Medication Update

The article offers medical briefs. Topics include the authorization of a new drug called Gohibic for critically ill patients with COVID-19;the approval of an over-the-counter naloxone nasal spray for opioid overdose treatment;and the Food and Drug Administration approval of a long-acting antifungal called Rezzayo for the treatment of candidemia and invasive candidiasis for hypertension medications.

Low Barrier Tele-Buprenorphine in the Time of COVID-19: A Case Report

Background: To reduce the spread of coronavirus disease 2019 (COVID-19), many substance use disorder treatment programs have transitioned to telemedicine. Emergency regulatory changes allow buprenorphine initiation without an in-person visit. We describe the use of videoconferencing for buprenorphine initiation combined with street outreach to engage 2 patients experiencing homelessness with severe opioid use disorder (OUD). Case Presentation: Patient 1 was a 30-year-old man with severe OUD who had relapsed to injection heroin/fentanyl after incarceration. A community drop-in center outreach harm reduction specialist facilitated a videoconference with an addiction specialist at an OUD bridge clinic. The patient completed a community buprenorphine/naloxone initiation and self-titrated to his prior dose, 8/2 mg twice daily. One week later, he reconnected with the outreach team for a follow-up videoconference visit. Patient 2, a 36-year-old man with severe OUD, connected to the addiction specialist via a syringe service program harm reduction specialist. He had been trying to connect to a community buprenorphine/naloxone provider, but access was limited due to COVID-19, so he was using diverted buprenorphine/naloxone to reduce opioid use. He was restarted on his previous dose of 12/3 mg daily which was continued via phone follow-up 16 days later. Conclusion(s): COVID-19-related regulatory changes allow buprenorphine initiation via telemedicine. We describe 2 cases where telemedicine was combined with street outreach to connect patients experiencing homelessness with OUD to treatment. These cases highlight an important opportunity to provide access to life-saving OUD treatment for vulnerable patients in the setting of a pandemic that mandates reduced face-to-face clinical interactions.Copyright © 2020 Lippincott Williams and Wilkins. All rights reserved.

Impacts of the COVID-19 pandemic on enrollment in medications for opioid use disorder (MOUD) in Vancouver, Canada: An interrupted time series analysis.

BACKGROUND: In anticipation of COVID-19 related disruptions to opioid use disorder (OUD) care, new provincial and federal guidance for the management of OUD and risk mitigation guidance (RMG) for prescription of pharmaceutical opioids were introduced in British Columbia, Canada, in March 2020. This study evaluated the combined impacts of the COVID-19 pandemic and counteracting OUD policies on enrollment in medications for OUD (MOUD). METHODS: Using data from three cohorts of people with presumed OUD in Vancouver, we conducted an interrupted time series analysis to estimate the combined effects impact of the COVID-19 pandemic and counteracting OUD policies on the prevalence of enrollment in MOUD overall, as well as in individual MOUDs (methadone, buprenorphine/naloxone, slow-release oral morphine) between November 2018 and November 2021, controlling for pre-existing trends. In sub-analysis we considered RMG opioids together with MOUD. RESULTS: We included 760 participants with presumed OUD. In the post-COVID-19 period, MOUD and slow-release oral morphine prevalence rates showed an estimated immediate increase in level (+7.6%, 95% CI: 0.6%, 14.6% and 1.8%, 95% CI: 0.3%, 3.3%, respectively), followed by a decline in the monthly trend (-0.8% per month, 95% CI: -1.4%, -0.2% and -0.2% per month, 95% CI: -0.4, -0.1, respectively). There were no significant changes in the prevalence trends of enrollment in methadone, buprenorphine/naloxone, or when RMG opioids were considered together with MOUD. CONCLUSIONS: Despite immediate improvements in MOUD enrollment in the post-COVID-19 period, this beneficial trend reversed over time. RMG opioids appeared to have provided additional benefits to sustain retention in OUD care.

Considerations for the design of overdose education and naloxone distribution interventions: results of a multi-stakeholder workshop.

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.

Feasibility and Acceptability of an Overdose Prevention Intervention Delivered by Community Pharmacists for Patients Prescribed Opioids for Chronic Non-Cancer Pain.

