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Background: Opioid-related overdose is the leading cause of death for people recently released from incarceration, however treatment with medications for opioid use disorder (MOUD) during incarceration can reduce the mortality risk. This study seeks to qualitatively analyze perceptions of post-release overdose risk from the perspectives of people who received MOUD while incarcerated in one of eight Massachusetts jails during 2021–2022 using the Risk Environment Framework to guide analyses. Methods: N = 38 participants with lived experience of MOUD treatment during incarceration who are now living in the community were interviewed on factors that may contribute to or protect against post-release overdose risk. Themes were identified inductively and deductively using the Risk Environment Framework and its domains, which organizes themes along physical, social, economic, and policy environments on both the micro- and macro- scales. Results: The physical risk environment included loss of opioid tolerance during incarceration, polysubstance use, and the toxicity of the regional drug supply as key producers of increased risk for post-release overdose. Social drivers of risk included peer group risk norms—including peer-driven harm reduction practices and interpersonal relationships between drug sellers and buyers—as well as macro-level social determinants of health such as housing insecurity and availability of mental health services. Economic drivers of post-release overdose risk included lack of income generation during incarceration and employment challenges. Participants discussed several aspects of policy that contribute to post-release overdose risk, including availability of harm reduction supplies, public health services, and broader policy around MOUD. Conclusions: The perspectives of people with lived experience are vital to understanding the disproportionate risks of overdose for those recently released from incarceration. Our results highlight the intersectional factors that produce and reproduce the post-release overdose risk environment, providing support for interventions across each domain of the Risk Environment Framework. By capturing perspectives from people with lived experience of OUD and incarceration during this critical period of risk, we can better identify interventions that target and mitigate overdose-related harm in this population. [ABSTRACT FROM AUTHOR]

Families of people with opioid use disorder (OUD) often provide informal care, serving an integral supportive role in the healthcare system. Yet these family members are often overlooked as a population under strain and in need of support themselves. In this study, we examine the stress faced by family members of persons with OUD in Massachusetts, USA, through semi-structured qualitative interviews (N = 22, April–July 2018). Data revealed that family members experience shame around OUD and live in a state of overwhelming worry about opioid overdose and that this fear permeates all aspects of their lives, impacting their health, relationships, employment, and finances. Effective coping and social support mitigated some of these challenges. This study fills a gap in the research by examining the challenges distinct to supporting a loved one with OUD – largely stress and trauma related to opioid overdose. [ABSTRACT FROM AUTHOR]

Background: Fatal opioid-involved overdose rates increased precipitously from 5.0 per 100,000 population to 33.5 in Massachusetts between 1999 and 2022. Methods: We used spatial rate smoothing techniques to identify persistent opioid overdose-involved fatality clusters at the ZIP Code Tabulation Area (ZCTA) level. Rate smoothing techniques were employed to identify locations of high fatal opioid overdose rates where population counts were low. In Massachusetts, this included areas with both sparse data and low population density. We used Local Indicators of Spatial Association (LISA) cluster analyses with the raw incidence rates, and the Empirical Bayes smoothed rates to identify clusters from 2011 to 2021. We also estimated Empirical Bayes LISA cluster estimates to identify clusters during the same period. We constructed measures of the socio-built environment and potentially inappropriate prescribing using principal components analysis. The resulting measures were used as covariates in Conditional Autoregressive Bayesian models that acknowledge spatial autocorrelation to predict both, if a ZCTA was part of an opioid-involved cluster for fatal overdose rates, as well as the number of times that it was part of a cluster of high incidence rates. Results: LISA clusters for smoothed data were able to identify whether a ZCTA was part of a opioid involved fatality incidence cluster earlier in the study period, when compared to LISA clusters based on raw rates. PCA helped in identifying unique socio-environmental factors, such as minoritized populations and poverty, potentially inappropriate prescribing, access to amenities, and rurality by combining socioeconomic, built environment and prescription variables that were highly correlated with each other. In all models except for those that used raw rates to estimate whether a ZCTA was part of a high fatality cluster, opioid overdose fatality clusters in Massachusetts had high percentages of Black and Hispanic residents, and households experiencing poverty. The models that were fitted on Empirical Bayes LISA identified this phenomenon earlier in the study period than the raw rate LISA. However, all the models identified minoritized populations and poverty as significant factors in predicting the persistence of a ZCTA being part of a high opioid overdose cluster during this time period. Conclusion: Conducting spatially robust analyses may help inform policies to identify community-level risks for opioid-involved overdose deaths sooner than depending on raw incidence rates alone. The results can help inform policy makers and planners about locations of persistent risk. [ABSTRACT FROM AUTHOR]

Identifying predictors of opioid overdose following release from prison is critical for opioid overdose prevention. We leveraged an individually linked, state-wide database from 2015–2020 to predict the risk of opioid overdose within 90 days of release from Massachusetts state prisons. We developed two decision tree modeling schemes: a model fit on all individuals with a single weight for those that experienced an opioid overdose and models stratified by race/ethnicity. We compared the performance of each model using several performance measures and identified factors that were most predictive of opioid overdose within racial/ethnic groups and across models. We found that out of 44,246 prison releases in Massachusetts between 2015–2020, 2237 (5.1%) resulted in opioid overdose in the 90 days following release. The performance of the two predictive models varied. The single weight model had high sensitivity (79%) and low specificity (56%) for predicting opioid overdose and was more sensitive for White non-Hispanic individuals (sensitivity = 84%) than for racial/ethnic minority individuals. Stratified models had better balanced performance metrics for both White non-Hispanic and racial/ethnic minority groups and identified different predictors of overdose between racial/ethnic groups. Across racial/ethnic groups and models, involuntary commitment (involuntary treatment for alcohol/substance use disorder) was an important predictor of opioid overdose. [ABSTRACT FROM AUTHOR]

Post-overdose outreach programs can play a key role in reducing opioid overdose deaths and increasing access to healthcare services. The design and implementation of these programs, especially in rural communities, remains a gap in knowledge. We aimed to understand the lessons learned from the implementation experiences of the Community, Opportunity, Network, Navigation, Exploration, and Connection Team (CONNECT), a post-overdose outreach program based in a rural community in Massachusetts. We conducted semi-structured focus groups and interviews with 21 community partners after the first year of implementation in 2022. Participants included behavioral health, medical, public health, and public safety personnel involved in the design and implementation of CONNECT. Using a combination of thematic and rapid qualitative analysis methods, we inductively coded transcripts for salient themes. Themes were mapped onto the Health Equity Implementation Framework to better understand implementation and health-equity factors. Facilitators to implementation of this innovation included efficient inter-partner data sharing and coordination, and ability to offer numerous health services to clients to meet their needs. Key partners identified that CONNECT serves clients who use opioids, have previous involvement with the legal system, and reside in low-income areas within this rural region. Unhoused individuals and individuals who do not call 9–11 after an overdose were identified as populations of need that CONNECT was missing due to structural barriers. Partners shared how the context of this rural community came with challenges related to limited access to health services and pervasive stigma towards substance use, while it was also perceived to foster a culture of collaboration and unity among multidisciplinary key partners. Post overdose outreach programs serve clients with complex health needs. The ability to access services for these health needs is shaped by the post overdose outreach program and its key partners, and by the broader community context. As post-overdose outreach programs continue to expand as a promising strategy to address the opioid overdose crisis, there exists a need to contextualize implementation strategies to inform adaptations and develop best-practices. [ABSTRACT FROM AUTHOR]

Objective: Timely data on drug overdose deaths can help identify community needs, evaluate the effectiveness of interventions, and allocate resources. We identified variations in death investigation and reporting systems within and between states that affect the timeliness and accuracy of death certificate information. Methods: The HEALing Communities Study (HCS) is a community-engaged, data-driven approach to combating the opioid crisis in 67 communities in 4 states: Kentucky, Massachusetts, New York, and Ohio. HCS conducted a survey of coroners and medical examiners to understand variability in drug overdose death data. We compared survey results in Massachusetts, New York, and Ohio with national data to investigate the completeness of provisional death counts by type of death investigation system. Results: Communities in each HCS state had different ways of collecting and reporting mortality data. Completion of death certificates for drug overdoses ranged from <2 weeks in 23% (7 of 31) of those surveyed to more than 3 months in 10% (3 of 31) of those surveyed. Variabilities in the timeliness of reporting drug overdose deaths were not associated with type of coroner or medical examiner office in each state, urban versus rural setting, or specificity of drug information on the death certificate. Conclusion: Having specific drug information on the death certificate may increase death certificate quality, comparability, and accuracy. We recommend the following: (1) all coroners and medical examiners should be trained on conducting death investigations, interpreting toxicology reports, and completing death certificates; (2) 1 office in each state should oversee all coroners and medical examiners to increase data consistency; and (3) communities should identify and address barriers to timely death certification. [ABSTRACT FROM AUTHOR]

