Naloxone distribution programs for preventing opioid overdose deaths

Naloxone Education
Naloxone is an opioid antagonist that acts fast. It is applied by medical experts to reverse incidents of opioid overdose. It has been in use since 1971. The FDA has approved Naloxone for prescription applications. The drug works by antagonizing the effects of opioid through displacing agonists of opioid receptors in the CNS. The outcome is that it successfully represses the effects of respiratory depression. The drug can be administered through the nose (intranasal) or via IV. It can be done subcutaneously too, and works against all agonists of opioid. It works against morphine, oxycodone, heroin and methadone. In order to reverse the effects of opioids, there may be a need to repeat the dose. In patients that depend on opioid, the major effects of Naloxone include precipitated withdrawal. The effect comes from the fast displacement of opioid agonist from the receptors of opioid. It uses a similar mechanism that Naloxone uses to reverse depression of the respiratory system. Naloxone does not manifest psychoactive properties. It isn’t a scheduled drug and does not carry any potential for abuse. Public health organizers and those from the community have designed and developed education about overdose and the distribution of Naloxone (OEND) plans to forestall overdose fatalities in those who use heroin and among people who abuse pharmaceutical opioids. In an OEND programs survey done in 2010, 188 plans based in 15 states and in the District of Colombia gave people Naloxone that they could take home to opioid users. Between 1996 and 2010, Naloxone had been distributed to over 50, 000 people through the programs. They received an overdose reversal report of over 10, 000 people. The strategies for prevention used by the OEND may be useful to the prevention of pharmaceutical opioid overdose linked deaths, in specialty medical care. Providing Naloxone as one of the ways to deal with issues of opioid overdose has been supported by a number of Federal agencies in the US.The Substance Abuse and Mental Services Administration, in 2013, made public the toolkit to offer local governments and communities, information to evolve policies to stop deaths related to overdose of opioid. Countries such as Scotland and Wales developed national distribution centers for Naloxone (Mueller et al., 2015).
The Background & Significance
Opioid overdose related deaths can be prevented if an individual gets the basic life support, and the timely administration of Naloxone. Naloxone is an effective antidote against opioid overdose. The drug can reverse such an overdose in full if it is administered in time. The drug is effective when delivered by intravenous means, intranasal, subcutaneous or by intramuscular means. When administered to people with no history of taking opioid, it has no effect at all. The access to Naloxone is restricted to professionals in the health sector. Naloxone is still limited in many countries. Italy has already made Naloxone accessible from pharmacies with no need for prescription. Since incidents of overdose are often either witnessed by a friend or a relative, if such people accessed Naloxone, they could easily help to reverse the opioid overdose, even as they wait for medical care to come. Naloxone, when administered by lay people could still save a life but it should not be substituted for complete medical care (WHO, 2018).
A survey done recently in America revealed that over 10, 000 reversals were products of a distribution of about 50 000 kits of Naloxone via a local opioid overdose prevention program. Several countries have decided to use the same approach. In Scotland, a policy to allow people that have been exposed to opioid overdose, and those that are at the risk of being overdosed to access Naloxone was developed in 2011. The same has happened in several states in the US. When an evaluation of the status of the implementation of the policy and its effect on the individuals at risk was conducted, including those in prison, it was established that the ratio of overdose incidences happening in a period of four weeks after leaving incarceration had reduced by half, since Naloxone was introduced (WHO, 2018).
The likely effect of Naloxone prescription plan for users of opioid is pointed out in the experience from the Drug Overdose Prevention and Education program. The program was set up in 2003 in liaison with the San Francisco Department of Health. It is noted that 11% of people who were on Naloxone prescription confessed having used the drug in an opioid overdose event. It is also noted that 83% of such overdose events were successfully reversed with Naloxone. More access to Naloxone to treat those on prescribed opioid for management of pain and the ones on illicit opioid is one of the effective multifaceted approaches in handling the opioid problem. Many settings present a potential opportunity for the prescription of Naloxone to patients at a high risk of overdose. Such opportunities arise in such settings as emergency departments of health facilities, primary care spaces, correctional institutions, centers for the treatment of addiction and pharmacies. However, the literature available suggests that such opportunities are missed, even when they present (Dunne, 2018).
Opioid overdose prevention based in the community which incorporates the use of Naloxone has spread wider, with regard to an alarmingly high overdose incidence in the past few years. The distribution program for Naloxone seems to be safe. The evidence of these developments is scarce because there is no data from randomized trials. Data analysis from the San Francisco Drug Overdose Prevention and Education Project revealed that between 2003, September, and December 2009, Naloxone successfully reversed 400 cases of overdose with a 90% success rate and a minute percentage of adverse effects cases (Enteen et al., 2010).
The Overdose Education and Naloxone Distribution plan was recently examined by an interrupted time series survey from Massachusetts. The death rates as a result of overdose were compared in counties with varying rates of OEND plan usage (Walleyet al., 2013). The researchers concluded that the communities with a higher rate of intake of OEND exhibited lower rates of death from opioid overdose. In a more recent study, it was found that bystanders who constitute, largely, opioid users will use Naloxone to reverse the overdose of opioid when given proper training for doing the same (Clark, Wilder, &Winstanley, 2014). In the same way, a review of take-home Naloxone plans done by the European Monitoring Center for Drugs and Drug Addiction (2015) summarized that the take-home programs for Naloxone reduced the deaths emanating from opioid overdose. An analysis of cost effectiveness, recently, showed that giving Naloxone to users of heroin seems to be cost-effective, spanning a range of assumptions and clearly below the widely accepted threshold of willingness-to-pay (Coffin & Sullivan, 2013; Center for Evidence-based Policy, 2015).

