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Introduction Opiate use disorder is a common condition in healthcare services in Ireland, where over 200 opiate overdose deaths occur annually. There is limited addiction medicine education at undergraduate level and medical graduates may not be adequately prepared to diagnose and manage opioid use disorders and emergency drug overdose presentations. Therefore, we examined final-year medical students' learning experiences and attitudes toward opioid use disorder, overdose and community naloxone provision as an emerging overdose treatment. Methods We administered an anonymous paper-based survey to 243 undergraduate medical students undertaking their final professional completion module prior to graduation from University College Dublin, Ireland. Results were compared with parallel surveys of General Practitioners (GPs) and GP trainees. Results A total of 197 (82.1%) completed the survey. Just under half were male, and most were aged under 25 (63.3%) and of Irish nationality (76.7%). The students felt moderately prepared to recognise opioid use disorder, but felt less prepared to manage other aspects of its care. Most had taken a history from a patient with an opioid use disorder (82.8%), and a third had witnessed at least one opioid overdose. Although 10.3% had seen naloxone administered, most had never administered naloxone themselves (98.5%). Half supported wider naloxone availability; this was lower than support rates among GPs (63.6%) and GP trainees (66.1%). Conclusions Our findings suggest an unmet learning need in undergraduate training on opioid use disorder, with potential consequences for patient care.

Background The work context of the general practitioner (GP) potentially lends itself to the provision of early community based, cardiac arrest care. GPs have traditionally encountered out of hospital cardiac arrest (OHCA) as a component of routine patient care but have not been formally linked with the statutory ambulance service. Computer aided dispatch technology now allows real time GP text message alert to nearby cardiac arrest events. Aim To examine the feasibility, uptake and outcome of a novel scheme to alert GPs to nearby OHCA events in their communities. Methods GPs are recruited to voluntarily participate in a cardiac arrest text alert initiative called the ‘MERIT 3′ project. GPs indicate the hours during which they wish to receive OHCA text alerts, and also specify a geo-location from which they will receive alerts to OHCA events occurring within a specified radius. Data on alerts, responses, OHCA incidents and outcomes are gathered prospectively, using ambulance control and GP data and with corroborative data from the national OHCA registry. Results 423 general practices throughout Ireland were invited to participate. In the initial 12 months, 100 GPs from 85 individual practices have enrolled, 74 GPs have received alerts and 26 GPs have responded to incidents. Only 222/781 (28.4%) text alerts issued by ambulance control have proven to be recognised as cardiac arrests with resuscitation attempts. GPs have attended 51/776 (6.6%) OHCA incidents to which they have been alerted, with resuscitation undertaken in 34 cases with three survivors. Conclusion Text alert activation of GPs to nearby OHCA events has proven feasible, with significant activity during the establishment period, but a low survival rate which is similar to the overall national OHCA survival rate. A high proportion of alerts do not involve resuscitation opportunities.

Heroin use continues to drive opioid-related overdoses and mortality globally (Degenhardt & Hall, 2012). Not-as-prescribed use of prescription opioids increases the number of victims of this epidemic (Logan, Liu, Paulozzi, Zhang, & Jones, 2013). Naloxone has been shown to reduce mortality in overdose among people who use heroin and other opioids; however, its administration in a number of countries, including Ireland, is limited to paramedics and health professionals (Bury, 2015), despite proven effectiveness of overdose education and naloxone distribution (OEND) programmes by trained lay-people worldwide (McAuley, Aucott, & Matheson, 2015). The effectiveness of these programmes has been demonstrated around outcomes such as knowledge, skills, attitudes and reduced overdose deaths (Coffin & Sullivan, 2013), and involved groups including social workers and needle-exchange staff as well as family and friends of people who use opioids (Walley et al., 2013). While recent systematic reviews have demonstrated the efficacy and feasibility of training diverse groups in OEND (Behar, Santos, Wheeler, Rowe, & Coffin, 2015), the potential and capacity of general practice (GP), to contribute in this area have not been fully characterised (Nielsen & Van Hout, 2016). A naloxone demonstration project is underway in Ireland at the moment and aims to reduce Ireland’s high number of opioid-related deaths (Department of Health, 2015). European Commission Irish Research Council ELEVATE Marie Curie Actions

Setting Sudden Cardiac Death accounts for approximately 5000 deaths in Ireland each year. Nationally, out-of-hospital cardiac arrest has a very low resuscitation rate, reported at less than 5%. Ireland has a well developed general practice network which routinely manages emergencies arising in the community setting. However, little is known about its potential impact on Sudden Cardiac Death. This study reports on the incidence and management of cardiac arrest in Irish general practice. Method A national training/equipment project in defibrillation in general practice (MERIT) has established a network to prospectively report all cardiac arrests with a resuscitation attempt in general practice. Three monthly surveys of the network record events; structured debriefing uses a modified Utstein template to detail events and their outcomes. Results 426 practices reported data during a 36-month period (85–97% response rate to surveys), reporting 144 events, of which data are available on 136 events. 88.4% of events were witnessed, 31.6% by general practice staff. 58.2% of events occurred in the general practice or in the patient's home. The general practitioner (GP) was on scene before the ambulance in 72.6% of cases and 52.3% of the patients involved were patients of the GP attending. 52.3% of patients were defibrillated, 32.6% had return of spontaneous circulation at some point and 26 patients (19.5%) were discharged from hospital. Conclusions Cardiac arrest in general practice is compatible with structured, effective interventions and significant rates of successful resuscitation. All general practices should be capable of providing this care.

