Naloxone access among an urban population of opioid users

2126 Correspondence / American Journal of Emergency Medicine 36 (2018) 21032128

were inadequate in the vast majority of episodes reviewed. The outcome depicted in the TVMD reviewed was also unrealistic.

As TVMD may serve as a source of medical knowledge, it is important to portray accurate information, especially improving the fidelity of the CPR techniques depicted. High rates of successful outcomes may give viewers false expectations towards survival rates after a cardiac arrest.

Luz Ramirez, R.A. Alejandro Castaneda R.A.

Dorrington Medical Associates, PA, Houston, TX, USA

Daryelle S. Varon, MS

Dorrington Medical Associates, PA, Houston, TX, USA St. James School of Medicine, Anguilla, British West Indies

Sharon Einav, MSc, MD

Hebrew University School of Medicine, Shaare Tzedek Medical Center,

Jerusalem, Israel

Salim R. Surani, MD

Texas A&M University, Corpus Christi, TX, USA

Joseph Varon, MD The University of Texas Health Science Center at Houston, USA The University of Texas, Medical Branch at Galveston, USA United Memorial Medical Center, Houston, TX, USA

Corresponding author at: 2219 Dorrington Street, Houston, TX

77030, USA.

E-mail address: [email protected].

23 March 2018


  1. Diem S, Lantos J, Tulsky J, et al. Cardiopulmonary resuscitation on television-miracles and misinformation. N Engl J Med 1996;334(24):1578-338.
  2. Gordon PN, Williamson S, Lawler PG, et al. As seen on TV: observational study of car- diopulmonary resuscitation in British television medical dramas. BMJ 1998;317 (7161):780-3.
  3. Duarte F, Einav S, Varon J. False memories: healthcare professionals’ claims of having seen a patient returning to normal activity after CPR. Am J Emerg Med 2016;34: 925-7.
  4. Berger E. From Dr. Kildare to Grey’s Anatomy. TV physicians change real patients ex- pectations. Ann Emerg Med 2010;56(3):21A-3A.

    Naloxone access among an urban population of opioid users

    Opioids, both prescription and illicit, are the main cause of drug over- dose deaths. Per the CDC, opioids were involved in 33,091 deaths in 2015, and opioid overdoses have quadrupled since 1999 [1]. The distribution of naloxone to at-risk populations has been shown to reduce the likelihood of death from an overdose [2] and has been recommended by most major professional medical organizations [3-6]. Our urban center hosts one of the oldest Naloxone distribution programs in the country [7].

    Although all opioids have a role in the rising numbers of overdose deaths, previous literature has shown that not all opioid users are the same. The type and route of initial opioid use correlate to different rates of escalation [8] and different reasons for use [9]. Our study sought to evaluate whether naloxone awareness and access differs depending on the type of opioid used.

    A convenience sample of patients who presented to the Emergency Department (ED) at John H Stroger Jr. Hospital of Cook County in Chi- cago, IL for any complaint, and were identified by their care providers as opioid users, were administered a 14-question survey. This included basic demographic information, questions about which opioids they currently used, history of intravenous Heroin use, awareness of and ac- cess to naloxone, how they obtained naloxone and if they had ever used it. From April 2016 to October 2016, 101 patients were surveyed. Inclu- sion criteria: opioid use within the previous 3 months and age greater than 18 years. Exclusion criteria: acute intoxication and inability to con- sent, incarceration, involuntary psychiatric admissions, and those tak- ing opioids as prescribed. This study received IRB exempt status.

    The average age of survey responders was 47.3 years old (range 22-72 years old); 72% were male; 57% black, 31% white; 15% Hispanic. When asked about their current use, 38% injected heroin, 72% snorted heroin, 8% used prescription pills. When asked if they had ever injected heroin, 53% replied that they had.

    When asked about naloxone, 55% of all responders had heard of it and 22% had access to it at some point. When looking just at the re- sponders with a history of injecting heroin, 76% had heard of naloxone and 39% had access to it at some point. When looking at the responders with no history of injecting heroin, 32% had heard of naloxone, and 2% had access to it at some point.

    It is unclear from our study why naloxone awareness and access dif- fered so much between patients with and without a history of injection heroin use. In our population, snorting heroin was the most common method of opioid use. Perhaps because this population was not using needles, they had no need to go to needle exchange harm reduction pro- grams, which was the primary provider of take-home naloxone found in our survey results. It is also possible that snorting heroin is perceived to be safer [10], and thus this population may be less worried about over- dose and death. This is a concerning hypothesis because, although the absorption kinetics are altered when heroin is snorted, overdose is still possible, especially given the recent trend of heroin laced with more po- tent Synthetic opioids, such as fentanyl [11].

