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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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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The Role of Clinicians in Addressing the Opioid Overdose Epidemic - Slides

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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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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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Correlates of Overdose Risk Perception among Illicit Opioid Users

BACKGROUND:

Opioid-related mortality continues to increase in the United States. The current study assesses demographic and behavioral predictors of perceived overdose risk among individuals who use opioids illicitly. By examining these correlates in the context of established overdose risk factors, we aim to assess whether characteristics and behaviors that have been associated with actual overdose risk translate to higher perception of risk.

METHODS:

We conducted a cross-sectional survey of 172 adult illicit opioid users in San Francisco, CA and used multivariable logistic regression to identify predictors of perception of high risk for opioid overdose.

RESULTS:

Age (aOR=0.96, 95%CI=0.93-1.00) and number of injection days per month (0.91, 0.86-0.97) were associated with a lower odds of perceived high overdose risk. There was no independent association between use of opioid analgesics, concurrent use of opioids and benzodiazepines or cocaine, or HIV status and overdose risk perception.

CONCLUSIONS:

Opioid users who injected more frequently and those who were older were less likely to perceive themselves as being at risk of overdose, notwithstanding that those who inject more are at higher risk of overdose and those who are older are at higher risk overdose mortality. In addition, despite being established overdose risk factors, there was no relationship between use of opioid analgesics, concurrent use of opioids and cocaine or benzodiazepines, or self-reported HIV status and overdose risk perception. These findings highlight key populations of opioid users and established risk factors that may merit focused attention as part of education-based overdose prevention and opioid management strategies.

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By:  Rowe C1, Santos GM2, Behar E3, Coffin PO2.

• 1San Francisco Department of Public Health, 25 Van Ness Avenue, Suite 500, San Francisco, CA 94102, USA. Electronic address: chris.rowe@sfdph.org.
• 2San Francisco Department of Public Health, 25 Van Ness Avenue, Suite 500, San Francisco, CA 94102, USA; University of California, San Francisco, 500 Parnassus Avenue, San Francisco, CA 94143, USA.
• 3San Francisco Department of Public Health, 25 Van Ness Avenue, Suite 500, San Francisco, CA 94102, USA. 
• Drug Alcohol Depend. 2015 Dec 30. pii: S0376-8716(15)01833-5. doi: 10.1016/j.drugalcdep.2015.12.018. 

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What are opioids:  http://goo.gl/ncoQ9R 

Brief Overdose Education Is Sufficient for Naloxone Distribution to Opioid Users

BACKGROUND:

While drug users are frequently equipped with naloxone for lay opioid overdose reversal, the amount of education needed to ensure knowledge of indications and administration is unknown.

METHODS:

We administered four instruments, assessing comfort and knowledge around opioid overdose and naloxone administration, to opioid users receiving naloxone for the first time (N=60) and upon returning for a refill (N=54) at community distribution programs. Participants completed the instruments prior to receiving naloxone; first-time recipients repeated the instruments immediately after the standardized 5-10min education.

RESULTS:

Comfort with recognition of, response to, and administration of naloxone for an overdose event significantly increased after brief education among first-time recipients (p<0.05). Knowledge of appropriate responses to opioid overdose was high across all assessments; 96% of participants could identify at least one acceptable action to assess and one acceptable action to care for an opioid overdose. Facility with naloxone administration was high across all assessments and significantly increased for intranasal administration after education for first-time recipients (p<0.001). First-time recipients (before and after education) and refillers demonstrated a high level of knowledge on the Brief Overdose Recognition and Response Assessment, correctly identifying a mean of 13.7 out of 16 overdose scenarios.

CONCLUSIONS:

Opioid users seeking naloxone in San Francisco have a high level of baseline knowledge around recognizing and responding to opioid overdose and those returning for refills retain that knowledge. Brief education is sufficient to improve comfort and facility in recognizing and managing overdos

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By:  Behar E1, Santos GM2, Wheeler E3, Rowe C4, Coffin PO2.

• 1San Francisco Department of Public Health, Substance Use Research Unit, San Francisco, CA, USA. Electronic address: Emily.behar@sfdph.org.
• 2San Francisco Department of Public Health, Substance Use Research Unit, San Francisco, CA, USA; University of California San Francisco, San Francisco, CA, USA.
• 3Harm Reduction Coalition, Oakland, CA, USA.
• 4San Francisco Department of Public Health, Substance Use Research Unit, San Francisco, CA, USA; University of California Berkeley, Berkeley, CA, USA.
• Drug Alcohol Depend. 2015 Mar 1;148:209-12. doi: 10.1016/j.drugalcdep.2014.12.009. Epub 2014 Dec 19. 

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Evaluation of Overdose Prevention Trainings in NYC: Knowledge and Self-Efficacy among Participants Twelve Months after Training

BACKGROUND:

Prevention of unintentional opioid overdose deaths is effective through overdose prevention trainings (OPTs), in which laypersons are taught overdose response through six actions. This longitudinal study examines trainee knowledge twelve months after OPT completion.

METHODS:

We enrolled participants following OPT at six sites. At twelve months follow-up, participants were asked to: name the drug overdoses that naloxone reverses; name overdose response actions. We created a 6-point scale comprised of number of correct overdose response actions mentioned (check breathing; administer sternum rub; call 911; give rescue breathing; administer naloxone; put victim in recovery position). We compared mean knowledge by participant sociodemographic characteristics, confidence, and site of OPT training (indoors versus outdoors).

