesian models.

RESULTS:

The adjusted rates of fatal and non-fatal opioid overdose were 0.7/100 py (95% CI: 0.4-1.1) and 15.8/100 py (95% CI: 14.3-17.6), respectively. The adjusted lethality was 4.2% (95% CI: 2.5-6.5).

CONCLUSIONS:

Four out of 100 opioid overdoses are fatal. These are preventable deaths that could be avoided before or after the overdose takes place. Resources are urgently needed to prevent fatal opioid overdose.

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By:  Espelt A1, Barrio G, Álamo-Junquera D, Bravo MJ, Sarasa-Renedo A, Vallejo F, Molist G, Brugal MT; ITINERE Project Group.

Eur Addict Res. 2015;21(6):300-6. doi: 10.1159/000377626. Epub 2015 May 28.

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Neighborhood-Level & Spatial Characteristics Associated with Lay Naloxone Reversal Events & Opioid Overdose Deaths

There were over 23,000 opioid overdose deaths in the USA in 2013, and opioid-related mortality is increasing. Increased access to naloxone, particularly through community-based lay naloxone distribution, is a widely supported strategy to reduce opioid overdose mortality; however, little is known about the ecological and spatial patterns of the distribution and utilization of lay naloxone. 

This study aims to investigate the neighborhood-level correlates and spatial relationships of lay naloxone distribution and utilization and opioid overdose deaths. We determined the locations of lay naloxone distribution sites and the number of unintentional opioid overdose deaths and reported reversal events in San Francisco census tracts (n = 195) from 2010 to 2012. 

We used Wilcoxon rank-sum tests to compare census tract characteristics across tracts adjacent and not adjacent to distribution sites and multivariable negative binomial regression models to assess the association between census tract characteristics, including distance to the nearest site, and counts of opioid overdose deaths and naloxone reversal events. 

Three hundred forty-two opioid overdose deaths and 316 overdose reversals with valid location data were included in our analysis. Census tracts including or adjacent to a distribution site had higher income inequality, lower percentage black or African American residents, more drug arrests, higher population density, more overdose deaths, and more reversal events (all p < 0.05). 

In multivariable analysis, greater distance to the nearest distribution site (up to a distance of 4000 m) was associated with a lower count of Naloxone reversals [incidence rate ratio (IRR) = 0.51 per 500 m increase, 95% CI 0.39-0.67, p < 0.001] but was not significantly associated with opioid overdose deaths. 

These findings affirm that locating lay naloxone distribution sites in areas with high levels of substance use and overdose risk facilitates reversals of opioid overdoses in those immediate areas but suggests that alternative delivery methods may be necessary to reach individuals in other areas with less concentrated risk.

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By:  Rowe C1, Santos GM2,3, Vittinghoff E3, Wheeler E4, Davidson P5, Coffin PO2,3.

• 1San Francisco Department of Public Health, 25 Van Ness Avenue, Ste. 500, San Francisco, CA, 94102, USA. chris.rowe@sfdph.org.
• 2San Francisco Department of Public Health, 25 Van Ness Avenue, Ste. 500, San Francisco, CA, 94102, USA.
• 3University of California, San Francisco, 500 Parnassus Avenue, San Francisco, CA, 94143, USA.
• 4Drug Overdose Prevention and Education Project, Harm Reduction Coalition, 1440 Broadway, Suite 902, Oakland, CA, 94612, USA.
• 5University of California, San Diego, 9500 Gilman Drive, La Jolla, California, CA, 92093, USA. 

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Life Expectancy and Cause of Death in Popular Musicians: Is the Popular Musician Lifestyle the Road to Ruin?

Does a combination of lifestyle pressures and personality, as reflected in genre, lead to the early death of popular musicians? We explored overall mortality, cause of death, and changes in patterns of death over time and by music genre membership in popular musicians who died between 1950 and 2014. 

The death records of 13,195 popular musicians were coded for age and year of death, cause of death, gender, and music genre. Musician death statistics were compared with age-matched deaths in the US population using actuarial methods. Although the common perception is of a glamorous, free-wheeling lifestyle for this occupational group, the figures tell a very different story. 

Results showed that popular musicians have shortened life expectancy compared with comparable general populations. Results showed excess mortality from violent deaths (suicide, homicide, accidental death, including vehicular deaths and drug overdoses) and liver disease for each age group studied compared with population mortality patterns. These excess deaths were highest for the under-25-year age group and reduced chronologically thereafter. 