Review of health care cost of problem(s)
Opioid is commonly prescribed to help relieve pain for millions of Americans. However, the risk of misuse of prescription remains high. Indeed, the disorders associated with opioid use and its overdose is a growing concern across the country. The problem started rearing its ugly head from when opioid use was allowed for common use in the 1990s. It has been observed that the number of deaths resulting from the misuse of opioid has also increased. While the quantities of opioid dispensed to patients have significantly increased, there have not been matching numbers of patients relieved of pain. The later numbers have not changed. It has also been reported that about 218 000 people died between 1999 and 2017 from opioid overdoses. The deaths as a result of opioid prescription rose five times more in 2017 compared to 1999 ((National Academies of Sciences, Engineering, and Medicine, 2017).
Prescription for opioids rose significantly in the middle parts of the 90s.The use of non medical opioid also started taking root, shortly after the common use started increasing. Over 2.7 million new users were noted in 2002 (Kolodny et al., 2015). In 2012, the number of nonmedical users of opioid reduced slowly. Nevertheless, in general, the number of people using the drug through means other than medical, remains alarmingly high..The use of hydrocodone more than doubled between 1999 and 2011. Oxydone, on its part increased more than five-fold. The deaths that were linked to the overdose of opioid increased over four times (Chen et al., 2014). The deaths arising from the overdose of opioid are the most dramatic effects of a rise in the use of opioid. However, it is not the only consequence. It has been established that the rate of opioid use and visits to the emergency room for the use of opioids for non medical purposes, opioid use disorder, neonatal abstinence and admissions for treatment have risen since 2002. The death rates related to the use of opioid have risen for every population group. It has also been noted that the numbers are more worrying for males below 50 years (National Academies of Sciences, Engineering, and Medicine, 2017).
The public health burden has been increasingly caused by substance use disorders. The figures show that one out of every 10 adults can be associated with the abuse of alcohol. Drug overdoses that have led to deaths have also increased in the decade past. The economic effect of substance abuse, in terms of crime, losses in productivity and costs in health care, amounts to billions of dollars. A large number of health complications that lead to hospitalization are made worse by abuse of substances. Medical effects of substance abuse include infection of soft tissue, endocarditis, overdose and traumas or injuries resulting from intoxication. Medical complications that can be made worse by the abuse of substances include kidney disease, liver disease, diabetes and respiratory conditions. There is a high chance that people with disorders related to substance abuse will show low adherence tendencies to medical help. Health care costs are even more significantly affected when the disease burden has been taken into account. Hospitalizations have been examined in earlier researches. The incidence has been strongly associated with either substance abuse or alcoholism. Disorders related to substance abuse have commonly passed unnoticed in many health visits. Apart from being the general cause of hospitalization among patients, the abuse of substances has also been found to come with other effects with the potential to magnify the social and health implications (Gryczynski et al., 2016).
Assessment of the Phenomena (problem statement)
The use of Naloxone can be widely associated with professional researchers for the past 40 years. However, community activism, pre hospital surroundings from the 90s regarding reducing of harm, people and organizations that use drugs have pushed the issue to the podium for fighting the crisis linked to the abuse of Naloxone. Over 644 Naloxone sites for distribution were managed in the US through the opioid prevention programs totaling 136 by 2014.Over 152, 283 Naloxone kits were distributed to people without special knowledge. Over 26, 43 overdose reversals were also realized for the period between 1999 and 2014 through the efforts (Wheeler et al., 2015). Apart from the extensive literature relating to clinical application, and pharmacological information, the evidence for increased community access to Naloxone has also increased. Available data indicates that educating people about the effects of overdose of opioids and allowing those at risk of being exposed to the overuse of opioid to access Naloxone leads to a reduced number of those who abuse heroin. There is also likely to be a lower number of emergency visits triggered by the abuse of opioids (Coffin et al., 2016). There has been a decrease of between 35 to 45% in deaths resulting from the overdose of opioid (Bird et al., 2016). Raising the amount of Naloxone is a core sign of the efforts by the community to reduce the incidents of deaths resulting from the use of opioid (National Academies of Sciences, Engineering, and Medicine, 2017).
