Opioid Overdose First Aid Education (EIT): Scoping Review

Conflict of Interest Declaration

The ILCOR Continuous Evidence Evaluation process is guided by a rigorous ILCOR Conflict of Interest policy. The following Task Force members and other authors were recused from the discussion as they declared a conflict of interest: (none)

The following Task Force members and other authors declared an intellectual conflict of interest and this was acknowledged and managed by the Task Force Chairs and Conflict of Interest committees: (none)

Task Force Scoping Review Citation

Pellegrino JL., Krob, J, Orkin A, Bhanji F, Bigham B, Bray J, Breckwoldt J, Cheng A, Duff J, Glerup Lauridsen K, Gilfoyle E, Hiese M, Iwami T, Lockey A, Ma M, Monsieurs K, Okamoto D, Yeung J, Finn J, Greif R. on behalf of the International Liaison Committee on Resuscitation Education, Implementation, and Teams Task Force.

Opioid Overdose First Aid Education: Scoping Review and Task Force Insights [Internet] Brussels, Belgium: International Liaison Committee on Resuscitation (ILCOR) Education, Implementation, and Teams Task Force, 2020 January 03. Available from: http://ilcor.org

Methodological Preamble

The continuous evidence evaluation process started with a systematic review of the value of naloxone during resuscitation of opioid overdose/ poisoning victims conducted by the ILCOR BLS Task Force. Evidence for specific education approaches that included naloxone administration as well as other general first aid competencies, time frames, and populations was sought and considered by the Education, Implementation, and Teams Task Force through a Scoping Review on current published articles, which did not include any grey literature.

Scoping Review

We expect to submit this Scoping Review for Publication in January 2020.

PICOST

The PICOST (Population, Intervention, Comparator, Outcome, Study Designs and Timeframe)

Population: First aiders responding to opioid overdose.

Intervention: Education on response/care of individual in an opioid overdose emergency

Comparators: Another or no specialized education.

Outcomes: Any clinical or educational outcome; survival, first aid provided, skills, attitude, knowledge.

Study Designs: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) are eligible for inclusion.

Timeframe: All years and all languages were included as long as there was an English abstract; unpublished studies (e.g., conference abstracts, trial protocols) were excluded. Literature search updated to November 13, 2019

Search Strategies

Opioid Overdose Education

Database(s): EBM Reviews - Cochrane Database of Systematic Reviews 2005 to November 13, 2019, EBM Reviews - ACP Journal Club 1991 to October 2019, EBM Reviews - Database of Abstracts of Reviews of Effects 1st Quarter 2016, EBM Reviews - Cochrane Clinical Answers October 2019, EBM Reviews - Cochrane Central Register of Controlled Trials October 2019, EBM Reviews - Cochrane Methodology Register 3rd Quarter 2012, EBM Reviews - Health Technology Assessment 4th Quarter 2016, EBM Reviews - NHS Economic Evaluation Database 1st Quarter 2016, Embase 1974 to 2019 November 13, Ovid MEDLINE(R) and Epub Ahead of Print, In-Process & Other Non-Indexed Citations and Daily 1946 to November 13, 2019
Search Strategy:

