Non-fatal opioid overdose, naloxone access, and naloxone training among people who recently used opioids or received opioid agonist treatment in Australia: The ETHOS Engage study

IntroductionOpioid agonist treatment (OAT) is a safe and effective treatment for opioid use disorder (OUD). However, people commonly stop and start OAT and their risk of death is high immediately after stopping. The prevalence of illicitly manufactured fentanyl and other highly potent synthetic opioids have increased in the illicit drug supply globally. Yet, there is limited evidence examining the relationship between OAT and mortality when these contaminants are widely available in the illicit drug supply. Objectives and ApproachWe aimed to compare the risk of mortality on and off OAT in a setting with a high prevalence of illicitly manufactured fentanyl and other potent synthetic opioids in the illicit drug supply. We linked five health administrative datasets in British Columbia, Canada, creating a cohort of 55,347 people with OUD who received OAT during a 23-year period (1996 to 2018). We compared the risk of mortality on and off treatment over time, and according to time since starting or stopping treatment and by medication type. Results7,030 of 55,347 (12.7%) OAT recipients died during follow-up. All-cause SMR was substantially lower on OAT (4.6 [4.4 to 4.8]) compared to off OAT (9.7 [9.5 to 10.0]). In a period of increasing prevalence of fentanyl, the relative risk of mortality off OAT was 2.1 [1.8 to 2.4] times higher than on OAT prior to the introduction of fentanyl, and increased to 3.4 [2.8 to 4.3] at the end of the study period (65% increase in relative risk). Conclusion / ImplicationsThe protective effect of OAT on mortality increased as fentanyl and other synthetic opioids became common in the illicit drug supply, while the risk of mortality remained high off OAT. As fentanyl becomes more widespread globally, these findings highlight the importance of interventions that improve retention on opioid agonist treatment and prevent recipients from stopping treatment.

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Rates of opioid agonist treatment prescribing in provincial prisons in Ontario, Canada, 2015–2018: a repeated cross-sectional analysis

BMJ Open ◽

10.1136/bmjopen-2021-048944 ◽

2021 ◽

Vol 11 (11) ◽

pp. e048944

Author(s):

Claire Bodkin ◽

Susan Bondy ◽

Leonora Regenstreif ◽

Lori Kiefer ◽

Fiona Kouyoumdjian

Keyword(s):

General Population ◽

Scale Up ◽

Unmet Need ◽

Opioid Overdose ◽

Opioid Agonist ◽

Access To Treatment ◽

Monthly Basis ◽

Cross Sectional ◽

Opioid Agonist Treatment ◽

Need For Treatment

ObjectiveTo describe opioid agonist treatment prescribing rates in provincial prisons and compare with community prescribing rates.DesignWe used quarterly, cross-sectional data on the number and proportion of people prescribed opioid agonist treatment in prison populations. Trends were compared with Ontario surveillance data from prescribers, reported on a monthly basis.SettingProvincial prisons and general population in Ontario, Canada between 2015 and 2018.ParticipantsAdults incarcerated in provincial prisons and people ages 15 years and older in Ontario.Main outcomes and measuresOpioid agonist treatment prescribing prevalence, defined as treatment with methadone or buprenorphine/naloxone.ResultsIn prison, 6.9%–8.4% of people were prescribed methadone; 0.8% to 4.8% buprenorphine/naloxone; and 8.2% to 13.2% either treatment over the study period. Between 2015 and 2018, methadone prescribing prevalence did not substantially change in prisons or in the general population. The prevalence rate of buprenorphine/naloxone prescribing increased in prisons by 1.70 times per year (95% CI 1.47 to 1.96), which was significantly higher than the increase in community prescribing: 1.20 (95% CI 1.19 to 1.21). Buprenorphine/naloxone prescribing prevalence was significantly different across prisons.ConclusionsThe increase in opioid agonist treatment prescribing between 2015 and 2018 in provincial prisons shows that efforts to scale up access to treatment in the context of the opioid overdose crisis have included people who experience incarceration in Ontario. Further work is needed to understand unmet need for treatment and treatment impacts.

