EXECUTIVE SUMMARY - Florida Department of Health



FATAL OPIOID OVERDOSE SURVEILLANCE REPORTFlorida Q3–Q4, 2018 Drug Overdose Surveillance and Funding Agency:Centers for Disease Control and PreventionGrant No. 1 NU17CE924896-01-00Authors:Jared Jashinsky, PhDEpidemiologistDivision of Emergency Preparedness and Community SupportBureau of Emergency Medical OversightFlorida Department of HealthAlaa SahliSurveillance InternInstitute of Public HealthCollege of Pharmacy and Pharmaceutical SciencesFlorida A&M University (FAMU)GIS Analyst:Dylan CummingsHealth Data and GIS AnalystFlorida Department of HealthDivision of Emergency Preparedness and Community SupportBureau of Emergency Medical OversightDisclaimer:This product is for reference purposes only and is not to be construed as a legal document. Any reliance on the information contained herein is at the user’s own risk. The Florida Department of Health and its agents assume no responsibility for any use of the information contained herein or any loss resulting therefrom.EXECUTIVE SUMMARYBACKGROUNDOpioid overdose rates have increased dramatically since the turn of the century and have continued to rise in recent years. Previous data from the Florida Drug Overdose Surveillance and Epidemiology (FL-DOSE) project reported 1,224 fatal opioid overdoses for the first half of 2018. The same data showed that males, adults ages 35–44, and Whites were most likely to fatally overdose on opioids. Lee, Volusia, and Palm Beach counties previously had the highest rates of fatal opioid overdoses among those reporting. The purpose of this report is to provide current estimates of the number of fatal opioid overdoses in Florida and rates of fatal overdoses across demographic and contextual groups, using data from FL-DOSE.METHODSThe number of fatal overdoses and related data were derived from Florida’s Vital Statistics death records and information provided by Florida medical examiners. Data in this report covered 50 of Florida’s 67 counties, or 74.8 percent of the population. Rates per 100,000 persons were estimated using data from the 2018 United States (U.S.) Census Bureau, 2014–2018 American Community Survey 5-Year Estimates. The population estimates were limited to counties reporting fatal opioid overdose data to FL-DOSE, and most analyses were limited to those ages 10 and older. Demographic information including sex, race and ethnicity, age, education, homelessness, and residence in Florida were collected for all decedents. County death rates were calculated using direct age-adjustment to facilitate comparisons.RESULTSAnalyses suggested these results are reasonably representative of Florida as a whole. Florida experienced 1,164 fatal opioid overdoses in the reporting counties between July and December of 2018, and a fatal opioid overdose rate of 8.59 per 100,000 individuals ages 10 and older. Most fatal overdoses occurred among Florida residents and not those visiting the state. Brevard, Okaloosa, and Palm Beach experienced the highest rates of fatal opioid overdoses. Adults ages 25–34 were the most likely age group to experience a fatal opioid overdose. Those with lower education as well as homeless individuals were at greater risk of fatal opioid overdose. Males were 2.2 times more likely than females and Whites were 3.1 times more likely than non-Whites to experience a fatal opioid overdose.TABLE OF CONTENTS TOC \o "1-3" \h \z \u BACKGROUND PAGEREF _Toc17788947 \h 1METHODS PAGEREF _Toc17788948 \h 2SAMPLE PAGEREF _Toc17788949 \h 2MEASURES PAGEREF _Toc17788950 \h 3Demographics PAGEREF _Toc17788951 \h 3Overdose Characteristics PAGEREF _Toc17788952 \h 4Fatal Opioid Overdose Rates PAGEREF _Toc17788953 \h 4SAMPLE REPRESENTATIVENESS PAGEREF _Toc17788954 \h 5RESULTS PAGEREF _Toc17788955 \h 6DEMOGRAPHICS PAGEREF _Toc17788956 \h 6OVERDOSE CHARACTERISTICS PAGEREF _Toc17788957 \h 7FATAL OPIOID OVERDOSE RATES PAGEREF _Toc17788958 \h 9DISCUSSION PAGEREF _Toc17788959 \h 15REFERENCES PAGEREF _Toc17788960 \h 16BACKGROUNDOpioid overdose rates have increased dramatically since the turn of the century and have continued to rise in recent years.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1056/nejmp1402780","ISSN":"0028-4793","abstract":"In any field, improving performance and accountability depends on having a shared goal that unites the interests and activities of all stakeholders. In health care, however, stakeholders have myriad, often conflicting goals, including access to services, profitability, high quality, cost containment, safety, convenience, patient-centeredness, and satisfaction. Lack of clarity about goals has led to divergent approaches, gaming of the system, and slow progress in performance improvement. Achieving high value for patients must become the overarching goal of health care delivery, with value defined as the health outcomes achieved per dollar spent.(1) This goal is what matters for patients and unites . . .","author":[{"dropping-particle":"","family":"Volkow","given":"Nora D.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Frieden","given":"Thomas R.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hyde","given":"Pamela S.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Cha","given":"Stephen S.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"New England Journal of Medicine","id":"ITEM-1","issue":"22","issued":{"date-parts":[["2014"]]},"page":"2063-2066","title":"Medication-Assisted Therapies — Tackling the Opioid-Overdose Epidemic","type":"article-journal","volume":"370"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1111/ajt.13776","ISSN":"1600-6143","author":[{"dropping-particle":"","family":"Rudd","given":"R A","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Aleshire","given":"N","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Zibbell","given":"J E","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Gladden","given":"R Matthew","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Morbidity and Mortality Weekly Report (MMWR)","id":"ITEM-2","issue":"50","issued":{"date-parts":[["2016"]]},"page":"1378-1382","title":"Increases in Drug and Opioid Overdose Deaths—United States, 2000–2014","type":"article-journal","volume":"64"},"uris":[""]},{"id":"ITEM-3","itemData":{"DOI":"10.2105/AJPH.2014.302367?journalCode=ajph","ISBN":"1545-861X (Electronic)\\r0149-2195 (Linking)","ISSN":"0149-2195","PMID":"28033313","author":[{"dropping-particle":"","family":"Rudd","given":"Rose A","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Seth","given":"Puja","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"David","given":"Felicita","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Scholl","given":"Lawrence","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Morbidity and Mortality Weekly Report (MMWR)","id":"ITEM-3","issue":"50-51","issued":{"date-parts":[["2016"]]},"page":"1445-1452","title":"Increases in Drug and Opioid-Involved Overdose Deaths — United States, 2010–2015","type":"article-journal","volume":"65"},"uris":[""]}],"mendeley":{"formattedCitation":"^1–3","plainTextFormattedCitation":"1–3","previouslyFormattedCitation":"^1–3"},"properties":{"noteIndex":0},"schema":""}1–3 In 2010, opioid analgesic overdose deaths represented 75 percent of all pharmaceutical overdose deaths. While opioid overdoses have been on the rise in general, overdoses from illegally produced fentanyl and synthetic opioid pain relievers are particularly on the rise.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1111/ajt.13776","ISSN":"1600-6143","author":[{"dropping-particle":"","family":"Rudd","given":"R A","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Aleshire","given":"N","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Zibbell","given":"J E","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Gladden","given":"R Matthew","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Morbidity and Mortality Weekly Report (MMWR)","id":"ITEM-1","issue":"50","issued":{"date-parts":[["2016"]]},"page":"1378-1382","title":"Increases in Drug and Opioid Overdose Deaths—United States, 2000–2014","type":"article-journal","volume":"64"},"uris":[""]}],"mendeley":{"formattedCitation":"²","plainTextFormattedCitation":"2","previouslyFormattedCitation":"²"},"properties":{"noteIndex":0},"schema":""}2 Between 2017 and 2018 the opioid overdose death rate decreased by 2 percent nationwide, but still remained high with 46,802 deaths.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"author":[{"dropping-particle":"","family":"Wilson","given":"Nana","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kariisa","given":"Mbabazi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Seth","given":"Puja","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Smith","given":"Herschel","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Davis","given":"Nicole L","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Morbidity and Mortality Weekly Report (MMWR)","id":"ITEM-1","issue":"11","issued":{"date-parts":[["2020"]]},"page":"290-297","title":"Drug and Opioid-Involved Overdose Deaths — United States, 2017–2018","type":"article-journal","volume":"69"},"uris":[""]}],"mendeley":{"formattedCitation":"⁴","plainTextFormattedCitation":"4","previouslyFormattedCitation":"⁴"},"properties":{"noteIndex":0},"schema":""}4 Opioid abusers accumulate 12 times the health care costs of a similar individual who does not abuse opioids.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"author":[{"dropping-particle":"","family":"White","given":"Alan G","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Birnbaum","given":"Howard G","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Mareva","given":"Milena 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compared to lower doses for pain management are more likely to experience both fatal and non-fatal opioid overdoses.