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Abstract Background Bystander administration of naloxone is a critical strategy to mitigate opioid overdose mortality. To ensure bystanders’ willingness to carry and administer naloxone in response to a suspected overdose, it is critical to select products for community distribution with the highest likelihood of being utilized. This study examines bystanders’ preference for and willingness to administer three naloxone products approved by the FDA for bystander use and identify product features driving preference. Methods The population was a convenience sample of individuals who attended the Kentucky State Fair, August 18–28, 2022, in Louisville, Kentucky. Participants (n = 503) watched a standardized overdose education and naloxone training video, rated their willingness to administer each of three products (i.e., higher-dose nasal spray, lower-dose nasal spray, intramuscular injection), selected a product to take home, and rated factors affecting choice. Results After training, 44.4% chose the higher-dose nasal spray, 30.1% chose the intramuscular injection, and 25.5% chose the lower-dose nasal spray. Factors most influencing choice on a 10-point Likert scale were ease of use (9 [7–10]), naloxone dose (8 [5–10]), and product familiarity (5 [5–9]). Conclusions Bystanders expressed high willingness to administer all studied formulations of naloxone products. Product choice preference varied as a function of product features. As the number and variety of available products continue to increase, continuous evaluation of formulation acceptability, in addition to including individuals with lived experience who are receiving and administering overdose reversal agents, is critical to support adoption and save lives.

Background: Bystander administration of naloxone is a critical strategy to mitigate opioid overdose mortality. To ensure bystanders' willingness to carry and administer naloxone in response to a suspected overdose, it is critical to select products for community distribution with the highest likelihood of being utilized. This study examines bystanders' preference for and willingness to administer three naloxone products approved by the FDA for bystander use and identify product features driving preference. Methods: The population was a convenience sample of individuals who attended the Kentucky State Fair, August 18–28, 2022, in Louisville, Kentucky. Participants (n = 503) watched a standardized overdose education and naloxone training video, rated their willingness to administer each of three products (i.e., higher-dose nasal spray, lower-dose nasal spray, intramuscular injection), selected a product to take home, and rated factors affecting choice. Results: After training, 44.4% chose the higher-dose nasal spray, 30.1% chose the intramuscular injection, and 25.5% chose the lower-dose nasal spray. Factors most influencing choice on a 10-point Likert scale were ease of use (9 [7–10]), naloxone dose (8 [5–10]), and product familiarity (5 [5–9]). Conclusions: Bystanders expressed high willingness to administer all studied formulations of naloxone products. Product choice preference varied as a function of product features. As the number and variety of available products continue to increase, continuous evaluation of formulation acceptability, in addition to including individuals with lived experience who are receiving and administering overdose reversal agents, is critical to support adoption and save lives. [ABSTRACT FROM AUTHOR]

Abstract Introduction Opioid overdose epidemic is a public health crisis that is impacting communities around the world. Overdose education and naloxone distribution programs equip and train lay people to respond in the event of an overdose. We aimed to understand factors to consider for the design of naloxone distribution programs in point-of-care settings from the point of view of community stakeholders. Methods We hosted a multi-stakeholder co-design workshop to elicit suggestions for a naloxone distribution program. We recruited people with lived experience of opioid overdose, community representatives, and other stakeholders from family practice, emergency medicine, addictions medicine, and public health to participate in a full-day facilitated co-design discussion wherein large and small group discussions were audio-recorded, transcribed and analysed using thematic approaches. Results A total of twenty-four participants participated in the multi-stakeholder workshop from five stakeholder groups including geographic and setting diversity. Collaborative dialogue and shared storytelling revealed seven considerations for the design of naloxone distribution programs specific to training needs and the provision of naloxone, these are: recognizing overdose, how much naloxone, impact of stigma, legal risk of responding, position as conventional first aid, friends and family as responders, support to call 911. Conclusion To create an naloxone distribution program in emergency departments, family practice and substance use treatment services, stigma is a central design consideration for training and naloxone kits. Design choices that reference the iconography, type, and form of materials associated with first aid have the potential to satisfy the need to de-stigmatize overdose response.

