Research paperNon-fatal opioid overdose, naloxone access, and naloxone training among people who recently used opioids or received opioid agonist treatment in Australia: The ETHOS Engage study
Introduction
Globally, in 2017 an estimated 40.5 million people were dependent on opioids (95% CI 34.3–47.9 million) and 109,500 people (95% CI 105,800–113,600) died from opioid overdose (GBD, 2017; Disease & Injury Incidence & Prevalence Collaborators, 2018). There are ∼93,000 people who recently injected drugs in Australia (Degenhardt et al., 2017) and one study estimated non-fatal overdose in the preceding year at 11.9% (Colledge et al., 2019). Non-fatal opioid overdose is a major determinant of morbidity among people who inject drugs (PWID) (Degenhardt et al., 2019; Warner-Smith, Darke, & Day, 2002) and is a predictor of subsequent overdose (Caudarella et al., 2016; Coffin et al., 2007; Forsyth, Carroll, Lennox, & Kinner, 2018). People who have experienced non-fatal overdose are a key population to be targeted for overdose prevention interventions.
Naloxone is a short-acting opioid antagonist which rapidly reverses opioid overdoses, preventing death (Strang et al., 2019). Take-home naloxone programmes train people at risk of overdose (including PWID, people who use illicit opioids, and chronic pain patients receiving opioids) and their peers to administer naloxone in the community setting. Such training programmes successfully increase overdose knowledge and give participants the skills to reverse an overdose (Chronister et al., 2018; Lewis, Vo, & Fishman, 2017; Lintzeris et al., 2020; McAuley, Aucott, & Matheson, 2015; Neale et al., 2019). In Australia, an estimated 30% of PWID at needle syringe programs in urban areas have received training on administering naloxone (Peacock et al., 2019) yet overdose rates are increasing (Man, Chrzanowska, Dobbins, Degenhardt & Peacock, 2019). Since 2016, naloxone has been available in Australian pharmacies over-the-counter to purchase without a prescription or prior training (Lenton, Dietze & Jauncey, 2016). Australian PWID have demonstrated high willingness to obtain take home naloxone from community pharmacies (Lintzeris et al., 2020) but the 2016 change in policy has not resulted in a notable increase in over-the-counter naloxone sales (Tse, Sanfilippo, Lam, Dietze & Nielsen, 2020). Research is needed to determine if naloxone training is reaching people most at risk of overdose.
Studies have identified various sociodemographic and behavioural factors which are associated with overdose; including older age (Kerr et al., 2007; Nechuta, Tyndall, Mukhopadhyay & McPheeters, 2018), younger age (Coffin et al., 2007), homelessness (Kerr et al., 2007; Sherman, Cheng & Kral, 2007), recent incarceration (Kerr et al., 2007; Pizzicato, Drake, Domer-Shank, Johnson & Viner, 2018), recent period of abstinence (Ahmad et al., 2021; Coffin et al., 2007) and intermittent injecting drug use (Brugal et al., 2002). Use of opioids concomitantly with alcohol or benzodiazepines is common in reported overdoses (Barocas et al., 2019; Darke et al., 2007; Tori, Larochelle & Naimi, 2020) and is associated with an increased risk of overdose compared to opioids alone (Dasgupta et al., 2016; Gudin, Mogali, Jones & Comer, 2014; Macleod et al., 2019; Park, Saitz, Ganoczy, Ilgen & Bohnert, 2015). Concurrent use of opioids and other depressant drugs, not necessarily concomitantly, has also been found to be a marker of increased risk of overdose (Olfson, Wall, Wang, Crystal & Blanco, 2018; Schneider, Park, Allen, Weir & Sherman, 2019, 2020). Existing research has looked beyond the use of individual drugs to understand overdose disparities by classifiying “drug use profiles” using latent class analysis (Schneider et al., 2019; Schneider et al., 2020) and number of drugs used (Ahmad et al., 2021; Alexander et al., 2015). The existing research does not investigate the additive effect of benzodiazepines and alcohol among people who use opioids, and its association with naloxone access and training. The focus on benzodiazepines and alcohol is warranted given the aforementioned risk of overdose when combined with opioids and the high proportion of PWID in Australia who use these drugs (Peacock et al., 2021). Given that non-fatal overdose is a predictor of subsequent overdose (Caudarella et al., 2016; Coffin et al., 2007; Forsyth et al., 2018), understanding the factors associated with non-fatal overdose can help target naloxone provision. Further investigation is needed using a single sample to investigate if the drug use profiles that are associated with non-fatal overdose are also associated with naloxone access and training.
