Opioid overdose reversals using naloxone in New York City by people who use opioids: Implications for public health and overdose harm reduction approaches from a qualitative study

Stephen Parkin; Joanne Neale; Caral Brown; Aimee N.C. Campbell; Felipe Castillo; Jermaine D. Jones; John Strang; Sandra D. Comer

doi:10.1016/j.drugpo.2020.102751

Opioid overdose reversals using naloxone in New York City by people who use opioids: Implications for public health and overdose harm reduction approaches from a qualitative study

Stephen Parkin^*, Joanne Neale, Caral Brown, Aimee N.C. Campbell, Felipe Castillo, Jermaine D. Jones, John Strang, Sandra D. Comer

^*Corresponding author for this work

Research output: Contribution to journal › Article › peer-review

22 Citations (Scopus)

Abstract

Background: Adverse reactions to naloxone, such as withdrawal symptoms and aggression, are widely recognised in the literature by pharmaceutical manufacturers and clinical practitioners as standard reactions of individuals who are physically dependent upon opioid drugs following the reversal of potentially fatal opioid overdose. This paper seeks to provide a differentiated view on reactions to naloxone that may have important implications for public health and harm reduction approaches. Methods: Analyses from a qualitative investigation embedded within a 5-year Randomised Controlled Trial (RCT) examined the risks and benefits of Overdose Education and Naloxone Distribution (OEND) training models (brief or extended training) in various populations of people who use opioids in New York City. The qualitative experiences (obtained through semi-structured interviews) of 46 people who use opioids and who were each involved in the delivery of naloxone, during 56 separate overdose events that occurred throughout 2016–2018, were studied. Situational analysis and inductive content analysis of interview data focused upon overdose reversals in an attempt to provide understandings of the various adverse effects associated with naloxone from their perspective. These analyses were supplemented by data sessions within the research team during which the findings obtained from situational analysis and inductive content analysis were reviewed and complemented by deductive (clinical) appraisals of the various physical and psychological effects associated with the overdose reversals. Results: People who use opioids recognise three distinct and interconnected outcomes that may follow a successful opioid overdose reversal after intramuscular or intranasal administration of naloxone. These outcomes are here termed, (i) ‘rage’ (describing a wide range of angry, hostile and/or aggressive outbursts), (ii) ‘withdrawal symptoms,’ and (iii) ‘not rage, not withdrawal’ (i.e., a wide range of short-lived, ‘harmless’ conditions (such as temporary amnesia, mild emotional outbursts, or physical discomfort) that do not include rage or withdrawal symptoms). Conclusion: Physical and psychological reactions to naloxone should not be understood exclusively as a consequence of acute, opioid-related, withdrawal symptoms. The three distinct and interconnected reversal outcomes identified in this study are considered from a harm reduction policy perspective and are further framed by concepts associated with ‘mediated toxicity’ (i.e., harm triggered by medicine). The overall conclusion is that harm reduction training programmes that are aligned to the policy and practice of take home naloxone may be strengthened by including awareness and training in how to best respond to ‘rage’ associated with overdose reversal following naloxone administration by people who use opioids and other laypersons.

Original language	English
Article number	102751
Journal	International Journal of Drug Policy
Volume	79
DOIs	https://doi.org/10.1016/j.drugpo.2020.102751
Publication status	Published - May 2020

Keywords

Mediated toxicity, harm reduction
Naloxone effects
Opioid overdose reversal
Opioid withdrawal symptoms
Rage
Take home naloxone

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

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10.1016/j.drugpo.2020.102751

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Parkin, S., Neale, J., Brown, C., Campbell, A. N. C., Castillo, F., Jones, J. D., Strang, J., & Comer, S. D. (2020). Opioid overdose reversals using naloxone in New York City by people who use opioids: Implications for public health and overdose harm reduction approaches from a qualitative study. International Journal of Drug Policy, 79, Article 102751. https://doi.org/10.1016/j.drugpo.2020.102751