#	Searches	Results
1	exp Opioid-Related Disorders/	45626
2	Heroin/ or Morphine/ or Opium/ or exp Narcotics/	444291
3	(narcotic* or opiate* or opioid* or oxycodone* or percocet* or percodan* or oxycontin* or hydrocodone* or hycodan* or hysingla* or robidone* or vantrela* or zohydro* or diamorphine* or heroin* or morphine* or arymo* or avinza* or depodur* or doloral* or duramorph* or infumorph* or kadian* or "m-ediat" or "m-eslon" or morphabond* or "ms contin" or "ms.ir" or opium* or oramorph* or paregoric* or roxanol* or statex* or zomorph* or astramorph* or codeine* or fentanyl* or fentanil* or phentanyl* or fentanest* or sublimaze* or duragesic* or durogesic* or fentora* or abstral* or actiq* or effentora* or oxaydo* or oxecta* or "oxy.ir" or hydromorphone* or dilaudid* or exalgo* or hydromorph* or vicodin* or tramadol* or conzip* or durela* or ralivia* or rybix* or ryzolt* or synapryn* or meperidine* or demerol*).tw,kf.	453541
4	or/1-3 [OPIATES]	637226
5	Drug overdose/	37555
6	(overdose* or over-dose*).tw,kf.	50606
7	(toxic* or poison*).tw,kf.	1624325
8	(po or to).fs.	1526906
9	or/5-8 [OVERDOSE]	2789118
10	Naloxone/ or Narcotic Antagonists/	71029
11	(naloxone* or narcan* or evzio*).tw,kf.	54031
12	or/10-11 [NALOXONE]	83726
13	First Aid/ or Emergency Medical Services/	144460
14	exp Emergency Responders/	19828
15	(first aid* or first respon* or EMT or emergency medical technician* or paramedic* or para-medic* or ambulance* or firefighter* or fire-fighter* or police* or prehospital or pre-hospital or nonmedical* or non-medical* or peer or peers or lay* or bystander* or by-stander*).tw,kf.	1345539
16	((expand* or increas) adj1 access adj5 (naloxone or narcan* or evzio*)).tw,kf.	104
17	(take-home or THN).tw,kf.	8286
18	(opioid overdose prevention program* or OOPP or OEND).tw,kf.	173
19	(educat* or train* or teach* or instruct* or skill* or informat*).tw,kf.	5553244
20	(recogni* or knowledge* or competen* or confiden* or empower*).tw,kf.	4493494
21	ed.fs. or education*.hw.	1679328
22	or/13-21 [FIRST AID/EDUCATION]	10730025
23	4 and 9 and 12 and 22	3192
24	exp Animals/ not (exp Animals/ and Humans/)	17012499
25	23 not 24 [ANIMAL-ONLY REMOVED]	2078
26	(comment or editorial or news or newspaper article).pt.	2002759
27	(letter not (letter and randomized controlled trial)).pt.	2135263
28	25 not (26 or 27) [OPINION PIECES REMOVED]	2011
29	28 use ppez	868
30	exp narcotic dependence/	56965
31	exp opiate agonist/ or exp narcotic analgesic agent/	418781
32	(narcotic* or opiate* or opioid* or oxycodone* or percocet* or percodan* or oxycontin* or hydrocodone* or hycodan* or hysingla* or robidone* or vantrela* or zohydro* or diamorphine* or heroin* or morphine* or arymo* or avinza* or depodur* or doloral* or duramorph* or infumorph* or kadian* or "m-ediat" or "m-eslon" or morphabond* or "ms contin" or "ms.ir" or opium* or oramorph* or paregoric* or roxanol* or statex* or zomorph* or astramorph* or codeine* or fentanyl* or fentanil* or phentanyl* or fentanest* or sublimaze* or duragesic* or durogesic* or fentora* or abstral* or actiq* or effentora* or oxaydo* or oxecta* or "oxy.ir" or hydromorphone* or dilaudid* or exalgo* or hydromorph* or vicodin* or tramadol* or conzip* or durela* or ralivia* or rybix* or ryzolt* or synapryn* or meperidine* or demerol*).tw,kw.	457491
33	or/30-32 [OPIATES]	702243
34	drug overdose/ or exp "drug toxicity and intoxication"/	195826
35	(overdose* or over-dose*).tw,kw.	51605
36	(toxic* or poison*).tw,kw.	1630043
37	to.fs.	938948
38	or/34-37 [OVERDOSE]	2376740
39	exp opiate antagonist/ or exp narcotic antagonist/	134380
40	(naloxone* or narcan* or evzio*).tw,kw.	54281
41	or/39-40 [NALOXONE]	145271
42	first aid/ or emergency treatment/ or emergency health service/ or emergency medical dispatch/	174437
43	rescue personnel/	7533
44	(first aid* or first respon* or EMT or emergency medical technician* or paramedic* or para-medic* or ambulance* or firefighter* or fire-fighter* or police* or prehospital or pre-hospital or nonmedical* or non-medical* or peer or peers or lay* or bystander* or by-stander*).tw,kw.	1350384