Naloxone is only available in the US by prescription means. Nevertheless, many states have explored innovative ways of allowing a wider access to Naloxone. Some of the approaches include standing orders in which pharmacists have the leeway to offer the drug under the order of prescriber, collaborative agreements by pharmacists; in which pharmacists have the permission to manage the medication on behalf of the prescribing agent and other requirements of regulation (Green et al., 2015). More laws with the objective of reducing the number of death incidents resulting from the overdose of opioid have been formulated. Moreover, the privilege and trusted access to individuals who use drugs offered through the programs is essential as the epidemic of opioid is increasingly dominated by access to illicit opioid as opposed to prescribed opioids.Young adults between the ages of 18 and 25 are the age group with the highest number of illicit use of opioid over the past year. Adults from the age of 26 onwards show the greatest use of the drug on prescription in the population.The Substance Abuse and Mental Health Services information shows that many of those who report prescription opioid abuse in the current groups started their use when they were in their early 20s. Such a development may demonstrate why the prescription opioid related mortality affects adults between 25 and 54 disproportionately (CDC, 2018). The full effect of prescription opioids in public health is made complicated by the fact that heroin is increasingly available. Heroin is not as expensive as prescription opioids. The fact that many people who develop OUD from prescribed opioids resort to heroin makes the situation worse.
Historical and Societal Perspective
It must be appreciated that severe pain that is constant has the potential of breaking even the most determined of people. However, we are commonly ready to provide liberal quantities of narcotics when drug addiction, in itself, is a dangerous stumbling block. Surgeon Warren Cole, 60 years ago, explained such a state of affairs about cancer pain, in a book. In the 70s, the dilemma by Cole was experienced in many doctors’ offices and emergency wards across the US landscape. Nurses and physicians were trained to offer minimal amounts of opioids to patients in pain. They administered such doses and even lower than the prescription unless in cases where death was about to happen. Studies showed that chronic pain had been underrated acutely. Part of the reason for underrating of pain was because of the special emotional effects that affect the rational use of the drug. Kathleen Foley (at Memorial- Sloan-Ketering Cancer Center, NY) from a group of pain management experts saw the restriction towards opioids as awkward. Two influential articles were published by Foley in 1981 and 1986. He noted that there was a low incidence of addiction in a small group that consisted of both cancer and non cancer victims. The articles alongside a letter with one paragraph in 1980 showed that addiction was not common among in-patients. It became a delicate campaign, for 20 years, for the use of opioids for the long term, in non cancer pain, steered by Foley and her close team member Russel Portenoy. Foley observed that there was no long term data that was published that showed high rates of addiction among patients. There had not been any long term controlled research of opioids for pain that was chronic. For many chronic pain patients and physicians, the view that long term opioids had the potential for safety and that there was no problem for patients to be trusted to be in charge of their own prescriptions was a welcome idea (Meldrum, 2016).
The best alternative to opioids known, thus far, is a multidisciplinary approach that involves reliance on psychological therapies such as Cognitive Behavioral Therapy, relaxation, coping with pain and self hypnosis. Although such approaches can succeed, a lot of third party players view them as too expensive. Insurance policy coverage is normally insufficient, and only the main medical outlets can back such programs. Less than 200, 000 patients participate, currently, in multidisciplinary treatment. But among pain management experts, still, many people challenged the view that therapy for chronic opioid use was safe. It signals to the progressive incidence of addictive conduct. The debate caused a continuous and serious fracture in the field. Many people that championed liberalized opioid treatment for chronic pain have retracted their argument. They admitted that their view led to the abuse that was not anticipated. Nevertheless, as the Center for Disease Control points out in their guidelines, patients experiencing severe chronic pain still need opioids. Thus, physicians will be expected to prescribe it, although they will have to be more cautious (Meldrum, 2016).
