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PloS One 2024Medical simulation offers a controlled environment for studying challenging clinical care situations that are difficult to observe directly. Overdose education and...
Medical simulation offers a controlled environment for studying challenging clinical care situations that are difficult to observe directly. Overdose education and naloxone distribution (OEND) programs aim to train potential rescuers in responding to opioid overdoses, but assessing rescuer performance in real-life situations before emergency medical services arrive is exceedingly complex. There is an opportunity to incorporate individuals with firsthand experience in treating out-of-hospital overdoses into the development of simulation scenarios. Realistic overdose simulations could provide OEND programs with valuable tools to effectively teach hands-on skills and support context-sensitive training regimens. In this research, semi-structured interviews were conducted with 17 individuals experienced in responding to opioid overdoses including emergency department physicians, first responders, OEND program instructors, and peer recovery specialists. Two coders conducted qualitative content analysis using open and axial thematic coding to identify nuances associated with illicit and prescription opioid overdoses. The results are presented as narrative findings complemented by summaries of the frequency of themes across the interviews. Over 20 hours of audio recording were transcribed verbatim and then coded. During the open and axial thematic coding process several primary themes, along with subthemes, were identified, highlighting the distinctions between illicit and prescription opioid overdoses. Distinct contextual details, such as locations, clinical presentations, the environment surrounding the patient, and bystanders' behavior, were used to create four example simulations of out-of-hospital overdoses. The narrative findings in this qualitative study offer context-sensitive information for developing out-of-hospital overdose scenarios applicable to simulation training. These insights can serve as a valuable resource, aiding instructors and researchers in systematically creating evidence-based scenarios for both training and research purposes.
Topics: Humans; Narcotic Antagonists; Opiate Overdose; Naloxone; Drug Overdose; Qualitative Research; Analgesics, Opioid; Opioid-Related Disorders
PubMed: 38547079
DOI: 10.1371/journal.pone.0294626 -
Inquiry : a Journal of Medical Care... 2024Opioid overdose and Opioid Use Disorder (OUD) statistics underscore an urgent need to significantly expand access to evidence-based OUD treatment. Office Based Opioid...
Network Analysis of Medical Claims Data Suggests Network-Based, Regional Targeting and Intervention Delivery Strategies to Increase Access to Office Based Opioid Treatment (OBOT) for Opioid Use Disorder (OUD).
Opioid overdose and Opioid Use Disorder (OUD) statistics underscore an urgent need to significantly expand access to evidence-based OUD treatment. Office Based Opioid Treatment (OBOT) has proven effective for treating OUD. However, limited access to these treatments persists. Recognizing the need for significant investment in clinical, behavioral, and translational research, the Indiana State Department of Health and Indiana University embarked on a research initiative supported by the "Responding to the Addictions Crisis" Grand Challenge Program. This brief presents recommendations based on existing research and our own analyses of medical claims data in Indiana, where opioid misuse is high and treatment access is limited. The recommendations cover target providers, intervention focus, priority regions, and delivery methods.
Topics: Humans; Analgesics, Opioid; Buprenorphine; Opiate Substitution Treatment; Opioid-Related Disorders; Ambulatory Care
PubMed: 38528788
DOI: 10.1177/00469580241238422 -
JAMA Network Open Mar 2024Patients treated in emergency departments (EDs) for opioid overdose often need drug treatment yet are rarely linked to services after discharge. Emergency...
IMPORTANCE
Patients treated in emergency departments (EDs) for opioid overdose often need drug treatment yet are rarely linked to services after discharge. Emergency department-based peer support is a promising approach for promoting treatment linkage, but evidence of its effectiveness is lacking.
OBJECTIVE
To examine the association of the Opioid Overdose Recovery Program (OORP), an ED peer recovery support service, with postdischarge addiction treatment initiation, repeat overdose, and acute care utilization.
DESIGN, SETTING, AND PARTICIPANTS
This intention-to-treat retrospective cohort study used 2014 to 2020 New Jersey Medicaid data for Medicaid enrollees aged 18 to 64 years who were treated for nonfatal opioid overdose from January 2015 to June 2020 at 70 New Jersey acute care hospitals. Data were analyzed from August 2022 to November 2023.
EXPOSURE
Hospital OORP implementation.