Abstract Background Naloxone is a medication that can quickly reverse an opioid overdose. Syringe service programs (SSPs) are community-based prevention programs that provide a range of evidence-based interventions in the USA, including naloxone distribution. Attributes of SSPs make them ideal settings for naloxone distribution—they have staff and delivery models that are designed to reach people who use drugs where they are. We assessed which outer and inner setting factors of SSPs were associated with naloxone distribution in the USA. Methods We surveyed SSPs in the USA known to the North American Syringe Exchange Network in 2019. Using the exploration, preparation, implementation and maintenance framework, we assessed inner and outer contextual factors associated with naloxone distribution among SSPs (n = 263 or 77% of SSPs). We utilized negative binomial regression to assess which factors were associated with the number of naloxone doses distributed and people receiving naloxone. Results SSPs reported distributing 710,232 naloxone doses to 230,506 people in the prior year. Regarding outer setting, SSPs located in areas with high levels of community support had a higher level of naloxone distribution (aIRR = 3.07; 95% confidence interval (CI): 2.09–4.51; p

Introduction: Opioid overdose epidemic is a public health crisis that is impacting communities around the world. Overdose education and naloxone distribution programs equip and train lay people to respond in the event of an overdose. We aimed to understand factors to consider for the design of naloxone distribution programs in point-of-care settings from the point of view of community stakeholders. Methods: We hosted a multi-stakeholder co-design workshop to elicit suggestions for a naloxone distribution program. We recruited people with lived experience of opioid overdose, community representatives, and other stakeholders from family practice, emergency medicine, addictions medicine, and public health to participate in a full-day facilitated co-design discussion wherein large and small group discussions were audio-recorded, transcribed and analysed using thematic approaches. Results: A total of twenty-four participants participated in the multi-stakeholder workshop from five stakeholder groups including geographic and setting diversity. Collaborative dialogue and shared storytelling revealed seven considerations for the design of naloxone distribution programs specific to training needs and the provision of naloxone, these are: recognizing overdose, how much naloxone, impact of stigma, legal risk of responding, position as conventional first aid, friends and family as responders, support to call 911. Conclusion: To create an naloxone distribution program in emergency departments, family practice and substance use treatment services, stigma is a central design consideration for training and naloxone kits. Design choices that reference the iconography, type, and form of materials associated with first aid have the potential to satisfy the need to de-stigmatize overdose response. [ABSTRACT FROM AUTHOR]

Background: Naloxone is a medication that can quickly reverse an opioid overdose. Syringe service programs (SSPs) are community-based prevention programs that provide a range of evidence-based interventions in the USA, including naloxone distribution. Attributes of SSPs make them ideal settings for naloxone distribution—they have staff and delivery models that are designed to reach people who use drugs where they are. We assessed which outer and inner setting factors of SSPs were associated with naloxone distribution in the USA. Methods: We surveyed SSPs in the USA known to the North American Syringe Exchange Network in 2019. Using the exploration, preparation, implementation and maintenance framework, we assessed inner and outer contextual factors associated with naloxone distribution among SSPs (n = 263 or 77% of SSPs). We utilized negative binomial regression to assess which factors were associated with the number of naloxone doses distributed and people receiving naloxone. Results: SSPs reported distributing 710,232 naloxone doses to 230,506 people in the prior year. Regarding outer setting, SSPs located in areas with high levels of community support had a higher level of naloxone distribution (aIRR = 3.07; 95% confidence interval (CI): 2.09–4.51; p < 0.001) and 110% (p = 0.022) higher rate of people receiving naloxone (aIRR = 2.10; 95% CI 1.46–3.02; p < 0.001) in the past 12 months. The legal status of SSPs and the level of need was not significantly associated with naloxone distribution. Regarding inner setting, SSPs with proactive refill systems (aIRR = 2.08; 95% CI 1.27–3.41; p = 0.004), greater number of distribution days (aIRR = 1.09 per day; 95% CI 1.06–1.11; p < 0.001) and older programs (aIRR = 1.06 per year; 95% CI 1.02–1.11; p = 0.004) were associated with higher levels of naloxone distribution. Also, SSPs with proactive refill systems (aIRR = 2.23; 95% CI 1.38–3.58; p = 0.001); greater number of distribution days (aIRR = 1.04; 95% CI 1.02–1.07; p < 0.001) and older programs (aIRR = 1.11; 95% CI 1.05–1.17; p < 0.001) were associated with a higher number of people receiving naloxone. Conclusion: We identified outer and inner setting factors of SSPs that were associated with greater naloxone distribution. It is critical to ensure SSPs are adequately resourced to build community support for services and develop service delivery models that maximize naloxone distribution to address the nation's opioid overdose crisis. [ABSTRACT FROM AUTHOR]

