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Frontiers in Public Health 2024Medications for opioid use disorder (MOUD) are especially important for formerly incarcerated individuals with opioid use disorder (OUD) and can reduce the risk of... (Review)
Review
Medications for opioid use disorder (MOUD) are especially important for formerly incarcerated individuals with opioid use disorder (OUD) and can reduce the risk of re-arrest and overdose during community reentry. Unfortunately, few formerly incarcerated individuals are able to access MOUD within the community, missing a critical tool for rehabilitation. A mini narrative review was conducted to highlight the published work that has been done to improve access to MOUD for formerly incarcerated individuals during reentry. The results yielded 15 records describing intervention evaluations, program descriptions, and research in progress. Most work is ongoing, showing promise that researchers have identified the importance of this problem. However additional research should be done to include other stakeholders and address the limitations of existing interventions and programs. Continued efforts can help ensure that formerly incarcerated individuals can safely and successfully reintegrate into society.
Topics: Humans; Opioid-Related Disorders; Prisoners; Health Services Accessibility; Opiate Substitution Treatment; Analgesics, Opioid
PubMed: 38803812
DOI: 10.3389/fpubh.2024.1377193 -
The Western Journal of Emergency... May 2024Bystander provision of naloxone is a key modality to reduce opioid overdose-related death. Naloxone training courses are available, but no standardized program exists....
INTRODUCTION
Bystander provision of naloxone is a key modality to reduce opioid overdose-related death. Naloxone training courses are available, but no standardized program exists. As part of a bystander empowerment course, we created and evaluated a brief naloxone training module.
METHODS
This was a retrospective evaluation of a naloxone training course, which was paired with Stop the Bleed training for hemorrhage control and was offered to administrative staff in an office building. Participants worked in an organization related to healthcare, but none were clinicians. The curriculum included the following topics: 1) background about the opioid epidemic; 2) how to recognize the signs of an opioid overdose; 3) actions not to take when encountering an overdose victim; 4) the correct steps to take when encountering an overdose victim; 5) an overview of naloxone products; and 6) Good Samaritan protection laws. The 20-minute didactic section was followed by a hands-on session with nasal naloxone kits and a simulation mannequin. The course was evaluated with the Opioid Overdose Knowledge (OOKS) and Opioid Overdose Attitudes (OOAS) scales for take-home naloxone training evaluation. We used the paired Wilcoxon signed-rank test to compare scores pre- and post-course.
RESULTS
Twenty-eight participants completed the course. The OOKS, measuring objective knowledge about opioid overdose and naloxone, had improved scores from a median of 73.2% (interquartile range [IQR] 68.3%-79.9%) to 91.5% (IQR 85.4%-95.1%), < 0.001. The three domains on the OOAS score also showed statistically significant results. Competency to manage an overdose improved on a five-point scale from a median of 2.5 (IQR 2.4-2.9) to a median of 3.7 (IQR 3.5-4.1), < 0.001. Concerns about managing an overdose decreased (improved) from a median of 2.3 (IQR 1.9-2.6) to median 1.8 (IQR 1.5-2.1), < 0.001. Readiness to intervene in an opioid overdose improved from a median of 4 (IQR 3.8-4.2) to a median of 4.2 (IQR 4-4.2), < 0.001.
CONCLUSION
A brief course designed to teach bystanders about opioid overdose and naloxone was feasible and effective. We encourage hospitals and other organizations to use and promulgate this model. Furthermore, we suggest the convening of a national consortium to achieve consensus on program content and delivery.