There have been increases in prescriptions of high strength opioids for chronic non-cancer pain (CNCP), but CNCP patients perceive themselves as being at low risk of opioid overdose and generally have limited overdose awareness. This study examined how an overdose prevention intervention (opioid safety education, naloxone training, and take-home naloxone (THN)) delivered by community pharmacists for patients prescribed high-strength opioids for CNCP would work in practice in Scotland. Twelve patients received the intervention. CNCP patients and Community Pharmacists were interviewed about their experiences of the intervention and perceptions of its acceptability and feasibility. CNCP patients did not initially perceive themselves as being at risk of overdose but, through the intervention, developed insight into opioid-related risk and the value of naloxone. Pharmacists also identified patients' low risk perceptions and low overdose awareness. While pharmacists had positive attitudes towards the intervention, they outlined challenges in delivering it under time and resource pressures and during the COVID-19 pandemic. Overdose prevention interventions are required in the CNCP population as this group has elevated risk factors for overdose but are commonly overlooked. Customised overdose prevention interventions for CNCP patients attend to gaps in overdose awareness and risk perceptions in this population.

Expanding Access to Opioid Use Disorder Treatment Via Telehealth in Lewis County, Washington

Purpose of Study Lewis County is in southwest Washington state. With a population per square mile of 31.4, Lewis County is more rural than the rest of the state (101.2 per square mile). Citizens of the county, as well as health care workers at Chehalis Family Medicine (located in Lewis County), report concerns over rates of opioid use disorder. While Lewis County's age adjusted rate per 100,000 of deaths due to opioid overdose from 2014-2017 was lower than that of Washington state (7.6 vs 9.3), its rate of opioid related hospitalizations was significantly higher (110.7 vs 81.5). Methods Used An asset-based approach was used to learn how Lewis County has been addressing opioid use disorder amongst its citizens. Interviews with health care providers, patients at Chehalis Family Medicine, and the pastor of a local church were performed. These conversations revealed a lack of access to public transportation creates a major barrier to receiving opioid use disorder treatment. A literature review of interventions implemented in rural areas to deliver medically assisted opioid use disorder treatment was performed. Summary of Results The recent use of telemedicine to deliver suboxone treatment at Chehalis Family Medicine has increased access to medically assisted treatment of opioid use disorder. Telemedicine has become more prevalent with some loosening of governmental regulations due to the COVID-19 pandemic. Based upon articles by Guille et al and Weintraub et al, administration of medically assisted opioid use disorder treatment via telehealth offers a means to expand access to care in rural communities. They demonstrated no significant differences in patient outcomes. Implementation of telemedicine at other suboxone clinics in Lewis County would improve access to suboxone treatment. Conclusions A strength-based framework allows the existing assets in Lewis County to be appraised so future work can build upon what has already proved effective for the community. Regarding opioid use disorder treatment, Lewis county has several low barrier suboxone clinics which could increase access for rural patients through implementation of telemedicine. Chehalis Family Medicine's recent success with telemedicine in suboxone treatment could serve as a template for how to do so effectively.

Racial and ethnic differences and COVID-19 pandemic-related changes in drug overdose deaths in North Carolina.

PURPOSE: To examine racial and ethnic differences and COVID-19 pandemic-related changes in key characteristics of drug overdose deaths in North Carolina. METHODS: We used North Carolina State Unintentional Drug Overdose Reporting System data to describe specific drug-involvement, bystander presence, and naloxone administration for drug overdose deaths by race and ethnicity during pre-COVID-19 (May 2019-February 2020) and COVID-19 periods (March 2020-December 2020). RESULTS: For all racial and ethnic groups, drug overdose death rates and the percentage with fentanyl and alcohol involvement increased from the pre-COVID-19 to COVID-19 period, with fentanyl involvement highest among American Indian and Alaska Native (82.2%) and Hispanic (81.4%) individuals and alcohol involvement highest among Hispanic individuals (41.2%) during the COVID-19 period. Cocaine involvement remained high among Black non-Hispanic individuals (60.2%) and increased among American Indian and Alaska Native individuals (50.6%). There was an increase in the percentage of deaths with a bystander present from the pre-COVID-19 to COVID-19 period for all racial and ethnic groups, with more than half having a bystander present during the COVID-19 period. There was a decrease in the percentage of naloxone administered for most racial and ethnic groups, with the lowest percentage among Black non-Hispanic individuals (22.7%). CONCLUSIONS: Efforts to address increasing inequities in drug overdose deaths, including expanded community naloxone access, are needed.