This study firstly aimed to estimate recent non-fatal opioid overdose, access to take-home naloxone, and receipt of naloxone training among people who used opioids or received opioid agonist treatment (OAT) in the preceding six months. This data will explain the extent of the problem and response. Secondly, the study evaluated factors associated with recent non-fatal opioid overdose, access to naloxone, and naloxone training, with a particular focus on drug use profile (concurrent use of opioids, benzodiazepines, and hazardous alcohol use). The findings will provide an overview of factors associated with recent opioid overdose, to understand if they are the same factors associated with naloxone access and training. Finally, the study described naloxone access and training in people reporting recent non-fatal opioid overdose. This will contribute to understanding the gaps in naloxone access among those most at risk of overdose.
Section snippets
Data sources
Enhancing Treatment of Hepatitis C in Opioid Substitution Settings (ETHOS) Engage is a national observational cohort study of people who have a history of injecting drug use, and report injecting drug use in the preceding six months or are currently receiving OAT (comprising methadone, buprenorphine, and buprenorphine-naloxone in Australia). The study procedures have been described elsewhere (Valerio et al., 2020). Participants were enrolled between 28 May 2018 and 06 September 2019.
Results
ETHOS Engage recruited 1468 participants; 5 (<1%) had insufficient questionnaire data, 16 (1%) withdrew participation, and 4 (<1%) were duplicate enrolments identified across sites, resulting in 1443 participants (98%) eligible for analysis. Of 1443 participants, 163 (11%) were excluded from this analysis as they did not report opioid use or receive OAT in the preceding six months.
In the study population who recently used opioids or received OAT (n = 1280), 35% were female, 62% were aged over
Discussion
In this national study of people who recently used opioids or received OAT in Australia, 7% reported recent opioid overdose, 17% reported ever having naloxone access, and 14% reported ever having naloxone training. Hazardous alcohol use and recent use of benzodiazepines was associated with an increased risk of overdose in people who recently used opioids, compared to people receiving OAT and using no other opioids. While groups at higher risk of non-fatal overdose (e.g. those with recent
Funding
The Enhancing Treatment of Hepatitis C in Opioid Substitution Settings (ETHOS) Engage study is funded by a National Health & Medical Research Council (NHMRC) Partnership project grant (1103165), including funding from New South Wales Health and Cepheid. Cepheid was not involved in the study design, methodology, and writing of this manuscript. The opinions expressed in the paper are those of the authors and do not necessarily represent those of Cepheid. The Kirby Institute is funded by the
Ethical approval
Yes.
Declarations of Interest
AP has received untied educational grant from Seqirus and Mundipharma for study of opioid medications. LD has received investigator-initiated untied educational grants for studies of opioid medications in Australia from Indivior, Mundipharma and Seqirus. PR has received speaker fees from Gilead and MSD, and research funding from Gilead. MM has received speaker fees from Abbvie. CT has received speaker fees from Abbvie and Gilead and has received a research grant from Merck outside the submitted
Acknowledgements
The authors thank all participants who took part in the ETHOS Engage study. We first give special acknowledgement to the following peer workers and organisations who helped invaluably with participant recruitment:
The NSW Users and AIDS Association (NUAA): Sara Adey, Rodd Hinton, Melanie Joyce; Youth Link Needle and Syringe Program, Cairns: Astrid Carthew; Hepatitis South Australia: Lisa Carter, Carol Holly; Harm Reduction Western Australia: Lyn Murphy.
We would also like to thank the
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2022, International Journal of Drug PolicyCitation Excerpt :Yet, findings were less clear with respect to prior engagement with drug treatment programmes. Together, these findings emphasize the importance of ongoing contact with community-based services in enabling naloxone carriage among PWID (Conway et al., 2021; Reed et al., 2019). We found that 39% of PWID included in our study did not carry naloxone, despite reporting very high availability of naloxone (94%).
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