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In the midst of the opioid crisis in the US, efforts to mitigate overdose risks have become paramount, leading some states to introduce mandates for coprescribing the life-saving overdose reversal drug naloxone. These mandates were designed to specifically address people receiving opioid analgesics who had an elevated risk for overdose. This included people receiving high opioid dosages, those concurrently using benzodiazepines, or those with a history of substance use disorder or overdose. Using a nationally representative, multipayer cohort of patients receiving prescription opioids, we investigated how naloxone codispensing rates changed at the state level from 2016 to 2021 among patients with an elevated risk for overdose. Then we used controlled interrupted time series analyses to assess mandates' longitudinal impact on naloxone codispensing in ten states that implemented mandates. We observed an immediate and significant increase in the naloxone codispensing rates in eight states after the implementation of mandates. Nevertheless, in five of these states, the codispensing rates exhibited a subsequent downward trend after the initial increase. State mandates show potential for improving naloxone codispensing; however, mandates alone might not be adequate for sustained change. Further research is needed to identify strategies complementing and enhancing the impact of mandates in combating the overdose crisis.

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OBJECTIVES: The United States faces an ongoing drug overdose crisis, but accurate information on the prevalence of opioid use disorder (OUD) remains limited. A recent analysis by Keyes et al used a multiplier approach with drug poisoning mortality data to estimate OUD prevalence. Although insightful, this approach made stringent and partly inconsistent assumptions in interpreting mortality data, particularly synthetic opioid (SO)-involved and non-opioid-involved mortality. We revise that approach and resulting estimates to resolve inconsistencies and examine several alternative assumptions. METHODS: We examine 4 adjustments to Keyes and colleagues' estimation approach: (A) revising how the equations account for SO effects on mortality, (B) incorporating fentanyl prevalence data to inform estimates of SO lethality, (C) using opioid-involved drug poisoning data to estimate a plausible range for OUD prevalence, and (D) adjusting mortality data to account for underreporting of opioid involvement. RESULTS: Revising the estimation equation and SO lethality effect (adj. A and B) while using Keyes and colleagues' original assumption that people with OUD account for all fatal drug poisonings yields slightly higher estimates, with OUD population reaching 9.3 million in 2016 before declining to 7.6 million by 2019. Using only opioid-involved drug poisoning data (adj. C and D) provides a lower range, peaking at 6.4 million in 2014-2015 and declining to 3.8 million in 2019. CONCLUSIONS: The revised estimation equation presented is feasible and addresses limitations of the earlier method and hence should be used in future estimations. Alternative assumptions around drug poisoning data can also provide a plausible range of estimates for OUD population.

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BACKGROUND AND OBJECTIVES: National trends reveal a concerning escalation in racial and ethnic disparities in buprenorphine treatment duration for opioid use disorder. However, the extent of such disparities at the state level remains largely unexplored. This study aims to examine such disparities at the state level. METHODS: We analyzed 9,040,620 buprenorphine prescriptions dispensed between January 2011 and December 2020 from IQVIA Longitudinal Prescription data. The primary outcome was the difference in median treatment duration between White people and racial and ethnic minorities. We also included a second outcome measurement to quantify the difference in median treatment duration among episodes lasting ≥180 days. Using quantile regressions, we examined racial and ethnic disparities in treatment duration, adjusting for the patient's age, sex, payment type, and calendar year of the treatment episode. All analyses were conducted at the state level. RESULTS: Our study revealed substantial statewide variations in racial and ethnic disparities. Specifically, 21 states showed longer treatment durations for White people across all episodes, and eight states displayed similar trends among episodes lasting ≥180 days. Five states exhibited longer treatment durations for White people in both overall and long-term episodes. Fifteen states showed no racial and ethnic disparities. CONCLUSION AND SCIENTIFIC SIGNIFICANCE: These results are among the first to indicate substantial statewide variations in racial and ethnic disparities in buprenorphine treatment episode duration, providing a critical foundation for targeted interventions to enhance buprenorphine treatment, especially in states confronting such pronounced racial and ethnic disparities.