Background and Aims: The onset of the coronavirus disease 2019 (COVID‐19) pandemic was associated with a surge in opioid overdose deaths in Massachusetts, particularly affecting racial and ethnic minority communities. We aimed to compare the impact of the pandemic on opioid overdose fatalities and naloxone distribution from community‐based programs across racial and ethnic groups in Massachusetts. Design: Interrupted time‐series. Setting and Cases: Opioid overdose deaths (OODs) among non‐Hispanic White, non‐Hispanic Black, Hispanic and non‐Hispanic other race people in Massachusetts, USA (January 2016 to June 2021). Measurements Rate of OODs per 100 000 people, rate of naloxone kits distributed per 100 000 people and ratio of naloxone kits per opioid overdose death as a measure of naloxone availability. We applied five imputation strategies using complete data in different periods to account for missingness of race and ethnicity for naloxone data. Findings Before COVID‐19 (January 2016 to February 2020), the rate of OODs declined among non‐Hispanic White people [0.2% monthly reduction (95% confidence interval = 0.0–0.4%)], yet was relatively constant among all other population groups. The rate of naloxone kits increased across all groups (0.8–1.2% monthly increase) and the ratio of naloxone kits per OOD death among non‐Hispanic White was 1.1% (0.8–1.4%) and among Hispanic people was 1.0% (0.2–1.8%). After the onset of the pandemic (March 2020+), non‐Hispanic Black people experienced an immediate increase in the rate of OODs [63.6% (16.4–130%)], whereas rates among other groups remained similar. Trends in naloxone rescue kit distribution did not substantively change among any groups, and the ratio of naloxone kits per OOD death for non‐Hispanic Black people did not compensate for the surge in OODs deaths in this group. Conclusions: With the onset of the COVID‐19 pandemic, there was a surge in opioid overdose deaths among non‐Hispanic Black people in Massachusetts, USA with no compensatory increase in naloxone rescue kit distribution. For non‐Hispanic White and Hispanic people, opioid overdose deaths remained stable and naloxone kit distribution continued to increase. [ABSTRACT FROM AUTHOR]

Aims: To create a novel emergency medical service (EMS) opioid‐related incident (ORI) tiering framework to describe more accurately the opioid epidemic in Massachusetts. By classifying the data, we could more accurately detail differing trends among the new categories. Design: Free‐text fields of Massachusetts EMS reports, from 2013 through 2020, were analyzed to identify ORIs and then categorized into a five‐tier severity cascade based on symptom presentation: 'dead on arrival,' 'acute overdose,' 'intoxication,' 'withdrawal' and 'other ORI.' As a validation of the new classification, an emergency medical technician, paramedic and emergency medical physician reviewed clinical reports and assigned a severity category to 100 randomly selected cases. The algorithm then assessed the same 100 cases to determine if it could accurately identify the severity category for each case. Findings Validation of the algorithm by clinical review indicated a substantial level of agreement between the algorithm and the reviewers. Over half of all ORIs were acute overdose (55%), 21% were intoxication, 20% were other ORI, 3% were withdrawal, and 1% were dead on arrival. Overall ORIs decreased in 2020, but the number of 'dead on arrival' increased 32% from 2019. Administration of naloxone also differed between the categories, with 95% of acute overdose and 29% of intoxication receiving naloxone. Conclusions: This novel categorization of emergency medical service opioid‐related incidents in Massachusetts, United States, reveals new trend details and strains on the emergency medical service system. Using these categories also improves dataset linkage within the state and interstate rate comparisons. [ABSTRACT FROM AUTHOR]

Prescription opioids (POs) have had a devastating effect on people and public health systems in the U.S. Due to the urgency and complexity of the opioid crisis, there is a need to expand qualitative research on the medical community's perspectives on opioid prescribing practices and the role that prescription drug monitoring programs (PDMPs) have played in mitigating this crisis. We conducted qualitative interviews with clinicians (n = 23) across specialties and a range of overdose hotspot and coldspot locations in Massachusetts during 2019. We aimed to capture their perspectives on the opioid crisis, changes in clinical practice, and experiences with opioid prescribing and PDMPs. Respondents consistently recognized the role clinicians played in the opioid crisis and reported reductions in their opioid prescribing, which were motivated by the crisis itself. The limitations of opioids in pain management were frequently discussed. While clinicians appreciated having greater awareness of their opioid prescribing and increased access to patient prescription histories, they also expressed concerns about surveillance of their prescribing and other unintended consequences. We observed that clinicians in opioid prescribing hotspots had more detailed and specific reflections on their experiences with the Massachusetts PDMP, MassPAT. Clinician perceptions of the severity of the opioid crisis in Massachusetts and thoughts on their role as prescribers were consistent across specialty, prescribing level, and practice location. Many clinicians in our sample cited use of the PDMP as an influence on their prescribing. Those practicing in opioid overdose hotspots had the most nuanced reflections about the system. [ABSTRACT FROM AUTHOR]

Background Since 2014, multiple outbreaks of human immunodeficiency virus (HIV) among people who inject drugs have occurred across the United States along with hepatitis C virus (HCV), skin and soft tissue infections (SSTIs), and infective endocarditis (IE), creating a converging public health crisis. Methods We analyzed the temporal patterns of infectious disease and overdose using a hierarchical Bayesian distributed lag logistic regression model examining the probability that a given geographic area experienced at least 1 HIV case in a given month as a function of the counts/rates of overdose, HCV, SSTI, and IE and associated medical procedures at different lagged time periods. Results Current-month HIV is associated with increasing HCV cases, abscess incision and drainage, and SSTI cases, in distinct temporal patterns. For example, 1 additional HCV case occurring 5 and 7 months previously is associated with a 4% increase in the odds of observing at least 1 current-month HIV case in a given locale (odds ratios, 1.04 [90% credible interval {CrI}: 1.01–1.10] and 1.04 [90% CrI: 1.00–1.09]). No such associations were observed for echocardiograms, IE, or overdose. Conclusions Lagged associations in other infections preceding rises in current-month HIV counts cannot be described as predictive of HIV outbreaks but may point toward newly discovered epidemics of injection drug use and associated clinical sequalae, prompting clinicians to screen patients more carefully for substance use disorder and associated infections. [ABSTRACT FROM AUTHOR]

This time-series analysis assesses the association of implementation of postoverdose outreach programs with opioid fatality rates in Massachusetts municipalities with high numbers of opioid-related medical emergency services responses. Key Points: Question: Among Massachusetts municipalities with high numbers of opioid-related medical emergency services responses, was implementation of postoverdose outreach programs associated with reductions in fatal opioid overdoses? Findings: In this multisite interrupted time-series analysis of 93 Massachusetts municipalities, implementation of postoverdose outreach programs was significantly associated with lower opioid fatality rates over time compared with municipalities that did not implement such programs. Meaning: In this study, among Massachusetts municipalities with high numbers of opioid-related emergency services responses, implementation of postoverdose outreach programs was significantly associated with lower opioid fatality rates over time. Importance: Nonfatal opioid overdose is the leading risk factor for subsequent fatal overdose and represents a critical opportunity to reduce future overdose and mortality. Postoverdose outreach programs emerged in Massachusetts beginning in 2013 with the main purpose of linking opioid overdose survivors to addiction treatment and harm reduction services. Objective: To evaluate whether the implementation of postoverdose outreach programs among Massachusetts municipalities was associated with lower opioid fatality rates compared with municipalities without postoverdose outreach programs. Design, Setting, and Participants: This retrospective interrupted time-series analysis was performed over 26 quarters (from January 1, 2013, through June 30, 2019) across 93 municipalities in Massachusetts. These 93 municipalities were selected based on a threshold of 30 or more opioid-related emergency medical services (EMS) responses in 2015. Data were analyzed from November 2021 to August 2022. Exposures: The main exposure was municipality postoverdose outreach programs. Municipalities had various program inceptions during the study period. Main Outcomes and Measures: The primary outcome was quarterly municipal opioid fatality rate per 100 000 population. The secondary outcome was quarterly municipal opioid-related EMS response (ambulance trips) rates per 100 000 population. Results: The mean (SD) population size across 93 municipalities was 47 622 (70 307), the mean (SD) proportion of female individuals was 51.5% (1.5%) and male individuals was 48.5% (1.5%), and the mean (SD) age proportions were 29.7% (4.0%) younger than 25 years, 26.0% (4.8%) aged 25 to 44 years, 14.8% (2.1%) aged 45 to 54 years, 13.4% (2.1%) aged 55 to 64 years, and 16.1% (4.4%) aged 65 years or older. Postoverdose programs were implemented in 58 municipalities (62%). Following implementation, there were no significant level changes in opioid fatality rate (adjusted rate ratio [aRR], 1.07; 95% CI, 0.96-1.19; P =.20). However, there was a significant slope decrease in opioid fatality rate (annualized aRR, 0.94; 95% CI, 0.90-0.98; P =.003) compared with the municipalities without the outreach programs. Similarly, there was a significant slope decrease in opioid-related EMS response rates (annualized aRR, 0.93; 95% CI, 0.89-0.98; P =.007). Several sensitivity analyses yielded similar findings. Conclusions and Relevance: In this study, among Massachusetts municipalities with high numbers of opioid-related EMS responses, implementation of postoverdose outreach programs was significantly associated with lower opioid fatality rates over time compared with municipalities that did not implement such programs. Program components, including cross-sectoral partnerships, operational best practices, involvement of law enforcement, and related program costs, warrant further evaluation to enhance effectiveness. [ABSTRACT FROM AUTHOR]