Overall mortality rates were twice as high compared with the population when averaged over the whole age range. Mortality impacts differed by music genre. In particular, excess suicides and liver-related disease were observed in country, metal, and rock musicians; excess homicides were observed in 6 of the 14 genres, in particular hip hop and rap musicians. For accidental death, actual deaths significantly exceeded expected deaths for country, folk, jazz, metal, pop, punk, and rock.

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By:  Kenny DT1, Asher A.

• 1Faculty of Arts and Social Sciences, Room 468, Bldg H04, The University of Sydney, NSW 2006, Australia. Tel 612 9114 0711, fax 612 9351 3838. dianna.kenny@sydney.edu.au. 
• Med Probl Perform Art. 2016 Mar;31(1):37-44.

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Sharing Overdose Data Across State Agencies to Inform Public Health Strategies: A Case Study

Data sharing and analysis are important components of coordinated and cost-effective public health strategies. However, legal and policy barriers have made data from different agencies difficult to share and analyze for policy development. 

To address a rise in overdose deaths, Maryland used an innovative and focused approach to bring together data on overdose decedents across multiple agencies. The effort was focused on developing discrete intervention points based on information yielded on decedents' lives, such as vulnerability upon release from incarceration. 

Key aspects of this approach included gubernatorial leadership, a unified commitment to data sharing across agencies with memoranda of understanding, and designation of a data management team. Preliminary results have yielded valuable insights and have helped inform policy. 

This process of navigating legal and privacy concerns in data sharing across multiple agencies may be applied to a variety of public health problems challenging health departments across the country.

Full PDF article at:   http://goo.gl/vVlkne

By:  Cherico-Hsii S1, Bankoski A1, Singal P2, Horon I1, Beane E3, Casey M3, Rebbert-Franklin K4, Sharfstein J1.

• 1Maryland Department of Health and Mental Hygiene, Baltimore, MD.
• 2Johns Hopkins University School of Medicine, Baltimore, MD.
• 3Office of the Governor of Maryland, Annapolis, MD.
• 4Maryland Department of Health and Mental Hygiene, Behavioral Health Administration, Catonsville, MD. 
• Public Health Rep. 2016 Mar-Apr;131(2):258-63.

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Demographics & Post-Mortem Toxicology Findings in Deaths among People Arrested Multiple Times for Use of Illicit Drugs and/or Impaired Driving

BACKGROUND:

Multiple arrests for use of illicit drugs and/or impaired driving strongly suggests the existence of a personality disorder and/or a substance abuse problem.

METHODS:

This retrospective study (1993-2010) used a national forensic toxicology database (TOXBASE), and we identified 3943 individuals with two or more arrests for use of illicit drugs and/or impaired driving. These individuals had subsequently died from a fatal drug poisoning or some other cause of death, such as trauma.

RESULTS:

Of the 3943 repeat offenders 1807 (46%) died from a fatal drug overdose and 2136 (54%) died from other causes (p<0.001). The repeat offenders were predominantly male (90% vs 10%) and mean age of drug poisoning deaths was 5 y younger (mean 35 y) than other causes of death (mean 40 y). Significantly more repeat offenders (46%) died from drug overdose compared with all other forensic autopsies (14%) (p<0.001). Four or more drugs were identified in femoral blood in 44% of deaths from poisoning (drug overdose) compared with 18% of deaths by other causes (p<0.001). The manner of death was considered accidental in 54% of deaths among repeat offenders compared with 28% for other suspicious deaths (p<0.001). The psychoactive substances most commonly identified in autopsy blood from repeat offenders were ethanol, morphine (from heroin), diazepam, amphetamines, cannabis, and various opioids.

CONCLUSIONS:

This study shows that people arrested multiple times for use of illicit drugs and/or impaired driving are more likely to die by accidentally overdosing with drugs. Lives might be saved if repeat offenders were sentenced to treatment and rehabilitation for their drug abuse problem instead of conventional penalties for drug-related crimes

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By:  Ahlner J1, Holmgren A2, Jones AW3.