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This cohort study investigates factors associated with abrupt discontinuation of long-term high-dose opioid treatment at the national level and across US states.

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OBJECTIVES: Because buprenorphine treatment of opioid use disorder reduces opioid overdose deaths (OODs), expanding access to care is an important policy and clinical care goal. Policymakers must choose within capacity limitations whether to expand the number of people with opioid use disorder who are treated or extend duration for existing patients. This inherent tradeoff could be made less acute with expanded buprenorphine treatment capacity. METHODS: To inform such decisions, we used a validated simulation model to project the effects of increasing buprenorphine treatment-seeking, average episode duration, and capacity (patients per provider) on OODs in the United States from 2023 to 2033, varying the start time to assess the effects of implementation delays. RESULTS: Results show that increasing treatment duration alone could cost lives in the short term by reducing capacity for new admissions yet save more lives in the long term than accomplished by only increasing treatment seeking. Increasing provider capacity had negligible effects. The most effective 2-policy combination was increasing capacity and duration simultaneously, which would reduce OODs up to 18.6% over a decade. By 2033, the greatest reduction in OODs (≥20%) was achieved when capacity was doubled and average duration reached 2 years, but only if the policy changes started in 2023. Delaying even a year diminishes the benefits. Treatment-seeking increases were equally beneficial whether they began in 2023 or 2025 but of only marginal benefit beyond what capacity and duration achieved. CONCLUSIONS: If policymakers only target 2 policies to reduce OODs, they should be to increase capacity and duration, enacted quickly and aggressively.

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AIMS, DESIGN AND SETTING: We sought to describe longitudinal trends in buprenorphine receipt and buprenorphine-waivered providers in the United States from 2003 to 2021 and measure whether the relationship between the two differed after capacity-building strategies were enacted nationally in 2017. This was a retrospective study of two separate cohorts covering the years 2003-21, testing whether the association between two trends in these cohorts changed comparing 2003 to 2016 and from 2017 to 2021, among buprenorphine providers in the United States, regardless of treatment setting. Patients receiving dispensed buprenorphine at retail pharmacies. PARTICIPANTS: All providers who have obtained a waiver to prescribe buprenorphine in the United States, and an estimate of the annual number of patients who had buprenorphine for opioid use disorder (OUD) dispensed to them at a retail pharmacy. MEASUREMENTS: We synthesized and summarized data from multiple sources to assess the cumulative number of buprenorphine-waivered providers over time. We used national-level prescription data from IQVIA to estimate annual buprenorphine receipt for OUD. FINDINGS: From 2003 to 2021, the number of buprenorphine-waivered providers in the United States increased from fewer than 5000 in the first 2 years of Food and Drug Administration (FDA) approval to more than 114 000 in 2021, while patients receiving buprenorphine products for OUD increased from approximately 19 000 to more than 1.4 million. The strength of association between waivered providers and patients is significantly different before and after 2017 (P < 0.001). From 2003 to 2016, for each additional provider, there was an average increase of 32.1 [95% confidence interval (CI) = 28.7-35.6] patients, but an increase of only 4.6 (95% CI= 3.5-5.7) patients for each additional provider, beginning in 2017. CONCLUSIONS: In the United States, the relationship between the rates of growth in buprenorphine providers and patients became weaker after 2017. While efforts to increase buprenorphine-waivered providers were successful, there was less success in translating that into significant increases in buprenorphine receipt.