Purpose: Overdose is a leading cause of death among people who use drugs (PWUDs), but policies to reduce fatal overdose have had mixed results. Summaries of naloxone access and Good Samaritan Laws (GSLs) in prior studies provide limited information about local context. Witnessing overdoses may also be an important consideration in providing services to PWUDs, as it contributes to post traumatic stress disorder (PTSD) symptoms, which complicate substance use disorder treatment. Methods: We aim to estimate the prevalence and correlates of witnessing and responding to an overdose, while exploring overdose context among rural PWUD. The Drug Injection Surveillance and Care Enhancement for Rural Northern New England (DISCERNNE) mixed‐methods study characterized substance use and risk behaviors in 11 rural Massachusetts, Vermont, and New Hampshire counties between 2018 and 2019. PWUD completed surveys (n = 589) and in‐depth interviews (n = 22). Findings: Among the survey participants, 84% had ever witnessed an overdose, which was associated with probable PTSD symptoms. Overall, 51% had ever called 911 for an overdose, though some experienced criminal legal system consequences despite GSL. Although naloxone access varied, 43% had ever used naloxone to reverse an overdose. Conclusions: PWUD in Northern New England commonly witnessed an overdose, which they experienced as traumatic. Participants were willing to respond to overdoses, but faced barriers to effective overdose response, including limited naloxone access and criminal legal system consequences. Equipping PWUDs with effective overdose response tools (education and naloxone) and enacting policies that further protect PWUDs from criminal legal system consequences could reduce overdose mortality. [ABSTRACT FROM AUTHOR]

Aim: To estimate the number of treatment initiations, averted fatal opioid overdoses and the cost‐effectiveness associated with offering buprenorphine–naloxone (buprenorphine) treatment on‐site within existing syringe service programs (SSPs) in Massachusetts, USA. Design, Setting and Participants: This was a cohort‐based mathematical model and cost‐effectiveness analysis. We derived model inputs from state and national surveillance data, clinical trials and observational cohort studies. We compared an intervention scenario where 30% of SSP clients initiated buprenorphine treatment on‐site at least once annually to a status quo scenario where no buprenorphine was available on‐site among community treatment providers in Massachusetts, 2020–30. In individuals with opioid use disorder (OUD) we assumed that 80% of SSP clients had recently injected drugs and that treatment within SSPs would have similar or improved retention compared with standard‐of‐care buprenorphine programs, but higher rates of active opioid use while in treatment. Measurements: Number of treatment initiations (i.e. individuals began treatment on a medication for opioid use disorder or entered medically managed withdrawal), averted fatal opioid overdoses, quality‐adjusted life‐years (QALYs) and life‐time discounted costs from a health sector and a limited societal perspective. Findings The status quo scenario resulted in 23 051 fatal overdoses and 1 511 613 treatment initiations over a 10‐year simulation period. An intervention scenario with on‐site SSP buprenorphine treatment averted 4797 (−20.8%) fatal opioid overdoses and resulted in 129 359 (+8.6%) additional treatment initiations compared with the status quo. The intervention scenario was the dominating scenario: providing OUD treatment through Massachusetts SSPs cost less (−$3612 per person) with patients accumulating more QALYs (0.2 per person) compared with the status quo scenario. Conclusions: Offering buprenorphine treatment on‐site within syringe service programs has the potential to decrease fatal overdoses substantially, improve treatment engagement and save on costs. [ABSTRACT FROM AUTHOR]

Background and Aims: Medications for opioid use disorder (MOUD) are shown to reduce opioid use and the risk of overdose. People with opioid use disorder (OUD) who exit inpatient medically managed withdrawal programs (detox) without initiating MOUD and linking to outpatient care have high rates of overdose. While detox encounters provide a theoretical opportunity for MOUD initiation, this is not ubiquitous in the United States. We used simulation modeling to estimate the population‐level health effects and cost‐effectiveness of a policy encouraging MOUD initiation during inpatient detox encounters. Design, Setting and Participants: We employed a dynamic population state‐transition model to evaluate the effectiveness and cost‐effectiveness of using detox programs as venues for initiating MOUD in Massachusetts, United States. We compared standard of care, where no detox patients initiate MOUD or link to outpatient MOUD providers, to strategies of offering MOUD to detox patients and linking those patients to outpatient MOUD. Measures: Budgetary impact to the Massachusetts health‐care sector, incremental cost‐effectiveness ratios (ICER) and total counts and percentage differences of fatal overdoses prevented. Findings: Initiating MOUD in detox with perfect linkage to outpatient MOUD would reduce fatal overdoses by 4.5% [95% confidence interval (CI) = 2.3–5.9], at an ICER of $56 000 per quality‐adjusted life‐year (QALY) gained, compared with the standard of care. With moderate linkage, fatal overdoses would be reduced by 2.3% (95% CI= 1.2–3.1) with an ICER of $78 500 per QALY gained, compared with standard of care. Budgetary increase to Massachusetts health‐care spending ranged from 0.5–1%. Conclusion: A simulation model indicates that initiation of medications for opioid use disorder and linkage policies among detox patients in Massachusetts, USA could prevent fatal opioid overdoses in the opioid use disorder population and would be cost‐effective from a health‐care sector perspective. [ABSTRACT FROM AUTHOR]

Background: In a previous statewide naloxone purchase trial conducted in Massachusetts, we documented high levels of naloxone accessibility, upon patient request, under the state's naloxone standing order (NSO) program. Equally important for reducing overdose mortality rates is expanding naloxone access via codispensing alongside opioid prescription and syringe purchases at pharmacies.Objective: To understand naloxone codispensing from the perspective of pharmacists under the Massachusetts NSO program.Methods: The study used a mixed methods design involving 3 focus groups and a quantitative survey. Participants in both the focus groups (N = 27) and survey (N = 339) were licensed Massachusetts pharmacists. Focus groups were conducted at 3 separate professional conferences for pharmacists. The survey was conducted using a stratified random sample of 400 chain and independent retail pharmacies across Massachusetts. All data were collected between September 2018 and November 2019. Quantitative and qualitative analyses examined current policies, practices, and attitudes regarding naloxone codispensing for patients at risk of opioid overdose.Results: Most pharmacists (69%) reported that they, their pharmacy, or both promoted codispensing alongside opioid prescriptions. A majority promoting naloxone codispensing did so for patients prescribed high opioid dosages (80%); fewer promoted codispensing for patients also prescribed benzodiazepines (20%). Facilitators to codispensing were pre-existing relationships between pharmacists and prescribers, mandatory pharmacist consultation, and universal naloxone promotion to all patients meeting certain criteria. Barriers to codispensing were pharmacists' concerns about offending patients by initiating a conversation about naloxone, insufficient technician training, workflow and resource constraints, and misconceptions surrounding naloxone. We found no substantive differences in outcomes between chain and independent pharmacies.Conclusion: We documented several facilitators and barriers to naloxone codispensing in Massachusetts pharmacies. Areas amenable to intervention include increased training for front-line pharmacy technicians, mandatory pharmacist consultation for opioid-prescribed patients, workflow reorganization, and addressing stigma concerns on the pharmacist end. [ABSTRACT FROM AUTHOR]

We introduce the concept of harm reduction capital (HRCap) as the combination of knowledge, resources, and skills related to substance use risk reduction, which we hypothesize to predict MOUD use and opioid overdose. In this study, we explored the interrelationships between ethnicity, HRCap, nonfatal overdose, and MOUD use among PWUD. Between 2017 and 2019, people who currently or in the past used opioids and who lived in Massachusetts completed a one-time survey on substance use history, treatment experiences, and use of harm reduction services. We fit first-order measurement constructs for positive and negative HRCap (facilitators and barriers). We used generalized structural equation models to examine the inter-relationships of the latent constructs with LatinX self-identification, past year overdose, and current use of MOUD. HRCap barriers were positively associated with past-year overdose (b=2.6, p<0.05), and LatinX self-identification was inversely associated with HRCap facilitators (b=-0.49, p<0.05). There was no association between overdose in the past year and the current use of MOUD. LatinX self-identification was positively associated with last year methadone treatment (b=0.89, p<0.05) but negatively associated with last year buprenorphine treatment (b=-0.68, p<0.07). Latinx PWUD reported lower positive HRCap than white non-LatinX PWUD and had differential utilization of MOUD. Our findings indicate that a recent overdose was not associated with the current use of MOUD, highlighting a severe gap in treatment utilization among individuals at the highest risk. The concept of HRCap and its use in the model highlight substance use treatment differences, opportunities for intervention, and empowerment. • Harm reduction capital – knowledge, and resources related to substance use risk reduction. • Harm reduction capital barriers associated with past year overdose. • Disparities in harm reduction capital and MOUD utilization among LatinX individuals. • No association between non-fatal overdose and MOUD use – opportunity to intervene. [ABSTRACT FROM AUTHOR]

