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The International Journal on Drug Policy Apr 2022The dominant focus of North America's current overdose crisis has been opioids, resulting in considerable research and harm reduction efforts to address opioid-related...
BACKGROUND
The dominant focus of North America's current overdose crisis has been opioids, resulting in considerable research and harm reduction efforts to address opioid-related overdose risks. Less attention has been paid to people who use stimulants (PWUS) despite recent increases in stimulant use and stimulant-involved overdoses (i.e., "overamping"). Stimulant users' definitions, risk factors and experiences of, and responses to, overamping are poorly understood, thereby putting PWUS at heightened risk of adverse health outcomes. This study explores how PWUS understand, experience, and respond to overamping.
METHODS
In-depth qualitative interviews were conducted with 61 PWUS in Vancouver, Canada's Downtown Eastside neighbourhood. Thematic analysis of interviews focused on contextualizing stimulant overdoses, including how PWUS understand, define, experience, and respond to overamping.
RESULTS
Participants associated overamping experiences with commonly identified signs and symptoms, such as rapid onset, elevated heart rate, incontinence, and audiovisua hallucinations, but also reported more serious indicators of overamping, such as unconsciousness, cardiac arrests and seizures. Our findings demonstrate that, among PWUS, there was no unified understanding of overamping such as with opioid overdose and individual experiences had substantial variation in severity and presentation. This impacted the ability to adequately respond to stimulant overdoses, which were primarily self-managed through methods including stabilizing breathing, polysubstance use, and cold showers.
CONCLUSION
Given the growing role of stimulants in North America's overdose crisis, there is an urgent need to improve the identification of stimulant overdoses in real world settings. Our findings identify a gap in current understandings of stimulant overdose, and demonstrate the need for public health and harm reduction interventions to better address overamp risk among PWUS, including harm reduction campaigns to disseminate information regarding identifying signs of, and proper responses to, overamping.
Topics: Analgesics, Opioid; Central Nervous System Stimulants; Drug Overdose; Harm Reduction; Humans; Opiate Overdose; Qualitative Research
PubMed: 35114520
DOI: 10.1016/j.drugpo.2022.103592 -
Drug and Alcohol Dependence Jul 2022Fentanyl has replaced most other non-prescribed opioids in much of North America. There is controversy over whether a hypothetical reduced efficacy of naloxone in...
BACKGROUND
Fentanyl has replaced most other non-prescribed opioids in much of North America. There is controversy over whether a hypothetical reduced efficacy of naloxone in reversing fentanyl is a major contributor to the coincident rising overdose mortality.
METHODS
We modified an existing Markov decision analytic model of heroin overdose and naloxone distribution to account for known risks of fentanyl by adjusting overdose risk, the likelihood of death in the event of overdose, and the proportion of cases in which available naloxone was administered in time to prevent death. We assumed near-universal survival when naloxone was administered promptly for heroin or fentanyl overdose, but allowed that to decline in sensitivity analyses for fentanyl. We varied the proportion of use that was fentanyl and adjusted the modified parameters accordingly to estimate mortality as the dominant opioid shifted.
RESULTS
Absent naloxone, the annual overdose death rate was 1.0% and 4.1% for heroin and fentanyl, respectively. With naloxone reaching 80% of those at risk, the overdose death rate was 0.7% and 3.6% for heroin and fentanyl, respectively, representing reductions of 26.4% and 12.0%. Monte Carlo simulations resulted in overdose mortality with fentanyl of 3.3-5.2% without naloxone and 2.6-4.9% with naloxone, with 95% certainty. Positing reduced efficacy for naloxone in reversing fentanyl resulted in 3.6% of fentanyl overdose deaths being prevented by naloxone.
CONCLUSIONS
Heightened risk for overdose and subsequent death, alongside the time-sensitive need for naloxone administration, fully account for increased mortality when fentanyl replaces heroin, assuming optimal pharmacologic efficacy of naloxone.
Topics: Analgesics, Opioid; Drug Overdose; Fentanyl; Heroin; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose
PubMed: 35588609
DOI: 10.1016/j.drugalcdep.2022.109478 -
Substance Abuse 2022Naloxone is an opioid antagonist medication that can be administered by lay people or medical professionals to reverse opioid overdoses and reduce overdose mortality....