Drug overdose is the leading cause of accidental death in the United States, with over 70% of drug related fatalities resulting from the use of opioids. Federal agencies have responded to this crisis with various recommendations including enhancing harm reduction approaches such as training laypersons to administer naloxone through Opioid Overdose Education and Naloxone Distribution (OEND) programs. Several studies have demonstrated that OEND programs effectively reduce opioid overdose mortality and are both safe and cost-effective, however, they are typically implemented in urban areas as part of large medical center research programs, needle exchanges, or drug treatment programs. Individuals living in areas without these programs or services lack access to critical and life-saving OEND. The current study examined the acceptability and feasibility of online recruitment, online opioid overdose education, and remote distribution of naloxone kits. Persons who illicitly use opioids and are at risk for overdose were recruited through online media and completed an opioid use questionnaire. If interested in receiving opioid overdose and naloxone administration training, participants completed pre- and post-intervention knowledge questionnaires, engaged in audiovisual training, and were randomized to either receive a naloxone kit or be given information on where they could obtain one. Preliminary results indicate feasibility and acceptability as evidenced by strong recruitment and retention, as well as high participant satisfaction ratings. Successful implementation of remote OEND through this project supports future employment of similar remote programs to expand this critical harm reduction strategy to high-risk individuals in areas lacking traditional OEND programs. Trial Registration #: Clinitaltrials.gov- NCT04303000.

Racialized health inequities in substance use-related harms might emerge from differential access to syringe service programs (SSPs). To explore this, we examined the association between county-level racialized environments, other factors, and (1) SSP presence, and (2) per capita syringe and (3) naloxone distribution. 2021 US National Survey of SSP data (n=295/412;72 % response rate) was used to identify SSP presence and the sum of syringes and naloxone doses distributed in 2020 by county. Study measures included racial residential segregation (RRS; i.e., divergence and dissimilarity indexes for Black:Non-Hispanic White & Hispanic:Non-Hispanic White) and covariates (i.e., demographic proportions, urban/suburban/rural classifications, 2020 US presidential Republican vote share, and overdose mortality from 2019). We used logit Generalized Estimating Equations to determine factors associated with county-level SSP presence, and zero inflated negative binomial regression models to determine factors associated with per capita syringe and naloxone distribution. SSPs were reported in 9 % (283/3106) of US counties. SSP presence was associated with higher divergence and dissimilarity indexes, urban and suburban counties, higher opioid overdose mortality, and lower 2020 Republican presidential vote share. Per capita syringes distributed was associated with lower RRS (divergence and Hispanic:White dissimilarity), lower racially minoritized population proportions and rural counties, while per capita naloxone distribution was associated with lower Hispanic and "other" population proportions, and rural counties. Racialized environments are associated with SSP presence but not the scope of those programs. Preventing HIV and HCV outbreaks, and overdose deaths requires addressing community level factors that influence SSP implementation and accessibility. • Racialized inequities in substance use-related harms persist. • Harm reduction services are critical to addressing overdose mortality. • Diverse county-level factors contribute to harm reduction services availability. • Racial residential segregation is associated with harm reduction services availability. • Political health determinants must be addressed to optimize harm reduction services. [ABSTRACT FROM AUTHOR]