Background and aims: Opioid‐related overdose death rates continue to rise in the United States, especially in racial/ethnic minority communities. Our objective was to determine if US municipalities with high percentages of non‐white residents have equitable access to the overdose antidote naloxone distributed by community‐based organizations. Methods: We used community‐based naloxone data from the Massachusetts Department of Public Health and the Rhode Island non‐pharmacy naloxone distribution program for 2016–18. We obtained publicly available opioid‐related overdose death data from Massachusetts and the Office of the State Medical Examiners in Rhode Island. We defined the naloxone coverage ratio as the number of community‐based naloxone kits received by a resident in a municipality divided by the number of opioid‐related overdose deaths among residents, updated annually. We used a Poisson regression with generalized estimating equations to analyze the relationship between the municipal racial/ethnic composition and naloxone coverage ratio. To account for the potential non‐linear relationship between naloxone coverage ratio and race/ethnicity we created B‐splines for the percentage of non‐white residents; and for a secondary analysis examining the percentage of African American/black and Hispanic residents. The models were adjusted for the percentage of residents in poverty, urbanicity, state and population size. Results: Between 2016 and 2018, the annual naloxone coverage ratios range was 0–135. There was no difference in naloxone coverage ratios among municipalities with varying percentages of non‐white residents in our multivariable analysis. In the secondary analysis, municipalities with higher percentages of African American/black residents had higher naloxone coverage ratios, independent of other factors. Naloxone coverage did not differ by percentage of Hispanic residents. Conclusions: There appear to be no municipal‐level racial/ethnic inequities in naloxone distribution in Rhode Island and Massachusetts, USA. [ABSTRACT FROM AUTHOR]

Introduction: Pediatric exposures to cannabis edibles have been associated with serious adverse effects, such as respiratory depression. Yet, their incidence and relationship to exposure characteristics are not well defined. We attempt to describe the temporal, demographic, and clinical characteristics of pediatric patients with edible cannabis exposures and examine the relationship between these characteristics and two clinical outcomes: need for respiratory support and hospital admission. Methods: A retrospective chart review was conducted at a single, tertiary care academic medical center covering a 28-month period. Inclusion criteria were: evaluation in the ED, age <18 years at the time of presentation, and physician documented exposure to edible cannabis. Exclusion criteria were: known or suspected co-ingestion of other substances. Results: Thirty-two cases of edible cannabis ingestions were identified. Age <10 years was associated with bradypnea, hypertension, hospital admission, and respiratory support. Use of respiratory support was significantly associated with the presence of lethargy, bradypnea, hypercarbia, seizure, and hypertension. There was a five-fold increase in the number of pediatric edible cannabis exposures after recreational cannabis dispensaries opened in Massachusetts. Five patients (16%) required respiratory support and eleven (34%) required hospital admission. Conclusions: There was a low incidence of need for respiratory support in our population, but hospital admission was more common. Severe symptoms (including lethargy and respiratory depression), need for respiratory support and hospital admission were more frequent in younger children. Exposures occurred with increasing frequency over time. Larger studies are needed to explore the relationship between THC dosage, age, and incidence of adverse outcomes. [ABSTRACT FROM AUTHOR]

Background: Stimulant use has increased across the US, with concomitant opioid and methamphetamine use doubling between 2011 and 2017. Shifting patterns of polysubstance use have led to rising psychostimulant-involved deaths. While it is known that individuals who use methamphetamine require greater access to treatment, there is still little known about methamphetamine use and treatment among individuals who are already engaged in outpatient substance use treatment. Objectives: To characterize care-engaged individuals who use methamphetamine to guide harm reduction and treatment strategies. Methods: Retrospective cohort study of individuals at a large academic medical center in Massachusetts with ≥ 2 positive methamphetamine oral fluid toxicology tests between August 2019 and January 2020. We performed descriptive analysis of sociodemographic, medical, and drug use characteristics and a comparative analysis of injection methamphetamine use versus other routes of use. Results: Included were 71 individuals [56 male (80%), 66 non-Hispanic white (94%), median age 36 (IQR 30–42)]. Nearly all had opioid (94%) and stimulant use disorder (92%). Most had (93%) or were (83%) being treated with medications for opioid use disorder, but few received pharmacologic treatment for methamphetamine use disorder (24%). None received contingency management treatment. People who inject methamphetamine (68%) were more likely to have a history of overdose (91% vs. 70%; p = 0.02), have HCV (94% vs. 52%; p < 0.01), use fentanyl (93% vs. 65%; p = 0.02), and engage in sex work (19% vs. 0%; p = 0.03) compared to those who used via other routes. Both groups had prevalent homelessness (88% vs. 73%; p = 0.15), incarceration (81% vs. 64%; p = 0.11), depression (94% vs. 87%; p = 0.34), and bacteremia (27% vs. 22%; p = 0.63). Conclusions: Individuals in our study had high prevalence of polysubstance use, particularly concomitant methamphetamine and opioid use. Individuals who were well connected to substance use treatment for their opioid use were still likely to be undertreated for their methamphetamine use disorder and would benefit from greater access to contingency management treatment, harm reduction resources, and resources to address adverse social determinants of health. [ABSTRACT FROM AUTHOR]

The coronavirus disease 2019 (COVID-19) pandemic has challenged the ability of harm reduction programs to provide vital services to adolescents, young adults, and people who use drugs, thereby increasing the risk of overdose, infection, withdrawal, and other complications of drug use. To evaluate the effect of the COVID-19 pandemic on harm reduction services for adolescents and young adults in Boston, we conducted a quantitative assessment of the Community Care in Reach (CCIR) youth pilot program to determine gaps in services created by its closure during the peak of the pandemic (March 19–June 21, 2020). We also conducted semistructured interviews with staff members at 6 harm reduction programs in Boston from April 27 through May 4, 2020, to identify gaps in harm reduction services, changes in substance use practices and patterns of engagement with people who use drugs, and how harm reduction programs adapted to pandemic conditions. During the pandemic, harm reduction programs struggled to maintain staffing, supplies, infection control measures, and regular connection with their participants. During the 3-month suspension of CCIR mobile van services, CCIR missed an estimated 363 contacts, 169 units of naloxone distributed, and 402 syringes distributed. Based on our findings, we propose the following recommendations for sustaining harm reduction services during times of crisis: pursuing high-level policy changes to eliminate political barriers to care and fund harm reduction efforts; enabling and empowering harm reduction programs to innovatively and safely distribute vital resources and build community during a crisis; and providing comprehensive support to people to minimize drug-related harms. [ABSTRACT FROM AUTHOR]

Background: Naloxone is an opioid antagonist that can reverse an opioid overdose. Increased opioid-related mortality rates led to greater distribution of naloxone without a prescription and administration of naloxone by laypersons. This study fills a gap in knowledge of naloxone experiences among active users of opioids living in suburban communities. Purpose: The purpose of this article is to provide nurse practitioners with an in-depth understanding of current naloxone use practices among people who experience overdose events. The specific aims are to compare access to naloxone in diverse suburban towns, to examine administration differences across settings, and to understand perspectives on naloxone experiences from people who are actively using opioids. Methodological orientation: The data for this analysis were drawn from an ethnographic study in the suburban towns around Atlanta, Georgia; Boston, Massachusetts; and New Haven, Connecticut. Short surveys and in-depth interviews were collected. Inductive methods were used to compare data across settings. Sample: The sample of 106 included 48% female, 62% White, 24% African American/Black, 13% more than one race, and 21% Hispanic/Latinx. The mean age was 41.35 years. Conclusions: Differences between study settings in access to naloxone, administration frequency, and delivery systems were found. Findings suggest more education and training is needed in overdose prevention and harm reduction intervention. Studies on delivery systems need to address the increase in fentanyl-related overdoses. Implications for practice: Nurse practitioners can help to target distribution of naloxone in local communities, facilitate collaboration with harm reduction services, and provide evidence-based education and training to laypersons. [ABSTRACT FROM AUTHOR]

Background: Post-overdose outreach programs engage overdose survivors and their families soon after an overdose event. Staff implementing these programs are routinely exposed to others' trauma, which makes them vulnerable to secondary traumatic stress (STS) and compassion fatigue. The purpose of this study was to explore experiences of STS and associated upstream and downstream risk and protective factors among program staff., Methods: We conducted a post-hoc analysis of semi-structured interviews with post-overdose outreach program staff in Massachusetts. Transcripts were analyzed using a multi-step hybrid inductive-deductive approach to explore approaches and responses to outreach work, factors that might give rise to STS, and compassion fatigue resilience. Findings were organized according to the three main constructs within Ludick and Figley's compassion fatigue resilience model (empathy, secondary traumatic stress, and compassion fatigue resilience)., Results: Thirty-eight interviews were conducted with staff from 11 post-overdose outreach programs in Massachusetts. Within the empathy construct, concern for others' well-being emerged as a motivator to engage in post-overdose outreach work - with staff trying to understand others' perspectives and using this connection to deliver respectful and compassionate services. Within the secondary traumatic stress construct, interviewees described regular and repeated exposure to others' trauma - made more difficult when exposures overlapped with staff members' personal social spheres. Within the compassion fatigue resilience construct, interviewees described the presence and absence of self-care practices and routines, social supports, and workplace supports. Job satisfaction and emotional detachment from work experiences also arose as potential protective factors. Interviewees reported inconsistent presence and utilization of formal support for STS and compassion fatigue within their post-overdose outreach teams., Conclusion: Post-overdose outreach program staff may experience secondary traumatic stress and may develop compassion fatigue, particularly in the absence of resilience and coping strategies and support. Compassion fatigue resilience approaches for post-overdose outreach staff warrant further development and study., (© 2024. The Author(s).)

