Friday, February 17, 2012

Naloxone programs in MMWR

This is a really big deal. MMWR is one of the principal publications of the medical and public health community. Articles are rigorously vetted and anything published here is taken seriously. Nice job Harm Reduction Coalition, Eliza Wheeler, Pete Davidson, Steve Jones, and Kevin Irwin!!

Some of the text ...

Community-Based Opioid Overdose Prevention Programs Providing Naloxone — United States, 2010


February 17, 2012 / 61(06);101-105

Drug overdose death rates have increased steadily in the United States since 1979. In 2008, a total of 36,450 drug overdose deaths (i.e., unintentional, intentional [suicide or homicide], or undetermined intent) were reported, with prescription opioid analgesics (e.g., oxycodone, hydrocodone, and methadone), cocaine, and heroin the drugs most commonly involved (1). Since the mid-1990s, community-based programs have offered opioid overdose prevention services to persons who use drugs, their families and friends, and service providers. Since 1996, an increasing number of these programs have provided the opioid antagonist naloxone hydrochloride, the treatment of choice to reverse the potentially fatal respiratory depression caused by overdose of heroin and other opioids (2). Naloxone has no effect on non-opioid overdoses (e.g., cocaine, benzodiazepines, or alcohol) (3). In October 2010, the Harm Reduction Coalition, a national advocacy and capacity-building organization, surveyed 50 programs known to distribute naloxone in the United States, to collect data on local program locations, naloxone distribution, and overdose reversals. This report summarizes the findings for the 48 programs that completed the survey and the 188 local programs represented by the responses. Since the first opioid overdose prevention program began distributing naloxone in 1996, the respondent programs reported training and distributing naloxone to 53,032 persons and receiving reports of 10,171 overdose reversals. Providing opioid overdose education and naloxone to persons who use drugs and to persons who might be present at an opioid overdose can help reduce opioid overdose mortality, a rapidly growing public health concern.

Overdose is common among persons who use opioids, including heroin users. In a 2002–2004 study of 329 drug users, 82% said they had used heroin, 64.6% had witnessed a drug overdose, and 34.6% had experienced an unintentional drug overdose (4). In 1996, community-based programs began offering naloxone and other opioid overdose prevention services to persons who use drugs, their families and friends, and service providers (e.g., health-care providers, homeless shelters, and substance abuse treatment programs). These services include education regarding overdose risk factors, recognition of signs of opioid overdose, appropriate responses to an overdose, and administration of naloxone.

To identify local program locations and assess the extent of naloxone distribution, in October 2010 the Harm Reduction Coalition e-mailed an online survey to staff members at the 50 programs then known to distribute naloxone. Follow-up e-mails and telephone calls were used to encourage participation, clarify responses, and obtain information on local, community-based programs. The survey included questions about the year the program began distributing naloxone, the number of persons trained in overdose prevention and naloxone administration, the number of overdose reversals reported, and whether the totals were estimates or based on program data. The survey also asked questions regarding the naloxone formulations currently distributed, any recent difficulties in obtaining naloxone, and the program's experience with naloxone distribution.

Staff members at 48 (96%) of the 50 programs completed the online survey. Since the first program began distributing naloxone in 1996, through June 2010, the 48 responding programs reported providing training and distributing naloxone to an estimated 53,032 persons (program range: zero to 16,220; median: 102.5; mean: 1,104.8).* From the first naloxone distribution in 1996 through June 2010, the programs received reports of 10,171 overdose reversals using naloxone (range: zero to 2,385; median: 32; mean: 211.9). During a recent 12-month period, respondents distributed an estimated 38,860 naloxone vials (Table).§ Using data from the survey, the number of programs beginning naloxone distribution each year during 1996–2010 was compared with the annual crude rates of unintentional drug overdose deaths per 100,000 population from 1979 to 2008 (Figure 1) (1).

The 48 responding programs were located in 15 states and the District of Columbia. Four responding programs provided consolidated data for multiple local, community-based programs. Three state health departments, in New York, New Mexico, and Massachusetts, provided data for 129 local programs (65, 56, and eight, respectively); a nongovernmental organization in Wisconsin provided data on a statewide operation with 16 local programs. In all, the 48 responding programs provided data for 188 local opioid overdose prevention programs that distributed naloxone (Figure 2). Nineteen (76.0%) of the 25 states with 2008 drug overdose death rates higher than the median and nine (69.2%) of the 13 states in the highest quartile (1) did not have a community-based opioid overdose prevention program that distributed naloxone (Figure 2).

For a recent 12-month period, the 48 responding programs reported distributing 38,860 naloxone vials, including refills (range: zero to 12,070; median: 97; mean: 809.6).Overdose prevention programs were characterized as small, medium, large, or very large, based on the number of naloxone vials distributed during that period. The six responding programs in the large and very large categories distributed 32,812 (84.4%) of the naloxone vials (Table).

