“Opioid Overdose Rates and Implementation of Overdose Education and Nasal Naloxone Distribution in Massachusetts: Interrupted Time Series Analysis

Clinical Addiction Research Education Unit, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA.
BMJ (online) (Impact Factor: 17.45). 01/2013; 346(jan30 5):f174. DOI: 10.1136/bmj.f174
Source: PubMed


OBJECTIVE: To evaluate the impact of state supported overdose education and nasal naloxone distribution (OEND) programs on rates of opioid related death from overdose and acute care utilization in Massachusetts. DESIGN: Interrupted time series analysis of opioid related overdose death and acute care utilization rates from 2002 to 2009 comparing community-year strata with high and low rates of OEND implementation to those with no implementation. SETTING: 19 Massachusetts communities (geographically distinct cities and towns) with at least five fatal opioid overdoses in each of the years 2004 to 2006. PARTICIPANTS: OEND was implemented among opioid users at risk for overdose, social service agency staff, family, and friends of opioid users. INTERVENTION: OEND programs equipped people at risk for overdose and bystanders with nasal naloxone rescue kits and trained them how to prevent, recognize, and respond to an overdose by engaging emergency medical services, providing rescue breathing, and delivering naloxone. MAIN OUTCOME MEASURES: Adjusted rate ratios for annual deaths related to opioid overdose and utilization of acute care hospitals. RESULTS: Among these communities, OEND programs trained 2912 potential bystanders who reported 327 rescues. Both community-year strata with 1-100 enrollments per 100 000 population (adjusted rate ratio 0.73, 95% confidence interval 0.57 to 0.91) and community-year strata with greater than 100 enrollments per 100 000 population (0.54, 0.39 to 0.76) had significantly reduced adjusted rate ratios compared with communities with no implementation. Differences in rates of acute care hospital utilization were not significant. CONCLUSIONS: Opioid overdose death rates were reduced in communities where OEND was implemented. This study provides observational evidence that by training potential bystanders to prevent, recognize, and respond to opioid overdoses, OEND is an effective intervention.

