Sarah E. Bowman

Preventing Death Among the Recently Incarcerated: An Argument for Naloxone Prescription Before Release

ABSTRACT Death from opiate overdose is a tremendous source of mortality, with a heightened risk in the weeks following incarceration. The goal of this study is to assess overdose experience and response among long-term opiate users involved in the criminal justice system. One hundred thirty-seven subjects from a project linking opiate-dependent individuals being released from prison with methadone maintenance programs were asked 73 questions regarding overdose. Most had experienced and witnessed multiple overdoses; 911 was often not called. The majority of personal overdoses occurred within 1 month of having been institutionalized. Nearly all participants expressed an interest in being trained in overdose prevention with Naloxone. The risk of death from overdose is greatly increased in the weeks following release from prison. A pre-release program of overdose prevention education, including Naloxone prescription, for inmates with a history of opiate addiction would likely prevent many overdose deaths.

Barriers to Medical Provider Support for Prescription Naloxone As Overdose Antidote for Lay Responders

Poisonings are the leading cause of adult injury death in the United States. Over 12 weeks in 2011, 143 key informant interviews were conducted using a structured interview guide in three study sites in New England. This analysis focuses on the 24 interviews with emergency department providers, substance use treatment providers, pain specialists, and generalist/family medicine practitioners. Using an iterative coding process, we analyzed statements regarding support and concern about naloxone prescription for pain patients and drug users. The studys implications and limitations are discussed and future research suggested. The Centers for Disease Control and Prevention funded this study.

Reducing the Health Consequences of Opioid Addiction in Primary Care

Addiction to prescription opioids is prevalent in primary care settings. Increasing prescription opioid use is largely responsible for a parallel increase in overdose nationally. Many patients most at risk for addiction and overdose come into regular contact with primary care providers. Lack of routine addiction screening results in missed treatment opportunities in this setting. We reviewed the literature on screening and brief interventions for addictive disorders in primary care settings, focusing on opioid addiction. Screening and brief interventions can improve health outcomes for chronic illnesses including diabetes, hypertension, and asthma. Similarly, through the use of screening and brief interventions, patients with addiction can achieve improved health outcome. A spectrum of low-threshold care options can reduce the negative health consequences among individuals with opioid addiction. Screening in primary care coupled with short interventions, including motivational interviewing, syringe distribution, naloxone prescription for overdose prevention, and buprenorphine treatment are effective ways to manage addiction and its associated risks and improve health outcomes for individuals with opioid addiction.

Revisiting Paulozzi et al.'s “Prescription Drug Monitoring Programs and Death Rates from Drug Overdose”

The ecological study by Paulozzi et al. (Online Early: 18 Feb. 2011) raised many critical questions about the use and effectiveness of prescription drug monitoring programs (PDMPs) for a serious public health problem: fatal drug overdose. Despite a rigorous statistical modeling approach, we have two fundamental concerns: the premise and exposure measurement. The premise of this analysis had two important flaws. First, PDMPs were conceived of and have been implemented and funded primarily by mechanisms that are extensions of the criminal justice system. Law enforcement, not public health practitioners or health providers, has been the primary beneficiary of PDMPs since inception, a trend which is only recently beginning to change [1]. Given their current form and common usage, it may be inappropriate to expect PDMPs to have any significant effect on prescription drug overdose mortality. The authors state that PDMPs “employ various interventions … to reduce the abuse and/or diversion of controlled substances” and, by doing so, may alter the rate of overdose death in a state, but they give no examples of states that have used their PDMP effectively in this manner. The most common intervention during the study period of 1999 to 2005 was law enforcement investigation. The authors provide no theory to explain how law enforcement investigation might mitigate drug overdose risk. …

Collaboration or Coercion? Partnering to Divert Prescription Opioid Medications

Diversion of prescription opioids is a widespread problem in the USA. While “doctor shopping” and pill brokering are well-described types of medication diversion, we sought to understand the social dynamic of diversion of prescription opioids and identify other diversion methods. Using qualitative data collected as part of a 12-week Rapid Assessment and Response study of prescription opioid overdose and abuse (the RARx Study) conducted in three communities in two New England states, we reviewed and thematically coded 195 interviews. Diversion took many forms: doctor shopping, pill brokering, and, most commonly, siphoning from the family medicine chest. Partnering—of patients with other “patients,” of patients with “caregivers”— to obtain prescription opioids was also described. Motivations for partnering indicated doing so out of fear of violence, for financial benefit, or in exchange for transportation or other services. Partnering for prescription opioids exhibited a range of power differentials, from collaboration to coercion, and tended to involve vulnerable populations such as the elderly, disabled, or destitute. Increased awareness among health providers of the ease of access and diversion of prescription opioids is needed to promote patient safety and prevent interpersonal violence.

Life After the Ban: An Assessment of US Syringe Exchange Programs’ Attitudes About and Early Experiences With Federal Funding

OBJECTIVES We aimed to determine whether syringe exchange programs (SEPs) currently receive or anticipate pursuing federal funding and barriers to funding applications following the recent removal of the long-standing ban on using federal funds for SEPs. METHODS We conducted a telephone-administered cross-sectional survey of US SEPs. Descriptive statistics summarized responses; bivariate analyses examined differences in pursuing funding and experiencing barriers by program characteristics. RESULTS Of the 187 SEPs (92.1%) that responded, 90.9% were legally authorized. Three received federal funds and 116 intended to pursue federal funding. Perceived federal funding barriers were common and included availability and accessibility of funds, legal requirements such as written police support, resource capacity to apply and comply with funding regulations, local political and structural organization, and concern around altering program culture. Programs without legal authorization, health department affiliation, large distribution, or comprehensive planning reported more federal funding barriers. CONCLUSIONS Policy implementation gaps appear to render federal support primarily symbolic. In practice, funding opportunities may not be available to all SEPs. Increased technical assistance and legal reform could improve access to federal funds, especially for SEPs with smaller capacity and tenuous local support.