The opioid crisis has resulted in unprecedented rates of overdose, yet much remains unknown about the locational and contextual attributes of overdose events. This study aimed to identify settings of nonfatal opioid overdose and their individual and community level predictors. Data from 3,326 overdose events show that residences are the most common overdose setting. Compared to overdoses occurring in residences, outdoor overdoses were more likely in communities with higher area deprivation index and population density, and overdoses in nonresidential settings were more likely among unhoused individuals. Findings demonstrate the need for comprehensive, yet tailored and localized approaches to overdose prevention. [ABSTRACT FROM AUTHOR]

Introduction Opioid overdose education and naloxone distribution (OEND) for use by laypersons are safe and effective at preventing deaths from opioid overdose, but emergency department (ED) implementation is challenging. Curricula addressing OEND could enable students to serve in value-added roles on the clinical team, overcome challenges of naloxone distribution, and improve patient care. Methods We created a 1-hour didactic session on opioid use disorder and OEND for first-year medical students in the emergency medicine elective. During two clinical shifts, students used this knowledge to perform screenings to identify patients at high risk of overdose. If a patient screened positive, students performed patient education and then notified the physician, who ordered a naloxone kit. Results Thirty students received the didactic and conducted screening shifts. Of 147 patients screened, 40% (n = 59) were positive for naloxone eligibility, 21% (n = 31) reported that someone close to them used opioids, 18% (n = 26) had witnessed an opioid overdose, 12% (n = 17) had previously overdosed themselves, and 12% (n = 18) previously knew what naloxone was. Fifty-nine naloxone kits were distributed over the 3-month pilot versus 13 naloxone prescriptions for patients discharged from the ED the prior year. Discussion Through didactic training and structured patient engagement, medical students gained knowledge of and hands-on experience with addiction medicine, discussed sensitive topics with patients, and identified a high volume of patients eligible to receive naloxone. Medical student screening for OEND in ED patients is feasible and adds significant value to the clinical team.

People leaving incarceration are at high risk of opioid-related overdose. Overdose fatalities are preventable with administration of naloxone. In response to this risk, overdose education and naloxone distribution (OEND) programs have been implemented in a handful of jails and prisons in the United States. We document the history, structure, and data from the San Francisco County Jail OEND program. During 4 years of operation, 637 people participated; 67% received naloxone upon release, of whom only 3.5% had been previously trained in community-based OEND programs. Of those who received naloxone, 32% reported reversing an overdose and 44% received refills from community-based programs after reentry. This confirms that implementation of OEND in criminal justice settings is feasible and reaches people who have not previously been trained as well as those willing to act as overdose responders. [ABSTRACT FROM AUTHOR]

Aims: To examine uptake following a large‐scale naloxone programme by estimating distribution rates since programme initiation and the proportion among a sample of high‐risk individuals who had attended naloxone training, currently possessed or had used naloxone. We also estimated the likelihood of naloxone possession and use as a function of programme duration, individual descriptive and substance use indicators. Design (1) Distribution data (June 2014–August 2017) and date of implementation for each city and (2) a cross‐sectional study among a sample of illicit substance users interviewed September 2017. Setting: Seven Norwegian cities. Participants: A total of 497 recruited users of illegal opioids and/or central stimulants. Measurements Primary outcomes: naloxone possession and use. Random‐intercepts logistic regression models (covariates: male, age, homelessness/shelter use, overdose, incarceration, opioid maintenance treatment, income sources, substance use indicators, programme duration). Findings Overall, 4631 naloxone nasal sprays were distributed in the two pilot cities, with a cumulative rate of 495 per 100 000 population. In the same two cities, among high‐risk individuals, 44% and 62% reported current naloxone possession. The possession rates of naloxone corresponded well to the duration of each participating city's distribution programme. Overall, in the six distributing cities, 58% reported naloxone training, 43% current possession and 15% naloxone use. The significant indicators for possession were programme duration [adjusted odds ratios (aOR) = 1.44, 95% confidence interval (CI = 0.82–2.37], female gender (aOR = 1.97, 95% CI = 1.20–3.24) and drug‐dealing (aOR = 2.36, 95% CI = 1.42–3.93). The significant indicators for naloxone use were programme duration (aOR = 1.49 95%, CI = 1.15–1.92), homelessness/shelter use (aOR = 2.06, 95% CI = 1.02–4.17), opioid maintenance treatment (OMT) (aOR = 2.07, 95% CI = 1.13–3.78), drug‐dealing (aOR = 2.40, 95% CI = 1.27–4.54) and heroin injecting (aOR = 2.13, 95% CI = 1.04–4.38). Conclusions: A large‐scale naloxone programme in seven Norwegian cities with a cumulative distribution rate of 495 per 100 000 population indicated good saturation in a sample of high‐risk individuals, with programme duration in each city as an important indicator for naloxone possession and use. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The Government of Manitoba launched the provincial Take-Home Naloxone Program in January 2017. By the end of September 2017, there were over 60 sites operating in Manitoba. These sites distributed 765 kits to people at risk of opioid overdose, and 93 of these kits were replacement kits used in overdose events. Most of these events occurred among males (60.2%) and in a private residence (72.0%). Fentanyl and carfentanil were the most common substances reported during overdose events. Take-Home Naloxone Program data provide important information about the unique context of the opioid crisis in Manitoba. [ABSTRACT FROM AUTHOR]

