If We Build It, Will They Come? Perspectives on Pharmacy-Based Naloxone Among Family and Friends of People who use Opioids: A Mixed Methods Study

Abstract Background: Expanding access to the opioid antagonist naloxone to reduce overdose mortality is a public health priority in the United States. Naloxone standing orders (NSOs) have been established in many states to increase naloxone dispensing at pharmacies, but increased pharmacy access does not ensure optimal uptake among those likely to witness an overdose. In a prior statewide purchase trial, we documented high levels of naloxone access at Massachusetts pharmacies under a statewide NSO. In this study, we characterize barriers to pharmacy-based naloxone uptake among potential opioid overdose “bystanders” (friends or family of people who use opioids) that may be amenable to intervention.Methods: Eligible bystanders were Massachusetts residents >18 years of age, did not use illicit opioids in the past 30 days, and knew someone who currently uses illicit opioids. We used a sequential mixed methods approach, in which a series of semi-structured qualitative interviews (N=22) were conducted to inform the development of a subsequent quantitative survey (N=260). Results: Most survey participants (77%) reported ever obtaining naloxone but few (21%) attempted to purchase it at a pharmacy. Qualitative participants revealed that barriers to utilizing the NSO included low perceived risk of overdose, which was rooted in misconceptions regarding the risks of prescription opioid misuse, denial about their loved one’s drug use, and drug use stereotypes; inaccurate beliefs about the impact of naloxone on riskier opioid use; and concerns regarding anticipated stigma and confidentiality. Many participants had engaged in mutual support groups, which served as a source of free naloxone for half (50%) of those who had ever obtained naloxone.Conclusions: Despite high levels of pharmacy naloxone access in Massachusetts, few bystanders in our study had attempted to obtain naloxone under the NSO. Low perceived risk of overdose, misinformation, stigma and confidentiality were important barriers to pharmacy naloxone uptake, all of which are amenable to intervention. Support groups provided a setting for addressing stigma and misinformation and provided a discreet and comfortable setting for naloxone access. Where these groups do not exist and for bystanders who do not participate in such groups, pharmacies are well-positioned to fill gaps in naloxone availability.

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Pharmacologic and Clinical Considerations of Nalmefene, a Long Duration Opioid Antagonist, in Opioid Overdose

Psychiatry International ◽

10.3390/psychiatryint2040028 ◽

2021 ◽

Vol 2 (4) ◽

pp. 365-378

Author(s):

Amber N. Edinoff ◽

Catherine A. Nix ◽

Tanner D. Reed ◽

Elizabeth M. Bozner ◽

Mark R. Alvarez ◽

...

Keyword(s):

Respiratory Depression ◽

The United States ◽

Opioid Use Disorder ◽

Opioid Antagonist ◽

Opioid Overdose ◽

Opioid Use ◽

Physical Damage ◽

Onset Of Action ◽

Duration Of Action ◽

Opioid Intoxication

Opioid use disorder is a well-established and growing problem in the United States. It is responsible for both psychosocial and physical damage to the affected individuals with a significant mortality rate. Given both the medical and non-medical consequences of this epidemic, it is important to understand the current treatments and approaches to opioid use disorder and acute opioid overdose. Naloxone is a competitive mu-opioid receptor antagonist that is used for the reversal of opioid intoxication. When given intravenously, naloxone has an onset of action of approximately 2 min with a duration of action of 60–90 min. Related to its empirical dosing and short duration of action, frequent monitoring of the patient is required so that the effects of opioid toxicity, namely respiratory depression, do not return to wreak havoc. Nalmefene is a pure opioid antagonist structurally similar to naltrexone that can serve as an alternative antidote for reversing respiratory depression associated with acute opioid overdose. Nalmefene is also known as 6-methylene naltrexone. Its main features of interest are its prolonged duration of action that surpasses most opioids and its ability to serve as an antidote for acute opioid overdose. This can be pivotal in reducing healthcare costs, increasing patient satisfaction, and redistributing the time that healthcare staff spend monitoring opioid overdose patients given naloxone.

