Christopher Welsh

Evaluation of the Staying Alive programme: Training injection drug users to properly administer naloxone and save lives

BACKGROUND In response to the high rates of opiate-related overdoses and deaths in the United States, a number of overdose prevention programmes have been implemented that include training drug users to administer naloxone, an opiate antagonist. The purpose of this study was to evaluate the Staying Alive (SA) programme in Baltimore, Maryland, which trained drug users to prevent and respond to opiate overdose using techniques including mouth-to-mouth resuscitation and administration of naloxone. METHODS Participants for the SA programme were recruited from multiple locations by Baltimore City Health Department Needle Exchange programme staff. A 1-h training was conducted by two facilitators. Participants who successfully completed the programme were provided with a kit that contained naloxone. Participants in the evaluation study were enrolled prior to the training session. The present analysis includes 85 participants who completed a pre- and post-test evaluation survey. RESULTS At both time points, 43 participants reported having witnessed an overdose. Post-training, naloxone was administered by 19 with no reported adverse effects. Post-training, a greater proportion of participants reported using resuscitation skills taught in the SA programme along with increased knowledge specifically about naloxone. CONCLUSIONS Results from this study provide additional evidence to support the effectiveness of overdose prevention training programmes that include skills building for drug users to administer naloxone.

Medical Outcomes Associated with Nonmedical Use of Methadone and Buprenorphine

BACKGROUND There exists a significant amount of misinformation regarding methadone and buprenorphine, and a belief that toxicity associated with nonmedical use of methadone and nonmedical use of buprenorphine is similar in severity and outcomes. OBJECTIVE The objective of this study is to compare outcomes associated with nonmedical use of methadone vs. nonmedical use of buprenorphine in patients presenting to the Emergency Department (ED) and reported to poison centers. METHODS This was a retrospective cohort study using data from the American Association of Poison Control Centers from January 1, 2003 to December 31, 2009 (7 years). Inclusion criteria were nonmedical use of methadone or buprenorphine (or buprenorphine/naloxone) as a single substance by history, age 18 years or older, ingestions only, evaluated in an ED. Outcome measures were clinical effects, treatments, disposition, and final medical outcomes. RESULTS Of 1,920 cases, 1,594 were in the methadone group and 326 were in the buprenorphine group. Frequently reported clinical effects were lethargy, 59.2% vs. 29.4%, and respiratory depression, 28.7% vs. 2.5%, for methadone and buprenorphine groups, respectively. Hospitalization rates were 67.4% in the methadone group and 32.2% in the buprenorphine group. Half of all patients in the methadone group were admitted to the intensive care unit (ICU) vs. only 15% of all the patients in the buprenorphine group. Twenty-six patients in the methadone group died vs. no deaths in the buprenorphine group. There were significant differences in the distribution of clinical effects, disposition, and medical outcomes (p < 0.001). CONCLUSIONS Patients who use methadone nonmedically have higher hospitalization rates, greater ICU utilization rates, and considerably worse medical outcomes when compared with patients who use buprenorphine nonmedically.

A case of heroin overdose reversed by sublingually administered buprenorphine/naloxone (Suboxone ® )

BACKGROUND Opioid overdose is a major source of morbidity and mortality in injection drug users in the United States and many other countries. CASE DESCRIPTION A case is described in which buprenorphine/naloxone (Suboxone) was administered sublingually to reverse a heroin overdose. CONCLUSIONS Sublingually administered buprenorphine/naloxone might be used as a means to reverse opioid overdose.

The use of medication for relapse prevention in substance dependence disorders.

Substance abuse is a significant problem in itself and can greatly complicate the symptomatology and treatment of comorbid psychiatric disorders. In the article, the authors review literature concerning the use of medication to prevent relapse to substance abuse or decrease substance use. Five different general strategies are employed for this purpose: 1) use of a drug with pharmacological properties similar to the substance of concern (i.e., agonist or substitution therapy); 2) use of a receptor antagonist to block or lessen the effects of the substance of concern; 3) use of a medication that produces a conditioned aversive reaction to the substance of concern; 4) use of a medication to reduce the reinforcing properties of the substance of concern; and 5) use of a substance to increase the metabolism or clearance of the substance of concern from the body. The authors review pharmacological treatments that have been studied for the treatment of dependence on the following types of substances: alcohol, sedative-hypnotics, opioids, stimulants, nicotine, hallucinogens, cannabis, inhalants, anabolic steroids, phencyclidine, and designer drugs. The article ends with a brief discussion of the importance of including psychosocial and behavioral interventions in any substance abuse treatment program.

Evaluating Training of Screening, Brief Intervention, and Referral to Treatment (SBIRT) for Substance Use: Reliability of the MD3 SBIRT Coding Scale

Screening, brief intervention, and referral to treatment (SBIRT) has become an empirically supported and widely implemented approach in primary and specialty care for addressing substance misuse. Accordingly, training of providers in SBIRT has increased exponentially in recent years. However, the quality and fidelity of training programs and subsequent interventions are largely unknown because of the lack of SBIRT-specific evaluation tools. The purpose of this study was to create a coding scale to assess quality and fidelity of SBIRT interactions addressing alcohol, tobacco, illicit drugs, and prescription medication misuse. The scale was developed to evaluate performance in an SBIRT residency training program. Scale development was based on training protocol and competencies with consultation from Motivational Interviewing coding experts. Trained medical residents practiced SBIRT with standardized patients during 10- to 15-min videotaped interactions. This study included 25 tapes from the Family Medicine program coded by 3 unique coder pairs with varying levels of coding experience. Interrater reliability was assessed for overall scale components and individual items via intraclass correlation coefficients. Coder pair-specific reliability was also assessed. Interrater reliability was excellent overall for the scale components (>.85) and nearly all items. Reliability was higher for more experienced coders, though still adequate for the trained coder pair. Descriptive data demonstrated a broad range of adherence and skills. Subscale correlations supported concurrent and discriminant validity. Data provide evidence that the MD3 SBIRT Coding Scale is a psychometrically reliable coding system for evaluating SBIRT interactions and can be used to evaluate implementation skills for fidelity, training, assessment, and research. Recommendations for refinement and further testing of the measure are discussed. (PsycINFO Database Record