45	((expand* or increas) adj1 access adj5 (naloxone or narcan* or evzio*)).tw,kw.	104
46	(take-home or THN).tw,kw.	8294
47	(opioid overdose prevention program* or OOPP or OEND).tw,kw.	173
48	(educat* or train* or teach* or instruct* or skill* or informat*).tw,kw.	5570601
49	(recogni* or knowledge* or competen* or confiden* or empower*).tw,kw.	4504687
50	education*.hw.	1534182
51	or/42-50 [FIRST AID/EDUCATION]	10709354
52	33 and 38 and 41 and 51	3598
53	exp animal experimentation/ or exp animal model/ or exp animal experiment/ or nonhuman/ or exp vertebrate/	48942612
54	exp human/ or exp human experimentation/ or exp human experiment/	39030904
55	52 not (53 not 54) [ANIMAL-ONLY REMOVED]	3341
56	editorial.pt.	1143095
57	letter.pt. not (randomized controlled trial/ and letter.pt.)	2135473
58	55 not (56 or 57) [OPINION PIECES REMOVED]	3244
59	conference abstract.pt.	3646198
60	58 not 59 [CONFERENCE ABSTRACTS REMOVED]	2711
61	60 use oemezd	1667
62	exp Opioid-Related Disorders/	45626
63	Heroin/ or Morphine/ or Opium/ or exp Narcotics/	444291
64	(narcotic* or opiate* or opioid* or oxycodone* or percocet* or percodan* or oxycontin* or hydrocodone* or hycodan* or hysingla* or robidone* or vantrela* or zohydro* or diamorphine* or heroin* or morphine* or arymo* or avinza* or depodur* or doloral* or duramorph* or infumorph* or kadian* or "m-ediat" or "m-eslon" or morphabond* or "ms contin" or "ms.ir" or opium* or oramorph* or paregoric* or roxanol* or statex* or zomorph* or astramorph* or codeine* or fentanyl* or fentanil* or phentanyl* or fentanest* or sublimaze* or duragesic* or durogesic* or fentora* or abstral* or actiq* or effentora* or oxaydo* or oxecta* or "oxy.ir" or hydromorphone* or dilaudid* or exalgo* or hydromorph* or vicodin* or tramadol* or conzip* or durela* or ralivia* or rybix* or ryzolt* or synapryn* or meperidine* or demerol*).tw,kw.	457491
65	or/62-64 [OPIATES]	639284
66	Drug overdose/	37555
67	(overdose* or over-dose*).tw,kw.	51605
68	(toxic* or poison*).tw,kw.	1630043
69	(po or to).fs.	1526906
70	or/66-69 [OVERDOSE]	2800335
71	Naloxone/ or Narcotic Antagonists/	71029
72	(naloxone* or narcan* or evzio*).tw,kw.	54281
73	or/71-72 [NALOXONE]	83834
74	First Aid/ or Emergency Medical Services/	144460
75	exp Emergency Responders/	19828
76	(first aid* or first respon* or EMT or emergency medical technician* or paramedic* or para-medic* or ambulance* or firefighter* or fire-fighter* or police* or prehospital or pre-hospital or nonmedical* or non-medical* or peer or peers or lay* or bystander* or by-stander*).tw,kw.	1350384
77	((expand* or increas) adj1 access adj5 (naloxone or narcan* or evzio*)).tw,kw.	104
78	(take-home or THN).tw,kw.	8294
79	(opioid overdose prevention program* or OOPP or OEND).tw,kw.	173
80	(educat* or train* or teach* or instruct* or skill* or informat*).tw,kw.	5570601
81	(recogni* or knowledge* or competen* or confiden* or empower*).tw,kw.	4504687
82	ed.fs. or education*.hw.	1679328
83	or/74-82 [FIRST AID/EDUCATION]	10752344
84	65 and 70 and 73 and 83	3230
85	conference abstract.pt.	3646198
86	84 not 85 [CONFERENCE ABSTRACTS REMOVED]	2733
87	86 use cctr	107
88	86 use coch	24
89	86 use dare	3
90	86 use clhta	1
91	86 use cleed	1
92	86 use acp	1
93	86 use clcmr	0
94	29 or 61 or 87 or 88 or 89 or 90 or 91 or 92 or 93 [ALL DATABASES - NO DUPLICATES REMOVED]	2672
95	remove duplicates from 94 [TOTAL UNIQUE RECORDS]	1858
96	95 use ppez [MEDLINE UNIQUE RECORDS]	126
97	95 use oemezd [EMBASE UNIQUE RECORDS]	1640
98	95 use cctr [CENTRAL UNIQUE RECORDS]	62
99	95 use coch [COCHRANE DATABASE OF SYSTEMATIC REVIEWS UNIQUE RECORDS]	24
100	95 use dare [DATABASE OF ABSTRACTS OF REVIEWS OF EFFECTS UNIQUE RECORDS]	3
101	95 use clhta [HEALTH TECHNOLOGY ASSESSMENT DATABASE]	1
102	95 use cleed [NATIONAL HEALTH SERVICE ECONOMIC EVALUATION DATABASE]	1
103	95 use acp [ACP JOURNAL CLUB UNIQUE RECORDS]	1
104	95 use clcmr [COCHRANE METHODOLOGY REGISTER DATABASE]	0

