EXECUTIVE SUMMARY - Florida Department of Health



FATAL OPIOID OVERDOSE SURVEILLANCE REPORTFlorida Q1–Q2, 2018 Enhanced State Opioid Overdose Funding Agency:Centers for Disease Control and PreventionGrant No. 1 NU17CE924896-01-00Author:Jared Jashinsky, PhDEpidemiologistFlorida Department of HealthDivision of Emergency Preparedness and Community SupportBureau of Emergency ManagementDisclaimer: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 Enhanced State Opioid Overdose Surveillance (FL-ESOOS) project reported 1,121 fatal opioid overdoses for the second half of 2017. The same data showed that men, adults ages 25–34, and whites were most likely to fatally overdose on opioids. Duval, Palm Beach, and Lee counties previously had the highest rates of fatal opioid overdoses. 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-ESOOS.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 57 of Florida’s 67 counties, or 82 percent of the population. Rates per 100,000 persons were estimated using data from the 2017 United States (U.S.) Census Bureau, 2013–2017 American Community Survey 5-Year Estimates. The population estimates were limited to counties reporting fatal opioid overdose data to FL-ESOOS, 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 1,224 fatal opioid overdoses in the reporting counties between January and June of 2018, and a fatal opioid overdose rate of 8.3 per 100,000 individuals ages 10 and older. Most fatal overdoses occurred among Florida residents and not those visiting the state. Lee, Volusia, and Palm Beach counties experienced the highest rates of fatal opioid overdoses. Adults ages 35–44 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. Men were 2.4 times more likely than females and whites were 3.4 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 4Demographics PAGEREF _Toc17788951 \h 4Overdose Characteristics PAGEREF _Toc17788952 \h 4Fatal Opioid Overdose Rates PAGEREF _Toc17788953 \h 5SAMPLE REPRESENTATIVENESS PAGEREF _Toc17788954 \h 5RESULTS PAGEREF _Toc17788955 \h 7DEMOGRAPHICS PAGEREF _Toc17788956 \h 7OVERDOSE CHARACTERISTICS PAGEREF _Toc17788957 \h 8FATAL OPIOID OVERDOSE RATES PAGEREF _Toc17788958 \h 10DISCUSSION 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 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 N","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Daher","given":"Maham","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Vallow","given":"Susan","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Schein","given":"Jeff","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Katz","given":"Nathaniel","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Journal of Managed Care Pharmacy","id":"ITEM-1","issue":"6","issued":{"date-parts":[["2005"]]},"page":"469-479","title":"Direct Costs of Opioid Abuse in an Insured Population in the United States","type":"article-journal","volume":"11"},"uris":[""]}],"mendeley":{"formattedCitation":"⁴","plainTextFormattedCitation":"4","previouslyFormattedCitation":"⁴"},"properties":{"noteIndex":0},"schema":""}4 The cost to society in the United States (U.S.) from opioid abuse through increased health care, workplace, and criminal justice costs was estimated as $66.5 billion (2019 dollars) in 2007. This number has likely only increased with the increase in opioid abuse in the U.S.People prescribed higher doses of opioids compared to lower doses for pain management are more likely to experience fatal and non-fatal opioid overdoses.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1059/0003-4819-152-2-201001190-00006.","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":"^5,6","plainTextFormattedCitation":"5,6","previouslyFormattedCitation":"^5,6"},"properties":{"noteIndex":0},"schema":""}5,6 These relationships hold even after controlling for demographic and health factors. Previous data from Florida’s opioid overdose surveillance system reported 1,121 fatal opioid overdoses for the second half of 2017. The same data showed that men, adults ages 25–34, and whites were most likely to fatally overdose on opioids.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"author":[{"dropping-particle":"","family":"Florida Department of Health","given":"","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-1","issued":{"date-parts":[["2017"]]},"number-of-pages":"1-30","publisher-place":"Tallahassee, FL","title":"Fatal Opioid Overdose Surveillance: Florida 2017 Q3-Q4","type":"report"},"uris":[""]}],"mendeley":{"formattedCitation":"⁷","plainTextFormattedCitation":"7","previouslyFormattedCitation":"⁷"},"properties":{"noteIndex":0},"schema":""}7 Duval, Palm Beach, and Lee counties previously had the highest rates of fatal opioid overdoses.