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Harm Reduction Journal Feb 2022Naloxone-based interventions as part of health systems can reverse an opioid overdose. Previous systematic reviews have identified the effectiveness of naloxone;...
BACKGROUND
Naloxone-based interventions as part of health systems can reverse an opioid overdose. Previous systematic reviews have identified the effectiveness of naloxone; however, the role of context and mechanisms for its use has not been explored. This realist systematic review aims to identify a theory of how naloxone works based on the contexts and mechanisms that contribute to the success of the intervention for improved outcomes.
METHODS
Pre-registered at PROSPERO, this realist review followed RAMESES standards of reporting. Keywords included 'naloxone' and ' opioid overdose'. All study designs were included. Data extraction using 55 relevant outputs based on realist logic produced evidence of two middle-range theories: Naloxone Bystander Intervention Theory and Skills Transfer Theory.
RESULTS
Harm reduction and/or low threshold contexts provide a non-judgemental approach which support in-group norms of helping and empower the social identity of the trained and untrained bystander. This context also creates the conditions necessary for skills transfer and diffusion of the intervention into social networks. Stigma and negative attitudes held by first responders and stakeholders involved in the implementation process, such as police or GPs, can prohibit the bystander response by inducing fear in responding. This interferes with skills transfer, naloxone use and carriage of naloxone kits.
CONCLUSIONS
The findings provide theoretically informed guidance regarding the harm reduction contexts that are essential for the successful implementation of naloxone-based interventions. Peer-to-peer models of training are helpful as it reinforces social identity and successful skills transfer between bystanders. Health systems may want to assess the prevalence of, and take steps to reduce opioid-related stigma with key stakeholders in contexts using a low threshold training approach to build an environment to support positive naloxone outcomes.
TRIAL REGISTRATION
PROSPERO 2019 CRD42019141003.
Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders
PubMed: 35197057
DOI: 10.1186/s12954-022-00599-4 -
Drug and Alcohol Dependence Jul 2021The opioid-related overdose epidemic remains a persistent public health problem in the United States and has been accelerated by the 2019 coronavirus disease pandemic....
BACKGROUND
The opioid-related overdose epidemic remains a persistent public health problem in the United States and has been accelerated by the 2019 coronavirus disease pandemic. Existing, evidence-based treatment options for opioid use disorder (OUD) are broadly underutilized, particularly by people experiencing homelessness (PEH). PEH are also more likely to misuse and overdose on opioids. To better understand current gaps and disparities in OUD treatment experienced by PEH and efforts to address them, we synthesized the literature reporting on the intersection of housing status and OUD treatment.
METHODS
We conducted a scoping review of the literature from the electronic databases MEDLINE, Embase, PsycINFO, and Web of Science Core Collection. We included studies describing treatment-related outcomes specific to PEH and articles assessing OUD treatment interventions tailored to this population. Relevant findings were compiled via thematic analysis and narratively synthesized.
RESULTS
60 articles met our inclusion criteria, including 43 descriptive and 17 intervention-focused studies. These studies demonstrated that PEH experience more barriers to OUD treatment than their housed counterparts and access inpatient and detoxification treatment more commonly than pharmacotherapy. However, the reviewed literature indicated that PEH have similar outcomes once engaged in pharmacotherapy. Efficacious interventions for PEH were low-barrier and targeted, with housing interventions also demonstrating benefit.
CONCLUSIONS
PEH have diminished access to evidence-based OUD treatment, particularly medications, and require targeted approaches to improve engagement and retention. To mitigate the disproportionate opioid-related morbidity and mortality PEH experience, innovative, flexible, and interdisciplinary OUD treatment models are necessary, with housing support playing an important role.
Topics: Buprenorphine; Health Services Accessibility; Health Services Misuse; Ill-Housed Persons; Humans; Methadone; Naltrexone; Opiate Substitution Treatment; Opioid-Related Disorders; United States
PubMed: 33985863
DOI: 10.1016/j.drugalcdep.2021.108717 -
Journal of Hospital Medicine Sep 2022Hospitalizations related to the consequences of opioid use are rising. National guidelines directing in-hospital opioid use disorder (OUD) management do not exist. OUD...
BACKGROUND
Hospitalizations related to the consequences of opioid use are rising. National guidelines directing in-hospital opioid use disorder (OUD) management do not exist. OUD treatment guidelines intended for other treatment settings could inform in-hospital OUD management.
OBJECTIVE
Evaluate the quality and content of existing guidelines for OUD treatment and management.
DATA SOURCES
OVID MEDLINE, PubMed, Ovid PsychINFO, EBSCOhost CINHAL, ERCI Guidelines Trust, websites of relevant societies and advocacy organizations, and selected international search engines.
