Pamela Leece

Development and Implementation of an Opioid Overdose Prevention and Response Program in Toronto, Ontario

ObjectivesWe describe the development of the first community-based opioid overdose prevention and response program with naloxone distribution offered by a public health unit in Canada (Prevent Overdose in Toronto, POINT).ParticipantsThe target population is people who use opioids by any route, throughout the City of Toronto.SettingThe POINT program is operated by the needle exchange program at Toronto Public Health (The Works) and offered at over 40 partner agency sites throughout Toronto.InterventionPOINT is a comprehensive program of overdose prevention and response training, including naloxone dispensing. Clients are instructed by public health staff on overdose risk factors, recognizing signs and symptoms of overdose, calling 911, naloxone administration, stimulation and chest compressions, and post-overdose care. Training is offered to clients one-on-one or in small groups. Clients receive a naloxone kit including two 1 mL ampoules of naloxone hydrochloride (0.4 mg/mL) and are advised to return to The Works for a refill and debriefing if the naloxone kit is used.OutcomesIn the first 8 months of the program, 209 clients were trained. Clients have reported 17 administrations of naloxone, and all overdose victims have reportedly survived. Client demand for POINT training has been high, and Toronto Public Health has expanded its capacity to provide training. Overall, reception to the program has been overwhelmingly positive.ConclusionWe are encouraged by the initial development and implementation experience with the naloxone program and its potential to save lives in Toronto. We have planned short-, intermediate-, and long-term process and outcome evaluations.RésuméObjectifsNous décrivons l’élaboration du premier programme communautaire de prévention et de lutte contre les surdoses d’opioïdes par la distribution de naloxone offert dans un bureau de santé publique au Canada (Prevent Overdose in Toronto, POINT).ParticipantsLa population cible est constituée des personnes consommant des opioïdes, par n’importe quelle voie, dans la ville de Toronto.LieuPrevent Overdose in Toronto est exécuté par le programme d’échange de seringues du Service de santé publique de Toronto (The Works) et offert sur plus de 40 sites d’organismes partenaires à Toronto.InterventionPOINT est un programme complet de formation à la prévention et à la lutte contre les surdoses incluant la distribution de naloxone. Le personnel de santé publique explique aux clients les facteurs de risque de surdose, les signes et les symptômes de surdose, quand composer le 911, le mode d’administration de la naloxone, la stimulation cardiaque et les compressions thoraciques, ainsi que les soins après une surdose. La formation est offerte aux clients individuellement ou en petits groupes. Les clients reçoivent une trousse de naloxone avec deux ampoules de chlorhydrate de naloxone de 1 mL (0,4 mg/mL); s’ils ont utilisé la naloxone, on leur demande de retourner à The Works pour renouveler leur trousse et faire un bilan.RésultatsAu cours des huit premiers mois du programme, 209 clients ont été formés. Les clients ont fait état de 17 administrations de naloxone; toutes les victimes de surdoses auraient survécu. La demande des clients pour la formation POINT étant élevée, le Service de santé publique de Toronto a renforcé ses capacités d’offrir cette formation. Globalement, l’accueil réservé au programme est extrêmement positif.ConclusionNous sommes encouragés par l’expérience d’élaboration et de mise en oeuvre initiale du programme de naloxone et par les vies qu’il pourrait sauver à Toronto. Nous planifions des évaluations à court, moyen et long terme du processus et des résultats.

Tamper-resistant drugs cannot solve the opioid crisis

Tamper-resistant formulations, designed to make drugs harder to crush, snort or inject, are being promoted in Canada and the United States as a strategy to prevent opioid-related harms such as overdose and addiction. In a research article published in CMAJ Open , Gomes and colleagues[1][1] examined

Predictors of Opioid-Related Death During Methadone Therapy.

We aimed to examine pharmacologic, demographic and medical comorbidity risk factors for opioid-related mortality among patients currently receiving methadone for an opioid use disorder. We conducted a population-based, nested case-control study linking healthcare and coroners records in Ontario, Canada, from January 31, 1994 to December 31, 2010. We included social assistance recipients receiving methadone for an opioid use disorder. Within this group, cases were those who died of opioid-related causes. For each case, we identified up to 5 controls matched on calendar quarter. The primary analysis examined the association between use of psychotropic drugs (benzodiazepines, antidepressants or antipsychotics) and opioid-related mortality. Secondary analyses examined the associations between baseline characteristics, health service utilization, comorbidities and opioid-related mortality. Among 43,545 patients receiving methadone for an opioid use disorder, we identified 175 (0.4%) opioid-related deaths, along with 873 matched controls. Psychotropic drug use was associated with a two fold increased risk of opioid-related death (adjusted odds ratio (OR) 2.0; 95% confidence interval (CI) 1.2 to 3.5). Specifically, benzodiazepines (adjusted OR 1.6; 95% CI 1.1 to 2.5) and antipsychotics (adjusted OR 2.3; 95% CI 1.5 to 3.5) were independently associated with opioid-related death. Other associated factors included chronic lung disease (adjusted OR 1.7; 95% CI 1.2 to 2.6), an alcohol use disorder (adjusted OR 1.9; 95% CI 1.2 to 3.2), mood disorders (adjusted OR 1.8; 95% CI 1.0 to 3.2), and a history of heart disease (adjusted OR 5.3; 95% CI 2.0 to 14.0). Psychotropic drug use is associated with opioid-related death in patients receiving methadone. Mindfulness of these factors may reduce the risk of death among methadone recipients.

