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The ongoing opioid crisis presents a significant public health challenge particularly for people who use opioids (PWUO). Naloxone is an opioid antagonist crucial to reducing opioid overdose mortality. Inconsistencies exist among PWUO in obtaining, carrying, discussing, and administering naloxone. Using sequential mixed methods, this study was aimed at investigating the use of implementation intentions on naloxone use among PWUO. Semi-structured interviews were conducted with 83 PWUO to gather individual experiences with using naloxone and contextual details regarding its use. An essentialist thematic analysis with inductive coding revealed valuable insights into where, for whom, and when naloxone is implemented. The analysis identified major themes such as caring for others' needs, knowledge gaps, reinforcement through overdose experiences, duality of overdose and compassion, and stigma. Minor themes related to syringe services program implementation and drug use were identified. Building on these qualitative findings a quantitative analysis determined the impact of implementation intentions on naloxone implementation. Participants were randomly assigned to develop implementation intentions or goal intentions for the use of naloxone. Follow-up surveys assessed changes in participants' intentions to obtain, carry, discuss, and administer naloxone and their actual implementation over a 6-month period. At the 3-month follow-up the experimental condition exhibited statistically significant positive intentions to obtain naloxone and engage in discussions about naloxone in social contexts of drug use. Changes in the magnitude of naloxone implementation were observed at the 3- and 6-month timepoints. Specifically, the self-reported discussion of naloxone showed noticeable changes in implementation frequency over time. This suggests that while implementation intentions may not have statistically significant effects on the use of naloxone it had some influence on the frequency of discussing naloxone prior to drug use. This work makes a valuable contribution to the existing literature because of its attempt to apply the Theory of Planned Behavior and implementation intentions in a novel way. Though the experimental hypothesis was not supported statistically significant observations were made for some behaviors at the 3-month follow-up. The pragmatic nature of the setting enhances the relevance of the findings and provides valuable insights for future interventions supporting PWUO. / Doctor of Philosophy / The ongoing crisis of opioid addiction poses a significant public health challenge particularly for individuals who use opioids. Naloxone is a medication that can reverse opioid overdoses and it plays a crucial role in saving lives. People who use opioids often face difficulties in accessing, carrying, discussing, and using naloxone consistently. This study was aimed at investigating the use of naloxone by employing qualitative and quantitative methods. We conducted interviews with 83 individuals who use opioids to explore their experiences and gather insights into naloxone use. These interviews provided valuable information about when, where, and for whom naloxone is used. Several important themes emerged including the significance of helping others, knowledge gaps, the influence of personal experiences, the conflict between the fear of overdose and caring for others, and the stigma associated with drug use. We investigated the impact of a specific approach called "implementation intentions" in improving naloxone use. Participants were randomly assigned to create specific plans or general goals for naloxone use. Through surveys conducted over a 6-month period we examined changes in participants' intentions and actions related to naloxone use. Although the specific approach did not yield significant improvements, we observed changes in how people discussed naloxone over time. This study contributes to the existing research by introducing innovative ideas to support positive behavioral changes among individuals who use opioids. The real-world setting in which the study took place enhances the applicability of the findings and offers valuable insights for future programs supporting individuals who use opioids.

