Interventions to address the U.S. opioid crisis primarily target opioid use, misuse, and addiction, but because the opioid crisis includes multiple substances, the opioid specificity of interventions may limit their ability to address the broader problem of polysubstance use. Overlap of opioids with other substances ranges from shifts among the substances used across the lifespan to simultaneous co-use of substances that span similar and disparate pharmacological categories. Evidence suggests that nonmedical opioid users quite commonly use other drugs, and this polysubstance use contributes to increasing morbidity and mortality. Reasons for adding other substances to opioids include enhancement of the high (additive or synergistic reward), compensation for undesired effects of one drug by taking another, compensation for negative internal states, or a common predisposition that is related to all substance consumption. But consumption of multiple substances may itself have unique effects. To achieve the maximum benefit, addressing the overlap of opioids with multiple other substances is needed across the spectrum of prevention and treatment interventions, overdose reversal, public health surveillance, and research. By addressing the multiple patterns of consumption and the reasons that people mix opioids with other substances, interventions and research may be enhanced.

/pdf/polysubstance-use-in-the-u-s-opioid-crisis-ruah4zdohp.pdf

Polysubstance use in the U.S. opioid crisis

There has been a dramatic increase of deaths due to illicit fentanyl. We examined the pharmacology of fentanyl and reviewed data on the number of repeat doses of naloxone used to treat fentanyl overdoses. Multiple sequential doses of naloxone have been required in a certain percentage of opioid overdoses due to fentanyl. In addition, fentanyl appears to differ from other opioids as having a very rapid onset with high systemic levels found in overdose victims. A rapid competition is required by naloxone to out-compete large numbers of opioid receptors occupied by fentanyl in the CNS. Taken together, we propose that higher doses of naloxone are needed to combat the new era of overdoses due to the more potent synthetic opioids such as fentanyl.

/pdf/higher-doses-of-naloxone-are-needed-in-the-synthetic-opioid-48wfg9h3ia.pdf

Higher doses of naloxone are needed in the synthetic opioid era

Naloxone is a well-established essential medicine for the treatment of life-threatening heroin/opioid overdose in emergency medicine. Over two decades, the concept of 'take-home naloxone' has evolved, comprising pre-provision of an emergency supply to laypersons likely to witness an opioid overdose (e.g. peers and family members of people who use opioids as well as non-medical personnel), with the recommendation to administer the naloxone to the overdose victim as interim care while awaiting an ambulance. There is an urgent need for more widespread naloxone access considering the growing problem of opioid overdose deaths, accounting for more than 100,000 deaths worldwide annually. Rises in mortality are particularly sharp in North America, where the ongoing prescription opioid problem is now overlaid with a rapid growth in overdose deaths from heroin and illicit fentanyl. Using opioids alone is dangerous, and the mortality risk is clustered at certain times and contexts, including on prison release and discharge from hospital and residential care. The provision of take-home naloxone has required the introduction of new legislation and new naloxone products. These include pre-filled syringes and auto-injectors and, crucially, new concentrated nasal sprays (four formulations recently approved in different countries) with speed of onset comparable to intramuscular naloxone and relative bioavailability of approximately 40-50%. Choosing the right naloxone dose in the fentanyl era is a matter of ongoing debate, but the safety margin of the approved nasal sprays is superior to improvised nasal kits. New legislation in different countries permits over-the-counter sales or other prescription-free methods of provision. However, access remains uneven with take-home naloxone still not provided in many countries and communities, and with ongoing barriers contributing to implementation inertia. Take-home naloxone is an important component of the response to the global overdose problem, but greater commitment to implementation will be essential, alongside improved affordable products, if a greater impact is to be achieved.

/pdf/take-home-naloxone-for-the-emergency-interim-management-of-2oux7id6d9.pdf

Take-Home Naloxone for the Emergency Interim Management of Opioid Overdose: The Public Health Application of an Emergency Medicine

As the opioid epidemic in the United States has continued since the early 2000s (1,2), most descriptions have focused on misuse and deaths. Increased cooperation with state and local partners has enabled more rapid and comprehensive surveillance of nonfatal opioid overdoses (3).* Naloxone administrations obtained from emergency medical services (EMS) patient care records have served as a useful proxy for overdose surveillance in individual communities and might be a previously unused data source to describe the opioid epidemic, including fatal and nonfatal events, on a national level (4-6). Using data from the National Emergency Medical Services Information System (NEMSIS),† the trend in rate of EMS naloxone administration events from 2012 to 2016 was compared with opioid overdose mortality rates from National Vital Statistics System multiple cause-of-death mortality files. During 2012-2016, the rate of EMS naloxone administration events increased 75.1%, from 573.6 to 1004.4 administrations per 100,000 EMS events, mirroring the 79.7% increase in opioid overdose mortality from 7.4 deaths per 100,000 persons to 13.3. A bimodal age distribution of patients receiving naloxone from EMS parallels a similar age distribution of deaths, with persons aged 25-34 years and 45-54 years most affected. However, an accurate estimate of the complete injury burden of the opioid epidemic requires assessing nonfatal overdoses in addition to deaths. Evaluating and monitoring nonfatal overdose events via the novel approach of using EMS data might assist in the development of timely interventions to address the evolving opioid crisis.

