Background: Deaths from unintentional opioid overdose are increasing worldwide. In the United States alone, opioid overdose fatalities have surpassed all other causes of unintentional deaths in the 25-64-year-old population (Rudd et al, 2016). The overuse/abuse of opiates and opioid analgesics has reached epidemic proportions throughout much of the world, prompting the World Health Organization (WHO, 2014) to issue guidelines for harm reduction strategies aimed at preventing opioid fatalities from accidental overdose. These guidelines specify that those who witness overdoses should have the tools to intervene.
The rapid escalation of opioid overdose fatalities worldwide has led to Opioid Use Disorder (OUD) becoming a major public health issue. The United States Federal Government Department of Health and Human Services has called on states to implement multi-pronged programs to combat the problem (ASPE, 2015). Both the Substance Abuse and Mental Health Services Administration (SAMHSA, 2018), and the Center for Disease Control (CDC, 2018) support state-based policy initiatives focused on decreasing opioid overdose fatalities by directing funding and guiding policy. Although comprehensive long-term approaches to combating this crisis are being implemented in many states, short term strategies to reduce harm and prevent deaths from overdose must take priority.
The concept of harm reduction originated in the public health setting. Harm reduction principles central to practice include acceptance that drug use is a reality and focuses on decreasing the harmful consequences of opioid overdose, including death. There are many opportunities to implement harm reduction strategies in the opioid use population and decrease the morbidity and mortality associated with opioid abuse, dependence, and overdose. These strategies include overdose education, naloxone distribution, and policies aimed at increasing bystander assistance in cases of opioid overdose (Hawk, et al, 2015).
Harm reduction initiatives aimed specifically at reversing the effects of opioid overdose include expanding the utilization of naloxone, accelerating the availability of user friendly Narcan products, and identifying and disseminating best practice naloxone delivery models and strategies within communities at risk (ASPE, 2015). Narcan overdose education and lay administration of naloxone is associated with increased overdose recognition and management as well as improved odds of recovery from opioid overdose (Giglio, 2015). In Maryland, one of these harm reduction initiatives is a call to improve access to the opioid reversal agent Naloxone (Narcan) for those who are at greatest risk.
The city of Baltimore has one of the oldest community-based overdose prevention programs in the country. Despite this, Baltimore also has one of the highest rates of opioid overdose fatalities in the state (MDH, 2018). Naloxone is an opioid antagonist, that when administered in a timely manner, can reverse the effects of opioids and prevent fatal overdoses. Baltimore has some of the least restrictive and most effective public health harm reduction plans in the nation, yet deaths from opioid overdoses continue to rise. One proposed reason for this is that those who are most at risk do not have the information or resources readily available to intervene peer-to-peer.
Under the Maryland Department of Health and Mental Hygiene Overdose Response Program, there is currently a statewide standing order that allows all Maryland-licensed pharmacists to dispense naloxone to any individual. With this standing order in place, a person-specific prescription is not required in order for pharmacists to dispense Naloxone. The standing order allows dispensing to any individual, does not require that the individual have any previous training on use of naloxone, and allows for dispensing of 2 doses of Naloxone which is covered by Maryland Medicaid (MDHMH, 2017).
Much of the literature that has been published about access to naloxone has examined difficulties around prescriber and system efforts. There is little information about user level issues. There is also a current research gap about the implementation of overdose reversal agents from patients’ perspectives. The questions become: 1) “What are the barriers to utilization of naloxone for emergency intervention to reverse opioid overdose and prevent overdose fatalities among the opioid using population?” 2) “Does an informational Harm Reduction intervention aimed at addressing some of these barriers affect knowledge of and likelihood to utilize Narcan for Opioid Overdose reversal? This study contributes to the overall knowledge about existing barriers to harm reduction strategies and the effects of a targeted intervetnion to address those barriers for the substance use disorder population.
Purpose: The purpose of this study was to assess participants’ knowledge about overdose risk factors and signs of opioid overdose, to examine perceived barriers to utilizing overdose reversal strategies at the community level, and to evaluate one harm reduction intervention as it relates to improving outcomes.
Method/Design: The population for this study was a convenience sample of patients enrolled in the Intensive Outpatient Program (IOP) at an urban teaching hospital. The method was a questionnaire administered once during the IOP experience prior to the intervention, and again with the same group after the intervention (test-retest). The methodology also included administering the same questionnaire once to a non-equivalent group exposed to the intervention prior to testing. The intervention was 3 posters placed at high exposure areas with matching trifold handouts available at the same points of contact.
Design: Quasi-experimental nonequivalent control group, and “test-retest” design.
Results: An eIRB was approved and administration of questionnaire was completed late 2018, patient harm reduction, community-based resources and barriers were examined. An intervention provided to the SUD outpatient clinic was created. Additionally, effects of this targeted harm reduction intervention were evaluated.
Conclusion: This study can benefit health care providers by identifying perceived and actual barriers to utilization of naloxone to reverse opioid overdose in the SUD population so that improvements can be made to the programs in terms of increasing knowledge about, access to, and dissemination of life saving practices. Further research is needed in communities where opioid overdose fatalities are high to improve the implementation of harm reduction strategies for those at risk of opioid overdose and ensure future benefits to society as a whole as an integral piece of an improved strategy for harm reduction in the larger opioid using population.