Involuntary civil commitment (ICC) to treatment for opioid use disorder (OUD) prevents imminent overdose, but also restricts autonomy and raises other ethical concerns. Using the Kass Public Health Ethics Framework, we identified ICC benefits and harms. Benefits include: protection of vulnerable, underserved patients; reduced legal consequences; resources for families; and "on-demand" treatment access. Harms include: stigmatizing and punitive experiences; heightened family conflict and social isolation; eroded patient self-determination; limited or no provision of OUD medications; and long-term overdose risk. To use ICC ethically, it should be recognized as comprising vulnerable patients worthy of added protections; be a last resort option; utilize consensual, humanizing processes; provide medications and other evidence-based-treatment; integrate with existing healthcare systems; and demonstrate effective outcomes before diffusion. ICC to OUD treatment carries significant potential harms that, if unaddressed, may outweigh its benefits. Findings can inform innovations for ensuring that ICC is used in an ethically responsible way. [ABSTRACT FROM AUTHOR]

Objectives: Massachusetts was among the first states to allow standing orders to facilitate pharmacy-based naloxone purchases and reduce opioid overdose deaths. We conducted a unique purchase trial to establish a valid measure of standing order naloxone in Massachusetts, using purchasers from 2 high priority populations to determine whether naloxone is less accessible to those who use illicit opioids than other potential purchasers.Design: Purchase trial.Setting and Participants: The study used a stratified random sample of 200 chain and independent retail pharmacies across Massachusetts. Each pharmacy underwent 2 purchase attempts-1 by a person who used illicit opioids (PWUIO) and 1 by a potential bystander who did not use illicit opioids but had a relationship with someone at risk of opioid overdose.Outcome Measure: Successful or unsuccessful naloxone purchase attempt.Results: Overall, 322 of 397 purchase attempts (81%) were successful, with no statistically significant difference between PWUIO and bystanders (P = 0.221). Most purchases (93%) resulted in the acquisition of single-step nasal naloxone (Narcan; median cost $133.38). Forty percent of the purchases included state-mandated verbal counseling, and PWUIO were significantly less likely to receive counseling than bystanders (30% vs. 51%, P < 0.001). Common reasons for failed purchase were not stocking naloxone (47%), price > $150 (25%), and requiring a prescription (15%). Chain pharmacies were significantly more likely to sell naloxone than independent pharmacies (86% vs. 53%, P < 0.001).Conclusion: We documented high levels of naloxone access for both PWUIO and bystanders, suggesting Massachusetts could serve as a model for states seeking to improve pharmacy-based naloxone access. Additional implementation efforts should focus on expanding availability at independent pharmacies and supporting pharmacies in proactively offering naloxone to PWUIO and other high-risk individuals. [ABSTRACT FROM AUTHOR]

Aim: To identify associations between opioid‐related mortality and neighborhood‐level risk factors. Design Cross‐sectional study. Setting: Massachusetts, USA. Participants: Using 2011–14 Massachusetts death certificate data, we identified opioid‐related (n = 3089) and non‐opioid‐related premature deaths (n = 8729). Measurements: The independent variables consisted of four sets of neighborhood‐level factors: (1) psychosocial, (2) economic, (3) built environment and (4) health‐related. At the individual level we included the following compositional factors: age at death, sex, race/ethnicity, marital status, education, veteran status and nativity. The primary outcome of interest was opioid‐related mortality. Findings Multi‐level models identified number of social associations per 10 000 [odds ratio (OR) = 0.84, P = 0.002, 95% confidence interval (CI) = 0.75–0.94] and number of hospital beds per 10 000 (OR = 0.78, P < 0.001, 95% CI = 0.68–0.88) to be inversely associated with opioid‐related mortality, whereas the percentage living in poverty (OR = 1.01, P = 0.008, 95% CI = 1.00–1.01), food insecurity rate (OR = 1.21, P = 0.002, 95% CI = 1.07–1.37), number of federally qualified health centers (OR = 1.02, P = 0.028, 95% CI = 1.02–1.08) and per‐capita morphine milligram equivalents of hydromorphone (OR = 1.05, P = 0.003, 95% CI = 1.01–1.08) were positively associated with opioid‐related mortality. Conclusions: Opioid‐related deaths between 2011 and 2014 in the state of Massachusetts appear to be positively associated with the percentage living in poverty, food insecurity rate, number of federally qualified health centers and per‐capita morphine milligram equivalents of hydromorphone, but inversely associated with number of social associations per 10 000 and number of hospital beds per 10 000. [ABSTRACT FROM AUTHOR]

Objectives: Pharmacies provide accessible sources of naloxone to caregivers, patients taking opioids, and individuals using drugs. While laws permit expanded pharmacy naloxone access, prior work identified barriers like concerns about stigma of addiction and time constraints that inhibit scale-up. We sought to examine similarities and differences in experiences obtaining naloxone at the pharmacy over a 1-year period in 2 states, and to explore reactions from people with opioid use disorder, patients taking opioids for chronic pain, caregivers of opioid users, and pharmacists to communication tools and patient outreach materials designed to improve naloxone uptake.Design: Eight focus groups (FGs) held December 2016 to April 2017 in Massachusetts and Rhode Island.Setting and Participants: Participants were recruited from pharmacies, health clinics, and community organizations; pharmacists were recruited from professional organizations and pharmacy colleges.Outcome Measures: The FGs were led by trained qualitative researchers using a topic guide and prototypes designed for input. Five analysts applied a coding scheme to transcripts. Thematic analysis involved synthesis of coded data and connections between themes, with comparisons across groups and to first-year findings.Results: A total of 56 individuals participated: patients taking opioids for chronic pain (n = 13), people with opioid use disorders (n = 15), caregivers (n = 13), and pharmacists (n = 16). Fear of future consequences and stigma in the pharmacy was a prominent theme from the previous year. Four new themes emerged: experience providing pharmacy naloxone, clinician-pharmacist-partnered approaches, naloxone coprescription, and fentanyl as motivator for pharmacy naloxone. Prototypes for prompting consumers about naloxone availability, materials facilitating naloxone conversations, and posters designed to address stigma were well received.Conclusions: Experiences dispensing naloxone are quickly evolving, and a greater diversity of patients are obtaining pharmacy naloxone. Persistent stigma-related concerns underscore the need for tools to help pharmacists offer naloxone, facilitate patient requests, and provide reassurance when getting naloxone. [ABSTRACT FROM AUTHOR]

Background and aim: Medically managed opioid withdrawal (detox) can increase the risk of subsequent opioid overdose. We assessed the association between mortality following detox and receipt of medications for opioid use disorder (MOUD) and residential treatment after detox. Design Cohort study generated from individually linked public health data sets. Setting: Massachusetts, USA. Participants: A total of 30 681 opioid detox patients with 61 819 detox episodes between 2012 and 2014. Measurements Treatment categories included no post‐detox treatment, MOUD, residential treatment or both MOUD and residential treatment identified at monthly intervals. We classified treatment exposures in two ways: (a) 'on‐treatment' included any month where a treatment was received and (b) 'with‐discontinuation' individuals were considered exposed through the month following treatment discontinuation. We conducted multivariable Cox proportional hazards analyses and extended Kaplan–Meier estimator cumulative incidence for all‐cause and opioid‐related mortality for the treatment categories as monthly time‐varying exposure variables. Findings Twelve months after detox, 41% received MOUD for a median of 3 months, 35% received residential treatment for a median of 2 months and 13% received both for a median of 5 months. In on‐treatment analyses for all‐cause mortality compared with no treatment, adjusted hazard ratios (AHR) were 0.34 [95% confidence interval (CI) = 0.27–0.43] for MOUD, 0.63 (95% CI = 0.47–0.84) for residential treatment and 0.11 (95% CI = 0.03–0.43) for both. In with‐discontinuation analyses for all‐cause mortality, compared with no treatment, AHRs were 0.52 (95% CI = 0.42–0.63) for MOUD, 0.76 (95% CI = 0.59–0.96) for residential treatment and 0.21 (95% CI = 0.08–0.55) for both. Results were similar for opioid‐related overdose mortality. Conclusions: Among people who have undergone medically managed opioid withdrawal, receipt of medications for opioid use disorder, residential treatment or the combination of medications for opioid use disorder and residential treatment were associated with substantially reduced mortality compared with no treatment. [ABSTRACT FROM AUTHOR]

Objective: To explore mortality rates and trends according to the occupation of workers who died from the deaths of despair (DoD). Methods: Death certificates for deaths due to poisonings (including opioid-related overdoses), suicides, and alcoholic liver disease occurring in Massachusetts from 2000 to 2015 were collected and coded according to the occupation of the decedent. Mortality rates and trends in mortality were calculated for each occupation. Results: DoDs increased by more than 50% between 2000 to 2004 and 2011 to 2015. There were substantial differences in mortality rates and trends according to occupation. Blue collar workers were at a particularly elevated risk for DoD and had elevated trends for these deaths, notably: construction and farming, fishing, and forestry workers. Conclusions: Interventions should be targeted to occupations with elevated mortality rates and trends. Occupational risk factors that may contribute to these disparities should be explored. [ABSTRACT FROM AUTHOR]

