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      Post-overdose interventions triggered by calling 911: Centering the perspectives of people who use drugs (PWUDs)

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          Abstract

          Background

          Opioid overdose deaths have increased exponentially in the United States. Bystander response to opioid overdose ideally involves administering naloxone, providing rescue breathing, and calling 911 to summon emergency medical assistance. Recently in the US, public health and public safety agencies have begun seeking to use 911 calls as a method to identify and deliver post-overdose interventions to opioid overdose patients. Little is known about the opinions of PWUDs about the barriers, benefits, or potential harms of post-overdose interventions linked to the 911 system. We sought to understand the perspectives of PWUDs about a method for using 911 data to identify opioid overdose cases and trigger a post-overdose intervention.

          Methods and findings

          We conducted three focus groups with 11 PWUDs in 2018. Results are organized into 4 categories: willingness to call 911 (benefits and risks of calling), thoughts about a technique to identify opioid overdoses in 911 data (benefits and concerns), thoughts about the proposed post-overdose intervention (benefits and concerns), and recommendations for developing an ideal post-overdose intervention. For most participants, calling 911 was synonymous with “calling the police” and law enforcement-related fears were pervasive, limiting willingness to engage with the 911 system. The technique to identify opioid overdoses and the proposed post-overdose intervention were identified as potentially lifesaving, but the benefits were balanced by concerns related to law enforcement involvement, intervention timing, and risks to privacy/reputation. Nearly universally, participants wished for a way to summon emergency medical assistance without triggering a law enforcement response.

          Conclusions

          The fact that the 911 system in the US inextricably links emergency medical assistance with law enforcement response inherently problematizes calling 911 for PWUDs, and has implications for surveillance and intervention. It is imperative to center the perspectives of PWUDs when designing and implementing interventions that rely on the 911 system for activation.

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          Most cited references 26

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          Changing dynamics of the drug overdose epidemic in the United States from 1979 through 2016

          Better understanding of the dynamics of the current U.S. overdose epidemic may aid in the development of more effective prevention and control strategies. We analyzed records of 599,255 deaths from 1979 through 2016 from the National Vital Statistics System in which accidental drug poisoning was identified as the main cause of death. By examining all available data on accidental poisoning deaths back to 1979 and showing that the overall 38-year curve is exponential, we provide evidence that the current wave of opioid overdose deaths (due to prescription opioids, heroin, and fentanyl) may just be the latest manifestation of a more fundamental longer-term process. The 38+ year smooth exponential curve of total U.S. annual accidental drug poisoning deaths is a composite of multiple distinctive subepidemics of different drugs (primarily prescription opioids, heroin, methadone, synthetic opioids, cocaine, and methamphetamine), each with its own specific demographic and geographic characteristics.
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            Naloxone distribution and cardiopulmonary resuscitation training for injection drug users to prevent heroin overdose death: a pilot intervention study.

             K Seal (2005)
            Fatal heroin overdose has become a leading cause of death among injection drug users (IDUs). Several recent feasibility studies have concluded that naloxone distribution programs for heroin injectors should be implemented to decrease heroin over-dose deaths, but there have been no prospective trials of such programs in North America. This pilot study was undertaken to investigate the safety and feasibility of training injection drug using partners to perform cardiopulmonary resuscitation (CPR) and administer naloxone in the event of heroin overdose. During May and June 2001, 24 IDUs (12 pairs of injection partners) were recruited from street settings in San Francisco. Participants took part in 8-hour training in heroin overdose prevention, CPR, and the use of naloxone. Following the intervention, participants were prospectively followed for 6 months to determine the number and outcomes of witnessed heroin overdoses, outcomes of participant interventions, and changes in participants' knowledge of overdose and drug use behavior. Study participants witnessed 20 heroin overdose events during 6 months follow-up. They performed CPR in 16 (80%) events, administered naloxone in 15 (75%) and did one or the other in 19 (95%). All overdose victims survived. Knowledge about heroin overdose management increased, whereas heroin use decreased. IDUs can be trained to respond to heroin overdose emergencies by performing CPR and administering naloxone. Future research is needed to evaluate the effectiveness of this peer intervention to prevent fatal heroin overdose.
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              Prescribing naloxone to actively injecting heroin users: a program to reduce heroin overdose deaths.

              Heroin overdose deaths have increased alarmingly in Chicago over the past decade. Naloxone, an opioid antagonist with no abuse potential, has been used to reverse opiate overdose in emergency medical settings for decades. We describe here a program to educate opiate users in the prevention of opiate overdose and its reversal with intramuscular naloxone. Participant education and naloxone prescription are accomplished within a large comprehensive harm reduction program network. Since institution of the program in January 2001, more than 3,500 10 ml (0.4 mg/ml) vials of naloxone have been prescribed and 319 reports of peer reversals received. The Medical Examiner of Cook County reported a steady increase in heroin overdose deaths since 1991, with a four-fold increase between 1996 and 2000. This trend reversed in 2001, with a 20% decrease in 2001 and 10% decreases in 2002 and 2003.
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                Author and article information