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1059/0003-4819-152-2-201001190-00006.Overdose","ISBN":"0003-4819 (Print)\\r1539-3704 (Electronic)","PMID":"20083827","abstract":"Conclusions—Patients receiving higher doses of prescribed opioids are at increased risk of opioid overdose, underscoring the need for close supervision of these patients.","author":[{"dropping-particle":"","family":"Dunn","given":"Kate M","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Saunders","given":"Kathleen W","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rutter","given":"Carolyn M","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Banta-Green","given":"Caleb J","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Merrill","given":"Joseph O","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sullivan","given":"Mark D","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Weisner","given":"Constance M","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Silverberg","given":"Michael J","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Campbell","given":"Cynthia I","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Psaty","given":"Bruce M","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Korff","given":"Michael","non-dropping-particle":"Von","parse-names":false,"suffix":""}],"container-title":"Annals of Internal Medicine","id":"ITEM-1","issue":"2","issued":{"date-parts":[["2010"]]},"page":"85-92","title":"Overdose and prescribed opioids: Associations among chronic non-cancer pain patients","type":"article-journal","volume":"152"},"uris":[""]},{"id":"ITEM-2","itemData":{"author":[{"dropping-particle":"","family":"Bohnert","given":"Amy SB","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Valenstein","given":"Marcia","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bair","given":"Matthew J","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ganoczy","given":"Dara","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"McCarthy","given":"John F","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ilgen","given":"Mark A","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Blow","given":"Frederic C","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Journal of the American Medical Association","id":"ITEM-2","issue":"13","issued":{"date-parts":[["2011"]]},"page":"1315-1321","title":"Association Between Opioid Prescribing Patterns and Opioid Overdose-Related Deaths","type":"article-journal","volume":"305"},"uris":[""]}],"mendeley":{"formattedCitation":"^6,7","plainTextFormattedCitation":"6,7","previouslyFormattedCitation":"^6,7"},"properties":{"noteIndex":0},"schema":""}6,7 These relationships hold even after controlling for demographic and health factors. Previous data from Florida’s opioid overdose surveillance system reported 1,224 fatal opioid overdoses for the first half of 2018. The same data showed that Whites, males, and adults ages 35–44 were most likely to fatally overdose on opioids.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"author":[{"dropping-particle":"","family":"Jashinsky","given":"Jared M","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-1","issued":{"date-parts":[["2019"]]},"number-of-pages":"1-21","publisher-place":"Tallahassee, FL","title":"Fatal Opioid Overdose Surveillance Report: Florida Q1–Q2, 2018","type":"report"},"uris":[""]}],"mendeley":{"formattedCitation":"⁸","plainTextFormattedCitation":"8","previouslyFormattedCitation":"⁸"},"properties":{"noteIndex":0},"schema":""}8 Lee, Volusia, and Palm Beach counties had the highest rates of fatal opioid overdoses among those counties reporting during the first half of 2018.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"author":[{"dropping-particle":"","family":"Jashinsky","given":"Jared M","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-1","issued":{"date-parts":[["2019"]]},"number-of-pages":"1-21","publisher-place":"Tallahassee, FL","title":"Fatal Opioid Overdose Surveillance Report: Florida Q1–Q2, 2018","type":"report"},"uris":[""]}],"mendeley":{"formattedCitation":"⁸","plainTextFormattedCitation":"8","previouslyFormattedCitation":"⁸"},"properties":{"noteIndex":0},"schema":""}8Naloxone is a medication that can reverse the fatal effects of an overdose, such as failed breathing and loss of consciousness.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"","author":[{"dropping-particle":"","family":"Centers for Disease Control and Prevention (CDC)","given":"","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-1","issued":{"date-parts":[["2018"]]},"number-of-pages":"1-6","title":"Using Naloxone to Reverse Opioid Overdose in the Workplace: Information for Employers and Workers","type":"report"},"uris":[""]}],"mendeley":{"formattedCitation":"⁹","plainTextFormattedCitation":"9","previouslyFormattedCitation":"⁹"},"properties":{"noteIndex":0},"schema":""}9 Naloxone has been distributed in many states to medical professionals, and even to lay individuals in some states.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"abstract":"Drug overdose death rates have increased steadily in the United States since 1979. In 2008, a total of 36,450 drug overdose deaths (i.e., unintentional, intentional [suicide or homicide], or undetermined intent) were reported, with prescription opioid analgesics (e.g., oxycodone, hydrocodone, and methadone), cocaine, and heroin the drugs most commonly involved (1). Since the mid-1990s, community-based programs have offered opioid overdose prevention services to persons who use drugs, their families and friends, and service providers. Since 1996, an increasing number of these programs have provided the opioid antagonist naloxone hydrochloride, the treatment of choice to reverse the potentially fatal respiratory depression caused by overdose of heroin and other opioids (2). Naloxone has no effect on non-opioid overdoses (e.g., cocaine, benzodiazepines, or alcohol) (3). In October 2010, the Harm Reduction Coalition, a national advocacy and capacity-building organization, surveyed 50 programs known to distribute naloxone in the United States, to collect data on local program locations, naloxone distribution, and overdose reversals. This report summarizes the findings for the 48 programs that completed the survey and the 188 local programs represented by the responses. Since the first opioid overdose prevention program began distributing naloxone in 1996, the respondent programs reported training and distributing naloxone to 53,032 persons and receiving reports of 10,171 overdose reversals. Providing opioid overdose education and naloxone to persons who use drugs and to persons who might be present at an opioid overdose can help reduce opioid overdose mortality, a rapidly growing public health concern. Overdose is common among persons who use opioids, including heroin users. In a 2002– 2004 study of 329 drug users, 82% said they had used heroin, 64.6% had witnessed a drug overdose, and 34.6% had experienced an unintentional drug overdose (4). In 1996, community-based programs began offering naloxone and other opioid overdose prevention services to persons who use drugs, their families and friends, and service providers (e.g., Corresponding contributor: Eliza Wheeler, wheeler@, 510-444-6969.","author":[{"dropping-particle":"","family":"Wheeler","given":"Eliza","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Davidson","given":"Peter J","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Jones","given":"T Stephen","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Irwin","given":"Kevin S","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"MMWR Morb Mortal Wkly Rep","id":"ITEM-1","issue":"6","issued":{"date-parts":[["2012"]]},"page":"101-105","title":"Community-Based Opioid Overdose Prevention Programs Providing Naloxone — United States, 2010 Drug Overdose Prevention and Education (DOPE) Project, Harm Reduction Coalition, Oakland","type":"article-journal","volume":"61"},"uris":[""]}],"mendeley":{"formattedCitation":"¹⁰","plainTextFormattedCitation":"10","previouslyFormattedCitation":"¹⁰"},"properties":{"noteIndex":0},"schema":""}10 Distributing naloxone and training lay people in its use have been found to effectively reduce fatal opioid overdoses and to be cost effective.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1136/bmj.f174","ISSN":"17561833","abstract":"OBJECTIVE To evaluate the impact of state supported overdose education and nasal naloxone distribution (OEND) programs on rates of opioid related death from overdose and acute care utilization in Massachusetts. DESIGN Interrupted time series analysis of opioid related overdose death and acute care utilization rates from 2002 to 2009 comparing community-year strata with high and low rates of OEND implementation to those with no implementation. SETTING 19 Massachusetts communities (geographically distinct cities and towns) with at least five fatal opioid overdoses in each of the years 2004 to 2006. PARTICIPANTS OEND was implemented among opioid users at risk for overdose, social service agency staff, family, and friends of opioid users. INTERVENTION OEND programs equipped people at risk for overdose and bystanders with nasal naloxone rescue kits and trained them how to prevent, recognize, and respond to an overdose by engaging emergency medical services, providing rescue breathing, and delivering naloxone. MAIN OUTCOME MEASURES Adjusted rate ratios for annual deaths related to opioid overdose and utilization of acute care hospitals. RESULTS Among these communities, OEND programs trained 2912 potential bystanders who reported 327 rescues. Both community-year strata with 1-100 enrollments per 100,000 population (adjusted rate ratio 0.73, 95% confidence interval 0.57 to 0.91) and community-year strata with greater than 100 enrollments per 100,000 population (0.54, 0.39 to 0.76) had significantly reduced adjusted rate ratios compared with communities with no implementation. Differences in rates of acute care hospital utilization were not significant. CONCLUSIONS Opioid overdose death rates were reduced in communities where OEND was implemented. This study provides observational evidence that by training potential bystanders to prevent, recognize, and respond to opioid overdoses, OEND is an effective intervention.","author":[{"dropping-particle":"","family":"Walley","given":"Alexander Y.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Xuan","given":"Ziming","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hackman","given":"H. 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Method: This study adapted an integrated Markov and decision analytic model to Russian cities. The model took a lifetime, societal perspective, relied on published literature, and was calibrated to epidemiologic findings. Results: For each 20% of heroin users reached with naloxone distribution, the model predicted a 13.4% reduction in overdose deaths in the first 5 years and 7.6% over a lifetime; on probabilistic analysis, one death would be prevented for every 89 naloxone kits distributed (95% CI=32-260). Naloxone distribution was cost-effective in all deterministic and probabilistic sensitivity analyses and cost-saving if resulting in a reduction in overdose events. Naloxone distribution increased costs by US$13 (95% CI=US$3-US$32) and QALYs by 0.137 (95% CI=0.022-0.389) for an incremental cost of US$94 per QALY gained (95% CI=US$40-US$325). In a worst-case scenario where overdose was rarely witnessed and naloxone was rarely used, minimally effective, and expensive, the incremental cost was US$1987 per QALY gained. If national expenditures on drug-related HIV, tuberculosis, and criminal justice were applied to heroin users, the incremental cost was US$928 per QALY gained. Conclusions: Naloxone distribution to heroin users for lay overdose reversal is highly likely to reduce overdose deaths in target communities and is robustly cost-effective, even within the constraints of this conservative model. ? 