Brief overdose education is sufficient for naloxone distribution to opioid users

Highlights

• Comfort with recognition of, response to, and administration of naloxone for an overdose significantly increased after brief education among first-time recipients.

• 96% of participants could identify at least one acceptable action to assess and one acceptable action to care for an opioid overdose.

• Facility with naloxone administration was high across all assessments and significantly increased for intranasal administration after education for first-time recipients.

• First-time recipients (before and after education) and refillers demonstrated a high level of knowledge on the Brief Overdose Recognition and Response Assessment.

Abstract

Background

While drug users are frequently equipped with naloxone for lay opioid overdose reversal, the amount of education needed to ensure knowledge of indications and administration is unknown.

Methods

We administered four instruments, assessing comfort and knowledge around opioid overdose and naloxone administration, to opioid users receiving naloxone for the first time (N = 60) and upon returning for a refill (N = 54) at community distribution programs. Participants completed the instruments prior to receiving naloxone; first-time recipients repeated the instruments immediately after the standardized 5–10 min education.

Results

Comfort with recognition of, response to, and administration of naloxone for an overdose event significantly increased after brief education among first-time recipients (p < 0.05). Knowledge of appropriate responses to opioid overdose was high across all assessments; 96% of participants could identify at least one acceptable action to assess and one acceptable action to care for an opioid overdose. Facility with naloxone administration was high across all assessments and significantly increased for intranasal administration after education for first-time recipients (p < 0.001). First-time recipients (before and after education) and refillers demonstrated a high level of knowledge on the Brief Overdose Recognition and Response Assessment, correctly identifying a mean of 13.7 out of 16 overdose scenarios.

Conclusions

Opioid users seeking naloxone in San Francisco have a high level of baseline knowledge around recognizing and responding to opioid overdose and those returning for refills retain that knowledge. Brief education is sufficient to improve comfort and facility in recognizing and managing overdose.

Introduction

Distribution of naloxone to laypersons is increasingly employed in response to the national epidemic of opioid overdose mortality (Centers for Disease and Prevention, 2012). Naloxone is a short-acting, high affinity opioid antagonist that rapidly reverses the effects of opioids through injection or intranasal administration. Naloxone has no abuse potential and is remarkably safe, with essentially no effects in the absence of opioids (Sporer, 1999). Two decades of experience with naloxone distribution have demonstrated that it can be safely administered by laypersons and high-level observational data suggest that making this medication available to those at risk of experiencing or witnessing an opioid overdose results in community-level reductions in opioid overdose mortality (Walley et al., 2013, Kerr et al., 2009, Barton et al., 2005).

Early naloxone programs dispensed naloxone with brief, sometimes optional, education (Dettmer et al., 2001, Maxwell et al., 2006). As naloxone distribution programs emerged in more formal settings, such as university-based research studies, longer trainings were developed (Seal et al., 2005) and have become standard in selected locations. Some of the 27 states with additional legislative protections for naloxone distribution, such as Maryland, require lengthy trainings that may constitute significant barriers to accessing naloxone (Public Health Law Research, 2014). As the overdose epidemic has expanded to prescription opioid users, many programs, such as those in busy medical clinics, again provide only brief education with naloxone prescriptions, addressing key elements like when and how to utilize naloxone. Multiple studies have demonstrated improved recognition and response to opioid overdose and use of naloxone after educational sessions (Doe-Simkins et al., 2009, Green et al., 2008, Walley et al., 2013, Williams et al., 2014). Recent work has demonstrated similar efficacy of education lasting 13 to 18 min (Jones et al., 2014). In fact, a recent paper from the Massachusetts naloxone program found that untrained respondents who utilized naloxone obtained by others exhibited high levels of competence with the medication (Doe-Simkins et al., 2014). While there is general consensus on the elements of education necessary for naloxone distribution (review of risk factors for, recognition of, and management of overdose, including naloxone administration), there is dramatic variation in practice regarding the duration – from 5 min to 8 h – of that education (Clark et al., 2014).

In San Francisco, the Drug Overdose Prevention and Education Project (DOPE) has been distributing naloxone since 2003, primarily through low-threshold drug services such as syringe access programs, with education lasting 5 to 10 min. We sought to determine if this brief education was sufficient to educate the target population on overdose recognition and management, including naloxone administration.