Opioid overdose prevention and naloxone distribution in Rhode Island.

Michael A. Yokell, ScB, Traci C. Green, MSc, PhD, Sarah Bowman, MPH, Michelle McKenzie, MPH, and Josiah D. Rich, MD, MPH  introduCtion Opioid overdose is a major public health concern that affects a diverse group of individuals across all categories of race, class, and geography. Overdose is the leading cause of adult accidental death in Rhode Island, making our state one of only 16 where overdose mortality exceeds that of motor vehicle accidents. Drug-related deaths, of which overdose is the largest component, claimed the lives of 193 Rhode Islanders in 2008. Opioid overdose (OD) occurs when opioids bind receptors in the brain stem, diminishing sensitivity to carbon dioxide and ultimately resulting in respiratory failure. Naloxone Hydrochloride (brand name Narcan) is an opioid antagonist capable of reversing overdose due to opioids, such as heroin or prescription opioids. Naloxone has no potential for abuse; its only major contraindication, allergic reaction to prior administration, is rare. For more than three decades, emergency medical personnel have administered naloxone as a standard pre-hospital treatment for opioid overdose. Naloxone has been available, by prescription, to at-risk drug users and their family/friends since 1999 through select programs across the country. A common argument against the provision of naloxone to at-risk injection drug users (IDUs) is that the availability of naloxone will increase their risk behavior. To the contrary, Seal et al. observed a decline in heroin use in participants enrolled in their naloxone (and resuscitation) intervention in San Francisco, with a simultaneous increase in overdose prevention knowledge. In two different studies of drug users in Rhode Island, the majority expressed a willingness to administer naloxone to a peer in the event of an overdose. Evaluations of naloxone interventions in major US cities, including San Francisco, Baltimore, Chicago, and New York, have found a notable increase in overdose knowledge among drug users trained in opioid OD recognition and response, dissemination of this knowledge through peer networks, and successful usage of naloxone by study participants. Massachusetts instituted a statewide pilot OD prevention program in late 2007, which is operated by the Department of Public Health (DPH). The DPH purchases naloxone and distributes it to training centers, monitors the program, and tracks participant enrollment and naloxone use. The medical director has issued a standing order that allows nonmedical personnel to distribute naloxone to trained lay responders in the community without a prescription. In Wilkes County, North Carolina, Project Lazarus began distributing naloxone through physicians in 2010, in collaboration with the state Medical Board. Naloxone is prescribed and distributed by physicians when patients with documented risk factors for overdose are prescribed opioid medications. This paper presents an overview and pilot evaluation of PONI (Preventing Overdose and Naloxone Intervention), the opioid overdose prevention program in Rhode Island.