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Importance: Buprenorphine is an effective and cost-effective medication to treat opioid use disorder (OUD), but is not readily available to many people with OUD in the US. The current cost-effectiveness literature does not consider interventions that concurrently increase buprenorphine initiation, duration, and capacity. Objective: To conduct a cost-effectiveness analysis and compare interventions associated with increased buprenorphine treatment initiation, duration, and capacity. Design and Setting: This study modeled the effects of 5 interventions individually and in combination using SOURCE, a recent system dynamics model of prescription opioid and illicit opioid use, treatment, and remission, calibrated to US data from 1999 to 2020. The analysis was run during a 12-year time horizon from 2021 to 2032, with lifetime follow-up. A probabilistic sensitivity analysis on intervention effectiveness and costs was conducted. Analyses were performed from April 2021 through March 2023. Modeled participants included people with opioid misuse and OUD in the US. Interventions: Interventions included emergency department buprenorphine initiation, contingency management, psychotherapy, telehealth, and expansion of hub-and-spoke narcotic treatment programs, individually and in combination. Main Outcomes and Measures: Total national opioid overdose deaths, quality-adjusted life years (QALYs) gained, and costs from the societal and health care perspective. Results: Projections showed that contingency management expansion would avert 3530 opioid overdose deaths over 12 years, more than any other single-intervention strategy. Interventions that increased buprenorphine treatment duration initially were associated with an increased number of opioid overdose deaths in the absence of expanded treatment capacity. With an incremental cost- effectiveness ratio of $19 381 per QALY gained (2021 USD), the strategy that expanded contingency management, hub-and-spoke training, emergency department initiation, and telehealth was the preferred strategy for any willingness-to-pay threshold from $20 000 to $200 000/QALY gained, as it was associated with increased treatment duration and capacity simultaneously. Conclusion and Relevance: This modeling analysis simulated the effects of implementing several intervention strategies across the buprenorphine cascade of care and found that strategies that were concurrently associated with increased buprenorphine treatment initiation, duration, and capacity were cost-effective.

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In 2020, the ongoing US opioid overdose crisis collided with the emerging COVID-19 pandemic. Opioid overdose deaths (OODs) rose an unprecedented 38%, due to a combination of COVID-19 disrupting services essential to people who use drugs, continued increases in fentanyls in the illicit drug supply, and other factors. How much did these factors contribute to increased OODs? We used a validated simulation model of the opioid overdose crisis, SOURCE, to estimate excess OODs in 2020 and the distribution of that excess attributable to various factors. Factors affecting OODs that could have been disrupted by COVID-19, and for which data were available, included opioid prescribing, naloxone distribution, and receipt of medications for opioid use disorder. We also accounted for fentanyls' presence in the heroin supply. We estimated a total of 18,276 potential excess OODs, including 1,792 lives saved due to increases in buprenorphine receipt and naloxone distribution and decreases in opioid prescribing. Critically, growth in fentanyls drove 43% (7,879) of the excess OODs. A further 8% is attributable to first-ever declines in methadone maintenance treatment and extended-released injectable naltrexone treatment, most likely due to COVID-19-related disruptions. In all, 49% of potential excess OODs remain unexplained, at least some of which are likely due to additional COVID-19-related disruptions. While the confluence of various COVID-19-related factors could have been responsible for more than half of excess OODs, fentanyls continued to play a singular role in excess OODs, highlighting the urgency of mitigating their effects on overdoses.

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This study aimed to identify the strongest barriers and motivators associated with each step toward buprenorphine prescribing (1. obtaining a waiver, 2. beginning to prescribe, and 3. prescribing to more people) among a sample of Missouri-based medical professionals (N = 130). Item weights (number of endorsements times mean rank of the item's importance) were calculated based on their responses. Across groups, lack of access to psychosocial support services, need for higher levels of care, and clinical complexity were strong barriers. Among non-prescribers (n = 57, 46.3%), administrative burden, potential of becoming an addiction clinic, and concern about misuse and diversion were most heavily weighted. Among prescribers (n = 66, 53.7%), patients' inability to afford medications was a barrier across phases. Prominent motivators among all groups were the effectiveness of buprenorphine, improvement in other health outcomes, and a personal interest in treating addiction. Only prescribers reported the presence of institutional support and mentors as significant motivators.