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Increased opioid analgesic (OA) prescribing has been associated with increased risk of prescription opioid diversion, misuse, and abuse. States established prescription drug monitoring programs (PDMPs) to collect and analyze electronic records for dispensed controlled substances to reduce prescription drug abuse and diversion. PDMP data can be used by prescribers for tracking patient’s history of controlled substance prescribing to inform clinical decisions. The studies in this dissertation are focused on the less utilized potential of the PDMP data to enhance public health surveillance to monitor OA prescribing and co-prescribing and association with opioid overdose mortality and morbidity. Longitudinal analysis of OA prescribing and evaluation of the effect of recent policies and opioid prescribing guidelines require consensus measures for OA utilization and computational tools for uniform operationalization by researchers and agencies. Statistical macros and computational tools for OA utilization measures were developed and tested with Kentucky PDMP data. A set of covariate measures using mortality and morbidity surveillance data were also developed as proxy measures for prevalence of painful conditions justifying OA utilization, and availability of heroin and medication treatment for opioid use disorder. A series of epidemiological studies used the developed OA measures as outcomes, and adjusted for time-varying socio-demographic and health care utilization covariates in population-averaged statistical models to assess longitudinal trend and pattern changes in OA utilization in Kentucky in recent years. The first study, “Trends and Patterns of OA Prescribing: Regional and Rural-Urban Variations in Kentucky from 2012 to 2015,” shows significant downward trends in rates of residents with OA prescriptions. Despite the significant decline over time, and after accounting for prevalence of injuries and cancer, the rate of dispensed OA prescriptions among residents in Kentucky Appalachian counties remained significantly higher than the rest of the state. The second study, “Population-Level Measures for High-Risk OA Prescribing: Longitudinal Trends and Relationships with Pain-Associated Conditions,” shows significant reduction in high-risk OA prescribing (e.g., high daily dosage, long-term use, concurrent prescriptions for OA and benzodiazepines) from 2012 to 2016, significantly positive associations between high-risk OA prescribing and cancer mortality rates with no substantial change in the association magnitude over time, and declining strengths of positive associations between high-risk OA prescribing and acute traumatic injuries or chronic non-cancer pain over the study period. The third study, “A Reciprocal Association between Longitudinal Trends of Buprenorphine/Naloxone Prescribing and High-Dose OA Prescribing,” indicates a significant reciprocal relationship between high-dose OA prescribing and buprenorphine/ naloxone prescribing, and a clinically meaningful effect of buprenorphine/naloxone prescribing on reducing OA utilization. The results from the studies advanced the understanding of the epidemiology of opioid use and misuse in Kentucky, and identified actionable risk and protective factors that can inform policy, education, and drug overdose prevention interventions. The developed operational definition inventory and computational tools could stimulate further research in Kentucky and comparative studies in other states.

Diss. (sammanfattning) Stockholm : Karolinska institutet, 2007. / Härtill 4 uppsatser.

1 ABSTRACT Background The annual drug overdose rates have been increasing exponentially since the 90's worldwide. Toxicological information centre (TIC) represents a valuable source of information for evaluating the trends in the drug poisonings in Czech Republic. Aim of the study The purpose was to analyze the number and trends in the calls concerning poisonings due to central nervous system (CNS) affecting drugs, identify the reasons of medication errors caused by laymen, frequency and consequences of these errors across all age groups and also to analyze the numbers, causes, symptoms and severity of the paracetamol intoxications. Methods During the reference period the data from the enquiries were extracted from the TIC electronic database, discharge reports from the hospital were studied or phone call follow-ups with the patients were carried out to be able to evaluate the outcome of the poisonings. Results In the years 1997-2002 the number of calls caused by poisoning with tricyclic antidepressants and barbiturates decreased (by 366.7 % and 340,0 %, respectively) whereas the calls due to selective serotonin reuptake inhibitors and benzodiazepines overdose increased (by 1347.4 % and 359.8 %). The 0-5 years old children are at the highest risk of experiencing medication errors or accidental poisonings...