A scoping literature review of pharmacy-based opioid misuse screening and brief interventions.

BACKGROUND: Although prescription opioid dispensing rates have continued to decrease, overdose deaths involving prescription opioids have increased during the COVID-19 pandemic. Screening and brief interventions (SBI) are an effective prevention strategy to identify and address opioid misuse and safety risks. Emerging literature on pharmacy-based SBI needs to be systematically appraised to develop robust interventions. OBJECTIVE: Our objective was to conduct a scoping review of the literature regarding pharmacy-based opioid misuse SBI to identify relevant literature that explore the topic, evaluate the patient-centeredness of included studies, and explore the use of dissemination and implementation science in the literature. METHODS: The review was conducted according to Preferred Reporting of Systematic Reviews and Meta-analyses -Scoping reviews (PRISMA-Sc) guidelines. We searched PubMed, CINHAL, PsychInfo, and Scopus for studies regarding pharmacy-based SBI, published in the last 20 years. We also conducted a separate grey literature search. Two of three total reviewers screened each abstract individually and identified eligible full-texts for inclusion. We critically appraised quality of included studies and qualitatively synthesized the relevant information. RESULTS: The search resulted in 21 studies (categorized as intervention, descriptive, and observational research) and 3 grey literature reports. Of the recently published 21 studies, 11 were observational research, with six interventions in the pilot stages. Screening tools varied but naloxone was the brief intervention in 15 of the 24 results. Only eight studies had high validity, reliability, and applicability and only five were patient-centered. Implementation science principles were addressed in eight studies (mainly interventions). Overall, the findings suggest high potential for evidence-based SBI to be successful. CONCLUSIONS: Overall, the review suggested a strong lack of a patient-centered and implementation science-focused approach to designing pharmacy-based opioid misuse SBI. Findings suggest that a patient-centered, implementation focused approach is needed for effective and sustained pharmacy-based opioid misuse SBI.

An exploratory study of a hands-on naloxone training for rural clinicians and staff.

INTRODUCTION: Since the COVID-19 pandemic, an increase in fentanyl-combined drugs has led to a surge in opioid overdose deaths in the United States. Higher opioid overdose mortality rates are problematic in rural communities, and there are few prevention, treatment, and recovery resources for individuals experiencing opioid use disorder. METHOD: This exploratory project aimed to investigate a hands-on naloxone training for rural clinicians and staff. Rural clinicians and staff at two behavioral health centers were recruited to participate in a 30-min lecture and 30-min hands-on intranasal naloxone training using a low-fidelity mannequin. A pre-post opioid knowledge questionnaire, rubric based on the Substance Abuse and Mental Health Services Administration toolkit, and investigator-generated survey were used to evaluate opioid knowledge and response, demonstration of intranasal naloxone administration, and participants' perceptions of the training. Enrollment characteristics were summarized using descriptive statistics and paired t-tests were used to assess mean differences. RESULTS: Of the nine participants in the project, seven (87.5%) were female and six (75.0%) were Black. Four participants assumed a therapist role, attained a MS or MA degree, and had 5 or more years of experience working in healthcare. The total mean rubric score for all participants was 96.0 (SD = 8.8). No significant pre-post mean differences among opioid knowledge, overdose risk, and overdose response categories were found, all p > 0.05. However, post-intervention mean scores were slightly higher in all categories except overdose risk. Most participants (77.8%) responded that they felt comfortable handling an opioid situation and teaching the training to community members. Open-ended responses indicated that participants liked the demonstrations, examples used, hands-on nature of the training, and the presentation materials. CONCLUSION: A hands-on naloxone training is beneficial for training rural clinicians and staff to respond to opioid overdose. This training may be a promising solution to reduce response time between recognition of opioid symptoms and administration of the life-saving medication, naloxone. Future studies should examine the efficacy of this training in larger samples with the inclusion of rural interdisciplinary teams, trusted community leaders, and family and friends of those impacted by opioid use disorder. CLINICAL RELEVANCE: This innovative hands-on naloxone training is designed for rural clinicians and residents who are most likely to witness individuals experiencing opioid toxicity. The primary goal is to reduce response time between recognition of signs and symptoms and administration of the life-saving medication, Naloxone.