CINAHL

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#	Query	Results
S18	S17 NOT (PT commentary OR PT letter OR PT editorial)	721
S17	S16 NOT (MH "Animals+") NOT ((MH "Human") AND (MH "Animals+"))	763
S16	S3 and S6 and S9 and S15	764
S15	S10 or S11 or S12 or S13 or S14	1,766,410
S14	TI (educat* or train* or teach* or instruct* or skill* or informat* or recogni* or knowledge* or competen* or confiden* or empower) or AB (educat or train* or teach* or instruct* or skill* or informat* or recogni* or knowledge* or competen* or confiden* or empower*)	1,158,938
S13	TI ((expand* or increas) N1 access N4 (naloxone or narcan* or evzio)) or AB ((expand or increas) N1 access N4 (naloxone or narcan* or evzio*))	45
S12	TI (first aid* or first respon* or EMT or emergency medical technician* or paramedic* or para-medic* or ambulance* or firefighter* or fire-fighter* or police* or prehospital or pre-hospital or nonmedical* or non-medical* or peer or peers or lay* or bystander* or by-stander* or take-home or THN or opioid overdose prevention program* or OOPP or OEND) or AB (first aid* or first respon* or EMT or emergency medical technician* or paramedic* or para-medic* or ambulance* or firefighter* or fire-fighter* or police* or prehospital or pre-hospital or nonmedical* or non-medical* or peer or peers or lay* or bystander* or by-stander* or take-home or THN or opioid overdose prevention program* or OOPP or OEND)	159,407
S11	MH ("Education+")	830,788
S10	MH ("First Aid" or "Emergency Treatment" or "Emergency Medical Services" or "Emergency Service" or "Emergency Medical Technicians")	79,634
S9	S7 or S8	8,159
S8	TI (naloxone* or narcan* or evzio) or AB (naloxone or narcan* or evzio*)	2,760
S7	(MH "Narcotic Antagonists+")	7,176
S6	S4 or S5	71,680
S5	TI (overdose* or over-dose* or toxic* or poison) or AB (overdose or over-dose* or toxic* or poison*)	65,895
S4	MH ("Overdose" or "Drug Toxicity")	12,198
S3	S1 or S2	62,097
S2	TI (narcotic* or opiate* or opioid* or oxycodone* or percocet* or percodan* or oxycontin* or hydrocodone* or hycodan* or hysingla* or robidone* or vantrela* or zohydro* or diamorphine* or heroin* or morphine* or arymo* or avinza* or depodur* or doloral* or duramorph* or infumorph* or kadian* or "m-ediat" or "m-eslon" or morphabond* or "ms contin" or "ms.ir" or opium* or oramorph* or paregoric* or roxanol* or statex* or zomorph* or astramorph* or codeine* or fentanyl* or fentanil* or phentanyl* or fentanest* or sublimaze* or duragesic* or durogesic* or fentora* or abstral* or actiq* or effentora* or oxaydo* or oxecta* or "oxy.ir" or hydromorphone* or dilaudid* or exalgo* or hydromorph* or vicodin* or tramadol* or conzip* or durela* or ralivia* or rybix* or ryzolt* or synapryn* or meperidine* or demerol) or AB (narcotic or opiate* or opioid* or oxycodone* or percocet* or percodan* or oxycontin* or hydrocodone* or hycodan* or hysingla* or robidone* or vantrela* or zohydro* or diamorphine* or heroin* or morphine* or arymo* or avinza* or depodur* or doloral* or duramorph* or infumorph* or kadian* or "m-ediat" or "m-eslon" or morphabond* or "ms contin" or "ms.ir" or opium* or oramorph* or paregoric* or roxanol* or statex* or zomorph* or astramorph* or codeine* or fentanyl* or fentanil* or phentanyl* or fentanest* or sublimaze* or duragesic* or durogesic* or fentora* or abstral* or actiq* or effentora* or oxaydo* or oxecta* or "oxy.ir" or hydromorphone* or dilaudid* or exalgo* or hydromorph* or vicodin* or tramadol* or conzip* or durela* or ralivia* or rybix* or ryzolt* or synapryn* or meperidine* or demerol*)	45,023
S1	MH ("Narcotics+" or "Analgesics, Opioid+")	43,678

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ERIC

#	Query	Results
S6	S3 and S4 and S5	7
S5	TI (naloxone* or narcan* or evzio) or AB (naloxone or narcan* or evzio*)	17
S4	TI (overdose* or over-dose* or toxic* or poison) or AB (overdose or over-dose* or toxic* or poison*)	1,900
S3	S1 or S2	1,527
S2	TI (narcotic* or opiate* or opioid* or oxycodone* or percocet* or percodan* or oxycontin* or hydrocodone* or hycodan* or hysingla* or robidone* or vantrela* or zohydro* or diamorphine* or heroin* or morphine* or arymo* or avinza* or depodur* or doloral* or duramorph* or infumorph* or kadian* or "m-ediat" or "m-eslon" or morphabond* or "ms contin" or "ms.ir" or opium* or oramorph* or paregoric* or roxanol* or statex* or zomorph* or astramorph* or codeine* or fentanyl* or fentanil* or phentanyl* or fentanest* or sublimaze* or duragesic* or durogesic* or fentora* or abstral* or actiq* or effentora* or oxaydo* or oxecta* or "oxy.ir" or hydromorphone* or dilaudid* or exalgo* or hydromorph* or vicodin* or tramadol* or conzip* or durela* or ralivia* or rybix* or ryzolt* or synapryn* or meperidine* or demerol) or AB (narcotic or opiate* or opioid* or oxycodone* or percocet* or percodan* or oxycontin* or hydrocodone* or hycodan* or hysingla* or robidone* or vantrela* or zohydro* or diamorphine* or heroin* or morphine* or arymo* or avinza* or depodur* or doloral* or duramorph* or infumorph* or kadian* or "m-ediat" or "m-eslon" or morphabond* or "ms contin" or "ms.ir" or opium* or oramorph* or paregoric* or roxanol* or statex* or zomorph* or astramorph* or codeine* or fentanyl* or fentanil* or phentanyl* or fentanest* or sublimaze* or duragesic* or durogesic* or fentora* or abstral* or actiq* or effentora* or oxaydo* or oxecta* or "oxy.ir" or hydromorphone* or dilaudid* or exalgo* or hydromorph* or vicodin* or tramadol* or conzip* or durela* or ralivia* or rybix* or ryzolt* or synapryn* or meperidine* or demerol*)	1,091
S1	DE "Narcotics"	681