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This cohort study examines racial and ethnic differences in the duration of buprenorphine treatment for opioid use disorder in the US from 2006 to 2020.

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Opioid overdose deaths remain a major public health crisis. We used a system dynamics simulation model of the U.S. opioid-using population age 12 and older to explore the impacts of 11 strategies on the prevalence of opioid use disorder (OUD) and fatal opioid overdoses from 2022 to 2032. These strategies spanned opioid misuse and OUD prevention, buprenorphine capacity, recovery support, and overdose harm reduction. By 2032, three strategies saved the most lives: (i) reducing the risk of opioid overdose involving fentanyl use, which may be achieved through fentanyl-focused harm reduction services; (ii) increasing naloxone distribution to people who use opioids; and (iii) recovery support for people in remission, which reduced deaths by reducing OUD. Increasing buprenorphine providers' capacity to treat more people decreased fatal overdose, but only in the short term. Our analysis provides insight into the kinds of multifaceted approaches needed to save lives.

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INTRODUCTION: Patients who initially survive opioid-related overdose are at high risk for subsequent mortality. Our health system aimed to evaluate the presence of disparities in prescribing naloxone following opioid overdose. METHODS: This was a retrospective cohort study of patients seen in our health system, which comprises two academic centers and eight community hospitals. Eligible patients had at least one visit to any of our hospital's emergency departments (EDs) with a diagnosis code indicating opioid-related overdose between May 1, 2018, and April 30, 2021. The primary outcome measure was prescription of nasal naloxone after at least one visit for opioid-related overdose during the study period. RESULTS: The health system had 1348 unique patients who presented 1593 times to at least one of the EDs with opioid overdose. Of included patients, 580 (43.2%) received one or more prescriptions for naloxone. The majority (68.9%, n = 925) were male. For race/ethnicity, 74.5% (1000) were Non-Hispanic White, 8.0% (n = 108) were Non-Hispanic Black, and 13.0% (n = 175) were Hispanic/Latinx. Compared with the reference age group of 16-24 years, only those 65+ were less likely to receive naloxone (adjusted odds ratio [aOR] 0.41, 95% confidence interval [CI] 0.20-0.84). The study found no difference for gender (male aOR 1.23, 95% CI 0.97-1.57 compared to female). Hispanic/Latinx patients were more likely to receive a prescription when compared to Non-Hispanic White patients (aOR 1.72, 95% CI 1.22-2.44), while no difference occurred between Non-Hispanic Black compared to Non-Hispanic White patients (aOR 1.31, 95% CI 0.87-1.98). CONCLUSIONS: Naloxone prescribing after overdose in our system was suboptimal, with fewer than half of patients with an overdose diagnosis code receiving this lifesaving and evidence-based intervention. Patients who were Hispanic/Latinx were more likely to receive naloxone than other race and ethnicity groups, and patients who were older were less likely to receive it. Health systems need ongoing equity-informed implementation of programs to expand access to naloxone to all patients at risk.

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The opioid crisis is a major public health challenge in the United States, killing about 70,000 people in 2020 alone. Long delays and feedbacks between policy actions and their effects on drug-use behavior create dynamic complexity, complicating policy decision-making. In 2017, the National Academies of Sciences, Engineering, and Medicine called for a quantitative systems model to help understand and address this complexity and guide policy decisions. Here, we present SOURCE (Simulation of Opioid Use, Response, Consequences, and Effects), a dynamic simulation model developed in response to that charge. SOURCE tracks the US population aged ≥12 y through the stages of prescription and illicit opioid (e.g., heroin, illicit fentanyl) misuse and use disorder, addiction treatment, remission, and overdose death. Using data spanning from 1999 to 2020, we highlight how risks of drug use initiation and overdose have evolved in response to essential endogenous feedback mechanisms, including: 1) social influence on drug use initiation and escalation among people who use opioids; 2) risk perception and response based on overdose mortality, influencing potential new initiates; and 3) capacity limits on treatment engagement; as well as other drivers, such as 4) supply-side changes in prescription opioid and heroin availability; and 5) the competing influences of illicit fentanyl and overdose death prevention efforts. Our estimates yield a more nuanced understanding of the historical trajectory of the crisis, providing a basis for projecting future scenarios and informing policy planning.

