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Awareness, Possession, and Use of Take-Home Naloxone Among Illicit Drug Users, Vancouver, British Columbia, 2014-2015
Abstract
Objectives:
Although take-home naloxone (THN) programs are integral in strategies to prevent overdose deaths among opioid users, the uptake of THN among people who use drugs (PWUD) (including non-opioid users) is unknown. The objectives of this study were to determine awareness, possession, and use of THN among PWUD in Vancouver, Canada, and identify barriers to adopting this strategy.
Methods:
From December 1, 2014, to May 29, 2015, participants in 2 prospective cohort studies of PWUD in Vancouver completed a standardized questionnaire, which asked about awareness, possession, and use of THN; sociodemographic characteristics; and drug use patterns. We conducted multivariable logistic regression analyses to determine factors independently associated with awareness and possession of THN.
Results:
Of 1137 PWUD, 727 (64%) reported at least 1 previous overdose ever, and 220 (19%) had witnessed an overdose in the previous 6 months. Although 769 (68%) participants overall reported awareness of THN, only 88 of 392 (22%) opioid users had a THN kit, 18 (20%) of whom had previously administered naloxone. Factors that were positively associated with awareness of THN included witnessing an overdose in the previous 6 months (adjusted odds ratio [aOR] = 2.23; 95% confidence interval [CI], 1.49-3.34; P < .001), possession of THN (aOR = 1.85; 95% CI, 1.11-3.06; P = .02), younger age (aOR = 1.02; 95% CI, 1.01-1.04; P = .003), white race (aOR = 1.67; 95% CI, 1.27-2.19; P < .001), hepatitis C infection (aOR = 1.63; 95% CI, 1.13-2.36; P = .01), residing in Vancouver's Downtown Eastside neighborhood (aOR = 1.93; 95% CI, 1.47-2.53; P < .001), and at least daily heroin injection (aOR = 1.69; 95% CI, 1.09-2.62; P < .02).
Conclusion:
Efforts to improve knowledge of and participation in the THN program may contribute to reduced opioid overdose mortality in Vancouver.
... Naloxone ownership in Oregon may also vary by numerous factors. Quantitative and qualitative studies indicate that carrying, using and receiving naloxone are associated with a variety of characteristics and behaviors (Faul et al., 2015;Geiger et al., 2019;Heavey et al., 2018;Kenney et al., 2018;Nolan et al., 2017). ...
... Participants in NHBS were asked, "Do you currently own naloxone?" and participants in OR-HOPE were asked "Do you currently have naloxone or Narcan with you or at home?" Potential predictors of interest were chosen a priori based on existing literature and included age (continuous) (Frank et al., 2016;Geiger et al., 2019;Nolan et al., 2017;Sumner et al., 2016), race/ethnicity (white non-Hispanic, black non-Hispanic, Hispanic, multiracial, other) (Frank et al., 2016;Kenney et al., 2018;Nolan et al., 2017;Rowe et al., 2015Rowe et al., , 2016, sex (male, female, transgender) (Kestler et al., 2017;Madah-Amiri et al., 2019;Sumner et al., 2016;Tobin et al., 2018), education (high school education or less, beyond high school education) (Cohen and Syme, 2013;Hahn and Truman, 2015), homelessness (recently experienced homelessness) (Madah-Amiri et al., 2019;Reed et al., 2019), arrest (recently arrest/held) (Reed et al., 2019), current health insurance status (insured, not/don't know) (Frank et al., 2016), drug of choice (heroin, methamphetamine, cocaine, goofball, speedball, other) (Banta-Green et al., 2017;Fairbairn et al., 2017;Kenney et al., 2018;Madah-Amiri et al., 2019;Rowe et al., 2015), frequency of injection (>1x a day, 1x a day, >1x a week, <1x a week, never) (Heavey et al., 2018;Nolan et al., 2017), recently acquiring sterile needles from a syringe service program (SSP) (Reed et al., 2019;Rowe et al., 2016) or pharmacy (Abouk et al., 2019;Jones et al., 2016), witnessing an overdose (Kenney et al., 2018;Kestler et al., 2017;Nolan et al., 2017;Rowe et al., 2015), experiencing an overdose (Kenney et al., 2018), and receiving overdose response training (Centers for Disease Control and Prevention, 2012;Doe-Simkins et al., 2014;Neale et al., 2019). ...
... Participants in NHBS were asked, "Do you currently own naloxone?" and participants in OR-HOPE were asked "Do you currently have naloxone or Narcan with you or at home?" Potential predictors of interest were chosen a priori based on existing literature and included age (continuous) (Frank et al., 2016;Geiger et al., 2019;Nolan et al., 2017;Sumner et al., 2016), race/ethnicity (white non-Hispanic, black non-Hispanic, Hispanic, multiracial, other) (Frank et al., 2016;Kenney et al., 2018;Nolan et al., 2017;Rowe et al., 2015Rowe et al., , 2016, sex (male, female, transgender) (Kestler et al., 2017;Madah-Amiri et al., 2019;Sumner et al., 2016;Tobin et al., 2018), education (high school education or less, beyond high school education) (Cohen and Syme, 2013;Hahn and Truman, 2015), homelessness (recently experienced homelessness) (Madah-Amiri et al., 2019;Reed et al., 2019), arrest (recently arrest/held) (Reed et al., 2019), current health insurance status (insured, not/don't know) (Frank et al., 2016), drug of choice (heroin, methamphetamine, cocaine, goofball, speedball, other) (Banta-Green et al., 2017;Fairbairn et al., 2017;Kenney et al., 2018;Madah-Amiri et al., 2019;Rowe et al., 2015), frequency of injection (>1x a day, 1x a day, >1x a week, <1x a week, never) (Heavey et al., 2018;Nolan et al., 2017), recently acquiring sterile needles from a syringe service program (SSP) (Reed et al., 2019;Rowe et al., 2016) or pharmacy (Abouk et al., 2019;Jones et al., 2016), witnessing an overdose (Kenney et al., 2018;Kestler et al., 2017;Nolan et al., 2017;Rowe et al., 2015), experiencing an overdose (Kenney et al., 2018), and receiving overdose response training (Centers for Disease Control and Prevention, 2012;Doe-Simkins et al., 2014;Neale et al., 2019). ...
Purpose
. Naloxone is an opioid antagonist that can be effectively administered by bystanders to prevent overdose. We determined the proportion of people who had naloxone and identified predictors of naloxone ownership among two samples of people who inject drugs (PWID) who use opioids in Portland and rural Western Oregon.
Basic procedures
. We used data from participants in Portland’s National HIV Behavioral Surveillance (NHBS, N = 477) and the Oregon HIV/Hepatitis and Opioid Prevention and Engagement Study (OR-HOPE, N = 133). For each sample, we determined the proportion of participants who had naloxone and estimated unadjusted and adjusted relative risk of having naloxone associated with participant characteristics.
Main findings
. Sixty one percent of NHBS and 30% of OR-HOPE participants had naloxone. In adjusted analysis, having naloxone was associated with female gender, injecting goofballs (compared to heroin alone), housing stability, and overdose training in the urban NHBS sample, and having naloxone was associated with drug of choice, frequency of injection, and race in the rural OR-HOPE sample. In both samples, having naloxone was crudely associated with SSP use, but this was attenuated after adjustment.
Principal conclusions
. Naloxone ownership was insufficient and highly variable among two samples of PWID who use opioids in Oregon. People who use methamphetamine, males, and people experiencing homelessness may be at increased risk for not having naloxone and SSP may play a key role in improving access.
... Previous studies have examined correlates of naloxone possession and use among youth (Goldman-Hasbun et al., 2017;Mitchell et al., 2017) and PWUD in North America (Nolan et al., 2017;Rowe et al., 2015;Tobin et al., 2018) and elsewhere (Madah-Amiri et al., 2019), but have primarily drawn on information from large cities and urban centers. In BC, these studies have almost exclusively relied on data from BC's largest city, Vancouver, and may not be generalizable across the province. ...
... In Canada, a study by Nolan et al. conducted through two prospective cohorts between 2014 and 2015 with people who used opioids (n = 506) in Vancouver and found that 22.4% possessed a naloxone kit (Nolan et al., 2017). Similarly, analysis of the 2015 iteration of the HRCS found that 17.0% of all survey respondents (n = 812), and 20.0% of people who used opioids, possessed a naloxone kit (Davis et al., 2016). ...
... Validation studies in the literature also suggest that three-and sevenday recall, as used in our study, is accurate and shows good concordance with urinalysis data (Cherpitel et al., 2018). Previous surveys have asked participants to recall drug use within the past six (Nolan et al., 2017), and even 12 months (Government of Canada, 2018). Given the quickly changing nature of the opioid crisis and naloxone distribution practices, the current findings also help inform naloxone distribution and education practices across North America, where similar publicly funded programs are underway (Canadian Agency for Drugs and Technologies in Health, 2018; Hewlett and Wermeling, 2013). ...
