BACKGROUND: Naloxone, an opioid antagonist, offers a powerful tool for preventing opioid overdose deaths. Because studies have shown opioid overdose education and naloxone distribution (OEND) programs to be a safe, feasible, and effective intervention, several policymakers and public health agencies have advocated for broader access to this life-saving medication. Community health centers (CHCs) are a promising location for expanding naloxone access. This investigation examined the experience of CHC-based HIV primary care teams with a variety of overdose education and naloxone access (OENA) strategies in order to inform future dissemination efforts. METHODS: A mixed methods study was conducted with eight CHCs located in Massachusetts communities experiencing high opioid overdose fatality rates. Individual and group interviews with 29 clinic staff members; clinic and participant surveys; and document review were used to elucidate the OENA strategies. The Consolidated Framework for Implementation Research guided the data collection process and subsequent analysis, which revealed several factors supporting or hindering implementation of OENA activities in CHC primary care settings. RESULTS: Operating in a facilitative state policy environment, the CHCs utilized a mix of approaches to OENA: providing clinic-based services, issuing prescriptions, utilizing pharmacy standing orders, and making referrals to existing community-based OEND programs. With prescribers having limited time and competing priorities, nurses, health educators, and other staff played a prominent role in OENA. Pharmacies also served as important access points for patients and community residents. Several strategies were used to engage patients, including active outreach, partnerships with external organizations, and efforts to destigmatize substance use disorders. Clinic staff participation was enhanced through leadership support for harm reduction approaches, ongoing training, peer modeling, and information sharing. CONCLUSIONS: This study demonstrated that OENA can be integrated into CHC primary care services, adapted to the clinic context, and modified as needed. Successful implementation required a systems-level response, grounded in a team-based care model and a consideration of patient needs. The process for naloxone reimbursement needs to be determined to minimize CHC or patient barriers and ensure sustainability. Clinic training and technical assistance plans should be customized according to the staff members’ potential roles and their stage of readiness.

Purpose of review: Overdose deaths have increased significantly over the last 5 years. This review analyzes the severity and nature of the epidemic, its impact on society, factors driving the increase in mortality, special populations disproportionately affected, and solutions to decrease overdose deaths. A thorough understanding of opioid overdose rates and deaths position the reader to respond most effectively in their sphere of influence. Recent findings: Final statistics for 2017 show a continued worsening of the epidemic. Recent studies focus on the evolving role of synthetic fentanyl, risk factors for fatal overdose, variation of mortality across demographic and socioeconomic regions, and the effectiveness of harm reduction strategies such as naloxone. Summary: The national overdose death rate continues to rise unabated with a 9.6% increase during 2017, with an estimated cost over $550 billion in 2019. There are, however, effective strategies to identify and treat individuals at risk for a fatal overdose. The root cause of addiction is the brain’s response to despair, social stressors, and societal structural inequities. It is unlikely we will see a significant decrease in addiction and its consequences until these root causes are addressed. Additional research is needed on the role of social determinants in addiction, strategies to treat incarcerated individuals, the role of suicidal ideation in fatal overdose, and risk factors, and frequency of non-fatal overdose.

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Introduction: The entire United States has felt the effects of the overdose epidemic, but rural Appalachia has experienced disproportionate overdose deaths. This variation in overdose mortality can be attributed to the risk environment for overdose in rural Appalachia. Overdose prevention behaviors are individual level behaviors that people who inject drugs can implement that may have the potential to reduce their risk of overdose, however limited research exists regarding the utilization of those behaviors. It is important to consider how the risk environment can influence the utilization of overdose prevention behaviors among people who inject drugs. Therefore, the purpose of this research was to identify overdose prevention behaviors among people who inject drugs in rural Appalachia and better understand the relationship between those behaviors and the rural risk environment for overdose. Methods: This research was conducted using a mixed methods approach, including a scoping review, qualitative, and quantitative study. A scoping review was used to identify overdose prevention strategies and behaviors in rural America. Semi-structured interviews were used to identify overdose prevention behaviors among people who inject drugs in rural Appalachia. A quantitative survey was used to examine the relationship between risk environment determinants and overdose prevention behaviors utilization among people who inject drugs in rural Appalachia. Results: Results of primary data collection showed that people who inject drugs in rural Appalachia do utilize overdose prevention behaviors, including several drug checking methods and safe use behaviors. However, environmental barriers and disparities among people who inject drugs in rural Appalachia were highlighted in this research. Potential relationships exist between environmental determinants and the utilization of some overdose prevention behaviors. Conclusion: This research found the need for several policy and community program implications which all stem from the War on Drugs. Results highlighted the need for systems level change regarding the care for people who inject drugs, which includes the necessity for policy makers to consider harm reduction methods to reduce overdose mortality among people who live in rural Appalachia.

With the rise of accidental fentanyl overdoses and recreational opioid use in college-aged populations, the need for campus-based overdose prevention and harm reduction measures is at an all-time high. Naloxone, an opioid antagonist, is an FDA-approved, lifesaving, medication which can be intranasally delivered by laypersons. Naloxone reverses opioid overdose, essentially buying time until an overdosing individual receives emergency medical attention. While some previous studies have examined access to naloxone on college campuses, to my knowledge no study has explored distribution of naloxone in residential college areas, such as dormitories and within Greek housing. Therefore, the purpose of this thesis was to identify themes in student perception surrounding naloxone, as well as potential processes and barriers/facilitators to naloxone distribution within residential areas (e.g., dormitories, sorority housing, and fraternity housing.) This study addresses these issues through qualitative, semi-structured, interviews with a convenience sample of students at the University of Central Florida, with questions informed by the Consolidated Framework for Implementation Research and Proctor et al. implementation outcomes. Seven students (n = 7) participated in the interview, all of whom either had personal experience with substance use disorder (SUD) or were close to someone with SUD. I analyzed data for themes using a mixed deductive-inductive template analysis approach in Dedoose software. Resulting themes relating to barriers to distribution within residential areas were as follows: lack of knowledge; fear of negative consequences from external parties; desire of administrators to maintain image of a “drug free campus”; lack of funding for distribution; student desire to avoid stigmatization. Resulting themes relating to facilitators to distribution in residential areas included the following: active involvement of peers; providing free naloxone; educating students about where to get and how to use naloxone; physical accessibility; and anonymous ways to access naloxone. Targeting residential areas for naloxone distribution was also discussed as a theme. Types of people who could/should be involved in naloxone distribution included the following: residential assistants; secondary distributors; pharmacists; UCF leadership; sorority and fraternity leaders; and student liaisons. Study results could be used to inform efforts at UCF and other colleges to expand naloxone access.

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.

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...