MAIN OUTCOMES AND MEASURES
The primary outcome was medication for opioid use disorder (MOUD) initiation within 60 days of discharge. Secondary outcomes included psychosocial treatment initiation, medically treated drug overdoses, and all-cause acute care visits after discharge. An event study design was used to compare 180-day outcomes between patients treated in OORP hospitals and those treated in non-OORP hospitals. Analyses adjusted for patient demographics, comorbidities, and prior service use and for community-level sociodemographics and drug treatment access.
RESULTS
A total of 12 046 individuals were included in the study (62.0% male). Preimplementation outcome trends were similar for patients treated in OORP and non-OORP hospitals. Implementation of the OORP was associated with an increase of 0.034 (95% CI, 0.004-0.064) in the probability of 60-day MOUD initiation in the half-year after implementation, representing a 45% increase above the preimplementation mean probability of 0.075 (95% CI, 0.066-0.084). Program implementation was associated with fewer repeat medically treated overdoses 4 half-years (-0.086; 95% CI, -0.154 to -0.018) and 5 half-years (-0.106; 95% CI, -0.184 to -0.028) after implementation. Results differed slightly depending on the reference period used, and hospital-specific models showed substantial heterogeneity in program outcomes across facilities.
CONCLUSIONS AND RELEVANCE
In this cohort study of patients treated for opioid overdose, OORP implementation was associated with an increase in MOUD initiation and a decrease in repeat medically treated overdoses. The large variation in outcomes across hospitals suggests that treatment effects were heterogeneous and may depend on factors such as implementation success, program embeddedness, and availability of other hospital- and community-based OUD services.
Topics: United States; Humans; Male; Female; Opiate Overdose; Aftercare; Cohort Studies; Retrospective Studies; Patient Discharge; Drug Overdose; Opioid-Related Disorders; Emergency Service, Hospital
PubMed: 38526490
DOI: 10.1001/jamanetworkopen.2024.3614 -
JAMA Network Open Mar 2024Agonist medications for opioid use disorder (MOUD), buprenorphine and methadone, in carceral settings might reduce the risk of postrelease opioid overdose but are...
IMPORTANCE
Agonist medications for opioid use disorder (MOUD), buprenorphine and methadone, in carceral settings might reduce the risk of postrelease opioid overdose but are uncommonly offered. In April 2019, the Massachusetts Department of Correction (MADOC), the state prison system, provided buprenorphine for incarcerated individuals in addition to previously offered injectable naltrexone.
OBJECTIVE
To evaluate postrelease outcomes after buprenorphine implementation.
DESIGN, SETTING, AND PARTICIPANTS
This cohort study with interrupted time-series analysis used linked data across multiple statewide data sets in the Massachusetts Public Health Data Warehouse stratified by sex due to differences in carceral systems. Eligible participants were individuals sentenced and released from a MADOC facility to the community. The study period for the male sample was January 2014 to November 2020; for the female sample, January 2015 to October 2019. Data were analyzed between February 2022 and January 2024.
EXPOSURE
April 2019 implementation of buprenorphine during incarceration.
MAIN OUTCOMES AND MEASURES
Receipt of MOUD within 4 weeks after release, opioid overdose, and all-cause mortality within 8 weeks after release, each measured as a percentage of monthly releases who experienced the outcome. Segmented linear regression analyzed changes in outcome rates after implementation.
RESULTS
A total of 15 225 individuals were included. In the male sample there were 14 582 releases among 12 688 individuals (mean [SD] age, 35.0 [10.8] years; 133 Asian and Pacific Islander [0.9%], 4079 Black [28.0%], 4208 Hispanic [28.9%], 6117 White [41.9%]), a rate of 175.7 releases per month; the female sample included 3269 releases among 2537 individuals (mean [SD] age, 34.9 [9.8] years; 328 Black [10.0%], 225 Hispanic [6.9%], 2545 White [77.9%]), a rate of 56.4 releases per month. Among male participants at 20 months postimplementation, the monthly rate of postrelease buprenorphine receipt was higher than would have been expected under baseline trends (21.2% vs 10.6% of monthly releases; 18.6 additional releases per month). Naltrexone receipt was lower than expected (1.0% vs 6.0%; 8.8 fewer releases per month). Monthly rates of methadone receipt (1.4%) and opioid overdose (1.8%) were not significantly different than expected. All-cause mortality was lower than expected (1.9% vs 2.8%; 1.5 fewer deaths per month). Among female participants at 7 months postimplementation, buprenorphine receipt was higher than expected (31.6% vs 9.5%; 12.4 additional releases per month). Naltrexone receipt was lower than expected (3.4% vs 7.2%) but not statistically significantly different. Monthly rates of methadone receipt (1.1%), opioid overdose (4.8%), and all-cause mortality (1.6%) were not significantly different than expected.
