Evaluation of an Experimental Web-based Educational Module on Opioid-related Occupational Safety Among Police Officers: Protocol for a Randomized Pragmatic Trial to Minimize Barriers to Overdose Response.

BACKGROUND: As drug-related morbidity and mortality continue to surge, police officers are on the front lines of the North American overdose (OD) crisis. Drug law enforcement shapes health risks among people who use drugs (PWUD), while also impacting the occupational health and wellness of officers. Effective interventions to align law enforcement practices with public health and occupational safety goals remain underresearched. OBJECTIVE: The Opioids and Police Safety Study (OPS) aims to shift police practices relating to PWUD. It adapts and evaluates the relative effectiveness of a curriculum that bundles content on public health promotion with occupational risk reduction (ORR) to supplement a web-based OD response and naloxone training platform (GetNaloxoneNow.org, or GNN). This novel approach has the potential to improve public health and occupational safety practices, including using naloxone to reverse ODs, referring PWUD to treatment and other supportive services, and avoiding syringe confiscation. METHODS: This longitudinal study uses a randomized pragmatic trial design. A sample of 300 active-duty police officers from select counties in Pennsylvania, Vermont, and New Hampshire with high OD fatality rates will be randomized (n=150 each) to either the experimental arm (GNN + OPS) or the control arm (GNN + COVID-19 ORR). A pre- and posttraining survey will be administered to all 300 officers, after which they will be administered quarterly surveys for 12 months. A subsample of police officers will also be qualitatively followed in a simultaneous embedded mixed-methods approach. Research ethics approval was obtained from the New York University Institutional Review Board. RESULTS: Results will provide an understanding of the experiences, knowledge, and perceptions of this sample of law enforcement personnel. Generalized linear models will be used to analyze differences in key behavioral outcomes between the participants in each of the 2 study arms and across multiple time points (anticipated minimum effect size to be detected, d=0.50). Findings will be disseminated widely, and the training products will be available nationally once the study is completed. CONCLUSIONS: The OPS is the first study to longitudinally assess the impact of a web-based opioid-related ORR intervention for law enforcement in the U.S. Our randomized pragmatic clinical trial aims to remove barriers to life-saving police engagement with PWUD/people who inject drugs by focusing both on the safety of law enforcement and evidence-based and best practices for working with persons at risk of an opioid OD. Our simultaneous embedded mixed-methods approach will provide empirical evaluation of the diffusion of the naloxone-based response among law enforcement. TRIAL REGISTRATION: ClinicalTrail.gov NCT05008523; https://clinicaltrials.gov/show/NCT05008523. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/33451.

Build It Better for Public Health: Improved Data Infrastructure Is Vital to Bending the Curve of the Overdose Crisis

For most decedents, the COD is determined by the attending physician or nurse;however, death investigations are required for cases in which the COD is sudden or unexpected, is not of natural causes, is unattended, or is unexplained.2 Therefore, coroners and medical examiners are typically the authorized certifiers of death in cases involving overdose.3 In this issue of AJPH (p. S36), Merlin et al. provide a timely analysis of overdose surveillance in the health care settings, where deaths may be miscategorized by attending physicians for decedents with underlying illness. According to Centers for Disease Control and Prevention (CDC) data, of the 28 states with county coroners, 22 states do not have a state medical examiner, and half do not require the coroner position to be held by a medical professional or an individual with certified credentials to conduct autopsies, such as pathology, toxicology, and forensic medicine.4 The accuracy of COD related to drugs is higher for medical examiners than for coroners. [...]the specific drug was not listed for 38% of death certificates in states with decentralized county coroner systems, compared with 8% in states with a statewide medical examiner system, leading to underestimates for death rates.3 Even in situations where medical examiners are present, death investigations continue to be substantially underfunded and threaten the accuracy of COD data. COD determination exists within a broader context of institutional racism and racial bias in clinical policy and practice.11 Genomic research has unequivocally determined that race is not a biological categorization;yet, erroneous beliefs persist in the medical community about biological differences between Black and White individuals.12 These biases are associated with clinical recommendations and how services are delivered.13 Recognizing signs that overdose may have occurred is also limited by the lack of foundational training provided by medical institutions for substance use disorder, despite its being a leading COD for unintentional injury.