Naloxone Analogy and Opioid Overdose Terminology Preferences among Rural Caregivers: Differences by Race.

BACKGROUND: Despite national and state policies aimed at increasing naloxone access via pharmacies, opioid overdose death rates rose during the COVID-19 pandemic, particularly among Blacks and American Indians (AI) in rural areas. Caregivers, or third parties who can administer naloxone during an overdose event, are important individuals in the naloxone administration cascade, yet no studies have explored rural caregivers' opioid overdose terminology and naloxone analogy preferences or whether these preferences differ by race. OBJECTIVES: To identify rural caregivers' overdose terminology and naloxone analogy preferences and determine whether preferences differ by race. METHODS: A sample of 40 caregivers who lived with someone at high risk of overdose and used pharmacies in four largely rural states was recruited. Each caregiver completed a demographic survey and a 20-45-minute audio-recorded semi-structured interview that was transcribed, de-identified and imported into a qualitative software package for thematic analysis by two independent coders using a codebook. Overdose terminology and naloxone analogy preferences were analyzed for differences by race. RESULTS: The sample was 57.5% White, 35% Black, and 7.5% AI. Many participants (43%) preferred that pharmacists use the term "bad reaction" to refer to overdose events over the terms "accidental overdose" (37%) and "overdose" (20%). The majority of White and Black participants preferred "bad reaction" while AI participants preferred "accidental overdose." For naloxone analogies, "EpiPen" was most preferred (64%), regardless of race. "Fire extinguisher" (17%), "lifesaver" (9.5%), and other analogies (9.5%) were preferred by some White and Black participants but not AI participants. CONCLUSION: Our findings suggest that pharmacists should use the "bad reaction" term and "EpiPen" analogy when counseling rural caregivers about overdose and naloxone, respectively. Caregivers' preferences varied by race, suggesting that pharmacists may want to tailor the terminology and analogy they use when discussing naloxone with caregivers.

Surge in Adverse Events for Prescription Opioids and Opioid Overdose Treatments during the COVID-19 Pandemic

The opioid epidemic is one of the most pressing public health issues of our time, with hundreds of deaths daily due to opioid overdose. This research investigates the number of reported adverse events related to the use of prescription opioids and opioid overdose treatments during the COVID-19 pandemic, lending further insight into the impact the COVID-19 pandemic has had on the opioid epidemic. We hypothesized that adverse events for both prescription opioids and opioid overdose treatments rose during the COVID-19 pandemic, due to isolation and lack of access to healthcare services. Using data from the Food and Drug Administration Adverse Event Reporting System (FAERS), we analyzed the number of adverse drug events (ADE) in the years 2020 and 2021 compared to 2019, specifically for the medications Naloxone(G), Naloxone Hydrochloride(G), Oxycodone(G), Oxycodone Hydrochloride(G), and Oxycontin(P). We also analyzed the most commonly reported types of adverse reactions and the age of the reporters. The data reveals an alarming spike in the number of ADEs attributed to Naloxone(G) from 2019 to 2020, increasing by 148% and then another 29% in 2021. Similarly, the number of ADEs reported for Naloxone Hydrochloride(G) nearly rose four-fold from 66 to 246. For the prescription opioid Oxycodone(G), there was a 78% increase in ADEs from 2019 to 2020. More concerningly, there was a 434% spike in the number of ADEs for Oxycodone Hydrochloride(G) and more than thirteen-fold the number of cases in 2020 than 2019 for Oxycontin(P). Finally, we found the most commonly reported reactions were "overdose,” "drug dependence,” "drug withdrawal syndrome,” and "drug abuse”;the 18–64-year-old age group reported the majority of the cases. These results highlight the need to increase focus on the opioid epidemic, specifically monitoring the use of prescription opioids. © 2022, Avestia Publishing. All rights reserved.