Naloxone is an opioid antagonist medication that can be administered by lay people or medical professionals to reverse opioid overdoses and reduce overdose mortality. Cost was identified as a potential barrier to providing expanded overdose education and naloxone distribution (OEND) in New York City (NYC) in 2017. We estimated the cost of delivering OEND for different types of opioid overdose prevention programs (OOPPs) in NYC. : We interviewed naloxone coordinators at 11 syringe service programs (SSPs) and 10 purposively sampled non-SSPs in NYC from December 2017 to September 2019. The samples included diverse non-SSP program types, program sizes, and OEND funding sources. We calculated one-time start up costs and ongoing operating costs using micro-costing methods to estimate the cost of personnel time and materials for OEND activities from the program perspective, but excluding naloxone kit costs. : Implementing an OEND program required a one-time median startup cost of $874 for SSPs and $2,548 for other programs excluding overhead, with 80% of those costs attributed to time and travel for training staff. SSPs spent a median of $90 per staff member trained and non-SSPs spent $150 per staff member. The median monthly cost of OEND program activities excluding overhead was $1,579 for SSPs and $2,529 for non-SSPs. The costs for non-SSPs varied by size, with larger, multi-site programs having higher median costs compared to single-site programs. The estimated median cost per kit dispensed excluding and including overhead was $19 versus $25 per kit for SSPs, and $36 versus $43 per kit for non-SSPs, respectively. : OEND operating costs vary by program type and number of sites. Funders should consider that providing free naloxone to OEND programs does not cover full operating costs. Further exploration of cost-effectiveness and program efficiency should be considered across different types of OEND settings.
Topics: Analgesics, Opioid; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; New York City; Opiate Overdose; Opioid-Related Disorders
PubMed: 34666633
DOI: 10.1080/08897077.2021.1986877 -
Public Health Reports (Washington, D.C.... 2021Although trends in opioid-related death rates in the United States have been described, the association between state-level opioid overdose death rates in early waves...
OBJECTIVES
Although trends in opioid-related death rates in the United States have been described, the association between state-level opioid overdose death rates in early waves and substance-related overdose death rates in later waves has not been characterized. We examined the relationship between state-level opioid overdose death rates at the beginning of the crisis (1999-2004) and overdose death rates for opioids and other substances in later years.
METHODS
Using 1999-2018 multiple cause of death data from the Centers for Disease Control and Prevention, we first categorized each state by quartile of baseline (1999-2004) opioid overdose death rates. By baseline opioid overdose death rates, we then compared states' annual overdose death rates from any opioid, heroin, synthetic opioids, sedatives, stimulants/methamphetamine, and cocaine from 2005 through 2018. To test the association between baseline opioid overdose death rates and subsequent substance-related overdose death rates for all 6 substances, we estimated unadjusted and adjusted linear models controlling for annual state-level unemployment, median household income, age, sex, and race/ethnicity.
RESULTS
Our results suggest 2 characteristics of the opioid crisis: persistence and pervasiveness. In adjusted analyses, we found that for each additional opioid overdose death per 100 000 population at baseline, states had 23.5 more opioid deaths, 4.4 more heroin deaths, 8.0 more synthetic opioid deaths, 9.2 more sedative deaths, 3.3 more stimulant deaths, and 4.6 more cocaine deaths per 100 000 population from 2005 to 2018.
CONCLUSION
These findings have important implications for continued surveillance to assist policy makers in deciding how to deploy resources to combat not just opioid use disorder but also polysubstance use disorder and broader problems of substance use disorder.
Topics: Age Distribution; Centers for Disease Control and Prevention, U.S.; Central Nervous System Stimulants; Drug Overdose; Heroin; Humans; Hypnotics and Sedatives; Opiate Overdose; Opioid-Related Disorders; Sex Distribution; Socioeconomic Factors; Synthetic Drugs; United States
PubMed: 33301695
DOI: 10.1177/0033354920969171 -
Maternal and Child Health Journal Jul 2023Opioid overdose is a leading cause of maternal mortality, yet limited attention has been given to the consequences of opioid use disorder (OUD) in the year following... (Review)
Review
OBJECTIVE
Opioid overdose is a leading cause of maternal mortality, yet limited attention has been given to the consequences of opioid use disorder (OUD) in the year following delivery when most drug-related deaths occur. This article provides an overview of the literature on OUD and overdose in the first year postpartum and provides recommendations to advance maternal opioid research.
APPROACH
A rapid scoping review of peer-reviewed research (2010-2021) on OUD and overdose in the year following delivery was conducted in PubMed, PsycINFO, and Web of Science databases. This article discusses existing research, remaining knowledge gaps, and methodological considerations needed.
RESULTS
Seven studies were included. Medication for OUD (MOUD) was the only identified factor associated with a reduction in overdose rates. Key literature gaps include the role of mental health disorders and co-occurring substance use, as well as interpersonal, social, and environmental contexts that may contribute to postpartum opioid problems and overdose.