The sum of societal cost for opioid abuse in 2007 was found to be $ 55.7 billion. Lost productivity at work contributed $25.6 billion. The cost of health care was $ 25.0 billion while the costs for criminal justice stood at $ 5.1 billion. The lost productivity at the workplace contributed 49.9% of the sum of societal costs. Premature death made up the largest part, accounting for $ 11.2 billion (43.8%). Lost wages and absenteeism was the next pair of the most costly components. They contributed $ 7.9 billion and 2.0 billion American dollars respectively. Medically linked absenteeism and the cost of incarceration accounted for amounts that could be compared: $1.8 billion which represented 7.1%. Excess costs of disability $ accounted for $ 807 million. Opioid abuse patients accounted for 64.5 %. They also accounted for 90.1 % of absenteeism that is medically related and costs related to disability. Care givers contributed the remainder (35.5 and 9.9%) The cost of healthcare contributed to about $ 25 billion which represented 44.9% of the whole societal cost. In the latter, costs for excess medical supplies and drugs were the central contributors standing at $ 23.7 billion. Out of the whole set of correctional facility costs; two thirds were met at the state level. The outcome of the analysis document is that the growing issue of prescription opioid abuse puts a significant economic burden on the society, particularly in the areas of healthcare, lost productivity at the workplace and criminal justice system (Birnbaum et al., 2011).
Incidence and Prevalence
The incidence of prescription opioid abuse and dependence in the USA has risen in the last ten years, which represents a significant public health risk. Illicit opioid and prescription abuse is common. Deaths relating to overdose are more common. The rise in opioid overdose is linked to over 16 500 deaths occurring annually in the USA. It is critically important to educate both patients and their family members regarding the risks of opioid overdose at the point of dispensing (Bailey&Wermeling, 2014).
It is common to apply the use of opioid analgesics to treat acute chronic pain. Over 60 million patients in 2016 had prescription opioid analgesics refilled or filled. Apart from the ubiquitous application of these analgesics, the effectiveness of using opioids for treating the pain resulting from chronic cancer is not clearly known. The connection between their use, addiction and overdose are well documented. Owing to over-prescription and misuse, an opioid epidemic has emerged in the US. The economic and health burdens of abuse of opioids emanated in the first ten years of the new millennium, and so did the level of opioid abuse and misuse. By the year 2016, it is estimated that over 2.1 million Americans were experiencing opioid use disorder. Over 42, 000 of them died as a result of opioid overdose. The US Department of Health and Human Services declared a crisis of opioid as an emergency in Public health (Hagemeier, 2018).
Evidence of support for APRN’s role in solutions
Partly, the epidemic at the moment has been informed by efforts that mean well but end up being ineffective in pain management. In remarks relating to the national pain strategy crafted by a diverse expert team, it was noted by the American Nurses Association that nurses commonly lead in transformation, attitudinally, in pain management issues. Since APRN’s work in a range of direct health care, leadership, coordination and executive roles, they are best placed to help the patients and their family members through the risks and gains of pain management alternatives. As patient advocates and educators, nurses sit in a unique position to help patients with pain that is not related to opioid use, including other modalities of treatment, surgery, physiotherapy, psychological therapies, physical, complementary and alternative medicine (American Nurses Association, 2018).
The American Nurses Association came up, recently, with a blueprint of what nurses should do to address the opioid crisis. They presented the following proposals
· That APRNs and nurses in general, who prescribe opioids safely and effectively, should be incorporated in the ongoing training program for the education of medical professionals in the prescription of opioids (University of Alabama in Huntsville, 2018).
· That Nurses, first providers, care givers, family and friends of identified opioid users be allowed more access to Naloxone so as to raise the odds of treating overdosed victims (University of Alabama in Huntsville, 2018). Accountability and proper education is critical for Advanced Practice Nurses prescribing opioids, and for nurses at the bedside, administering the same for their patients (Jukiewicz, Alhofaian, Thompson & Gary, 2017).