2013 All rights reserved: reproduction in whole or part not permitted.","author":[{"dropping-particle":"","family":"Coffin","given":"Phillip O","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sullivan","given":"Sean D","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Annals of Internal Medicine","id":"ITEM-2","issue":"1","issued":{"date-parts":[["2013"]]},"page":"1-9","title":"Cost-Effectiveness of Distributing Naloxone to Heroin Users for Lay Overdose Reversal","type":"article-journal","volume":"158"},"uris":[""]},{"id":"ITEM-3","itemData":{"DOI":"10.1097/ADM.0000000000000034","ISBN":"0000000000000","ISSN":"19353227","abstract":"Community-based opioid overdose prevention programs (OOPPs) that include the distribution of naloxone have increased in response to alarmingly high overdose rates in recent years. This systematic review describes the current state of the literature on OOPPs, with particular focus on the effectiveness of these programs.We used systematic search criteria to identify relevant articles, which we abstracted and assigned a quality assessment score. Nineteen articles evaluating OOPPs met the search criteria for this systematic review. Principal findings included participant demographics, the number of naloxone administrations, percentage of survival in overdose victims receiving naloxone, post-naloxone administration outcome measures, OOPP characteristics, changes in knowledge pertaining to overdose responses, and barriers to naloxone administration during overdose responses. The current evidence from nonrandomized studies suggests that bystanders (mostly opioid users) can and will use naloxone to reverse opioid overdoses when properly trained, and that this training can be done successfully through OOPPs. Copyright ? 2014 American Society of Addiction Medicine.","author":[{"dropping-particle":"","family":"Clark","given":"Angela K.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wilder","given":"Christine M.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Winstanley","given":"Erin L.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Journal of Addiction Medicine","id":"ITEM-3","issue":"3","issued":{"date-parts":[["2014"]]},"page":"153-163","title":"A Systematic Review of Community Opioid Overdose Prevention and Naloxone Distribution Programs","type":"article-journal","volume":"8"},"uris":[""]}],"mendeley":{"formattedCitation":"^11–13","plainTextFormattedCitation":"11–13","previouslyFormattedCitation":"^11–13"},"properties":{"noteIndex":0},"schema":""}11–13 The World Health Organization and other medical groups recommend expansion of naloxone to lay persons in contact with opioid users and thus in a position to administer during opioid overdoses.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.3109/15563650.2014.968657","ISSN":"15569519","abstract":"noabstact Extract: Drug overdose deaths have increased steadily in the United States (U.S.) since 1979. During the past three decades, drug overdose deaths have tripled. In 2008, the number of unintentional poisoning deaths exceeded the number of motor vehicle deaths for the first time. Of the 38,329 drug overdose deaths in the United States in 2010, 22,134 (60%) were related to pharmaceuticals, with 75% of those deaths involving prescription opioid analgesics. Concomitantly, heroin deaths have risen by 55% between 2000 and 2010. Deaths from use of fentanyl-laced or acetyl fentanyl-laced heroin were reported in multiple states in 2013. In 2012, the Centers for Disease Control characterized opioid overdose deaths as an epidemic. Most of these deaths are preventable. Overdose of opioids, including morphine, oxycodone, hydrocodone, methadone, and fentanyl, cause respiratory depression that can lead to hypoxia and, if untreated, death. The exact neuronal mechanisms by which opioids depress respiration in humans are complex. Opioids reduce the sensitivity of the medullary chemoreceptors to hypercapnia. In addition, opioids depress the ventilatory response to hypoxia. The combined losses of hypercarbic and hypoxic drives deprive the victim of the stimulus to breathe. This results in a disruption of the respiratory pattern with prolongation of inspiration and, at higher doses, reduction of chest wall compliance, decrease in tidal volume, and slowing of respiratory rate and apnea. Naloxone is a medication that displaces the opioid agonist from the mu receptor. Timely administration of naloxone reverses opioid-induced respiratory depression-that is, its primary clinical indication. Naloxone is very effective, inexpensive, and has been used since 1970 in hospitals and by emergency medical systems (EMS) for this purpose. The Food and Drug Administration (FDA) has approved the intravenous, intramuscular, and subcutaneous routes of administration of naloxone for opioid reversal; onset of action is rapid via any of these routes. While not specifically approved by FDA for intranasal administration, multiple scientific studies support this route of administration. Intranasal administration has been routinely used in many pediatric emergency departments for years. Currently in the U.S., naloxone is principally administered in the health care setting, but use by laypersons is becoming more common.","author":[{"dropping-particle":"","family":"Doyon","given":"Suzanne","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Aks","given":"Steven E","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Schaeffer","given":"Scott","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Journal of Medical Toxicology","id":"ITEM-1","issue":"4","issued":{"date-parts":[["2014"]]},"page":"431-434","title":"Expanding Access to Naloxone in the United States","type":"article-journal","volume":"10"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.4324/9781315775425","ISBN":"9781317687399","abstract":"This section of the survey explored a number of areas relating to substance use and abuse including consumption, influencing factors, access to substances and the social context of drug use. Young people were also asked about the substance use of their family members.","author":[{"dropping-particle":"","family":"World Health Organization","given":"","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-2","issued":{"date-parts":[["2014"]]},"number-of-pages":"1-74","publisher-place":"Geneva, Switzerland","title":"Community management of opioid overdose","type":"report"},"uris":[""]}],"mendeley":{"formattedCitation":"^14,15","plainTextFormattedCitation":"14,15","previouslyFormattedCitation":"^14,15"},"properties":{"noteIndex":0},"schema":""}14,15 Of laypeople to whom naloxone is distributed, drug users are the most frequent recipients and have reversed the most opioid overdoses.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"ISSN":"1545-861X","PMID":"26086633","abstract":"Drug overdose deaths in the United States have more than doubled since 1999. During 2013, 43,982 drug overdose deaths (unintentional, intentional [suicide or homicide], or undetermined intent) were reported. Among these, 16,235 (37%) were associated with prescription opioid analgesics (e.g., oxycodone and hydrocodone) and 8,257 (19%) with heroin. For many years, community-based programs have offered opioid overdose prevention services to laypersons who might witness an overdose, including persons who use drugs, their families and friends, and service providers. Since 1996, an increasing number of programs provide laypersons with training and kits containing the opioid antagonist naloxone hydrochloride (naloxone) to reverse the potentially fatal respiratory depression caused by heroin and other opioids. In July 2014, the Harm Reduction Coalition (HRC), a national advocacy and capacity-building organization, surveyed 140 managers of organizations in the United States known to provide naloxone kits to laypersons. Managers at 136 organizations completed the survey, reporting on the amount of naloxone distributed, overdose reversals by bystanders, and other program data for 644 sites that were providing naloxone kits to laypersons as of June 2014. From 1996 through June 2014, surveyed organizations provided naloxone kits to 152,283 laypersons and received reports of 26,463 overdose reversals. Providing opioid overdose training and naloxone kits to laypersons who might witness an opioid overdose can help reduce opioid overdose mortality.","author":[{"dropping-particle":"","family":"Wheeler","given":"Eliza","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Jones","given":"T Stephen","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Gilbert","given":"Michael K","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Davidson","given":"Peter J","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Morbidity and Mortality Weekly Report (MMWR)","id":"ITEM-1","issue":"23","issued":{"date-parts":[["2015"]]},"page":"631-635","title":"Opioid Overdose Prevention Programs Providing Naloxone to Laypersons — United States, 2014","type":"article-journal","volume":"64"},"uris":[""]}],"mendeley":{"formattedCitation":"¹⁶","plainTextFormattedCitation":"16","previouslyFormattedCitation":"¹⁶"},"properties":{"noteIndex":0},"schema":""}16 Increasing distribution of naloxone in Florida would help reduce the number of fatal opioid overdoses in the state. States with naloxone access laws making naloxone available without a prescription experienced reductions in fatal opioid overdoses.