Introduction:
In response to North America's opioid crisis, access to naloxone has increased. However, our understanding of the correlates of possessing a naloxone kit is limited. This study seeks to determine the prevalence and correlates of kit possession among people who use drugs (PWUD) in British Columbia (BC) Canada.
Methods:
This analysis used cross-sectional survey data collected in 2018 from 27 harm reduction sites in BC. Descriptive statistics and Poisson regression with robust error variance were used to examine factors associated with naloxone kit possession.
Results:
Overall, 70.7% (n = 246) of the total sample (n = 348) reported having a naloxone kit. Having a kit was significantly associated with self-reported opioid use in comparison with non-opioid use (Adjusted Prevalence Ratio (APR): 2.39; 95% CI: 1.33-4.32). Those reporting 'injection' as their preferred drug administration method were also more likely to possess a kit compared to those that predominantly preferred inhalation, smoking, or snorting (APR: 2.39; 95% CI: 1.25-4.58). Urbanicity, age, gender, and having regular housing were not significantly associated with possessing a kit.
Conclusions:
This study is the first to examine naloxone kit possession across geographies, including non-urban areas. Lower kit possession among those that preferred inhaling, smoking or snorting drugs may reflect misconceptions around overdose risk of non-injection drug administration. Our study supports the need for enhanced awareness around the risk of opioid overdose with non-injection administration and suggests a need for comprehensive public health messaging that aims to address overdose risk and response.
... Based on prior literature, we hypothesized that we would identify subgroups with higher intensities of involvement that could benefit from targeted OEND due to their low naloxone awareness [23,[27][28][29][30][31]. We also hypothesized that, consistent with prior research, personally experiencing and witnessing an overdose would be associated with higher naloxone knowledge [32][33][34]. ...
... We summarized associations using bivariate and adjusted prevalence ratios from quasi-Poisson regression models with robust standard errors, an approach appropriate for highly prevalent binary outcomes [41,42]. Adjusted models included sociodemographic characteristics (age, race, housing status, education level) and substance use characteristics (heroin use and injection drug use), as these covariates could be associated with naloxone knowledge or related outcomes and the main exposures for this analysis (overdose, witnessed overdose, and justice involvement) [5,32,33,43,44]. For regression analyses, we formed a categorical justice involvement variable by assigning participants to their most likely latent justice involvement class (i.e., the modal class assignment approach). ...
... The prevalence of experiencing and witnessing an overdose in our study approached the maximum estimates reported in a 2015 systematic review (i.e., 50-96% of people who use illicit drugs witness an overdose and 17-68% personally experience an overdose) [5]. The fact that just over half of participants had heard of naloxone and identified it as an overdose treatment, demonstrating lower awareness than has been documented in prior studies [32,43,44,47], highlights the need for the educational component of OEND in this setting. Naloxone knowledge was particularly low among male participants who had never personally experienced an overdose. ...
Background:
Persons in addiction treatment are likely to experience and/or witness drug overdoses following treatment and thus could benefit from overdose education and naloxone distribution (OEND) programs. Diverting individuals from the criminal justice system to addiction treatment represents one treatment engagement pathway, yet OEND needs among these individuals have not been fully described.
Methods:
We characterized justice involvement patterns among 514 people who use opioids (PWUO) participating in a criminal justice diversion addiction treatment program during 2014-2016 using a gender-stratified latent class analysis. We described prevalence and correlates of naloxone knowledge using quasi-Poisson regression models with robust standard errors.
Results:
Only 56% of participants correctly identified naloxone as an opioid overdose treatment despite that 68% had experienced an overdose and 79% had witnessed another person overdose. We identified two latent justice involvement classes: low involvement (20.3% of men, 46.5% of women), characterized by older age at first arrest, more past-year arrests, and less time incarcerated; and high involvement (79.7% of men, 53.5% of women), characterized by younger age at first arrest and more lifetime arrests and time incarcerated. Justice involvement was not associated with naloxone knowledge. Male participants who had personally overdosed more commonly identified naloxone as an overdose treatment after adjustment for age, race, education level, housing status, heroin use, and injection drug use (prevalence ratio [95% confidence interval]: men 1.5 [1.1-2.0]).
Conclusions:
All PWUO in criminal justice diversion programs could benefit from OEND given the high propensity to experience and witness overdoses and low naloxone knowledge across justice involvement backgrounds and genders.
... Our findings build on a qualitative study conducted in Vancouver, B.C., which found THN programs to be generally well-received among street-involved youth, though the study did not assess rates of uptake in this population [16]. Our findings also build on previous studies that have examined knowledge of and participation in THN programs among PWUD [8,22]. One recent study examining THN participation among adult PWUD in Vancouver, B.C., also identified an alarming gap between the rates of knowledge and possession of THN [22]. ...
... Our findings also build on previous studies that have examined knowledge of and participation in THN programs among PWUD [8,22]. One recent study examining THN participation among adult PWUD in Vancouver, B.C., also identified an alarming gap between the rates of knowledge and possession of THN [22]. One likely explanation for this gap is an underestimation of overdose risk (both personal and witnessed) among PWUD. ...
... One likely explanation for this gap is an underestimation of overdose risk (both personal and witnessed) among PWUD. There is in fact evidence that PWUD are likely to underestimate their own risk of opioid overdose [23], which has been identified as a major barrier to THN ownership among adult PWUD [22]. Interestingly, one study in the U.S. found that people who use opioids reported their desire to help an overdosing peer to be a bigger motivation for THN enrollment than a fear of personal overdose [24], further suggesting that PWUD tend to underestimate their risk of personal overdose and may also be underestimating their risk of witnessing an overdose. ...
Background:
The distribution of take-home naloxone (THN) kits has been an important strategy in reducing overdose fatalities among people who use drugs. However, little is known about the use of THN among youth who are street-involved. The present study explores knowledge and possession of THN among street-involved youth in a Canadian setting.
Methods:
Data were derived from the At-Risk Youth Study (ARYS), a prospective cohort of street-involved youth age 14-28 at enrollment in Vancouver, Canada. Participants completed a standardized questionnaire, which included items related to knowledge and possession of THN, sociodemographic characteristics, and substance use-related factors. Multivariable logistic regression models were used to identify factors independently associated with knowledge and possession of THN.
Results:
Between December 2014 and November 2016, 177 youth were interviewed, including 68 females (38.4%). While 126 (71.2%) participants reported knowledge of THN, only 40 (22.6%) possessed a THN kit. Caucasian/white ethnicity was found to be positively associated with both knowledge and possession of THN (both p < 0.05). Public injection drug use in the last 6 months was found to be positively associated with knowledge of THN, while daily heroin use and daily methamphetamine use were associated with possession of THN (all p < 0.05). Male gender was negatively associated with possession of THN (p < 0.05).
Conclusions:
These findings highlight important gaps between knowledge and possession of THN among youth and the need to increase participation in THN programs among specific populations including non-white and male youth. Further research is needed to gain a better understanding of the barriers that may prevent certain youth from acquiring THN kits.
... Research has indicated that, with the availability of naloxone, residents in diverse housing environments have been able to take care of their own overdose prevention needs, mitigating accessibility barriers such as stigma, restrictive housing policies and limited hours and access to harm reduction and health services [27,28,30]. The expansion of naloxone programs within housing, including programs that facilitate PWUD-led approaches to naloxone training, distribution and overdose response (e.g., the Tenant Overdose Response Organizers in Vancouver), have been shown to be highly effective in reducing the number of fatal overdoses, and enabling PWUD to quickly attend to an overdose [27,28,[31][32][33][34]. While naloxone is a critical lifesaving intervention that should be made easily available across jurisdictions, some have suggested that naloxone distribution within supportive housing as a sole response to the unregulated drug toxicity crisis is insufficient as it places the onus of attending to an overdose onto individuals who may not be ready or able to administer naloxone-particularly those who are using alone. ...
... Additionally, there is heightened potential for those in supportive housing, where housing rules and surveillance are most likely to be experienced, to witness and attend to overdoses fueled by the unpredicable, unregulated drug supply [1]. While research on naloxone programs within supportive housing highlights the critical importance of widespread access to naloxone-for example, by reducing the number of overdose deaths, offering easy access to naloxone for residents, and providing PWUD with the ability to respond quickly to an overdose [28,32]-naloxone ultimately does not address the 'upstream' drivers of overdoses, leaving PWUD at continued risk of critical injury or death [24]. ...
Introduction
Since the beginning of the COVID-19 pandemic, COVID-19 risk mitigation measures have expanded to include increased rules and surveillance in supportive housing. Yet, in the context of the dual public health emergencies of COVID-19 and the unregulated drug toxicity crisis, we have not evaluated the unintended health and social consequences of such measures, especially on criminalized women. In order to address this dearth of evidence, our aim was to assess the association between increased housing rules and surveillance during COVID-19 and (a) nonfatal overdose, and (b) administration of naloxone for overdose reversal among women sex workers who use drugs in Vancouver, BC.