References
American Nurses Association. (2018). The Opioid Epidemic: The Evolving Role of Nursing. Retrieved February 7, 2019, from https://ncsbn.org/2018_ANA_Opioid_Epidemic.pdf
Bailey, A. M., & Wermeling, D. P. (2014). Naloxone for opioid overdose prevention: pharmacists' role in community-based practice settings. The Annals of pharmacotherapy, 48(5), 601-6.
Bird, S. M., McAuley, A., Perry, S., & Hunter, C. (2016). Effectiveness of Scotland's National Naloxone Programme: response to letter to editor. Addiction, 111(7), 1304-1306.
Birnbaum, H. G., White, A. G., Schiller, M., Waldman, T., Cleveland, J. M., & Roland, C. L. (2011). Societal costs of prescription opioid abuse, dependence, and misuse in the United States. Pain medicine, 12(4), 657-667.
CDC. (2018, December 19). Opioid Overdose. Retrieved February 8, 2019, from https://www.cdc.gov/drugoverdose/data/prescribing.html?CDC_AA_refVal=https://www.cdc.gov/drugoverdose/data/overdose.html
Center for Evidence-based Policy (2015). Best Practices in Naloxone Treatment Programs for Opioid Overdose.Retrieved February 23, 2019, fromhttps://www.ohsu.edu/xd/research/centers-institutes/evidence-based-policy-center/evidence/med/upload/MED_best_practices_naloxone_report_final.pdf
Chen, L. H., Hedegaard, H., & Warner, M. (2014). Drug-poisoning deaths involving opioid analgesics: United States, 1999-2011. NCHS data brief, (166), 1-8.
Clark, A., Wilder, C., &Winstanley, E. (2014) A systematic review of community opioid overdoseprevention and naloxone distribution programs. Journal of Addiction Medicine, 8(3),153-163.
Coffin, P., & Sullivan, S. (2013). Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal. Annals of Internal Medicine, 158(1), 1-9
Coffin, P. O., Behar, E., Rowe, C., Santos, G. M., Coffa, D., Bald, M., &Vittinghoff, E. (2016). Nonrandomized intervention study of Naloxonecoprescription for primary care patients receiving long-term opioid therapy for pain. Annals of internal medicine, 165(4), 245-252.
Dunne, R. (2018). Prescribing naloxone for opioid overdose intervention. Retrieved February 23, 2019, from https://www.futuremedicine.com/doi/full/10.2217/pmt-2017-0065
Enteen, L., Bauer, J., McLean, R., Wheeler, E., Huriaux, E., Kral, A., & Bamberger, J. (2010). Overdose prevention and naloxone prescription for opioid users in san francisco. Journal of Urban Health, 87(6), 931-941.
European Monitoring Centre for Drugs and Drug Addiction. (2015). Preventing fatal overdoses: A systematic review of the effectiveness of take-home naloxone. Luxembourg: Publications Office of the European Union.
Green, T. C., Griffel, C., Dailey, T., Garg, P., Thorley, E., Kaczmarsky, C., ...& Butler, S. F. (2015, December). How did you know you got the right pill? Prescription opioid identification and measurement error in the abuse deterrent formulation era. In Addiction science & clinical practice (Vol. 10, No. 1, p. A16). BioMed Central.
Gryczynski, J., Schwartz, R. P., O’Grady, K. E., Restivo, L., Mitchell, S. G., & Jaffe, J. H. (2016). Understanding patterns of high-cost health care use across different substance user groups. Health Affairs, 35(1), 12-19.
Hagemeier, N. E. (2018). Introduction to the opioid epidemic: the economic burden on the healthcare system and impact on quality of life. Am J Manag Care, 24(10 Suppl), S200-S206.
Jukiewicz, D. A., Alhofaian, A., Thompson, Z., & Gary, F. A. (2017). Reviewing opioid use, monitoring, and legislature: Nursing perspectives. International Journal of Nursing Sciences, 4(4), 430-436.
Kolodny, A., Courtwright, D. T., Hwang, C. S., Kreiner, P., Eadie, J. L., Clark, T. W., & Alexander, G. C. (2015). The prescription opioid and heroin crisis: a public health approach to an epidemic of addiction. Annual review of public health, 36, 559-574.
Meldrum M. L. (2016). The Ongoing Opioid Prescription Epidemic: Historical Context. American journal of public health, 106(8), 1365-6.
Mueller, S. R., Walley, A. Y., Calcaterra, S. L., Glanz, J. M., & Binswanger, I. A. (2015). A Review of Opioid Overdose Prevention and Naloxone Prescribing: Implications for Translating Community Programming Into Clinical Practice. Substance abuse, 36(2), 240-53.
National Academies of Sciences, Engineering, and Medicine. (2017). Pain management and the opioid epidemic: balancing societal and individual benefits and risks of prescription opioid use. National Academies Press.
University of Alabama in Huntsville. (2018, March 06). How Can Nurses Help Solve the Opioid Crisis? Retrieved February 23, 2019, from https://online.uah.edu/articles/rnbsn/nurses-opioid-crisis.aspx
Walley A., Xuan, Z., Hackman, H., Quinn, E., Doe-Simkins, M., Soresnen-Alawad, A., …Ozonoff, A. (2013). Opioid overdose rates and implementation of overdose education and naloxone distribution in Massachusetts: Interrupted time series analysis. BMJ, 346, f174. http://dx.doi.org/10.1136/bmj.f174
Wheeler, E., Jones, T. S., Gilbert, M. K., & Davidson, P. J. (2015). Opioid overdose prevention programs providing Naloxone to laypersons-United States, 2014. MMWR. Morbidity and mortality weekly report, 64(23), 631-635.
WHO. (2018, August 21). Information sheet on opioid overdose. Retrieved February 7, 2019, from https://www.who.int/substance_abuse/information-sheet/en/


