Improving Naloxone Distribution in the Opioid Epidemic A - - PowerPoint PPT Presentation

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Improving Naloxone Distribution in the Opioid Epidemic A - - PowerPoint PPT Presentation

Apr 09, 2024 166 likes •789 views

Improving Naloxone Distribution in the Opioid Epidemic A cost-effectiveness analysis of naloxone distribution to first responders and laypeople Tarlise Townsend , Freida Blostein, Tran Doan, Sammie Madson-Olson, Paige Galecki, and David Hutton

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Improving Naloxone Distribution in the Opioid Epidemic

A cost-effectiveness analysis of naloxone distribution to first responders and laypeople

Tarlise Townsend, Freida Blostein, Tran Doan, Sammie Madson-Olson, Paige Galecki, and David Hutton

University of Michigan School of Public Health Department of Health Management and Policy

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Drug overdose deaths, 1980-2016

The New York Times

60,000 Peak HIV deaths (1995) Peak gun deaths (1993) 59,000 to 69,000

  • verdose deaths

(2016) 50,000 40,000 30,000 20,000 10,000 Peak car crash deaths (1972)

1980 1985 1990 1995 2000 2005 2010 2015

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How can we distribute naloxone for maximum benefit given scarce resources?

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How can we distribute naloxone for maximum benefit given scarce resources?

Distribution to laypersons: users & others likely to witness an overdose Distribution to first responders: EMS, firefighters, & law enforcement

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How can we distribute naloxone for maximum benefit given scarce resources?

Pros

  • Earlier administration than in ER

Distribution to first responders: EMS, firefighters, & law enforcement

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How can we distribute naloxone for maximum benefit given scarce resources?

Distribution to first responders: EMS, firefighters, & law enforcement

Pros

  • Earlier administration than in ER
  • Most overdoses witnessed
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SLIDE 8

How can we distribute naloxone for maximum benefit given scarce resources?

Pros

  • Earlier administration than in ER
  • Most overdoses witnessed
  • First responders trained for such

situations

Distribution to first responders: EMS, firefighters, & law enforcement

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How can we distribute naloxone for maximum benefit given scarce resources?

Pros

  • Earlier administration than in ER
  • Most overdoses witnessed
  • First responders trained for such

situations Cons

  • Barriers to calling 911

Distribution to first responders: EMS, firefighters, & law enforcement

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How can we distribute naloxone for maximum benefit given scarce resources?

Distribution to laypersons: users & others likely to witness an overdose

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How can we distribute naloxone for maximum benefit given scarce resources?

Pros

  • Most overdoses witnessed

Distribution to laypersons: users & others likely to witness an overdose

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SLIDE 12

How can we distribute naloxone for maximum benefit given scarce resources?

Pros

  • Most overdoses witnessed
  • Laypeople administer effectively

Distribution to laypersons: users & others likely to witness an overdose

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How can we distribute naloxone for maximum benefit given scarce resources?

Pros

  • Most overdoses witnessed
  • Laypeople administer effectively
  • Earlier administration than FRs

Distribution to laypersons: users & others likely to witness an overdose

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How can we distribute naloxone for maximum benefit given scarce resources?

Pros

  • Most overdoses witnessed
  • Laypeople administer effectively
  • Earlier administration than FRs
  • Benefits a population not available to

FRs

Distribution to laypersons: users & others likely to witness an overdose

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How can we distribute naloxone for maximum benefit given scarce resources?

Pros

  • Most overdoses witnessed
  • Laypeople administer effectively
  • Earlier administration than FRs
  • Benefits a population not available to

FRs

  • Very cost-effective (Coffin & Sullivan, 2013)

Distribution to laypersons: users & others likely to witness an overdose

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How can we distribute naloxone for maximum benefit given scarce resources?

Pros

  • Most overdoses witnessed
  • Laypeople administer effectively
  • Earlier administration than FRs
  • Benefits a population not available to

FRs

  • Very cost-effective (Coffin & Sullivan, 2013)

Cons

  • Less politically palatable

Distribution to laypersons: users & others likely to witness an overdose

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How can we distribute naloxone for maximum benefit given scarce resources?