Methods
This study is nested within An Evaluation of Sex Workers Health Access (AESHA), a community-based prospective cohort of women sex workers in Metro Vancouver (2010–present). Using cross-sectional data collected during the first year of COVID-19 (April 2020–2021), we developed separate multivariable logistic regression confounder models to examine the independent associations between experiencing increased housing rules and surveillance during COVID-19 on (a) nonfatal overdose, and (b) administration of naloxone for overdose reversal in the last 6 months.
Results
Amongst 166 participants, 10.8% reported experiencing a recent non-fatal overdose and 31.3% recently administered naloxone for overdose reversal. 56.6% reported experiencing increased rules and surveillance within their housing during COVID-19. The prevalence of non-fatal overdose and administering naloxone was significantly elevated among those exposed to increased housing rules and surveillance during COVID-19 versus those who were unexposed (83.3% vs. 52.1%; 75.0% vs. 48.2%, respectively). In separate multivariate confounder models, exposure to increased housing rules and surveillance during COVID-19 was independently associated with increased odds of administering naloxone [AOR: 3.66, CI: 1.63–8.21], and marginally associated with non-fatal overdose [AOR: 3.49, CI: 0.92–13.27].
Conclusion
Efforts to prioritize the right to safe, adequate and affordable housing must avoid reinforcing an overly coercive reliance on surveillance measures which, while often well-intended, can negatively shape residents’ well-being. Furthermore, public health responses to pandemics must include criminalized populations so that measures do not exacerbate overdose risk. Implementation of a regulated drug supply is recommended, alongside housing policies that promote residents' rights, safety, and health.
... Our data revealed that the majority of the respondents were familiar with THN distribution programs and naloxone use, suggesting that public awareness initiatives sponsored by the local and state health departments have been effective. Our study showed a smaller discrepancy between awareness of THN programs and access to naloxone compared with findings from other studies (Dietze et al., 2018;Goldman-Hasburn et al., 2017;Nolan et al., 2017;McAuley et al., 2016). One possible explanation for the difference is the regional variation in the presence of active OEND programs. ...
... compared to patients with non-overdose related ED visit. (Follman et al., 2019;Kestler et al., 2017;Nolan et al., 2017;O'Brien et al., 2019). We speculate that this may be due to higher involvement of the respondents in the non-overdose group with OTPs, whose participants likely have greater contact and involvement with OEND programs and harm reduction activities as well as access to resources and support for their opioid misuse (Wheeler et al., 2015). ...
Background
The opioid epidemic has prompted the expansion of take-home naloxone (THN) distribution programs. The proportion of emergency department (ED) patients with opioid misuse who have access to a naloxone kit (NK) and barriers to using it are unclear. Objective: Characterizing the access and barrier to NK use among at-risk ED patients. Methods: We enrolled a convenience sample of ED patients with active opioid misuse from May 21–July 31, 2018. We administered a survey to collect patients’ demographic data, substance use history, and access to and use of NK. The primary outcome was NK access (prior receipt of a kit or prescription); secondary outcomes were knowledge and use of NK, and barriers to obtaining and using it. Results: Of 165 respondents, 71.5% knew of THN programs and 57.6% (n = 95) had access to THN by either having received a NK (n = 90) or a prescription (n = 5); 34 respondents received both. Among 39 (23.6%) who received a naloxone prescription, 25 (64.1%) filled it. 60.0% (n = 99) reported knowing how to administer naloxone; lack of training was the primary reason (n = 63/66, 96.9%) for their unfamiliarity. Patients who presented after an opioid overdose (25.5%; n = 42) were less likely to have knowledge of THN programs (57.1% vs. 76.4%), and to have received a NK (35.7% vs. 61.0%). Conclusion: Awareness of THN programs was high among our cohort. But approximately 60% the respondents received a NK or knew how to use it. Despite efforts to expand THN access, gaps in knowledge, access, and use exist.
... In a community-based cohort of current and former PWID living in Baltimore, nearly half reported recently receiving naloxone training and many had recently received a supply of naloxone (38%), but recent use (9%) and regular possession (9%) of naloxone were much less frequently reported. These findings support prior research on lifetime engagement in the 'naloxone cascade' in Baltimore [18] and other settings [23], where awareness of naloxone was high (70-90%), but possession and use were low (20-30%). Unfortunately, the pervasiveness of fentanyl in the Baltimore drug supply [24] and the resulting rise in overdose mortality rates locally demonstrate that there is a dire need for not only OEND, but ready and consistent access to naloxone. ...
... Similarly, the lack of an association between recent non-fatal overdose and carrying naloxone may suggest missed opportunities for intervention following overdose, given that nearly half of overdose events in this study resulted in an ED visit and only 28% of participants who reported overdose were given a supply of or prescription for naloxone after experiencing a nonfatal overdose. Trainings by first responders or in ED could be particularly effective given that a history of overdose is a strong predictor of subsequent overdose, though research suggests that witnessing an overdose is a stronger predictor of naloxone uptake than personal experience of overdose [23,[29][30][31]. Prior research has also demonstrated that patients generally accept take-home naloxone kits when offered in the ED [29], however there is some evidence to show that overdose prevention interventions among those at risk in the ED may not have an impact on subsequent overdose [32]. ...
Introduction
Overdose is a leading cause of death in the United States, especially among people who inject drugs (PWID). Improving naloxone access and carrying among PWID may offset recent increases in overdose mortality associated with the influx of synthetic opioids in the drug market. This study characterized prevalence and correlates of several naloxone outcomes among PWID.
Methods
During 2018, a survey to assess experience with naloxone was administered to 915 participants in the AIDS Linked to the IntraVenous Experience (ALIVE) study, an ongoing community-based observational cohort of people who currently inject or formerly injected drugs in Baltimore, Maryland. We examined the associations of naloxone outcomes (training, supply, use, and regular possession) with socio-demographic, substance use and healthcare utilization factors among PWID in order to characterize gaps in naloxone implementation among this high-risk population.
Results
Median age was 56 years, 34% were female, 85% were African American, and 31% recently injected. In the past six months, 46% (n = 421) reported receiving training in overdose prevention, 38% (n = 346) had received a supply of naloxone, 9% (n = 85) had administered naloxone, and 9% (n = 82) reported usually carrying a supply of naloxone. Recent non-fatal overdose was not associated with any naloxone outcomes in adjusted analysis. Active opioid use (aOR = 2.10, 95% CI: 1.03, 4.28) and recent treatment of alcohol or substance use disorder (aOR = 2.01, 95% CI: 1.13, 3.56) were associated with regularly carrying naloxone.
Conclusion
Further work is needed to encourage PWID to carry and effectively use naloxone to decrease rates of fatal opioid overdose. While accessing treatment for substance use disorder was positively associated with carrying naloxone, EMS response to 911 calls for overdose, the emergency department, and syringe services programs may be settings in which naloxone access and carrying could be encouraged among PWID.
... To our knowledge, this was the first study to examine naloxone awareness and acquisition among postsecondary students in Canada. Previous studies occurred early in the opioid crisis and predominantly focused on healthcare providers or small groups of people who use opioids, especially those at higher risk of harm due to factors like injection drug use and street involvement (Goldman-Hasbun et al., 2017;Heavey et al., 2018;Kirane et al., 2016;Nolan, 2017;Tobin et al., 2018). We found that less than half of postsecondary students (47%) were aware of naloxone. ...
Objectives
This cross-sectional study assessed naloxone awareness, acquisition rates, and reasons for acquisition among postsecondary students in Canada aged 17‒25 years.
Methods
Using data from the 2021‒2022 Canadian Postsecondary Education Alcohol and Drug Use Survey, we conducted descriptive analyses of 31,643 students to characterize naloxone awareness, acquisition, and reasons for acquisition overall and by age, gender, race, international student status, and opioid pain reliever (OPR) use. Using multivariable logistic regression, we assessed the relationship between demographic variables and naloxone awareness and acquisition.
Results
Among postsecondary students in Canada, only 47% had heard of naloxone, and only 5% had acquired it in the past year. Significant predictors of naloxone awareness and acquisition included gender, age, race, international student status, and OPR use. Older students, non-binary students, domestic students, and Indigenous students had higher odds of both naloxone awareness and acquisition. Students who had used OPRs in the past year were less likely to be aware of naloxone (AOR = 0.85, 95% CI: 0.80–0.91). However, among those who were aware, they were more likely to have acquired naloxone (AOR = 1.16, 95% CI: 1.01–1.34) than those who had not used OPRs. Among students who had acquired naloxone in the past year, 97% reported their main reason for obtaining it was for use in emergencies involving other people.
Conclusion
Low naloxone awareness and acquisition among postsecondary students in Canada represent an important public health gap. Increasing naloxone awareness and acquisition may play an important role in enhancing safety on campuses and beyond.
... 441 In Vancouver, Canada, a survey of people who inject drugs demonstrated that 68% reported awareness of THN, 19% had witnessed an overdose in the past 6 months, but only 22% had a THN kit. 442 In the United States, state-level public health campaigns have been deployed to improve awareness such as Ohio's "Stop overdose. Carry naloxone." ...
