Joint RCEM and NPIS best practice guideline: assessment and management of acute opioid toxicity in adults in the emergency department.

The Royal College of Emergency Medicine Toxicology Special Interest Group in collaboration with the UK National Poisons Information Service and the Clinical Toxicology Department at Guy's and St Thomas' NHS Foundation Trust has produced guidance to support clinicians working in the ED with the assessment and management of adults with acute opioid toxicity.Considerations regarding identification of acute opioid toxicity are discussed and recommendations regarding treatment options and secondary prevention are made. There is a focus on making recommendations on the best available evidence.

Resuscitation simulation among people who are likely to witness opioid overdose: Experiences from the SOONER Trial.

The opioid crisis is a growing public health emergency and increasing resources are being directed towards overdose education. Simulation has emerged as a novel strategy for training overdose response, yet little is known about training non-clinicians in bystander resuscitation. Understanding the perspectives of individuals who are likely to experience or witness opioid overdose is critical to ensure that emergency response is effective. The Surviving Opioid Overdose with Naloxone Education and Resuscitation (SOONER) study evaluates the effectiveness of a novel naloxone education and distribution tool among people who are non-clinicians and likely to witness opioid overdose. Participants' resuscitation skills are evaluated using a realistic overdose simulation as the primary outcome of the trial. The purpose of our study is to describe the experience of participants with the simulation process in the SOONER study. We employed a semi-structured debriefing interview and a follow up qualitative interview to understand the experience of participants with simulation. A qualitative content analysis was performed using data from 21 participants who participated in the SOONER study. Our qualitative analysis identified 5 themes and 17 subthemes which described the experience of participants within the simulation process. These themes included realism, valuing practical experience, improving self-efficacy, gaining new perspective and bidirectional learning. Our analysis found that simulation was a positive and empowering experience for participants in the SOONER trial, most of whom are marginalized in society. Our study supports the notion that expanding simulation-based education to non-clinicians may offer an acceptable and effective way of supplementing current opioid overdose education strategies. Increasing the accessibility of simulation-based education may represent a paradigm shift whereby simulation is transformed from a primarily academic practice into a patient-based community resource.

Risk of Opioid Overdose Associated With Concomitant Use of Oxycodone and Selective Serotonin Reuptake Inhibitors.

Importance: Some selective serotonin reuptake inhibitors (SSRIs) inhibit the enzymes responsible for the metabolism of oxycodone, a potent prescription opioid. The clinical consequences of this interaction on the risk of opioid overdose have not been elucidated. Objective: To compare opioid overdose rates in patients initiating oxycodone while taking SSRIs that are potent inhibitors of the cytochrome-P450 2D6 enzyme (CYP2D6) vs SSRIs that are not. Design, Setting, and Participants: This cohort study included adults who initiated oxycodone while receiving SSRI therapy between 2000 and 2020 whose data were included in 3 US health insurance databases. Exposures: Use of SSRIs that strongly inhibit CYP2D6 enzyme (fluoxetine or paroxetine) vs use of other SSRIs at the time of oxycodone initiation. Main Outcomes and Measures: Opioid overdose hospitalization or emergency department visit. Outcomes were assessed within 365 days of oxycodone initiation; in primary analyses, patients were followed up until the discontinuation of either oxycodone or their index SSRI group. Propensity score matching weights were used to adjust for confounding. Crude and weighted (adjusted) incidence rates and hazard ratios were estimated using Cox regression models, separately within each database and overall, stratifying on database. Results: A total of 2 037 490 initiated oxycodone while taking SSRIs (1 475 114 [72.4%] women; mean [SD] age, 50.1 [15.3] years). Most (1 418 712 [69.6%]) were receiving other SSRIs at the time of oxycodone initiation. In the primary analysis, we observed 1035 overdose events (0.05% of the study cohort). The adjusted incidence rate of opioid overdose in those using inhibiting SSRIs at the time of oxycodone initiation (9.47 per 1000 person-years) was higher than in those using other SSRIs (7.66 per 1000 person-years), indicating a greater risk of overdose among patients using CYP2D6-inhibiting SSRIs (adjusted hazard ratio, 1.23; 95% CI, 1.06-1.31). Results were consistent across multiple subgroup and sensitivity analyses. Conclusions and Relevance: In this cohort study of US adults, initiating oxycodone in patients treated with paroxetine or fluoxetine was associated with a small increased risk of opioid overdose.