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"author":[{"dropping-particle":"","family":"Florida Department of Health","given":"","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-1","issued":{"date-parts":[["2017"]]},"number-of-pages":"1-30","publisher-place":"Tallahassee, FL","title":"Fatal Opioid Overdose Surveillance: Florida 2017 Q3-Q4","type":"report"},"uris":[""]}],"mendeley":{"formattedCitation":"⁷","plainTextFormattedCitation":"7","previouslyFormattedCitation":"⁷"},"properties":{"noteIndex":0},"schema":""}7Naloxone 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":"⁸","plainTextFormattedCitation":"8","previouslyFormattedCitation":"⁸"},"properties":{"noteIndex":0},"schema":""}8 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":"⁹","plainTextFormattedCitation":"9","previouslyFormattedCitation":"⁹"},"properties":{"noteIndex":0},"schema":""}9 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. 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-1","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-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":[""]},{"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":"^10–12","plainTextFormattedCitation":"10–12","previouslyFormattedCitation":"^10–12"},"properties":{"noteIndex":0},"schema":""}10–12 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":"^13,14","plainTextFormattedCitation":"13,14","previouslyFormattedCitation":"^13,14"},"properties":{"noteIndex":0},"schema":""}13,14 Drug users are the laypeople most often given naloxone and, of laypeople, 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":"¹⁵","plainTextFormattedCitation":"15","previouslyFormattedCitation":"¹⁵"},"properties":{"noteIndex":0},"schema":""}15 Increasing distribution of naloxone in Florida would help reduce the number of fatal opioid overdoses in the state. 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 Enhanced State Opioid Overdose Surveillance (FL-ESOOS) project. Rates of fatal overdoses across various demographic and contextual groups are also presented. Those groups most at risk are identified to characterize the epidemic, as well as highlight those most at 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 FL-ESOOS 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 25 Medical Examiner (ME) Districts covering 57 of Florida’s 67 counties, accounting for 82.05 of Florida’s population. A list of all participating ME Districts and their respective counties are in Table 2, and a geographical presentation is in Figure 1. The only counties not to participate were Broward, Citrus, Hernando, Indian River, Lake, Marion, Martin, Okeechobee, St. Lucie, and Sumter counties.The total population from the included geographic area, used to calculate rates per 100,000 persons, were estimated using data from the 2013–2017 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":"¹⁶","plainTextFormattedCitation":"16","previouslyFormattedCitation":"¹⁶"},"properties":{"noteIndex":0},"schema":""}16 The 2013-2017 5-year estimate was the most up-to-date population and demographic estimates of county level data in Florida. Though 2013–2017 is not the same population from 2018, it was expected to be sufficiently similar to facilitate these analyses. The estimated population of Florida between 2013 and 2017 was 20,278,447; however, for the purpose of these analyses the population estimates were limited to those counties reporting fatal opioid overdose data to FL-ESOOS. A total of 16,638,076 individuals were estimated to live in Florida’s reporting counties between 2013 and 2017, and 14,791,030 for those ages 10 years and older.Table 2: Participating Districts and CountiesDistrictCounty 2013–2017 Population1Escambia, Okaloosa, Santa Rosa, and Walton737,7502Franklin, Gadsden, Jefferson, Leon, Liberty, Taylor, and Wakulla420,0463Columbia, Dixie, Hamilton, Lafayette, Madison, and Suwannee170,0614Clay, Duval, Nassau, Columbia and Hamilton1,193,7696Pasco and Pinellas1,447,9787Volusia518,6608Alachua, Baker, Bradford, Gilchrist, Levy, and Union386,3819Orange1,290,21610Hardee, Highlands, and Polk779,75911Miami-Dade2,702,60212Desoto, Manatee, and Sarasota804,05613Hillsborough1,351,08714Bay, Calhoun, Gulf, Holmes, Jackson, and Washington303,11915Palm Beach1,426,77216Monroe76,74518Brevard568,18320Collier356,77421Glades, Hendry, and Lee752,42622Charlotte173,23623Flagler, Putnam, St. Johns404,02824Seminole449,26025Osceola325,168Figure 1: Counties Participating in FL-ESOOS Fatal Opioid Overdose SurveillanceMEASURESMeasures 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 orientation was considered, but missing data made it not possible. No one was recorded as transgender, but there could have been errors in the data when recording information after death. 