/pdf/naloxone-administration-frequency-during-emergency-medical-4pcqg2lzjv.pdf

Naloxone Administration Frequency During Emergency Medical Service Events — United States, 2012–2016

A scoping review of opioid misuse in the rural United States.

https://www.tandfonline.com/doi/pdf/10.1080/10903127.2017.1315203

Multiple Naloxone Administrations Among Emergency Medical Service Providers is Increasing

Background As the emergency department (ED) has evolved into the de-facto site of care for a variety of substance use disorder (SUD) presentations, trends in ED utilization are an essential public health surveillance tool. Changes in ED visit patterns during the COVID-19 pandemic may reflect changes in access to outpatient treatment, changes in SUD incidence, or the unintended effects of public policy to mitigate COVID-19. We use a national emergency medicine registry to describe and characterize trends in ED visitation for SUDs since 2019. Methods We included all ED visits identified in a national emergency medicine clinical quality registry, which included 174 sites across 33 states with data from January 2019 through June 2021. We defined SUD using ED visit diagnosis codes including: opioid overdose and opioid use disorder (OUD), alcohol use disorders (AUD), and other SUD. To characterize changes in ED utilization, we plotted the 3-week moving average ratio of visit counts in 2020 and 2021 as compared to visit counts in 2019. Findings While overall ED visits declined in the early pandemic period and had not returned to 2019 baseline by June 2021, ED visit counts for SUD demonstrated smaller declines in March and April of 2020, so that the proportion of overall ED visits that were for SUD increased. Furthermore, in the second half of 2020, ED visits for SUD returned to baseline, and increased above baseline for OUD ever since May 2020. Conclusions We observe distinct patterns in ED visitation for SUDs over the course of the COVID-19 pandemic, particularly for OUD for which ED visitation barely declined and now exceeds previous baselines. These trends likely demonstrate the essential role of hospital-based EDs in providing 24/7/365 care for people with SUDs and mental health conditions. Allocation of resources must be directed towards the ED as a de-facto safety net for populations in crisis.

/pdf/emergency-department-utilization-for-substance-use-disorders-5qyz9u6s.pdf

Emergency department utilization for substance use disorders and mental health conditions during COVID-19

National Systematic Legal Review of State Policies on Emergency Medical Services Licensure Levels' Authority to Administer Opioid Antagonists.

Background Prehospital emergency care training programs are effective in reducing mortality and disability in low-income countries. Implementation of a specifically designed program in the mountainous regions of Nepal has the potential to benefit local populations, trekking and mountaineering guides, and adventure tourists. Objective Our aims were to survey Nepal Mountaineering Association (NMA) members' past experiences with emergencies and medical training, characterize a geographic-specific prehospital emergency care training program, and evaluate the effectiveness and outcome of the program. Methods Sixty-two trekking guides, police officers, and students attended the 2-day training program in Pokhara, Nepal in May 2014. Training curriculum was determined in coordination with the NMA. Instructors included Tulane University faculty, surgical residents, and graduate students. Surveys identified participants' experience with emergencies, confidence in providing emergency care, and interest in future trainings. Multiple modalities were utilized to assess trainees' comprehension. Results Participants rated the program as valuable and expressed desire for additional trainings. Survey results indicated that participants had prior experience with a myriad of emergencies, were more confident in managing traumatic emergencies than medical or environmental, and showed that few had previously received training in cardiopulmonary resuscitation. Areas of instruction included general first responder and geographic-specific content. Participants achieved the course objectives and documented their abilities to successfully manage simulated clinical problems. Conclusions The training program, an international collaboration, was documented to be successful by instructors, NMA leadership, and participants. The training program's content matched the participants' specific needs and abilities. Areas for improvement include providing content related to burns, motorcycle injuries, cold-exposure injuries, fever management, and toxicology emergencies.

Jeremiah M Kinsman

Papers

Multiple Naloxone Administrations Among Emergency Medical Service Providers is Increasing

Naloxone Administration Frequency During Emergency Medical Service Events — United States, 2012–2016

Emergency department utilization for substance use disorders and mental health conditions during COVID-19

National Systematic Legal Review of State Policies on Emergency Medical Services Licensure Levels' Authority to Administer Opioid Antagonists.

Prehospital Emergency Care Education for the Nepal Mountaineering Association