Aims: To examine how the risks of incident opioid use disorder (OUD), non‐fatal and fatal overdose have changed over time among opioid‐naive individuals receiving an initial opioid prescription. Design Retrospective, longitudinal study using the Massachusetts Chapter 55 data set, which linked multiple administrative data sets to study the opioid epidemic. We identified the cumulative incidence of OUD, non‐fatal and fatal overdose among the opioid‐naive initiating opioid treatment in Massachusetts from 2011 to 2014 and estimated rates of these outcomes at 6 months and at 1, 2, 3 and 4 years to 2015. We used Cox regression to examine the association between characteristics of the initial prescription and risk of these outcomes. Setting: Massachusetts, USA. Participants: Massachusetts residents aged ≥ 11 years in 2011–15 who were opioid‐naive (no opioid prescriptions or evidence of OUD in the 6 months prior to the index prescription) (n = 2 154 426). The mean age was 49.1 years, 55.3% were female and 47.3% had commercial insurance. Measurements Opioid prescriptions were identified in the Prescription Monitoring Program (PMP) database, as were the characteristics of the initial prescription database. The outcomes of OUD and non‐fatal overdose were identified from claims in the All Payer Claims Database (APCD) and hospital encounters in the acute hospital case mix files. Fatal overdoses were identified using Registry of Vital Records and Statistics (RVRS) death certificates and the Office of the Chief Medical Examiner (OCME) circumstances of death and toxicology reports. Findings Among opioid‐naive individuals receiving an initial opioid prescription, the risk of incident OUD appears to have declined between 2011 and 2014, while rates of overdose were largely unchanged. For example, the 1‐year OUD rate was 1.18% in 2011, 1.11% in 2012, 1.26% in 2013 and 0.94% in 2014. Longer therapy duration was associated with higher risk of OUD [hazard ratio (HR) = 2.24, 95% confidence interval (CI) = 2.19–2.29 for duration of 3 or more months], non‐fatal (HR = 1.67, 95% CI = 1.53–1.82) and fatal opioid overdose (HR = 2.24, 95% CI = 1.91–2.61). Concurrent benzodiazepine treatment was also associated with higher risk of OUD (HR = 1.14, 95% CI = 1.12–1.17), non‐fatal (HR = 1.20, 95% CI = 1.10–1.30) and fatal overdose (HR = 1.86, 95% CI = 1.61–2.16). Conclusions: Among opioid‐naive individuals in Massachusetts receiving an initial opioid prescription, the risk of incident opioid use disorder appears to have declined between 2011 and 2014, while rates of overdose were largely unchanged. Longer therapy duration and concurrent benzodiazepines were associated with higher rates of opioid use disorder and opioid overdose. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to evaluate pharmacist attitudes regarding recommending pharmacy-based naloxone (PBN). The influence of gender, practice setting, the number of years of practice, state, and PBN involvement were explored. Barriers to, and facilitators of, provision of PBN were also assessed.Design: A 71-question survey was designed to assess experience with, and attitudes toward, PBN. We employed a cross-sectional study design and utilized the online survey site Qualtrics (Qualtrics International Inc, Provo, UT).Setting and Participants: The survey was e-mailed to approximately 2900 licensed pharmacists from all practice settings in Massachusetts (approximately 1400) and Rhode Island (approximately 1500) and was open from April 5, 2016, until July 13, 2016.Outcome Measures: Attitudes toward opioid overdose prevention (12 questions) were used to develop the Opioid Overdose Prevention Attitude (OOPA) scale which consisted of 3 subscales: Opioid Overdose Prevention Attitude, Public Health Attitude, and Naloxone Dispensing Attitude.Results: Of the approximately 2900 pharmacists who received the survey, 402 responded (13%), and 245 (137 from Massachusetts and 108 from Rhode Island) were included in the analyses. The majority (79%) identified as White or Caucasian, and 127 (51.8%) stated they had ever dispensed naloxone. Of those, 85 (67%) had done so in the past 30 days. We examined differences in the OOPA subscales by pharmacists' characteristics and pharmacy practice settings. Working in a pharmacy that had a standing order or collaborative practice agreement allowing pharmacists to dispense naloxone without a physician's prescription, or in a pharmacy that stocked naloxone resulted in more positive attitudes toward opioid overdose prevention and public health prevention.Conclusion: Respondents who practiced in a pharmacy with a standing order or collaborative practice agreement were more likely to have dispensed naloxone. Both stocking naloxone and ever having dispensed naloxone were associated with higher OOPA scores. More research is needed to better understand how pharmacist attitudes influence the distribution of naloxone. [ABSTRACT FROM AUTHOR]

Public health-public safety partnerships for post-overdose outreach have emerged in many communities to prevent future overdose events. These efforts often identify overdose survivors through emergency call data and seek to link them with relevant services. The aim of this study was to describe how post-overdose outreach programs in Massachusetts manage the confidentiality of identifiable information and privacy of survivors. In 2019, 138 Massachusetts programs completed surveys eliciting responses to questions about program operations. Descriptive statistics were calculated from the closed-ended survey responses. Thirty-eight interviews were conducted among outreach staff members during 2019–2020. Interview transcripts and open-ended survey responses were thematically analyzed using deductive and inductive approaches. Of programs that completed the survey, 90 % (n = 124/138) reported acting to protect the privacy of survivors following overdose events, and 84 % (n = 114/135) reported implementing a protocol to maintain the confidentiality of personal information. Interviews with outreach team members indicated substantial variation in practice. Outreach programs regularly employed discretion in determining actions in the field, sometimes undermining survivor privacy and confidentiality (e.g., by disclosing the overdose event to family members). Programs aiming to prioritize privacy and confidentiality attempted to make initial contact with survivors by phone, limited or concealed materials left behind when no one was home, and/or limited the number of contact attempts. Despite the establishment of privacy and confidentiality protocols within most post-overdose outreach programs, application of these procedures was varied, discretionary, and at times viewed by staff as competing with engagement efforts. Individual outreach overdose teams should prioritize privacy and confidentiality during outreach to protect overdose survivors from undesired exposure. In addition to individual program changes, access to overdose survivor information could be changed across all programs to bolster privacy and confidentiality protocols. For example, transitioning the management of overdose-related information to non-law enforcement agencies would limit officers' ability to disseminate such information at their discretion. [ABSTRACT FROM AUTHOR]

Introduction: Social determinants of health (SDoH), such as socioeconomic status, education level, and food insecurity, are believed to influence the opioid crisis. While global SDoH indices such as the CDC's Social Vulnerability Index (SVI) and Area Deprivation Index (ADI) combine the explanatory power of multiple social factors for understanding health outcomes, they may be less applicable to the specific challenges of opioid misuse and associated outcomes. This study develops a novel index tailored to opioid misuse outcomes, tests the efficacy of this index in predicting drug overdose deaths across contexts, and compares the explanatory power of this index to other SDoH indices., Methods: Focusing on four HEALing Communities Study (HCS) states (Kentucky, Massachusetts, New York and Ohio; encompassing 4269 ZIP codes), we identified multilevel SDoH potentially associated with opioid misuse and aggregated publicly available data for each measure. We then leveraged a random forest model to develop a composite measure that predicts age-adjusted drug overdose mortality rates based on SDoH. We used this composite measure to understand HCS and non-HCS communities in terms of overdose risk across areas of varying racial composition. Finally, we compared variance in drug overdose deaths explained by this index to variance explained by the SVI and ADI., Results: Our composite measure included 28 SDoH measures and explained approximately 89 % percent of variance in age-adjusted drug overdose mortality across HCS states. Health care measures, including emergency department visits and primary care provider availability, were top predictors within the index. Index accuracy was robust within and outside of HCS communities and states. This measure identified high levels of overdose mortality risk in segregated communities., Conclusions: Existing SDoH indices fail to explain much variation in area-level overdose mortality rates. Having tailored composite indices can help us to identify places in which residents are at highest risk based on their composite contexts. A comprehensive index can also help to develop effective community interventions for programs such as HCS by considering the context in which people live., (Copyright © 2023. Published by Elsevier Inc.)