CONCLUSIONS AND RELEVANCE
In this cohort study of state prison releases, postrelease buprenorphine receipt increased and naltrexone receipt decreased after buprenorphine became available during incarceration.
Topics: Female; Male; Humans; Adult; Prisons; Opiate Overdose; Naltrexone; Cohort Studies; Opioid-Related Disorders; Methadone; Buprenorphine
PubMed: 38497959
DOI: 10.1001/jamanetworkopen.2024.2732 -
JAMIA Open Oct 2023Accurate identification of opioid overdose (OOD) cases in electronic healthcare record (EHR) data is an important element in surveillance, empirical research, and...
BACKGROUND
Accurate identification of opioid overdose (OOD) cases in electronic healthcare record (EHR) data is an important element in surveillance, empirical research, and clinical intervention. We sought to improve existing OOD electronic phenotypes by incorporating new data types beyond diagnostic codes and by applying several statistical and machine learning methods.
MATERIALS AND METHODS
We developed an EHR dataset of emergency department visits involving OOD cases or patients considered at risk for an OOD and ascertained true OOD status through manual chart reviews. We developed and validated prediction models using Random Forest, Extreme Gradient Boost, and Elastic Net models that incorporated 717 features involving primary and second diagnoses, chief complaints, medications prescribed, vital signs, laboratory results, and procedural codes. We also developed models limited to single data types.
RESULTS
A total of 1718 records involving 1485 patients were manually reviewed; 541 (36.4%) patients had one or more OOD. Prediction performance was similar for all models; sensitivity varied from 94% to 97%; and area under the receiver operating characteristic curve (AUC) was 98% for all methods. The primary diagnosis and chief complaint were the most important contributors to AUC performance; primary diagnoses and medication class contributed most to sensitivity; chief complaint, primary diagnosis, and vital signs were most important for specificity. Models limited to decision support data types available in real time demonstrated robust prediction performance.
CONCLUSIONS
Substantial prediction performance improvements were demonstrated for identifying OODs in EHR data. Our e-phenotypes could be applied in surveillance, retrospective empirical applications, or clinical decision support systems.
PubMed: 38486917
DOI: 10.1093/jamiaopen/ooad081 -
Journal of the American College of... Apr 2024Recent increases in pediatric and adolescent opioid fatalities mandate an urgent need for early consideration of possible opioid exposure and specific diagnostic and...
Recent increases in pediatric and adolescent opioid fatalities mandate an urgent need for early consideration of possible opioid exposure and specific diagnostic and management strategies and interventions tailored to these unique populations. In contrast to adults, pediatric methods of exposure include accidental ingestions, prescription misuse, and household exposure. Early recognition, appropriate diagnostic evaluation, along with specialized treatment for opioid toxicity in this demographic are discussed. A key focus is on Naloxone, an essential medication for opioid intoxication, addressing its unique challenges in pediatric use. Unique pediatric considerations include recognition of accidental ingestions in our youngest population, critical social aspects including home safety and intentional exposure, and harm reduction strategies, mainly through Naloxone distribution and education on safe medication practices. It calls for a multifaceted approach, including creating pediatric-specific guidelines, to combat the opioid crisis among children and to work to lower morbidity and mortality from opioid overdoses.
PubMed: 38464332
DOI: 10.1002/emp2.13134 -
The International Journal on Drug Policy Apr 2024The UK is experiencing its highest rate of drug related deaths in 25 years. Poor and inconsistent access to healthcare negatively impacts health outcomes for people who...
BACKGROUND
The UK is experiencing its highest rate of drug related deaths in 25 years. Poor and inconsistent access to healthcare negatively impacts health outcomes for people who use drugs. Innovation in models of care which promote access and availability of physical treatment is fundamental. Heroin Assisted Treatment (HAT) is a treatment modality targeted at the most marginalised people who use drugs, at high risk of mortality and morbidity. The first service-provider initiated HAT service in the UK ran between October 2019 and November 2022 in Middlesbrough, England. The service was co-located within a specialist primary care facility offering acute healthcare treatment alongside injectable diamorphine.