Conference Proceedings 33rd AAAP Annual Meeting and Scientific Symposium

The proceedings contain 20 papers. The topics discussed include: the effect of specialty addiction consultation on prescribing medication for opioid use disorder (MOUD) during general hospital admission;mindfulness-based interventions for adolescent drug and alcohol use: a systematic review and meta-analysis;early changes in irritability predict longer-term abstinence from drug use in adults with stimulant use disorder: findings from the stride study;carfentanil, a highly potent opioid responding to high doses of naloxone, what can help?;an inpatient protocol for managing methamphetamine withdrawal;COVID-19 treatment outcome in a cohort of methamphetamine and cannabis users;the impact of COVID-19 on overdose risk and healthcare-seeking behaviors among hospitalized patients with opioid use disorder;and inpatient low dose transitions from full agonist opioids including methadone onto long-acting depot buprenorphine: case series from a multicenter clinical trial.

Treatment Court Family Nights: An Accessible and Adaptable Support for Families Engaging in Recovery.

Introduction: While public health measures including physical distancing and stay-at-home orders have clear benefits in COVID-19 mitigation and prevention, they have provided unique challenges for individuals with substance use disorder (SUD), including Treatment Court (TC) participants. Methods: This study involved a qualitative evaluation of TC Family Nights; one series of Family Nights was conducted before the COVID-19 pandemic and the second series was adapted and held remotely due to COVID-19 distancing requirements. Results: Several important themes emerged, including general positive experiences, accessible session logistics, naloxone training, attention to stigma, building recovery capital, group engagement, social interaction, and community action. These themes will help inform future SUD recovery education. Conclusion: Online recovery support events provide a new model for courts and recovery organizations that seek multiple ways to provide connection and support for their participants and families during times when accessibility is prioritized, in-person activities are discouraged, and in resource-sparse and geographically isolated communities.

"A lotta people switched playing hard ball to playing Russian roulette": Experiences with rising overdose incidence caused by drug supply changes during the COVID-19 pandemic in the San Diego-Tijuana border metroplex.

Background: People who use drugs (PWUD) in the San Diego, USA and Tijuana, Mexico metroplex face high overdose risk related to historic methamphetamine use and relatively recent fentanyl introduction into local drug supplies. The personal overdose experiences of PWUD in this region are understudied, however, and may have been influenced by the COVID pandemic. Methods: From September-November 2021, we conducted 28 qualitative interviews among PWUD ≥18 years old sampled from an ongoing cohort study in the San Diego-Tijuana metroplex. Interviews explored overdose experiences and changes in the drug supply. Thematic analysis of coded interview transcripts explored overdose experiences, perspectives on drug supply changes, interactions with harm reduction services, and naloxone access. Results: Among 28 participants, 13 had experienced an overdose. Participants discussed rising levels of fentanyl in local drug supplies and increasing overdose incidents in their social networks. Participants discussed a general shift from injecting heroin to smoking fentanyl in their networks. Participants' most common concerns included having consistent access to a safe and potent drug supply and naloxone. Conclusion: Participants prioritized adapting to drug supply changes and preventing overdose compared to other health concerns, such as HIV and COVID-19. Efforts to address overdose in this region could benefit from drug checking services and expanded, equitable delivery of naloxone.

Characteristics, symptom management and outcomes in COVID-19 patients referred to palliative care in a tertiary hospital

Introduction: Coronavirus disease 2019 (COVID-19) variants pose unique challenges with inevitable premature death when cases of severe disease exponentially rise in a healthcare system. It is imperative that palliative care is provided with a proactive approach to symptom recognition, assessment, management and treatment escalation to ensure comfort throughout the course of this illness. Objectives:To evaluate the characteristics, symptom burden, palliative care management and outcomes of COVID-19 patients referred to a palliative care unit (PCU) in a single tertiary hospital. Clinical outcomes specifically observed the management of agitation in these patients based on their Richmond Agitation and Sedation Scale (RASS) scores. Methods: A retrospective observational study was conducted in a tertiary hospital by reviewing electronic medical records and extracting data from 1st June 2021to 31st July 2021 of all COVID-19 patients referred to the PCU. Results: A cohort of 154 (75 males, 79 females) COVID-19 patients was referred to the PCU with a mean age of 67 (20- 95) years. The median number of days of COVID-19 illness before referral was 7(4-11), with 79.3% of patients being in categories 4 and 5. The median duration of the PCU involvement was 4(1-24) days;74% of families were engaged in virtual platform communication. The most prevalent symptoms were dyspnoea (73.4%) and agitation (41.6%). Common medications used were opioids, antipsychotics and benzodiazepines. Among agitated patients, none had RASS scores above +2 in the last encounter. Palliative care doctors in the team reported complete effectiveness in patient's symptom control in 74% of patients. Conclusions:A hallmark of severe COVID-19 is rapid deterioration, which calls for proactive assessment and urgent palliation. Breathlessness and agitation are priority symptoms to address. Among agitated patients, benzodiazepines and antipsychotics are highly effective in addressing agitation and reducing RASS scores. Communication with families using virtual platforms is effective in providing a supportive presence and closure when face-to-face communication is not possible.