N.B. Concept of first aid/education not searched as ERIC is an education database – by default all records are related to education. Concept of Bottom of Form

FINAL database searches

2019-11-14

Summary

Database	Hits
MEDLINE (Ovid)	868
Embase (Ovid)	1667
Cochrane CENTRAL Register of Controlled Trials (Ovid)	107
Cochrane Database of Systematic Reviews (Ovid)	24
Database of Abstracts of Reviews of Effects (Ovid)	3
ACP Journal Club (Ovid)	1
Cochrane Methodology Register Database (Ovid)	0
Health Technology Assessment Database (Ovid)	1
National Health Service Economic Evaluation Database (Ovid)	1
CINAHL (Ebsco)	721
ERIC (Ebsco)	7
Total citations	3400
Duplicates	1327
Total unique citations	2073

Inclusion and Exclusion criteria

Inclusion: Randomized controlled trials (RCTs) and non-randomized studies (non-randomized controlled trials, interrupted time series, controlled before-and-after studies, cohort studies) are eligible for inclusion.

Must have:

Outcomes: Educational, First Aid, Victim, Population
Description of Education
Non-clinical environment for practice

Exclusion: studies that did not specifically answer the question, unpublished studies, and studies only published in abstract form, unless accepted for publication.

Data tables

^{Studies with a comparison group (n=8)}

Citation 1^st Author, Year, 1^st page (Country)	Study Design (type, learners, size, intervention, duration)	Key Findings
Williams, 2014, 250 (England)	Randomized controlled trial; non-blinded Family members of people who use heroin Take Home Naloxone (THN) training Facilitator led- group education, skill practice, 60 minutes (n=69) Passive pamphlet (n=54 control) N = 187; 123 completed 3-month follow up 13 (11%) participants witnessed an overdose @ 3 months: Naloxone use in 8 instances: 3x control group and 5x facilitator-trained group. 2 facilitator trained administered naloxone; in other instances naloxone was given by ambulance personnel. @ follow up significant increase in knowledge for facilitator led @ follow up significant increase in attitude for facilitator led & passive
Dunn, 2017, S39 (United States)	Randomized pre-post trial; non-blinded People undergoing outpatient opioid detoxification Opioid overdose information Pamphlet (N = 25) Computer (N = 24) Computer + Mastery (N = 27) N=76; 43 completed 1 or 3-month follow up Pre, post, 1-month, 3-month follow up @ post intervention significant increase in opioid knowledge by computer groups v. pamphlet @ post intervention significant increase by all groups in opioid response knowledge (41.8% to 73.8%) No difference in groups’ opioid overdose knowledge pre or post, as it was initially high, and assumed to be a group characteristic based on personal experience. By the one (81%) and three (77%) month follow-up visits, the majority of participants in the completed sample provided a urine sample that tested positive for an opioid, indicating relapse to opioid use.
Espelt, 2017, 12 (Spain)	Quasi-experimental, pre-implementation to post-systematic implementation overdose prevention training People who inject opioids Time before and after a standardized education program established Pre-Intervention Group Without Training in Overdose Prevention (PREIGW, n=529) Pre-Intervention Group with Sporadic Training in Overdose Prevention (PREIGS, n=196) Comparison Group (CG, n=502) Intervention Group (IG, n=220) Pre-intervention 2008-2009; Systematic-intervention 2010-2011 12 month follow-up Knowledge of overdose prevention increased after implementing systematic training program. Compared to the PREIGW, the IG gave more correct answers (IRR = 1.40;95%CI:1.33– 1.47), and fewer incorrect answers (IRR = 0.33;95%CI:0.25–0.44). IG: 158 (72%) received naloxone, of whom 94 (59%) reported having witnessed ≥1 overdose in the 12 months prior to the interview, 68% of whom (n = 64) helped the sufferer (59% of these administered naloxone), thus 40% used the kit in response to an overdose they witnessed. Knowledge about overdose prevention was greater after the implementation of systematic program; Incidence Rate Ratio of correct answers 1.09 (CI 1.04-1.16) PREIGS and 1.40 (CI 1.33-1.47) IG