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POP4Teens: Results of a randomized controlled trial to evaluate the effectiveness of a web-based program to prevent adolescent prescription opioid misuse (Preprint)

10.2196/preprints.18487 ◽

2020 ◽

Author(s):

Lisa A. Marsch ◽

Sarah K. Moore ◽

Michael Grabinski ◽

Sarah E. Bessen ◽

Jacob Borodovsky ◽

...

Keyword(s):

Randomized Controlled Trial ◽

Perceived Risk ◽

Risk Perceptions ◽

Controlled Trial ◽

The United States ◽

Prescription Opioid ◽

Dissemination And Implementation ◽

Opioid Use ◽

Web Based ◽

Randomized Controlled

BACKGROUND Prescription opioid use is not uncommon among adolescents in the United States. Despite recent declines from unprecedented peaks in adolescent prescription opioid (PO) use, there is seemingly paradoxical evidence that prescription opioid-related consequences (e.g., opioid use disorder and overdoses) are increasing. These trends and their possible consequences emphasize the importance of prevention efforts targeting PO misuse. To our knowledge, we have developed the first interactive, web-based program focused specifically on prevention of PO misuse among adolescents. OBJECTIVE Evaluate the effectiveness of a web-based program designed to prevent adolescent prescription opioid (PO) misuse, Pop4Teens (P4T) compared to an active control website, Just Think Twice (JTT) on impacting PO-related attitudes, knowledge, risk perception and intentions to use. METHODS We conducted an online, randomized controlled trial in 2018. A total of 406 adolescents (aged 12-17) were randomly assigned to P4T or JTT. The outcome variables were attitudes, knowledge, and risk perceptions associated with PO misuse, intentions to use POs, and program feedback. Data were collected at baseline, 1-, 3-, and 6-months. RESULTS Both programs produced significant and sustained improvements on intentions to use POs, increased perceived risk, impacted expectancies consistent with prevention, and improved PO refusal skills. P4T produced significantly greater increases in PO-related knowledge compared to JTT and was reportedly easier to use and more liked. Baseline scores for youth reporting past-year medical use of POs, friends who engage in non-medical use of prescription opioids, and/or poor mental health underscored their at-risk status compared to youth who were not in those groups. CONCLUSIONS P4T positively impacted all study variables consistent with preventing PO misuse among teens. P4Ts online nature simplifies dissemination and implementation of this novel tool designed to help meet the challenges of the evolving national opioid crisis. CLINICALTRIAL ClinicalTrials.gov NCT02737696; https://clinicaltrials.gov/ct2/show/NCT02737696?term=marsch&rank=6

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Revisiting the Fetal Assault Law in Tennessee: Implications and the Way Forward

Policy Politics & Nursing Practice ◽

10.1177/1527154421989994 ◽

2021 ◽

pp. 152715442198999

Author(s):

Caroline K. Darlington ◽

Peggy A. Compton ◽

Sadie P. Hutson

Keyword(s):

United States ◽

Health Care ◽

Drug Use ◽

Health Care Providers ◽

Well Being ◽

The United States ◽

Care Providers ◽

Opioid Use ◽

The Impact ◽

In Pregnancy

The rising prevalence of opioid use disorder (OUD) among those living in the United States has demanded a collaborative response from health care and policy spheres. Addressing OUD among pregnant women is especially difficult, given the controversies surrounding the medical and ethical balance between meeting maternal versus fetal/newborn needs. Most medical organizations discourage the criminalization of drug use in pregnancy due to the adverse public health outcomes of such an approach. Despite this recommendation, many states continue to use punitive law to address drug use in pregnancy. In 2014, the Fetal Assault Law in Tennessee (TN) became the first law in the United States to directly allow women to be prosecuted for drug use in pregnancy. Since its expiration in 2016, this law has been re-introduced several times to the TN legislature in support of permanent implementation. This article outlines the impact of the initial Fetal Assault Law on maternal/newborn health in TN and provides alternative immediate, short-term, and long-term health policy strategies through which health care providers and legislators can better advocate for the well-being of both mothers with OUD and their infants.