• 1Department of Forensic Genetics and Forensic Toxicology, Swedish National Board of Forensic Medicine, Linköping, Sweden; Department of Clinical Pharmacology, Faculty of Medicine, Linköping University, Linköping, Sweden.
• 2Department of Forensic Genetics and Forensic Toxicology, Swedish National Board of Forensic Medicine, Linköping, Sweden.
• 3Department of Forensic Genetics and Forensic Toxicology, Swedish National Board of Forensic Medicine, Linköping, Sweden; Department of Clinical Pharmacology, Faculty of Medicine, Linköping University, Linköping, Sweden. Electronic address: wayne.jones@liu.se. 
• Forensic Sci Int. 2016 Feb 3;265:138-143. doi: 10.1016/j.forsciint.2016.01.036.

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‘What Is Known About Community Pharmacy Supply of Naloxone’: A Scoping Review

Highlights

• Take-home naloxone may be expanded through community pharmacy.
• Early work indicates pharmacists are willing to supply naloxone.
• Existing models for community pharmacy of naloxone supply exist.
• Supply models have important cost implications for consumers.
• Larger implementation studies are needed to determine effectiveness.

Abstract

Background

There is growing evidence that expanded supply of take-home naloxone to prevent opioid overdose deaths is needed. Potential routes for expansion of naloxone provision include through community pharmacies. The aim of this scoping review is to establish what is known about community pharmacy supply of naloxone, in light of unique challenges and opportunities present in pharmacy settings.

Methods

A scoping review methodology was employed using the six stage iterative process advocated by Arksey and O’ Malley (2005) and Levac et al. (2010). Searches used key words and terms such as ‘naloxone’; ‘overdose prevention/drug overdose/opiate overdose’; ‘community/retail pharmacy’; ‘pharmacist/pharmacy/community pharmacy/pharmaceutical services’; ‘professional practice/role’; ‘community care’; attitude of health personnel’; ‘training/supply/cost’). Appropriate search terms were selected for each database. After initial exploratory searches, comprehensive searches were conducted with Cochrane Database of Systematic Reviews, Medline, Medline in Process, Embase, PsycINFO and CINAHL. Eligibility criteria centered on whether studies broadly described supply of naloxone in community pharmacy or had content relating to community pharmacy supply.

Results

The search identified 95 articles, of which 16 were related to pharmacy supply of naloxone. Five themes were presented after initial review of the data and consultation with the project Expert Group, and are; ‘Pharmacists Perceptions of Naloxone: Facilitators and Barriers’, ‘Patient Populations: Identification and Recruitment’, ‘Supply Systems and Cost’, ‘Legal Issues’, and ‘Training of Pharmacists and Community Pharmacy Naloxone Recipients’.

Conclusion

The community pharmacy based route for distribution of take home naloxone provision warrants further consideration and development. Existing strengths include a range of established supply models, and training curricula, few direct concerns regarding legal liability of pharmacists in the supply of naloxone (once legal supply systems have been established) and the wide range of potential identifiable patient populations, which include pain patients that may not be in contact with existing naloxone supply programmes.

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By:  Suzanne Nielsen, Marie Claire Van Hout

Affiliations

• National Drug and Alcohol Research Centre, University of New South Wales, Australia

• Drug and Alcohol Services, South Eastern Sydney Local Health District

Correspondence

• Corresponding author.at: National Drug and Alcohol Research Centre University of New South Wales Sydney 2052, Australia.

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Assessment of Provider Attitudes Toward #Naloxone on Twitter

BACKGROUND:

As opioid overdose rates continue to pose a major public health crisis, the need for naloxone treatment by emergency first responders is critical. Little is known about the views of those who administer naloxone. The current study examines attitudes of health professionals on the social media platform Twitter to better understand their perceptions of opioid users, the role of naloxone and potential training needs.

METHODS:

Public comments on Twitter regarding naloxone were collected for a period of three consecutive months. The occupations of individuals who posted tweets were identified through Twitter profiles or hashtags. Categories of emergency service first responders and medical personnel were created. Qualitative analysis using a grounded theory approach was used to produce thematic content. The relationships between occupation and each theme were analyzed using Pearson chi-square statistics and post-hoc analyses.