Objective: To assess missed opportunities for reducing fatal opioid overdoses, characteristics of decedents by opioid overdose with and without problematic opioid use who received health care services within one year of death were examined.Methods: Of 157 decedents in the Worcester, Massachusetts, area between 2008 and 2012, 112 had contact with the health care system. Electronic medical records were reviewed for clinical characteristics, health service use, universal precautions, and substance use disorder management. Problematic opioid use was defined as individuals having documented opioid use disorders or aberrant drug-related behavior. Data were analyzed with chi-square tests with adjusted residual for categorical variables and t tests for continuous variables.Results: Decedents were predominantly Caucasian males with a mean±SD age of 41.0±11.7. Problematic opioid use by definition meant users (N=53) had opioid use disorder as a principal diagnosis and were likely to have a comorbid substance use disorder. Decedents with nonproblematic opioid use had diagnoses of chronic pain and mental illness. They were more likely to have been seen last in surgical and subspecialty settings (29% versus 11%). The proportion with an opioid prescription was higher among those with problematic use (72% versus 37%) who also had a higher total daily morphine equivalent, compared with those with nonproblematic use (165.4±282.7 versus 55.6±117.7 mg per day).Conclusions: Persons with problematic opioid use are a recognizable group with a high risk of death by opioid overdose whose therapeutic management needs improvement to reduce fatal outcomes. Different strategies must be developed for identifying and treating nonproblematic opioid use to reduce risk of death. [ABSTRACT FROM AUTHOR]

Objectives: To examine the effect of age on the likelihood of PIP of opioids and the effect of PIP on adverse outcomes. Design: Retrospective cohort study. Setting: Data from multiple state agencies in Massachusetts from 2011 to 2015. Participants: Adult Massachusetts residents (N=3,078,163) who received at least one prescription opioid during the study period; approximately half (1,589,365) aged 50 and older. Measurements: We measured exposure to 5 types of PIP: high‐dose opioids, coprescription with benzodiazepines, multiple opioid prescribers, multiple opioid pharmacies, and continuous opioid therapy without a pain diagnosis. We examined 3 adverse outcomes: nonfatal opioid overdose, fatal opioid overdose, and all‐cause mortality. Results: The rate of any PIP increased with age, from 2% of individuals age 18 to 29 to 14% of those aged 50 and older. Older adults also had higher rates of exposure to 2 or more different types of PIP (40–49, 2.5%; 50–69, 5%; ≥70, 4%). Of covariates assessed, older age was the greatest predictor of PIP. In analyses stratified according to age, any PIP and specific types of PIP were associated with nonfatal overdose, fatal overdose, and all‐cause mortality in younger and older adults. Conclusion: Older adults are more likely to be exposed to PIP, which increases their risk of adverse events. Strategies to reduce exposure to PIP and to improve outcomes in those already exposed will be instrumental to addressing the opioid crisis in older adults. J Am Geriatr Soc 67:128–132, 2019. [ABSTRACT FROM AUTHOR]

• Post-overdose outreach programs are growing in scope and number. • How post-overdose outreach program practices affect overdose rates is unknown. • Fatal overdose rates were lower in municipalities where programs offered more social services. • Outreach intensity was associated with fewer opioid-related 911 calls in some cases. • Provision of social services (housing, transport, food, employment) may be key to program success. Post-overdose outreach programs have proliferated in response to opioid overdose. Implementing these programs is associated with reductions in overdose rates, but the role of specific program characteristics in overdose trends has not been evaluated. Among 58 Massachusetts municipalities with post-overdose outreach programs, we examined associations between five domains of post-overdose outreach program characteristics (outreach contact rate, naloxone distribution, coercive practices, harm reduction activities, and social service provision or referral) and rates of fatal opioid overdoses and opioid-related emergency medical system responses (i.e., ambulance activations) per calendar quarter from 2013 to 2019 using segmented regression analyses with adjustment for municipal covariates and fixed effects. For both outcomes, each domain was modeled: a) individually, b) with other characteristics, and c) with other characteristics and municipal-level fixed effects. There were no significant associations (p < 0.05) between outreach contact rate, naloxone distribution, coercive practices, or harm reduction activities with municipal fatal overdose trends. Municipalities with programs providing or referring to more social services experienced 21% fewer fatal overdoses compared to programs providing or referring to more social services (Rate Ratio (RR) 0.79, 95% Confidence Interval (CI) 0.66–0.93, p = 0.01). Compared to municipalities in quarters when programs had no outreach contacts, municipalities with some, but less than the median outreach contacts, experienced 14% lower opioid-related emergency responses (RR 0.86, 95% CI 0.78–0.96, p = 0.01). Associations between naloxone distribution, coercive practices, harm reduction practices, or social services and opioid-related emergency responses were not consistently significant across modeling approaches. Municipalities with post-overdose outreach programs providing or referring to more social services had lower fatal opioid overdose rates. Municipalities in quarters when programs outreached to overdose survivors had fewer opioid-related emergency responses, but only among programs with below the median number of outreach contacts. Social service linkage should be core to post-overdose programs. Evaluations should assess program characteristics to optimize program design. [ABSTRACT FROM AUTHOR]

Death certificate data provide powerful and sobering records of the opioid overdose crisis. In Massachusetts, where address-level decedent data are publicly available upon request, mapping and spatial analysis of fatal overdoses can provide valuable insights to inform prevention interventions. We describe how we used this approach to support a community-level intervention to reduce opioid-involved overdose mortality. We developed a method to clean and geocode decedent data that substituted injury locations (the likely location of fatal overdoses) for deaths recorded in hospitals. After geomasking for greater privacy protection, we created maps to visualize the spatial distribution of decedent residence addresses, alone and juxtaposed with drive and walk-time distances to opioid treatment programs (OTPs), and place of death by overdose address. We used spatial statistical analyses to identify locations with significant clusters of overdoses. In the 8 intervention communities, 785 individuals died from opioid-involved overdoses between 2017 and 2020. We found that 19.7% of fatal overdoses were recorded in hospitals, 50.2% occurred at the decedent's residence, and 30.1% at another location. We identified overdose hotspots in study communities. By juxtaposing decedent residence data with drive- and walk-time analyses, we highlighted actionable spatial gaps in access to OTP treatment. To better understand local fatal opioid overdose risk environments and inform the development of community-level prevention interventions, we used publicly available address-level decedent data to conduct nuanced spatial analyses. Our approach can be replicated in other jurisdictions to inform overdose prevention responses. • Sensitive use of address-level data aids hyper-local understanding of opioid OD. • Injury data, when available, clarifies locations of ODs recorded at hospitals. • Mapping decedent home addresses and drive/walk times highlights treatment deserts. [ABSTRACT FROM AUTHOR]

• Overdose survivors experiencing homelessness struggle to stay safe and meet their basic needs. • They found the housing and substance use treatment systems fragmented and difficult to access. • Many live on the street because they find the shelter system unwelcoming. • Overdose survivors experiencing homelessness desire low barrier services, including housing. • Participants want their voices included in developing solutions to homelessness and overdose. Opioid overdose causes one in four deaths among people experiencing homelessness in Boston, MA. To reduce overdose risks, the experience and perspectives of people experiencing homelessness should be incorporated into housing, overdose prevention, and substance use treatment efforts. In 2021, we conducted qualitative interviews with 59 opioid overdose survivors to inform equitable access to treatment services. In response to policy debate surrounding a public drug scene near a key recruitment site, we conducted a targeted thematic analysis of transcribed interview data from a subset of participants experiencing unsheltered homelessness (n=29) to explore their perspectives and recommendations on housing, overdose prevention, and substance use treatment. Among 29 participants who identified as non-Hispanic Black (n=10), Hispanic/Latinx (n=10), or as non-Hispanic White (n=9), the median number of self-reported opioid overdoses in the past three months was 2.0 (SD 3.7). Three themes emerged from this targeted analysis: (1) Participants described inadequate housing resources and unwelcoming shelter environments. (2) Participants near a large public drug scene explained how unsheltered homelessness was chaotic, dangerous, and disruptive to recovery goals. (3) Participants provided recommendations for improving housing and addiction treatment systems and including their perspectives in the development of solutions to the intersecting housing and opioid overdose crises. The overdose prevention, housing and substance use treatment systems must address the needs of opioid overdose survivors experiencing unsheltered homelessness. Overdose survivors experiencing unsheltered homelessness described a chaotic public drug scene but resorted to residing in nearby encampments because the existing shelter, housing, and addiction treatment systems were unwelcoming, difficult to navigate, or unaffordable. Despite efforts to provide low-threshold housing in Boston, additional low-barrier housing services (i.e., including harm reduction resources and without "sobriety" requirements) could promote the health and safety of people who use drugs and are experiencing homelessness. [ABSTRACT FROM AUTHOR]

Objective: Pre-stationing naloxone, a competitive antagonist that can reverse the effects of opioid overdose, in public spaces may expedite antidote delivery. Our study aimed to determine the feasibility of bystander-assisted overdose treatment using pre-stationed naloxone. Methods: Convenience sample of bystanders in Cambridge, Massachusetts in April 2017. Subjects assisted a simulated patient described as unconscious. Subjects interacted with simulated EMS dispatch to locate a nearby box, unlock it, and administer naloxone. Results: Fifty participants completed the simulation. Median time from simulated ambulance dispatch to naloxone administration was 189 seconds, and from arrival at patient side to administration 61 seconds. All but one participant (98.0%) correctly administered naloxone. Subjects' comfort with administration and willingness to provide medical care increased from before to after the trial. Comfort in administering naloxone varied significantly with level of previous training prior to, but not following, study participation. Conclusions: Bystanders are willing and able to access pre-stationed naloxone and administer it to a simulated patient in a public space. Public access naloxone stations may be a useful tool to reduce time to naloxone administration, particularly in areas where opioid overdoses are clustered. [ABSTRACT FROM AUTHOR]