Impact of an overdose reversal program in the context of a safe consumption site in Northern Mexico.

Background: Drug overdoses are prevalent in low- and middle-income countries but are scarcely reported in the literature. We report on an opioid overdose reversal and naloxone distribution program that was instituted at the first safe consumption site in Latin America. Methods: A cross-sectional analysis of witnessed drug overdoses and naloxone distribution between 1 June 2019 and 31 May 2021 in Mexicali, Mexico. Case report forms were entered in an electronic database. Trends in overdose and naloxone distribution were described. Comparisons were made before and after the COVID-19 pandemic was declared in the city. Maps were created to represent the geographic distribution of overdose in the city. Results: During the study period 1,534 doses of naloxone were distributed throughout the community. In addition, there were 464 overdoses reported during this period, of which 4 were fatal. There was a 30% increase in reported overdoses from the period before the COVID-19 pandemic to the period after the pandemic was declared (p = 0.03). Most common substance reported included heroin (93%), sedatives (21%), methamphetamine (16%) and fentanyl (14%). Naloxone was given in 96% of cases (median 1 dose, IQR 1-2 doses) and emergency services were called in 20% of cases. Conclusions: An opioid overdose reversal program in Mexicali, Mexico was able to distribute naloxone and register drug overdoses between 2019 and 2021 as a harm reduction strategy. This adds to the growing body of literature on the impact of community-based programs on preventing fatal overdoses and the potential for implementation in low-resource settings.

Two Cases of Dextromethorphan Overdose Reversed by Naloxone.

We present two rare cases highlighting the rare toxicological manifestation of dextromethorphan (DXM). The DXM toxicity profile is predominantly hallucinations, agitation, irritability with seizures, and coma in severe overdose. The cases that follow are unique in the sense that both patients had features of opioid toxidrome, rarely manifested in DXM abuse. A young male and female in their mid-20s and early 30s, respectively, were brought to the emergency room for their excessive somnolence; both had reduced respiratory rate, bilaterally small pupils (sluggish reactive to light), and the rest of their examination findings were unremarkable. Primary stabilization in the form of noninvasive ventilation (NIV) trial and subsequent rapid sequence intubation (RSI) for persistent respiratory depression. Followed by the exhaustive exclusion of differentials, opioid-like toxidrome was treated with naloxone, and both patients made a good recovery and were discharged home in good health. The emergency physician should be prepared for the rare toxicological manifestations of commonly available over-the-counter medications among the youth. These case reports highlight the role of naloxone in DXM toxicity reversal.

A scoping review of implementation considerations for harm reduction vending machines.