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Understanding Steps and Challenges to Take-home Naloxone and Buprenorphine/naloxone Implementation in Québec Emergency Rooms: Suboxed Project

10.21203/rs.3.rs-33331/v2 ◽

2020 ◽

Author(s):

Annie Talbot ◽

Rania Khemiri ◽

Luc Londei-Leduc ◽

Christine Robin ◽

Suzanne Marcotte ◽

...

Keyword(s):

At Risk ◽

Governance Structure ◽

The United States ◽

Opioid Overdose ◽

Emergency Rooms ◽

Opioid Agonist ◽

Clinical Algorithm ◽

Opioid Agonist Treatment ◽

System A ◽

Clinical Culture

Abstract BackgroundDeaths attributable to drug abuse are on the rise across Canada. It is estimated that there were more than 13,900 opioid-related deaths from January 2016 to June 2019 in the country. Emergency departments (EDs) are often on the frontline of care provided to people at risk of opioid overdose within Québec’s healthcare system. A variety of programs to implement take-home naloxone distribution and/or the provision of opioid agonist treatment for ED patients who are at risk for overdose have been created in the United States and in Europe. However, few EDs in Canada have developed protocols for the provision of take-home naloxone and/or opioid agonist treatment by ED doctors.MethodsA clinical algorithm for take home naloxone (THN) and prescription of buprenorphine/naloxone (B/N) was implemented in three EDs of Québec, Canada. This first phase of the SuboxED project required selecting clinical experts, describing the patient population, and creating partnerships with pharmacists and opioid agonist treatment clinics.Results:The clinical experts developed tools based on literature reviews and national and international guidelines. They also created educational tools and trained over 328 ED clinical staff. In addition, SuboxED ensured that a supply of take-home naloxone and B/n was available in the three ED sites for the study.ConclusionImplementing the proposed clinical algorithm for THN and prescription of B/N was challenging: drug supply and ED staff’s buy-in were among the most notable difficulties of SuboxED. Planning training sessions at three different institutions, each with its own governance structure and clinical culture, local realities and harm reduction priorities was complicated. Engaging already overworked ED teams consistently working in a gridlocked environments, revealed in itself to be a difficult endeavour.In the next phase of SuboxED, we will focus on data collection and analysis to evaluate both the implementation of the protocol through a retrospective review of electronic health records and satisfaction surveys of patients and healthcare professionals.Trial registration: none

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Understanding Steps and Challenges to Take-home Naloxone and Buprenorphine/naloxone Implementation in Québec Emergency Rooms: Suboxed Project

10.21203/rs.3.rs-33331/v1 ◽

2020 ◽

Author(s):

Annie Talbot ◽

Rania Khemiri ◽

Luc Londei-Leduc ◽

Christine Robin ◽

Suzanne Marcotte ◽

...

Keyword(s):