Emergency Department Visits for Nonfatal Opioid Overdose During the COVID-19 Pandemic Across Six US Health Care Systems.

STUDY OBJECTIVE: People with opioid use disorder are vulnerable to disruptions in access to addiction treatment and social support during the COVID-19 pandemic. Our study objective was to understand changes in emergency department (ED) utilization following a nonfatal opioid overdose during COVID-19 compared to historical controls in 6 healthcare systems across the United States. METHODS: Opioid overdoses were retrospectively identified among adult visits to 25 EDs in Alabama, Colorado, Connecticut, North Carolina, Massachusetts, and Rhode Island from January 2018 to December 2020. Overdose visit counts and rates per 100 all-cause ED visits during the COVID-19 pandemic were compared with the levels predicted based on 2018 and 2019 visits using graphical analysis and an epidemiologic outbreak detection cumulative sum algorithm. RESULTS: Overdose visit counts increased by 10.5% (n=3486; 95% confidence interval [CI] 4.18% to 17.0%) in 2020 compared with the counts in 2018 and 2019 (n=3020 and n=3285, respectively), despite a 14% decline in all-cause ED visits. Opioid overdose rates increased by 28.5% (95% CI 23.3% to 34.0%) from 0.25 per 100 ED visits in 2018 to 2019 to 0.32 per 100 ED visits in 2020. Although all 6 studied health care systems experienced overdose ED visit rates more than the 95th percentile prediction in 6 or more weeks of 2020 (compared with 2.6 weeks as expected by chance), 2 health care systems experienced sustained outbreaks during the COVID-19 pandemic. CONCLUSION: Despite decreases in ED visits for other medical emergencies, the numbers and rates of opioid overdose-related ED visits in 6 health care systems increased during 2020, suggesting a widespread increase in opioid-related complications during the COVID-19 pandemic. Expanded community- and hospital-based interventions are needed to support people with opioid use disorder and save lives during the COVID-19 pandemic.

Unintentional Opioid Overdoses Treated at University Clinic of Toxicology-Skopje in a Nine-Year-Period.

BACKGROUND: The aim of this study was to assess the epidemiological profile of unintentional opioid overdoses, the prevalence and number of psychotropic substances involved in opioid overdoses. METHODS: This was a descriptive study, in which 180 participants were enrolled, and covered a nine-years-period. For collecting data was used the National patient electronic system "My term". The variables as gender, age, duration of opioid dependence, number of overdoses, type of substance, number of antidote ampoules, duration of hospitalization were analyzed. Severity of poisoning was made by using the Poison severity score. RESULTS: Opioid overdose cases were significantly higher among males than females. Mean age with standard deviation (SD) was 32.23 ± 6.71 years. Mean years (±SD) of duration of opioid use disorder was 11.60 ± 5.89 years. The most commonly used primary substance was methadone in 68.89% and heroin in 31.11% cases. Twenty patients were treated with mechanical ventilation because of the severe respiratory depression. Poison severity score was moderate in 51.11%, severe in 45.56% and fatal in 3.33% of the cases. CONCLUSION: Most of the cases, predominantly males used one or two substances. The combination of methadone and benzodiazepine was most frequently used and the most common way was by injecting the abused substances. In most of the subjects PSS score was moderate and severe with no differences between genders.

Hospitalizations for opioid-related overdose and timing of concurrent opioid and benzodiazepine use: A nested case-control study.