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1001/jamainternmed.2019.0272","author":[{"dropping-particle":"","family":"Abouk","given":"Rahi","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Pacula","given":"Rosalie L","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Powell","given":"David","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"JAMA Internal Medicine","id":"ITEM-1","issue":"6","issued":{"date-parts":[["2019"]]},"page":"805-811","title":"Association Between State Laws Facilitating Pharmacy Distribution of Naloxone and Risk of Fatal Overdose","type":"article-journal","volume":"179"},"uris":[""]},{"id":"ITEM-2","itemData":{"author":[{"dropping-particle":"","family":"McClellan","given":"Chandler","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lambdin","given":"Barrot H","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ali","given":"Mir M","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Mutter","given":"Ryan","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Davis","given":"Corey","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wheeler","given":"Eliza","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Pemberton","given":"Michael","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kral","given":"Alex H","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Addictive Behaviors","id":"ITEM-2","issued":{"date-parts":[["2018"]]},"page":"90-95","title":"Opioid-overdose laws association with opioid use and overdose mortality","type":"article-journal","volume":"86"},"uris":[""]}],"mendeley":{"formattedCitation":"^17,18","plainTextFormattedCitation":"17,18","previouslyFormattedCitation":"^17,18"},"properties":{"noteIndex":0},"schema":""}17,18 Florida implemented a naloxone access law starting in 2016.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"author":[{"dropping-particle":"","family":"2019 Florida Statues","given":"","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-1","issued":{"date-parts":[["2019"]]},"number":"381.887","publisher-place":"United States","title":"Emergency treatment for suspected opioid overdose","type":"legislation"},"uris":[""]}],"mendeley":{"formattedCitation":"¹⁹","plainTextFormattedCitation":"19","previouslyFormattedCitation":"¹⁹"},"properties":{"noteIndex":0},"schema":""}19 The Florida Department of Children and Families and the Florida Department of Health are involved in efforts to distribute naloxone for use by first responders and members of the community.The purpose of this report is to provide current estimates of the number of fatal opioid overdoses in Florida with data from the Florida Drug Overdose Surveillance and Epidemiology (FL-DOSE) project. It also presents rates of fatal overdoses across various demographic and contextual groups. Those groups most at risk are identified to characterize the epidemic, as well as highlight those most in need of targeted interventions.METHODSThe methods of this report are outlined below, including details of the sample, representativeness of data, and measures. The number of fatal overdoses and related data were derived from Florida’s Vital Statistics death records and information provided by Florida medical examiners for this surveillance project. Florida Department of Health data abstractors were trained in accurate data abstraction methods and follow specific protocols to promote data accuracy and consistent practices. All analyses were conducted in SAS Enterprise 9.4 by a Florida Department of Health epidemiologist.Data abstracted for the FL-DOSE project must meet the case definition presented in Table 1. Decedents must meet the three criteria to be considered a fatal opioid overdose case: be labeled a drug poisoning death, have an opioid or opiate as a contributing cause of death on the death certificate, and have an opioid or opiate listed as a contributing cause of death on the toxicology report. Table 1: Case Definition for Fatal Opioid Overdose Meets Three CriteriaDeath Certificate ICD-10 CM CODDeath Certificate Contributing CODToxicologyX40: Unintentional drug poisoningX41: Unintentional drug poisoningX42: Unintentional drug poisoningX43: Unintentional drug poisoningX44: Unintentional drug poisoningY10: Undetermined intent drug poisoningY11: Undetermined intent drug poisoningY12: Undetermined intent drug poisoningY13: Undetermined intent drug poisoningY14: Undetermined intent drug poisoningT40.0: Poisoning by opiumT40.1: Poisoning by heroinT40.2: Poisoning by other opioidsT40.3: Poisoning by methadoneT40.4: Poisoning by synthetic narcoticsT40.6: Poisoning by other unspecified narcoticsSubstance class: Opioid or opiateSAMPLEData in this report represent 22 Medical Examiner (ME) Districts covering 50 of Florida’s 67 counties, accounting for 74.8 percent of Florida’s population. A list of all participating ME Districts and their respective counties are in Table 2. The only counties not to participate were Broward, Calhoun, Citrus, Collier, Hendry, Hernando, Indian River, Lake, Lee, Leon, Marion, Martin, Okeechobee, St. Lucie, Sumter, Suwanee, and Wakulla.The total population from the included geographic area, used to calculate rates per 100,000 persons, were estimated using data from the 2014–2018 American Community Survey 5-Year Estimates.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"author":[{"dropping-particle":"","family":"U.S. Census Bureau","given":"","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-1","issued":{"date-parts":[["2018"]]},"title":"Understanding and Using ACS Single-Year and Multiyear Estimates","type":"report"},"uris":[""]}],"mendeley":{"formattedCitation":"²⁰","plainTextFormattedCitation":"20","previouslyFormattedCitation":"²⁰"},"properties":{"noteIndex":0},"schema":""}20 The 2014-2018 5-year estimate was the most up-to-date population and demographic estimates of county level data in Florida. The estimated population of Florida between 2014 and 2018 was 20,598,139; however, for the purpose of these analyses the population estimates were limited to those counties reporting fatal opioid overdose data to FL-DOSE. A total of 15,402,670 individuals were estimated to live in Florida’s reporting counties between 2014 and 2018, and 13,556,979 for those ages 10 years and older.Table 2: Participating Districts and CountiesDistrictCounty 2014–2018 Population1Escambia, Okaloosa, Santa Rosa, and Walton748,5592Franklin, Gadsden, Jefferson, Liberty, and Taylor102,3213Columbia, Dixie, Hamilton, and Lafayette127,0294Clay, Duval, and Nassau1,212,098 6Pasco and Pinellas1,468,4687Volusia527,6348Alachua, Baker, Bradford, Gilchrist, Levy, and Union390,7279Orange1,321,19410Hardee, Highlands, and Polk798,00011Miami-Dade2,715,51612Desoto, Manatee, and Sarasota822,39613Hillsborough1,378,88314Bay, Gulf, Holmes, Jackson, and Washington291,00515Palm Beach1,446,27716Monroe76,32518Brevard576,80821Glades13,36322Charlotte176,95423Flagler, Putnam, St. Johns415,40824Seminole455,08625Osceola338,619MEASURESMeasures were created for a collection of related variables. Variables can be categorized as the decedent demographics, characteristics of the overdose, and fatal opioid overdose rates. The sections below explain how the measures were created.DemographicsDemographic information including sex, race and ethnicity, age, education, homelessness, and residence in Florida were collected for all decedents. Frequencies and percentages of decedents for each category were calculated.Sex was recorded as male or female. Reporting on sexual orientations and the percentages of transgender people was considered, but these data were either missing or unreliable given the focus of medical examiner reports on assigned sex. Racial and ethnic categories were those recommended by the National Institutes of Health.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"URL":"","accessed":{"date-parts":[["2019","8","13"]]},"author":[{"dropping-particle":"","family":"National Institutes of Health","given":"","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"NOT-OD-15-089","id":"ITEM-1","issued":{"date-parts":[["2015"]]},"title":"Racial and Ethnic Categories and Definitions for NIH Diversity Programs and for Other Reporting Purposes","type":"webpage"},"uris":[""]}],"mendeley":{"formattedCitation":"²¹","plainTextFormattedCitation":"21","previouslyFormattedCitation":"²¹"},"properties":{"noteIndex":0},"schema":""}21 People were categorized as White for persons with origins among any of the original peoples of Europe, North Africa, or the Middle East; Black for persons with origins among any of the Black racial groups of Africa; Asian for persons with origins among any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent; American Indian for persons with origins among any of the original people of North America and who maintains cultural identification through tribal affiliation or community recognition (includes Alaska Natives); and Hispanic for persons reporting their ethnicity as Hispanic no matter their reported race. Those with a reported race, but a missing Hispanic status were counted as non-Hispanic. People reporting multiple races were categorized as multiracial. Unknown race/ethnicity was also an option. Age was originally measured in years but was grouped for this report to match reporting by the Centers for Disease Control and Prevention. All analyses excluded anyone below the age of 10, which during this time period was one child 11 months old, unless stated otherwise.Education was originally recorded using census categories, but some groups were collapsed to facilitate in reporting. Education was categorized as less than high school, high school graduate, some college, bachelor’s degree, graduate or professional degree, or unknown. Yes, no, and unknown categories were applied to homelessness, military experience, and Florida residence. Recent release from an institution was coded as yes or no for whether an individual had been admitted to or released from one of the following institutions in the month before death: jail, prison, or a detention facility; hospital; psychiatric hospital, other psychiatric institution; long-term residential health facility (e.g., nursing home); supervised residential facility related to alcohol or substance abuse treatment (e.g., residential treatment facility, sober house or group home); and supervised residential facilities not related to alcohol or substance abuse treatment (e.g., halfway houses or work-release homes). Overdose CharacteristicsA measure was created of whether a decedent fatally abused an opiate from a collection of sources. Decedents were coded for whether they had fatally abused an opiate prescribed to themselves, an unprescribed opiate other than heroin (e.g., illicitly obtained or created), heroin, an opiate prescribed to an intimate partner, an opiate prescribed to a family member, a prescribed opiate from another source, or an opiate from an unknown source. Frequencies and percentages of decedents for each category were calculated. Frequency of the presence of 4-ANPP in all decedents and by drug source was also conducted. Though not found in all illicitly manufactured fentanyl, when 4-ANPP is detected it is a strong indication that fentanyl was illicitly manufactured.Polysubstance drug abuse was tested for each decedent by checking what other substances were listed as a cause of death in addition to opioids, as measured by toxicology testing. Commonly found substances that are not generally overdose related, such as caffeine and nicotine, were excluded from these analyses. The five most common substances are presented in this report. Percentage of all decedents and demographic groups who fatally overdosed on the five substances in addition to opioids were calculated.Institution type was collected for decedents who had recently been released from a treatment center or other institution. Institutions included residential facilities both related and not related to substance abuse treatment; jail, prison, or a detention facility; hospital; psychiatric hospital; or other institution. Frequencies and percentages of decedents for each institution were calculated. Lastly, the location of death for each decedent was recorded. Locations included hospital inpatient, emergency department or clinic, decedent’s home, or other location. Counts for each location were calculated, as well as the percent of decedents who died in each location who were administered naloxone.Fatal Opioid Overdose RatesFatal opioid overdose rates were calculated by age range, sex, and county. County-level overdose rates were directly age-adjusted to facilitate comparisons across counties without concern for differences in ages across counties.