Matrix Table

Source Citation
Purpose/Problem
Design/Sample
Instruments/Measures
[Include Reliability/Validity]
Results
[Include actual data]
Strengths/Weaknesses

Coffin, P. O., & Sullivan, S. D. (2013). Cost-effectiveness of distributing Naloxone to heroin users for lay overdose reversal. Annals of internal medicine, 158(1), 1-9.













































Mueller, S. R., Walley, A. Y., Calcaterra, S. L., Glanz, J. M., & Binswanger, I. A. (2015). A Review of Opioid Overdose Prevention and Naloxone Prescribing: Implications for Translating Community Programming Into Clinical Practice. Substance abuse, 36(2), 240-53.





























Walley, A. Y., Xuan, Z., Hackman, H. H., Quinn, E., Doe-Simkins, M., Sorensen-Alawad, A., ... &Ozonoff, A. (2013). Opioid overdose rates and implementation of overdose education and nasal Naloxone distribution in Massachusetts: interrupted time series analysis. Bmj, 346, f174.







































Binswanger, I. A., Koester, S., Mueller, S. R., Gardner, E. M., Goddard, K., & Glanz, J. M. (2015). Overdose education and Naloxone for patients prescribed opioids in primary care: a qualitative study of primary care staff. Journal of general internal medicine, 30(12), 1837-1844.































































Bailey, A. M., &Wermeling, D. P. (2014). Naloxone for opioid overdose prevention: pharmacists' role in community-based practice settings. The Annals of pharmacotherapy, 48(5), 601-6.

























































To estimate the cost-effectiveness of distributing Naloxone, an opioid antagonist, to heroin users for use at witnessed overdoses














































 For this review, the researchers summarized and classified existing publications on overdose education and Naloxone distribution to identify evidence of effectiveness and opportunities for translation into conventional medical settings.






























To evaluate the impact of state supported overdose education and nasal Naloxone distribution (OEND) programs on rates of opioid related death from overdose and acute care utilization in Massachusetts.











































To investigate the knowledge, attitudes and beliefs about overdose education and Naloxone prescription among clinical staff in primary care.




































































To describe outpatient Naloxone dispensing practices, including methods by which practitioners implement dispensing programs, prescribing patterns that include targeted patient populations, barriers to successful implementation, and methods for patient education.




















































Integrated Markov and decision analytic model using deterministic and probabilistic analyses and incorporating recurrent overdoses and a secondary analysis assuming heroin users are a net cost to society.








































Searched English language PubMed for articles on Naloxone based on primary data collection from humans, including feasibility studies, program evaluations, surveys, qualitative studies and studies comparing the effectiveness of different routes of Naloxone administration.
























Interrupted time series analysis of opioid related overdose death and acute care utilization rates from 2002 to 2009 comparing community-year strata with high and low rates of OEND implementation to those with no implementation.

19 Massachusetts communities (geographically distinct cities and towns) with at least five fatal opioid overdoses in each of the years 2004 to 2006.




























This was a qualitative study using focus groups to elucidate both clinic-level and provider-level barriers and facilitators.

Ten primary care internal medicine, family medicine and infectious disease/HIV practices in three large Colorado health systems.


























































Interviews were conducted with providers to obtain insight into the practice of dispensing Naloxone.