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Pattern of Opioid Overdoses and Interventions at the Emergency Department: Impact of COVID-19

10.21203/rs.3.rs-1083704/v1 ◽

2021 ◽

Author(s):

Katherine L Potaka ◽

Rebecca Freeman ◽

Danny Soo ◽

Nam-Anh Nguyen ◽

Tin Fei Sim ◽

...

Keyword(s):

Emergency Department ◽

Practice Guidelines ◽

Large Scale ◽

Opioid Antagonist ◽

Opioid Overdose ◽

Opioid Use ◽

Post Discharge ◽

Retrospective Audit ◽

Drug Overdoses ◽

The Impact

Abstract BackgroundOpioid-related overdoses cause substantial numbers of preventable deaths. Naloxone is an opioid antagonist available in take-home naloxone (THN) kits as a lifesaving measure for opioid overdose. As the emergency department (ED) is a primary point of contact for patients with high-risk opioid use, evidence-based recommendations from the Society of Hospital Pharmacists of Australia THN practice guidelines include the provision of THN, accompanied by psychosocial interventions. However, implementation of these guidelines in practice is unknown. This study investigated ED opioid-related overdose presentations, concordance of post-overdose interventions with the THN practice guidelines, and the impact, if any, of the SARS-CoV-2 (COVID-19) pandemic on case presentations.MethodsA single-centre retrospective audit was conducted at a major tertiary hospital of patients presenting with overdoses involving opioids and non-opioids between March to August 2019 and March to August 2020. Patient presentations and interventions delivered by the paramedics, ED and upon discharge from the ED were collated from medical records and analysed using descriptive statistics, chi square and independent T-tests.ResultsThe majority (66.2%) of patients presented to hospital with mixed drug overdoses involving opioids and non-opioids. Pharmaceutical opioids were implicated in a greater proportion (72.1%) of overdoses than illicit opioids. Fewer patients presented in March to August 2020 as compared with 2019 (26 vs. 42), and mixed drug overdoses were more frequent in 2020 than 2019 (80.8% vs. 57.1%). Referral to outpatient psychology (22.0%) and drug and alcohol services (20.3%) were amongst the most common post-discharge interventions. Naloxone was provided to 28 patients (41.2%) by the paramedics and/or ED. No patients received THN upon discharge.ConclusionsThis study highlights opportunities to improve ED provision of THN and other interventions post-opioid overdose. Large-scale multi-centre studies are required to ascertain the capacity of EDs to provide THN and the impact of COVID-19 on opioid overdose presentations.

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The impact of the opioid crisis on U.S. state prison systems

Health & Justice ◽

10.1186/s40352-021-00143-9 ◽

2021 ◽

Vol 9 (1) ◽

Author(s):

Christy K. Scott ◽

Michael L. Dennis ◽

Christine E. Grella ◽

Allison F. Mischel ◽

John Carnevale

Keyword(s):