Franko, 2017, 375 (United States)	Randomized to overdose response training College students Overdose identification and intervention Standard web presentation of overdose recognition and response (control, n=64) Enhanced web presentation (voice over .ppt, video of overdose simulation) (n=69)	2 min to complete enhanced versus 2:10 min for standardized Simulation response differences (significant frequency differences in favor of enhanced web presentation) Determines if the patient has a pulse (checks pulse) Determines if the patient is breathing (e.g., chest rise/fall, put ear to nose) Slightly tilts patient’s head to expose nasal passage better Properly administers naloxone
Dwyer, 2015, 381 (United States)	Cross-sectional Emergency department patients seen by licensed drug counselors Overdoes education and response Standard state curriculum (OE, n=359) Standard state curriculum + 5 min naloxone training (OEN, n=56) N=415 Median time between ED index visit and survey completion was 12 months for OE only (range: 8-17 months), and 11 months for OEN (range: 5-19 months) Those responding to an overdose (27) 14 of 19 OEN called 9-1-1 versus 3 of 8 in the OE group (non-sig) No sig difference in rescue breathing rates 6 of 19 OEN administered nasal naloxone versus 0 of 8 OE Only knowledge difference was OEN recognizing that periods of opioid abstinence impacted chances of overdose
Jones, 2014, 166 (United States)	Quasi-experimental, pre-post People who use heroin Overdose training mandated by the New York State Department of Health (NYSDOH) N=84 pre-post test (n=44) Pretest only- control (n = 40) Training period 15 minutes Post intervention confidence in naloxone use was significantly higher (9.4) in comparison to the untrained group [t(82) = 16.17, p < 0.05], and their pre-training baseline [t(43) = 22.09, p < 0.05].
Doe-Simkins, 2014, 297 (United States)	Retrospective cohort study People who use substances (participants) Opioid Overdose Training N = 4,926 Rescues self-reported (pre-training n=91; post-training n=508 Survey reporting period 2006-2010 No statistically significant differences in help-seeking (call for help/ 9-1-1 rescue breathing staying with the poisoned victim success of naloxone administration No sig difference in drug usage among participants
Lott, 2016, 221 (United States)	Quasi-experimental, pre-post Outpatient treatment for people with Opioid Use Disorder Embedded 30-45 Opioid Overdose Prevention within a 4-week program – Small group lecture Intervention group (IG; n=43); follow-up (n=16) No intervention (n=14); follow-up (n=6) 3-month follow-up IG showed greater improvement in the Opioid Overdose Knowledge Scale (OOKS) total score and the Naloxone Use subdomain score in comparison to the control group. However, post-hoc comparisons of the intervention versus control follow-up scores for OOKS Total and Naloxone Use were not significant. IG pre-to follow-up no change in naloxone access reported following this educational intervention IG no reported use of naloxone in past year at follow-up

Task Force Insights

1. Why this topic was reviewed.

In 2015, the Advanced Life Support (ALS) Task Force recommended the used of naloxone for individuals in cardiac arrest due to opioid toxicity (strong recommendation, very-low-quality evidence). {ILCOR 2015 441} Although the Basic Life Support (BLS) Taskforce in 2015 did not make a treatment recommendation for using naloxone within resuscitation guidelines for suspected opioid overdose, due to the lack of evidence, they did in their #891 CoSTR suggest offering opioid overdose response education, with or without naloxone distribution, to persons at risk for opioid overdose in any setting (weak recommendation, very-low-quality evidence). {ILCOR 2015 811; ILCOR 2015 891} The EIT Taskforce chose to identify the scope of current opioid overdose response education programs reporting outcomes to recommend further systematic review or identify gaps in the existing literature on the education of the use of naloxone in possible opioid overdose.

2. Narrative summary of evidence identified

We found an insufficient number of quality studies to support a more specific systematic review comparing one educational intervention versus another or no education. Eight studies {Williams 2014 250; Doe-Simkins 2014 297; Dunn 2017 S39; Dwyer 2015 381; Espelt 2017 12; Franko 2019 375; Jones 2014 166; Lott 2016 221} of 59 studies finally identified, from a systematic search of 2057, used a comparator group.