    Many physicians and EDs have started prescribing naloxone. Illinois has also enacted legislation to allow the purchase of naloxone at pharma- cies without prescription. None of our survey responders got naloxone from their physicians, from an ED, or purchased it for themselves. All re- sponders with access to naloxone had gotten it for free from a harm- reduction program or from someone they knew. Given that the push to make naloxone more widely available is a somewhat recent phenome- non, perhaps we have not yet seen the results of these efforts. This may also represent a local phenomenon showing the relative success that harm reduction programs have had in Chicago to distribute naloxone.

    Of the 22 people who had naloxone, 7 had it used on themselves, 10 had used it on someone else, and 9 had used it more than once. In total, 43 naloxone reversals were reported. This is consistent with previously reported data showing that naloxone distribution results in a high num- ber of overdose reversals in the community [2].

    Our survey suggests that current naloxone distribution programs are missing certain populations of opioid users, especially those who have no history of injecting heroin. Further study is needed to elucidate the extent and the reasons why these populations are being missed, so that we may distribute naloxone more effectively to at-risk populations going forward. Emergency providers may be uniquely positioned to identify these naloxone-unaware populations and provide them with a lifesaving antidote.

    Special thanks to the Cook County Emergency Medicine Research Associates Program, Errick Christian, and Dr. John Bailitz.

    Source of support

    This research did not receive any specific grant from funding agen- cies in the public, commercial, or not-for-profit sectors.

    Correspondence / American Journal of Emergency Medicine 36 (2018) 21032128 2127

    Jenna K. Nikolaides, MD, MA Toxikon Consortium, Department of Emergency Medicine, Division of Toxicology, 1900 West Polk Street, 10th Floor, Chicago, IL 60612, USA Corresponding author at: Toxikon Consortium, Department of Emergency Medicine, Division of Toxicology, 1900 West Polk Street,

    10th Floor, Chicago, IL 60612, USA.

    E-mail address: [email protected].

    Lum Rizvanolli, BS Cook County Health and Hospital System, Department of Emergency Medicine, 1900 West Polk Street, 10th Floor, Chicago, IL 60612, USA

    Michael Rozum, BS Cook County Health and Hospital System, Department of Emergency Medicine, 1900 West Polk Street, 10th Floor, Chicago, IL 60612, USA Rush Medical College, 600 S. Paulina St, Chicago, IL 60612, USA

    Steven E. Aks, DO Toxikon Consortium, Department of Emergency Medicine, Division of Toxicology, 1900 West Polk Street, 10th Floor, Chicago, IL 60612, USA Cook County Health and Hospital System, Department of Emergency Medicine, 1900 West Polk Street, 10th Floor, Chicago, IL 60612, USA

    19 December 2017


    Centers for Disease Control and Prevention. Opioid overdose. Drug overdose death data.; December 16, 2016, Accessed date: 29 August 2017.

  5. Wheeler E, Jones TS, Gilbert MK, Davidson PJ. Centers for disease control (CDC). Opi- oid overdose prevention programs providing naloxone to laypersons–United States, 2014. MMWR Morb Mortal Wkly Rep 2015;64:631-5.
  6. American Medical Association. AMA adds new tools to combat opioids. https://; June 15, 2016, Accessed

    date: 29 August 2017.

    American College of Emergency Physicians. Naloxone prescriptions by emergency phy- sicians.–Practice-Management/Naloxone-Prescriptions- by-Emergency-Physicians/; October 2015, Accessed date: 29 August 2017.