Background: Opioid overdose deaths in the US rose dramatically in the past 16 years, creating an urgent national health crisis with no signs of immediate relief. In 2017, the President of the US officially declared the opioid epidemic to be a national emergency and called for additional resources to respond to the crisis. Distributing naloxone to community laypersons and people at high risk for opioid overdose can prevent overdose death, but optimal distribution methods have not yet been pinpointed.Methods: We conducted a sequential exploratory mixed methods design using qualitative data to inform an agent-based model to improve understanding of effective community-based naloxone distribution to laypersons to reverse opioid overdose. The individuals in the model were endowed with cognitive and behavioral variables and accessed naloxone via community sites such as pharmacies, hospitals, and urgent-care centers. We compared overdose deaths over a simulated 6-month period while varying the number of distribution sites (0, 1, and 10) and number of kits given to individuals per visit (1 versus 10). Specifically, we ran thirty simulations for each of thirteen distribution models and report average overdose deaths for each. The baseline comparator was no naloxone distribution. Our simulations explored the effects of distribution through syringe exchange sites with and without secondary distribution, which refers to distribution of naloxone kits by laypersons within their social networks and enables ten additional laypersons to administer naloxone to reverse opioid overdose.Results: Our baseline model with no naloxone distribution predicted there would be 167.9 deaths in a six month period. A single distribution site, even with 10 kits picked up per visit, decreased overdose deaths by only 8.3% relative to baseline. However, adding secondary distribution through social networks to a single site resulted in 42.5% fewer overdose deaths relative to baseline. That is slightly higher than the 39.9% decrease associated with a tenfold increase in the number of sites, all distributing ten kits but with no secondary distribution. This suggests that, as long as multiple kits are picked up per visit, adding secondary distribution is at least as effective as increasing sites from one to ten. Combining the addition of secondary distribution with an increase in sites from one to ten resulted in a 61.1% drop in deaths relative to the baseline. Adding distribution through a syringe exchange site resulted in a drop of approximately 65% of deaths relative to baseline. In fact, when enabling distribution through a clean-syringe site, the secondary distribution through networks contributed no additional drops in deaths.Conclusion: Community-based naloxone distribution to reverse opioid overdose may significantly reduce deaths. Optimal distribution methods may include secondary distribution so that the person who picks up naloxone kits can enable others in the community to administer naloxone, as well as targeting naloxone distribution to sites where individuals at high-risk for opioid overdose death are likely to visit, such as syringe-exchange programs. This study design, which paired exploratory qualitative data with agent-based modeling, can be used in other settings seeking to implement and improve naloxone distribution programs. [ABSTRACT FROM AUTHOR]