METHODS
Analysis of anonymised health records for healthcare costs (not including drug treatment) took place using descriptive statistics prior and during engagement with HAT, at both three (n=15) and six (n=12) months. Primary outcome measures were incidents of wound care, skin and soft tissue infections (SSTIs), overdose (OD) events, unplanned overnight stays in hospital, treatment engagement (general and within hospital care settings) and ambulance incidents. Secondary outcome measures were costs associated with these events.
RESULTS
A shift in healthcare access for participants during HAT engagement was observed. HAT service attendance appeared to support health promoting preventative care, and reduce reactive reliance on emergency healthcare systems. At three and six months, engagement for preventative wound care and treatment for SSTIs increased at the practice. Unplanned emergency healthcare interactions for ODs, overnight hospital stays, serious SSTIs, and ambulance incidents reduced, and there was an increase in treatment engagement (i.e. a reduction in appointments which were not engaged with). There was a decrease in treatment engagement in hospital settings. Changes in healthcare utilisation during HAT translated to a reduction in healthcare costs of 58% within six months compared to the same timeframe from the period directly prior to commencing HAT.
CONCLUSION
This exploratory study highlights the potential for innovative harm reduction interventions such as HAT, co-located with primary care services, to improve healthcare access and engagement for a high-risk population. Increased uptake of primary healthcare services translated to reductions in emergency healthcare use and associated costs. Although costs of HAT provision are substantial, the notable cost-savings in health care should be an important consideration in service implementation planning.
Topics: Humans; Primary Health Care; Health Services Accessibility; Heroin Dependence; Health Care Costs; Female; Male; Adult; United Kingdom; Heroin; Drug Overdose; Middle Aged; Delivery of Health Care; England; Opiate Substitution Treatment
PubMed: 38460217
DOI: 10.1016/j.drugpo.2024.104367 -
JMIR Research Protocols Mar 2024Despite strong and growing interest in ending the ongoing opioid health crisis, there has been limited success in reducing the prevalence of opioid addiction and the...
BACKGROUND
Despite strong and growing interest in ending the ongoing opioid health crisis, there has been limited success in reducing the prevalence of opioid addiction and the number of deaths associated with opioid overdoses. Further, 1 explanation for this is that existing interventions target those who are opiate-dependent but do not prevent opioid-naïve patients from becoming addicted.
OBJECTIVE
Leveraging behavioral economics at the patient level could help patients successfully use, discontinue, and dispose of their opioid medications in an acute pain setting. The primary goal of this project is to evaluate the effect of the 3 versions of the Opioid Management for You (OPY) tool on measures of opioid use relative to the standard of care by leveraging a pragmatic randomized controlled trial (RCT).
METHODS
A team of researchers from the Center for Learning Health System Sciences (CLHSS) at the University of Minnesota partnered with M Health Fairview to design, build, and test the 3 versions of the OPY tool: social influence, precommitment, and testimonial version. The tool is being built using the Epic Care Companion (Epic Inc) platform and interacts with the patient through their existing MyChart (Epic Systems Corporation) personal health record account, and Epic patient portal, accessed through a phone app or the MyChart website. We have demonstrated feasibility with pilot data of the social influence version of the OPY app by targeting our pilot to a specific cohort of patients undergoing upper-extremity procedures. This study will use a group sequential RCT design to test the impact of this important health system initiative. Patients who meet OPY inclusion criteria will be stratified into low, intermediate, and high risk of opiate use based on their type of surgery.
RESULTS
This study is being funded and supported by the CLHSS Rapid Prospective Evaluation and Digital Technology Innovation Programs, and M Health Fairview. Support and coordination provided by CLHSS include the structure of engagement, survey development, data collection, statistical analysis, and dissemination. The project was initially started in August 2022. The pilot was launched in February 2023 and is still running, with the data last counted in August 2023. The actual RCT is planned to start by early 2024.
CONCLUSIONS
Through this RCT, we will test our hypothesis that patient opioid use and diverted prescription opioid availability can both be improved by information delivery applied through a behavioral economics lens via sending nudges directly to the opioid users through their personal health record.
TRIAL REGISTRATION
ClinicalTrials.gov NCT06124079; https://clinicaltrials.gov/study/NCT06124079.
INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)
PRR1-10.2196/52882.