United States ◽

Criminal Justice ◽

Technical Assistance ◽

Sampling Strategy ◽

The United States ◽

Opioid Overdose ◽

Opioid Use ◽

State Prison ◽

Prison Systems ◽

The Impact

Abstract Background Prior studies have documented limited use of medications to treat opioid use disorders (OUD) for people incarcerated within state prisons in the United States. Using the framework of the criminal justice OUD service cascade, this study interviewed representatives of prison systems in states most heavily impacted by opioid overdose regarding the provision of medications for OUD (MOUD). Methods A stratified sampling strategy included states with high indicators of opioid-overdose deaths. Two sampling strata targeted states with: 1) OUD overdose rates significantly higher than the per capita national average; or 2) high absolute number of OUD overdose fatalities. Interviews were completed with representatives from 21 of the 23 (91%) targeted states in 2019, representing 583 prisons across these states. Interviews assessed service provision across the criminal justice OUD service cascade, including OUD screening, withdrawal management, MOUD availability and provision, overdose prevention, re-entry services, barriers, and needs for training and technical assistance. Results MOUD (buprenorphine, methadone, or naltrexone) was available in at least one prison in approximately 90% of the state prison systems and all three medications were available in at least one prison in 62% of systems. However, MOUD provision was limited to subsets of prisons within these systems: 15% provided buprenorphine, 9% provided methadone, 36% provided naltrexone, and only 7% provided all three. Buprenorphine and methadone were most frequently provided to pregnant women or individuals already receiving these at admission, whereas naltrexone was primarily used at release. Funding was the most frequently cited barrier for all medications. Conclusion Study findings yield a complex picture of how, when, and to whom MOUD is provided across prisons within prison systems in states most heavily impacted by opioid overdose in the United States and have implications for expanding availability.

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Opioid use disorder and treatment: challenges and opportunities

BMC Health Services Research ◽

10.1186/s12913-019-4751-4 ◽

2019 ◽

Vol 19 (1) ◽

Cited By ~ 2

Author(s):

Kim A. Hoffman ◽

Javier Ponce Terashima ◽

Dennis McCarty

Keyword(s):

Partial Agonist ◽

Opioid Analgesics ◽

Opioid Use Disorder ◽

Psychosocial Treatment ◽

Opioid Antagonist ◽

Prescription Opioid ◽

Opioid Overdose ◽

Opioid Epidemic ◽

Opioid Use ◽

Services Research

Abstract Background Addiction health service researchers have focused efforts on opioid use disorder (OUD) and strategies to address the emerging public health threats associated with the epidemics of opioid use and opioid overdose. The increase in OUD is associated with widespread access to prescription opioid analgesics, enhanced purity of heroin, the introduction of potent illicit fentanyl compounds, and a rising tide of opioid overdose fatalities. These deaths have become the face of the opioid epidemic. Main Text OUD is a chronic disorder that usually requires both medications for opioid use disorder (MOUD) and psychosocial treatment and support. Research has found that MOUD with an opioid receptor agonist (methadone), partial agonist (buprenorphine), or opioid antagonist (extended-release naltrexone) can support recovery. Despite compelling evidence that MOUD are effective, they remain underutilized. More research is needed on these therapies to understand the feasibility of implementation in clinic settings. Conclusion This special issue focuses on how health services research has emerged as an important contributor to efforts to control the opioid epidemic in North America and Europe.

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“The idea is to help people achieve greater success and liberty”: a qualitative study of expanded methadone take-home access in opioid use disorder treatment

10.1101/2021.08.20.21262382 ◽

2021 ◽

Author(s):

Leslie W. Suen ◽

Stacy Castellanos ◽

Neena Joshi ◽

Shannon Satterwhite ◽

Kelly R. Knight

Keyword(s):