BACKGROUND: Concurrent opioid and benzodiazepine (BZD) use is a prevalent high-risk prescribing behavior that increases the risk of opioid overdose. However, there is limited evidence on the relationship between timing of concurrent use and risk of opioid overdose. OBJECTIVE: To evaluate the likelihood of opioid-related overdose across levels of duration, recency, and daily dose of concurrent use. DESIGN: A nested case-control study was conducted using Truven MarketScan claims data (2009-2018). PARTICIPANTS: Commercially insured adults (age 18-64 years old) with a new opioid dispensing in 2010-2018. MAIN MEASURES: Cases of opioid-related overdose were identified based on hospitalization diagnosis codes. Controls were matched to cases in a 10:1 ratio by age, sex, opioid start date, and cancer history. Concurrent use was classified based on duration, timing, and daily dose of overlapping opioids and BZDs during 90 days before the event. Conditional logistic regression models were used to evaluate the relationship between concurrent use and opioid-related overdose. KEY RESULTS: Among 11,137,866 dispensed a new opioid, a total of 3388 patients experienced opioid-related overdose and were matched to 33,893 controls. Cases and controls were 34 years old on average and 54% female. Patients with concurrent use were significantly more likely to have opioid-related overdose compared to patients receiving opioids, BZDs, or neither (OR 9.28; 95% CI 7.87, 10.93). Longer concurrent use of 1-7, 8-30, and 31-90 days was associated with 4.6, 12.1, and 26.7-fold higher likelihood of opioid-related overdose (p < 0.01). Patients with overlapping prescriptions during previous 0-30, 31-60, and 61-90 days were 13.2, 6.0, and 3.2-times more likely to experience an overdose (p < 0.01). CONCLUSIONS: Patients with an opioid-related overdose were more likely to be prescribed concurrent opioid and BZD across all levels of duration, timing, and daily dose. Future policies and quality measures should be pursued to prevent concurrent use unless medically necessary.

Adapting harm reduction services during COVID-19: lessons from the supervised injecting facilities in Australia.

The COVID-19 crisis has had profound impacts on health service provision, particularly those providing client facing services. Supervised injecting facilities and drug consumption rooms across the world have been particularly challenged during the pandemic, as have their client group-people who consume drugs. Several services across Europe and North America closed due to difficulties complying with physical distancing requirements. In contrast, the two supervised injecting facilities in Australia (the Uniting Medically Supervised Injecting Centre-MSIC-in Sydney and the North Richmond Community Health Medically Supervised Injecting Room-MSIR-in Melbourne) remained open (as at the time of writing-December 2020). Both services have implemented a comprehensive range of strategies to continue providing safer injecting spaces as well as communicating crucial health information and facilitating access to ancillary services (such as accommodation) and drug treatment for their clients. This paper documents these strategies and the challenges both services are facing during the pandemic. Remaining open poses potential risks relating to COVID-19 transmission for both staff and clients. However, given the harms associated with closing these services, which include the potential loss of life from injecting in unsafe/unsupervised environments, the public and individual health benefits of remaining open are greater. Both services are deemed 'essential health services', and their continued operation has important benefits for people who inject drugs in Sydney and Melbourne.

Characteristics of post-overdose public health-public safety outreach in Massachusetts.

BACKGROUND: As a response to mounting overdose fatalities, cross-agency outreach efforts have emerged to reduce future risk among overdose survivors. We aimed to characterize such programs in Massachusetts, with focus on team composition, approach, services provided, and funding. METHODS: We conducted a two-phase cross-sectional survey of public health and safety providers in Massachusetts. Providers in all 351 municipalities received a screening survey. Those with programs received a second, detailed survey. We analyzed responses using descriptive statistics. RESULTS: As of July 2019, 44 % (156/351) of Massachusetts municipalities reported post-overdose outreach programs, with 75 % (104/138) formed between 2016-2019. Teams conducted home-based outreach 1-3 days following overdose events. Police departments typically supplied location information on overdose events (99 %, 136/138) and commonly participated in outreach visits (86 %, 118/138) alongside public health personnel, usually from community-based organizations. Teams provided or made referrals to services including inpatient addiction treatment, recovery support, outpatient medication, overdose prevention education, and naloxone. Some programs deployed law enforcement tools, including pre-visit warrant queries (57 %, 79/138), which occasionally led to arrest (11 %, 9/79). Many programs (81 %, 112/138) assisted families with involuntary commitment to treatment - although this was usually considered an option of last resort. Most programs were grant-funded (76 %, 104/136) and engaged in cross-municipal collaboration (94 %, 130/138). CONCLUSIONS: Post-overdose outreach programs have expanded, typically as collaborations between police and public health. Further research is needed to better understand the implications of involving police and to determine best practices for increasing engagement in treatment and harm reduction services and reduce subsequent overdose.

