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• W2963005590 abstract "Overcoming barriers to the broad implementation of evidence-based interventions that reduce overdose deaths, including take-home naloxone, opioid agonist therapy and overdose prevention sites, is necessary to maximize their impact. Using a sophisticated mathematical simulation model, Irvine et al. 1 demonstrate the ecological fallacy of the conventional wisdom that the surge in opioid overdose deaths in North America is proof that harm reduction-based interventions are ineffective. Rather, their results suggest that the surge in deaths is a secular disaster brought on by a dramatic change in the illicit opioid supply; namely, the introduction of fentanyl. Combining a valid model framework with regional data that include evidence for take-home naloxone (THN), overdose prevention sites (OPS) and opioid agonist therapies (OAT), they show how much worse the overdose epidemic would have been if not for these interventions. Scale-up and implementation of these three interventions in the year following the declaration of a public health emergency averted more than 60% of the deaths that would have occurred in their absence. Although all models are constrained by their assumptions and data, the Bayesian framework used in this analysis limits and more accurately quantifies the uncertainty such that the authors provide us with a reasonable roadmap. If, however, we are to consistently and substantially reduce overdose deaths, we first need to confront and address the most significant barriers—misinformation, bias and political roadblocks—that prevent full implementation of all these interventions. First, it is crucial to address misinformation about the opioid epidemic, some of which surrounds naloxone. Naloxone is an opioid antagonist that can prevent death by reversing an opioid overdose. Overdose education and naloxone distribution (OEND) programs such as THN have proved efficacious at reducing overdose deaths in North America and Europe 2-4. Despite this, there remain concerns that distribution may encourage illicit opioid use and paradoxically increase the number of overdoses 5. This misconception is driven partly by lack of knowledge, but more so by studies that use questionable methods and draw unsupported conclusions 6. Given that THN alone averted more than 1500 deaths in this analysis—more than either OPS or OAT alone—efforts are needed to target misinformation about the use and distribution of naloxone. Furthermore, this analysis demonstrates the importance of OAT (methadone and buprenorphine): 600 deaths were averted by OAT alone and 2630 when combined with THN. Although many factors hinder the expansion of OAT, notable among them is bias. While there is little controversy that opioid use disorder (OUD) should be treated with medications, there remains controversy—at least in the United States—concerning the type of medication that should be used. Among the three Food and Drug Administration (FDA)-approved medications to treat OUD, naltrexone is favored by a range of institutions and patient support groups, primarily because it is not an opioid 7. A common belief is that by using OAT an individual is ‘replacing one opioid with another’. Such beliefs are likely to be connected to particular views about the meaning of abstinence and the effects of OAT; yet ‘abstinence’ is defined by the American Society of Addiction Medicine as ‘intentional and consistent restraint from the pathological pursuit of reward and/or relief that involves the use of substances and other behaviors’. Therefore, abstinence from illicit opioids can occur while an individual receives OAT. Expansion of OAT will continue to be limited until we address bias against it. Treatment is only effective if we meet people where they are, which means ensuring that their opportunity to receive medications are not hampered by biased beliefs. Additionally, there are political roadblocks that hinder full implementation of these interventions; most notable are those that surround OPS. Also known as safe consumption sites or supervised injection facilities, these are facilities where individuals can consume pre-obtained drugs while being monitored for signs of overdose. They have demonstrated efficacy at preventing overdose deaths, linking people to addiction treatment and increasing screening and linkage for transmissible infections (e.g. HIV) 8, 9. Several US municipalities have advocated for OPS, but political opposition at all governmental levels has so far impeded implementation. The authors demonstrate that, in isolation, OPS accounted for 5% of the deaths averted, but their value is in their synergy with the other interventions. OPS are a crucial element in averting overdose deaths. Political roadblocks to their implementation diminish our ability to realize the full impact of all of these interventions. Finally, underlying and perpetuating these barriers is the criminalization of drug use, which is a form of structural stigmatization of the disease of addiction. By criminalizing and, therefore, stigmatizing the disease, we perpetuate a cycle that breeds misinformation, limits medication availability and allows for political roadblocks to effective interventions. All this undermines a person's path to sustained recovery. In conclusion, Irvine et al. provide us with a roadmap of what works and what is possible with broad implementation of life-saving interventions. Although this process may be complex, costly and, in some cases, met with resistance, each day without full implementation is a missed opportunity to prevent these tragic deaths. None. The author would like to thank Drs Benjamin Linas and Alexander Walley for their thoughtful insight into this manuscript." @default.
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• W2963005590 date "2019-07-19" @default.
• W2963005590 modified "2023-09-27" @default.
• W2963005590 title "Commentary on Irvine et al . (2019): Barriers to implementing a successful roadmap for preventing opioid‐related overdose deaths" @default.
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• W2963005590 doi "https://doi.org/10.1111/add.14738" @default.
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