@article{b1f3cf7d88d04423accfeeaef3e76759,

title = "Opioid overdose reversals using naloxone in New York City by people who use opioids: Implications for public health and overdose harm reduction approaches from a qualitative study",

abstract = "Background: Adverse reactions to naloxone, such as withdrawal symptoms and aggression, are widely recognised in the literature by pharmaceutical manufacturers and clinical practitioners as standard reactions of individuals who are physically dependent upon opioid drugs following the reversal of potentially fatal opioid overdose. This paper seeks to provide a differentiated view on reactions to naloxone that may have important implications for public health and harm reduction approaches. Methods: Analyses from a qualitative investigation embedded within a 5-year Randomised Controlled Trial (RCT) examined the risks and benefits of Overdose Education and Naloxone Distribution (OEND) training models (brief or extended training) in various populations of people who use opioids in New York City. The qualitative experiences (obtained through semi-structured interviews) of 46 people who use opioids and who were each involved in the delivery of naloxone, during 56 separate overdose events that occurred throughout 2016–2018, were studied. Situational analysis and inductive content analysis of interview data focused upon overdose reversals in an attempt to provide understandings of the various adverse effects associated with naloxone from their perspective. These analyses were supplemented by data sessions within the research team during which the findings obtained from situational analysis and inductive content analysis were reviewed and complemented by deductive (clinical) appraisals of the various physical and psychological effects associated with the overdose reversals. Results: People who use opioids recognise three distinct and interconnected outcomes that may follow a successful opioid overdose reversal after intramuscular or intranasal administration of naloxone. These outcomes are here termed, (i) {\textquoteleft}rage{\textquoteright} (describing a wide range of angry, hostile and/or aggressive outbursts), (ii) {\textquoteleft}withdrawal symptoms,{\textquoteright} and (iii) {\textquoteleft}not rage, not withdrawal{\textquoteright} (i.e., a wide range of short-lived, {\textquoteleft}harmless{\textquoteright} conditions (such as temporary amnesia, mild emotional outbursts, or physical discomfort) that do not include rage or withdrawal symptoms). Conclusion: Physical and psychological reactions to naloxone should not be understood exclusively as a consequence of acute, opioid-related, withdrawal symptoms. The three distinct and interconnected reversal outcomes identified in this study are considered from a harm reduction policy perspective and are further framed by concepts associated with {\textquoteleft}mediated toxicity{\textquoteright} (i.e., harm triggered by medicine). The overall conclusion is that harm reduction training programmes that are aligned to the policy and practice of take home naloxone may be strengthened by including awareness and training in how to best respond to {\textquoteleft}rage{\textquoteright} associated with overdose reversal following naloxone administration by people who use opioids and other laypersons.",

keywords = "Mediated toxicity, harm reduction, Naloxone effects, Opioid overdose reversal, Opioid withdrawal symptoms, Rage, Take home naloxone",

author = "Stephen Parkin and Joanne Neale and Caral Brown and Campbell, {Aimee N.C.} and Felipe Castillo and Jones, {Jermaine D.} and John Strang and Comer, {Sandra D.}",

year = "2020",

month = may,

doi = "10.1016/j.drugpo.2020.102751",

language = "English",

volume = "79",

journal = "International Journal of Drug Policy",

issn = "0955-3959",

publisher = "Elsevier",

}

Parkin, S , Neale, J, Brown, C, Campbell, ANC, Castillo, F, Jones, JD, Strang, J & Comer, SD 2020, 'Opioid overdose reversals using naloxone in New York City by people who use opioids: Implications for public health and overdose harm reduction approaches from a qualitative study', International Journal of Drug Policy, vol. 79, 102751. https://doi.org/10.1016/j.drugpo.2020.102751

Opioid overdose reversals using naloxone in New York City by people who use opioids: Implications for public health and overdose harm reduction approaches from a qualitative study. / Parkin, Stephen ; Neale, Joanne; Brown, Caral et al.
In: International Journal of Drug Policy, Vol. 79, 102751, 05.2020.

Research output: Contribution to journal › Article › peer-review

TY - JOUR

T1 - Opioid overdose reversals using naloxone in New York City by people who use opioids

T2 - Implications for public health and overdose harm reduction approaches from a qualitative study

AU - Parkin, Stephen

AU - Neale, Joanne

AU - Brown, Caral

AU - Campbell, Aimee N.C.

AU - Castillo, Felipe

AU - Jones, Jermaine D.

AU - Strang, John

AU - Comer, Sandra D.