Pros

  • Most overdoses witnessed
  • Laypeople administer effectively
  • Earlier administration than FRs
  • Benefits a population not available to

FRs

  • Very cost-effective (Coffin & Sullivan, 2013)

Cons

  • Less politically palatable
  • Higher number needed to treat

Distribution to laypersons: users & others likely to witness an overdose

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  • More resources are allocated to naloxone for first

responders than for laypeople

The Question

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  • More resources are allocated to naloxone for first

responders than for laypeople

  • Layperson distribution is highly cost-effective

The Question

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  • More resources are allocated to naloxone for first

responders than for laypeople

  • Layperson distribution is highly cost-effective

…So is our disproportionate emphasis on first responder distribution merited?

The Question

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Compared to the status quo, what’s most cost-effective?

Few laypeople have naloxone Some first responders have naloxone

  • /-

(status quo)

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Compared to the status quo, what’s most cost-effective?

Few laypeople have naloxone Some first responders have naloxone More first responders have naloxone

  • /+
  • /-

(status quo)

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Compared to the status quo, what’s most cost-effective?

Few laypeople have naloxone More laypeople have naloxone Some first responders have naloxone More first responders have naloxone

+/-

  • /+
  • /-

(status quo)

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Compared to the status quo, what’s most cost-effective?

+/+

Few laypeople have naloxone More laypeople have naloxone Some first responders have naloxone More first responders have naloxone

+/-

  • /+
  • /-

(status quo)

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More Basics

  • Population: Users of heroin or other illicit opioids and misusers of

prescription pain relievers

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More Basics

  • Population: Users of heroin or other illicit opioids and misusers of

prescription pain relievers

  • Perspectives: Societal (productivity)
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More Basics

  • Population: Users of heroin or other illicit opioids and misusers of

prescription pain relievers

  • Perspectives: Societal (productivity)
  • Horizon: Lifetime
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More Basics

  • Population: Users of heroin or other illicit opioids and misusers of

prescription pain relievers

  • Perspectives: Societal (productivity)
  • Horizon: Lifetime
  • Data sources: National databases, one-off studies, expert interviews
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Simplified Markov Model

Currently misusing opioids Not currently misusing opioids

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Simplified Markov Model

Currently misusing opioids Not currently misusing opioids

Dead

Overdose + all other causes All other causes

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Currently misusing opioids

Integrated Decision Tree (Simplified)

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Currently misusing opioids

Overdoses Witnessed

Integrated Decision Tree (Simplified)

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Currently misusing opioids

Overdoses Witnessed

Integrated Decision Tree (Simplified)

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Currently misusing opioids

Overdoses Witnessed

Integrated Decision Tree (Simplified)

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Currently misusing opioids

Overdoses Witnessed

Integrated Decision Tree (Simplified)

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Cost (billions of dollars)

132 138 144 72.4 72.8 73.2 73.6 74.0

Effectiveness (millions of QALYs) Status quo Increased FR

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Cost (billions of dollars)

132 138 144 72.4 72.8 73.2 73.6 74.0

Effectiveness (millions of QALYs) Increased LP Status quo Increased FR

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Cost (billions of dollars)

132 138 144 72.4 72.8 73.2 73.6 74.0

Effectiveness (millions of QALYs) Increased LP Status quo Increased FR (Dominated!)