STUDY SELECTION
Guidelines published between January 2010 to June 2020 addressing OUD treatment, opioid withdrawal management, opioid overdose prevention, and care transitions among adults.
DATA EXTRACTION
We assessed quality using the Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument.
DATA SYNTHESIS
Nineteen guidelines met the selection criteria. Most recommendations were based on observational studies or expert consensus. Guidelines recommended the use of nonstigmatizing language among patients with OUD; to assess patients with unhealthy opioid use for OUD using the Diagnostic Statistical Manual of Diseases-5th Edition criteria; use of methadone or buprenorphine to treat OUD and opioid withdrawal; use of multimodal, nonopioid therapy, and when needed, short-acting opioid analgesics in addition to buprenorphine or methadone, for acute pain management; ensuring linkage to ongoing methadone or buprenorphine treatment; referring patients to psychosocial treatment; and ensuring access to naloxone for opioid overdose reversal.
CONCLUSIONS
Included guidelines were informed by studies with various levels of rigor and quality. Future research should systematically study buprenorphine and methadone initiation and titration among people using fentanyl and people with pain, especially during hospitalization.
Topics: Adult; Analgesics, Opioid; Buprenorphine; Hospitalization; Humans; Methadone; Opiate Overdose; Opioid-Related Disorders
PubMed: 35880821
DOI: 10.1002/jhm.12908 -
Hospital Pediatrics Apr 2020Vancomycin is a medication with potential for significant harm with both overdosing and underdosing. Obesity may affect vancomycin pharmacokinetics and is increasingly... (Meta-Analysis)
Meta-Analysis Review
CONTEXT
Vancomycin is a medication with potential for significant harm with both overdosing and underdosing. Obesity may affect vancomycin pharmacokinetics and is increasingly common among children.
OBJECTIVE
We aimed to determine if children with overweight or obesity have increased vancomycin trough concentrations with total body weight (TBW) dosing compared with children with normal weight.
DATA SOURCES
We conducted a search of Medline and Medline In-Process & Other Non-Indexed Citations from 1952 (the year vancomycin was discovered) to November 2017.
STUDY SELECTION
Search terms included vancomycin, body weight, and body composition terms and were limited to children. Studies were reviewed and screened by ≥2 reviewers.
DATA EXTRACTION
The primary outcome was vancomycin level. Data were extracted by 2 reviewers. We performed quality assessment using the Newcastle-Ottawa quality assessment scale.
RESULTS
We identified 271 records. After abstract and full-text screening, we identified 7 studies for full review. Six of the 7 studies used a matched case-control design, although there was significant variation in study methodology. Four of the 7 studies were included in a meta-analysis, which revealed a small but significant difference in vancomycin trough levels between children with normal weight and children with overweight or obesity when dosed by using TBW ( = 521; mean difference 2.2 U [95% confidence interval: 1.0-3.4]).
CONCLUSIONS
High-quality data to guide vancomycin dosing in children with obesity are lacking. More studies evaluating dosing strategies in children with obesity are warranted because using TBW to dose vancomycin may lead to higher vancomycin concentrations and potential toxicity.
Topics: Anti-Bacterial Agents; Child; Humans; Overweight; Pediatric Obesity; Vancomycin
PubMed: 32213528
DOI: 10.1542/hpeds.2019-0287 -
Addiction (Abingdon, England) Jan 2021Naloxone access laws (NALs) have been suggested to be an important strategy to reduce opioid-related harm. We describe the evolution of NALs across states and over time...
BACKGROUND AND AIMS
Naloxone access laws (NALs) have been suggested to be an important strategy to reduce opioid-related harm. We describe the evolution of NALs across states and over time and review existing evidence of their overall association with naloxone distribution and opioid overdose as well as the potential effects of specific NAL components.
METHODS
Descriptive analysis of temporal variation in US regional adoption of NAL components, accompanied by a systematic search of 13 databases for studies (published between 2005 and 20 December 2019) assessing the effects of NALs on naloxone distribution or opioid-related health outcomes. Eleven studies, all published since 2018, met inclusion criteria. Study time-frames spanned 1999-2017. Opioid-related overdose mortality, emergency department episodes and naloxone distribution were correlated with the presence of a NAL and, where data were available, NAL components.