Changes in Opioid Overdose Emergency Encounters Associated with Expansion of Wisconsin Medicaid to Childless Adults in Poverty.

OBJECTIVE: The purpose of this study was to measure changes in the payer mix and incidence of emergency department (ED) opioid-related overdose encounters after an April 2014 expansion of Medicaid to childless adults led to a 43% increase in Medicaid coverage for men and 8% for women statewide. METHOD: We explored two competing hypotheses using data visualization and comparative interrupted time-series analysis (CITS): (a) expanded eligibility for Medicaid is associated with a change in payer mix only and (b) sociodemographic groups that gained Medicaid eligibility were more likely to use ED services for opioid overdose. Data included encounters at all Wisconsin nonfederal hospitals over 23 quarters from 2010 to 2015 and American Community Survey estimates of pre- and post-policy Medicaid eligibility by sex and age. RESULTS: We found an increase in the share of opioid-related ED visits covered by Medicaid for men and women ages 19-29 and for men ages 30-49 following the expansion. The number of visits increased substantially in April 2014 for men ages 30-49, with Medicaid-covered visits driving this result. We found little evidence of an increase in overall visits for other age groups for either men or women. CONCLUSIONS: The relationship between Medicaid expansion and opioid ED use is complex. Changes in case mix and increased access to care likely both play a role in the overall increase in these ED visits. Being uninsured may be an important barrier to seeking emergency care for opioid-related overdoses.

Education, Implementation, and Teams: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations.

For this 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, the Education, Implementation, and Teams Task Force applied the population, intervention, comparator, outcome, study design, time frame format and performed 15 systematic reviews, applying the Grading of Recommendations, Assessment, Development, and Evaluation guidance. Furthermore, 4 scoping reviews and 7 evidence updates assessed any new evidence to determine if a change in any existing treatment recommendation was required. The topics covered included training for the treatment of opioid overdose; basic life support, including automated external defibrillator training; measuring implementation and performance in communities, and cardiac arrest centers; advanced life support training, including team and leadership training and rapid response teams; measuring cardiopulmonary resuscitation performance, feedback devices, and debriefing; and the use of social media to improve cardiopulmonary resuscitation application.

A brief telephone-delivered peer intervention to encourage enrollment in medication for opioid use disorder in individuals surviving an opioid overdose: Results from a randomized pilot trial.

BACKGROUND: Medication for opioid use disorder (MOUD) can decrease the risk of opioid overdose (OOD) in individuals with opioid use disorder. Peer recovery support services (PRSS) are increasingly used to promote MOUD engagement but evidence of their efficacy is limited. This study's objective was to evaluate a single 20-minute telephone-delivered PRSS intervention for increasing MOUD enrollment and decreasing recurring OODs. METHOD: This single-site, randomized controlled pilot trial enrolled adults, primarily recruited from a syringe service program, with an opioid-positive urine drug screen (UDS) reporting having been treated for an OOD within the past 6 months. Participants (N = 80) were randomized to PRSS (n = 40) or Control (n = 40) condition with all participants receiving personally-tailored OOD education and naloxone. Outcome measures obtained at 3 (n = 66), 6 (n = 58), and 12 (n = 44) months post-randomization included verified MOUD enrollment (primary), self-reported OOD, and opioid use assessed by self-report and UDS. RESULTS: Through 12-month follow-up, 32.5 % of PRSS, compared to 17.5 % of Control participants enrolled in MOUD (X2 = 2.4, p = 0.12; odds ratio = 2.27 (0.79-6.49)). PRSS participants were significantly less likely to have experienced an OOD through 12-month follow-up (12.5 % of PRSS participants, 32.5 % of Control, p = 0.03). No significant treatment effect was found for opioid use through 12-month follow-up as measured by either opioid-positive UDSs or self-reported past month opioid use days. Based on self-report, PRSS had good acceptability for both the interventionists and participants. CONCLUSIONS: The results suggest that further development and testing of this PRSS telephone intervention to encourage MOUD enrollment and reduce OOD may be warranted.