Opioid Overdose Fatality Prevention

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An Agenda for Naloxone Distribution Research and Practice: Meeting Report of the Surviving Opioid Overdose with Naloxone (SOON) International Working Group

Opioid-related mortality is a serious and growing issue in North America. Naloxone distribution and basic life support training for people at risk of overdose is a promising opportunity to improve access to potentially lifesaving bystander interventions and essential healthcare. We convened a unique international working group of experts in public health, resuscitation science, and health research methodology, along with clinical, community, policy, industry stakeholders and members of the lay public to explore and address key challenges and opportunities for rigorous research on this intervention. The findings from the Surviving Opioid Overdose with Naloxone (SOON) International Working Group explored potential research opportunities and identified barriers in four priority areas: research methods, resuscitation guidelines, naloxone delivery device development, and knowledge translation. This novel collaborative effort: • Identified key steps and challenges for developing an appropriate, feasible and rigorous pragmatic trial of naloxone distribution in various clinical settings; • Identified emerging naloxone delivery devices and technologies, and described how these devices may alter standards of care for overdose prevention research and practice • Engaged resuscitation experts in the development of bystander resuscitation protocols for opioid-associated resuscitative emergencies; and, • Identified strategies to overcome knowledge translation barriers for patients and providers, as well as characteristics for effective educational tools and program implementation. The SOON collaboration aims to advance the investigation, implementation, and practice of overdose education and naloxone distribution. Through diverse collaborations, we can use best science to improve practice for individuals at risk of opioid overdose.

The Epidemic as Stigma: The Bioethics of Opioids:

In this paper, we claim that we can only seek to eradicate the stigma associated with the contemporary opioid overdose epidemic when we understand how opioid stigma and the epidemic have co-evolved. Rather than conceptualizing stigma as a parallel social process alongside the epidemiologically and physiologically defined harms of the epidemic, we argue that the stigmatized history of opioids and their use defines the epidemic. We conclude by offering recommendations for disrupting the burden of opioid stigma.

Patterns of physician prescribing for opioid maintenance treatment in Ontario, Canada in 2014

BACKGROUND Despite concerns surrounding high patient volumes in methadone clinics, little is known about the practice patterns of opioid maintenance therapy (OMT) providers in Ontario. We examined the distribution of these services and how physician characteristics differ based on prescribing volume. METHODS We conducted a cross-sectional study among prescribers of methadone or buprenorphine to Ontario public drug beneficiaries in 2014 by stratifying physicians into low- (lower 50%), moderate- (51-89%) and high-volume (top 10%) prescribers. We summarized the distribution of OMT prescription days dispensed and urine drug screens (UDS) ordered using Lorenz curves and examined physician characteristics using descriptive statistics. RESULTS We identified 893 OMT prescribers in 2014. Physicians were mostly male (67.5%; N=603), and middle-aged (median was 50). High-volume methadone providers (N=57) prescribed approximately 56% (N=4,115,322) of the total days of methadone (Gini coefficient=0.76, 95% CI 0.74-0.79) while high-volume buprenorphine providers (N=64) prescribed 61% (N=589,463) of the total days of buprenorphine (Gini coefficient=0.78, 95% CI 0.75-0.80). On average, each high-volume methadone prescriber treated 435 OMT patients and billed 43 UDS per patient, while each high-volume buprenorphine prescriber treated 64 OMT patients and billed 22 UDS per patient. Daily OMT patient volume was on average 74 for high-volume methadone prescribers and 6 for high-volume buprenorphine prescribers. CONCLUSIONS OMT services are highly concentrated among a small portion of OMT providers who carry high daily patient volumes. Future research should examine the quality of primary care received by their patients to better elucidate the possible consequences of this highly unequal distribution of services.

Peak event analysis: a novel empirical method for the evaluation of elevated particulate events