At Risk ◽

Emergency Departments ◽

Governance Structure ◽

The United States ◽

Opioid Overdose ◽

Drug Supply ◽

Emergency Rooms ◽

Opioid Agonist ◽

Clinical Algorithm ◽

Opioid Agonist Treatment

Abstract BackgroundDeaths attributable to drug abuse are on the rise across Canada. It is estimated that there were more than 13,900 opioid-related deaths from January 2016 to June 2019 in the country. Emergency departments (EDs) are often on the frontline of care provided to people at risk of opioid overdose within Québec’s healthcare system. A variety of programs to implement take-home naloxone distribution and/or the provision of opioid agonist treatment for ED patients who are at risk for overdose have been created in the United States and in Europe. However, few EDs in Canada have developed protocols for the provision of take-home naloxone and/or opioid agonist treatment by ED doctors.MethodsA clinical algorithm for take home naloxone (THN) and prescription of buprenorphine/naloxone (B/N) was implemented in three EDs of Québec, Canada. This first phase of the SuboxED project required selecting clinical experts, describing the patient population, and creating partnerships with pharmacists and opioid agonist treatment clinics.Results:The clinical experts developed tools based on literature reviews and national and international guidelines. They also created educational tools and trained over 328 ED clinical staff. In addition, SuboxED ensured that a supply of take-home naloxone and B/n was available in the three ED sites for the study.ConclusionImplementing the proposed clinical algorithm for THN and prescription of B/N was challenging: drug supply and ED staff’s buy-in were among the most notable difficulties of SuboxED. Planning training sessions at three different institutions, each with its own governance structure and clinical culture, local realities and harm reduction priorities was complicated. Engaging already overworked ED teams consistently working in a gridlocked environments, revealed in itself to be a difficult endeavour.In the next phase of SuboxED, we will focus on data collection and analysis to evaluate both the implementation of the protocol through a retrospective review of electronic health records and satisfaction surveys of patients and healthcare professionals.Trial registration: noneContribution to the literatureIn the midst of the opioid overdose crisis, initiating a clinical algorithm for take-home naloxone and prescription of B/n in three operationally different Canadian emergency departments was feasible.Implementing a clinical algorithm for take-home naloxone and prescription of B/n is challenging; significant barriers involve drug supply, ED staff buy-in, training, engaging already overworked ED team.

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Opioid overdose deaths and the expansion of opioid agonist treatment: A population‐based prospective cohort study

Addiction ◽

10.1111/add.15739 ◽

2021 ◽

Author(s):

Ole Rogeberg ◽

Daniel Bergsvik ◽

Thomas Clausen

Keyword(s):

Cohort Study ◽

Prospective Cohort Study ◽

Prospective Cohort ◽

Population Based ◽

Opioid Overdose ◽

Opioid Agonist ◽

Opioid Agonist Treatment ◽

Overdose Deaths

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Naloxone prescribing by psychiatric clinical pharmacists for patients receiving opioid agonist treatment

Mental Health Clinician ◽

10.9740/mhc.2015.01.046 ◽

2015 ◽

Vol 5 (1) ◽

pp. 46-49 ◽

Cited By ~ 3

Author(s):

Michelle Geier ◽

James J. Gasper

Keyword(s):

San Francisco ◽

Improve Patient Safety ◽

Integrated Treatment ◽

Opioid Overdose ◽

Opioid Use ◽

Opioid Agonist ◽

Overdose Prevention ◽

Opioid Agonist Treatment ◽

Clinical Pharmacists ◽

Prevention Training

Take-home naloxone is an important intervention for addressing opioid overdoses. Patients with a history of a substance use disorder are at an elevated risk of experiencing an overdose, and even in substance-abuse treatment, they may continue to witness peer overdoses. The purpose of this innovative practice was for psychiatric clinical pharmacists to improve access to intranasal naloxone and provide opioid overdose prevention training for patients receiving opioid agonist treatment (OAT). This program took place at a San Francisco Department of Public Health pharmacy that provides OAT (buprenorphine and methadone) to approximately 200 patients with opioid use disorders as part of an integrated treatment program. During the 17-month study period, 47 intranasal naloxone kits were prescribed. Patients reported 3 successful opioid overdose reversals using intranasal naloxone. Based on these findings, psychiatric clinical pharmacists can improve patient safety by increasing access to intranasal naloxone and opioid overdose prevention training for patients receiving OAT.

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Fentanyl assisted treatment: a possible role in the opioid overdose epidemic?