Decision Making ◽

Qualitative Study ◽

Clinical Decision Making ◽

The United States ◽

Opioid Use Disorder ◽

Opioid Overdose ◽

Opioid Use ◽

Housing Status ◽

The Impact ◽

Overdose Deaths

AbstractBackgroundPrior to the COVID-19 pandemic, the United States (US) was already facing an epidemic of opioid overdose deaths. Overdose deaths continued to surge during the pandemic. To limit COVID-19 spread and to avoid disruptions in access to medications for opioid use disorder (MOUD), including buprenorphine and methadone, US federal and state agencies granted unprecedented exemptions to existing MOUD guidelines for Opioid Treatment Programs (OTPs), including loosening criteria for unsupervised take-home doses. We conducted a qualitative study to evaluate the impact of these policy changes on MOUD treatment experiences for providers and patients at an OTP in California.MethodsWe interviewed 10 providers and 20 patients receiving MOUD. We transcribed, coded, and analyzed all interviews to identify emergent themes.ResultsProviders discussed clinical decision-making processes and experiences providing take-homes. Implementation of expanded take-home policies was cautious. Providers reported making individualized decisions, using patient factors to decide if benefits outweighed risks of overdose and misuse. Decision-making factors included patient drug use, overdose risk, housing status, and vulnerability to COVID-19. New patient groups started receiving take-homes and providers noted few adverse events. Patients who received take-homes reported increased autonomy and treatment flexibility, which in turn increased likelihood of treatment stabilization and engagement. Patients who remained ineligible for take-homes, usually due to ongoing non-prescribed opioid or benzodiazepine use, desired greater transparency and shared decision-making.ConclusionFederal exemptions in response to COVID-19 led to the unprecedented expansion of access to MOUD take-homes within OTPs. Providers and patients perceived benefits to expanding access to take-homes and experienced few adverse outcomes, suggesting expanded take-home policies should remain post-COVID-19. Future studies should explore whether these findings are generalizable to other OTPs and assess larger samples to quantify patient-level outcomes resulting from expanded take-home policies.

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Evidence of Modeling Impact in Development of Policies for Controlling the Opioid Epidemic and Improving Public Health: A Scoping Review

Substance Abuse Research and Treatment ◽

10.1177/1178221819866211 ◽

2019 ◽

Vol 13 ◽

pp. 117822181986621 ◽

Cited By ~ 1

Author(s):

Nasser Sharareh ◽

Shabnam S Sabounchi ◽

Mary McFarland ◽

Rachel Hess

Keyword(s):

Public Health ◽

Scoping Review ◽

Conceptual Modeling ◽

The United States ◽

Opioid Addiction ◽

Dynamics Simulation ◽

Prescription Opioid ◽

Opioid Overdose ◽

Opioid Epidemic ◽

The Impact

Background: Opioid addiction and overdose rates are reaching unprecedented levels in the U.S., with around 47,736 overdose deaths in 2017. Many stakeholders affect the opioid epidemic, including government entities, healthcare providers and policymakers, and opioid users. Simulation and conceptual modeling can help us understand the dynamics of the opioid epidemic by simplifying the real world and informing policymakers about different health interventions that could reduce the deaths caused by opioid overdose in the United States every year. Objectives: To conduct a scoping review of simulation and conceptual models that propose policies capable of controlling the opioid epidemic. We demonstrate the strengths and limitations of these models and provide a framework for further improvement of future decision support tools. Methods: Using the methodology of a scoping review, we identified articles published after 2000 from eight electronic databases to map the literature that uses simulation and conceptual modeling in developing public health policies to address the opioid epidemic. Results: We reviewed 472 papers of which 14 were appropriate for inclusion. Each used either system dynamics simulation modeling, mathematical modeling, conceptual modeling, or agent-based modeling. All included studies tested and proposed strategies to improve health outcomes related to the opioid epidemic. Factors considered in the models included physicians prescribing opioids, trafficking, users recruiting new users, and doctor shopping; no model investigated the impact of age and spatial factors on the dynamics of the epidemic. Key findings from these studies were (1) prevention of opioid initiation is better than treatment of opioid addiction, (2) the analysis of an intervention’s impact should include both benefits and harms, and (3) interventions with short-term benefits might have a counterproductive impact on the epidemic in long run. Conclusions: While most studies examined the role of prescription opioids and trafficking on this epidemic, the transition of patients from prescription opioid use to nonprescription use including heroin and synthetic opioids such as fentanyl impacts the system significantly and results in an epidemic with quite different characteristics than what it had a decade ago. We recommend including the impact of age and geographic location on the opioid epidemic using modeling methods.