Topics: Naloxone; Humans; Narcotic Antagonists; Retrospective Studies; Male; Female; Drug Overdose; Opiate Overdose; Adult; Program Evaluation; Curriculum; Health Knowledge, Attitudes, Practice; Middle Aged
PubMed: 38801036
DOI: 10.5811/westjem.60409 -
Harm Reduction Journal May 2024Naloxone is an effective FDA-approved opioid antagonist for reversing opioid overdoses. Naloxone is available to the public and can be administered through intramuscular... (Review)
Review
Naloxone is an effective FDA-approved opioid antagonist for reversing opioid overdoses. Naloxone is available to the public and can be administered through intramuscular (IM), intravenous (IV), and intranasal spray (IN) routes. Our literature review investigates the adequacy of two doses of standard IM or IN naloxone in reversing fentanyl overdoses compared to newer high-dose naloxone formulations. Moreover, our initiative incorporates the experiences of people who use drugs, enabling a more practical and contextually-grounded analysis. The evidence indicates that the vast majority of fentanyl overdoses can be successfully reversed using two standard IM or IN dosages. Exceptions include cases of carfentanil overdose, which necessitates ≥ 3 doses for reversal. Multiple studies documented the risk of precipitated withdrawal using ≥ 2 doses of naloxone, notably including the possibility of recurring overdose symptoms after resuscitation, contingent upon the half-life of the specific opioid involved. We recommend distributing multiple doses of standard IM or IN naloxone to bystanders and educating individuals on the adequacy of two doses in reversing fentanyl overdoses. Individuals should continue administration until the recipient is revived, ensuring appropriate intervals between each dose along with rescue breaths, and calling emergency medical services if the individual is unresponsive after two doses. We do not recommend high-dose naloxone formulations as a substitute for four doses of IM or IN naloxone due to the higher cost, risk of precipitated withdrawal, and limited evidence compared to standard doses. Future research must take into consideration lived and living experience, scientific evidence, conflicts of interest, and the bodily autonomy of people who use drugs.
Topics: Humans; Naloxone; Narcotic Antagonists; Drug Overdose; Fentanyl; Opiate Overdose; Analgesics, Opioid; Administration, Intranasal
PubMed: 38741224
DOI: 10.1186/s12954-024-00994-z -
Harm Reduction Journal May 2024Mortality related to opioid overdose in the U.S. has risen sharply in the past decade. In California, opioid overdose death rates more than tripled from 2018 to 2021,...
BACKGROUND
Mortality related to opioid overdose in the U.S. has risen sharply in the past decade. In California, opioid overdose death rates more than tripled from 2018 to 2021, and deaths from synthetic opioids such as fentanyl increased more than seven times in those three years alone. Heightened attention to this crisis has attracted funding and programming opportunities for prevention and harm reduction interventions. Drug checking services offer people who use drugs the opportunity to test the chemical content of their own supply, but are not widely used in North America. We report on qualitative data from providers and clients of harm reduction and drug checking services, to explore how these services are used, experienced, and considered.
METHODS
We conducted in-depth semi-structured key informant interviews across two samples of drug checking stakeholders: "clients" (individuals who use drugs and receive harm reduction services) and "providers" (subject matter experts and those providing clinical and harm reduction services to people who use drugs). Provider interviews were conducted via Zoom from June-November, 2022. Client interviews were conducted in person in San Francisco over a one-week period in November 2022. Data were analyzed following the tenets of thematic analysis.
RESULTS
We found that the value of drug checking includes but extends well beyond overdose prevention. Participants discussed ways that drug checking can fill a regulatory vacuum, serve as a tool of informal market regulation at the community level, and empower public health surveillance systems and clinical response. We present our findings within three key themes: (1) the role of drug checking in overdose prevention; (2) benefits to the overall agency, health, and wellbeing of people who use drugs; and (3) impacts of drug checking services at the community and systems levels.
CONCLUSION
This study contributes to growing evidence of the effectiveness of drug checking services in mitigating risks associated with substance use, including overdose, through enabling people who use and sell drugs to test their own supply. It further contributes to discussions around the utility of drug checking and harm reduction, in order to inform legislation and funding allocation.
Topics: Humans; Harm Reduction; Female; Qualitative Research; Male; Opiate Overdose; Adult; San Francisco; Drug Users; Opioid-Related Disorders; Drug Overdose
PubMed: 38734643
DOI: 10.1186/s12954-024-01014-w -
BMJ Open Apr 2024Opioid agonist treatment (OAT) tapering involves a gradual reduction in daily medication dose to ultimately reach a state of opioid abstinence. Due to the high risk of...
What is the ideal time to begin tapering opioid agonist treatment? A protocol for a retrospective population-based comparative effectiveness study in British Columbia, Canada.