                Contributors
                Role: ConceptualizationRole: Formal analysisRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: Project administrationRole: ResourcesRole: Writing – original draftRole: Writing – review & editing
                Role: ConceptualizationRole: Data curationRole: InvestigationRole: Project administrationRole: ValidationRole: Writing – review & editing
                Role: ConceptualizationRole: InvestigationRole: Methodology
                Role: ConceptualizationRole: Funding acquisitionRole: MethodologyRole: ValidationRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: MethodologyRole: ValidationRole: Writing – review & editing
                Role: ConceptualizationRole: ValidationRole: Writing – review & editing
                Role: ConceptualizationRole: ValidationRole: Writing – review & editing
                Role: ConceptualizationRole: ValidationRole: Writing – review & editing
                Role: ConceptualizationRole: Funding acquisitionRole: InvestigationRole: MethodologyRole: ValidationRole: Writing – review & editing
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                17 October 2019
                2019
                : 14
                : 10
                Affiliations
                [1 ] School of Community Health Sciences, University of Nevada, Reno, Nevada, United States of America
                [2 ] Nevada Center for Applied Research, University of Nevada, Reno, Nevada, United States of America
                [3 ] School of Public Health, University of Nevada, Las Vegas, Nevada, United States of America
                [4 ] FirstWatch, Inc., Carlsbad, California, United States of America
                [5 ] Division of Infectious Disease and Global Public Health, Department of Medicine, University of California, San Diego, California, United States of America
                Douglas Mental Health University Institute, CANADA
                Author notes

                Competing Interests: FirstWatch is a company that creates technological solutions to manage and use real-time 9-1-1 data to inform emergency medical response. Prior to working at FirstWatch, SRV was a Project Coordinator on an NIH/NIDA-funded study related to this report. SRV conducted data collection and analysis related the larger study while she was employed as Project Coordinator for the NIH/NIDA-funded study. Her contributions towards the preparation of the current manuscript occurred while she was employed by FirstWatch, Inc. FirstWatch was compensated as a vendor to query 9-1-1 data for the larger NIH-funded studies related to this report, but has not contributed in any way to the development of the current manuscript other than with salary support paid to Dr. Verdugo as discussed in the ‘Funding’ section. KW and PJD have testified as unpaid invited experts (PJD) and public comment (KW) on the topic of opioid overdose and naloxone availability for the US Food and Drug Administration and US National Institutes of Health and other state and local governmental bodies. KW holds a separate grant from Arnold Ventures to examine the feasibility, acceptability, and outcomes of an emergency department-based post-overdose intervention. These declarations do not alter our adherence to the PLOS ONE policies on sharing data and materials.

                Article
                PONE-D-19-17411
                10.1371/journal.pone.0223823
                6797193
                31622401
                © 2019 Wagner et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                Page count
                Figures: 0, Tables: 1, Pages: 14
                Product
                Funding
                Funded by: funder-id http://dx.doi.org/10.13039/100000026, National Institute on Drug Abuse;
                Award ID: R01DA040648
                Award Recipient :
                Funded by: funder-id http://dx.doi.org/10.13039/100000057, National Institute of General Medical Sciences;
                Award ID: P20GM103440
                Award Recipient :
                Research reported in this publication was supported by the US National Institutes of Health under awards P20GM103440 (KW, BL) and R01DA040648 (PJD, KW). The funder provided support in the form of salaries for authors (KW, BL, PJD) but did not have any additional role in the study design, data collection and analysis, decision to publish, or preparation of the manuscript. The commercial company FirstWatch, Inc. provided support in the form of salary for author SRV beginning in September 2018 and had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. The specific roles of these authors are articulated in the ‘author contributions’ section. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or FirstWatch, Inc.
                Categories
                Research Article
                Medicine and Health Sciences
                Pharmacology
                Drugs
                Analgesics
                Opioids
                Medicine and Health Sciences
                Pain Management
                Analgesics
                Opioids
                Medicine and Health Sciences
                Pharmacology
                Drugs
                Opioids
                Medicine and Health Sciences
                Critical Care and Emergency Medicine
                Social Sciences
                Law and Legal Sciences
                Criminal Justice System
                Law Enforcement
                Social Sciences
                Sociology
                Criminology
                Police
                People and Places
                Population Groupings
                Professions
                Police
                Medicine and Health Sciences
                Public and Occupational Health
                Medicine and Health Sciences
                Public and Occupational Health
                Safety
                Medicine and Health Sciences
                Pharmacology
                Drug Research and Development
                People and places
                Geographical locations
                North America
                United States
                Nevada
                Custom metadata
                Because of the sensitive nature of the information contained in the transcripts (e.g., details about illegal behavior) and potential for severe ethical, legal, and social consequences resulting from broken confidentiality, full transcripts cannot not be made publicly available, per restrictions imposed by the Reno Research Integrity Office, and IRB. Redacted excerpts of the qualitative transcripts used in the current analysis will be made available to qualified researchers subject to review and approval by the appropriate Institutional Review Board(s). Requests can be made to the University of Nevada, Reno Research Integrity Office by calling +1-775-327-2368 or via email to Reno RIO director, Nancy Mood: nmoody@ 123456unr.edu .

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