Opioid Overdose First Aid Education (EIT): Scoping Review

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ILCOR staff

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This Review is a draft version prepared by ILCOR, with the purpose to allow the public to comment and is labeled “Draft for Public Comment". The comments will be considered by ILCOR. The next version will be labelled “draft" to comply with copyright rules of journals. The final Review will be published on this website once a summary article has been published in a scientific Journal and labeled as “final”.

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

Top of Form

#

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

Bottom of Form

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

1st Author, Year, 1st 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.


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