The rise in America’s drug poisoning rates has been described as a public health crisis and has long been attributed to the rapid rise in opioid supply due to increased volumes of medical prescribing in the United States that began in the mid-1990s and peaked in 2012. In 2016, the introduction of the “deaths of despair” hypothesis provided a more nuanced explanation for the rising rates of drug poisoning deaths: increasing income inequality and stagnation of middle-class worker wages, driven by long-term shifts in the labor market, reduced employment opportunities and overall life prospects for persons with a high school degree or less, driving increases in “deaths of despair” (i.e., deaths from suicide, cirrhosis of the liver, and drug poisonings). This focus on economic and social conditions as capable of shaping geospatial differences in drug demand and attendant drug-related harms (e.g., drug poisonings) provides a larger context to factors potentially underlying the heterogeneous distribution of prescription opioid supply across the United States. However, despite the likelihood that economic and social conditions may be important demand-side factors that also interact with supply-side factors to produce the rates of fatal drug poisonings, little information exists about the effect of area-level socioeconomic conditions on fatal drug poisoning rates, and no study has investigated whether socioeconomic conditions interact with prescription opioid supply to affect area-level rates of fatal drug poisonings. The overarching goal of this dissertation was to test the independent and joint effects of supply- and demand-side factors, operationalized as prescription opioid supply and socioeconomic conditions, on fatal drug poisoning in the U.S. First, a systematic review of the literature was conducted to critically evaluate the evidence on the ecological relationship of prescription opioid supply and socioeconomic conditions on rates of drug poisoning deaths. The systematic review provides robust evidence of the independent effect of each prescription opioid supply and socioeconomic conditions on rates of drug poisoning deaths. The gap in the literature on the joint effects of prescription opioid supply and socioeconomic conditions was clear, with no study examining the interaction between supply- and demand-side factors on rates of fatal drug poisonings. Moreover, although greater prescription opioid supply was associated with higher rates of fatal drug poisonings in most of the studies, two studies presented contradictory findings, with one study showing no effect of supply on drug poisoning deaths and the other showing locations with higher levels of prescription opioid supply were associated with fewer drug-related deaths. Three limitations were also identified in the reviewed studies that could partially explain the observed associations. First, although studies aggregated data on drug poisoning deaths to a range of administrative spatial levels, including census tract, 5-digit ZIP code, county, 3-digit ZIP code, and state, no study investigated the sensitivity of findings to the level of geographic aggregation. Second, spatial modeling requires the assessment of spatial autocorrelation in both the unadjusted and adjusted data, but few studies even assessed spatial autocorrelation in the data, and fewer still incorporated spatial dependencies in the model. This is important because when spatial autocorrelation is present, the independence assumption in standard statistical regression models is violated, potentially causing bias and loss of efficiency. Third, studies operationalized prescription opioid supply and socioeconomic conditions using a variety of different measures, and no study assessed the sensitivity of findings to the different measures of supply and socioeconomic conditions. Second, the ecological relationship between prescription opioid supply and fatal drug poisonings was examined. For this, pooled cross-sectional time series data from 3,109 U.S. counties in 49 states (2006-2016) were used in Bayesian Poisson conditional autoregressive models to estimate the effect of county prescription opioid supply on four types of drug poisoning deaths: any drug (drug-related death), any opioid (opioid-related death), any prescription opioid but not heroin (prescription opioid-related death), and heroin (heroin-related death), adjusting for compositional and contextual differences across counties. Comparisons were made by type of drug poisoning (any drug, any opioid, prescription opioids only, heroin), level of geographic aggregation (county versus state), and measure of prescription opioid supply (rate of opioid-prescribing per 100 persons and morphine milligram equivalents per-capita). Results indicated a positive association between prescription opioid supply and rates of fatal drug poisonings consistent across changes in type of drug poisoning, level of aggregation, and measure of prescription opioid supply. However, removing confounders from the model caused the direction of the effect estimate to reverse for drug poisoning deaths from any drug, any opioid, and heroin. These results suggested that differences in adjustment for confounding could explain most of the inconsistent findings in the literature. Finally, a rigorous test of the hypothesis that worse socioeconomic conditions increase risk of fatal drug poisonings at the county level, and interact with prescription opioid supply was conducted. This analysis used the same pooled cross-sectional time series data from 3,109 U.S. counties in 49 states (2006-2016). The analysis modeled the effect of five key socioeconomic variables, including three single socioeconomic variables (unemployment, poverty rate, income inequality) and two index variables (Rey index, American Human Development Index [HDI]) on four types of drug poisoning deaths: any drug (drug-related death), any opioid (opioid-related death), any prescription opioid but not heroin (prescription opioid-related death), and heroin (heroin-related death). Using a hierarchical Bayesian modeling approach to account for spatial dependence and the variability of fatal drug poisoning rates due to the small number of events, the independent effect of socioeconomic conditions on rates of drug poisoning deaths and their joint multiplicative and additive effect with prescription opioid supply were estimated. Results showed that rates of fatal drug poisonings were higher in more economically and socially disadvantaged counties; the five key indicator variables were differentially associated with drug poisoning rates; and the American Human Development Index (HDI) and income inequality were most strongly associated with fatal drug poisoning rates. Finally, the results indicate that both HDI and income inequality interact with county-level prescription opioid supply to affect drug poisoning rates. Specifically, the effect of higher prescription opioid supply on rates of fatal drug poisonings was greater in counties with higher HDI and more equal income distributions than counties with lower HDI and less equal income distributions. Overall, this dissertation increased knowledge about the separate and conjoint roles of supply- and demand-side factors in the geospatial distribution of fatal drug poisonings in the U.S. The idea that area-level prescription opioid supply are key drivers of prescription drug use, misuse, and addiction and the attendant consequences, including nonfatal and fatal drug poisonings, has been in the literature for well over a decade. However, no study to date has shown that area-level socioeconomic conditions modify the effect of prescription opioid supply on fatal drug poisonings. By identifying important contextual factors capable of modifying the effect of prescription opioid supply reductions on mortality, high-risk geographic areas can be prioritized for interventions to counter any unintended effects of reducing the prescription opioid supply in an area. As federal and state policies continue to target the rising rates of fatal drug poisonings, these findings show that area-level socioeconomic conditions may represent an important target for policy intervention during the current drug poisoning crisis and a critical piece of information necessary for predicting any future drug-related crises.