PubMed: 38457203
DOI: 10.2196/52882 -
Mathematical Biosciences and... Feb 2024A leading crisis in the United States is the opioid use disorder (OUD) epidemic. Opioid overdose deaths have been increasing, with over 100,000 deaths due to overdose...
A leading crisis in the United States is the opioid use disorder (OUD) epidemic. Opioid overdose deaths have been increasing, with over 100,000 deaths due to overdose from April 2020 to April 2021. This paper presents a mathematical model to address illicit OUD (IOUD), initiation, casual use, treatment, relapse, recovery, and opioid overdose deaths within an epidemiological framework. Within this model, individuals remain in the recovery class unless they relapse back to use and due to the limited availability of specialty treatment facilities for individuals with OUD, a saturation treatment function was incorporated. Additionally, a casual user class and its corresponding specialty treatment class were incorporated. We use both heroin and all-illicit opioids datasets to find parameter estimates for our models. Bistability of equilibrium solutions was found for realistic parameter values for the heroin-only dataset. This result implies that it would be beneficial to increase the availability of treatment. An alarming effect was discovered about the high overdose death rate: by 2046, the disorder-free equilibrium would be the only stable equilibrium. This consequence is concerning because it means the epidemic would end due to high overdose death rates. The IOUD model with a casual user class, its sensitivity results, and the comparison of parameters for both datasets, showed the importance of not overlooking the influence that casual users have in driving the all-illicit opioid epidemic. Casual users stay in the casual user class longer and are not going to treatment as quickly as the users of the heroin epidemic. Another result was that the users of the all-illicit opioids were going to the recovered class by means other than specialty treatment. However, the change in the relapse rate has more of an influence for those individuals than in the heroin-only epidemic. The results above from analyzing this model may inform health and policy officials, leading to more effective treatment options and prevention efforts.
Topics: Humans; United States; Heroin; Opiate Overdose; Opioid-Related Disorders; Analgesics, Opioid; Drug Overdose; Models, Theoretical; Recurrence
PubMed: 38454724
DOI: 10.3934/mbe.2024141 -
BMJ Open Mar 2024This study aims to characterise oxycodone's distribution and opioid-related overdoses in the USA by state from 2000 to 2021. (Observational Study)
Observational Study
OBJECTIVES
This study aims to characterise oxycodone's distribution and opioid-related overdoses in the USA by state from 2000 to 2021.
DESIGN
This is an observational study.
SETTING
More than 80 000 Americans died of an opioid overdose in 2021 as the USA continues to struggle with an opioid crisis. Prescription opioids play a substantial role, introducing patients to opioids and providing a supply of drugs that can be redirected to those seeking to misuse them.
METHODS
The Drug Enforcement Administration annual summary reports from the Automation of Reports and Consolidated Orders System provided weights of oxycodone distributed per state by business type (pharmacies, hospitals and practitioners). Weights were converted to morphine milligram equivalents (MME) per capita and normalised for population. The Centers for Disease Control and Prevention Wide-ranging ONline Data for Epidemiologic Research provided mortality data for heroin, other opioids, methadone, other synthetic narcotics and other/unspecified narcotics.
RESULTS
There was a sharp 280.13% increase in total MME/person of oxycodone from 2000 to 2010, followed by a slower 54.34% decrease from 2010 to 2021. Florida (2007-2011), Delaware (2003-2020) and Tennessee (2012-2021) displayed consistent and substantial elevations in combined MME/person compared with other states. In the peak year (2010), there was a 15-fold difference between the highest and lowest states. MME/person from only pharmacies, which constituted >94% of the total, showed similar results. Hospitals in Alaska (2000-2001, 2008, 2010-2021), Colorado (2008-2021) and DC (2000-2011) distributed substantially more MME/person over many years compared with other states. Florida stood out in practitioner-distributed oxycodone, with an elevation of almost 15-fold the average state from 2006 to 2010. Opioid-related deaths increased +806% from 2000 to 2021, largely driven by heroin, other opioids and other synthetic narcotics.
CONCLUSIONS
Oxycodone distribution across the USA showed marked differences between states and business types over time. Investigation of opioid policies in states of interest may provide insight for future actions to mitigate opioid misuse.
Topics: Humans; Analgesics, Opioid; Drug Overdose; Heroin; Narcotics; Opiate Overdose; Oxycodone; Tennessee; United States
PubMed: 38453203
DOI: 10.1136/bmjopen-2023-073765