Opioid Overdose Harm Reduction in the Substance Use Disorder Population

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 question becomes “What are the barriers to utilization of naloxone for emergency intervention to reverse opioid overdose and prevent overdose fatalities among the opioid using population?”.

Purpose: The purpose of this study is to assess participants’ knowledge about overdose risk factors and signs of opioid overdose, and to examine perceived barriers to utilizing overdose reversal strategies at the population level.

Method: The population for this study will be a convenience sample of patients enrolled in the Intensive Outpatient Program (IOP) at an urban teaching hospital. The method will be a questionnaire administered once during the IOP experience.

Results: Pending eIRB approval and administration of the questionnaire in early 2019, patient harm reduction, knowledge of risk factors for and signs of opioid overdose, and barriers to Narcan utilization at the population level will be examined.

Conclusion: This study can benefit health care providers by identifying perceived and actual barriers to utilization of naloxone to reverse opioid overdose in this population. Improvements can be made to programs that address addiction and recovery, by increasing patients' knowledge about, access to, and utilization 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. This can 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.