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"author":[{"dropping-particle":"","family":"Buescher","given":"Paul A","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-1","issue":"13","issued":{"date-parts":[["2010"]]},"number-of-pages":"1-9","publisher-place":"Raleigh, NC","title":"Statistical Primer: Age-Adjusted Death Rates","type":"report"},"uris":[""]}],"mendeley":{"formattedCitation":"²²","plainTextFormattedCitation":"22","previouslyFormattedCitation":"²²"},"properties":{"noteIndex":0},"schema":""}22 Population estimates for county rates were limited to individuals ages 10 and older to reflect inclusion of decedents ages 10 and older.Fatal opioid overdose rates were calculated by education categories. To more accurately represent the education levels instead of age of a community, only individuals ages 25 and older were included as decedents and in population estimates when calculating rates by education. Missing education values for decedents were proportionally added to the other education category frequencies.Fatal opioid overdose rates were calculated by homelessness status. Population estimates for rates involving homelessness included all ages. A point-in-time estimate of homelessness on January 1st of 2018 was used as the estimate of the Florida population who is homeless on a given day during the second half of 2018.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"author":[{"dropping-particle":"","family":"Nazworth","given":"Shannon","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-1","issued":{"date-parts":[["2018"]]},"number-of-pages":"1-71","publisher-place":"FL","title":"Council on Homelessness: Annual Report","type":"report"},"uris":[""]}],"mendeley":{"formattedCitation":"²³","plainTextFormattedCitation":"23","previouslyFormattedCitation":"²³"},"properties":{"noteIndex":0},"schema":""}23 These point-in-time estimates are likely an underestimate of homelessness, but this effect on calculated relative risk would be mitigated by missing FL-DOSE data on homelessness and lack of representation in all Florida counties. Some data were missing due to FL-DOSE not having record of the decedent’s homelessness status. Most overdoses occur at home, and identifying addresses would be easier than identifying homelessness, so it is likely that the presence of missing homelessness data for decedents would make a relative risk for fatal opioid overdoses more conservative. Lastly, population estimates of homelessness were for all of Florida while overdose numbers were only included from those counties reporting data to FL-DOSE.SAMPLE REPRESENTATIVENESSDemographic differences were assessed between the 50 counties reporting data to FL-DOSE and the entire state of Florida, or what this report would include if all counties were reporting data. Table 3 presents the demographic breakdowns as well as the differences between the reporting counties and the entire state for sex, race/ethnicity, age, and education. All categories of the reporting counties were within one percent of the entire state of Florida except for there was more representation of Hispanic or Latino individuals. Though only 74.8 percent of Florida’s population is included in this report, the demographic similarities suggest it is likely the report’s results are generally representative of the state of Florida with only a slight over representation of Hispanic or Latino individuals. Table 3: Demographic Variables of Reporting Counties and the State of FloridaVariable% of Reporting Counties% of FloridaDifferenceSex Female51.07%51.10%0.03 Male48.93%48.90%-0.03Race/Ethnicity White53.40%54.36%0.96 Hispanic or Latino26.60%25.17%-1.43 Black or African American14.75%15.38%0.63 Asian2.78%2.66%-0.12 American Indian or Alaska Native0.20%0.20%0.00 Pacific Islander0.06%0.05%-0.01 Other0.33%0.33%0.00 Multiracial 1.89%1.84%-0.05Age 10–145.68%5.71%0.03 15–2412.08%12.07%-0.01 25–3413.18%12.94%-0.24 35–4412.18%12.11%-0.07 45–5413.32%13.35%0.03 55–6412.96%13.18%0.22 65–7410.29%10.91%0.62 75–845.84%6.22%0.38 85+2.48%2.60%0.12Education of those 25 and Older Less than high school12.14%12.05%-0.09 High school graduate28.46%28.81%0.35 Some college30.00%29.97%-0.03 Bachelor’s degree18.80%18.53%-0.27 Graduate or professional degree10.60%10.63%0.03RESULTSThe findings of this report are detailed below. Findings are divided into sections for the demographics of decedents, characteristics of the overdoses, and fatal opioid overdose rates.DEMOGRAPHICSThis section details the demographic breakdowns of all opioid overdose decedents in Florida’s reporting counties between July 1, 2018 and December 31, 2018. Frequency and percentage values for all demographic variables are found in Table 4. A majority of fatal opioid overdoses were in males, Whites, and high school graduates. Most fatal overdoses occurred in Florida residents as opposed to those visiting the state.Table 4: Demographic VariablesVariableFrequencyPercentSex Female38132.73% Male78367.27%Race/Ethnicity White90777.92% Hispanic or Latino16514.18% Black or African American736.27% Asian60.52% American Indian or Alaska Native30.26% Multiracial60.52% Unknown40.34%Age 10–1410.09% 15–24786.70% 25–3435730.67% 35–4431126.72% 45–5421418.38% 55–6417615.12% 65–74242.06% 75-8420.17% 85+10.09%Education Less than high school20117.27% High school graduate53846.22% Some college26522.77% Bachelor’s degree796.79% Graduate or professional degree211.80% Unknown605.15%Homelessness Homeless736.27% Not Homeless65256.01% Unknown43937.71%Military Experience Yes736.27% No1,03789.09% Unknown544.64%Florida Residence Resident1,08192.87% Non-resident625.33% Unknown211.80%OVERDOSE CHARACTERISTICScenter713105A large portion of fatal opioid overdoses involves illicit drugs00A large portion of fatal opioid overdoses involves illicit drugsThis section details the characteristics of all fatal opioid overdoses in Florida’s reporting areas between July 1, 2018 and December 31, 2018. Characteristics include abuse of own prescription opioid, polysubstance drug abuse, recent release from institution, and naloxone administration by location.Frequency and the percent of decedents who fatally overdosed on drugs from different sources are presented in Table 5. Including only the substances where the sources were known, only 3.69 percent of decedents fatally overdosed on an opiate prescribed to themselves. A little over half of decedents fatally overdosed on illicit non-prescribed opiates other than heroin. A total of 197 decedents tested positive for 4-ANPP, or 17 percent of the sample. Though not found in all illicitly manufactured fentanyl, when 4-ANPP is detected it is a strong indication that fentanyl was illicitly manufactured. Checking for the percentage of decedents who tested positive for 4-ANPP by source found 21 percent of decedents who fatally overdoses on a non-prescription drug other than heroin, 12 percent of decedents who fatally overdosed on heroin, and 2 percent of those who fatally overdoses on an opiate prescribed to themselves.Table 5: Frequency and Percent of Decedents Who Fatally Overdosed on an Opiate from Different SourcesPrescription TypeFrequencyPercentNon-prescribed drug, other than heroin61652.92%Non-prescribed drug, heroin23920.53%Prescribed to decedent433.69%Intimate Partner00.00%Family (non-intimate partner)10.09%Other30.26%Unknown65155.93%*Percentages do not add to 100% because decedents could exhibit one or more of fatal overdose prescription typesPolysubstance drug abuse was also frequent among decedents. The five most common substances that caused a decedent’s death in addition to opioids were alcohol, amphetamines, antidepressants, benzodiazepines, and cocaine. The percentage of decedents and demographic groups whose deaths were caused by a given substance in addition to opioids can be found in Table 6. Cocaine and benzodiazepines were listed most often as a cause of death in addition to opioids. About half of decedents, 49.23 percent, had at least one of the five substances in Table 6 listed as the cause of death in addition to opioids.While specific numbers are available in Table 6, the following section points out some of the most notable differences in other substances that caused deaths among demographic groups. Females tended to have antidepressants, benzodiazepines, and cocaine listed as an additional cause of death while males were slightly more likely to have alcohol listed. Black individuals in comparison to Whites and Hispanics or Latinos were more likely to have alcohol and cocaine listed as causes of death. Hispanics were more likely to have benzodiazepines listed, but less likely to have amphetamines and antidepressants listed compared to Whites and Blacks. Whites were less likely than Blacks and Hispanics or Latinos to have cocaine listed as an additional cause of death.Those ages 15–24 were the most likely to have benzodiazepines listed as a cause of death, those ages 25–34 were the most likely to have amphetamines and cocaine listed as a cause of death, and those ages 55–64 were the most likely to have alcohol and antidepressants listed as a cause of