Real-world study of multiple naloxone administrations for opioid overdose reversal among emergency medical service providers.

Background: The increasing rates of highly potent, illicit synthetic opioids (i.e., fentanyl) in the US is exacerbating the ongoing opioid epidemic. Multiple naloxone administrations (MNA) may be required to successfully reverse opioid overdoses. We conducted a real-world study to assess the rate of MNA for opioid overdose and identify factors associated with MNA. Methods: Data from the 2015-2020 National Emergency Medical Services Information System was examined to determine trends in events requiring MNA. Logistic regression analysis was performed to determine factors associated with MNA. Results: The percentage of individuals receiving MNA increased from 18.4% in 2015 to 28.4% in 2020. The odds of an event requiring MNA significantly increased by 11% annually. The adjusted odds ratio (aOR) for MNA were greatest among males, when advanced life support (ALS) was provided, and when the dispatch complaint indicated there was a drug poisoning event. Conclusions: The 54% increase in MNA since 2015 parallels the rise in overdose deaths attributable to synthetic opioids. This growth is visible in all regions of the country, including the West, where the prevalence of illicitly manufactured synthetic opioids is intensifying. Given this phenomenon, higher naloxone formulations may fulfill an unmet need in addressing the opioid overdose crisis.

The need for multiple naloxone administrations for opioid overdose reversals: A review of the literature.

Background A growing challenge in the opioid epidemic is the rise of highly potent synthetic opioids, (i.e., illicitly manufactured fentanyl [IMF]) entering the US non-prescription opioid market. Successful reversal may require multiple doses of naloxone, the standard of care for opioid overdose. We conducted a narrative literature review to summarize the rates of multiple naloxone administrations (MNA) for opioid overdose reversal. Methods: A MEDLINE search was conducted for published articles using MESH search terms: opioid overdose, naloxone and multiple naloxone administration. Of the 2,101 studies identified, articles meeting inclusion/exclusion criteria were reviewed, categorized by primary and secondary outcomes of interest and summarized by data source and study design. Results: A total of 24 articles meeting eligibility criteria were included. Among EMS-based studies, MNA rates ranged from 9% to 53%; in general, bystander-reported studies were notably higher, from 16% to 89%. Variation in study design, data sources, year and geography, may have contributed to these ranges. Three studies that included longitudinal results reported a significant percent increase between 26% and 43% in annual MNA rates or a significant increase in mean naloxone doses over time (p < .001). Conclusions: This summary found that multiple naloxone administrations during opioid overdose encounters vary widely, have occurred in up to 89% of all opioid overdoses, and have significantly increased over time. Higher naloxone formulations may fulfill an unmet need in opioid overdose reversals, given the rising rates of overdoses involving IMF. Further studies are needed to gain a better understanding of MNA during opioid overdose encounters, particularly across a wider geographic region in the US in order to inform continuing efforts to combat the opioid epidemic.

A novel virus-inducible enhancer of the interferon-ß gene with tightly linked promoter and enhancer activities.

Long-range enhancers of transcription are a key component of the genomic regulatory architecture. Recent studies have identified bi-directionally transcribed RNAs emanating from these enhancers known as eRNAs. However, it remains unclear how tightly coupled eRNA production is with enhancer activity. Through our systematic search for long-range elements that interact with the interferon-ß gene, a model system for studying inducible transcription, we have identified a novel enhancer, which we have named L2 that regulates the expression of interferon-ß. We have demonstrated its virus-inducible enhancer activity by analyzing epigenomic profiles, transcription factor association, nascent RNA production and activity in reporter assays. This enhancer exhibits intimately linked virus-inducible enhancer and bidirectional promoter activity that is largely dependent on a conserved Interferon Stimulated Response Element and robustly generates virus inducible eRNAs. Notably, its enhancer and promoter activities are fully retained in reporter assays even upon a complete elimination of its associated eRNA sequences. Finally, we show that L2 regulates IFNB1 expression by siRNA knockdown of eRNAs, and the deletion of L2 in a BAC transfection assay. Thus, L2 is a novel enhancer that regulates IFNB1 and whose eRNAs exert significant activity in vivo that is distinct from those activities recapitulated in the luciferase reporter assays.