Opioid overdose fatalities have quadrupled in the United States since the turn of the century, and are becoming increasingly recognized as a nationwide epidemic. While naloxone (narcan) has long been the standard treatment for overdose in clinical settings, it has not been issued to opioid users or their family members in the U.S. until relatively recently. As naloxone distribution and overdose training become more widespread, they are being incorporated into more and more abstinence-oriented settings including detoxes, halfway houses, and outpatient methadone and suboxone treatment programs. This qualitative study explored whether the staff at such programs found that training their patients to use naloxone was disruptive or controversial, and whether they found it difficult to reconcile these trainings’ basis in harm reduction with their personal and organizational philosophies about substance use and recovery. Ten subjects from Eastern and Central Massachusetts were interviewed about their experience introducing naloxone to their patients under the aegis of the Massachusetts Department of Public Health’s Opioid Overdose Prevention Pilot Program, and their interviews were analyzed from a descriptive phenomenological perspective. This approach seeks to distill the essence of a phenomenon by analyzing the narratives of those who have experienced it, and has been found especially useful when exploring questions that have not yet been studied in depth. The analysis identified eleven recurring themes, grouped into four broad domains (What is overdose prevention training? What is narcan? What is harm reduction? What is the goal of treatment?). These themes suggested that while subjects overwhelmingly experienced naloxone distribution and overdose prevention training as positive additions to their workplace, this experience did not necessarily lead to more engagement with the broader concept of harm reduction.

Purpose: To evaluate the effectiveness of the West Virginia Prescription Drug Abuse Quitline (WVPDAQ). Methods: Descriptive data and inferential analyses are provided for the period of operations from 9/11/2008 to 3/1/2010. Chi-square tests for Independence compared differences between callers completing at least one follow-up survey against callers completing only the baseline intake survey were observed. A Wilcoxon signed rank sum test tested differences between the scores of intake callers and follow-up callers at the one-week (n=177) and one-month (n=89) intervals. Results: A total of 1,056 calls were received, including 670 intakes, 177 1st follow-ups, 89 2nd follow-ups, and 36 3rd follow ups, and 84 caller satisfaction surveys. Chi-square analyses determined that callers who only completed the intake survey tended to have initiated drug use at a younger age ([less than or equal to] 39 years of age, [chi square]=7.63, p=.02). Longitudinal findings indicated significant self-reported declines in daily drug use (p<.0001), increased intentions to quit in the next 30 days (p<.0001), and declines in requesting a referral for treatment (p<.0001) at the one-month follow-up. Finally, approximately 19% (n=17) of callers reported obtaining a counseling/ treatment appointment as a result of calling the WVPDAQ at the one-month follow up. Conclusions: Preliminary results suggest the WVPDAQ has established itself as a meaningful resource to combat prescription drug abuse in West Virginia. Sustainable funding and greater integration of the WVPDAQ into existing and developing treatment infrastructure could provide more affordable options for the state of West Virginia and its citizens.

The selective serotonin reuptake inhibitors appear to have a much wider margin of safety than most other classes of antidepressants. Although there is limited experience with acute overdoses of fluoxetine alone, few serious adverse effects have been reported. There has been almost no experience, however, with significant fluoxetine overdoses in children. This report describes the accidental ingestion of as much as 43 mg/kg of fluoxetine by a 4-year-old child. In this case, serum blood levels of the drug and its major metabolite were consistent with a large ingestion and are among the highest reported in the medical literature. Toxic effects were relatively mild and consisted of a brief spell of unresponsiveness, sinus tachycardia, and moderate psychomotor agitation and dyskinesia. Supportive care was provided and the child recovered completely.