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":"¹⁷","plainTextFormattedCitation":"17","previouslyFormattedCitation":"¹⁷"},"properties":{"noteIndex":0},"schema":""}17 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 biracial. 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, and graduate or professional degree. Yes and no 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. Polysubstance drug abuse was tested for each decedent by checking what other substances were present in the body at the point of death, as measured by toxicology testing. Commonly found substances that are not generally overdose related, such as caffeine and tobacco, were excluded from these analyses. The five most common substances are presented in this report. Frequencies and percentages of decedents for each substance were calculated.The type of institution was collected for decedents who had recently been released from a treatment or other institution. Institutions included residential facilities 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. Population estimates for rates involving age range, sex, and county were limited to individuals ages 10 and older to reflect inclusion of only those overdoses among individuals ages 10 and older. 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":"¹⁸","plainTextFormattedCitation":"18","previouslyFormattedCitation":"¹⁸"},"properties":{"noteIndex":0},"schema":""}18Fatal 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, but were collected using 2016 data for the geographic areas used in the State of Florida Report: 2016 Homeless Census Estimates produced by the Florida Coalition for the Homeless.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"author":[{"dropping-particle":"","family":"Ullman","given":"Michael D","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-1","issued":{"date-parts":[["2016"]]},"title":"State of Florida Report: 2016 Homeless Census Estimates and Funding Need to End Chronic Homelessness","type":"report"},"uris":[""]}],"mendeley":{"formattedCitation":"¹⁹","plainTextFormattedCitation":"19","previouslyFormattedCitation":"¹⁹"},"properties":{"noteIndex":0},"schema":""}19 Point-in-time (PIT) estimates of homelessness can be converted to annual estimates using a multiplier of 2.5, as conducted in the report.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"author":[{"dropping-particle":"","family":"Ullman","given":"Michael D","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-1","issued":{"date-parts":[["2016"]]},"title":"State of Florida Report: 2016 Homeless Census Estimates and Funding Need to End Chronic Homelessness","type":"report"},"uris":[""]}],"mendeley":{"formattedCitation":"¹⁹","plainTextFormattedCitation":"19","previouslyFormattedCitation":"¹⁹"},"properties":{"noteIndex":0},"schema":""}19 The present analysis used 1.75 as an adjustment of PIT homelessness to create a 6-month homeless variable to match the time frame of this report. The Florida Coalition for the Homeless 2016 report did not have homeless data for Baker, Bradford, Calhoun, DeSoto, Dixie, Franklin, Gadsden, Gilchrist, Glades, Gulf, Holmes, Jefferson, Levy, Liberty, Madison, Nassau, Okeechobee, Taylor, Union, Wakulla, and Washington counties. These counties were removed from the homelessness rates analyses in addition to the counties not included due to not reporting fatal opioid overdose data. Lastly, some data were missing due to FL-ESOOS 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.SAMPLE REPRESENTATIVENESSDemographic differences were assessed between the 57 counties reporting data to FL-ESOOS 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. Though only 82.05 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. Table 3: Demographic Variables of Reporting Counties and the State of FloridaVariable% of Reporting Counties% of FloridaDifferenceSex Female51.06%51.11%0.05 Male48.94%48.89%-0.05Race/Ethnicity White55.38%55.94%0.56 Hispanic or Latino27.09%26.49%-0.60 Black or African American15.29%16.12%0.84 Asian2.96%3.03%0.07 American Indian or Alaska Native0.52%0.52%0.00Age 10–146.45%6.43%-0.02 15–2414.11%13.80%-0.31 25–3414.72%14.42%-0.30 35–4413.78%13.66%-0.12 45–5415.27%15.25%-0.01 55–6414.58%14.68%0.10 65–7411.67%12.02%0.36 75–846.61%6.84%0.23Education Less than high school12.75%12.42%-0.33 High school graduate28.90%28.97%0.07 Some college29.95%30.16%0.22 Bachelor’s degree18.11%18.17%0.06 Graduate or professional degree10.29%10.28%-0.02RESULTSThe 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 January 1, 2018 and June 30, 2018. Frequency and percentage values for all demographic variables are found in Table 4. For the two biracial individuals, one reported their races as black or African American and white, while the other reported Asian and white. 