RESULTS
Existing evidence suggests mixed, but generally beneficial, effects for NALs. Nearly all studies show that NALs, particularly those that permit naloxone distribution without patient-specific prescriptions, are associated with increased naloxone access [incidence rate ratios (IRR) range from 1.40, 95% confidence interval (CI) = 1.15-1.66 to 7.75, 95% CI = 1.22-49.35] and increased opioid-related emergency department visits (IRR range from 1.14, 95% CI = 1.07-1.20 to 1.15, 95% CI = 1.02-1.29). Most studies show NALs are associated with reduced overdose mortality, although findings vary depending on the specific NAL components and time-period analyzed (IRR range from 0.66, 95% CI = 0.42-0.90 to 1.27, 95% CI = 1.27-1.27). Few studies account for the variation in opioid environments (i.e. illicit versus prescription) or other policy dimensions that may be correlated with outcomes.
CONCLUSIONS
The existing literature on naloxone access laws in the United States supports beneficial effects for increased naloxone distribution, but provides inconclusive evidence for reduced fatal opioid overdose. Mixed findings may reflect variation in the laws' design and implementation, confounding effects of concurrent policy adoption, or differential effectiveness in light of changing opioid environments.
Topics: Drug and Narcotic Control; Harm Reduction; Health Services Accessibility; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; United States
PubMed: 32533570
DOI: 10.1111/add.15163 -
Epidemiologic Reviews Jan 2020The opioid overdose epidemic is typically described as having occurred in 3 waves, with morbidity and mortality accruing over time principally from prescription opioids...
The opioid overdose epidemic is typically described as having occurred in 3 waves, with morbidity and mortality accruing over time principally from prescription opioids (1999-2010), heroin (2011-2013), and illicit fentanyl and other synthetic opioids (2014-present). However, the increasing presence of synthetic opioids mixed into the illicit drug supply, including with stimulants such as cocaine and methamphetamine, as well as rising stimulant-related deaths, reflects the rapidly evolving nature of the overdose epidemic, posing urgent and novel public health challenges. We synthesize the evidence underlying these trends, consider key questions such as where and how concomitant exposure to fentanyl and stimulants is occurring, and identify actions for key stakeholders regarding how these emerging threats, and continued evolution of the overdose epidemic, can best be addressed.
Topics: Analgesics, Opioid; Central Nervous System Stimulants; Drug Overdose; Female; Humans; Male; Public Health; United States
PubMed: 33511987
DOI: 10.1093/epirev/mxaa011 -
Substance Abuse Treatment, Prevention,... Feb 2021There is a high risk of death from opioid overdose following release from prison. Efforts to develop and implement overdose prevention programs for justice-involved...
BACKGROUND
There is a high risk of death from opioid overdose following release from prison. Efforts to develop and implement overdose prevention programs for justice-involved populations have increased in recent years. An understanding of the gaps in knowledge on prevention interventions is needed to accelerate development, implementation, and dissemination of effective strategies.
METHODS
A systematic search process identified 43 published papers addressing opioid overdose prevention in criminal justice settings or among justice-involved populations from 2010 to February 2020. Cross-cutting themes were identified, coded and qualitatively analyzed.
RESULTS
Papers were coded into five categories: acceptability (n = 8), accessibility (n = 4), effectiveness (n = 5), feasibility (n = 7), and participant overdose risk (n = 19). Common themes were: (1) Acceptability of naloxone is associated with injection drug use, overdose history, and perceived risk within the situational context; (2) Accessibility of naloxone is a function of the interface between corrections and community; (3) Evaluations of overdose prevention interventions are few, but generally show increases in knowledge or reductions in opioid overdose; (4) Coordinated efforts are needed to implement prevention interventions, address logistical challenges, and develop linkages between corrections and community providers; (5) Overdose is highest immediately following release from prison or jail, often preceded by service-system interactions, and associated with drug-use severity, injection use, and mental health disorders, as well as risks in the post-release environment.
CONCLUSION
Study findings can inform the development of overdose prevention interventions that target justice-involved individuals and policies to support their implementation across criminal justice and community-based service systems.
Topics: Analgesics, Opioid; Criminal Law; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders
PubMed: 33618744
DOI: 10.1186/s13011-021-00346-1 -
Journal of Substance Abuse Treatment Jun 2017There are high levels of prescription and consumption of prescription opioids in the US. Misuse of prescription opioids has been shown to be highly correlated with... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
There are high levels of prescription and consumption of prescription opioids in the US. Misuse of prescription opioids has been shown to be highly correlated with prescription opioid-related morbidity and mortality including fatal and non-fatal overdose. We characterized the past-year prevalence of prescription opioid misuse among those 11-30years of age in the US.
METHODS
A systematic review and meta-analysis were carried out following a published protocol and PRISMA guidelines. We searched electronic databases; reports were eligible if they were published between 1/1/1990-5/30/2014, and included data on individuals 11-30years of age from the US. Study quality was assessed using the Newcastle-Ottawa Scale.