Opioid overdose is the leading cause of death for Americans 25 to 64 years of age, and opioid use disorder affects >2 million Americans. The epidemiology of opioid-associated out-of-hospital cardiac arrest in the United States is changing rapidly, with exponential increases in death resulting from synthetic opioids and linear increases in heroin deaths more than offsetting modest reductions in deaths from prescription opioids. The pathophysiology of polysubstance toxidromes involving opioids, asphyxial death, and prolonged hypoxemia leading to global ischemia (cardiac arrest) differs from that of sudden cardiac arrest. People who use opioids may also develop bacteremia, central nervous system vasculitis and leukoencephalopathy, torsades de pointes, pulmonary vasculopathy, and pulmonary edema. Emergency management of opioid poisoning requires recognition by the lay public or emergency dispatchers, prompt emergency response, and effective ventilation coupled to compressions in the setting of opioid-associated out-of-hospital cardiac arrest. Effective ventilation is challenging to teach, whereas naloxone, an opioid antagonist, can be administered by emergency medical personnel, trained laypeople, and the general public with dispatcher instruction to prevent cardiac arrest. Opioid education and naloxone distributions programs have been developed to teach people who are likely to encounter a person with opioid poisoning how to administer naloxone, deliver high-quality compressions, and perform rescue breathing. Current American Heart Association recommendations call for laypeople and others who cannot reliably establish the presence of a pulse to initiate cardiopulmonary resuscitation in any individual who is unconscious and not breathing normally; if opioid overdose is suspected, naloxone should also be administered. Secondary prevention, including counseling, opioid overdose education with take-home naloxone, and medication for opioid use disorder, is important to prevent recurrent opioid overdose.
... McAuley et al. found that the highest proportions of naloxone supply were with those reported recent injecting [12]. This is similar to a study from Vancouver that found half of those who were in possession of naloxone also reported daily heroin injection [33]. In this study, however, recent injection drug use was not found to be a significant predictor for naloxone possession, but it was for naloxone use. ...
Aims:
To examine uptake following a large-scale naloxone program by estimating distribution rates since program initiation and the proportion among a sample of high-risk individuals that had attended naloxone training, currently possessed, or had used naloxone. We also estimated the likelihood of naloxone possession and use as a function of program duration, individual descriptive, and substance use indicators.
Design:
1) Distribution data (June 2014-August 2017) and date of implementation for each city and 2) a cross-sectional study among a sample of illicit substance users interviewed September 2017.
Setting:
Seven Norwegian cities PARTICIPANTS: 497 recruited users of illegal opioids and/or central stimulants MEASUREMENTS: Primary outcomes: naloxone possession and use. Random-intercepts logistic regression models (covariates: male, age, homelessness/shelter use, overdose, incarceration, opioid maintenance treatment, income sources, substance use indicators, program duration).
Findings:
Overall, 4,631 naloxone nasal sprays were distributed in the two pilot cities with a cumulative rate of 495 per 100,000 population. In the same two cities, among high-risk individuals, 44% and 62% reported current naloxone possession. The possession rates of naloxone corresponded well to the duration of each participating city's distribution program. Overall, in the six distributing cities, 58% reported naloxone training, 43% current possession, and 15% naloxone use. The significant indicators for possession were program duration (Adjusted Odds Ratios (AOR) 1.44 95% Confidence Intervals (CI=0.82-2.37), female gender (AOR 1.97 95% CI=1.20-3.24) and drug-dealing (AOR 2.36 95% CI=1.42-3.93). The significant indicators for naloxone use were program duration (AOR 1.49 95% CI=1.15-1.92), homelessness/shelter use (AOR 2.06 95% CI= 1.02-4.17), OMT (AOR 2.07 95% CI=1.13-3.78), drug-dealing (AOR 2.40 95% CI=1.27-4.54), and heroin injecting (AOR 2.13 95% CI=1.04-4.38).
Conclusions:
A large-scale naloxone programme in seven Norwegian cities with a cumulative distribution rate of 495 per 100,000 population indicated good saturation in a sample of high-risk individuals, with program duration in each city as an important indicator for naloxone possession and use.
... Furthermore, these experiences were reported at significantly higher rates among those who indicated obtaining naloxone for someone other than themselves. These findings are consistent with studies showing that witnessing an overdose or knowing someone who died from an overdose is potentially a strong motivator for first time naloxone access [35]. However, a better understanding of the broader lay responder population's awareness and motivations for obtaining naloxone could greatly benefit prevention efforts. ...
Background
To reduce fatal drug overdoses, two approaches many states have followed is to pass laws expanding naloxone access and Good Samaritan protections for lay persons with high likelihood to respond to an opioid overdose. Most prior research has examined attitudes and knowledge among lay responders in large metropolitan areas who actively use illicit substances. The present study addresses current gaps in knowledge related to this issue through an analysis of data collected from a broader group of lay responders who received naloxone kits from 20 local health departments across Indiana.
Methods
Postcard surveys were included inside naloxone kits distributed in 20 Indiana counties, for which 217 returned cards indicated the person completing it was a lay responder. The survey captured demographic information and experiences with overdose, including the use of 911 and knowledge about Good Samaritan protections.
Results
Few respondents had administered naloxone before, but approximately one third had witnessed a prior overdose and the majority knew someone who had died from one. Those who knew someone who had overdosed were more likely to have obtained naloxone for someone other than themselves. Also, persons with knowledge of Good Samaritan protections or who had previously used naloxone were significantly more likely to have indicated calling 911 at the scene of a previously witnessed overdose. Primary reasons for not calling 911 included fear of the police and the person who overdosed waking up on their own.
Conclusions
Knowing someone who has had a fatal or non-fatal overdose appears to be a strong motivating factor for obtaining naloxone. Clarifying and strengthening Good Samaritan protections, educating lay persons about these protections, and working to improve police interactions with the public when they are called to an overdose scene are likely to improve implementation and outcomes of naloxone distribution and opioid-related Good Samaritan laws.
Background:
Prescription opioids have been increasingly prescribed for chronic pain while the opioid-related death rates grow. Naloxone, an opioid antagonist, is increasingly recommended in these patients, yet there is limited research that investigates the intention to get naloxone. This study aimed to investigate intention toward getting naloxone in patients prescribed opioids for chronic pain and to assess the predictive utility of the theory of reasoned action (TRA) constructs in explaining intention to get naloxone.
Methods:
This was a cross-sectional study of a panel of U.S. adult patients prescribed opioids for chronic pain using a Qualtrics®XM survey. These patients participated in the study during February to March 2020. The online internet survey assessed the main outcome of intention to get naloxone and constructs of TRA (attitudes and subjective norms); additional measures assessed the characteristics of patients' opioid overdose risk factors, knowledge of naloxone, and their demographics. The relationship between TRA constructs, namely, attitudes and subjective norms, and the intention variable was examined using logistic regression analyses with the intention outcome contrasted as follows: high intention (scores ≥ 5) and non-high intention (scores < 5).
Results:
A total of 549 participants completed the survey. Most of them were female (53.01%), White or Caucasian (83.61%), non-Hispanic (87.57%) and had a mean age of 44.16 years (SD = 13.37). Of these, 167 (30.42%) had high intention to get naloxone. The TRA construct of subjective norm was significantly associated with increased likelihood of higher intentions to get naloxone (OR 3.04, 95% CI 2.50-3.70, P < 0.0001).
Conclusions:
Our study provides empirical support of the TRA in predicting intention to get naloxone among chronic pain patients currently taking opioids. Subjective norms significantly predicted intention to get naloxone in these patients. The interventions targeting important reference groups of these patients would have greater impact on increasing intention to get naloxone in this population. Future studies should test whether theory-based interventions focusing on strengthening subjective norms increase intention to get naloxone in this population.
Objective
To examine the relative changes in opioid overdose mortality rates between states that have and have not adopted naloxone co-prescribing laws.
Methods
We performed a synthetic control analysis. National Vital Statistics data for the years 2012–2018 were analysed, and five states with naloxone co-prescribing laws were examined: Arizona, Florida, Rhode Island, Vermont, and Virginia. Opioid overdose-related deaths were identified through cause-of-death ICD-10 codes.
Results
Our pooled analysis for all opioid-related deaths showed no significant changes in opioid-related mortality rates in treated states, post naloxone co-prescribing law adoption (−0.05; 95% CI: −0.43, 0.33). Rates of other and unspecified narcotic-related mortality rates in Rhode Island were found to have decreased post-law adoption (−0.13; 95% CI: −0.25, −0.00).
Conclusions
These findings suggest that naloxone co-prescribing laws were not associated with changes to overall opioid overdose mortality rates, post-law adoption, during the study period. However, Rhode Island did see a decrease in other and unspecified narcotic-related mortality rates post-law adoption. This is perhaps due to the comprehensive nature of the state's law. As overall rates of naloxone co-prescribing remain low, interventions to enhance naloxone prescribing and distribution may be necessary for co-prescribing laws to impact opioid-related mortality rates.