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Connections between substance use, impairment, and road safety have been frequently researched. Yet, little is known about how simultaneous use of opioids and alcohol affects road safety outcomes, which is an increasingly critical link within the current landscape of the substance use environment and public health. Lack of this understanding is partly due to testing complications and data limitations. We define polysubstance use here as alcohol and opioids consumed together or within a small-time window such that both are present in the system. This polysubstance use is on the rise and produces greater health risks than when the substances are consumed separately. Given the increasing rate of opioid use, high prevalence of alcohol use, and dangers of polysubstance use, we aim to synthesize literature on the prevalence and impact of this polysubstance on road safety-related outcomes. We performed a systematic review of studies published between 1974 and 2020 that examined opioid and alcohol use exposures and road safety-related outcomes. Out of 644 initial findings, 20 studies were included in this review. Outcomes included motor vehicle crash injuries, deaths, or driver culpability; suspected driving under the influence; and simulated driving performance. Evidence from multiple sources showed a significant rise, approximately 1% to 7%, in the prevalence of opioids among fatally injured drivers in the U.S. from 1995 to 2016. Information published on the simultaneous presence of opioids and alcohol in people involved in crashes was scarce. The limited available findings point toward an overlap where up to 30% of opioid-positive people involved in a crash were also positive for alcohol. Studies also suggest a possibly elevated risk presented by this polysubstance use relative to the substances used alone, though the majority of identified studies did not estimate this association. The synthesized research indicates that alcohol and opioid use is not uncommon and may be increasing among people involved in adverse driving events. More research and better data are needed to improve estimates of association with road traffic-related outcomes, potentially improving substance testing in current surveillance systems or using linked data sets and other novel data sources to improve estimates.

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Background: Online communities such as Reddit can provide social support for those recovering from opioid use disorder. However, it is unclear whether and how advice-seekers differ from other users. Our research addresses this gap by identifying key characteristics of r/suboxone users that predict advice-seeking behavior. Objective: The objective of this analysis is to identify and describe advice-seekers on Reddit for buprenorphine-naloxone use using text annotation, social network analysis, and statistical modeling techniques. Methods: We collected 5258 posts and their comments from Reddit between 2014 and 2019. Among 202 posts which met our inclusion criteria, we annotated each post to determine which were advice-seeking (n = 137) or not advice-seeking (n = 65). We also annotated each posting user's buprenorphine-naloxone use status (current versus formerly taking and, if currently taking, whether inducting or tapering versus other stages) and quantified their connectedness using social network analysis. To analyze the relationship between Reddit users' advice-seeking and their social connectivity and medication use status, we constructed four models which varied in their inclusion of explanatory variables for social connectedness and buprenorphine use status. Results: The stepwise model containing "total degree" (p = 0.002), "using: inducting/tapering" (p < 0.001), and "using: other" (p = 0.01) outperformed all other models. Reddit users with fewer connections and who are currently using buprenorphine-naloxone are more likely to seek advice than those who are well-connected and no longer using the medication, respectively. Importantly, advice-seeking behavior is most accurately predicted using a combination of network characteristics and medication use status, rather than either factor alone. Conclusions: Our findings provide insights for the clinical care of people recovering from opioid use disorder and the nature of online medical advice-seeking overall. Clinicians should be especially attentive (e.g., through frequent follow-up) to patients who are inducting or tapering buprenorphine-naloxone or signal limited social support.