Evaluation of the Overdose Education and Naloxone Distribution Program of the Baltimore Student Harm Reduction Coalition

Although historically the majority of overdose education and naloxone distribution (OEND) programs have targeted opioid users, states are increasingly passing laws that enable third-party prescriptions of naloxone to individuals who may be able to respond to an overdose, including friends and family members of individuals who use opioids. In this report, we discuss the Baltimore Student Harm Reduction Coalition (BSHRC) OEND program, Marylands first community-based, state-authorized training program under a new law allowing third-party naloxone prescription. In an 8-month pilot period, 250 free naloxone kits were distributed, and 3 overdose reversals were reported to BSHRC. Trainings were effective in increasing self-efficacy surrounding overdose prevention and response, which appears to persist at up to 12 months following the training.

Evaluation of brief screens for gambling disorder in the substance use treatment setting

BACKGROUND AND OBJECTIVES The goal of this study was to determine the diagnostic accuracy of brief screens for Gambling Disorder within a sample of people receiving outpatient treatment for substance use disorders. METHODS Individuals (n = 300) recruited from intensive outpatient substance use treatment (23.67%) or methadone maintenance programs (76.34%) participated in the study. Four brief screens for Gambling Disorder were administered and compared to DSM-5 criteria. Receiver operator curves were created and an Area Under the Curve (AUC) analysis (an overall summary of the utility of the scale to correctly identify Gambling Disorder) was assessed for each. RESULTS On average participants were aged 46.4 years (SD = 10.2), African American/Black (70.7%), with an income less than

Screening, Testing, and Reporting for Drug and Alcohol Use on Labor and Delivery: A Survey of Maryland Birthing Hospitals

20,000/year (89.5%). Half the participants were female. Approximately 40% of participants (40.5%; n = 121) met DSM-5 criteria for Gambling Disorder. Accuracy of the brief screens as measured by hit rate were .88 for the BBGS, .77 for the Lie/Bet, .75 for NODS-PERC, and .73 for the NODS-CLiP. AUC analysis revealed that the NODS-PERC (AUC: .93 (95% CI: .91-.96)) and NODS-CLiP (AUC: .90 (95% CI: .86-.93)) had excellent accuracy. DISCUSSION AND CONCLUSIONS The NODS-PERC and NODS-CLiP had excellent accuracy at all cut-off points. However, the BBGS appeared to have the best accuracy at its specified cut-off point. SCIENTIFIC SIGNIFICANCE Commonly used brief screens for Gambling Disorder appear to be associated with good diagnostic accuracy when used in substance use treatment settings. The choice of which brief screen to use may best be decided by the needs of the clinical setting.

Incorporation of poison center services in a state-wide overdose education and naloxone distribution program

Recent amendments to the Child Abuse Prevention and Treatment Act tie the receipt of federal block grants to mandatory reporting of substance-exposed newborns. To determine rates of screening, testing, and reporting of drug and alcohol use at the time of delivery, we administered a telephone survey of nursing managers and perinatal social workers at Maryland birthing hospitals. Of the 34 hospitals, 31 responded (response rate 91%). Although 97% of hospitals reported universal screening, only 6% used a validated instrument. Testing was reported by 94% with 45% reporting universal maternal testing and 7% universal newborn testing. Only 32% reported obtaining maternal consent prior to testing. There is significant heterogeneity in screening and testing for substance use in birthing hospitals. Given federal reporting mandates, state-level practices need to be standardized.

Harry Potter and the Underage Drinkers: Can We Use This to Talk to Teens about Alcohol?.

BACKGROUND To help curb the opioid overdose epidemic, many states are implementing overdose education and naloxone distribution (OEND) programs. Few evaluations of these programs exist. Marylands OEND program incorporated the services of the poison center. It asked bystanders to call the poison center within 2 hours of administration of naloxone. Bystanders included law enforcement (LE). OBJECTIVE Description of the initial experience with this unique OEND program component. METHODS Retrospective case series of all cases of bystander-administered naloxone reported to the Maryland Poison Center over 16 months. Cases were followed to final outcome, for example, hospital discharge or death. Indications for naloxone included suspected opioid exposure and unresponsiveness, respiratory depression, or cyanosis. Naloxone response was defined as persons ability to breathe, talk, or walk within minutes of administration. RESULTS Seventy-eight cases of bystander-administered naloxone were reported. Positive response to naloxone was observed in 75.6% of overall cases. Response rates were 86.1% and 70.9% for suspected exposures to heroin and prescription opioids, respectively. Two individuals failed to respond to naloxone and died. DISCUSSION Naloxone response rates were higher and admission to the intensive care unit rates were lower in heroin overdoses than prescription opioid overdoses. CONCLUSIONS This retrospective case series of 78 cases of bystander-administered naloxone reports a 75.6% overall rate of reversal. SCIENTIFIC SIGNIFICANCE The findings of this study may be more generalizable. Incorporation of poison center services facilitated the capture of more timely data not usually available to OEND programs. (Am J Addict 2016;25:301-306).