Growing racial/ethnic disparities in overdose mortality before and during the COVID-19 pandemic in California.

As overdose mortality is spiking during the COVID-19 pandemic, few race/ethnicity-stratified trends are available. This is of particular concern as overdose mortality was increasing most rapidly in Black and Latinx communities prior to the pandemic. We used quarterly, age-standardized overdose mortality rates from California to assess trends by race/ethnicity and drug involved over time. Rates from 2020 Q2-Q4 were compared to expected trends based on ARIMA forecasting models fit using data from 2006 to 2020 Q1. In 2020 Q2-Q4 overdose death rates rose by 49.8% from 2019, exceeding an expected increase of 11.5% (95%CI: 0.5%-22.5%). Rates significantly exceeded forecasted trends for all racial/ethnic groups. Black/African American individuals saw an increase of 52.4% from 2019, compared to 42.6% among their White counterparts. The absolute Black-White overdose mortality gap rose from 0.7 higher per 100,000 for Black individuals in 2018 to 4.8 in 2019, and further increased to 9.9 during the pandemic. Black overdose mortality in California was therefore 34.3% higher than that of White individuals in 2020 Q2-Q4. This reflects growing methamphetamine-, cocaine-, and fentanyl-involved deaths among Black communities. Growing racial disparities in overdose must be understood in the context of the unequal social and economic fallout from the COVID-19 pandemic, during which time Black communities have been subjected to the dual burden of disproportionate COVID-19 deaths and rising overdose mortality. Increased investments are required to ameliorate racial/ethnic disparities in substance use treatment, harm reduction, and the structural drivers of overdose, as part of the COVID-19 response and post-pandemic recovery efforts.

Racial/Ethnic, Social, and Geographic Trends in Overdose-Associated Cardiac Arrests Observed by US Emergency Medical Services During the COVID-19 Pandemic.

Importance: Provisional records from the US Centers for Disease Control and Prevention (CDC) through July 2020 indicate that overdose deaths spiked during the early months of the COVID-19 pandemic, yet more recent trends are not available, and the data are not disaggregated by month of occurrence, race/ethnicity, or other social categories. In contrast, data from emergency medical services (EMS) provide a source of information nearly in real time that may be useful for rapid and more granular surveillance of overdose mortality. Objective: To describe racial/ethnic, social, and geographic trends in EMS-observed overdose-associated cardiac arrests during the COVID-19 pandemic through December 2020 and assess the concordance with CDC-reported provisional total overdose mortality through May 2020. Design, Setting, and Participants: This cohort study included more than 11 000 EMS agencies in 49 US states that participate in the National EMS Information System and 83.7 million EMS activations in which patient contact was made. Exposures: Year and month of occurrence of overdose-associated cardiac arrest; patient race/ethnicity; census region and division; county-level urbanicity; and zip code-level racial/ethnic composition, poverty, and educational attainment. Main Outcomes and Measures: Overdose-associated cardiac arrests per 100 000 EMS activations with patient contact in 2020 were compared with a baseline of values from 2018 and 2019. Aggregate numbers of overdose-associated cardiac arrests and percentage increases were compared with provisional total mortality in CDC records from rolling 12-month windows with end months spanning January 2018 through July 2020. Results: Among 33.4 million EMS activations in 2020, 16.8 million (50.2%) involved female patients and 16.3 million (48.8%) involved non-Hispanic White individuals. Overdose-associated cardiac arrests were elevated by 42.1% nationally in 2020 (42.3 per 100 000 EMS activations at baseline vs 60.1 per 100 000 EMS activations in 2020). The highest percentage increases were seen among Latinx individuals (49.7%; 38.8 per 100 000 activations at baseline vs 58.1 per 100 000 activations in 2020) and Black or African American individuals (50.3%; 21.5 per 100 000 activations at baseline vs 32.3 per 100 000 activations in 2020), people living in more impoverished neighborhoods (46.4%; 42.0 per 100 000 activations at baseline vs 61.5 per 100 000 activations in 2020), and the Pacific states (63.8%; 33.1 per 100 000 activations at baseline vs 54.2 per 100 000 activations in 2020), despite lower rates at baseline for these groups. The EMS records were available 6 to 12 months ahead of CDC mortality figures and showed a high concordance (r = 0.98) for months in which both data sets were available. If the historical association between EMS-observed and total overdose mortality holds true, an expected total of approximately 90 632 (95% CI, 85 737-95 525) overdose deaths may eventually be reported by the CDC for 2020. Conclusions and Relevance: In this cohort study, records from EMS agencies provided an effective manner to rapidly surveil shifts in US overdose mortality. Unprecedented overdose deaths during the pandemic necessitate investments in overdose prevention as an essential aspect of the COVID-19 response and postpandemic recovery. This is particularly urgent for more socioeconomically disadvantaged and racial/ethnic minority communities subjected to the compounded burden of disproportionate COVID-19 mortality and rising overdose deaths.