RESULTS
A total of 3211 abstracts were reviewed for inclusion; after discarding duplicates and identifying non-eligible reports, a total of 19 unique reports, providing 34 estimates, were included in the final systematic review and meta-analysis. The range of past-year prescription opioid misuse prevalence the reports was 0.7%-16.3%. An increase in prevalence of 0.4% was observed over the years of data collection.
CONCLUSIONS
This systematic review and meta-analysis found a high prevalence of past-year prescription opioid misuse among individuals 11-30years of age. Importantly, we identified an increase in past-year prevalence 1990-2014. Misuse of prescription opioids has played an important role in national increases of fatal and non-fatal drug overdose, heroin use and injection, and HIV and HCV infection among young people. The observed high and increasing prevalence of prescription opioid misuse is an urgent public health issue.
Topics: Adolescent; Adult; Analgesics, Opioid; Child; Drug Overdose; Humans; Opioid-Related Disorders; Prescription Drug Misuse; Prevalence; Public Health; United States; Young Adult
PubMed: 28476268
DOI: 10.1016/j.jsat.2017.03.007 -
Frontiers in Psychiatry 2024Fentanyl is a highly potent opioid and has, until recently, been considered an unwanted contaminant in the street drug supply among people who use drugs (PWUD). However,...
OBJECTIVES
Fentanyl is a highly potent opioid and has, until recently, been considered an unwanted contaminant in the street drug supply among people who use drugs (PWUD). However, it has become a drug of choice for an increasing number of individuals. This systematic review evaluated intentional non-medical fentanyl use among PWUD, specifically by summarizing demographic variance, reasons for use, and resulting patterns of use.
METHODS
The search strategy was developed with a combination of free text keywords and MeSH and non-MeSH keywords, and adapted with database-specific filters to Ovid MEDLINE, Embase, Web of Science, and PsychINFO. Studies included were human studies with intentional use of non-medical fentanyl or analogues in individuals older than 13. Only peer-reviewed original articles available in English were included.
RESULTS
The search resulted in 4437 studies after de-duplication, of which 132 were selected for full-text review. Out of 41 papers included, it was found that individuals who use fentanyl intentionally were more likely to be young, male, and White. They were also more likely to have experienced overdoses, and report injection drug use. There is evidence that fentanyl seeking behaviours are motivated by greater potency, delay of withdrawal, lower cost, and greater availability.
CONCLUSIONS
Among PWUD, individuals who intentionally use fentanyl have severe substance use patterns, precarious living situations, and extensive overdose history. In response to the increasing number of individuals who use fentanyl, alternative treatment approaches need to be developed for more effective management of withdrawal and opioid use disorder.
SYSTEMATIC REVIEW REGISTRATION
https://www.crd.york.ac.uk/prospero/, identifier CRD42021272111.
PubMed: 38414500
DOI: 10.3389/fpsyt.2024.1347678 -
Substance Abuse 2022Concurrent with the opioid overdose crisis there has been an increase in hospitalizations among people with opioid use disorder (OUD), with one in ten hospitalized...
Concurrent with the opioid overdose crisis there has been an increase in hospitalizations among people with opioid use disorder (OUD), with one in ten hospitalized medical or surgical patients having comorbid opioid-related diagnoses. We sought to conduct a systematic review of hospital-based interventions, their staffing composition, and their impact on outcomes for patients with OUD hospitalized for medical or surgical conditions. Authors searched PubMed MEDLINE, PsychINFO, and CINAHL from January 2015 through October 2020. The authors screened 463 titles and abstracts for inclusion and reviewed 96 full-text studies. Seventeen articles met inclusion criteria. Extracted were study characteristics, outcomes, and intervention components. Methodological quality was evaluated using the Methodological Quality Rating Scale. Ten of the 17 included studies were controlled retrospective cohort studies, five were uncontrolled retrospective studies, one was a prospective quasi-experimental evaluation, and one was a secondary analysis of a completed randomized clinical trial. Intervention components and outcomes varied across studies. Outcomes included in-hospital initiation and post-discharge connection to medication for OUD, healthcare utilization, and discharge against medical advice. Results were mixed regarding the impact of existing interventions on outcomes. Most studies focused on linkage to medication for OUD during hospitalization and connection to post-discharge OUD care. Given that many individuals with OUD require hospitalization, there is a need for OUD-related interventions for this patient population. Interventions with the best evidence of efficacy facilitated connection to post-discharge OUD care and employed an Addiction Medicine Consult model.
Topics: Aftercare; Hospitalization; Humans; Opioid-Related Disorders; Patient Discharge; Prospective Studies; Randomized Controlled Trials as Topic; Retrospective Studies
PubMed: 34283698
DOI: 10.1080/08897077.2021.1949663