Background
Drug-related deaths globally are increasing year on year, with the largest proportion of these being opioid-related. The opioid antagonist naloxone distributed for take-home use (‘Take-Home Naloxone (THN)’) has been championed as one method of tackling this public health crisis, however to be effective it must be available at an opioid overdose. Ownership and carriage are therefore fundamental to THN success. This study aimed to assess the prevalence of ownership and carriage of THN internationally among people who use drugs (PWUD).
Methods
NHS Scotland Journals, AMED, EMBASE, HMIC, MEDLINE, PsycINFO, CINAHL Complete, PubMed, Cochrane Library, PROSPERO and grey literature were searched for articles which measured prevalence of THN ownership or carriage between 1996 and 2020. Ownership was defined as report of a personal supply of THN. Carriage was defined as the participant carrying THN on their person at time of data collection or reporting a frequency of how often they carry THN. Risk of bias was evaluated using the Joanna Briggs Checklist for Prevalence Studies.
Results
Systematic search yielded 6363 papers, with ten eligible papers identified. Eight articles were included in ownership prevalence and five articles included for carriage prevalence, with an overlap of three studies between both measures. Pooled prevalence indicated moderate ownership levels (57%, CI 47-67%) but lower carriage levels (20%, CI 12-31%). Analysis was complicated by the limited number of available studies and lack of standardised terminology and measurement.
Conclusion
Understanding naloxone ownership and carriage globally is hampered by limited evidence and heterogeneity across studies. From the available data, prevalence of THN carriage overall appears low, despite moderate ownership. Given the variation across studies, future research should seek to utilise more standardised terminology and methods of measurement. Furthermore, services distributing THN must ensure the importance of regular carriage of naloxone is consistently emphasised.
Objective
To evaluate racial (Black/White) differences in overdose response training and take-home naloxone (THN) possession and administration among clients and nonclients of the Baltimore syringe service program (SSP).
Methods
The study derived data from a cross-sectional survey of 263 (183 SSP clients, 80 nonclients) people who inject drugs (PWID). The study recruited SSP clients using targeted sampling and recruited nonclients through peer referral from April to November 2016.
Results
In our sample, 61% of the participants were Black, 42% were between the ages of 18 and 44, and 70% were males. SSP clients, regardless of race, were more likely to have received overdose response training than Black nonclients (Black clients AOR: 3.85, 95% CI: 1.88, 7.92; White clients AOR: 2.73, 95% CI: 1.29, 5.75). The study found no significant differences in overdose response training between Black and White nonclients. SSP clients and White nonclients were more likely to possess THN than Black nonclients (Black clients: AOR: 4.21, 95% CI: 2.00, 8.87; White clients: AOR: 3.54, 95% CI: 1.56, 8.04; White nonclients AOR: 4.49, 95% CI: 1.50,13.47).
Conclusion
SSP clients were more likely to receive overdose response training than their nonclient peers who they referred to the study, illustrating the utility of SSPs in reaching PWID at high risk of overdose. We also observed that Black PWID, who did not access services at the SSP, were the least likely to possess THN, suggesting the need to employ outreach targeting Black PWID who do not access this central harm reduction intervention.
This paper is the fortieth consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2017 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).
In February 2016, Surrey Fire Service and Vancouver Fire and Rescue Services implemented their naloxone administration protocol in response to unprecedented numbers of opioid-related overdose calls. Both departments initiated training protocols to facilitate the necessary licensing of firefighters to administer intermuscular injections. The report titled “A Response to Illicit Drug Overdoses: Naloxone Administration in Surrey and Vancouver, British Columbia” (2017) documented the perceptions of firefighters in both municipalities regarding training adequacy and experiences with overdose calls in the field. The report emphasized that: an inter-agency, collaborative and evidence-based response is required; firefighters felt adequately prepared to administer naloxone; and, there is an expressed interest in further medical response training. All of these directions were reiterated in the fire station discussions associated with the current project.
Background:
The British Columbia take-home naloxone (BCTHN) program has been in operation since 2012 and has resulted in the successful reversal of over 581 opioid overdoses. The study aims to explore BCTHN program participant perspectives about the program, barriers to participants contacting emergency services (calling "911") during an overdose, and perspectives of law enforcement officials on naloxone administration by police officers.
Methods:
Two focus groups and four individual interviews were conducted with BCTHN program participants; interviews with two law enforcement officials were also conducted. Qualitative analysis of all transcripts was performed.
Results:
Positive themes about the BCTHN program from participants included easy to understand training, correcting misperceptions in the community, and positive interactions with emergency services. Potential barriers to contacting emergency services during an overdose include concerns about being arrested for outstanding warrants or for other illegal activities (such as drug possession) and confiscation of kits. Law enforcement officials noted that warrants were complex situational issues, kits would normally not be confiscated, and admitted arrests for drug possession or other activities may not serve the public good in an overdose situation. Law enforcement officials were concerned about legal liability and jurisdictional/authorization issues if naloxone administration privileges were expanded to police.
Conclusions:
Program participants and law enforcement officials expressed differing perspectives about warrants, kit confiscation, and arrests. Facilitating communication between BCTHN program participants and other stakeholders may address some of the confusion and remove potential barriers to further improving program outcomes. Naloxone administration by law enforcement would require policies to address jurisdiction/authorization and liability issues.
Introduction and aims:
Opioid overdose prevention programs providing take-home naloxone have been expanding internationally. This paper summarises findings and lessons learnt from the Overdose Prevention and Emergency Naloxone Project which is the first take-home naloxone program in Australia implemented in a health care setting.
Methods:
The Project intervention provided education and take-home naloxone to opioid-using clients at Kirketon Road Centre and The Langton Centre in Sydney. The evaluation study examined uptake and acceptability of the intervention; participants' knowledge and attitudes regarding overdose and participants' experience in opioid overdose situations six months after the intervention. Participants completed baseline, post-training and follow-up questionnaires regarding overdose prevention and management which were analysed using repeated measures analysis of variance.
Results:
Eighty-three people participated in the intervention, with 35 (42%) completing follow-up interviews-51% reporting using naloxone with 30 overdoses successfully reversed. There were significant improvements in knowledge and attitudes immediately following training with much retained at follow-up, particularly regarding feeling informed enough (97%) and confident to inject naloxone (100%).
Discussion:
Take-home naloxone programs can be successfully implemented in Australian health settings. Barriers to uptake, such as lengthy processes and misperceptions around interest in overdose prevention, should be addressed in future program implementation.
Background and aims:
Fatal outcome of opioid overdose, once detected, is preventable through timely administration of the antidote naloxone. Take-home naloxone provision directly to opioid users for emergency use has been implemented recently in more than 15 countries worldwide, albeit mainly as pilot schemes and without formal evaluation. This systematic review assesses the effectiveness of take-home naloxone, with two specific aims: (1) to study the impact of take-home naloxone distribution on overdose-related mortality; and (2) to assess the safety of take-home naloxone in terms of adverse events.
Methods:
PubMed, MEDLINE and PsychINFO were searched for English-language peer-reviewed publications (randomized or observational trials) using the Boolean search query: (opioid OR opiate) AND overdose AND prevention. Evidence was evaluated using the nine Bradford Hill criteria for causation, devised to assess a potential causal relationship between public health interventions and clinical outcomes when only observational data are available.
Results:
A total of 1397 records (1164 after removal of duplicates) were retrieved, with 22 observational studies meeting eligibility criteria. Due to variability in size and quality of the included studies, meta-analysis was dismissed in favour of narrative synthesis. From eligible studies, we found take-home naloxone met all nine Bradford Hill criteria. The additional five World Health Organization criteria were all either met partially (two) or fully (three). Even with take-home naloxone administration, fatal outcome was reported in one in 123 overdose cases (0.8%; 95% confidence interval = 0.4, 1.2).
Conclusions:
Take-home naloxone programmes are found to reduce overdose mortality among programme participants and in the community and have a low rate of adverse events.
AimsTo assess the effectiveness for Scotland's National Naloxone Programme (NNP) by comparison between 2006-10 (before) and 2011-13 (after NNP started in January 2011) and to assess cost-effectiveness. DesignThis was a pre-post evaluation of a national policy. Cost-effectiveness was assessed by prescription costs against life-years gained per opioid-related death (ORD) averted. SettingScotland, in community settings and all prisons. InterventionBrief training and standardized naloxone supply became available to individuals at risk of opioid overdose. MeasurementsORDs as identified by National Records of Scotland. Look-back determined the proportion of ORDs who, in the 4weeks before ORD, had been (i) released from prison (primary outcome) and (ii) released from prison or discharged from hospital (secondary). We report 95% confidence intervals for effectiveness in reducing the primary (and secondary) outcome in 2011-13 versus 2006-10. Prescription costs were assessed against 1 or 10 life-years gained per averted ORD. FindingsIn 2006-10, 9.8% of ORDs (193 of 1970) were in people released from prison within 4weeks of death, whereas only 6.3% of ORDs in 2011-13 followed prison release (76 of 1212, P<0.001; this represented a difference of 3.5% [95% confidence interval (CI)=1.6-5.4%)]. This reduction in the proportion of prison release ORDs translates into 42 fewer prison release ORDs (95% CI=19-65) during 2011-13, when 12000 naloxone kits were issued at current prescription cost of 225000. Scotland's secondary outcome reduced from 19.0 to 14.9%, a difference of 4.1% (95% CI=1.4-6.7%). Conclusions
Scotland's National Naloxone Programme, which started in 2011, was associated with a 36% reduction in the proportion of opioid-related deaths that occurred in the 4weeks following release from prison.