death. Each group with higher education was more likely to have benzodiazepines listed as a cause of death. Those with a bachelor’s degree were the most likely to have cocaine listed as an additional cause of death.Homeless individuals were more likely to have alcohol, amphetamines, and cocaine listed as an additional cause of death, while those who were not homeless were more likely to have antidepressants and benzodiazepines listed. Those with military experience compared to those who did not were more likely to have benzodiazepines listed as an additional cause of death.Table 6: Percentage of Decedents and Demographic Groups Whose Deaths Were Caused by a Given Substance in Addition to OpioidsSubstance TypeAlcoholAmphetamineAntidepressantBenzodiazepineCocaineAll Decedents 9.97%12.03% 2.23%16.58%24.83%Sex Female 8.66%12.86% 4.46%21.26%28.35% Male10.60%11.62% 1.15%14.30%23.12%Race/Ethnicity White 9.48%12.02% 2.54%15.66%20.84% Hispanic/Latino 8.48% 9.70% 0.61%22.42%38.18% Black17.81%13.70% 2.74%10.96%42.47%Age 15–24 7.69%11.54% 1.28%23.08%21.79% 25–34 9.80%15.41% 0.84%16.53%28.01% 35–4410.93%14.79% 2.25%15.11%24.12% 45–54 9.81% 9.35% 2.80%13.55%23.83% 55–6411.36% 5.11% 5.11%21.02%24.43%Education < HS10.45%14.93% 1.99%10.95%26.37% HS grad 8.92%12.27% 2.04%17.10%23.42% Some college 9.81% 8.30% 2.64%17.36%21.89% Bach. degree12.66%11.39% 1.27%24.05%31.65%Homelessness Homeless16.44%21.92% 0.00% 9.59%34.25% Not homeless 9.66% 9.36% 1.84%18.87%21.93%Military Experience Yes10.96% 9.59% 1.37%23.29%26.03% No 9.64%11.76% 2.22%16.20%23.92%Florida Residence Resident 9.53%14.52% 9.53%14.52% 9.53% Non-resident11.93%11.29%11.93%11.29%11.93%Data showed that 7.69 percent of decedents were recently released from some institution (e.g., detention facility, hospital, residential facility). Table 7 details the percentage of decedents released from the most common institutions among the 82 decedents who had recently been released.Table 7: Most Common Institutions from which Decedents were Recently Released Institution TypeFrequencyPercentHospitalJail, prison, or a detention facilitySupervised residential facility related to alcohol or substance abuse treatmentSupervised residential facilities not related to alcohol or substance abuse treatment292818335.37%34.15%21.95%3.66% Other institution44.88%After the overdose, decedents were most likely to have died in their own home, at an emergency department or outpatient facility, or at a hospital. Naloxone was administered to 15.25 percent of all decedents. These deaths could stem from cases where the drug was administered too late, multiple drugs were in their system, or an insufficient dose was given. Table 8 shows the percent of naloxone administration by most common location of death.Table 8: Percent of Naloxone Administration by Most Common Locations of Death Death LocationTotal DecedentsNaloxone AdministeredHospital inpatient9229.35%ED/Outpatient18148.33%Decedent’s home5655.14%Dead on arrival633.33%Hospice facility812.50%Other2649.50%FATAL OPIOID OVERDOSE RATESFlorida experienced 1,164 fatal opioid overdoses in the reporting counties between July and December of 2018. A total of 8.59 per 100,000 individuals ages 10 and older died of opioid overdoses in the reporting counties during these six months. This section shares fatal opioid overdose count and rates by categories of interest: county, sex, age, education, race/ethnicity, and homelessness.84109956881,164 fatal opioid overdoses in Florida’s reporting counties between July and December of 2018001,164 fatal opioid overdoses in Florida’s reporting counties between July and December of 2018Age-adjusted fatal opioid overdose rates in all reporting Florida counties can be found in Table 9 and Figure 1. Eight counties experienced an age-adjusted fatal opioid overdose rate greater than 10 per 100,000. In descending order, they were Brevard, Okaloosa, Palm Beach, Duval, Clay, Osceola, Pinellas, and Volusia counties. Fatal opioid overdose rates based on counts of less than 16 were suppressed to avoid interpreting unstable rates.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"URL":"","accessed":{"date-parts":[["2020","12","20"]]},"author":[{"dropping-particle":"","family":"Centers for Disease Control and Prevention (CDC)","given":"","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-1","issued":{"date-parts":[["2020"]]},"title":"Suppression of Rates and Counts","type":"webpage"},"uris":[""]}],"mendeley":{"formattedCitation":"²⁴","plainTextFormattedCitation":"24","previouslyFormattedCitation":"²⁴"},"properties":{"noteIndex":0},"schema":""}24 Fatal opioid overdose rates by age ranges among people ages 10 and older are presented in Figure 2. During these months, people ages 25–34 had the highest death rate of 17.59 deaths per 100,000. Narrowing in more specifically, people ages 30–34 had the highest death rate with 20.31 deaths per 100,000. Fatal opioid overdose rates for males and females ages 10 and older are presented in Figure 3. During these months, males and females had 10.39 and 4.84 fatal opioid overdoses respectively per 100,000. Males were 2.15 times more likely than females to fatally overdose on opioids.Fatal opioid overdose rates by education groups among people ages 25 and older are presented in Figure 4. High school graduates were the most at-risk for fatal opioid overdose with 17.31 deaths per 100,000 people ages 25 and older over the six months. A dose response was observed with more education being related to less risk of fatal opioid overdose. The only exception was those with less than a high school degree were less likely to fatally overdose than those with a high school degree. It is possible that this anomaly is due to more older individuals not having graduated from high school, with older age being related to lower opioid overdose risk. Fatal opioid overdose rates by race and ethnicity among people of all ages are presented in Figure 5. Whites were the most at risk of fatal opioid overdose with 11.03 deaths per 100,000 individuals over the six months. Whites were 3.08 times more likely than all other race and ethnicities to experience a fatal opioid overdose.A very small percentage of Florida residents are estimated to be homeless. It is estimated that 0.14 percent of Florida residents were homeless on January 1 of 2018, or 29,717 individuals.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"author":[{"dropping-particle":"","family":"Nazworth","given":"Shannon","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-1","issued":{"date-parts":[["2018"]]},"number-of-pages":"1-71","publisher-place":"FL","title":"Council on Homelessness: Annual Report","type":"report"},"uris":[""]}],"mendeley":{"formattedCitation":"²³","plainTextFormattedCitation":"23","previouslyFormattedCitation":"²³"},"properties":{"noteIndex":0},"schema":""}23 However, this group has a much larger risk of fatal opioid overdose. Homeless individuals were well over 10 times more likely to experience a fatal opioid overdose compared to non-homeless individuals.Table 9: Fatal Opioid Overdose Rates Per 100,000 People Ages 10+ by County, July–December 2018 CountyCountRawAge-AdjustedCountyCount RawAge-AdjustedAlachua4 * *Lee–– –Baker1 * *Leon–– –Bay14 * *Levy1* *Bradford1 * *Liberty00.00 0.00Brevard10419.9222.19Madison00.00 0.00Broward– –?? –??Manatee247.167.97Calhoun– – –Marion–– –??Charlotte3 * *Martin–– –??Citrus– –?? –??Miami-Dade953.943.69Clay2111.5811.38Monroe4* *Collier– – –Nassau5* *Columbia6 * *Okaloosa2916.5815.52DeSoto1 * *Okeechobee––?? –??Dixie00.000.00Orange11910.289.33Duval13016.1915.20Osceola3511.9011.17Escambia2810.189.72Palm Beach18314.1315.21Flagler4 * *Pasco347.467.63Franklin00.000.00Pinellas9210.5611.16Gadsden00.000.00Polk223.743.84Gilchrist00.000.00Putnam1* *Glades00.000.00Santa Rosa4* *Gulf00.000.00Sarasota207.327.90Hamilton00.000.00Seminole7* *Hardee00.000.00St. Johns7* *Hendry– – –St. Lucie–– –Hernando– –?? –??Sumter–– –Highlands1 * *Suwannee–– –Hillsborough1099.058.30Taylor0 0.00 0.00Holmes1 * *Union1* *Indian River– –?? –??Volusia469.6410.59Jackson00.000.00Wakulla–– –Jefferson00.000.00Walton4* *Lafayette00.000.00Washington00.000.00Lake– – –??‘–‘ signifies no data reported by county; ‘ * ’ signifies a suppressed rate due to insufficient case counts (i.e., <16) Figure 1: Age-Adjusted Fatal Opioid Overdose Rates per 100,000 People Ages 10+ by County, July–December 2018Figure 2: Fatal Opioid Overdose Rate by Age in Years; People Ages 10+; Florida’s Reporting Counties; July–December 20188096252040255* *00* *46577252049780* *00* *Figure 3: Fatal Opioid Overdose Rate by Sex; People Ages 10+; Florida’s Reporting Counties; July–December 2018Figure 4: Fatal Opioid Overdose Rate by Education; Adults 25+; Florida’s Reporting Counties; July–December 2018Figure 5: Fatal Opioid Overdose Rate by Racial/Ethnic Groups; All Ages; Florida’s Reporting Counties; July–December 201835331401884045 * * *00 * * *DISCUSSIONThough not all Florida’s population is included in this report, the demographic similarities of the sample suggest it is likely the report’s results are generally representative of the state of Florida. The section below identifies the most salient points of the report and discusses areas of particular opportunity for the state. Florida experienced 1,164 fatal opioid overdoses in the reporting counties between July and December of 2018. Florida experienced 8.6 deaths per 100,000 individuals ages 10 and older during these months. Combining this death rate with that observed during the first half of the year found that Florida experienced 16.9 fatal opioid overdoses per 100,000 population in 2018.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"author":[{"dropping-particle":"","family":"Jashinsky","given":"Jared M","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-1","issued":{"date-parts":[["2019"]]},"number-of-pages":"1-21","publisher-place":"Tallahassee, FL","title":"Fatal Opioid Overdose Surveillance Report: Florida Q1–Q2, 2018","type":"report"},"uris":[""]}],"mendeley":{"formattedCitation":"⁸","plainTextFormattedCitation":"8","previouslyFormattedCitation":"⁸"},"properties":{"noteIndex":0},"schema":""}8 The 16.9 overdoses per 100,000 is only slightly higher than the national average of 14.6 per 100,000.