Drug overdose is the leading cause of accidental death in the United States, with over 70% of drug related fatalities resulting from the use of opioids. Federal agencies have responded to this crisis with various recommendations including enhancing harm reduction approaches such as training laypersons to administer naloxone through Opioid Overdose Education and Naloxone Distribution (OEND) programs. Several studies have demonstrated that OEND programs effectively reduce opioid overdose mortality and are both safe and cost-effective, however, they are typically implemented in urban areas as part of large medical center research programs, needle exchanges, or drug treatment programs. Individuals living in areas without these programs or services lack access to critical and life-saving OEND. The current study examined the acceptability and feasibility of online recruitment, online opioid overdose education, and remote distribution of naloxone kits. Persons who illicitly use opioids and are at risk for overdose were recruited through online media and completed an opioid use questionnaire. If interested in receiving opioid overdose and naloxone administration training, participants completed pre- and post-intervention knowledge questionnaires, engaged in audiovisual training, and were randomized to either receive a naloxone kit or be given information on where they could obtain one. Preliminary results indicate feasibility and acceptability as evidenced by strong recruitment and retention, as well as high participant satisfaction ratings. Successful implementation of remote OEND through this project supports future employment of similar remote programs to expand this critical harm reduction strategy to high-risk individuals in areas lacking traditional OEND programs., Trial Registration #: Clinitaltrials.gov- NCT04303000., Competing Interests: Dr. Carpenter has received consulting honoraria from Pfizer and Frutarom Inc. The authors declare that there is no conflict of interest.

Background: Racial/ethnic minorities have experienced disproportionate opioid-related overdose death rates in recent years. In this context, we examined inequities in community-based naloxone access across racial/ethnic groups in Massachusetts.Methods: We used data from: the Massachusetts Department of Public Health on community-based overdose education and naloxone distribution (OEND) programs; the Massachusetts Office of the Chief Medical Examiner on opioid-related overdose deaths, and; the United States Census American Community Survey for regional demographic/socioeconomic details to estimate community populations by race/ethnicity and racial segregation between African American/Black and white residents. Race/ethnicity groups included in the analysis were African American/Black (non-Hispanic), Hispanic, white (non-Hispanic), and "other" (non-Hispanic). We evaluated racial/ethnic differences in naloxone distribution across regions in Massachusetts and neighborhoods in Boston descriptively and spatially, plotting the race/ethnicity-specific number of kits per opioid-related overdose death per jurisdiction. Lastly, we constructed generalized estimating equations models with a negative binomial distribution to compare the race/ethnicity-specific naloxone distribution rate by OEND programs.Results: From 2016-2019, the median annual rate of naloxone kits received from OEND programs in Massachusetts per racial/ethnicity group ranged between 160 and 447 per 100,000. In a multivariable analysis, we found that the naloxone distribution rates for racial/ethnic minorities were lower than the rate for white residents. We also found naloxone was more likely to be distributed in racially segregated communities than non-segregated communities.Conclusion: We identified racial/ethnic inequities in naloxone receipt by individuals in Massachusetts. Additional resources focused on designing and implementing OEND programs for racial/ethnic minorities are warranted to ensure equitable access to naloxone. [ABSTRACT FROM AUTHOR]

Aims This study assessed overdose and naloxone administration knowledge among current or former opioid abusers trained and untrained in overdose–response in the United States. Design and participants Ten individuals, divided equally between those trained or not trained in overdose recognition and response, were recruited from each of six sites ( n = 62). Setting US-based overdose training and naloxone distribution programs in Baltimore, San Francisco, Chicago, New York and New Mexico. Measurements Participants completed a brief questionnaire on overdose knowledge that included the task of rating 16 putative overdose scenarios for: (i) whether an overdose was occurring and (ii) if naloxone was indicated. Bivariate and multivariable analyses compared results for those trained to untrained. Responses were also compared to those of 11 medical experts using weighted and unweighted kappa statistics. Findings Respondents were primarily male (72.6%); 45.8% had experienced an overdose and 72% had ever witnessed an overdose. Trained participants recognized more opioid overdose scenarios accurately ( t60 = 3.76, P < 0.001) and instances where naloxone was indicated ( t59 = 2.2, P < 0.05) than did untrained participants. Receipt of training and higher perceived competency in recognizing signs of an opioid overdose were associated independently with higher overdose recognition scores. Trained respondents were as skilled as medical experts in recognizing opioid overdose situations (weighted kappa = 0.85) and when naloxone was indicated (kappa = 1.0). Conclusions Results suggest that naloxone training programs in the United States improve participants' ability to recognize and respond to opioid overdoses in the community. Drug users with overdose training and confidence in their abilities to respond may effectively prevent overdose mortality. [ABSTRACT FROM AUTHOR]