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Cost (billions of dollars)

132 138 144 72.4 72.8 73.2 73.6 74.0

Effectiveness (millions of QALYs) Status quo Increased FR (Dominated!) Increased LP Combined ($5800 per QALY)

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Threshold:

Prevalence of LP naloxone required for net benefit equal to 75% FRs equipped

Net Monetary Benefit (billions)

3,480 3,600 0.04 0.5 1.0 Prevalence of LP naloxone in high-LP condition

18% of LPs

High LP, High FR High LP, Low FR Low LP, High FR Low LP, Low FR

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Results highly robust to sensitivity analyses

  • No strategy surpassed $50,000 per QALY
  • No meaningful changes in rankings
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Implications of the “Safety Net” Hypothesis

Increase of 14%

0.8 0.9 1.0 1.1 1.2 Relative Risk of Overdose

Net Monetary Benefit (billions)

3,480 3,720

Implications

  • f the

“Safety Net” Hypothesis

High LP, High FR High LP, Low FR Low LP, High FR Low LP, Low FR

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Takeaways

  • Compared to increased first responder distribution,

increased layperson distribution entails greater gain at less cost.

  • Results are highly robust to sensitivity analyses.
  • Therefore, our current imbalance is not merited.
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Thank You…

Tran Doan Sammie Madson-Olson Paige Galecki Freida Blostein David Hutton

Coauthors: Informants:

  • Alice Bell, Prevention Point Pittsburgh
  • Leo Beletsky, Northeastern University
  • Robert Childs, North Carolina Harm Reduction Coalition
  • Rebecca Haffajee, University of Michigan
  • Brandon Hool, The Grand Rapids Red Project
  • Jimena Loveluck, Michigan Unified
  • Dominick Zurlo, New Mexico Department of Health Harm Reduction Program
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SLIDE 46

SUPPLEMENTARY SLIDES

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Summary

  • Background:
  • As opioid deaths rise, improved naloxone distribution is

crucial

  • Currently, first responder distribution is disproportionately

emphasized

  • Objective: Compare the cost-effectiveness of naloxone

distribution to (a) first responders and (b) laypeople

  • Takeaways:
  • Layperson distribution entails greater gain at less cost
  • Therefore, our current imbalance is not merited
  • Results are highly robust to sensitivity analysis
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Tornado Analysis

Prevalence of users Mortality due to overdose Utility of user Probability of subsequent OD Increased probability of OD if LP has Nx

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Parameter Base Case Value Range

Prevalence: First responder naloxone Low: 0.5 High: 0.75 Low: 0.1-0.5 High: 0-1 Prevalence: Layperson naloxone Low: 0.04 High: 0.75 Low: 0-0.1 High: 0-1 Prevalence: Opioid use 0.012 0.01-0.02 Probability: Overdose First: 0.05 Subsequent: 0.175 First: 0.0125-0.125 Subsequent: 0.095-0.32 Probability: Overdose is witnessed 0.8 0.55-0.9 Probability: Witness administers naloxone (if available) 0.5 0.4-0.9 Probability: Witness calls 911 0.55 0.1-0.7 Mortality reduction: Layperson naloxone administration 0.5 0.3-0.9 Mortality reduction: First responder naloxone administration 0.5 0.3-0.9

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Model Checks:

  • After 10 years, about 30% of

those alive are abstinent.

  • ~35,000 annual fatalities (not

shown)

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Mortality reduction due to FR naloxone 10% 25% 40% 55% 70%

Two-Way Sensitivity Analysis

Mortality reduction due to LP naloxone 10% 25% 40% 55% 70%

High LP, Low FR Low LP, High FR

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One-Way SA: Probability of Overdose (First)

Net Monetary Benefit

High LP, High FR High LP, Low FR Low LP, High FR Low LP, Low FR

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Net Monetary Benefit

One-Way SA: Probability of Overdose (Subsequent)

High LP, High FR High LP, Low FR Low LP, High FR Low LP, Low FR

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One-Way SA: Probability that Overdose is Witnessed

Net Monetary Benefit

High LP, High FR High LP, Low FR Low LP, High FR Low LP, Low FR

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One-Way SA: Base probability that the witness calls 911

Net Monetary Benefit

High LP, High FR High LP, Low FR Low LP, High FR Low LP, Low FR

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Programs providing naloxone to laypersons (2013)

Centers for Disease Control and Prevention

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Network for Public Health Law

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