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"author":[{"dropping-particle":"","family":"Kaiser Family Foundation","given":"","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"State Health Facts","id":"ITEM-1","issued":{"date-parts":[["217"]]},"title":"Opioid Overdose Death Rates and All Drug Overdose Death Rates Per 100,000 Population (Age-Adjusted)","type":"webpage"},"uris":["",""]}],"mendeley":{"formattedCitation":"²⁵","plainTextFormattedCitation":"25","previouslyFormattedCitation":"²⁵"},"properties":{"noteIndex":0},"schema":""}25 Though Florida does not have as large of a problem per population as many states, Florida as the third most populous state in the U.S. represents a large proportion of the opioid epidemic in the U.S.The most affected counties in Florida experienced significant age-adjusted fatal opioid overdose rates. During all of 2018 Brevard, Palm Beach, and Duval counties had the highest age-adjusted opioid overdose rates in Florida. These county rates are similar to the rates for some of the most affected U.S. states (e.g., Maryland at fifth, Massachusetts at seventh).ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"author":[{"dropping-particle":"","family":"Kaiser Family Foundation","given":"","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"State Health Facts","id":"ITEM-1","issued":{"date-parts":[["217"]]},"title":"Opioid Overdose Death Rates and All Drug Overdose Death Rates Per 100,000 Population (Age-Adjusted)","type":"webpage"},"uris":["",""]}],"mendeley":{"formattedCitation":"²⁵","plainTextFormattedCitation":"25","previouslyFormattedCitation":"²⁵"},"properties":{"noteIndex":0},"schema":""}25As public health resources are often limited, it is imperative to make the largest impacts possible in these most at-risk groups. The groups that have presented as most at-risk of overdosing on opioids are young to middle aged adults, males, Whites, the homeless, and those with lower education. These findings are similar to previous reporting in the state that males, Whites, and those with lower education were at greater risk of fatal opioid overdose.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"author":[{"dropping-particle":"","family":"Jashinsky","given":"Jared M","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-1","issued":{"date-parts":[["2019"]]},"number-of-pages":"1-21","publisher-place":"Tallahassee, FL","title":"Fatal Opioid Overdose Surveillance Report: Florida Q1–Q2, 2018","type":"report"},"uris":[""]}],"mendeley":{"formattedCitation":"⁸","plainTextFormattedCitation":"8","previouslyFormattedCitation":"⁸"},"properties":{"noteIndex":0},"schema":""}8 While targeting the most at-risk individuals, interventions can also be tailored to focus on the types of drugs that different groups use in combination with opioids. Among all these demographic groups, cocaine was the drug most commonly combined with opioids. A large portion of fatal opioid overdoses involves illicit drugs. Careful prescribing and education to people prescribed opioids can help many, but there is still a large problem of illicitly manufactured and distributed opioids. Finding higher percentages of decedents testing positive for 4-ANPP who fatally overdosed on a non-prescription opiate other than heroin compared to those from an opiate prescribed to themselves provided a convergent validity check of the two measures. It is expected that 4-ANPP presence would be associated with the use of non-prescribed opiates. More could be done to prevent people from accessing other’s prescriptions and combating illicitly manufactured opioids. Naloxone was not administered in almost all cases where deaths occurred outside medical settings (e.g., decedent’s home). Many areas have successfully distributed naloxone to laypersons to combat fatal opioid overdoses in settings where medical professionals are not present.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"abstract":"Drug overdose death rates have increased steadily in the United States since 1979. In 2008, a total of 36,450 drug overdose deaths (i.e., unintentional, intentional [suicide or homicide], or undetermined intent) were reported, with prescription opioid analgesics (e.g., oxycodone, hydrocodone, and methadone), cocaine, and heroin the drugs most commonly involved (1). Since the mid-1990s, community-based programs have offered opioid overdose prevention services to persons who use drugs, their families and friends, and service providers. Since 1996, an increasing number of these programs have provided the opioid antagonist naloxone hydrochloride, the treatment of choice to reverse the potentially fatal respiratory depression caused by overdose of heroin and other opioids (2). Naloxone has no effect on non-opioid overdoses (e.g., cocaine, benzodiazepines, or alcohol) (3). In October 2010, the Harm Reduction Coalition, a national advocacy and capacity-building organization, surveyed 50 programs known to distribute naloxone in the United States, to collect data on local program locations, naloxone distribution, and overdose reversals. This report summarizes the findings for the 48 programs that completed the survey and the 188 local programs represented by the responses. Since the first opioid overdose prevention program began distributing naloxone in 1996, the respondent programs reported training and distributing naloxone to 53,032 persons and receiving reports of 10,171 overdose reversals. Providing opioid overdose education and naloxone to persons who use drugs and to persons who might be present at an opioid overdose can help reduce opioid overdose mortality, a rapidly growing public health concern. Overdose is common among persons who use opioids, including heroin users. In a 2002– 2004 study of 329 drug users, 82% said they had used heroin, 64.6% had witnessed a drug overdose, and 34.6% had experienced an unintentional drug overdose (4). In 1996, community-based programs began offering naloxone and other opioid overdose prevention services to persons who use drugs, their families and friends, and service providers (e.g., Corresponding contributor: Eliza Wheeler, wheeler@, 510-444-6969.","author":[{"dropping-particle":"","family":"Wheeler","given":"Eliza","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Davidson","given":"Peter J","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Jones","given":"T Stephen","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Irwin","given":"Kevin S","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"MMWR Morb Mortal Wkly Rep","id":"ITEM-1","issue":"6","issued":{"date-parts":[["2012"]]},"page":"101-105","title":"Community-Based Opioid Overdose Prevention Programs Providing Naloxone — United States, 2010 Drug Overdose Prevention and Education (DOPE) Project, Harm Reduction Coalition, Oakland","type":"article-journal","volume":"61"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.1136/bmj.f174","ISSN":"17561833","abstract":"OBJECTIVE To evaluate the impact of state supported overdose education and nasal naloxone distribution (OEND) programs on rates of opioid related death from overdose and acute care utilization in Massachusetts. DESIGN Interrupted time series analysis of opioid related overdose death and acute care utilization rates from 2002 to 2009 comparing community-year strata with high and low rates of OEND implementation to those with no implementation. SETTING 19 Massachusetts communities (geographically distinct cities and towns) with at least five fatal opioid overdoses in each of the years 2004 to 2006. PARTICIPANTS OEND was implemented among opioid users at risk for overdose, social service agency staff, family, and friends of opioid users. INTERVENTION OEND programs equipped people at risk for overdose and bystanders with nasal naloxone rescue kits and trained them how to prevent, recognize, and respond to an overdose by engaging emergency medical services, providing rescue breathing, and delivering naloxone. MAIN OUTCOME MEASURES Adjusted rate ratios for annual deaths related to opioid overdose and utilization of acute care hospitals. RESULTS Among these communities, OEND programs trained 2912 potential bystanders who reported 327 rescues. Both community-year strata with 1-100 enrollments per 100,000 population (adjusted rate ratio 0.73, 95% confidence interval 0.57 to 0.91) and community-year strata with greater than 100 enrollments per 100,000 population (0.54, 0.39 to 0.76) had significantly reduced adjusted rate ratios compared with communities with no implementation. Differences in rates of acute care hospital utilization were not significant. CONCLUSIONS Opioid overdose death rates were reduced in communities where OEND was implemented. This study provides observational evidence that by training potential bystanders to prevent, recognize, and respond to opioid overdoses, OEND is an effective intervention.","author":[{"dropping-particle":"","family":"Walley","given":"Alexander Y.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Xuan","given":"Ziming","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hackman","given":"H. Holly","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Quinn","given":"Emily","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Doe-Simkins","given":"Maya","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sorensen-Alawad","given":"Amy","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ruiz","given":"Sarah","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ozonoff","given":"Al","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"BMJ (Online)","id":"ITEM-2","issue":"f174","issued":{"date-parts":[["2013"]]},"page":"1-13","title":"Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: Interrupted time series analysis","type":"article-journal","volume":"346"},"uris":[""]},{"id":"ITEM-3","itemData":{"DOI":"10.3111/13696998.2013.811080","abstract":"Objective: To evaluate the cost-effectiveness of distributing naloxone to illicit opioid users for lay overdose reversal in Russian cities. Method: This study adapted an integrated Markov and decision analytic model to Russian cities. The model took a lifetime, societal perspective, relied on published literature, and was calibrated to epidemiologic findings. Results: For each 20% of heroin users reached with naloxone distribution, the model predicted a 13.4% reduction in overdose deaths in the first 5 years and 7.6% over a lifetime; on probabilistic analysis, one death would be prevented for every 89 naloxone kits distributed (95% CI=32-260). Naloxone distribution was cost-effective in all deterministic and probabilistic sensitivity analyses and cost-saving if resulting in a reduction in overdose events. Naloxone distribution increased costs by US$13 (95% CI=US$3-US$32) and QALYs by 0.137 (95% CI=0.022-0.389) for an incremental cost of US$94 per QALY gained (95% CI=US$40-US$325). In a worst-case scenario where overdose was rarely witnessed and naloxone was rarely used, minimally effective, and expensive, the incremental cost was US$1987 per QALY gained. If national expenditures on drug-related HIV, tuberculosis, and criminal justice were applied to heroin users, the incremental cost was US$928 per QALY gained. Conclusions: Naloxone distribution to heroin users for lay overdose reversal is highly likely to reduce overdose deaths in target communities and is robustly cost-effective, even within the constraints of this conservative model. ? 