INTRODUCTION
Opioid agonist treatment (OAT) tapering involves a gradual reduction in daily medication dose to ultimately reach a state of opioid abstinence. Due to the high risk of relapse and overdose after tapering, this practice is not recommended by clinical guidelines, however, clients may still request to taper off medication. The ideal time to initiate an OAT taper is not known. However, ethically, taper plans should acknowledge clients' preferences and autonomy but apply principles of shared informed decision-making regarding safety and efficacy. Linked population-level data capturing real-world tapering practices provide a valuable opportunity to improve existing evidence on when to contemplate starting an OAT taper. Our objective is to determine the comparative effectiveness of alternative times from OAT initiation at which a taper can be initiated, with a primary outcome of taper completion, as observed in clinical practice in British Columbia (BC), Canada.
METHODS AND ANALYSIS
We propose a population-level retrospective observational study with a linkage of eight provincial health administrative databases in BC, Canada (01 January 2010 to 17 March 2020). Our primary outcomes include taper completion and all-cause mortality during treatment. We propose a 'per-protocol' target trial to compare different durations to taper initiation on the likelihood of taper completion. A range of sensitivity analyses will be used to assess the heterogeneity and robustness of the results including assessment of effectiveness and safety.
ETHICS AND DISSEMINATION
The protocol, cohort creation and analysis plan have been classified and approved as a quality improvement initiative by Providence Health Care Research Ethics Board and the Simon Fraser University Office of Research Ethics. Results will be disseminated to local advocacy groups and decision-makers, national and international clinical guideline developers, presented at international conferences and published in peer-reviewed journals electronically and in print.
Topics: Humans; British Columbia; Retrospective Studies; Opioid-Related Disorders; Opiate Substitution Treatment; Analgesics, Opioid; Drug Tapering; Comparative Effectiveness Research; Time Factors; Research Design
PubMed: 38684262
DOI: 10.1136/bmjopen-2023-083453 -
BMC Emergency Medicine Apr 2024Distribution of take-home naloxone (THN) by emergency services may increase access to THN and reduce deaths and morbidity from opioid overdose. As part of a feasibility...
Is a randomised controlled trial of take home naloxone distributed in emergency settings likely to be feasible and acceptable? Findings from a UK qualitative study exploring perspectives of people who use opioids and emergency services staff.
OBJECTIVE
Distribution of take-home naloxone (THN) by emergency services may increase access to THN and reduce deaths and morbidity from opioid overdose. As part of a feasibility study for a randomised controlled trial (RCT) of distribution of THN kits and education within ambulance services and Emergency Departments (EDs), we used qualitative methods to explore key stakeholders' perceptions of feasibility and acceptability of delivering the trial.
METHODS
We undertook semi-structured interviews and focus groups with 26 people who use opioids and with 20 paramedics and ED staff from two intervention sites between 2019 and 2021. Interviews and focus groups were recorded, transcribed verbatim and analysed using Framework Analysis.
RESULTS
People using opioids reported high awareness of overdose management, including personal experience of THN use. Staff perceived emergency service provision of THN as a low-cost, low-risk intervention with potential to reduce mortality, morbidity and health service use. Staff understood the trial aims and considered it compatible with their work. All participants supported widening access to THN but reported limited trial recruitment opportunities partly due to difficulties in consenting patients during overdose. Procedural problems, restrictive recruitment protocols, limited staff buy-in and patients already owning THN limited trial recruitment. Determining trial effectiveness was challenging due to high levels of alternative community provision of THN.
CONCLUSIONS
Distribution of THN in emergency settings was considered feasible and acceptable for stakeholders but an RCT to establish the effectiveness of THN delivery is unlikely to generate further useful evidence due to difficulties in recruiting patients and assessing benefits.
Topics: Adult; Female; Humans; Male; Middle Aged; Drug Overdose; Emergency Medical Services; Emergency Service, Hospital; Feasibility Studies; Focus Groups; Interviews as Topic; Naloxone; Narcotic Antagonists; Opiate Overdose; Opioid-Related Disorders; Qualitative Research; United Kingdom; Randomized Controlled Trials as Topic
PubMed: 38679713
DOI: 10.1186/s12873-024-00987-y -
Drug and Alcohol Dependence Jun 2024We examined the number and characteristics of high-volume buprenorphine prescribers and the nature of their buprenorphine prescribing from 2009 to 2018. (Observational Study)
Observational Study
BACKGROUND
We examined the number and characteristics of high-volume buprenorphine prescribers and the nature of their buprenorphine prescribing from 2009 to 2018.
