National Drug Research Institute, Curtin University, Melbourne, Victoria, Australia.
Disease Elimination Program, Burnet Institute, Melbourne, Victoria, Australia.
JAMA Netw Open. 2023 Aug 1;6(8):e2327319. doi: 10.1001/jamanetworkopen.2023.27319.
Concerns that take-home naloxone (THN) training may lead to riskier drug use (as a form of overdose risk compensation) remain a substantial barrier to training implementation. However, there was limited good-quality evidence in a systematic review of the association between THN access and subsequent risk compensation behaviors.
To assess whether THN training is associated with changes in overdose risk behaviors, indexed through injecting frequency, in a cohort of people who inject drugs.
DESIGN, SETTING, AND PARTICIPANTS: This cohort study used prospectively collected self-reported behavioral data before and after THN training of participants in The Melbourne Injecting Drug User Cohort Study (SuperMIX). Annual interviews were conducted in and around Melbourne, Victoria, Australia, from 2008 to 2021. SuperMIX participants were adults who regularly injected heroin or methamphetamine in the 6 months preceding their baseline interview. The current study included only people who inject drugs who reported THN training and had participated in at least 1 interview before THN training.
In 2017, the SuperMIX baseline or follow-up survey began asking participants if and when they had received THN training. The first THN training date that was recorded was included as the exposure variable. Subsequent participant interviews were excluded from analysis.
Injecting frequency was the primary outcome and was used as an indicator of overdose risk. Secondary outcomes were opioid injecting frequency, benzodiazepine use frequency, and the proportion of the time drugs were used alone. Fixed-effects generalized linear (Poisson) multilevel modeling was used to estimate the association between THN training and the primary and secondary outcomes. Time-varying covariates included housing status, income, time in study, recent opioid overdose, recent drug treatment, and needle and syringe coverage. Findings were expressed as incidence rate ratios (IRRs) with 95% CIs.
There were 1328 participants (mean [SD] age, 32.4 [9.0] years; 893 men [67.2%]) who completed a baseline interview in the SuperMIX cohort, and 965 participants completed either a baseline or follow-up interview in or after 2017. Of these 965 participants, 390 (40.4%) reported THN training. A total of 189 people who inject drugs had pretraining participant interviews with data on injecting frequency and were included in the final analysis (mean [SD] number of interviews over the study period, 6.2 [2.2]). In fixed-effects regression analyses adjusted for covariates, there was no change in the frequency of injecting (IRR, 0.91; 95% CI, 0.69-1.20; P = .51), opioid injecting (IRR, 0.95; 95% CI, 0.74-1.23; P = .71), benzodiazepine use (IRR, 0.96; 95% CI, 0.69-1.33; P = .80), or the proportion of reported time of using drugs alone (IRR, 1.04; 95% CI, 0.86-1.26; P = .67) before and after THN training.
This cohort study of people who inject drugs found no evidence of an increase in injecting frequency, along with other markers of overdose risk, after THN training and supply. The findings suggest that THN training should not be withheld because of concerns about risk compensation and that advocacy for availability and uptake of THN is required to address unprecedented opioid-associated mortality.
人们仍然担心，将纳洛酮带回家（THN）培训可能会导致更危险的药物使用（作为一种过量风险补偿形式），这仍然是培训实施的一个重大障碍。然而，在一项对 THN 获得与随后的风险补偿行为之间关联的系统评价中，高质量证据有限。
评估 THN 培训是否与接受培训的注射毒品者的过量风险行为的变化相关，该行为通过注射频率来衡量。
设计、地点和参与者：这项队列研究使用前瞻性收集的自我报告行为数据，在墨尔本注射毒品使用者队列研究（SuperMIX）中接受 THN 培训的参与者中进行。每年在澳大利亚维多利亚州墨尔本及其周边地区进行访谈，时间从 2008 年到 2021 年。SuperMIX 参与者是在基线访谈前 6 个月内经常注射海洛因或甲基苯丙胺的成年人。目前的研究仅包括报告接受过 THN 培训且至少参加过一次培训前访谈的注射毒品者。
2017 年，SuperMIX 基线或随访调查开始询问参与者是否接受过 THN 培训以及何时接受过 THN 培训。记录的第一次 THN 培训日期被作为暴露变量。随后的参与者访谈被排除在分析之外。
注射频率是主要结果，用作过量风险的指标。次要结果是阿片类药物注射频率、苯二氮䓬类药物使用频率以及单独使用药物的时间比例。使用固定效应广义线性（泊松）多水平模型来估计 THN 培训与主要和次要结果之间的关联。时间变化的协变量包括住房状况、收入、研究时间、最近的阿片类药物过量、最近的药物治疗以及针和注射器的覆盖率。结果以发病率比（IRR）表示，置信区间为 95%。
在 SuperMIX 队列中，有 1328 名参与者（平均[标准差]年龄，32.4[9.0]岁；893 名男性[67.2%]）完成了基线访谈，其中 965 名参与者完成了基线或 2017 年以后的随访访谈。在这 965 名参与者中，390 名（40.4%）报告接受了 THN 培训。共有 189 名注射毒品者在研究期间进行了预培训参与者访谈，并收集了注射频率数据，这些人被纳入最终分析（研究期间平均[标准差]访谈次数，6.2[2.2]）。在调整了协变量的固定效应回归分析中，注射频率没有变化（IRR，0.91；95%置信区间，0.69-1.20；P=0.51）、阿片类药物注射频率（IRR，0.95；95%置信区间，0.74-1.23；P=0.71）、苯二氮䓬类药物使用频率（IRR，0.96；95%置信区间，0.69-1.33；P=0.80）或单独使用药物的时间比例（IRR，1.04；95%置信区间，0.86-1.26；P=0.67）在 THN 培训前后。
这项对注射毒品者的队列研究发现，在接受 THN 培训和供应后，没有证据表明注射频率以及其他过量风险指标增加。研究结果表明，不应因为担心风险补偿而拒绝提供 THN，需要倡导 THN 的可用性和采用，以解决前所未有的阿片类药物相关死亡问题。
