Improve Links to Treatment for People who Experience Non-Lethal Overdoses or Naloxone Revivals

Introductory Paragraph

The National Survey on Drug Use and Health reports that 4 out 5 Americans with a SUD do not receive proper treatment, despite a decades-long epidemic. Drug overdose is one of the leading causes of death for those with a SUD, and those who experience at least one non-fatal overdose have a heavy increase of dying from a subsequent overdose. The treatment community has a powerful role to play in reversing these negative statistics. It can encourage providers, clinicians, and insurance agencies to learn about the impacts of overdose and the benefits of prevention, treatment, and harm reduction. Likewise, treatment providers can help to expand access to and education about Naloxone, even if the patient doesn’t have a current opioid prescription. This article builds upon the SAFE Solutions article on harm reduction titled "Increase Access to Overdose Reversal Medications."

Key Information

Social Impact of Overdose

Non-lethal overdoses and substance use disorders come at a great social cost when left ineffectively treated. Community consequences include productivity losses and healthcare and treatment costs and incarceration costs. Approximately 65% of inmates qualify as having a substance use disorder. Communities that employ various harm reduction services, such as access to Naloxone, Fentanyl testing strips, syringe service programs (SSP), mental health services, and MAT see improvements that impact the individual and the community as a whole. Benefits of access to treatment for nonlethal overdose include:

• Health seeking behaviors - access to a SSP has shown a five-fold increase in the number of people seeking treatment for their SUD.
• Cost benefit - SUD treatment is cheaper than incarceration, with every $1 spent on treatment saving $4 in health care costs.
• Improvement in job performance - Ohio programs saw 91% decrease in absenteeism).

The opioid epidemic is being made considerably more dangerous with the spike in Fentanyl-related overdoses. It is a highly addictive pain medication, and it is commonly added to other drugs to enhance potency and decrease costs. The addition of Fentanyl is made even more deadly because it is often added to illicit drugs without the consumer being aware, and just a small amount can trigger an overdose. It is virtually undetectable to the unsuspecting user, as it can not be seen, tasted, or smelled.

Risk Factors for Overdose

In order to provide comprehensive, effective treatment options, it is critical for clinicians and community leaders to be aware of risk factors surrounding non-lethal overdoses. The following have been linked to increasing the risk of a person experiencing a non-lethal overdose:

• Recent release from prison or hospital, with heightened risk periods for non-lethal overdose including the day of admission to prison and 1-4 weeks after release from prison
• 1-2 weeks after hospital discharge
• being dispensed opioids or Benzodiazepines for pain
• 3 or more weeks after discontinuation of antipsychotics
• Polysubstance use of Benzodiazepine and opioids, decreasing the efficacy of Naloxone
• Use of opioids for long-term pain management
• Rotating opioid medication regimens (incomplete cross-tolerance)
• History of SUD or prescription misuse and need for pain relief medication
• Completion of detoxification or abstinence (reduced tolerance & high risk of return to use)

Types of Treatment for Overdose

Recognizing the signs of an overdose is the first critical step to treatment and prevention of it becoming lethal. Signs of an overdose that everyone should be aware of include:

• unconsciousness
• very small pupils
• slow or shallow breathing
• vomiting
• inability to speak
• faint heartbeat
• limp arms and legs
• pale skin
• purple lips and fingernails

If an overdose is suspected, call 911 immediately; administer Naloxone if available; move the person to their side and remain with them; and administer CPR if necessary until a first responder arrives. Naloxone is an opioid antagonist which rapidly reverses the symptoms of an opioid overdose by quickly restoring normal breathing. It is important to note that Naloxone is a treatment for opioid overdose and NOT for opioid use disorder. It is available as an injection or a nasal spray and can be administered by first responders, family, and friends. Co-prescription of Naloxone and opioids has been shown in some research to reduce the risk of overdose, even if the Naloxone prescription doesn’t get filled, indicating that its prescription serves as an effective educational strategy.