2013 All rights reserved: reproduction in whole or part not permitted.","author":[{"dropping-particle":"","family":"Coffin","given":"Phillip O","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sullivan","given":"Sean D","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Annals of Internal Medicine","id":"ITEM-3","issue":"1","issued":{"date-parts":[["2013"]]},"page":"1-9","title":"Cost-Effectiveness of Distributing Naloxone to Heroin Users for Lay Overdose Reversal","type":"article-journal","volume":"158"},"uris":[""]},{"id":"ITEM-4","itemData":{"DOI":"10.1097/ADM.0000000000000034","ISBN":"0000000000000","ISSN":"19353227","abstract":"Community-based opioid overdose prevention programs (OOPPs) that include the distribution of naloxone have increased in response to alarmingly high overdose rates in recent years. This systematic review describes the current state of the literature on OOPPs, with particular focus on the effectiveness of these programs.We used systematic search criteria to identify relevant articles, which we abstracted and assigned a quality assessment score. Nineteen articles evaluating OOPPs met the search criteria for this systematic review. Principal findings included participant demographics, the number of naloxone administrations, percentage of survival in overdose victims receiving naloxone, post-naloxone administration outcome measures, OOPP characteristics, changes in knowledge pertaining to overdose responses, and barriers to naloxone administration during overdose responses. The current evidence from nonrandomized studies suggests that bystanders (mostly opioid users) can and will use naloxone to reverse opioid overdoses when properly trained, and that this training can be done successfully through OOPPs. Copyright ? 2014 American Society of Addiction Medicine.","author":[{"dropping-particle":"","family":"Clark","given":"Angela K.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Wilder","given":"Christine M.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Winstanley","given":"Erin L.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Journal of Addiction Medicine","id":"ITEM-4","issue":"3","issued":{"date-parts":[["2014"]]},"page":"153-163","title":"A Systematic Review of Community Opioid Overdose Prevention and Naloxone Distribution Programs","type":"article-journal","volume":"8"},"uris":[""]}],"mendeley":{"formattedCitation":"^10–13","plainTextFormattedCitation":"10–13","previouslyFormattedCitation":"^10–13"},"properties":{"noteIndex":0},"schema":""}10–13 Though better, naloxone was administered in less than half of cases where deaths occurred in medical settings (i.e., hospital, emergency department, outpatient). More work should be done in the state to distribute naloxone to both medical professionals and laypersons alike. Naloxone is highly effective at rapidly reversing the effects of an opioid overdose, presents minimal risks, and is cost-effective.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"","author":[{"dropping-particle":"","family":"Centers for Disease Control and Prevention (CDC)","given":"","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-1","issued":{"date-parts":[["2018"]]},"number-of-pages":"1-6","title":"Using Naloxone to Reverse Opioid Overdose in the Workplace: Information for Employers and Workers","type":"report"},"uris":[""]},{"id":"ITEM-2","itemData":{"DOI":"10.3111/13696998.2013.811080","abstract":"Objective: To evaluate the cost-effectiveness of distributing naloxone to illicit opioid users for lay overdose reversal in Russian cities. Method: This study adapted an integrated Markov and decision analytic model to Russian cities. The model took a lifetime, societal perspective, relied on published literature, and was calibrated to epidemiologic findings. Results: For each 20% of heroin users reached with naloxone distribution, the model predicted a 13.4% reduction in overdose deaths in the first 5 years and 7.6% over a lifetime; on probabilistic analysis, one death would be prevented for every 89 naloxone kits distributed (95% CI=32-260). Naloxone distribution was cost-effective in all deterministic and probabilistic sensitivity analyses and cost-saving if resulting in a reduction in overdose events. Naloxone distribution increased costs by US$13 (95% CI=US$3-US$32) and QALYs by 0.137 (95% CI=0.022-0.389) for an incremental cost of US$94 per QALY gained (95% CI=US$40-US$325). In a worst-case scenario where overdose was rarely witnessed and naloxone was rarely used, minimally effective, and expensive, the incremental cost was US$1987 per QALY gained. If national expenditures on drug-related HIV, tuberculosis, and criminal justice were applied to heroin users, the incremental cost was US$928 per QALY gained. Conclusions: Naloxone distribution to heroin users for lay overdose reversal is highly likely to reduce overdose deaths in target communities and is robustly cost-effective, even within the constraints of this conservative model. ? 2013 All rights reserved: reproduction in whole or part not permitted.","author":[{"dropping-particle":"","family":"Coffin","given":"Phillip O","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sullivan","given":"Sean D","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Annals of Internal Medicine","id":"ITEM-2","issue":"1","issued":{"date-parts":[["2013"]]},"page":"1-9","title":"Cost-Effectiveness of Distributing Naloxone to Heroin Users for Lay Overdose Reversal","type":"article-journal","volume":"158"},"uris":[""]}],"mendeley":{"formattedCitation":"^9,12","plainTextFormattedCitation":"9,12","previouslyFormattedCitation":"^9,12"},"properties":{"noteIndex":0},"schema":""}9,12Florida Department of Health implements the Helping Emergency Responders Obtain Support (HEROS) Program where Florida agencies who employ emergency responders and agree to report naloxone administrations through approved systems, can receive free naloxone. Eligible applicants can visit to learn more and enroll in the program.REFERENCESADDIN Mendeley Bibliography CSL_BIBLIOGRAPHY 1. Volkow ND, Frieden TR, Hyde PS, Cha SS. Medication-Assisted Therapies — Tackling the Opioid-Overdose Epidemic. N Engl J Med. 2014;370(22):2063-2066. doi:10.1056/nejmp14027802. Rudd RA, Aleshire N, Zibbell JE, Gladden RM. Increases in Drug and Opioid Overdose Deaths—United States, 2000–2014. Morb Mortal Wkly Rep. 2016;64(50):1378-1382. doi:10.1111/ajt.137763. Rudd RA, Seth P, David F, Scholl L. Increases in Drug and Opioid-Involved Overdose Deaths — United States, 2010–2015. Morb Mortal Wkly Rep. 2016;65(50-51):1445-1452. doi:10.2105/AJPH.2014.302367?journalCode=ajph4. Wilson N, Kariisa M, Seth P, Smith H, Davis NL. Drug and Opioid-Involved Overdose Deaths — United States, 2017–2018. Morb Mortal Wkly Rep. 2020;69(11):290-297. . White AG, Birnbaum HG, Mareva MN, et al. Direct Costs of Opioid Abuse in an Insured Population in the United States. J Manag Care Pharm. 2005;11(6):469-479.6. Dunn KM, Saunders KW, Rutter CM, et al. Overdose and prescribed opioids: Associations among chronic non-cancer pain patients. Ann Intern Med. 2010;152(2):85-92. doi:10.1059/0003-4819-152-2-201001190-00006.Overdose7. Bohnert AS, Valenstein M, Bair MJ, et al. Association Between Opioid Prescribing Patterns and Opioid Overdose-Related Deaths. J Am Med Assoc. 2011;305(13):1315-1321.8. Jashinsky JM. Fatal Opioid Overdose Surveillance Report: Florida Q1–Q2, 2018. Tallahassee, FL; 2019. . Centers for Disease Control and Prevention (CDC). Using Naloxone to Reverse Opioid Overdose in the Workplace: Information for Employers and Workers.; 2018. doi:. Wheeler E, Davidson PJ, Jones TS, Irwin KS. Community-Based Opioid Overdose Prevention Programs Providing Naloxone — United States, 2010 Drug Overdose Prevention and Education (DOPE) Project, Harm Reduction Coalition, Oakland. MMWR Morb Mortal Wkly Rep. 2012;61(6):101-105.11. Walley AY, Xuan Z, Hackman HH, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: Interrupted time series analysis. BMJ. 2013;346(f174):1-13. doi:10.1136/bmj.f17412. Coffin PO, Sullivan SD. Cost-Effectiveness of Distributing Naloxone to Heroin Users for Lay Overdose Reversal. Ann Intern Med. 2013;158(1):1-9. doi:10.3111/13696998.2013.81108013. Clark AK, Wilder CM, Winstanley EL. A Systematic Review of Community Opioid Overdose Prevention and Naloxone Distribution Programs. J Addict Med. 2014;8(3):153-163. doi:10.1097/ADM.000000000000003414. Doyon S, Aks SE, Schaeffer S. Expanding Access to Naloxone in the United States. J Med Toxicol. 2014;10(4):431-434. doi:10.3109/15563650.2014.96865715. World Health Organization. Community Management of Opioid Overdose. Geneva, Switzerland; 2014. doi:10.4324/978131577542516. Wheeler E, Jones TS, Gilbert MK, Davidson PJ. Opioid Overdose Prevention Programs Providing Naloxone to Laypersons — United States, 2014. Morb Mortal Wkly Rep. 2015;64(23):631-635. . Abouk R, Pacula RL, Powell D. Association Between State Laws Facilitating Pharmacy Distribution of Naloxone and Risk of Fatal Overdose. JAMA Intern Med. 2019;179(6):805-811. doi:10.1001/jamainternmed.2019.027218. McClellan C, Lambdin BH, Ali MM, et al. Opioid-overdose laws association with opioid use and overdose mortality. Addict Behav. 2018;86:90-95. . 2019 Florida Statues. Emergency Treatment for Suspected Opioid Overdose. United States; 2019. . U.S. Census Bureau. Understanding and Using ACS Single-Year and Multiyear Estimates.; 2018. . National Institutes of Health. Racial and Ethnic Categories and Definitions for NIH Diversity Programs and for Other Reporting Purposes. NOT-OD-15-089. . Published 2015. Accessed August 13, 2019.22. Buescher PA. Statistical Primer: Age-Adjusted Death Rates. Raleigh, NC; 2010. . Nazworth S. Council on Homelessness: Annual Report. FL; 2018. on Homelessness Annual Report 2018.pdf.24. Centers for Disease Control and Prevention (CDC). Suppression of Rates and Counts. . Published 2020. Accessed December 20, 2020.25. Kaiser Family Foundation. Opioid Overdose Death Rates and All Drug Overdose Death Rates Per 100,000 Population (Age-Adjusted). State Health Facts. ................
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