CONCLUSION
There remains a limited understanding of why women in the first year postpartum are particularly vulnerable to opioid overdose. Recommendations include: (1) identifying subgroups of women with OUD at highest risk for postpartum overdose, (2) assessing opioid use, overdose, and risks throughout the first year postpartum, (3) evaluating the effect of co-occurring physical and mental health conditions and substance use disorders, (4) investigating the social and contextual determinants of opioid use and overdose after delivery, (5) increasing MOUD retention and treatment engagement postpartum, and (6) utilizing rigorous and multidisciplinary research methods to understand and prevent postpartum overdose.
Topics: Humans; Female; Analgesics, Opioid; Opiate Overdose; Opioid-Related Disorders; Drug Overdose; Opiate Substitution Treatment; Postpartum Period
PubMed: 36840785
DOI: 10.1007/s10995-023-03614-7 -
Drug and Alcohol Dependence Apr 2020Nonfatal opioid overdose (OD) is an opportunity to identify patients who may benefit from interventions to reduce repeated overdose (rOD). In this study, we sought to...
BACKGROUND
Nonfatal opioid overdose (OD) is an opportunity to identify patients who may benefit from interventions to reduce repeated overdose (rOD). In this study, we sought to determine risk and protective factors associated with rOD.
METHODS
In this retrospective cohort study of 4,155 patients aged 18-64 who presented to one of 16 emergency departments in a single Western Pennsylvania health system between July 2015 and January 2018 for index opioid overdose (iOD) and survived to discharge, we identified demographic and clinical factors association with rOD within one-year. Relative risk of repeated opioid overdose was estimated using adjusted Cox proportional hazard ratios (aHRs).
RESULTS
14.9 % of patients (95 % CI 13.9-16.1) had a rOD, with 29 % occurring within 30 days from iOD. The adjusted hazard of opioid overdose was increased for male patients (aHR = 1.19; 95 % CI 1.01, 1.41), those with pre-iOD diagnoses of anxiety (aHR = 1.41; 95 % CI1.13, 1.77), depression (aHR = 1.44; 95 % CI 1.17, 1.78), substance use disorders (aHR = 1.30; 95 % CI 1.09, 1.55), and alcohol use disorder (aHR = 1.52; 95 % CI 1.02, 2.25). The hazard was lower for individuals prescribed an opioid in the 90 days prior to iOD (aHR = 0.59; 95 % CI 0.37, 0.97) and those admitted to the hospital for iOD (aHR = 0.56; 95 % CI 0.37, 0.86).
CONCLUSION
We found that, among ED patients who survive an initial OD, mental health and substance use diagnoses are associated with a higher hazard of repeated overdoses whereas opioids prescriptions and admission are associated with lower hazards.
Topics: Adolescent; Adult; Aged; Analgesics, Opioid; Cohort Studies; Drug Prescriptions; Emergency Service, Hospital; Female; Humans; Male; Middle Aged; Opiate Overdose; Patient Discharge; Pennsylvania; Protective Factors; Retrospective Studies; Risk Factors; Survival; Young Adult
PubMed: 32058246
DOI: 10.1016/j.drugalcdep.2020.107890 -
Annual Review of Public Health Apr 2021More than 750,000 people in the United States died from an overdose between 1999 and 2018; two-thirds of those deaths involved an opioid. In this review, we present... (Review)
Review
More than 750,000 people in the United States died from an overdose between 1999 and 2018; two-thirds of those deaths involved an opioid. In this review, we present trends in opioid overdose rates during this period and discuss how the proliferation of opioid prescribing to treat chronic pain, changes in the heroin and illegally manufactured opioid synthetics markets, and social factors, including deindustrialization and concentrated poverty, contributed to the rise of the overdose epidemic. We also examine how current policies implemented to address the overdose epidemic may have contributed to reducing prescription opioid overdoses but increased overdoses involving illegal opioids. Finally, we identify new directions for research to understand the causes and solutions to this critical public health problem, including research on heterogeneous policy effects across social groups, effective approaches to reduce overdoses of illegal opioids, and the role of social contexts in shaping policy implementation and impact.
Topics: Analgesics, Opioid; Chronic Pain; Epidemics; Humans; Illicit Drugs; Opiate Overdose; Policy; Practice Patterns, Physicians'; Social Environment; United States
PubMed: 33256535
DOI: 10.1146/annurev-publhealth-090419-102727 -
Infectious Disease Clinics of North... Sep 2020Opioid use disorder is complex and not easily quantified among US populations because there are no dedicated reporting systems in place. We review indicators of opioid... (Review)
Review
Opioid use disorder is complex and not easily quantified among US populations because there are no dedicated reporting systems in place. We review indicators of opioid use disorder available at the state and county (human immunodeficiency virus diagnoses among people who inject drugs, hepatitis C diagnosis in people <50 years, opioid overdose death rates, and opioid prescription rate). The interpretation of the ecological results and the visualization of indicators at the local level will provide actionable insights for clinicians and public health officials seeking to mitigate the consequences of opioid use disorder at the patient and community levels.