The one RCT reported first aid/ naloxone use at 8 of 13 witnessed overdoses within 3 months of interventions, 2 of the 5 witnessed by facilitator trained group administered naloxone, zero of 3 in the passive group. {Williams 2014 250}

In a larger study {Espelt 2017 12} with standardized education and naloxone distribution, 158 (72%) received naloxone, of whom 94 (59%) reported having witnessed ≥1 overdose in the 12 months prior to the interview, 68% of whom (n = 64) helped the sufferer (59% of these administered naloxone), thus 40% used the kit in response to an overdose they witnessed. In another study {Dwyer 2015 381}, for those responding to an overdose (n=27) there were no significant differences in calling 9-1-1 or rescue breathing between standard education and standard education plus naloxone groups. However, 6 of 19 standard education plus naloxone administered nasal naloxone versus 0 of 8 in standard education.

In a retrospective cohort study {Doe-Simkins 2014 297} of “training” versus “no training”, no statistically significant differences in first aid behaviors were reported, including:

help-seeking (call for help/ 9-1-1)
rescue breathing
staying with the poisoned victim
success of naloxone administration

In a simulation study {Franko 2017 375}, a brief enhanced web education intervention when compared to a standard web presentation (<3 minutes), showed increased frequency of:

Pulse check
Breathing check (e.g., chest rise/fall, put ear to nose)
Tilting head to assist breathing
Properly administered naloxone

A heterogeneous reporting of educational outcomes exists {Williams 2014 250; Dunn 2017 S39; Dwyer 2015 381; Espelt 2017 12; Franko 2019 375; Jones 2014 166; Lott 2016 221}:

Knowledge of opioid overdose risks
Identification of opioid overdose
Knowledge of opioid overdose response
Knowledge of opioid antagonist (naloxone)
Skill to provide naloxone
Attitude/ willingness to aid
Attitude to call EMS and/or involve law enforcement

Surveying the 59 studies included, the domains of first aid education {IFRC 2016 25} were not represented in each intervention:

Plan & Prepare 45 (76%)- total curricular impact on behaviors of carrying naloxone; which groups to train
Early recognition 52 (88%)- what are the best means for improving recognition of OD (e.g., visuals v. words, previous experience) (knowledge, skills)
First Aid 59 (100%)- FA is contextual and more than just naloxone (knowledge, skills)
Accessing help 42 (71%)- area to improve based on observational studies, role of Law Enforcement Officers as barriers or naloxone delivery agents during event and post rescue
Advanced care 8 (14%)- did not include in this scoping review (pharmacy & medical education), but literature is developing on the need for advanced care if resuscitation is successful with naloxone.
Self-recovery 8 (17%)- linkages back to tertiary prevention. Any mental trauma for responders or social push back from poisoned victims or community.

Overall, 62.7% of the 59 studies had people who use illicit opioids enrolled as learners, 81.4% reported educational outcomes along with 47.5% reporting first aid outcomes. 84% of 43 manuscripts reporting no skill practice had positive educational outcomes versus 75% of 16 manuscripts reporting skill practice. This reversed with poisoned victim outcomes, where 90% of 16 manuscripts reporting skill practice also reported positive results versus 79% of 43 manuscripts reporting no skill practice. In terms of length of education intervention, all 6 manuscripts reporting training time to be ≤15 minutes (brief) reported either positive outcomes for education and/or poisoning victim. Of the 22 trainings from 16-60 minutes (Standalone programs) and reporting educational outcomes, 16 (73%) were positive. Of the 16 reporting poisoned victim outcomes 14 (88%) were positive. Of the 7 education programs >60 minutes (Opioid education embedded in other prevention) and reporting educational outcomes 6 (86%) were positive; 3 reported poisoned victim outcomes 1 (33%) was positive.

3. Narrative Reporting of the task force discussions

The EIT Task Force identified and raised the following as limitations and possibilities within opioid overdose education:

Inconsistent reporting of educational interventions makes comparison between studies challenging to readers. The use of the Guideline for Reporting Evidence-based practice Educational interventions and Teaching (GREET) checklist for educational interventions would help standardize future analysis {Phillips 2016 doi:10.1186/s12909-016-0759-1}.
With only one RCT and seven other studies with control groups, a lack of experimental rigor limits comparison and strength of any future recommendations.
First Aid and Survival outcomes were self-reported by people generally coming in for a refill of their prescription for naloxone. The verifiability of this data was not reported. A prospective means to validate self-reported use of first aid/naloxone in these emergencies should be developed. For example, if EMS was called, corroborating poisoned victim status, naloxone administration, and outcome could help establish validity. This is challenging as there is existing debate about the need for hospitalization post overdose reversal.
The interventions that reported training people in the skills also reported on survival outcomes 61% of the time (11/18) compared to no-skill intervention 45% (19/42), as noted above the positive outcomes for poisoned victim were also higher in skill inclusive training (91%- 10/11 v.79%- 15/19). Brief training (<15 minutes) for people who use opioids non-medically without skills appears beneficial for positive poisoned victim outcomes, perhaps due to personal and social experience with drugs. Also, standalone education (16-60 minutes) with skill training for people who use opioids medically and non-medically and first responders appears to show benefits for poisoned victim outcomes.