Background: Although widely acknowledged, few data exist on the scope of general practice involvement in the management of prehospital emergencies. A study was undertaken to explore the frequency and types of emergencies dealt with and the interventions undertaken by GPs who had completed Immediate Care training. Methods: All participants in Immediate Care courses in Ireland in 2002, 2003 and 2004 were invited to complete an anonymised questionnaire in which they estimated their experience of emergencies since completing a course. Sections dealt with personal/practice information, types of emergencies, interventions used and follow-up training. Results: 448 participants completed courses, 408 were available to participate in the study and 259 (63.5%) responded; 66.6% of GPs responded. The mean reporting period was 29.4 months (range 18–53). Participants included many younger female GPs at the start of their general practice careers. Although most emergencies dealt with were medical, few other patterns emerged in the timing or setting of emergencies. 88% of GPs had called an ambulance in an emergency at least once in the preceding year. 84% of GPs had managed a suspected acute myocardial infarction at least once during the reporting period; seizures, serious injuries, paediatric emergencies and hypoglycaemia were dealt with by up to half of all GPs. Interventions used included intravenous access in a medical emergency (69%), intravenous fluid administration (51%), intravenous morphine (54%), cardiopulmonary resuscitation (37%), defibrillation (21%), use of airway adjuncts (28%) and use of advanced life support drugs in cardiac arrest (24%). Conclusions: GPs make frequent use of a wide range of interventions in prehospital emergencies. Issues relating to tailored training, adequate equipment, collaboration with the emergency services and skills maintenance are highlighted by these data.

Background Overdose is the most common cause of fatalities among opioid users. Naloxone is a life-saving medication for reversing opioid overdose. In Ireland, it is currently available to ambulance and emergency care services, but General Practitioners (GP) are in regular contact with opioid users and their families. This positions them to provide naloxone themselves or to instruct patients how to use it. The new Clinical Practice Guidelines of the Pre-hospital Emergency Care Council of Ireland allows trained bystanders to administer intranasal naloxone. We describe the development and process evaluation of an educational intervention, designed to help GP trainees identify and manage opioid overdose with intranasal naloxone. Methods Participants (N = 23) from one postgraduate training scheme in Ireland participated in a one-hour training session. The repeated-measures design, using the validated Opioid Overdose Knowledge (OOKS) and Attitudes (OOAS) Scales, examined changes immediately after training. Acceptability and satisfaction with training were measured with a self-administered questionnaire. Results Knowledge of the risks of overdose and appropriate actions to be taken increased significantly post-training [OOKS mean difference, 3.52 (standard deviation 4.45); P

Background: Opioid overdose is the primary cause of death among drug users globally. Personal and social determinants of overdose have been studied before, but the environmental factors lacked research attention. Area deprivation or presence of addiction clinics may contribute to overdose. Objectives: To examine the baseline incidence of all new opioid overdoses in an ambulance service, and their relationship with urban deprivation and presence of addiction services. Methods: A prospective chart review of pre-hospital advanced life support patients was performed on confirmed opioid overdose calls. Demographic, geographic, and clinical information, i.e. presentation, treatment, outcomes, was collected for each call. The Census data were used to calculate deprivation. Geographical information software mapped the urban deprivation and addiction services against the overdose locations. Results: There were 469 overdoses, 13 of which were fatal; most were male (80%), of a young age (32 years), with a high rate of repeated overdoses (26%), and common poly-drug use (9.6%). Majority occurred in daytime (275), on the streets (212). Overdoses were more likely in more affluent areas (r = .15, P < .05), and in a 1000 m radius of addiction services. Residential overdoses were in more deprived areas than street overdoses (mean difference 7.8, t(170) = 3.99, P < .001). Street overdoses were more common in the city centre than suburbs (χ2(1) = 33.04, P < 0.001). Conclusions: the identified clusters of increased incidence – urban overdose hotspots - suggest a link between environment characteristics and overdoses. This highlights a need to establish overdose education and naloxone distribution in the overdose hotspots. MERIT

Background: Ireland’s health services are undergoing dramatic reorganisation. The establishment of general practitioner (GP) out of hours cooperatives and the integration of current ambulance services into a national ambulance service are among the issues that will impact on prehospital care of emergencies. The study aimed to explore the perceptions of GPs and emergency medical technicians (EMTs) of their own and each other’s roles in the context of such reforms. Methods: A census of all GPs (511) and EMTs (301) in three of Ireland’s eight health board regions was undertaken. A questionnaire containing 31 statements asked respondents to indicate their agreement (or lack of it) in areas such as general relationships, care, and training, roles in emergencies and future developments. Results: Of the personnel contacted, 72% of GPs and 75% of EMTs responded. They report excellent working relationships, agree that the ambulance service is of high quality, and that GPs are willing to provide care in emergencies. However, working links are less satisfactory for EMTs, who report a far higher perception of GP use of emergency ambulances than reported by GPs. Both groups are interested in innovative future links. Discussion: Convergence between the professional groups in different geographic areas and between the disciplines across the areas is striking. They include areas of satisfaction and dissatisfaction. The need for improved liaison between the disciplines is clear.