Introduction: Opioid overdose education and naloxone distribution (OEND) for use by laypersons are safe and effective at preventing deaths from opioid overdose, but emergency department (ED) implementation is challenging. Curricula addressing OEND could enable students to serve in value-added roles on the clinical team, overcome challenges of naloxone distribution, and improve patient care., Methods: We created a 1-hour didactic session on opioid use disorder and OEND for first-year medical students in the emergency medicine elective. During two clinical shifts, students used this knowledge to perform screenings to identify patients at high risk of overdose. If a patient screened positive, students performed patient education and then notified the physician, who ordered a naloxone kit., Results: Thirty students received the didactic and conducted screening shifts. Of 147 patients screened, 40% ( n = 59) were positive for naloxone eligibility, 21% ( n = 31) reported that someone close to them used opioids, 18% ( n = 26) had witnessed an opioid overdose, 12% ( n = 17) had previously overdosed themselves, and 12% ( n = 18) previously knew what naloxone was. Fifty-nine naloxone kits were distributed over the 3-month pilot versus 13 naloxone prescriptions for patients discharged from the ED the prior year., Discussion: Through didactic training and structured patient engagement, medical students gained knowledge of and hands-on experience with addiction medicine, discussed sensitive topics with patients, and identified a high volume of patients eligible to receive naloxone. Medical student screening for OEND in ED patients is feasible and adds significant value to the clinical team., (© 2021 Moore et al.)

Background : Opioid overdose deaths continue to rise nationally. The demand for naloxone, the opioid overdose antidote, is outpacing the supply. With increasing naloxone requests, tools to prioritize distribution are critical to ensure available supplies will reach those at highest risk of overdose. Methods : We developed a standardized "Naloxone Request Form" (NRF) and corresponding weighted prioritization algorithm to serve as decisional aid to better enable grant staff to prioritize naloxone distribution in a data-driven manner. The algorithm computed raw priority scores for each agency, which were then separated into the predetermined quintiles. Historical naloxone distribution decisions were compared with agencies' prioritization quintile. Results : Results demonstrated that the NRF and corresponding algorithm was successful at prioritizing agencies based on potential impact. Although, overall, naloxone was distributed more heavily to the agencies deemed highest priority, our algorithm identified significant shortcomings of the "first come, first served" method of distribution we had initially deployed. Conclusions : This work has laid the foundation to use this tool prospectively to allow for data-driven decision-making for naloxone distribution. Our tool is flexible and can be customized to best fit the needs of a variety of programs and locations to ensure the distribution of limited supplies of naloxone have the greatest impact.

Background: Overdose education with naloxone distribution (OEND) is a key national strategy to reduce morbidity and mortality related to opioid overdoses. Train-the-trainer model has been one method to increase the pool of trainers to facilitate greater dissemination of OEND. This exploratory study seeks to (1) evaluate participant's change in knowledge and confidence, (2) examine if pre- and post-training test outcomes differed by occupation and level of experience, and (3) determine if train-the-trainer participants trained others 6 months later. Methods: Fifteen train-the-trainer sessions were delivered to staff from community organizations who served high-risk clients in four counties whose overdose death rates ranged from 11.2 to 32.8 per 100,000. Participants were administered pre- and post-training tests from September 2017 to December 2018. A follow-up survey was conducted 6 months post-training to evaluate outcomes. Final paired pre-and post-training surveys of 109 participants were used for analysis. Paired sample t -tests were used to evaluate changes in the knowledge and confidence in teaching others. One-way ANOVA compared the change scores across groups with different demographic or experiential characteristics. Kruskal-Wallis Test was used for Likert scales. Results: The one and one-half hour train-the-trainer curriculum increased participants' knowledge and confidence to teach others ( p  < .001). This was particularly true for participants who had no prior experience compared to those who had some experience with naloxone ( p  = .0003). Changes in confidence to teach others significantly improved among demographic subgroups of participants. At 6 months after completing the train-the-trainer curriculum, 14 participants had trained 243 new trainees. Conclusions: Implementing a train-the-trainer model for OEND increases knowledge and participants' confidence to teach others. This demonstrates the important potential of the train-the-trainer model to respond to the growing opioid overdose epidemic.