Knowledge Gaps

In trying to understand the limitations of the current evidence base for opioid overdose education, the EIT task force identified gaps that if filled would strengthen future guidelines:

Validation of a tool(s) that works across populations to report educational outcomes. Specifically, for educational outcomes (opioid knowledge and risks, opioid overdose early recognition, first aid for overdoes and skills, accessing additional help, knowledge of self-recovery for poisoned victim and first aider).
Exploration of the relationships between domains of first aid education and how to better move poisoning victims through the actions of lay responders through chain of survival behaviors.
Comparison of educational approaches within populations of potential responders (i.e., people who use opioids non-medically or are likely to witness overdose, prescribed, carers- family, teachers, first responders, and unrelated bystanders) and comparison of an educational approach between groups.
Social-ecological relationships between bystander and risk/opportunity to aid. For example, costs and opportunities for training people who use opioids non-medically directly versus random bystanders; differences in educational and helping motivations between groups; length of intervention.
Evidence to support the timing of naloxone within a resuscitation sequence, to help standardize education.
Evidence based practice for lay responders to recognize opioid overdoses, to help standardize education

References

Doe-Simkins M, Quinn E, Xuan Z, Sorensen-Alawad A, Hackman H, Ozonoff A, Walley AY. Overdose rescues by trained and untrained participants and change in opioid use among substance-using participants in overdose education and naloxone distribution programs: a retrospective cohort study. BMC Public Health [Internet]. 2014;14:297.

Dunn KE, Yepez-Laubach C, Nuzzo PA, Fingerhood M, Kelly A, Berman S, Bigelow GE. Randomized controlled trial of a computerized opioid overdose education intervention. Drug Alcohol Depend 2017;173:S39–S47.

Dwyer K, Walley AY, Langlois BK, Mitchell PM, Nelson KP, Cromwell J, Bernstein E. Opioid education and nasal naloxone rescue kits in the emergency department. West J Emerg Med 2015;16:381–384.

Espelt A, Bosque-Prous M, Folch C, Sarasa-Renedo A, Majo X, Casabona J, Brugal MT, Esteve A, Montoliu A, Munoz R, Gonzalez V, Ausina V, Vecino C, Colom J, Merono M, Altabas A. Is systematic training in opioid overdose prevention effective? PLoS One 2017;12.

Franko TS, Distefano D, Lewis L. A novel naloxone training compared with current recommended training in an overdose simulation. J Am Pharm Assoc. 2019;59:375–378.

ILCOR. Opioid Toxicity. 2015 [cited 2019 Dec 26]; Available from: https://volunteer.heart.org/apps/pico/Pages/PublicComment.aspx?q=441

ILCOR. Resuscitation care for suspected opioid-associated emergencies. 2015 [cited 2019 Dec 26]; Available from: https://volunteer.heart.org/apps/pico/Pages/PublicComment.aspx?q=811

ILCOR. Opioid overdose response education. 2015 [cited 2019 Dec 26]; Available from: https://volunteer.heart.org/apps/pico/Pages/PublicComment.aspx?q=891

International Federation of Red Cross Red Crescent Societies. International first aid and resuscitation guidelines 2016 [Internet]. Geneva, Switzerland: International Federation of Red Cross Red Crescent Societies; 2016. Available from: http://www.ifrc.org/Global/Publications/Health/First-Aid-2016-Guidelines_EN.pdf

Jones JD, Roux P, Stancliff S, Matthews W, Comer SD. Brief overdose education can significantly increase accurate recognition of opioid overdose among heroin users. Int J Drug Policy. 2014;25:166–170.

Lott DC, Rhodes J. Opioid overdose and naloxone education in a substance use disorder treatment program. Am J Addict. 2016;25:221–226.

Phillips, A.C., Lewis, L.K., McEvoy, M.P. et al. Development and validation of the guideline for reporting evidence-based practice educational interventions and teaching (GREET). BMC Med Educ 16, 237 (2016) doi:10.1186/s12909-016-0759-1

Williams A V, Marsden J, Strang J. Training family members to manage heroin overdose and administer naloxone: randomized trial of effects on knowledge and attitudes. Addiction. 2014;109:250–259.

Opioid Overdose First Aid Education (EIT): Scoping Review

ILCOR staff

Conflict of Interest Declaration

Task Force Scoping Review Citation

Scoping Review

PICOST

Search Strategies

Inclusion and Exclusion criteria

Data tables

Task Force Insights

Knowledge Gaps

References

Discussion

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