BACKGROUND: Community-based harm reduction vending machines (HRVM) are not new to the field of public health; numerous countries have implemented them in response to the needs of people who use drugs over the last three decades. However, until recently, few existed in the United States. Given the rapidity with which communities are standing up harm reduction vending machines, there is a pressing need for a consolidated examination of implementation evidence. This scoping review summarizes existing literature using multiple implementation science frameworks. METHODS: The scoping review was conducted in five stages including (1) Identify the research question; (2) Identify relevant studies; (3) Select the publications based on inclusion/exclusion criteria; (4) Review and extract data; and, (5) Summarize results. PubMed, Embase, and Web of Science were searched and authors screened publications in English from any year. Data were extracted by applying implementation constructs from RE-AIM and the Consolidated Framework for Implementation Research (CFIR). Both frameworks provided a useful lens through which to develop knowledge about the facilitators and barriers to HRVM implementation. The review is reported according to PRISMA guidelines. RESULTS: After applying the full inclusion and exclusion criteria, including the intervention of interest ("vending machines") and population of interest ("people who use drugs"), a total of 22 studies were included in the scoping review. None of the studies reported on race, making it difficult to retroactively apply a racial equity lens. Among those articles that examined effectiveness, the outcomes were mixed between clear effectiveness and inconclusive results. Evidence emerged, however, to address all CFIR constructs, and positive outcomes were observed from HRVM's after-hour availability and increased program reach. RECOMMENDATIONS: HRVM implementation best practices include maximizing accessibility up to 24 h, 7 days a week, offering syringe disposal options, ensuring capability of data collection, and allowing for anonymity of use. Organizations that implement HRVM should establish strong feedback loops between them, their program participants, and the broader community upfront. Considerations for future research include rigorous study designs to evaluate effectiveness outcomes (e.g. reduced drug overdose deaths) and examination of HRVM reach among ethnic and racial communities.

Opioid overdose prevention education in Texas during the COVID-19 pandemic.

BACKGROUND: Distribution of naloxone and training on its proper use are evidence-based strategies for preventing opioid overdose deaths. In-person naloxone training was conducted in major metropolitan areas and urban centers across Texas as part of a state-wide targeted opioid response program. The training program transitioned to a live, virtual format during the COVID-19 public health emergency declaration. This manuscript describes the impact of this transition through analyses of the characteristics of communities reached using the new virtual training format. CASE PRESENTATION: Training participant addresses were compared to county rates of opioid overdose deaths and broadband internet access, and census block comparison to health services shortages, rural designation, and race/ethnicity community characteristics. CONCLUSIONS: The virtual training format reached more learners than the in-person events. Training reached nearly half of the counties in Texas, including all with recent opioid overdose deaths. Most participants lived in communities with a shortage of health service providers, and training reached rural areas, those with limited broadband internet availability, and majority Hispanic communities. In the context of restrictions on in-person gathering, the training program successfully shifted to a live, online format. This transition increased participation above rates observed pre-pandemic and reached communities with the need for equipping those most likely to witness an opioid overdose with the proper use of naloxone.

Responding to a surge in overdose deaths: perspectives from US syringe services programs.

BACKGROUND: US overdose deaths have reached a record high. Syringe services programs (SSPs) play a critical role in addressing this crisis by providing multiple services to people who use drugs (PWUD) that help prevent overdose death. This study examined the perspectives of leadership and staff from a geographically diverse sample of US SSPs on factors contributing to the overdose surge, their organization's response, and ongoing barriers to preventing overdose death. METHODS: From 2/11/2021 to 4/23/2021, we conducted semi-structured interviews with leadership and staff from 27 SSPs sampled from the North American Syringe Exchange Network directory. Interviews were transcribed and qualitatively analyzed using a Rapid Assessment Process. RESULTS: Respondents reported that increased intentional and unintentional fentanyl use (both alone and combined with other substances) was a major driver of the overdose surge. They also described how the COVID-19 pandemic increased solitary drug use and led to abrupt increases in use due to life disruptions and worsened mental health among PWUD. In response to this surge, SSPs have increased naloxone distribution, including providing more doses per person and expanding distribution to people using non-opioid drugs. They are also adapting overdose prevention education to increase awareness of fentanyl risks, including for people using non-opioid drugs. Some are distributing fentanyl test strips, though a few respondents expressed doubts about strips' effectiveness in reducing overdose harms. Some SSPs are expanding education and naloxone training/distribution in the broader community, beyond PWUD and their friends/family. Respondents described several ongoing barriers to preventing overdose death, including not reaching certain groups at risk of overdose (PWUD who do not inject, PWUD experiencing homelessness, and PWUD of color), an inconsistent naloxone supply and lack of access to intranasal naloxone in particular, inadequate funding, underestimates of overdoses, legal/policy barriers, and community stigma. CONCLUSIONS: SSPs remain essential in preventing overdose deaths amid record numbers likely driven by increased fentanyl use and COVID-19-related impacts. These findings can inform efforts to support SSPs in this work. In the face of ongoing barriers, support for SSPs-including increased resources, political support, and community partnership-is urgently needed to address the worsening overdose crisis.