RESULTS:

A total of 368 individuals posted 467 naloxone-related tweets. Occupations consisted of professional first responders such as emergency medical technicians (EMTs), firefighters, and paramedics (n = 122); law enforcement officers (n = 70); nurses (n = 62); physicians (n = 48); other health professionals including pharmacists, pharmacy technicians, counselors, social workers (n = 31); naloxone-trained individuals (n = 12); and students (n = 23). Primary themes included burnout, education and training, information-seeking, news updates, optimism, policy and economics, stigma, and treatment. The highest levels of burnout, fatigue and stigma regarding naloxone and opioid overdose were among nurses, EMTs, other health care providers and physicians. In contrast, individuals who self-identified as "naloxone-trained" had the highest optimism and the lowest amount of burnout and stigma.

CONCLUSIONS:

Provider training and refinement of naloxone administration procedures is needed to improve treatment outcomes and reduce provider stigma. Social networking sites such as Twitter may have potential for offering psychoeducation to health care providers.

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By:  Haug NA1, Bielenberg J1, Linder SH2, Lembke A3.

• 1 PGSP-Stanford University Psy.D. Consortium, Palo Alto University , Los Altos , CA , USA.
• 2 VA Palo Alto Health Care System , Palo Alto , CA , USA.
• 3 Department of Psychiatry and Behavioral Sciences , Stanford University School of Medicine , Stanford , CA , USA.
• Subst Abus. 2016 Feb 9:0.  

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Risk Factors for Opioid Overdose & Awareness of Overdose Risk among Veterans Prescribed Chronic Opioids for Addiction or Pain

Background

Rising overdose fatalities among US veterans suggest veterans taking prescription opioids may be at risk for overdose. However, it is unclear whether veterans prescribed chronic opioids are aware of this risk.

Objectives

The objective of this study was to identify risk factors and determine awareness of risk for opioid overdose in veterans treated with opioids for chronic pain, using veterans treated with methadone or buprenorphine for opioid use disorder as a high-risk comparator group.

Methods

Ninety veterans on chronic opioid medication for either opioid use disorder or pain management completed a questionnaire assessing risk factors, knowledge, and self-estimate of risk for overdose.

Results

Nearly all veterans in both groups had multiple overdose risk factors although individuals in the pain management group had on average a significantly lower total number of risk factors than did individuals in the opioid use disorder group (5.9 v. 8.5, p<0.0001). On average, participants treated for pain management scored slightly but significantly lower on knowledge of opioid overdose risk factors (12.1 v. 13.5, p<0.01). About 70% of participants, regardless of group, believed their overdose risk was below that of the average American adult. There was no significant relationship between self-estimate of overdose risk and either number or knowledge of opioid overdose risk factors.

Discussion

Our results suggest that veterans in both groups underestimated their risk for opioid overdose. Expansion of overdose education to include individuals on chronic opioids for pain management and a shift in educational approaches to overdose prevention may be indicated.

Below:  Participant estimate of risk for overdose on opioids in the next year, using visual analog scale graded from 0–100%

Full article at:   http://goo.gl/3UJ5wA

By:  Christine M. Wilder, M.D.,1,2,* Shannon C. Miller, M.D.,1,2 Elizabeth Tiffany, M.D.,2 Theresa Winhusen, Ph.D.,2 Erin L. Winstanley, Ph.D.,3 and Michael D. Stein, M.D.4

¹Department of Veterans Affairs Medical Center, 3200 Vine Street, Cincinnati, OH 45220

²Department of Psychiatry and Behavioral Neuroscience, University of Cincinnati College of Medicine, 3131 Harvey Avenue, Cincinnati, OH 45229

³James L. Winkle College of Pharmacy, University of Cincinnati, PO Box 670004, Cincinnati, OH 45267-0004

⁴Department of Medicine, Alpert School of Medicine of Brown University, Butler Hospital, 345 Blackstone Blvd, Providence, RI 09206

^*Corresponding Author: Christine M. Wilder, MD; Email: ude.cu@redliw.enitsirhC

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Stakeholder Perceptions & Operational Barriers in the Training & Distribution of Take-Home Naloxone within Prisons in England

BACKGROUND:

The aim of the study was to assess potential barriers and challenges to the implementation of take-home naloxone (THN) across ten prisons in one region of England.

METHODS:

Qualitative interviews deploying a grounded theory approach were utilised over a 12- to 18-month period that included an on-going structured dialogue with strategic and operational prison staff from the ten prisons and other key stakeholders (n = 17). Prisoner perceptions were addressed through four purposive focus groups belonging to different establishments (n = 26). Document analysis also included report minutes and access to management information and local performance reports. The data were thematically interpreted using visual mapping techniques.