METHODS
In this observational cohort study, IQVIA Real World retail pharmacy claims data were used to characterize trends in high-volume buprenorphine prescribers (clinicians with a mean of 30 or more active patients in every month that they were an active prescriber) during 2009-2018. Very high-volume prescribing (mean of 100+ patients per month) was also examined.
RESULTS
Overall, 94,491 clinicians prescribed buprenorphine dispensed during 2009-2018. The proportion of active prescribers meeting high-volume criteria increased from 7.4 % in 2009 to 16.7 % in 2018. High-volume prescribers accounted for 80 % of dispensed buprenorphine prescriptions during 2009-2018; very high-volume prescribers accounted for 26 %. Adult primary care physicians consistently comprised the majority of high-volume prescribers. Addiction specialists were much more likely to be high-volume prescribers compared to other specialties, including psychiatrists and pain specialists. By 2018, the proportion of prescriptions from high-volume prescribers paid by Medicaid had doubled to 40 %, accompanied by a decline in both self-pay and commercial insurance. High-volume prescribers were overwhelmingly concentrated in urban counties with the highest fatal overdose rates. In 2018, the highest density of high-volume prescribers was in New England and the mid-Atlantic region.
CONCLUSIONS
Growth in high-volume prescribers outpaced the overall growth in buprenorphine prescribers across 2009-2018. High-volume prescribers play an increasingly central role in providing medication for OUD in the U.S., yet results indicate key regional variation in the availability of high-volume buprenorphine prescribers.
Topics: Buprenorphine; Humans; Opioid-Related Disorders; Opiate Substitution Treatment; Practice Patterns, Physicians'; Adult; Male; Female; Middle Aged; United States; Cohort Studies; Drug Prescriptions; Narcotic Antagonists; Analgesics, Opioid
PubMed: 38678682
DOI: 10.1016/j.drugalcdep.2024.111290 -
International Journal of Environmental... Apr 2024With over 40,000 opioid-related overdose deaths between January 2016 and June 2023, the opioid-overdose crisis is a significant public health concern for Canada. The...
With over 40,000 opioid-related overdose deaths between January 2016 and June 2023, the opioid-overdose crisis is a significant public health concern for Canada. The opioid crisis arose from a complex system involving prescription opioid use, the use of prescription opioids not as prescribed, and non-medical opioid use. The increasing presence of fentanyl and its analogues in the illegal drugs supply has been an important driver of the crisis. In response to the overdose crisis, governments at the municipal, provincial/territorial, and federal levels have increased actions to address opioid-related harms. At the onset of the COVID-19 pandemic, concerns emerged over how the pandemic context may impact the opioid overdose crisis. Using evidence from a number of sources, we developed a dynamic mathematical model of opioid overdose death to simulate possible trajectories of overdose deaths during the COVID-19 pandemic. This model incorporates information on prescription opioid use, opioid use not as prescribed, non-medical opioid use, the level of fentanyl in the drug supply, and a measure of the proportion deaths preventable by new interventions. The simulated scenarios provided decision makers with insight into possible trajectories of the opioid crisis in Canada during the COVID-19 pandemic, highlighting the potential of the crisis to take a turn for the worse under certain assumptions, and thus, informing planning during a period when surveillance data were not yet available. This model provides a starting point for future models, and through its development, we have identified important data and evidence gaps that need to be filled in order to inform future action.
Topics: COVID-19; Humans; Canada; Opiate Overdose; Models, Theoretical; Fentanyl; Analgesics, Opioid; SARS-CoV-2; Opioid-Related Disorders; Pandemics; Drug Overdose
PubMed: 38673354
DOI: 10.3390/ijerph21040442 -
Harm Reduction Journal Apr 2024During the COVID-19 pandemic, clinics offering medication for opioid use disorder (MOUD) needed to rapidly introduce unsupervised take-home dosing, while relapsing...
"It didn't hurt me": patients' and providers' perspectives on unsupervised take-home doses, drug diversion, and overdose risks in the provision of medication for opioid use disorder during COVID-19 in San Juan, Puerto Rico.