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 Female37530.64% Male84969.36%Race/Ethnicity White98080.07% Hispanic or Latino16213.24% Black or African American695.64% Asian50.41% American Indian or Alaska Native10.08% Multiracial20.16% Unknown50.41%Age 10–1400% 15–24806.54% 25–3435028.59% 35–4433627.45% 45–5425821.08% 55–6418314.95% 65–74141.14% 75–8430.25%Education Less than high school21117.24% High school graduate57446.90% Some college28623.37% Bachelor’s degree725.88% Graduate or professional degree272.21% Unknown544.41%Homelessness Homeless887.19% Not Homeless83768.38% Unknown29924.43%Military Experience Yes655.31% No1,10890.52% Unknown514.17%Florida Residence Resident1,12191.58% Non-resident816.62% Unknown221.80%OVERDOSE CHARACTERISTICScenter713105About 5 percent of decedents fatally overdosed solely on their own prescription opioid00About 5 percent of decedents fatally overdosed solely on their own prescription opioidThis section details the characteristics of all fatal opioid overdoses in Florida’s reporting areas between January 1, 2018 and June 30, 2018. Characteristics include abuse of own prescription opioid, polysubstance drug abuse, recent release from institution, naloxone administration by location.Frequency and the percent of whether or not, or to whom, the opiate a decedent fatally overdosed on are presented in Table 5. Only 4.5 percent of decedents fatally overdosed solely on an opiate prescribed to themselves. It is likely that some of the unknown prescription types were prescribed to the decedent, but 9 of the 55 decedents who fatally overdosed on their own prescription also overdosed on an illicit opioid. Assuming a similar percentage of the unknown cases exclusively fatally overdosed on their own prescription opioid, 4.96 percent of the sample would have exclusively fatally overdosed on their own prescription opioid. The largest percentage, nearly three-quarters of decedents, used illicit non-prescribed opiate drugs other than heroin. Table 5: Frequency and percent of decedents Who Fatally Overdosed on an Opiate of Different Prescription TypesPrescription TypeFrequencyPercentNon-prescribed drug, other than heroin88672.39%Heroin26621.73%Prescribed to decedent554.49%Intimate Partner30.25%Family (non-intimate partner)20.16%Other80.65%Unknown39031.86%*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 in the decedents system in addition to opioids at death were alcohol, amphetamines, benzodiazepines, cocaine, and marijuana. In terms of most frequently found, substances such as caffeine and nicotine that are consistently in a sizable portion of the population’s bodies at all times were ignored. The percentage of decedents with the above substances in their bodies can be found in Table 6. Nearly half of decedents used cocaine and opioids while over a third used benzodiazepines and opioids at the time of death. Almost a fifth of the sample, 16.93 percent, used benzodiazepines, cocaine, and opioids at the same time at death. Most decedents, 82.34 percent, had at least one of the above five substances in their body in addition to opioids at the time of death.Table 6: Percentage of Decedents Exhibiting Polysubstance Drug Abuse with Given SubstancesSubstance TypeFrequencyPercentAlcohol31525.76%Amphetamines17314.15%Benzodiazepines44836.63%Cocaine54444.48%Marijuana19315.78%Data showed that 8.37 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 102 decedents who had recently been released.Table 7: Most Common Institutions from which Decedents were Recently Released Institution TypeFrequencyPercentResidential facilities not related to substance abuse treatment3534.31%Jail, prison, or a detention facility3029.41%Hospital2221.57%Psychiatric hospital43.92%Other institution43.92%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 13.81 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 inpatient8937.08%ED/Outpatient21041.90%Decedent’s home5624.98%Other3575.60%*Excludes two in hospital inpatient with missing administration values, two at home with missing administration values, and two missing locations where naloxone was not administeredFATAL OPIOID OVERDOSE RATEScenter9214361,224 fatal opioid overdoses in Florida’s reporting counties between January and June of 2018001,224 fatal opioid overdoses in Florida’s reporting counties between January and June of 2018Florida experienced 1,224 fatal opioid overdoses in the reporting counties between January and June of 2018. A total of 8.28 per 100,000 individuals ages 10 and older died of opioid overdoses 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.Age-adjusted