RESULTS:

The distribution and implementation of THN in a prison setting was characterised by significant barriers and challenges. As a result, four main themes were identified: a wide range of negative and confused perceptions of THN amongst prison staff and prisoners; inherent difficulties with the identification and engagement of eligible prisoners; the need to focus on individual prison processes to enhance the effective distribution of THN; and the need for senior prison staff engagement.

CONCLUSIONS:

The distribution of THN within a custodial setting requires consideration of a number of important factors which are discussed...

Since I’ve come to this jail, everyone [has been] banging on about getting myself sorted and off the drugs and everything you know. It’s taken a while and I’m in the right place to move forward for once, no more gear – nothing. I’m done with that life….. I’m clean now with no intention of using, so why do I need this? [Male prisoner, Prison 5]

What’ll happen is that I will leave here and as soon I get my feet on the ground the police will stop me, as always, and say…..’What’s this? You must be using again - you’re nicked [arrested]'. [Male prisoner, Prison 2]

Many of my staff understand what we are trying to do here which is get prisoners off drugs and abstinent by the time they leave here…if not abstinent entirely then at least in a positon to consider an abstinent life. For many staff, and it’s not just uniformed staff [prison officers], just handing out Naloxone give out the wrong message that says it’s alright now you can keep on using. I don’t agree with this view myself but I know they [staff] think it. [Healthcare Manager, Naloxone Action Group]

I am very concerned that Naloxone could be given out by prison officers or anyone else without healthcare input. The risks will be too great if something went wrong and the wrong person got hold of it. [Healthcare nurse, Naloxone Action Group] 

Full article at:   http://goo.gl/588N9e

By:   Sondhi A1, Ryan G2, Day E3.

• 1Therapeutic Solutions (Addictions) Communications House, 26 York Street, London, W1U 6PZ, UK. arun.sondhi@therapeutic-solutions.org.uk.
• 2Public Health England, 2nd Floor Skipton House London Road Elephant & Castle, London, SE1 6LH, UK.
• 3Addiction Psychiatry, Addictions Department, National Addiction Centre, Addiction Sciences Building, 4 Windsor Walk, Denmark Hill, London, SE5 8AF, UK.
• Harm Reduct J. 2016 Feb 3;13(1):5. doi: 10.1186/s12954-016-0094-1. 

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Drug Overdoses in the US

Below:  https://atlas.qz.com/charts/EJHSfd6rl

“There's Nothing Here”: Deindustrialization as Risk Environment for Overdose

Applying the “risk environment” approach proposed by ( Rhodes, 2002; Rhodes, 2009 ), this study considers the diverse contextual factors contributing to drug overdose in a deindustrialized region of the United States. 

The Monongahela Valley of Pennsylvania, once a global center of steel production, has suffered a mass exodus of jobs, residents, and businesses since a national manufacturing crisis erupted in the early 1980s; more recently, it has seen a dramatic uptick in accidental drug poisoning deaths. 

Where recent local and national media attention to overdose has focused on suburban areas and middle class victims, this study concentrates instead on the deteriorating mill city of McKeesport, Pennsylvania. Eighteen clients of the city's sole drug treatment facility participated in in-depth interviews concerning their direct experience with accidental overdose. Specifically, participants were asked to describe their own most recent overdose event and/or the last overdose they had personally witnessed. They were also asked to speculate upon the roots of the local overdose epidemic, while venturing possible remedies. 

In relating their overdose experiences, participants characterized a micro-level risk environment that was hidden behind closed doors, and populated by unprepared, ambivalent overdose “assistants.” Tasked with explaining a geographic concentration of overdose in and around McKeesport, interviewees referenced the hopelessness of the area and its lack of opportunity as driving the use of heroin, with many explicitly suggesting the need for jobs and community reinvestment to reduce fatalities. 

While state and county efforts to ameliorate overdose mortality have focused upon creating an open market in naloxone, this study suggests the need for interventions that address the poverty and social isolation of opiate users in the post-industrial periphery.

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By:  Katherine McLean

The Pennsylvania State University - Greater Allegheny, 4000 University Drive, McKeesport, PA, 15131, United States

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