PY - 2020/5

Y1 - 2020/5

N2 - Background: Adverse reactions to naloxone, such as withdrawal symptoms and aggression, are widely recognised in the literature by pharmaceutical manufacturers and clinical practitioners as standard reactions of individuals who are physically dependent upon opioid drugs following the reversal of potentially fatal opioid overdose. This paper seeks to provide a differentiated view on reactions to naloxone that may have important implications for public health and harm reduction approaches. Methods: Analyses from a qualitative investigation embedded within a 5-year Randomised Controlled Trial (RCT) examined the risks and benefits of Overdose Education and Naloxone Distribution (OEND) training models (brief or extended training) in various populations of people who use opioids in New York City. The qualitative experiences (obtained through semi-structured interviews) of 46 people who use opioids and who were each involved in the delivery of naloxone, during 56 separate overdose events that occurred throughout 2016–2018, were studied. Situational analysis and inductive content analysis of interview data focused upon overdose reversals in an attempt to provide understandings of the various adverse effects associated with naloxone from their perspective. These analyses were supplemented by data sessions within the research team during which the findings obtained from situational analysis and inductive content analysis were reviewed and complemented by deductive (clinical) appraisals of the various physical and psychological effects associated with the overdose reversals. Results: People who use opioids recognise three distinct and interconnected outcomes that may follow a successful opioid overdose reversal after intramuscular or intranasal administration of naloxone. These outcomes are here termed, (i) ‘rage’ (describing a wide range of angry, hostile and/or aggressive outbursts), (ii) ‘withdrawal symptoms,’ and (iii) ‘not rage, not withdrawal’ (i.e., a wide range of short-lived, ‘harmless’ conditions (such as temporary amnesia, mild emotional outbursts, or physical discomfort) that do not include rage or withdrawal symptoms). Conclusion: Physical and psychological reactions to naloxone should not be understood exclusively as a consequence of acute, opioid-related, withdrawal symptoms. The three distinct and interconnected reversal outcomes identified in this study are considered from a harm reduction policy perspective and are further framed by concepts associated with ‘mediated toxicity’ (i.e., harm triggered by medicine). The overall conclusion is that harm reduction training programmes that are aligned to the policy and practice of take home naloxone may be strengthened by including awareness and training in how to best respond to ‘rage’ associated with overdose reversal following naloxone administration by people who use opioids and other laypersons.

AB - Background: Adverse reactions to naloxone, such as withdrawal symptoms and aggression, are widely recognised in the literature by pharmaceutical manufacturers and clinical practitioners as standard reactions of individuals who are physically dependent upon opioid drugs following the reversal of potentially fatal opioid overdose. This paper seeks to provide a differentiated view on reactions to naloxone that may have important implications for public health and harm reduction approaches. Methods: Analyses from a qualitative investigation embedded within a 5-year Randomised Controlled Trial (RCT) examined the risks and benefits of Overdose Education and Naloxone Distribution (OEND) training models (brief or extended training) in various populations of people who use opioids in New York City. The qualitative experiences (obtained through semi-structured interviews) of 46 people who use opioids and who were each involved in the delivery of naloxone, during 56 separate overdose events that occurred throughout 2016–2018, were studied. Situational analysis and inductive content analysis of interview data focused upon overdose reversals in an attempt to provide understandings of the various adverse effects associated with naloxone from their perspective. These analyses were supplemented by data sessions within the research team during which the findings obtained from situational analysis and inductive content analysis were reviewed and complemented by deductive (clinical) appraisals of the various physical and psychological effects associated with the overdose reversals. Results: People who use opioids recognise three distinct and interconnected outcomes that may follow a successful opioid overdose reversal after intramuscular or intranasal administration of naloxone. These outcomes are here termed, (i) ‘rage’ (describing a wide range of angry, hostile and/or aggressive outbursts), (ii) ‘withdrawal symptoms,’ and (iii) ‘not rage, not withdrawal’ (i.e., a wide range of short-lived, ‘harmless’ conditions (such as temporary amnesia, mild emotional outbursts, or physical discomfort) that do not include rage or withdrawal symptoms). Conclusion: Physical and psychological reactions to naloxone should not be understood exclusively as a consequence of acute, opioid-related, withdrawal symptoms. The three distinct and interconnected reversal outcomes identified in this study are considered from a harm reduction policy perspective and are further framed by concepts associated with ‘mediated toxicity’ (i.e., harm triggered by medicine). The overall conclusion is that harm reduction training programmes that are aligned to the policy and practice of take home naloxone may be strengthened by including awareness and training in how to best respond to ‘rage’ associated with overdose reversal following naloxone administration by people who use opioids and other laypersons.

KW - Mediated toxicity, harm reduction

KW - Naloxone effects

KW - Opioid overdose reversal

KW - Opioid withdrawal symptoms

KW - Rage

KW - Take home naloxone

UR - http://www.scopus.com/inward/record.url?scp=85083200502&partnerID=8YFLogxK

U2 - 10.1016/j.drugpo.2020.102751

DO - 10.1016/j.drugpo.2020.102751

M3 - Article

AN - SCOPUS:85083200502

SN - 0955-3959

VL - 79

JO - International Journal of Drug Policy

JF - International Journal of Drug Policy

M1 - 102751

ER -

Opioid overdose reversals using naloxone in New York City by people who use opioids: Implications for public health and overdose harm reduction approaches from a qualitative study

Abstract

Keywords

UN SDGs

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