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INTRODUCTION: Alongside the emergence of COVID-19 in the United States, several reports highlighted increasing rates of opioid overdose from preliminary data. Yet, little is known about how state-level opioid overdose death trends and decedent characteristics have evolved using official death records. METHODS: We requested vital statistics data from 2018-2020 from all 50 states and the District of Columbia, receiving data from 14 states. Accounting for COVID-19, we excluded states without data past March 2020, leaving 11 states for analysis. We defined state-specific analysis periods from March 13 until the latest reliable date in each state's data, then conducted retrospective year-over-year analyses comparing opioid-related overdose death rates, the presence of specific opioids and other psychoactive substances, and decedents' sex, race, and age from 2020 to 2019 and 2019 to 2018 within each state's analysis period. We assessed whether significant changes in 2020 vs. 2019 in opioid overdose deaths were new or continuing trends using joinpoint regression. RESULTS: We found significant increases in opioid-related overdose death rates in Alaska (55.3%), Colorado (80.2%), Indiana (40.1%), Nevada (50.0%), North Carolina (30.5%), Rhode Island (29.6%), and Virginia (66.4%) - all continuing previous trends. Increases in synthetic opioid-involved overdose deaths were new in Alaska (136.5%), Indiana (27.6%), and Virginia (16.5%), whilst continuing in Colorado (44.4%), Connecticut (3.6%), Nevada (75.0%), and North Carolina (14.6%). We found new increases in male decedents in Indiana (12.0%), and continuing increases in Colorado (15.2%). We also found continuing increases in Black non-Hispanic decedents in Massachusetts (43.9%) and Virginia (33.7%). CONCLUSION: This research analyzes vital statistics data from 11 states, highlighting new trends in opioid overdose deaths and decedent characteristics across 10 of these states. These findings can inform state-specific public health interventions and highlight the need for timely and comprehensive fatal opioid overdose data, especially amidst concurrent crises such as COVID-19. Key messages:Our results highlight shifts in opioid overdose trends during the COVID-19 pandemic that cannot otherwise be extracted from aggregated or provisional opioid overdose death data such as those published by the Centres for Disease Control and Prevention.Fentanyl and other synthetic opioids continue to drive increases in fatal overdoses, making it difficult to separate these trends from any possible COVID-19-related factors.Black non-Hispanic people are making up an increasing proportion of opioid overdose deaths in some states.State-specific limitations and variations in data-reporting for vital statistics make it challenging to acquire and analyse up-to-date data on opioid-related overdose deaths. More timely and comprehensive data are needed to generate broader insights on the nature of the intersecting opioid and COVID-19 crises.

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BACKGROUND: Reports analyzing drug overdose (OD) mortality data during the COVID-19 pandemic are limited. Outcomes across states are heterogenous, necessitating assessments of associations between COVID-19 and OD deaths on a state-by-state level. This report aims to analyze trends in OD deaths in Massachusetts during COVID-19. METHODS: Analyzing 3,924 death records, we characterize opioid-, cocaine-, and amphetamine-involved OD mortality and substance co-presence trends from March 24-November 8 in 2020 as compared to 2018 and 2019. RESULTS: OD deaths involving amphetamines increased by 85% from 2019 to 2020 (61 vs. 113; P<0.001) but were steady from 2018 to 2019. Heroin's presence continued to decrease (341 in 2018, 247 in 2019, 157 in 2020; P<0.001); however, fentanyl was present in more than 85% of all OD deaths across all periods. Among OD deaths, alcohol involvement consistently increased, present in 250 deaths in 2018, 299 in 2019 (P=0.02), and 350 in 2020 (P=0.04). In 2019, 78% of OD decedents were White and 7% were Black, versus 73% and 10% in 2020 (P=0.02). CONCLUSION: Increased deaths involving stimulants, alcohol, and fentanyl reflect concerning trends in the era of COVID-19. Rising OD death rates among Black residents underscore that interventions focused on racial equity are necessary.