Twenty-one (43.7%) responding programs reported problems obtaining naloxone in the "past few months" before the survey. The most frequently reported reasons for difficulties obtaining naloxone were the cost of naloxone relative to available funding and the inability of suppliers to fill orders.**

Thursday, February 9, 2012

Starting new naloxone programs: 2 new how-to guides from Europe

Two great new resources out this week on starting your own naloxone program from colleagues in Europe.
  • The UK's National Treatment Agency for Substance Misuse Overdose and Training Programme for Families and Carers provides a list of minimum training elements and the questions a group needs to ask as they are trying to set it up. Good, simple, practical advice.
  • Janna Ataiants and Dasha Ocheret of EHRN put together an awesome step-by-step guide to setting up naloxone programs. Topics covered include choosing models for procurement, storage and distribution, staff training, determining how many kits are needed, and advocacy strategies. The Annexes have tools for quality assessment and case studies.

Sunday, February 5, 2012

Pubmed December/January 2012 Update

Lots of papers over the past 8 weeks ...

Evans JL, Tsui JI, Hahn JA, Davidson PJ, Lum PJ, Page K.
Am J Epidemiol. 2012 Jan 6.
Comments: Thought I'd start with the best one this time, an excellent and desperately needed analysis that includes some estimates on mortality rates in one of the few prospective cohorts left.

Comparative analysis of pathological and toxicological features of opiate overdose and non-overdose fatalities.
Soravisut N, Rattanasalee P, Junkuy A, Thampitak S, Sribanditmongkol P.
J Med Assoc Thai. 2011 Dec;94(12):1540-6.
Comment: An interesting analysis of medical examiner cases in Chiang Mai. Interesting that tourists represented a growing proportion of cases over time.

Christian G, Pike G, Santamaria J, Reece S, DuPont R, Mangham C.
Lancet. 2012 Jan 14;379(9811):117; author reply 118-9. No abstract available.Comment: An interesting critique of the seminal paper on the overdose fatality reduction associated with Vancouver's supervised injection facility. The authors' response appears to effectively belie the critique.

"Foam Cone" exuding from the mouth and nostrils following heroin overdose.
Dinis-Oliveira RJ, Santos A, Magalhães T.
Toxicol Mech Methods. 2012 Feb;22(2):159-60.Comment: I'm not able to access. Anyone?

CDC Grand Rounds: Prescription Drug Overdoses - a U.S. Epidemic.
Centers for Disease Control and Prevention (CDC)
MMWR Morb Mortal Wkly Rep. 2012 Jan 13;61:10-3.Comment: This is so watered down I'm not sure of the message.

Offer of a quick fix.
Gould M.
Nurs Stand. 2011 Nov 16-22;26(11):24-5.
Comment: I was only able to access this through my university account, but it is a really interesting discussion of the British prison-release take-home naloxone trial. Scotland dropped out and began routine naloxone distribution for all released prisoners. The ethics around the trial are complex - many doubt the need for proof while others point to the frustrating history of treatments assumed to work and later proven to be harmful. While it is true that similar interventions for other populations would not require proof for wide dissemination, broad application of naloxone distribution will be limited by the lack of randomized trial data.

Correlates of non-medical prescription drug use among a cohort of injection drug users in Baltimore City.
Khosla N, Juon HS, Kirk GD, Astemborski J, Mehta SH.
Addict Behav. 2011 Dec;36(12):1282-7. Epub 2011 Aug 5.
Comment: Lots of prescription opioid use among injectors.

Gibson A, Randall D, Degenhardt L.Addiction. 2011 Dec;106(12):2186-92. doi: 10.1111/j.1360-0443.2011.03575.x. Epub 2011 Oct 17.
Comment: This paper discusses another major interest of mine - hepatitis C. Hep C-related deaths have doubled since I began medical practice and will double again over the next 10-15 years. Broadened screening and improved access to treatment are desperately needed and will more than double the impact of the improved treatments we are already seeing.

A qualitative study exploring the reason for low dosage of methadone prescribed in the MMT clinics in China
Lin C, Detels R.
Drug Alcohol Depend. 2011 Aug 1;117(1):45-9. Epub 2011 Feb 9.
Comments: Interesting discussion of problems with methadone dosing in China.

Drug related deaths in the Split-Dalmatia County 1997-2007.
Susnjara IM, Smoljanović A, Gojanović MD.
Coll Antropol. 2011 Sep;35(3):823-8.
Comments: Basic epidemiology of overdose deaths in Croatia that again emphasizes the role of polydrug use.

Vento AE, Schifano F, Corkery JM, Pompili M, Innamorati M, Girardi P, Ghodse H.
Prog Neuropsychopharmacol Biol Psychiatry. 2011 Jul 1;35(5):1279-83.
Comments: Can't access full article and I'm unclear how the results tie to conclusions from the abstract.

Weber JM, Tataris KL, Hoffman JD, Aks SE, Mycyk MB.
Prehosp Emerg Care. 2011 Dec 22.
Comments: Nebulized naloxone is an interesting option for emergency medical services, although not widely available as a means of lay administration.