"It's Gonna be a Lifeline": Findings From Focus Group Research to Investigate What People Who Use Opioids Want From Peer-Based Postoverdose Interventions in the Emergency Department.

STUDY OBJECTIVE: Postoverdose interventions that deploy peer recovery support specialists to emergency departments (EDs) are a promising response to opioid overdoses among patients presenting in EDs. The objective of this study was to elicit patients' perspectives regarding the feasibility and acceptability of such an intervention and to ensure that their perspectives are represented in intervention design, implementation, and evaluation. METHOD: In 2019 the study investigators conducted focus groups with people who use opioids to elicit perspectives about a postoverdose intervention delivered in the ED by using a semistructured interview guide that asked about feasibility, acceptability, perceived benefits, and concerns. Focus groups were digitally recorded, transcribed, and analyzed for emerging themes. RESULTS: Nine focus groups with 30 people who use opioids were conducted. Key findings that could improve feasibility and acceptability of the intervention include the following: the importance of balancing the urgency of seeing patients quickly with a need to accommodate the experience of precipitated withdrawal symptoms; the need to address privacy concerns; and the need to address concerns related to cost, insurance coverage, and sustainability. Perceived benefits of the intervention included the ability of the peer recovery support specialist to provide advocacy and support, serve as a model of hope and encouragement for behavior change, and fill key service gaps. CONCLUSION: Postoverdose interventions in the ED provide the opportunity to integrate harm reduction-based interventions into traditional biomedical care facilities. These interventions can fill gaps in services and provide additional care and comfort for people who use opioids, but design, implementation, and evaluation should be informed by a patient-centered care perspective.

Opioid Overdose and Addiction Treatment: A Collaborative Model of Compassion, Patience, and Respect.

PURPOSE: The purpose of this article is to describe the creation and outcomes of a collaborative model and care facility for opioid overdose and addiction treatment based on compassion, patience, and respect: The Maryhaven Addiction Stabilization Center (MASC). APPROACH: MASC was created with the vision to serve clients who have recently overdosed on opioids. In this article, the research, planning, building, and implementation of an opioid treatment center composed of an admission and triage unit, inpatient withdrawal management unit, and inpatient residential unit are described. A multi-agency and multi-disciplinary approach were used to immediately engage patients and connect them to treatment for opioid addiction. FINDINGS: Implementation of a collaborative model of care offers patients who overdose on opioids with immediate access to admission for treatment. This has resulted in significantly higher numbers of patients seeking and staying in treatment. CONCLUSIONS: Through multi-agency collaboration and a shared commitment to addressing the challenges of the opioid epidemic in innovative ways, more patients who are struggling with addiction have increased opportunities to engage in treatment and move towards recovery. CLINICAL RELEVANCE: Clinicians, first responders, and communities can employ MASC principles to guide their approaches to serve patients who have recently overdosed on opioids or who are in active addiction.

Links between suicidal intent, polysubstance use, and medical treatment after non-fatal opioid overdose.