Context.— In British Columbia, human immunodeficiency virus (HIV)–infected
persons eligible for antiretroviral therapy may receive it free but the extent
to which HIV-infected injection drug users access it is unknown.Objective.— To identify patient and physician characteristics associated with antiretroviral
therapy utilization in HIV-infected injection drug users.Design.— Prospective cohort study with record linkage between survey data and
data from a provincial HIV/AIDS (acquired immunodeficiency syndrome) drug
treatment program.Setting.— British Columbia, where antiretroviral therapies are offered free to
all persons with HIV infection with CD4 cell counts less than 0.50×109/L (500/µL) and/or HIV-1 RNA levels higher than 5000 copies/mL.Subjects.— A total of 177 HIV-infected injection drug users eligible for antiretroviral
therapy, recruited through the prospective cohort study since May 1996.Main Outcome Measures.— Patient use of antiretroviral drugs through the provincial drug treatment
program and physician experience treating HIV infection.Results.— After a median of 11 months after first eligibility, only 71 (40%) of
177 patients had received any antiretroviral drugs, primarily double combinations
(47/71 [66%]). Both patient and physician characteristics were associated
with use of antiretroviral drugs. After adjusting for CD4 cell count and HIV-1
RNA level at eligibility, odds of not receiving antiretrovirals were increased
more than 2-fold for females (odds ratio [OR], 2.53; 95% confidence interval
[CI], 1.08-5.93) and 3-fold for those not currently enrolled in drug or alcohol
treatment programs (OR, 3.49; 95% CI, 1.45-8.40). Younger drug users were
less likely to receive therapy (OR, 0.47/10-y increase; 95% CI, 0.28-0.80).
Those with physicians having the least experience treating persons with HIV
infection were more than 5 times less likely to receive therapy (OR, 5.55;
95% CI, 2.49-12.37).Conclusions.— Despite free antiretroviral therapy, many HIV-infected injection drug
users are not receiving it. Public health efforts should target younger and
female drug users, and physicians with less experience treating HIV infection.
Introduction
Evidence suggests that people who inject drugs often begin their drug use and injecting practices in adolescence, yet there are limited data available on the HIV epidemic and the responses for this population. The comprehensive package of interventions for the prevention, treatment and care of HIV infection among people who inject drugs first laid out in 2009 (revised in 2012) by World Health Organization, United Nations Office of Drugs and Crime and Joint United Nations Programme on HIV/AIDS, does not consider the unique needs of adolescent and young people. In order to better understand the values and preferences of young people who inject drugs in accessing harm reduction services and support, we undertook a series of community consultations with young people with experience of injecting drugs during adolescence.
Methods
Community consultations (4–14 persons) were held in 14 countries. Participants were recruited using a combined criterion and maximum variation sampling strategy. Data were analyzed using collaborative qualitative data analysis. Frequency analysis of themes was conducted.
Results
Nineteen community consultations were organized with a total of 132 participants. All participants had experienced injecting drugs before the age of 18. They had the following age distribution: 18–20 (37%), 21–25 (48%) and 26–30 (15%). Of the participants, 73.5% were male while 25.7% were female, with one transgender participant. Barriers to accessing the comprehensive package included: lack of information and knowledge of services, age restrictions on services, belief that services were not needed, fear of law enforcement, fear of stigma, lack of concern, high cost, lack of outreach, lack of knowledge of HCV/TB and lack of youth friendly services.
Conclusions
The consultations provide a rare insight into the lived experiences of adolescents who inject drugs and highlight the dissonance between their reality and current policy and programmatic approaches. Findings suggest that harm reduction and HIV policies and programmes should adapt the comprehensive package to reach young people and explore linkages to other sectors such as education and employment to ensure they are fully supported and protected. Continued participation of the community of young people who inject drugs can help ensure policy and programmes respond to the social exclusion and denial of rights and prevent HIV infection among adolescents who inject drugs.
As physicians have increased opioid prescribing, overdose deaths from pharmaceutical opioids have substantially increased in the United States. Naloxone hydrochloride (naloxone), an opioid antagonist, is the standard of care for treatment of opioid induced respiratory depression. Since 1996, community-based programs have offered overdose prevention education and distributed naloxone for bystander administration to people who use opioids, particularly heroin. There is growing interest in translating overdose education and naloxone distribution (OEND) into conventional medical settings for patients who are prescribed pharmaceutical opioids. For this review, we summarized and classified existing publications on overdose education and naloxone distribution to identify evidence of effectiveness and opportunities for translation into conventional medical settings.
For this review, we searched English language PubMed for articles on naloxone based on primary data collection from humans, including feasibility studies, program evaluations, surveys, qualitative studies and studies comparing the effectiveness of different routes of naloxone administration. We also included cost-effectiveness studies.
We identified 41 articles that represented 5 categories: evaluations of OEND programs, effects of OEND programs on experiences and attitudes of participants, willingness of medical providers to prescribe naloxone, comparisons of different routes of naloxone administration, and the cost-effectiveness of naloxone.
Existing research suggests that people who are at risk for overdose and other bystanders are willing and able to be trained to prevent overdoses and administer naloxone. Counseling patients about the risks of opioid overdose and prescribing naloxone is an emerging clinical practice which may reduce fatalities from overdose while enhancing the safe prescribing of opioids.
Introduction
Adolescence is a time of physical, emotional and social transitions that have implications for health. In addition to being at high risk for HIV, young key populations (YKP) may experience other health problems attributable to high-risk behaviour or their developmental stage, or a combination of both.
Discussion
We reviewed the needs, barriers and gaps for other non-HIV health services for YKP. We searched PubMed and Google Scholar for articles that provided specific age-related data on sexual and reproductive health; mental health; violence; and substance use problems for adolescent, youth or young sex workers, men who have sex with men, transgender people, and people who inject drugs.
Results
YKP experience more unprotected sex, sexually transmitted infections including HIV, unintended pregnancy, violence, mental health disorders and substance use compared to older members of key populations and youth among the general population. YKP experience significant barriers to accessing care; coverage of services is low, largely because of stigma and discrimination experienced at both the health system and policy levels.
Discussion
YKP require comprehensive, integrated services that respond to their specific developmental needs, including health, educational and social services within the context of a human rights-based approach. The recent WHO Consolidated Guidelines on HIV Prevention, Diagnosis, Treatment and Care for Key Populations are an important first step for a more comprehensive approach to HIV programming for YKP, but there are limited data on the effective delivery of combined interventions for YKP. Significant investments in research and implementation will be required to ensure adequate provision and coverage of services for YKP. In addition, greater commitments to harm reduction and rights-based approaches are needed to address structural barriers to access to care.
Background: In August 2012, the British Columbia Take Home Naloxone (BCTHN) program was introduced to help to reduce opioid overdose and its consequences. This study evaluates the BCTHN program, identifying the successes and challenges of implementing a provincial program in Canada.
Methods: In this cross-sectional study, we reviewed the records of the BCTHN administrative program to report on program outcomes (participation and overdose reversals). Focus groups and individual interviews were conducted with 40 clients in Vancouver; 12 individual interviews were completed with service providers, police officers and parents of people who use opioids from both the Vancouver and Interior regions of British Columbia. Qualitative data were analyzed using content analysis and a qualitative descriptive approach.
Results: As of March 13, 2014, the BCTHN program had been implemented at 40 sites, trained 1318 participants in overdose prevention, recognition and response, distributed 836 kits to clients and received reports of 85 overdose reversals. Stakeholders were supportive of the program, and clients reported greater confidence in response to overdose. Service providers found the program training materials easy to use and that training increased client engagement. Some of the challenges included difficulty in identifying physician
willing to prescribe, recruitment of some at-risk populations (e.g., long-term opioid users and patients with chronic pain), and clients’ reluctance to call 911. We also found that the police had some misconceptions about BCTHN.
Interpretation: The BCTHN program was easy to implement, empowering for clients and was responsible for reversing 85 overdoses in its first 20 months. We suggest communities across Canada should consider implementing take-home naloxone programs and evaluate their findings.
