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Opioid Overdose Deaths: This state has highest need for naloxone compared to others in the US

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To effectively prevent opioid overdose deaths in the US, the distribution of naloxone, a life-saving treatment that can reverse the toxic effects of an opioid overdose, must be considerably extended across the United States, with more community-based and pharmacy-initiated access points.

The study, which was published in The Lancet Public Health journal, is the first to assess naloxone needs for each state in the United States, and it discovered major gaps in access to and distribution of this life-saving medicine.

The authors calculated the amount of additional naloxone kits needed to prevent 80 percent of witnessed opioid overdose deaths in 2017 using estimates from 12 simulated states, with estimates ranging from no additional naloxone kits needed to as much as 1,270 kits per 100,000 persons per year.

The study also found that naloxone requirements differ by epidemic type and naloxone distribution routes, with places with heavy fentanyl usage requiring more naloxone kits.

The most successful routes for distributing naloxone were through community programs and pharmacies.

The investigators conclude that making naloxone more widely available in the community, particularly among those most at risk of witnessing a drug overdose and drug users, could prevent a significant number of opioid overdose deaths.

“Our study provided estimates for naloxone needs by state, but a consistent national framework for reporting opioid overdoses and tracking community-based and pharmacy-initiated naloxone distribution is also urgently needed to inform policies and allocate resources that will finally turn the tide on this unprecedented epidemic,” said senior author Prof Traci Green of Brandeis University (USA).

More naloxone is needed to combat the opioid overdose crisis in the US.

To estimate the number of naloxone kits needed per state in order to reduce fatal opioid overdoses over one year, the authors considered the type of naloxone access point (community programme, provider prescribed, or pharmacy initiated); the dynamics of the epidemic type  (prescription opioid, heroin, fentanyl, or mixed epidemic) in each state; and how choice of access point and the type of epidemic affects state-specific naloxone needs. The authors modelled naloxone needs for 12 U.S. states identified as representative of each epidemic type based on 2017 data, and the number of kits needed to avert deaths in 80% of all witnessed overdoses. Naloxone need for all other states were projected based on the models.

For instance, the state of Massachusetts, which has a well-established state-wide community-based naloxone distribution program but also is experiencing widespread fentanyl use, would need to distribute an estimated 740 extra community program kits per 100,000 people to achieve this goal. In states where kits were already distributed widely, and fentanyl use was not widespread, fewer additional kits were needed. In Arizona, for instance, the target of 80% of witnessed deaths averted was met in 2017. However, Arizona has seen large increases in fentanyl use since 2017, suggesting greater naloxone need to align with the evolving epidemic; this study’s model can help to inform the future need. Among the 12 representative states, Illinois, a large state with high numbers of overdoses involving heroin and fentanyl, relied less upon prescribers and pharmacies for naloxone distribution and more upon one centralized community-based naloxone distribution programme hub at the time of the study. Illinois would need to distribute 1,720 naloxone kits per 100,000 people per year to meet the goal of averting 80% of witnessed overdose deaths.

“Naloxone is one of several interventions that can help reduce deaths from overdose and so we used the concept of saturation to answer, mathematically, how many deaths we can expect to avert and how many naloxone kits a state would need to make substantial progress in saving lives. Unfortunately, no state reached that saturation point. But, based on our study, now we know where we need to go and have meaningful benchmarks to aim for,” said first author Prof Michael Irvine of the British Columbia Centre for Disease Control (Canada).

The authors found that across state-specific results, naloxone kits provided through community-based and pharmacy-initiated access points resulted in a higher probability of naloxone use in witnessed overdoses and a higher number of deaths averted per 100,000 people than through prescription-only access points. Because naloxone may be confiscated or stolen, ensuring naloxone remains within reach of people at risk of experiencing or witnessing an overdose is crucial.

The importance of community-based and pharmacy-initiated access points also highlighted the variations in the opioid epidemic by region. Fentanyl overdose deaths were concentrated in the eastern United States while the midwest displayed a mixed epidemic of prescription opioids, fentanyl, and heroin. States in the western United States were primarily characterised by prescription opioid epidemics except for the southwest and Pacific Northwest, which had a mixture of prescription opioid and heroin epidemics. Alaska and Hawaii had prescription opioid epidemics.

“Although our calculations suggest a substantial public health effect from expanded naloxone distribution, it’s important to remember that naloxone has no effectiveness against an unwitnessed overdose. The nuances of the epidemic must be understood by region and epidemic type and improving naloxone availability at the community level is only one part of a much more urgent need to reform public health policies around drug use. These policies should include scaled-up interventions aimed at ensuring overdoses are witnessed, such as safe consumption sites and improved education about harm reduction practices. More importantly, the deep underlying social determinants of health that can perpetuate drug addiction and overdoses, such as poverty, excessive incarceration, and structural racism must be addressed to break the deadly cycle of addiction,” added Prof Green.

The authors acknowledge some limitations of their study. The data used in the study were from 2017, and rates of overdoses have increased since 2017 across the USA, and epidemic types may have evolved. The authors relied on data from community-based naloxone programmes, estimated overdose events, and estimated deaths due to overdose. Because of the unavailability of accurate data, the authors also relied on expert opinion to inform components of the study, including the saturation point of naloxone distribution by state. Furthermore, some jurisdictions under-report deaths due to overdose; therefore, state-specific calculations might underestimate the need for naloxone. Finally, for simplicity, the authors assumed that use of a naloxone kit would result in survival from an overdose.

Image Credit: Getty

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