Once the emergency of the overdose has passed, the individual is at an increased risk of subsequent overdosing, making the discharge period a critical time for an intervention. Comprehensive treatment addresses many physical and mental health implications of nonlethal overdose. Treatment may look different for each individual, including the following:

• MAT is clinically effective in treating substance use. For alcohol use disorder, common medications include Disulfiram, Naltrexone, and Acamprosate. FDA-approved options for opioid addiction include Methadone, Buprenorphine, and Naltrexone. The use of MAT has been shown to decrease opioid cravings and “help to sever the ties between opioid use and established situational or emotional triggers.” MAT has been clinically found to be the safest option for treating opioid use disorder, therefore access is vital.
• Behavioral Therapy in Conjunction with MAT targets the broad range of issues and problems that medication doesn’t address, and addresses the “limitations associated with each form of medication.” The combination of behavioral therapy and medication is appropriate for individuals whose drug use is the result of extenuating factors such as stress, trauma, resource insecurity, etc., and is seen as an effective addition for those with comorbidities.
• Individual and Group Substance Use Treatment Therapy. Targeted group therapy provides support, witness to recovery, education, resources, accountability, stability, and a model of appropriate behavior. Individual and family therapies have been shown to reduce use, promote prosocial behaviors, and improve family functioning.
• Harm Reduction Services. The CDC reports that providing access to evidence-based harm reduction services such as Naloxone, 911, Good Samaritan Laws, SSPs, and MAT can greatly reduce future overdoses.

Relevant Research

• This study found a demographic shift in overdose populations. Nonlethal overdose had primarily been seen in the non-Hispanic white community. However, the epidemic has broadened, and non-Hispanic Black men have seen the highest increase in opioid overdoses. At the time of the study, there was no difference in the likelihood of nonlethal overdose between non-Hispanic White or Black men. This suggests a marked need to address the causes of this change and treatment implementation.

• This article examines the unintended effects of drug-reducing policies designed to tackle the opioid epidemic by inhibiting the practice of over-prescribing. Research revealed a reduction in misuse of prescription drugs, but it also found an increase in opioid deaths related to the illicit drug market, suggesting that those who had their prescriptions restricted sought out drugs from an illegal third party.

• This article documents the efficacy of the OdRi Questionnaire that assesses risk factors for an overdose to be used in the medical and mental health fields. The tool shows promise in identifying those at risk for an overdose based upon key components addressing personal, situational, and organizational factors. Results showed mental health, specifically depression, to be a positive predictor of overdoses, along with early-life trauma and stress. Lack of treatment for illicit drug use was a positive predictor for overdoses.

Impactful Federal, State, and Local Policies

Policy progress is being made at the federal level. An ACA Medicaid expansion now allows those leaving incarceration to have Medicaid coverage, expanding their access to MAT and other treatment options upon release from jail or prison. The Centers for Medicare & Medicaid Services has been working toward federal implementation of PDMPs for prescriptions under Medicare’s Part D plan. However, outpatient Methadone treatment can only be used when the patient is enrolled in a state or federally certified opioid treatment program which usually requires a daily visit.

Most states have also made considerable progress in the policy domain. However, there is substantial variability in state policies. For example, every state provides ‘’criminal liability’’ protections for first responders and laypersons who administer Naloxone, but 46 states & D.C. provide ‘’civil liability’’ protections, 37 states offer’’ criminal liability’’ protections, and 41 offer ‘’civil liability’’ protections for prescribing or distributing Naloxone. Likewise, 47 states plus D.C. have some form of Good Samaritan Law, but Wyoming, Kansas & Texas do not. Finally, requirements for reporting of non-fatal overdoses vary from state-to-state.

Available Tools and Resources

• SAMHSA has developed the “Opioid Overdose Prevention Toolkit” which provides steps for first responders, information for prescribers, safety advice for patients and family, and information on recovering from an opioid overdose. It also provides a state-by-state directory of opioid treatment programs. SAMHSA also has a resource for drug-free workplace on policies, testing, employee help and education, supervisor training, and program implementation. Its goal is to assist employers and employees in working towards treating/preventing drug misuse and improve testing that will help with gainful employment rather than punitive termination.

• The CDC has published “Evidence-Based Strategies for Preventing Opioid Overdose: What’s Working in the United States.” CDC manages the DOSE program which provides a national dashboard on trends of drug overdoses.

• The Rhode Island Department of Health has published a “Master List of Evidence-Based and Innovative Interventions for Drug Overdose Prevention,” covering the pillars of prevention, rescue, treatment, and recovery.

• Warm Handoffs offers a wide range of resources for the overdose survivor to help prevent future overdoses and negative health outcomes. This is a cross-disciplinary effort involving medical and health care professionals, law enforcement, and social workers. Successful warm handoff interventions have included provision of Naloxone, post-overdose outreach and follow-up, and emergency department-based screening and referral.

• CHESS Health provides E-Recovery and mobile health connections to support people with opioid use disorder and to promote positive behavioral change.

Promising Practices

Florida’s PDMP is coupled with the implementation of regulated pain clinics and a ban on providers from giving prescription opioids in their offices. This effort resulted in a 50% decrease in overdose deaths.