<⁄span> In Canada, harm from nonmedical prescription opioid analgesic (POA) use (NMPOU) has increased in recent years; however, there are limitations to the current estimates of NMPOU. The 2009 Canadian Alcohol and Drug Use Monitoring Survey presents an opportunity to produce more accurate estimates of NMPOU.
<⁄span> To determine the prevalence of POA use, NMPOU and use of pain relievers to 'get high', and to assess correlations of these indicators with age, sex and provincial levels of dispensed POAs in Canada in 2009.
<⁄span> Data regarding POA use were obtained from the 2009 Canadian Alcohol and Drug Use Monitoring Survey (n=13,032). The amount of POAs dispensed in standardized daily doses was obtained from a representative sample of 2700 retail pharmacies across Canada. Associations among POA use, age, sex and the amount of POAs dispensed were evaluated using regression models. Differences in POA use across provinces were assessed using the Wald test.
<⁄span> In Canada in 2009, the prevalence of POA use was 19.2% (95% CI 18.0% to 20.5%), NMPOU was 4.8% (95% CI 4.1% to 5.5%) and the use of pain relievers to get high was 0.4% (95% CI 0.1% to 0.8%). NMPOU was significantly associated with age. The use of pain relievers to get high varied significantly across provinces, while POA use and NMPOU did not show significant variations. The amount of POAs dispensed per province was not significantly correlated with any type of POA use.
<⁄span> These findings confirm high POA use and NMPOU across Canada. Research is required to identify determinants of NMPOU.
Globally, young people under 25 accounted for an estimated 45% of all new HIV infections in 2007. Across the Eastern Europe and Central Asia region as many as 25% of injecting drug users (IDUs) are younger than 20. The Eurasian Harm Reduction assessment of young peoples' (under 25) drug use, risk behaviours and service availability and accessibility confirms, young people at risk of injecting, or those already experimenting with injecting drugs, find themselves isolated from health and prevention services, which increases the risks for health and social harms, while the approach towards young peoples' use rely heavily on law enforcement. Denying young drug users' access to life-saving drug treatment and other harm reduction services contributes to the risk environment surrounding their use and violates their right to health and well-being as identified in the Convention on the Rights of the Child. Governments, health care providers and harm reduction services should work together to create an environment in which young people can access needed services, including non-judgmental and low-threshold approaches offered by harm reduction programs.
In British Columbia, human immunodeficiency virus (HIV)-infected persons eligible for antiretroviral therapy may receive it free but the extent to which HIV-infected injection drug users access it is unknown.
To identify patient and physician characteristics associated with antiretroviral therapy utilization in HIV-infected injection drug users.
Prospective cohort study with record linkage between survey data and data from a provincial HIV/AIDS (acquired immunodeficiency syndrome) drug treatment program.
British Columbia, where antiretroviral therapies are offered free to all persons with HIV infection with CD4 cell counts less than 0.50 x 10(9)/L (500/microL) and/or HIV-1 RNA levels higher than 5000 copies/mL.
A total of 177 HIV-infected injection drug users eligible for antiretroviral therapy, recruited through the prospective cohort study since May 1996.
Patient use of antiretroviral drugs through the provincial drug treatment program and physician experience treating HIV infection.
After a median of 11 months after first eligibility, only 71 (40%) of 177 patients had received any antiretroviral drugs, primarily double combinations (47/71 [66%]). Both patient and physician characteristics were associated with use of antiretroviral drugs. After adjusting for CD4 cell count and HIV-1 RNA level at eligibility, odds of not receiving antiretrovirals were increased more than 2-fold for females (odds ratio [OR], 2.53; 95% confidence interval [CI], 1.08-5.93) and 3-fold for those not currently enrolled in drug or alcohol treatment programs (OR, 3.49; 95% CI, 1.45-8.40). Younger drug users were less likely to receive therapy (OR, 0.47/10-y increase; 95% CI, 0.28-0.80). Those with physicians having the least experience treating persons with HIV infection were more than 5 times less likely to receive therapy (OR, 5.55; 95% CI, 2.49-12.37).
Despite free antiretroviral therapy, many HIV-infected injection drug users are not receiving it. Public health efforts should target younger and female drug users, and physicians with less experience treating HIV infection.
Drug-induced and drug-related deaths have been increasing for the past decade throughout the US. In NYC, drug overdose accounts for nearly 900 deaths per year, a figure that exceeds the number of deaths each year from homicide. Naloxone, a highly effective opiate antagonist, has for decades been used by doctors and paramedics during emergency resuscitation after an opiate overdose. Following the lead of programs in Europe and the US who have successfully distributed take-home naloxone, the Overdose Prevention and Reversal Program at the Lower East Side Harm Reduction Center (LESHRC) has started providing a similar resource for opiate users in NYC. Participants in the program receive a prescription for two doses of naloxone, with refills as needed, and comprehensive training to reduce overdose risk, administer naloxone, perform rescue breathing, and call 911. As of September 2005, 204 participants have received naloxone and been trained, and 40 have revived an overdosing friend or family member. While naloxone accessibility stands as a proven life-saving measure, some opiates users at LESHRC have expressed only minimal interest in naloxone use, due to past experiences and common misconceptions.
In order to improve the naloxone distribution program two focus groups were conducted in December 2004 with 13 opiate users at LESHRC to examine knowledge about overdose and overdose prevention. The focus groups assessed participants' (i) experiences with overdose response, specifically naloxone (ii) understanding and perceptions of naloxone, (iii) comfort level with naloxone administration and (iv) feedback about increasing the visibility and desirability of the naloxone distribution program.
Analyses suggest that there is both support for and resistance to take-home naloxone, marked by enthusiasm for its potential role in reviving an overdosing individual, numerous misconceptions and negative views of its impact and use.
Focus group results will be used to increase participation in the program and reshape perceptions about naloxone among opiate users, also targeting those already prescribed naloxone to increase their comfort using it. Since NYC is advancing toward a citywide naloxone distribution program, the LESHRC program will play an important role in establishing protocol for effective and wide-reaching naloxone availability.
http://www.bccdc.ca/resource-gallery/Documents/Educational%20Materials/Epid/Other/THN%20report%20Aug_final.pdf
Background
Availability of the opioid antagonist naloxone for lay administration has grown substantially since first proposed in 1996. Gaps remain, though, in our understanding of how people who inject drugs (PWID) engage with naloxone programmes over time.
Aims
This paper aimed to address three specific evidence gaps: the extent of naloxone supply to PWID; supply-source (community or prisons); and the carriage of naloxone among PWID.
Materials and Methods
Analysis of Scotland’s Needle Exchange Surveillance Initiative (NESI) responses in 2011–12 and 2013–14 was undertaken with a specific focus on the extent of Scotland’s naloxone supply to PWID; including by source (community or prisons); and on the carriage of naloxone. Differences in responses between the two surveys were measured using Chi-square tests together with 95% confidence intervals for rate-differences over time.
Results
The proportion of NESI participants who reported that they had been prescribed naloxone within the last year increased significantly from 8% (175/2146; 95% CI: 7% to 9%) in 2011–12 to 32% (745/2331; 95% CI: 30% to 34%) in 2013–14. In contrast, the proportion of NESI participants who carried naloxone with them on the day they were interviewed decreased significantly from 16% (27/169; 95% CI: 10% to 22%) in 2011–12 to 5% (39/741; 95% CI: 4% to 7%) in 2013–14.
Conclusions
The supply of naloxone to PWID has increased significantly since the introduction of a National Naloxone Programme in Scotland in January 2011. In contrast, naloxone carriage is low and decreased between the two NESI surveys; this area requires further investigation.
Incarceration is common among people who inject drugs. Prior research has shown that incarceration is a marker of elevated risk for opioid overdose, suggesting that the criminal justice system may be an important, under-utilized venue for implementing overdose prevention strategies. To better understand the feasibility and acceptability of such strategies, we evaluated the utilization of naloxone-based overdose prevention training among people who inject drugs with and without a history of incarceration.
We surveyed clients who utilize a multi-site syringe exchange program (SEP) in 2 cities in the Midwestern United States. Participants completed an 88-item, computerized survey assessing history of incarceration, consequences associated with injection, injecting practices, and uptake of harm reduction strategies.
Among 543 respondents who injected drugs in the prior 30 days, 243 (43%) reported prior incarceration. Comparing those with and without a history of incarceration, there were no significant differences with respect to age, gender, or race. Those who observed an overdose, experienced overdose, and received training to administer or have administered naloxone were more likely to report incarceration. Overall, 69% of previously incarcerated clients had been trained to administer naloxone.
People who inject drugs with a history of incarceration appear to have a higher risk of opioid overdose than those never incarcerated, and are more willing to utilize naloxone as an overdose prevention strategy. Naloxone training and distribution is an important component of comprehensive prevention services for persons with opioid use disorders. Expansion of services for persons leaving correctional facilities should be considered.
Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.