Substance Abuse Treatment Prevention and Policy ◽

10.1186/s13011-019-0241-2 ◽

2019 ◽

Vol 14 (1) ◽

Cited By ~ 1

Author(s):

Geoff Bardwell ◽

Evan Wood ◽

Rupinder Brar

Keyword(s):

Treatment Options ◽

Adverse Outcomes ◽

Health Interventions ◽

Opioid Overdose ◽

Main Body ◽

Public Health Interventions ◽

Transdermal Fentanyl ◽

Opioid Agonist ◽

Opioid Agonist Treatment ◽

Long Acting

Abstract Background The current opioid overdose epidemic affecting communities across North America is increasingly driven by illicitly manufactured fentanyl and its related analogues. A variety of public health interventions have been implemented and scaled up, including opioid agonist treatments (OAT). While these treatments are successful for many individuals, they have a variety of limitations. It is critical to trial alternative treatments if conventional opioid agonist treatment options are not successful for a proportion of patients who use illicit fentanyl. Main body Prescription fentanyl has been widely used for pain management. The use of transdermal fentanyl, specifically, which provides long acting and stable drug levels post-titration over several days, should be explored as an opioid agonist treatment option. The use of transdermal fentanyl for patients who use illicit fentanyl is currently being piloted in Vancouver, Canada. To address potential diversion, the patch is signed, dated, and a film dressing is applied to mitigate tampering. Evaluation outcomes are still pending, but there have been no adverse outcomes thus far and clinical improvements have been noted for many patients. This exploratory therapeutic approach should be considered across multiple settings and rigorously evaluated. Conclusions There are known limitations to existing OAT options and there is a need to urgently evaluate alternative strategies for patients who are using illicit fentanyl not successfully treated with conventional OAT. Many patients may be attracted to, and retained in, fentanyl assisted treatment. This may be another strategy for certain patients to prevent harms caused by illicit fentanyl use, including overdose and death.

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Understandings steps and challenges to take-home naloxone and buprenorphine/naloxone implementation in Québec emergency rooms: SuboxED project

10.21203/rs.3.rs-28519/v1 ◽

2020 ◽

Author(s):

Annie Talbot ◽

Rania Khemiri ◽

Luc Londei-Leduc ◽

Christine Robin ◽

Suzanne Marcotte ◽

...

Keyword(s):

At Risk ◽

Governance Structure ◽

The United States ◽

Opioid Overdose ◽

Emergency Rooms ◽

Opioid Agonist ◽

Clinical Algorithm ◽

Opioid Agonist Treatment ◽

System A ◽

Clinical Culture

Abstract Background Deaths attributable to drug abuse are on the rise across Canada. It is estimated that there were more than 13,900 opioid-related deaths from January 2016 to June 2019 in the country. Emergency departments (EDs) are often on the frontline of care provided to people at risk of opioid overdose within Québec’s healthcare system. A variety of programs to implement take-home naloxone distribution and/or the provision of opioid agonist treatment for ED patients who are at risk for overdose have been created in the United States and in Europe. However, few EDs in Canada have developed protocols for the provision of take-home naloxone and/or opioid agonist treatment by ED doctors. Methods A clinical algorithm for take home naloxone (THN) and prescription of buprenorphine/naloxone (B/N) was implemented in three EDs of Québec, Canada. This first phase of the SuboxED project required selecting clinical experts, describing the patient population, and creating partnerships with pharmacists and opioid agonist treatment clinics. Results The clinical experts developed tools based on literature reviews and national and international guidelines. They also created educational tools and trained over 328 ED clinical staff. In addition, SuboxED ensured that a supply of take-home naloxone and B/n was available in the three ED sites for the study. Conclusion Implementing the proposed clinical algorithm for THN and prescription of B/N was challenging: drug supply and ED staff’s buy-in were among the most notable difficulties of SuboxED. Planning training sessions at three different institutions, each with its own governance structure and clinical culture, local realities and harm reduction priorities was complicated. Engaging already overworked ED teams consistently working in a gridlocked environments, revealed in itself to be a difficult endeavour. In the next phase of SuboxED, we will focus on data collection and analysis to evaluate both the implementation of the protocol through a retrospective review of electronic health records and satisfaction surveys of patients and healthcare professionals.

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