Topics: Analgesics, Opioid; Drug Prescriptions; Geography; HIV Infections; Hepatitis C; Humans; Opiate Overdose; Opioid-Related Disorders; Public Health
PubMed: 32782095
DOI: 10.1016/j.idc.2020.06.006 -
The International Journal on Drug Policy Nov 2021United States (US) policies to mitigate the opioid epidemic focus on reducing access to prescription opioids to prevent overdoses. We examined the impact of state...
BACKGROUND
United States (US) policies to mitigate the opioid epidemic focus on reducing access to prescription opioids to prevent overdoses. We examined the impact of state policies in Vermont (July 2017) and Maine (July 2016) on opioid overdoses and opioid-related adverse effects.
METHODS
Study population included patients 15 years and older in all-payer claims of Vermont (N = 597,683; Jan.2016-Dec.2018) and Maine (N = 1,370,960; Oct.2015-Dec.2017). We used interrupted time series analyses to assess the impact of opioid prescribing policies on monthly opioid overdose rate and opioid-related adverse effects rate. We used the International Classification of Disease-10-CM to identify overdoses (T40.0 × 1-T40.4 × 4, T40.601-T40.604, T40.691-T40.694) and adverse effects (T40.0 × 5, T40.2 × 5-T40.4 × 5, T40.605, T40.695).
RESULTS
Immediately after the policy, the level of Vermont's opioid overdose rate increased by 34% (95% confidence interval, CI: 1.09, 1.65) while the level of opioid-related adverse effects rate decreased by 29% (95% CI: 0.58, 0.87). In Maine, there was no level change in opioid overdose rate, but the slope of the adverse effects rate after the policy decreased by 3.5% (95% CI: 0.94, 0.99). These results varied within age and rurality subgroups in both states.
CONCLUSION
While the decrease in rate of adverse effects following the policy changes is promising, the increase in Vermont's opioid overdose rate may suggest there is an association between policy implementation and short-term risk to public health.
Topics: Analgesics, Opioid; Humans; Opiate Overdose; Policy; Practice Patterns, Physicians'; Prescriptions; United States
PubMed: 34107447
DOI: 10.1016/j.drugpo.2021.103306 -
Addiction (Abingdon, England) Feb 2022To assess whether naloxone prescribing in clinical contexts targeted pain patients most at risk for opioid overdose.
AIMS
To assess whether naloxone prescribing in clinical contexts targeted pain patients most at risk for opioid overdose.
DESIGN
A retrospective cohort study using data from the Health Facts Database.
SETTING
Over 600 United States healthcare facilities.
PARTICIPANTS
Three patient groups were followed for 2 years during 2009 to 2017: individuals with shoulder or long bone fractures (n = 252 424), chronic pain syndrome (CPS) (n = 76 141), or non-traumatic low back pain (n = 792 956) who received an opioid prescription. Groups were chosen based on previous work.
MEASUREMENTS
The outcome was opioid overdose identified by International Classification of Diseases codes (ICDs) and the primary predictor was number of naloxone prescriptions identified by National Drug Codes (NDCs).
FINDINGS
Opioid overdoses occurred among 0.16% of fracture patients (average follow-up time to overdose [AFU] = 240 days), 1.28% of CPS patients (AFU = 244 days), and 0.30% low back pain patients (AFU = 264 days). A total of 58 083 bone fracture patients received naloxone prescriptions, and naloxone prescription was associated with subsequent opioid overdose (hazard ratio [HR] = 1.87, 95% CI = 1.68-2.09), and number of subsequent overdoses (incidence rate ratio [IRR] = 1.89, 95% CI = 1.69-2.12). A total of 19 529 CPS patients received naloxone prescriptions, and naloxone prescription was associated with subsequent opioid overdose (HR = 1.69, 95% CI = 1.61-1.78) and number of subsequent overdoses (IRR = 1.74, 95% CI = 1.67-1.83). A total of 110 608 low back pain patients received naloxone prescriptions, and naloxone prescription was associated with subsequent opioid overdose (HR = 1.33, 95% CI = 1.27-1.40) and number of subsequent overdoses (IRR = 1.35, 95% CI = 1.29-1.41).
CONCLUSIONS
Receiving a naloxone prescription appears to be associated with increased risk of subsequent opioid overdose among patients with acute and chronic pain, suggesting prescribers often identify patients most in need of naloxone.
Topics: Analgesics, Opioid; Chronic Pain; Drug Overdose; Humans; Naloxone; Narcotic Antagonists; Opiate Overdose; Retrospective Studies; United States
PubMed: 34286895
DOI: 10.1111/add.15643