Objective:: To describe prevalence and incidence of HIV‐1, hepatitis C virus (HCV) and risk behaviours in a prospective cohort of injecting drug users (IDU). Setting:: Vancouver, which introduced a needle exchange programme (NEP) in 1988, and currently exchanges over 2 million needles per year. Design:: IDU who had injected illicit drugs within the previous month were recruited through street outreach. At baseline and semi‐annually, subjects underwent serology for HIV‐1 and HCV, and questionnaires on demographics, behaviours and NEP attendance were completed. Logistic regression analysis was used to identify determinants of HIV prevalence. Results:: Of 1006 IDU, 65% were men, and either white (65%) or Native (27%). Prevalence rates of HIV‐1 and HCV were 23 and 88%, respectively. The majority (92%) had attended Vancouver's NEP, which was the most important syringe source for 78%. Identical proportions of known HIV‐positive and HIV‐negative IDU reported lending used syringes (40%). Of HIV‐negative IDU, 39% borrowed used needles within the previous 6 months. Relative to HIV‐negative IDU, HIV‐positive IDU were more likely to frequently inject cocaine (72 versus 62%; P < 0.001). Independent predictors of HIV‐positive serostatus were low education, unstable housing, commercial sex, borrowing needles, being an established IDU, injecting with others, and frequent NEP attendance. Based on 24 seroconversions among 257 follow‐up visits, estimated HIV incidence was 18.6 per 100 person‐years (95% confidence interval, 11.1‐26.0). Conclusions:: Despite having the largest NEP in North America, Vancouver has been experiencing an ongoing HIV epidemic. Whereas NEP are crucial for sterile syringe provision, they should be considered one component of a comprehensive programme including counselling, support and education.
The non-medical use of and harms related to prescription opioid (PO) analgesics - key medications to treat severe and chronic pain - are an emerging public health concern globally. PO use is proportionally highest in North America, where, consequently, nonmedical PO use (NMPOU) and morbidity/mortality are high and well documented for the United States. Canada is the country with the second highest PO consumption rate in the world - with steeper recent increases in PO use than the US - mainly driven by substantial increases in the use of strong opioids (e.g., oxycodone). Indications and select data of NMPOU and PO-related morbidity and mortality have emerged in recent years, yet a systematic and comprehensive collection of relevant data to characterize the phenomenon in Canada does not exist.
This paper comprehensively reviews the available data in Canada regarding NMPOU, and PO-related harms, diversion, and interventions, and discusses implications for interventions and policy.
Narrative literature/data review.
Canada.
Publicly available data and information - either from journal publications, "grey literature" (e.g., government/technical reports) or Web sites reporting relevant data on Canada - were searched and narratively reviewed.
Indicators on NMPOU and PO-related harms in Canada are highly fragmented, and not nearly as systematic and comprehensive as they are in the US; virtually no national statistics/data are collected. Available -largely provincial/local - data indicate that PO misuse is increasingly common in key populations, including general adult and student populations, street-drug users, First Nations/Aboriginal Peoples, and correctional populations. Co-morbidities - e.g., pain, mental health problems, polysubstance use - among people reporting NMPOU appear to be high. Substance use treatment admissions for those with problematic PO use have risen substantially where reported. Opioid-related mortality (and oxycodone-related mortality, specifically) have increased considerably in Ontario where relevant data from the mid-1990s onward have been examined. In Canadian populations reporting NMPOU, sourcing of POs occurs through various diversion routes, including from family/friends, "double-doctoring," or street drug markets. In addition, losses and theft/robberies from pharmacies and licensed medications dealers appear to be on the rise. Finally, interventions (i.e., provincial PO guidelines, prescription monitoring programs, substance use treatment services) are fragmented and inconsistently applied throughout the country, and currently fail to effectively address the growing problem of NMPOU and PO-related harms across Canada.
This review did not rely on systematic review methodologies.
Corresponding to its increasing and high overall PO consumption levels, NMPOU and PO-related harms in Canada are high based on available data, and likely now constitute the third highest level of substance use burden of disease (after alcohol and tobacco). The data and monitoring situation in Canada regarding NMPOU and PO-related harms are fragmented, un-systematic, and insufficient. While major and concerted policy initiatives - primarily from the federal level - are absent to date, these urgently require vastly improved national data indicators and monitoring in order to allow for and evaluate evidence-based interventions on this urgent and extensive public health problem.
To describe prevalence and incidence of HIV-1, hepatitis C virus (HCV) and risk behaviours in a prospective cohort of injecting drugs users (IDU).
Vancouver, which introduced a needle exchange programme (NEP) in 1988, and currently exchanges over 2 million needles per year.
IDU who had injected illicit drugs within the previous month were recruited through street outreach. At baseline and semi-annually, subjects underwent serology for HIV-1 and HCV, and questionnaires on demographics, behaviours and NEP attendance were completed. Logistic regression analysis was used to identify determinants of HIV prevalence.
Of 1006 IDU, 65% were men, and either white (65%) or Native (27%). Prevalence rates of HIV-1 and HCV were 23 and 88%, respectively. The majority (92%) had attended Vancouver's NEP, which was the most important syringe source for 78%. Identical proportions of known HIV-positive and HIV-negative IDU reported lending used syringes (40%). Of HIV-negative IDU, 39% borrowed used needles within the previous 6 months. Relative to HIV-negative IDU, HIV-positive IDU were more likely to frequently inject cocaine (72 versus 62%; P < 0.001). Independent predictors of HIV-positive serostatus were low education, unstable housing, commercial sex, borrowing needles, being an established IDU, injecting with others, and frequent NEP attendance. Based on 24 seroconversions among 257 follow-up visits, estimated HIV incidence was 18.6 per 100 person-years (95% confidence interval, 11.1-26.0).
Despite having the largest NEP in North America, Vancouver has been experiencing an ongoing HIV epidemic. Whereas NEP are crucial for sterile syringe provision, they should be considered one component of a comprehensive programme including counselling, support and education.
To ascertain the prevalence and risk factors for non-fatal overdose among heroin users to assist in the development of an effective intervention.
Cross-sectional design.
Community setting, principally metropolitan Adelaide.
Current heroin users (used heroin in the previous six months).
A structured questionnaire including the Severity of Dependence Scale.
Of 218 current South Australian heroin users interviewed in 1996, 48% had experienced at least one non-fatal overdose their life-time (median: two overdoses), and 11% had overdosed in the previous 6 months. At some time, 70% had been present at someone else's overdose (median: three overdoses). At the time of their own most recent overdose, 52% had been using central nervous system depressants in addition to heroin, principally benzodiazepines (33%) and/or alcohol (22%). The majority of overdoses occurred in a private home (81%) and in the presence of other people (88%). Unrealistic optimism regarding the risk of overdose was evident across the sample. Despite almost half the sample reporting having had an overdose, and the belief expressed by respondents that on average about 50% of regular heroin users would overdose during their life-time 73% had, during the previous 6 months, "rarely" or "never" worried about possibly overdosing. Optimism regarding the possibility of future overdose was reduced in those with recent experience of overdose in comparison to the rest of the sample. A targeted intervention aimed at the reduction of overdose among heroin users is outlined.
Before proceeding with the introduction of an overdose fatality prevention programme including teaching in cardio-pulmonary resuscitation and distribution of naloxone, a pre-launch study of treatment and community samples of injecting drug misusers has been undertaken to establish (i) the extent of witnessing overdoses, (ii) the acceptability of naloxone distribution and training; and (iii) the likely impact of such measures.
Structured interview of two samples: (a) a community sample of injecting drug misusers recruited by selected privileged access interviewers (PAI) and interviewed by them in community settings and (b) a treatment sample of opiate addicts recruited from our methadone maintenance clinic (interviewed by in-house research staff).
(a) Three hundred and twelve injecting drug misusers with a history of having injected and currently still using injectable drugs; and (b) 142 opiate addicts in treatment at our local catchment area methadone maintenance clinic in South London.
History of personal overdose was found with 38% of the community sample and 55% of the treatment sample--mainly involving opiates and in the company of friends. Most (54% and 92%, respectively) had witnessed at least one overdose (again mostly involving opiates), of whom a third had witnessed a fatal overdose. Only a few (35%) already knew of the existence and effects of naloxone. After explanation to the treatment sample, 70% considered naloxone distribution to be a good proposal. Of the 13% opposed to the proposal, half thought it may lead them to use more drugs. Eighty-nine per cent of those who had witnessed an overdose fatality would have administered naloxone if it had been available. We estimate that at least two-thirds of witnessed overdose fatalities could be prevented by administration of home-based supplies of naloxone.
Substantial proportions of both community and treatment samples of drug misusers have witnessed an overdose death which could have been prevented through prior training in resuscitation techniques and administration of home-based supplies of naloxone. Such a new approach would be supported by most drug misusers. On the basis of these findings, we conclude that it is appropriate to proceed to a carefully constructed trial of naloxone distribution.
Providing comprehensive health services for young key populations: needs, barriers and gaps
- S Delany-Moretlwe
- Cowan
- Fm
- J Busza
SAS Version 9.4 for Windows
- Sas Institute
- Inc