Improve Links to Treatment for People who Experience Non-Lethal Overdoses or Naloxone Revivals
Of the 39 states that share overdose information with the CDC’s DOSE program, 32 have reported a significant increase in non-lethal drug overdoses (NLDO), with the country as a whole having a 21% monthly increase. Drug overdose, both fatal and non-fatal, are 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 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 .
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; heightened risk periods for non-lethal overdose include:
- the day of admission (to prison)
- weeks 1-4 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; increases the risk of NLDO and decreases the efficacy of naloxone
- Anyone who uses 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)
Personal Impact of Overdose Survival of an overdose has lasting physical, psychological, and personal health implications for the individual that increase in likelihood and severity of each overdose. These include:
- Opioid-Induced Respiratory Depression (OIRD) - most dangerous health consequence; acute respiratory compromise, dizziness, confusion, and ineptness.
- Brain injury - hypoxia-related brain injuries, complications caused by the OIRD
- Hypoxia injuries can contribute to:
- short-term memory loss,
- changes in cognitive and physical functioning,
- increased risk of stroke, mental disorientation,
- loss of bodily movement or lower-extremity paralysis,
- gait changes,
- slow reaction time,
- reduced motor skills,
- kidney failure,
- cardiac complications,
- neurological consequences and seizures,
- nerve damage,
- fluid buildup in lungs and pneumonia, and
- temporary motor paralysis
- Increased risk of comorbid mental illness
- Interruptions in education or career goals
- Family and relationship conflicts
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 loss of $20.8 billion 
- total cost consequence of non-lethal overdose: $72.3 billion (healthcare, treatment, & incarceration costs plus lost productivity cost)
- Increased crime rates - 65% of inmates also qualify as having a substance use disorder.
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 (but are not limited to) :
- very small pupils
- slow or shallow breathing
- inability to speak
- faint heartbeat
- limp arms and legs
- pale skin
- purple lips and fingernails
If an overdose is suspected, 911 needs to be called immediately; administer naloxone if available; remain with the person, moving them to their side; and/or administering CPR is necessary until a first responder arrives.
- Naloxone: an opioid antagonist, naloxone 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 OUD. 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 may look different for each individual.
- Medication-Based Treatment:- clinically effective in treating substance use. FDA-approved options for opioid addiction include methadone, buprenorphine, and naltrexone. For alcohol use disorder, common medications include disulfiram, naltrexone, and acamprosate. The use of MOUD has been shown to decrease opioid cravings and “help to sever the ties between opioid use and established situational or emotional triggers,”. MOUD has been clinically found to be the safest option for treating OUD, therefore access is vital for those with an OUD.
- Behavioral Therapy in Conjunction with Medication-Based Treatment: 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, Syringe Services Programs, academic detailing, and MAT/MOUD can greatly reduce future overdoses (lethal and non-lethal) .
Barriers to Treatment Medication for opioid use disorder (MOUD) has been recognized as a safe and effective treatment option, however, it remains unavailable to most people who need it due to ,:
- delivery and financing issues
- Administrative and legal barriers to medical provider prescription of FDA- approved medications
- moratoriums on mobile van clinic
- State funding for clinics (mobile and brick-and-mortar)
- insurance coverage (public and private)
- social stigma and misunderstanding surrounding MOUD
- varying state and hospital policies on administering MOUD
- Inadequate professional education and training (across disciplines)
- concerns about diverting medications of OUD
Impact of Treatment Treatment for overdose is comprehensive, including many factors that address the physical and mental health implications of NLDO. Areas that employ various harm reduction services, such as providing access to naloxone, fentanyl testing strips, syringe service programs (SSP), mental health services, and MOUD see improvements that impact the individual and the community as a whole,. Benefits of access to treatment for NLDO include:
- Health seeking behaviors - access to a SSP has shown a 5x increase in people seeking treatment for their SUD
- cost-benefits: SUD treatment is cheaper than incarceration; every $1 spent on treatment saves $4 in health care costs
- Improvement in job performance (Ohio programs saw 91% decrease in absenteeism) 
Important Consideration: Increase in Fentanyl-related overdoses, intentional or unintentional 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(illegally) 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 . While reports of fentanyl-related overdoses occur all over the U.S. there is a considerate problem in the mid-north Eastern States, south-eastern states, and California .
- Encourage providers, clinicians, and insurance agencies to learn about the impacts of overdose and the benefits of prevention, treatment, and access to resources.
- Expand access to and education about naloxone, even if the patient doesn’t have a current opioid prescription
- Improve access to time-sensitive resources for at-risk populations (recently incarcerated, prior SUD detox patients, and recently overdosed).
- Increase access to test strips that can detect the presence of fentanyl-laced drugs.
- When studying the effects of drug-reducing policies implemented to tackle the opioid epidemic and inhibit over-prescribing, Byungkyu, et al. (2021) found unintended and potentially harmful consequences of these policy interventions. While there was a reduction in misuse of prescription drugs, 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 .
- Doggui, Adib, and Baldacchino (2021) conducted research on a new tool(OdRi Questionnaire) that assesses risk factors for an overdose to be used in the medical and mental health fields. It has shown promise in identifying those at risk for an overdose (lethal or non-lethal) based on key components addressing the “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 recent and non-lifetime overdoses (17).
- A study was done out of MA to address the rapid increase in NLDO amongst people who use drugs and found a demographic shift. NLDO 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 NLDO of non-Hispanic White or Black men. This suggests a marked need to address the causes of this change and treatment implementation (19).