BackgroundWe report on a novel approach to the analysis of suspended particulate data in a rural setting in southern Ontario. Analyses of suspended particulate matter and associated air quality standards have conventionally focussed on 24-hour mean levels of total suspended particulates (TSP) and particulate matter <10 microns, <2.5 microns and <1 micron in diameter (PM10, PM2.5, PM1, respectively). Less emphasis has been placed on brief peaks in suspended particulate levels, which may pose a substantial nuisance, irritant, or health hazard. These events may also represent a common cause of public complaint and concern regarding air quality.MethodsMeasurements of TSP, PM10, PM2.5, and PM1 levels were taken using an automated device following local complaints of dusty conditions in rural south-central Ontario, Canada. The data consisted of 126,051 by-minute TSP, PM10, PM2.5, and PM1 measurements between May and August 2012. Two analyses were performed and compared. First, conventional descriptive statistics were computed by month for TSP, PM10, PM2.5, and PM1, including mean values and percentiles (70th, 90th, and 95th). Second, a novel graphical analysis method, using density curves and line plots, was conducted to examine peak events occurring at or above the 99th percentile of per-minute TSP readings. We refer to this method as “peak event analysis”. Findings of the novel method were compared with findings from the conventional approach.ResultsConventional analyses revealed that mean levels of all categories of suspended particulates and suspended particulate diameter ratios conformed to existing air quality standards. Our novel methodology revealed extreme outlier events above the 99th percentile of readings, with peak PM10 and TSP levels over 20 and 100 times higher than the respective mean values. Peak event analysis revealed and described rare and extreme peak dust events that would not have been detected using conventional descriptive statistics.ConclusionsPeak event analysis underscored extreme particulate events that may contribute to local complaints regarding intermittently dusty conditions. These outlier events may not appear through conventional analytical approaches. In comparison with conventional descriptive approaches, peak event analysis provided a more analytical and data-driven means to identify suspended particulate events with meaningful and perceptible effects on local residents.

Relation between opioid-related harms and socioeconomic inequalities in Ontario: a population-based descriptive study

BACKGROUND Negative health outcomes associated with the use of both prescribed and nonprescribed opioids are increasingly prevalent. We examined long-term trends in opioid-related harms in Ontario across a set of 6 indicators and the relation between harms and neighbourhood income in 2016. METHODS We examined rates of neonatal abstinence syndrome, opioid poisoning (fatal and nonfatal) and nonpoisoning opioid-related events from 2003 to 2016 in Ontario using population-based health administrative databases. We conducted descriptive analyses for harm indicators across neighbourhood income quintiles in 2016 (2015 for death). We examined social inequalities in opioid-related harms on both relative (prevalence ratio) and absolute (potential rate reduction) scales. RESULTS Rates of opioid-related harms increased dramatically between 2003 and 2016. In 2016, neonatal abstinence syndrome and opioid poisoning and nonpoisoning events showed a strong social gradient, with harm rates being lowest in higher-income neighbourhoods and highest in lower-income neighbourhoods. Prevalence ratios for the lowest-income neighbourhoods compared to the highest-income neighbourhoods ranged from 2.36 (95% confidence interval [CI] 2.15-2.58) for emergency department visits for opioid poisoning to 3.70 (95% CI 2.62-5.23) for neonatal abstinence syndrome. Potential rate reductions for opioid-related harms ranged from 34.8% (95% CI 29.1-40.1) to 49.9% (95% CI 36.7-60.5), which suggests that at least one-third of all harmful events could be prevented if all neighbourhoods had the same socioeconomic profile as the highest-income neighbourhoods. INTERPRETATION Rates of opioid-related harms increased in Ontario between 2003 and 2016, and people in lower-income neighbourhoods experienced substantially higher rates of opioid-related harms than those in higher-income neighbourhoods. This finding can inform planning for opioid-related public health interventions with consideration of health equity.

Out-of-hospital cardiac arrest survival in drug-related versus cardiac causes in Ontario: A retrospective cohort study

Background Drug overdose causes approximately 183,000 deaths worldwide annually and 50,000 deaths in Canada and the United States combined. Drug-related deaths are concentrated among young people, leading to a substantial burden of disease and loss of potential life years. Understanding the epidemiology, patterns of care, and prognosis of drug-related prehospital emergencies may lead to improved outcomes. Methods We conducted a retrospective cohort study of out-of-hospital cardiac arrests with drug-related and presumed cardiac causes between 2007 and 2013 using the Toronto Regional RescuNet Epistry database. The primary outcome was survival to hospital discharge. We computed standardized case fatality rates, and odds ratios of survival to hospital discharge for cardiac arrests with drug-related versus presumed cardiac causes, adjusting for confounders using logistic regression. Results The analysis involved 21,497 cardiac arrests, including 378 (1.8%) drug-related and 21,119 (98.2%) presumed cardiac. Compared with the presumed cardiac group, drug-related arrest patients were younger and less likely to receive bystander resuscitation, have initial shockable cardiac rhythms, or be transported to hospital. There were no significant differences in emergency medical service response times, return of spontaneous circulation, or survival to discharge. Standardized case fatality rates confirmed that these effects were not due to age or sex differences. Adjusting for known predictors of survival, drug-related cardiac arrest was associated with increased odds of survival to hospital discharge (OR1.44, 95%CI 1.15–1.81). Interpretation In out-of-hospital cardiac arrest, patients with drug-related causes are less likely than those with presumed cardiac causes to receive bystander resuscitation or have an initial shockable rhythm, but are more likely to survive after accounting for predictors of survival. The demographics and outcomes among drug-related cardiac arrest patients offers unique opportunities for prehospital intervention.