RESULTS:

273 of 344 OPT participants were reached at twelve months. Nearly all (99%) participants identified that naloxone reverses heroin; 77% opioid analgesics; and 68% methadone overdoses. Overdose response actions most frequently mentioned were giving naloxone (86%) and calling 911 (76%). The remaining four actions were mentioned by less than 40% of participants. Overall mean knowledge score was 2.7 out of 6. Mean knowledge scores were higher for college graduates than those with less than college education (3.2 vs 2.6, p<0.001), for those who felt very confident (mean score (ms) = 2.9), compared to somewhat confident (ms = 2.4) and a little or not at all confident (ms = 1.5) in their ability to reverse an overdose (p<.001), and for indoor-training recipients (3.0 vs 2.5, p = 0.02). There were no differences in mean knowledge scores for trainees by age, race, or gender.

CONCLUSIONS:

Our findings suggest the need for several improvements in OPT curriculum, including emphasis on naloxone reversal of opioid analgesic and methadone overdoses, and all 6 rescue actions. Lower knowledge scores among outdoor-trained participants likely reflect session brevity, suggesting that outdoor trainings need to be enhanced.

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By:  Maldjian L1, Siegler A1, Kunins HV1.

• 1a Department of Health and Mental Hygiene , Bureau of Alcohol and Drug Use Prevention, Care and Treatment , Queens , NY , USA.
• Subst Abus. 2016 Jan 5:0

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Patient Perspectives on an Opioid Overdose Education and Naloxone Distribution Program in the US Department of Veterans Affairs

BACKGROUND:

In an effort to prevent opioid overdose mortality among Veterans, Department of Veterans Affairs (VA) facilities began implementing Opioid Overdose Education and Naloxone Distribution (OEND) in 2013 and a national program began in 2014. VA is the first national health care system to implement OEND. The goal of this study is to examine patient perceptions of OEND training and naloxone kits.

METHODS:

Four focus groups were conducted between December 2014 and February 2015 with 21 patients trained in OEND. Participants were recruited from a VA residential facility in California with a substance use disorder treatment program (mandatory OEND training) and a homeless program (optional OEND training). Data were analyzed using matrices and open and closed coding approaches to identify what participants liked and did not like, group discussion disagreements, and suggestions for improvement.

RESULTS:

Veterans thought OEND training was interesting, novel, and empowering, and that naloxone kits will save lives. Some veterans expressed concern about using syringes in the kits. A few patients who never used opioids were not interested in receiving kits. Veterans had differing opinions about legal and liability issues, whether naloxone kits might contribute to relapse, and whether and how to involve family in training. Some veterans expressed uncertainty about the effects of naloxone. Suggested improvements included active learning approaches, enhanced training materials, and increased advertisement.

CONCLUSIONS:

OEND training was generally well-received among study participants, including those with no indication for a naloxone kit. Patients described a need for OEND and believed it could save lives. Patient feedback on OEND training benefits, concerns, opinions, and suggestions provides important insights to inform future OEND training programs both within VA and in other health care settings. Training is critical to maximizing the potential for OEND to save lives and this study includes specific suggestions for improving the effectiveness and acceptability of training.

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By:  Oliva EM1, Nevedal A1, Lewis ET1,2, McCaa MD1, Cochran MF1,3, Konicki PE4,5, Davis CS6, Wilder C7,8.

• 1 VA Palo Alto Health Care System - Center for Innovation to Implementation , Menlo Park , CA , USA.
• 2 VA Office of Mental Health Operations - Program Evaluation and Resource Center , Menlo Park , CA , USA.
• 3 Stanford University School of Medicine - Department of Psychiatry and Behavioral Sciences , Stanford , CA , USA.
• 4 Louis Stokes Cleveland VA Medical Center , Cleveland , OH , USA.
• 5 Case Western Reserve University School of Medicine - Department of Psychiatry , Cleveland , OH , USA.
• 6National Health Law Program , Los Angeles , CA , USA.
• 7 Cincinnati VA Medical Center , Cincinnati , OH , USA.
• 8 University of Cincinnati College of Medicine - Department of Psychiatry and Behavioral Neuroscience , Cincinnati , OH , USA.
• Subst Abus. 2015 Dec 16:0. 

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An Initial Evaluation of Web-Based Opioid Overdose Education

BACKGROUND:

Fatal opioid overdose is a significant public health concern in the United States. One approach to reducing fatalities is expanding overdose response education to broader audiences. This study examined responses to a web-based overdose education tool.

METHODS:

The results of 422 anonymous surveys submitted on www.stopoverdose.org were analyzed for participant demographics, knowledge of opioid overdose recognition and response, and knowledge of Washington's Good Samaritan overdose law. Characteristics, knowledge, and planned behavior of respondents with professional versus personal interest in overdose education were compared.

RESULTS:

Most respondents were age 35 or older (57%) and female (65%). The mean score on the knowledge quiz for overdose recognition and response items was 16.2 out of 18, and 1.5 out of 2 possible points for items concerning the law. Respondents indicating professional interest were significantly more likely to be 35 or older (p = .001) and to have received prior overdose education (p < .001), but less likely to know someone at risk for opioid overdose (p < .001) or report planning to obtain take-home naloxone (p < .001). No significant differences were found in overdose knowledge scores between groups.

CONCLUSIONS:

Online training may be effective among individuals with professional and personal interest in overdose, as general knowledge scores of overdose response were high among both groups. Lower scores reflecting knowledge of the law suggest that the web-based training may not have adequately presented this information. Overall, results suggest that a web-based platform may be a promising approach to basic overdose education.

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By:   Roe SS¹, Banta-Green CJ².

¹ Social Development Research Group , University of Washington , Seattle , Washington , USA.

² Alcohol and Drug Abuse Institute , University of Washington , Seattle , Washington , USA.

DOI:

10.3109/10826084.2015.1092986

 

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