Role of Overdose Prevention Sites in Coronavirus Response

From the Executive Summary: The coronavirus pandemic has compounded North America's overdose crisis. [...] In responding to these overlapping public health emergencies, we must draw on the full spectrum of science-driven prevention measures. Such measures include rapid scale-up in access to critical overdose prevention medications, including methadone, buprenorphine, and the opioid antidote naloxone. But we must also expand the limited toolkit of overdose prevention efforts in the United States to include overdose prevention sites. Also known as 'supervised consumption facilities' or 'safe injection sites,' these are safe, supervised spaces to use previously-obtained drugs and access essential care and support services. With nearly 300 such facilities operating worldwide, overdose prevention sites have shown overwhelming evidence of their public health benefit and cost-effectiveness. Despite these well-documented successes, advocates have been unsuccessful at opening a legally-sanctioned overdose prevention site in the United States. In the context of the COVID-19 [coronavirus disease 2019] pandemic, such sites are especially vital because of their potential to prevent both overdose fatalities and the spread of infectious diseases. By handling numerous medical emergencies, they also promise to conserve health care system resources during a time when these resources are acutely scarce. As coronavirus is fundamentally redefining the status quo, the imperative for overdose prevention sites has never been more urgent. The American public agrees: In new polling, we found substantial bipartisan support for overdose prevention sites and other harm reduction solutions as part of the response to coronavirus.Drugs--Overdose;Drug abuse--Prevention;COVID-19 (Disease);Public health

No "back to normal" after COVID-19 for our failed drug policies.

Before COVID-19 pandemic, advocates had long urged drug policy reforms based on health, security, civil rights, racial justice, fiscal stewardship, and other considerations. In the United States, such calls went largely unanswered. In response to COVID-19, public health and occupational safety concerns have rapidly transformed some drug policies, along with their enforcement. Almost contemporaneously, nationwide protests against violence and racism by militarized police have highlighted the enduring legacy of the Drug War in fueling carceral systems. Disruption from these historical events provides a once-in-a-century opportunity to reconsider the legal architecture of drug policy and policing-both in the U.S. and elsewhere. Rather than returning to a fundamentally broken and inequitable status quo, we urge envisioning a new drug policy in service to life, liberty, and the pursuit of happiness.

COVID-19 as a Frying Pan: The Promise and Perils of Pandemic-driven Reform.

: The imposition of new regulations can send industries scrambling to comply, fostering innovation in doing so. How we police and treat people with opioid use disorder (OUD), with recent widespread social unrest in reaction to police violence and systemic racism bringing the need for lasting structural changes to our justice system and social services into especially acute relief. Arbitrary laws and counterproductive policies previously subject to only incremental reform have given way to sweeping changes: people convicted of nonviolent drug crimes have been released from jails and prisons, the enforcement of drug laws has been cast aside as a priority, and the regulations surrounding addiction treatment medications and treating patients with OUD have been greatly loosened. These are changes many practitioners and advocates have sought for years if not decades, but they come with the reality that the old systems are culturally entrenched and likely to be resilient. It is critical that researchers evaluate these changes and synthesize the results with existing evidence in ways that empower efforts to make the most effective responses permanent. The COVID-19 pandemic makes for a challenging research environment, but its OUD-related interventions have created new regulatory systems that lend themselves to valuable opportunities for evaluation as natural experiments by the burgeoning field of legal epidemiology.