Introduction: The epidemic of opioid use disorder and opioid overdose carries extensive morbidity and mortality and necessitates a multi-pronged, community-level response. Bystander administration of the opioid overdose antidote naloxone is effective, but it is not universally available and requires consistent effort on the part of citizens to proactively carry naloxone. An alternate approach would be to position naloxone kits where they are most needed in a community, in a manner analogous to automated external defibrillators. We hypothesized that opioid overdoses would show geospatial clustering within a community, leading to potential target sites for such publicly deployed naloxone (PDN). Methods: We performed a retrospective chart review of 700 emergency medical service (EMS) runs that involved opioid overdose or naloxone administration in Cambridge, Massachusetts, between October 16, 2016 and May 10, 2017. We used geospatial analysis to examine for clustering in general, and to identify specific clusters amenable to PDN sites. Results: Opioid-related emergency medical services (EMS) runs in Cambridge, Massachusetts (MA), exhibit significant geospatial clustering, and we identified three clusters of opioid-related EMS runs in Cambridge, MA, with distinct characteristics. Models of PDN sites at these clusters show that approximately 40% of all opioid-related EMS runs in Cambridge, MA, would be accessible within 200 meters of PDN sites placed at cluster centroids. Conclusion: Identifying clusters of opioid-related EMS runs within a community may help to improve community coverage of naloxone, and strongly suggests that PDN could be a useful adjunct to bystander-administered naloxone in stemming the tide of opioid-related death. [ABSTRACT FROM AUTHOR]

Background: Opioid overdose is a significant public health problem. Collaborative programs between local public health and public safety agencies have emerged to connect overdose survivors and their personal networks with harm reduction and addiction treatment services following a non-fatal overdose event. This study explored the prevalence of these programs in Massachusetts and the different ways they have been structured and function.Methods: We sent an online screening questionnaire to police and fire departments in all 351 communities in Massachusetts to find instances in which they collaborated with a community-based public health agency to implement a post-overdose outreach and support program. We conducted telephone interviews with communities that implemented this type of program and categorized programs based on their structure, outreach approach, and other key characteristics.Results: Police and fire personnel from 110 of the 351 communities in Massachusetts (31% response rate) completed the screening survey. Among respondents, 21% (23/110) had implemented a collaborative, community-based, post-overdose program with a well-defined process to connect overdose survivors and their personal networks with support services or addiction treatment services. Using data from the interviews, we identified four types of programs: (1) Multi-Disciplinary Team Visit, (2) Police Visit with Referrals, (3) Clinician Outreach, and (4) Location-Based Outreach.Conclusions: This study represents the first attempt to systematically document an emerging approach intended to connect opioid overdose survivors and their personal networks with harm reduction and addiction treatment services soon after a non-fatal overdose event. These programs have the potential to increase engagement with the social service and addiction treatment systems by those who are at elevated risk for experiencing a fatal opioid overdose. [ABSTRACT FROM AUTHOR]

The epidemic of illicit intravenous drug use (IVDU) in the United States has been accompanied by a surge in drug overdose deaths and infectious sequelae. Candida albicans infections were associated with injection of contaminated impure brown heroin in the 1970s-1990s; however, candidiasis accompanying IVDU became considerably rarer as the purity of the heroin supply increased. We reviewed cases of candidemia occurring over a recent 7-year period in persons >14 years of age at a tertiary care hospital in central Massachusetts. Of the 198 patients with candidemia, 24 cases occurred in patients with a history of IVDU. Compared with non-IVDU patients, those with a history of IVDU were more likely to have non-albicans Candida, be co-infected with hepatitis C, and have end-organ involvement, including endocarditis and osteomyelitis. Thus, IVDU appears to be reemerging as a risk factor for invasive candidiasis. [ABSTRACT FROM AUTHOR]

Background: In the face of an increasingly fatal opioid crisis, Boston Health Care for the Homeless Program (BHCHP) opened the Supportive Place for Observation and Treatment (SPOT), a unique low-threshold harm reduction program for monitoring people who have injected drugs and are at imminent risk of overdose. This study examines the impact of the opening of the SPOT program on measures of injection drug-related public order in the neighborhood surrounding the facility.Methods: Data was collected at 10 weeks prior and 12 weeks post SPOT implementation on: number of over-sedated individuals in public, publicly discarded syringes, publicly discarded injection-related litter, and instances of active injection drug use or exchange of drugs. Changes were evaluated using Poisson log-linear regression models. Potential confounders such as weather and police presence were measured and controlled for.Results: The average number of over-sedated individuals observed in public significantly decreased by 28% (4.3 [95% Confidence Interval (CI) 2.7-6.9] v 3.1 [CI 1.4-6.8]) after SPOT opened. The opening of SPOT did not have a significant effect on the other measures of public order. The daily average number of publicly discarded syringes (28.5 [CI 24.5-33.1] v 28.4 [CI 22.0-36.5]), pieces of publicly discarded injection-related litter (376.3 [CI 358.6-394.8] v 375.0 [CI 345.8-406.6]), and observed instances of active use or exchange of drugs (0.2 [CI 0.1-0.9] v 0.1 [CI 0.0-0.1]) were not statistically significantly different after the opening of SPOT.Conclusions: The opening of SPOT was associated with a significant decrease in observed over-sedated individuals. Other measures of injection-drug related public order did not improve or worsen with the opening of SPOT, however, they have been shown to improve with the implementation of a supervised injection facility. [ABSTRACT FROM AUTHOR]

• Civil commitment is one strategy used by family members of someone with OUD to initiate treatment. • Families turn to civil commitment because they believe it prevents fatal opioid overdose. • Families are influenced to use civil commitment through social relationships and support groups. • Some report that civil commitment provides respite for families caring for someone with OUD. • Only a minority of families endorse the use of corrections facilities for civil commitment. Civil commitment statutes allow qualified individuals to petition for court-mandated commitment for someone with a substance use disorder (SUD). Despite a lack of empirical evidence showing efficacy of involuntary commitment, these statutes are prevalent worldwide. We examined perspectives on civil commitment among family members and close friends of people who use illicit opioids in Massachusetts, U.S.A. Eligible individuals were Massachusetts residents, ≥18 years of age, did not use illicit opioids but had a close relationship with someone who did. We used a sequential mixed methods approach in which semi-structured interviews (N=22) were followed by a quantitative survey (N=260). Thematic analysis was used to analyze qualitative data and survey data were analyzed using descriptive statistics. While some family members were influenced by SUD professionals to petition for civil commitment, influence from social networks based on personal experience was more common. Motivations for civil commitment included initiating recovery and believing that commitment would reduce overdose risk. Some reported that it afforded them respite from caring for, and worrying about, their loved one. A minority discussed increases in overdose risk following a period of forced abstinence. Participants expressed concerns about the variable quality of care during commitment, largely based on the use of corrections facilities for civil commitment in Massachusetts. A minority endorsed the use of these facilities for civil commitment. Despite participants' uncertainty and the harms stemming from civil commitment, including increased risk of overdose after forced abstinence and the use of corrections facilities, family members resorted to this mechanism to reduce immediate overdose risk. Our findings indicate that peer support groups are an appropriate forum to disseminate information about evidenced-based treatment and that family members and others close to those with SUD often lack adequate support for, and respite from, the stress of caring for them. [ABSTRACT FROM AUTHOR]

The opioid overdose epidemic continues to impact a large swath of the population in the US. Medications for opioid use disorders (MOUD) are an effective resource to combat the epidemic; however, there is limited research on MOUD treatment access that accounts for both supply of and demand for services. We aimed to examine access to buprenorphine prescribers in the HEALing Communities Study (HCS) Wave 2 communities in Massachusetts, Ohio, and Kentucky during 2021, and the association between buprenorphine access and opioid-related incidents, specifically fatal overdoses and opioid-related responses by emergency medical services (EMS). We calculated Enhanced 2-Step Floating Catchment Area (E2SFCA) accessibility indices for each state, as well as Wave 2 communities in each state, based on the location of providers (buprenorphine-waivered clinicians from the US Drug Enforcement Agency Active Registrants database), population-weighted centroids at the census block group level, and catchment areas defined by the state or community's average commute time. In advance of intervention initiation, we quantified the opioid-related risk environment of communities. We assessed gaps in services by using bivariate Local Moran's I analysis, incorporating accessibility indices and opioid-related incident data. Massachusetts Wave 2 HCS communities had the highest rates of buprenorphine prescribers per 1000 patients (median: 165.8) compared to Kentucky (38.8) and Ohio (40.1). While urban centers in all three states had higher E2SFCA index scores compared to rural communities, we observed that suburban communities often had limited access. Through bivariate Local Moran's I analysis, we identified numerous locations with low buprenorphine access surrounded by high opioid-related incidents, particularly in communities that surrounded Boston, Massachusetts; Columbus, Ohio; and Louisville, Kentucky. Rural communities demonstrated a great need for additional access to buprenorphine prescribers. However, policymakers should also direct attention toward suburban communities that have experienced significant increases in opioid-related incidents. • Accessibility and availability are critical domains of MOUD treatment access. • Floating catchment area analysis overcomes limits of fixed catchment methods. • Suburban sites had low buprenorphine access/high opioid-related incidents. • Massachusetts buprenorphine provider rates exceeded Kentucky and Ohio rates. [ABSTRACT FROM AUTHOR]

The author comments on a study which examined the cost-effectiveness and impact on fatal overdose and initiation of buprenorphine-naloxone treatment at syringe service programs in Massachusetts. Cited are the strengths and limitations of the study, the lessons that U.S. states should learn from Massachusetts with regards to building administrative big data warehouses for the public good, and the benefits of offering buprenorphine treatment in syringe service programs.