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Evaluating the Effectiveness of a Web-Based Program (POP4Teens) to Prevent Prescription Opioid Misuse Among Adolescents: Randomized Controlled Trial

JMIR Public Health and Surveillance ◽

10.2196/18487 ◽

2021 ◽

Vol 7 (2) ◽

pp. e18487

Author(s):

Lisa A Marsch ◽

Sarah K Moore ◽

Michael Grabinski ◽

Sarah Y Bessen ◽

Jacob Borodovsky ◽

...

Keyword(s):

Randomized Controlled Trial ◽

Perceived Risk ◽

Risk Perceptions ◽

Controlled Trial ◽

The United States ◽

Prescription Opioid ◽

Dissemination And Implementation ◽

Opioid Use ◽

Web Based ◽

Randomized Controlled

Background Prescription opioid (PO) use is common among adolescents in the United States. Despite recent declines from unprecedented peaks in adolescent PO use (eg, in 2012-2013), there is seemingly paradoxical evidence that PO-related consequences (eg, opioid use disorder and overdoses) are increasing. These trends and their possible consequences emphasize the importance of prevention efforts targeting PO misuse. To our knowledge, we have developed the first interactive web-based program (POP4Teens [P4T]) focused specifically on the prevention of PO misuse among adolescents. Objective This study aimed to evaluate the effectiveness of P4T, a web-based program designed to prevent adolescent PO misuse, in comparison with JustThinkTwice (JTT), an active control website, on PO-related attitudes, knowledge, risk perception, and intentions to use. Methods We conducted a web-based randomized controlled trial in 2018. A total of 406 adolescents (aged 12-17 years) were randomly assigned to either P4T or JTT. The outcome variables were attitudes, knowledge, and risk perceptions associated with PO misuse, intentions to use POs, and program feedback. Data were collected at baseline and at 1, 3, and 6 months. Results Both programs resulted in significant and sustained improvements in intention to use POs, increased perceived risk, impacted expectancies consistent with prevention, and improved PO refusal skills. P4T produced significantly greater increases in PO-related knowledge than JTT did, and it was reportedly easier to use and more liked. Baseline scores for youth reporting past-year medical use of POs, friends who engage in nonmedical use of POs, and/or poor mental health underscored their at-risk status compared with youth from the other groups. Conclusions P4T positively impacted all study variables that are known to prevent PO misuse among teens. Moreover, its web-based nature simplifies the dissemination and implementation of this novel tool designed to help meet the challenges of the evolving national opioid crisis. Trial Registration ClinicalTrials.gov NCT02737696; https://clinicaltrials.gov/ct2/show/NCT02737696

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Assessing the Relationships Between COVID-19 Stay-at-Home Orders and Opioid Overdoses in the State of Pennsylvania

Journal of Drug Issues ◽

10.1177/00220426211006362 ◽

2021 ◽

pp. 002204262110063

Author(s):

Brian King ◽

Ruchi Patel ◽

Andrea Rishworth

Keyword(s):

Age Groups ◽

The United States ◽

Opioid Use Disorder ◽

Opioid Overdose ◽

Policy Recommendations ◽

Opioid Use ◽

Fentanyl Analogs ◽

Measure Change ◽

Using Data ◽

At Home

COVID-19 is compounding opioid use disorder throughout the United States. While recent commentaries provide useful policy recommendations, few studies examine the intersection of COVID-19 policy responses and patterns of opioid overdose. We examine opioid overdoses prior to and following the Pennsylvania stay-at-home order implemented on April 1, 2020. Using data from the Pennsylvania Overdose Information Network, we measure change in monthly incidents of opioid-related overdose pre- versus post-April 1, and the significance of change by gender, age, race, drug class, and naloxone doses administered. Findings demonstrate statistically significant increases in overdose incidents among both men and women, White and Black groups, and several age groups, most notably the 30–39 and 40–49 ranges, following April 1. Significant increases were observed for overdoses involving heroin, fentanyl, fentanyl analogs or other synthetic opioids, pharmaceutical opioids, and carfentanil. The study emphasizes the need for opioid use to be addressed alongside efforts to mitigate and manage COVID-19 infection.

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