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    • "PMP websites can be a key source for such education, which could include overdose prevention strategies in addition to patient educational materials and treatment referrals for substance use disorders. For example, prescribing naloxone is a cost effective strategy (Coffin and Sullivan, 2013a,b) with demonstrated success for reducing opioid overdose deaths (Albert et al., 2011; Walley et al., 2013). Refining messaging and creating more comprehensive provider education may evolve from state innovations and recent CDC funding opportunities that equally prioritize development of community intervention for prescription drug overdose and PMP expansion (CDC, 2015b). "
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    ABSTRACT: State prescription monitoring programs (PMPs) purport to address the prescription opioid epidemic, but have evidenced limited effect on reducing opioid-related mortality. We systematically reviewed publicly available, PMP web-based materials from December, 2012 to October, 2013, to assess the degree to which overdose prevention was articulated in state PMP goals, mission statement, and accessible educational materials. The sites and available resources of 47 state PMPs with a web presence were reviewed by two independent coders for use of "overdose" and related terms. Website materials were further coded to capture five general thematic orientations: supply reduction-therapeutic, supply reduction-punitive, demand reduction, public health/research, and harm reduction oriented in content. Twenty-nine of 47 (62%) PMPs did not address overdose or related terms in available online materials; six (12.8%) contained overdose-oriented messaging; and two included specific overdose prevention tools for providers. There were a median of three thematic orientations represented on the 18 state PMP websites mentioning only the term overdose, compared with a median of 4.5 thematic domains on the six PMP websites with overdose-oriented content. A more comprehensive, public health orientation for PMPs that explicitly and publicly articulates their application and role in overdose prevention may increase PMP effectiveness and use. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
    Drug and alcohol dependence 05/2015; 153. DOI:10.1016/j.drugalcdep.2015.05.009 · 3.42 Impact Factor
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    • "England's prison-based N-ALIVE Trial will not test the effectiveness of THN at reducing deaths from opiate-overdose among those for whom naloxone was not prescribed. This is either a focal-strength (Strang et al., 2013); or a potential weakness from the wider-community perspective (Walley et al., 2013). Before/after policy evaluations explicitly take the wider-community perspective by not heeding whether the averted overdose fatalities are those for whom THN was specifically prescribed or their peers. "
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    ABSTRACT: Aims: Scotland was the first country to adopt take-home naloxone (THN) as a funded public health policy. We summarise the background and rigorous set-up for before/after monitoring to assess the impact on high-risk opiate-fatalities. Methods: Evidence-synthesis of prospectively monitored small-scale THN schemes led to a performance indicator for distribution of THN-kits relative to opiate-related deaths. Next, we explain the primary outcome and statistical power for Scotland’s before/after monitoring. Results: Fatality-rate at opiate overdoses witnessed by THN-trainees was 6% (9/153, 95% CI: 2–11%). National THN-schemes should aim to issue 20 times as many THN-kits as there are opiate-related deaths per annum; and at least nine times as many. Primary outcome for evaluating Scotland’s THN policy is reduction in the percentage of all opiate-related deaths with prison-release as a 4-week antecedent. Scotland’s baseline period is 2006–10, giving a denominator of 1970 opiate-related deaths. A priori plausible effectiveness was 20–30% reduction, relative to baseline, in the proportion of opiate-related deaths that had prison-release as a 4-week antecedent. A secondary outcome was also defined. Conclusion: If Scotland’s THN evaluation shifts the policy ground seismically, our new performance measure may prove useful on how many THN-kits nations should provide annually.
    Drugs: Education Prevention and Policy 11/2014; 22(1). DOI:10.3109/09687637.2014.981509 · 1.00 Impact Factor
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    • "We conducted a retrospective cohort study using program data from the Massachusetts Opioid Overdose Prevention Pilot program among participants who reported any substance use in the 30 days prior to enrollment (N = 4,926). This program and sample have been described previously [32,47]. "
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    ABSTRACT: One approach to preventing opioid overdose, a leading cause of premature, preventable mortality, is to provide overdose education and naloxone distribution (OEND). Two outstanding issues for OEND implementation include 1) the dissemination of OEND training from trained to untrained community members; and 2) the concern that OEND provides active substance users with a false sense of security resulting in increased opioid use. To compare overdose rescue behaviors between trained and untrained rescuers among people reporting naloxone rescue kit use; and determine whether heroin use changed after OEND, we conducted a retrospective cohort study among substance users in the Massachusetts OEND program from 2006 to 2010. We used chi square and t-test statistics to compare the differences in overdose management characteristics among overdoses managed by trained versus untrained participants. We employed Wilcoxon signed rank test to compare median difference among two repeated measures of substance use among participants with drug use information collected more than once. Among 4,926 substance-using participants, 295 trained and 78 untrained participants reported one or more rescues, resulting in 599 rescue reports. We found no statistically significant differences in help-seeking (p = 0.41), rescue breathing (p = 0.54), staying with the victim(p = 0.84) or in the success of naloxone administration(p = 0.69) by trained versus untrained rescuers. We identified 325 OEND participants who had drug use information collected more than once. We found no significant overall change in the number of days using heroin in past 30 days (decreased 38%, increased 35%, did not change 27%, p = 0.52). Among 4926 substance users who participated in OEND, 373(7.6%) reported administering naloxone during an overdose rescue. We found few differences in behavior between trained and untrained overdose rescuers. Prospective studies will be needed to determine the optimal level of training and whether naloxone rescue kits can meet an over-the-counter standard. With no clear evidence of increased heroin use, this concern should not impede expansion of OEND programs or policies that support them.
    BMC Public Health 04/2014; 14(1):297. DOI:10.1186/1471-2458-14-297 · 2.26 Impact Factor
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