Introduction: The surviving opioid overdose with naloxone education and resuscitation (SOONER) project uses co-design and trial methods to develop and evaluate a point-of-care overdose education and naloxone distribution (OEND) tool. We plan to conduct a randomised controlled trial to assess the effectiveness of our OEND tool in comparison with best available standard of care by observing participants' performance as a responder to a simulated overdose. Recruiting and retaining people at risk of or likely to witness opioid overdose raises scientific, logistical and bioethical challenges. A feasibility study is needed to establish the effectiveness of recruitment and retention strategies and acceptability of study procedures prior to launching the full trial., Methods and Analysis: Strategies to enhance recruitment include candidate-driven recruitment, verbal informed consent, and attractive, destigmatising materials. Adults at risk of or likely to witness opioid overdose will be recruited through an urban emergency department, inpatient and ambulatory addiction medicine service, and outpatient family practice settings. Participants randomised to the intervention arm will receive our OEND intervention; those in the control arm will be referred to existing OEND programme. Retention procedures include participant reminders, flexible scheduling, cash and comfort compensation, and strategies to maintain a consistent relationship between individual study staff and participants. Within 2 weeks following recruitment, participants will engage as a responder to a manikin-simulated overdose, and complete overdose knowledge and attitudes questionnaires. The primary outcome is recruitment and retention feasibility, defined as the recruitment of 28 participants within 28 days of recruitment and <50% attrition at the overdose simulation. Staff and participant feedback will also be collected and considered., Ethics and Dissemination: The study has been reviewed by ethics boards at St. Michael's Hospital, Toronto Public Health and the University of Toronto. Dissemination will occur through peer-reviewed publication and presentations., Trial Registration Number: ClinicalTrials.gov registry (NCT03821649)., Competing Interests: Competing interests: AO: evidence reviewer for ILCOR 2015, and writer for AHA/HSFC Guidelines on CPR and Resuscitation in 2015. Receives salary support from the Canadian Institutes of Health Research, the Schwartz/Reisman Emergency Medicine Institute, and the University of Toronto Department of Family and Community Medicine. AO is an evidence reviewer for the International Liaison Committee on Resuscitation and a coauthor for the 2015 American Heart Association Guidelines for CPR and ECC concerning opioid overdose and 2019 American Heart Association Guidelines updates on First Aid. CH: Contract with Toronto Central Local Health Integration Network as primary care clinical lead for the mid-east Toronto sub-region. MK: speaker honoraria from the Ontario Pharmacists Association continuing education programs on the topic of opioid use disorder. I do not address take home naloxone beyond mentioning that the programme exists (Major >$5000). Advisory Committee Member, Health Quality Ontario, Quality Standard on Opioid Use Disorder, but recused from voting on standards that involved take-home naloxone. PL: Advisory Committee Member, Health Quality Ontario, Quality Standard: Opioid Use Disorder; Quality Statement 6 pertains to access to naloxone and overdose education. LM: contributor to the 2015 guidelines and ILCOR consensus on science where opioid management was reviewed and updated., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

The Government of Manitoba launched the provincial Take-Home Naloxone Program in January 2017. By the end of September 2017, there were over 60 sites operating in Manitoba. These sites distributed 765 kits to people at risk of opioid overdose, and 93 of these kits were replacement kits used in overdose events. Most of these events occurred among males (60.2%) and in a private residence (72.0%). Fentanyl and carfentanil were the most common substances reported during overdose events. Take-Home Naloxone Program data provide important information about the unique context of the opioid crisis in Manitoba., Competing Interests: The authors have no conflict of interest to declare.