- Medications for Opioid Use Disorder Save Lives - a multi-agency data report covering the efficacy of MOUD. Chapter 3 targets MOUD in different populations and considerations for each .
Impactful Federal, State, and Local Policies
- Requirements for reporting of non-fatal overdoses vary state-to-state . The Network for Public Health Law provides a state-by-state factsheet for reporting requirements, along with the individual state law codes, sub-regulatory sources, and notes on each. (https://www.networkforphl.org/wp-content/uploads/2020/01/State-Non-Fatal-Overdose-Reporting-Requirements-Fact-Sheet.pdf)
- Every state & D.C. provide criminal liability protections for first responders & laypersons who administer naloxone; 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 ,.
- 47 states plus D.C. have some form of Good Samaritan Overdose Immunity and & Naloxone access law (Wyoming, Kansas & Texas do not). While these laws vary by jurisdiction and need more clarification amongst both citizens and responders, there has been an overall decrease in overdose deaths that data shows are due to an increase in calls from either the person overdosing or a witness, allowing first responders to act quickly ,.
- Many states have implemented prescription drug monitoring programs (PDMPs), electronic databases that track controlled substance prescriptions within the state . This allows providers real-time access to a patient’s prescription history and uses, preventing over-prescribing and curbing misuse. However, there has been a link between these programs and an increase in illegal, illicit drug trade . 37 states have PSMP requirements in place (see resource for comprehensive, interactive map) .
- Federal implementation of PDMPs for prescriptions under Medicair’s Part D plan has been delayed by the Centers for Medicare & Medicaid Services; the projected date is now January 1, 2023, .
- Federal activities that promote harm reducing services to prevent overdoses include :
*Advancing research and demonstrations on innovative harm reduction approaches, * Promoting evidence-based harm reduction services, especially integration in health care delivery, *examining sustainable funding strategies, and *developing educational materials and programs to reduce stigma.
- Outpatient methadone treatment can only be used when the patient is enrolled in a state or federally certified opioid treatment program (i.e. methadone clinics) that usually requires a daily visit .
- An ACA Medicaid expansion now allows those leaving incarceration to have Medicaid coverage, expanding their access to MOUD and other treatment options upon release from jail or prison .
Available Tools and Resources
Oftentimes, there are already great resources in the field that have been developed, but they are not housed in a single place. Please use this section to share information about those resources and drive the reader to that resource. It may be a worksheet, toolkit, fact sheet, framework/model, infographic, new technology, etc. I suggest no more than 5 really good links and a corresponding description for the reader. We also can use this section to highlight some of the great resources and programs at SAFE Project.
- SAMHSA Opioid Overdose Prevention Toolkit - provides facts, steps for first responders, information for prescribers, safety advice for patients and family, and info on recovering from an opioid overdose. (https://store.samhsa.gov/sites/default/files/d7/priv/sma18-4742.pdf).
- Opioid Treatment Program Directory (state-by-state): https://dpt2.samhsa.gov/treatment/
- SAMHSA has a drug-free workplace resource focusing on workplace policies, testing, employee help & education, supervisor training, and program implementation. Its goal is to assist employers & employees in working towards treating/preventing drug misuse and improve testing that will help with gainful employment rather than punitive termination: https://www.samhsa.gov/workplace/resources/drug-free-helpline
- Evidence-Based Strategies for Preventing Opioid Overdose: What’s Working in the United States - This CDC-produced handbook covers which strategies are working and why, and implementation for cross-disciplinaries. https://www.cdc.gov/drugoverdose/pdf/pubs/2018-evidence-based-strategies.pdf
- The Rhode Island Department of Health has put out a “Master List of Evidence-Based and Innovative Interventions for Drug Overdose Prevention,” covering the pillars of prevention, rescue, treatment, and recovery: https://health.ri.gov/publications/guides/MasterListOfEvidenceBasedAndInnovativeInterventionsForDrugOverdosePrevention.pdf
- Prevention Collaboration in Action Toolkit: https://pscollaboration.edc.org (for community collaboration efforts)
- The CDC has highlighted several states with promising PDMP programs . Specifically, Oregon is recognized for not just its successful PDMP implementation, but its use of the Core State Violence and Injury Prevention Program (SVIPP) grant as a whole. To combat their state’s opioid epidemic, the OHA provides a PDMP, data for prior Medicaid Methadone dose history, education and access to laypersons to provide naloxone, and collaborative “physician and allied health care training about safe and effective pain care,” .
- Florida’s PDMP is coupled with the implementation of regulated pain clinics and banning providers from giving prescription opioids in their offices. A 2012 review saw a 50% decrease in overdose deaths .
- The Drug-Free Communities (DFC) Program - a nationwide, collaborative effort led by the ONDCP and CDC; provides funding and support for community coalitions that aim to prevent and reduce youth substance use. The coalition work must use evidence-based frameworks and address the unique community challenges surrounding substance use and overdoses. Annual data has shown a marked decrease in youth substance use.
- Warm Handoffs  - a wide range of resources for the overdose survivor to help prevent future overdoses and negative health outcomes. This is a cross-discipline effort involving medical and health care professionals, law enforcement, and social workers. Successful warm handoff interventions have included:
Emergency department-based screening and referral, Emergency department naloxone provision, and Post-overdose outreach and follow-up
- E-Recovery/mobile health connections by CHESS Health , - provides 24/7 support for people with OUD, promotes positive behavior changes