BACKGROUND
During the COVID-19 pandemic, clinics offering medication for opioid use disorder (MOUD) needed to rapidly introduce unsupervised take-home dosing, while relapsing patients and patients unable to enter treatment faced increased risks of fentanyl-related overdose deaths and other drug-related harms. Based on a qualitative study of people who inject drugs (PWID) receiving MOUD treatment and MOUD staff in Puerto Rico, this paper documents the lived experiences of patients and providers during this period and the risk perceptions and management strategies to address substance misuse and drug diversion attributable to unsupervised take-home-dose delivery.
METHODS
In-depth qualitative interviews were conducted with patients (N = 25) and staff (N = 25) in two clinics providing MOUD in San Juan, Puerto Rico, during 2022. Patients and staff were receiving or providing treatment during the pandemic, and patients reported injection drug use during the past thirty days.
RESULTS
Patients were overwhelmingly male (84%), unmarried (72%), and unemployed (52%), with almost half (44%) injecting one to three times a day. Mean time in treatment was 7 years. Staff had a mean age of 46 years with more than half of the sample (63%) female. The majority of patients believed that unsupervised take-home dosing had no significant effect on their treatment adherence or engagement. In contrast, providers expressed concerns over the potential for drug diversion and possible increased risks of patient attrition, overdose episodes, and poor treatment outcomes.
CONCLUSION
This study underscores the importance of insider perspectives on harm-reduction changes in policy implemented during a health crisis. Of note is the finding that staff disagreed among themselves regarding the potential harms of diversion and changes in drug testing protocols. These different perspectives are important to address so that future pandemic policies are successfully designed and implemented. Our study also illuminates disagreement in risk assessments between patients and providers. This suggests that preparation for emergency treatment plans requires enhanced communication with patients to match treatments to the context of lived experience.
Topics: Humans; Male; Female; Puerto Rico; COVID-19; Adult; Opioid-Related Disorders; Middle Aged; Drug Overdose; Prescription Drug Diversion; Attitude of Health Personnel; Opiate Substitution Treatment; Substance Abuse, Intravenous; Qualitative Research; Analgesics, Opioid; SARS-CoV-2
PubMed: 38664796
DOI: 10.1186/s12954-024-01006-w -
Drug and Alcohol Dependence Jun 2024We introduce the concept of harm reduction capital (HRCap) as the combination of knowledge, resources, and skills related to substance use risk reduction, which we...
LatinX harm reduction capital, medication for opioid use disorder, and nonfatal overdose: A structural equation model analysis among people who use drugs in Massachusetts.
BACKGROUND
We introduce the concept of harm reduction capital (HRCap) as the combination of knowledge, resources, and skills related to substance use risk reduction, which we hypothesize to predict MOUD use and opioid overdose. In this study, we explored the interrelationships between ethnicity, HRCap, nonfatal overdose, and MOUD use among PWUD.
METHODS
Between 2017 and 2019, people who currently or in the past used opioids and who lived in Massachusetts completed a one-time survey on substance use history, treatment experiences, and use of harm reduction services. We fit first-order measurement constructs for positive and negative HRCap (facilitators and barriers). We used generalized structural equation models to examine the inter-relationships of the latent constructs with LatinX self-identification, past year overdose, and current use of MOUD.
RESULTS
HRCap barriers were positively associated with past-year overdose (b=2.6, p<0.05), and LatinX self-identification was inversely associated with HRCap facilitators (b=-0.49, p<0.05). There was no association between overdose in the past year and the current use of MOUD. LatinX self-identification was positively associated with last year methadone treatment (b=0.89, p<0.05) but negatively associated with last year buprenorphine treatment (b=-0.68, p<0.07). Latinx PWUD reported lower positive HRCap than white non-LatinX PWUD and had differential utilization of MOUD.
CONCLUSION
Our findings indicate that a recent overdose was not associated with the current use of MOUD, highlighting a severe gap in treatment utilization among individuals at the highest risk. The concept of HRCap and its use in the model highlight substance use treatment differences, opportunities for intervention, and empowerment.
Topics: Humans; Massachusetts; Male; Female; Hispanic or Latino; Harm Reduction; Adult; Opioid-Related Disorders; Drug Overdose; Middle Aged; Latent Class Analysis; Buprenorphine; Young Adult; Opiate Overdose; Drug Users; Opiate Substitution Treatment
PubMed: 38643530
DOI: 10.1016/j.drugalcdep.2024.111293