Treatment for hepatitis C virus genotype 1 infection in HIV-infected individuals on methadone maintenance therapy

BACKGROUND A minority of HIV/HCV coinfected patients with opiate addiction undergo HCV treatment. HCV therapy for HCV-monoinfected methadone maintenance (MM) recipients is safe and effective. We evaluated treatment efficacy and adherence to pegylated interferon (pegIFN) among HIV/HCV coinfected MM recipients. METHODS HCV treatment-naïve, HIV-infected persons 18-65 years with chronic HCV genotype 1 on MM were prospectively enrolled in an HCV treatment study at two HIV clinics. At weekly visits pegIFN alfa-2a injections were directly administered. Daily MM recipients had morning ribavirin delivered with methadone at off-site methadone clinics. Weekly take-home MM recipients took ribavirin unsupervised. Target enrollment was 30 participants. RESULTS During 18 recruitment months, 11 participants were enrolled, 6 of whom received daily methadone. Mean age was 46, 64% were female, 5 were Caucasian, 4 Black and 2 Hispanic. At baseline, 82% had high HCV RNA and 55% had stage 2 fibrosis or greater. The majority (91%) were on HAART, and 82% had undetectable HIV RNA with a median CD4(+) of 508cells/μL. All had polysubstance use history, non-substance-based psychiatric diagnoses and were on psychotropic medications pre-enrollment. Two (18%) participants achieved a Sustained Virologic Response (SVR). Two completed 48 treatment weeks, 5 were withdrawn due to adverse events, 2 dropped out prematurely and 2 had treatment discontinued for virologic non-response. Of on-treatment weeks, adherence to pegIFN was >99%. CONCLUSIONS SVR rate was comparable to historic controls for coinfected genotype 1 patients, with optimal pegIFN adherence. Adverse effects often prevented therapy completion in this population.

Development of an incarceration-specific overdose prevention video: Staying Alive on the Outside

Objectives: The first 2 weeks following release from prison are associated with extraordinary risk of fatal drug overdose. However, bystanders can reverse opioid overdoses using rescue breathing and naloxone, an overdose antidote. We reviewed overdose prevention and naloxone administration training videos for incarceration-specific and behaviour change theory–specific content and then developed a video that addressed these gaps. Design: Systematic review of educational videos and community-based participatory video development process. Setting: Community-based organisations, correctional health programmes. Method: Video development proceeded as a community-informed, iterative process of creating and testing the acceptability of a new DVD among end-user populations, community and correctional staff. Data collection and video development advisory process included three focus groups with opioid users and formerly incarcerated individuals, two consultations with national expert groups and overdose prevention programme staff and ongoing informal presentations to correctional staff and leadership. Results: Of nine eligible and reviewed videos, three contained theory-based learning components, and only one also contained peer-based content; none directly addressed post-incarceration overdose prevention. The created 19-minute film, Staying Alive on the Outside, uses interviews, conversation and model training sessions by peers, who candidly discuss the challenges of re-entry from prison, opioid addiction and relapse and misconceptions about opioid tolerance and overdose. Viewers learn strategies to avoid overdose while using opioids and what to do in an overdose. Peer ‘learners’ and peer ‘trainers’ model the dissemination of education and naloxone administration. Conclusion: The DVD is currently used in several prisons and jails; a multi-site evaluation of programme effectiveness is discussed.

Two Cases of Intranasal Naloxone Self-Administration in Opioid Overdose

BACKGROUND Overdose is a leading cause of death for former prisoners, exacting its greatest toll during the first 2 weeks post release. Protective effects have been observed with training individuals at high risk of overdose and prescribing them naloxone, an opioid antagonist that reverses the effects of the opioid-induced respiratory depression that causes death. CASES The authors report 2 people with opiate use histories who self-administered intranasal naloxone to treat their own heroin overdoses following release from prison. Patient A is a 34-year-old male, who reported having experienced an overdose on heroin the day after he was released from incarceration. Patient B is a 29-year-old female, who reported an overdose on her first injection of heroin, 17 days post release from incarceration. Both patients self-administered the medication but were assisted at some point during the injury by a witness whom they had personally instructed in how to prepare and administer the medication. Neither patient experienced withdrawal symptoms following exposure to naloxone. DISCUSSION Self-administration of naloxone should not be a goal of overdose death prevention training. A safer, more reliable approach is to prescribe naloxone to at-risk patients and train and also equip members of their household and social or drug-using networks in overdose prevention and response.

Backpack Needle Exchange: Background, Design, and Pilot Testing of a Program in Rhode Island

ABSTRACT Many individuals who inject drugs do not access existing needle and syringe exchange programs. The ability to obtain clean needles from needle exchanges is limited by operational difficulties, the hours of operation, the location of the programs, and a lack of transportation. Providing multiple points of access to clean needles, including mobile exchange sites, may be necessary to prevent the transmission of the human immunodeficiency virus and other blood-borne viruses. A novel backpack needle exchange outreach model was implemented in Providence, Rhode Island. Backpack exchange participants completed surveys similar to those done by clients of Providences storefront needle exchange. Backpack exchangers were significantly more likely to be Hispanic and inject more frequently than those who utilized the fixed site. Backpack exchange is a feasible method for providing needle exchange services and referrals to hard-to-reach injectors.