fatal opioid overdose rates in all reporting Florida counties can be found in Table 9 and Figure 2. Twelve counties experienced an age-adjusted fatal opioid overdose rate greater than 10 per 100,000. In descending order, they were Lee, Volusia, Palm Beach, Duval, Putnam, Brevard, Madison, Osceola, Clay, Seminole, Orange, and Levy counties. Fatal opioid overdose rates in counties with low overall counts should be interpreted cautiously as they can drastically change due to small amounts of error or underreporting. Fatal opioid overdose rates by age ranges among people ages 10 and older are presented in Figure 3. During these months, people ages 35–44 had the highest death rate of 14.18 deaths per 100,000. Narrowing in more specifically, people ages 35–40 had the highest death rate with 17.53 deaths per 100,000. Fatal opioid overdose rates for males and females ages 10 and older are presented in Figure 4. During these months, men and women had 11.79 and 4.94 fatal opioid overdoses respectively per 100,000. Men were 2.4 times more likely than women to fatally overdose on opioids.Fatal opioid overdose rates by education groups among people ages 25 and older are presented in Figure 5. High school graduates were the most at-risk for fatal opioid overdose with 16.64 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 6. Whites were the most at risk of fatal opioid overdose with 10.64 deaths per 100,000 individuals over the six months. Whites were 3.4 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 0.31 percent of Florida residents were homeless in the first six months of 2016, or 47,887 individuals. However, this group has a much larger risk of fatal opioid overdose. Homeless individuals were 34.42 times more likely to experience a fatal opioid overdose compared to non-homeless individuals. This estimate is sensitive to missing values given the small number of homeless individuals; however, it is likely safe to say that homeless individuals are over 10 times more likely to fatally overdose on opioids than non-homeless individuals.Table 9: Fatal Opioid Overdose Rates Per 100,000 People Ages 10+ by County CountyCountRawAge-AdjustedCountyCountRawAge-AdjustedAlachua62.582.56Lee10216.1618.70Baker00.000.00Leon72.732.94Bay63.803.72Levy38.5210.43Bradford00.000.00Liberty00.000.00Brevard6312.2713.19Madison212.1612.42Broward––??–??Manatee257.688.64Calhoun00.000.00Marion––??–??Charlotte21.231.07Martin––??–??Citrus––??–??Miami-Dade953.963.71Clay2212.3712.13Monroe45.705.53Collier216.507.80Nassau57.137.10Columbia58.348.14Okaloosa116.396.08DeSoto00.000.00Okeechobee––??–??Dixie00.000.00Orange13712.1210.88Duval12615.9014.71Osceola3713.1012.18Escambia124.394.13Palm Beach18314.3415.45Flagler22.092.49Pasco337.437.87Franklin00.000.00Pinellas556.376.67Gadsden00.000.00Polk71.221.27Gilchrist00.000.00Putnam812.4814.00Glades00.000.00Santa Rosa32.041.96Gulf00.000.00Sarasota164.285.80Hamilton00.000.00Seminole4711.7910.89Hardee00.000.00St. Johns83.974.73Hendry38.948.54St. Lucie––??–??Hernando––??–??Sumter––??–??Highlands11.101.42Suwannee00.000.00Hillsborough907.647.10Taylor00.000.00Holmes15.785.64Union17.336.11Indian River––??–??Volusia7215.3816.77Jackson24.564.56Wakulla00.000.00Jefferson00.000.00Walton11.771.53Lafayette00.000.00Washington00.000.00Lake––??–??‘–‘ signifies no data reported by countyFigure 2: Age-Adjusted Fatal Opioid Overdose Rates per 100,000 People Ages 10+ by CountyFigure 3: Fatal Opioid Overdose Rate by Age in Years; People Ages 10+; Florida’s Reporting Counties; January–June 2018Figure 4: Fatal Opioid Overdose Rate by Sex; People Ages 10+; Florida’s Reporting Counties; January–June 2018Figure 5: Fatal Opioid Overdose Rate by Education; Adults 25+; Florida’s Reporting Counties; January–June 2018Figure 6: Fatal Opioid Overdose Rate by Racial/Ethnic Groups; All Ages; Florida’s Reporting Counties; January–June 2018DISCUSSIONThough not all Florida’s population is included in this report, the demographic similarities of the sample suggested 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 1,224 fatal opioid overdoses in the reporting counties between January and June of 2018. Florida experienced 8.3 deaths per 100,000 individuals ages 10 and older during these months. If a similar rate of fatal opioid overdoses happened in the second half of 2018, the 16.6 overdoses per 100,000 would be comparable to the national average.