University of Pittsburgh, Graduate School of Public Health, Department of Behavioral and Community Health Sciences, 6124 Parran Hall, 130 DeSoto Street, Pittsburgh, PA, 15261, USA.
Int J Drug Policy. 2018 May;55:61-69. doi: 10.1016/j.drugpo.2018.02.008. Epub 2018 Mar 20.
Opioid overdose deaths in the US rose dramatically in the past 16 years, creating an urgent national health crisis with no signs of immediate relief. In 2017, the President of the US officially declared the opioid epidemic to be a national emergency and called for additional resources to respond to the crisis. Distributing naloxone to community laypersons and people at high risk for opioid overdose can prevent overdose death, but optimal distribution methods have not yet been pinpointed.
We conducted a sequential exploratory mixed methods design using qualitative data to inform an agent-based model to improve understanding of effective community-based naloxone distribution to laypersons to reverse opioid overdose. The individuals in the model were endowed with cognitive and behavioral variables and accessed naloxone via community sites such as pharmacies, hospitals, and urgent-care centers. We compared overdose deaths over a simulated 6-month period while varying the number of distribution sites (0, 1, and 10) and number of kits given to individuals per visit (1 versus 10). Specifically, we ran thirty simulations for each of thirteen distribution models and report average overdose deaths for each. The baseline comparator was no naloxone distribution. Our simulations explored the effects of distribution through syringe exchange sites with and without secondary distribution, which refers to distribution of naloxone kits by laypersons within their social networks and enables ten additional laypersons to administer naloxone to reverse opioid overdose.
Our baseline model with no naloxone distribution predicted there would be 167.9 deaths in a six month period. A single distribution site, even with 10 kits picked up per visit, decreased overdose deaths by only 8.3% relative to baseline. However, adding secondary distribution through social networks to a single site resulted in 42.5% fewer overdose deaths relative to baseline. That is slightly higher than the 39.9% decrease associated with a tenfold increase in the number of sites, all distributing ten kits but with no secondary distribution. This suggests that, as long as multiple kits are picked up per visit, adding secondary distribution is at least as effective as increasing sites from one to ten. Combining the addition of secondary distribution with an increase in sites from one to ten resulted in a 61.1% drop in deaths relative to the baseline. Adding distribution through a syringe exchange site resulted in a drop of approximately 65% of deaths relative to baseline. In fact, when enabling distribution through a clean-syringe site, the secondary distribution through networks contributed no additional drops in deaths.
Community-based naloxone distribution to reverse opioid overdose may significantly reduce deaths. Optimal distribution methods may include secondary distribution so that the person who picks up naloxone kits can enable others in the community to administer naloxone, as well as targeting naloxone distribution to sites where individuals at high-risk for opioid overdose death are likely to visit, such as syringe-exchange programs. This study design, which paired exploratory qualitative data with agent-based modeling, can be used in other settings seeking to implement and improve naloxone distribution programs.
美国的阿片类药物过量死亡人数在过去 16 年中急剧上升，这构成了一场紧迫的全国性健康危机，且没有迹象表明这种情况会立即得到缓解。2017 年，美国总统正式宣布阿片类药物泛滥为全国性紧急事件，并呼吁提供更多资源来应对这场危机。向社区非专业人员和阿片类药物过量高危人群分发纳洛酮可以预防过量死亡，但尚未确定最佳分发方法。
我们采用序贯探索性混合方法设计，使用定性数据为基于代理的模型提供信息，以提高对向社区非专业人员分发纳洛酮以逆转阿片类药物过量的有效方法的理解。模型中的个体被赋予认知和行为变量，并通过社区场所（如药店、医院和急诊中心）获得纳洛酮。我们比较了在模拟的 6 个月期间因不同的分配地点（0、1 和 10）和每次访问分配的套件数量（1 与 10）而导致的过量死亡人数。具体来说，我们对 13 种分配模型中的每一种进行了三十次模拟，并报告了每种模型的平均过量死亡人数。基线比较器是没有纳洛酮分配。我们的模拟探索了通过带有和不带有二次分配的注射器交换场所进行分配的效果，二次分配是指非专业人员在其社交网络中分发纳洛酮套件，从而使另外 10 名非专业人员能够使用纳洛酮来逆转阿片类药物过量。
我们的基线模型没有纳洛酮分配，预计在六个月内会有 167.9 人死亡。即使每次访问分配 10 个套件，单个分配地点也只能将过量死亡人数减少 8.3%，与基线相比。然而，通过社交网络增加二次分配，与基线相比，过量死亡人数减少了 42.5%。这略高于与增加站点数量（从一个增加到十个）相关的 39.9%的减少，但没有二次分配。这表明，只要每次访问都能领取多个套件，增加分配地点与增加分配地点一样有效。将二次分配与从一个站点增加到十个站点相结合，与基线相比，死亡人数下降了 61.1%。通过注射器交换站点进行分配可使死亡人数减少约 65%，与基线相比。事实上，当通过清洁注射器站点启用分配时，通过网络进行的二次分配并没有导致死亡人数进一步下降。
社区为逆转阿片类药物过量而分发纳洛酮可能会显著降低死亡人数。最佳的分配方法可能包括二次分配，以便领取纳洛酮套件的人可以使社区中的其他人能够使用纳洛酮，并且还可以将纳洛酮分配到高危阿片类药物过量死亡人群可能会去的地方，例如注射器交换计划。这种将探索性定性数据与基于代理的建模相结合的研究设计可用于其他寻求实施和改进纳洛酮分配计划的环境。