  7. Doyon S, Aks SE, Schaeffer S. Expanding access to naloxone in the United States. Clin Toxicol (Phila) 2014;52:989-92.
  8. World Health Organization. Naloxone: a take-home antidote to drug overdose that saves lives.; November 2014, Accessed date: 29 August 2017.
  9. Harm Reduction Coalition. Naloxone program case studies: Chicago recovery alliance. program-case-studies/chicago-recovery-alliance/; 2011, Accessed date: 29 August 2017.
  10. Hines LA, Lynskey M, Morley KI, Griffiths P, Gossop M, Powis B, et al. The relationship be- tween initial route of heroin administration and speed of transition to daily heroin use. Drug Alcohol Rev 2017 May 3. [Epub ahead of print].
  11. Canfield MC, Keller CE, Frydrych LM, Ashrafioun L, Purdy CH, Blondell RD. Prescrip- tion opioid use among patients seeking treatment for Opioid dependence. J Addict Med 2010 Jun 1;4(2):108-13.
  12. American Addiction Centers. Signs and risks of snorting heroin. http://; 2016. [accessed Aug 29, 2017].
  13. Ciccarone D. Fentanyl in the US heroin supply: a rapidly changing risk environment. Int J Drug Policy 2017 Aug;46:107-11.

    A comparison of comfort assessment of NECKLITE vs. NeXsplint cervical collar. Pilot data


    spinal cord injury is a severe and Life-threatening complication of trauma [1]. Until recently, it was obligatory to secure a patient with a suspected cervical spine trauma by using the cervical collar and by

    placing the patient on a spinal board which is equipped with head sta- bilizers [2-4]. However, numerous studies indicate that immobilization of the cervical spine with a cervical collar may be associated with patient’s discomfort due to the exacerbation of pain. Hauswald et al.

    indicated that the risk of neurological injury due to inadequate im- mobilization may be over-estimated.

    Therefore it seems reasonable to research new methods of stabiliza- tion of the cervical spine in trauma patients. New types of cervical col- lars may be of help, as due to the way they are built they do not put pressure on the Soft tissues, including mastoid processes, as well as they do not intensify the pain. The Necklite is a prime example of a mod- ern moldable cervical stabilization device, which molds to accommo- date to patient size and position. It is a semi-rigid collar which can be molded to combine safely both comfort and support. These characteris- tics allow the device to be folded or rolled for compact storage in back- packs, kits, and narrow pockets. A series of small, moldable tabs positioned under the chin conform to each patient’s unique features. Once applied and adjusted, the device securely stabilizes the neck.

    The aim of the study was the assessment of comfort when using the cervical collar as a method of immobilization of the cervical spine.

    The study was designed as a crossover randomized study. 87 healthy volunteers were included. They were chosen from the participants of Basic Life Support and Advanced Cardiovascular Life Support courses. The study protocol was approved by the Institutional Review Board of the Polish Society of Disaster Medicine (Approval number: 229.12.2017.IRB) and had been carried out from December 2017 to Feb- ruary 2018. Before the study all participants were informed about the aims of the study. The participation in the study was voluntary. Healthy participants without any degenerative changes within the cervical spine were included into the study.

    In the study two types of cervical collars were used:

    NECKLITE (FLAMOR SRL, San Pietro Mosezzo, Italy).

  14. NeXsplint cervical collar (NeXsplint; EmeGear, LLC, Carpinteria, CA, USA) which is designed to splint the Cervical Spine by securing the head to the torso of the patient above C-1 and below C-7; on two points anterior and two points posterior (Fig. 1).

    During the study, the participants wore a neck collar for 20 min, after which they had an hour of rest, after the rest a different type of collar was placed. The collar was adjusted and put on by independent instruc- tors. Both the order of the participants and the type of the collar were randomized. After completing the study, participants filled out a ques- tionnaire which assessed the comfort of using both types of collars. In the survey, the participants of the study were asked to define the pain associated with wearing the cervical collar – for this purpose a 100- degree scale was used (“1” – no pain, “100” – severe pain). If there was any pain, the participants were asked to show a precise localization in which they had experienced pain. Additionally we evaluated the partic- ipants’ preferences regarding the selection of the cervical collar.

    87 volunteers were included in the study. All of them wore both types of the cervical collars for 20 min each. Pain sensations accompany- ing different types of collars were varied and amounted to 9 +- 3 points for NECKLITE vs. 65 +- 21 points for NeXsplint (p b 0.001). The partici- pants of the study declared mastoid processes, mandible and the region of the sternum manubrium as the most painful places when wearing the NeXsplint collar.

    The study participants found the NECKLITE collar to be more patient- friendly when compared to the NeXsplint (95% vs. 5%, respectively) and they declared the NECKLITE to be their collar of choice during emer- gency for trauma patient.

    To sum up, during the comparison of two types of cervical collars on the healthy volunteers, the participants experienced less pain when using NECKLITE than NeXsplint. NECKLITE was also a type of collar that the participants of the study would use during real-life emergency.

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