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"URL":"","accessed":{"date-parts":[["2019","8","19"]]},"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":"²⁰","plainTextFormattedCitation":"20","previouslyFormattedCitation":"²⁰"},"properties":{"noteIndex":0},"schema":""}20 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. If the rates maintained through the end of 2018, Lee, Duval, Volusia, and Palm Beach counties would have respectively experienced raw annual fatal opioid overdose rates of 32.3, 31.8, 30.8, and 28.7 per 100,000 people ages 10 and older. These county rates are similar to some of the top states most affected by the opioid epidemic (e.g., Maryland at fifth, Massachusetts at seventh).ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"URL":"","accessed":{"date-parts":[["2019","8","19"]]},"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":"²⁰","plainTextFormattedCitation":"20","previouslyFormattedCitation":"²⁰"},"properties":{"noteIndex":0},"schema":""}20 These counties were similarly ranked at the end of 2017 with Duval at first, Palm Beach at second, Lee at third, and Volusia at fifth.ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"author":[{"dropping-particle":"","family":"Florida Department of Health","given":"","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-1","issued":{"date-parts":[["2017"]]},"number-of-pages":"1-30","publisher-place":"Tallahassee, FL","title":"Fatal Opioid Overdose Surveillance: Florida 2017 Q3-Q4","type":"report"},"uris":[""]}],"mendeley":{"formattedCitation":"⁷","plainTextFormattedCitation":"7","previouslyFormattedCitation":"⁷"},"properties":{"noteIndex":0},"schema":""}7Resources should be targeted toward individuals most at-risk, namely young to middle aged adults, men, whites, the homeless, and those with lower education. These findings are similar to previous reporting in the state that men, 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":"Florida Department of Health","given":"","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-1","issued":{"date-parts":[["2017"]]},"number-of-pages":"1-30","publisher-place":"Tallahassee, FL","title":"Fatal Opioid Overdose Surveillance: Florida 2017 Q3-Q4","type":"report"},"uris":[""]}],"mendeley":{"formattedCitation":"⁷","plainTextFormattedCitation":"7","previouslyFormattedCitation":"⁷"},"properties":{"noteIndex":0},"schema":""}7 As public health resources are often limited, it is imperative to make the largest impacts possible in these groups most at-risk.Decedents overdosed on a prescription opioid prescribed to themselves in approximately 5 percent of cases. Careful prescribing and education to those prescribed opioids might have helped for a small portion of the deceased individuals, but the much larger problem is in the illicit manufacturing and distribution of opioids. More could be done to prevent people from accessing other’s prescriptions and combating illicit forms of 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":"^9–12","plainTextFormattedCitation":"9–12","previouslyFormattedCitation":"^9–12"},"properties":{"noteIndex":0},"schema":""}9–12 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":"^8,11","plainTextFormattedCitation":"8,11","previouslyFormattedCitation":"^8,11"},"properties":{"noteIndex":0},"schema":""}8,11Florida 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/nejmp1402780.2. 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.13776.3. 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=ajph.4. 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):469-479.5. 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:10.1059/0003-4819-152-2-201001190-00006.6. 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):1315-1321.7. Florida Department of Health. Fatal Opioid Overdose Surveillance: Florida 2017 Q3-Q4. Tallahassee, FL; 2017. . 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):101-105.10. 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.f174.11. 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:10.3111/13696998.2013.811080.12. 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.0000000000000034.13. Doyon S, Aks SE, Schaeffer S. Expanding Access to Naloxone in the United States. J Med Toxicol. 2014;10(4):431-434. doi:10.3109/15563650.2014.968657.14. World Health Organization. Community Management of Opioid Overdose. Geneva, Switzerland; 2014. doi:10.4324/9781315775425.15. 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. . 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, 2019.18. Buescher PA. Statistical Primer: Age-Adjusted Death Rates. Raleigh, NC; 2010. . Ullman MD. State of Florida Report: 2016 Homeless Census Estimates and Funding Need to End Chronic Homelessness.; 2016. Homeless Report 2016 09_30_16 - final report.pdf.20. Kaiser Family Foundation. Opioid Overdose Death Rates and All Drug Overdose Death Rates Per 100,000 Population (Age-Adjusted). State Health Facts. . Published 217AD. Accessed August 19, 2019. ................
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