BACKGROUND: Suicidal thinking during non-fatal overdose may elevate risk for future completed suicide or intentional overdose. Long-term outcomes following an intentional non-fatal overdose may be improved through specific intervention and prevention responses beyond those designed for unintentional overdoses, yet little research has assessed suicidal intent during overdoses or defined characteristics that differentiate these events from unintentional overdoses. METHODS: Patients with a history of opioid overdose (n = 274) receiving residential addiction treatment in the Midwestern United States completed self-report surveys to classify their most recent opioid overdose as unintentional, actively suicidal (wanted to die), or passively suicidal (didn't care about the risks). We characterized correlates of intent using descriptive statistics and prevalence ratios. We also examined how intent related to thoughts of self-harm at the time of addiction treatment. RESULTS: Of opioid overdoses, 51 % involved suicidal intent (44 % passive and 7 % active). Active suicidal intent was positively associated with hospitalization. Active/passive intent (vs. no intent, aPR: 2.2, 95 % CI: 1.4-3.5) and use of ≥5 substances (vs. 1 substance, aPR: 3.6, 95 % CI: 1.2-10.6) at the last opioid overdose were associated with having thoughts of self-harm or suicide in the 2 weeks before survey completion in adjusted models. Participants who reported active/passive intent more commonly used cocaine or crack (27 %) with opioids during their last overdose relative to unintentional overdoses (16 %). CONCLUSIONS: Over half of opioid overdoses among individuals in addiction treatment involved some degree of suicidal thinking. Identifying patients most at risk will facilitate better targeting of suicide prevention and monitoring services.

Nurses' Knowledge of Opioids: Foundations for Clinical Practice.

BACKGROUND: The opioid crisis has influenced practice changes to mitigate risks to patients receiving opioids. It is essential that nurses understand contemporary guidelines to provide safe patient care for patients receiving opioids. PURPOSE: This study was designed to assess general knowledge of opioids among nurses in nonprescribing patient care roles. METHODS: A survey was developed, validated, and deployed to 564 nurses in a large hospital system. RESULTS: Nurses had strong knowledge of basic pharmacology, the conjunctive use of nonopioids for pain relief, and differences in analgesia for chronic versus acute pain. Opportunity for education included risk factors for opioid-related adverse events, medication combinations, differences in opioid tolerant and opioid-naïve patients, and recognition and management of overdose. CONCLUSIONS: Results of this study can be used to guide continuing education and academic curricula to ensure nurses are equipped with the key knowledge to provide safe quality clinical care and patient education.

Emergency Department Visits for Opioid Overdoses Among Patients With Cancer.

BACKGROUND: Patients with cancer may be at risk of high opioid use due to physical and psychosocial factors, although little data exist to inform providers and policymakers. Our aim is to examine overdoses from opioids leading to emergency department (ED) visits among patients with cancer in the United States. METHODS: The Healthcare Cost and Utilization Project Nationwide Emergency Department Sample was queried for all adult cancer-related patient visits with a primary diagnosis of opioid overdose between 2006 and 2015. Temporal trends and baseline differences between patients with and without opioid-related ED visits were evaluated. Multivariable logistic regression analysis was used to identify risk factors associated with opioid overdose. All statistical tests were two-sided. RESULTS: Between 2006 and 2015, there were a weighted total of 35 339 opioid-related ED visits among patients with cancer. During this time frame, the incidence of opioid-related ED visits for overdose increased twofold (P < .001). On multivariable regression (P < .001), comorbid diagnoses of chronic pain (odds ratio [OR] 4.51, 95% confidence interval [CI] = 4.13 to 4.93), substance use disorder (OR = 3.54, 95% CI = 3.28 to 3.82), and mood disorder (OR = 3.40, 95% CI = 3.16 to 3.65) were strongly associated with an opioid-related visit. Patients with head and neck cancer (OR = 2.04, 95% CI = 1.82 to 2.28) and multiple myeloma (OR = 1.73, 95% CI = 1.32 to 2.26) were also at risk for overdose. CONCLUSIONS: Over the study period, the incidence of opioid-related ED visits in patients with cancer increased approximately twofold. Comorbid diagnoses and primary disease site may predict risk for opioid overdose.