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OBJECTIVES: The rapid increase in opioid overdose and opioid use disorder (OUD) over the past 20 years is a complex problem associated with significant economic costs for healthcare systems and society. Simulation models have been developed to capture and identify ways to manage this complexity and to evaluate the potential costs of different strategies to reduce overdoses and OUD. A review of simulation-based economic evaluations is warranted to fully characterize this set of literature. METHODS: A systematic review of simulation-based economic evaluation (SBEE) studies in opioid research was initiated by searches in PubMed, EMBASE, and EbscoHOST. Extraction of a predefined set of items and a quality assessment were performed for each study. RESULTS: The screening process resulted in 23 SBEE studies ranging by year of publication from 1999 to 2019. Methodological quality of the cost analyses was moderately high. The most frequently evaluated strategies were methadone and buprenorphine maintenance treatments; the only harm reduction strategy explored was naloxone distribution. These strategies were consistently found to be cost-effective, especially naloxone distribution and methadone maintenance. Prevention strategies were limited to abuse-deterrent opioid formulations. Less than half (39%) of analyses adopted a societal perspective in their estimation of costs and effects from an opioid-related intervention. Prevention strategies and studies' accounting for patient and physician preference, changing costs, or result stratification were largely ignored in these SBEEs. CONCLUSION: The review shows consistently favorable cost analysis findings for naloxone distribution strategies and opioid agonist treatments and identifies major gaps for future research.

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INTRODUCTION: The opioid crisis is a pervasive public health threat in the U.S. Simulation modeling approaches that integrate a systems perspective are used to understand the complexity of this crisis and analyze what policy interventions can best address it. However, limitations in currently available data sources can hamper the quantification of these models. METHODS: To understand and discuss data needs and challenges for opioid systems modeling, a meeting of federal partners, modeling teams, and data experts was held at the U.S. Food and Drug Administration in April 2019. This paper synthesizes the meeting discussions and interprets them in the context of ongoing simulation modeling work. RESULTS: The current landscape of national-level quantitative data sources of potential use in opioid systems modeling is identified, and significant issues within data sources are discussed. Major recommendations on how to improve data sources are to: maintain close collaboration among modeling teams, enhance data collection to better fit modeling needs, focus on bridging the most crucial information gaps, engage in direct and regular interaction between modelers and data experts, and gain a clearer definition of policymakers' research questions and policy goals. CONCLUSIONS: This article provides an important step in identifying and discussing data challenges in opioid research generally and opioid systems modeling specifically. It also identifies opportunities for systems modelers and government agencies to improve opioid systems models.

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BACKGROUND: The devastating impact of the current opioid overdose crisis has led to new involvement of law enforcement officers. Training programs have focused on overdose recognition and response without targeting core attitudinal change by covering addiction or harm reduction principles. OBJECTIVES: This study examined the impact of a comprehensive overdose education and naloxone distribution (OEND) training on officers' attitudes toward overdose victims, knowledge of and competence to respond to an opioid overdose, and concerns about using naloxone. The training included the common information about overdose recognition and response, with added components covering broader content about addiction and harm reduction principles and philosophies. METHODS: A total of 787 (83% male) officers were administered surveys before and after attending a 2.5-3 hour comprehensive OEND training. Survey items measured overdose-related knowledge and attitudes, including attitudes about people who use drugs and who overdose. RESULTS: Following the training, participants' overdose-related knowledge and perceived competence to use naloxone improved. However, there were more nuanced changes in attitudes toward overdose victims: though 55.3% of officers reported more positive post-training attitudes, 31% reported more negative attitudes, and 13.7% reported no attitudinal change. Younger officers were most likely to report worsened attitudes. Improvements in attitudes toward overdose victims were associated with reductions in both naloxone-related concerns and risk compensation beliefs. CONCLUSIONS: Despite a comprehensive OEND training that addressed addiction and harm reduction and directly targeted hypothesized drivers of negative attitudes (e.g., risk compensation beliefs), some officers' attitudes worsened after the training. Randomized experiments of different training approaches would elucidate the mediators and moderators underlying these unexpected responses.

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