Opioid-caused deaths increased in Florida following legislative efforts to close “pill mills” in 2012, with resulting increases seen in counterfeit opioid pills and heroin use.(15) This data explores opioid epidemic-related morbidity and mortality in south Florida through the lens of hospital admissions following the implementation of IDEA-SSP. With the introduction of fentanyl and high-potency analogues into the drug supply, sharp increases in opioid mortality were seen statewide between 2014-2016.(2, 17) Given the heretofore unmitigated statewide overdose crisis, it would be expected that hospital data would reflect regional trends of increasing overdose-associated admissions. However, following SSP implementation, while number of PWIO in our cohort did not change significantly, overdoses reported in PWIO decreased significantly. The temporal association suggests that the IDEA-SSP community distribution of take-home naloxone may have produced early effects in mitigating overdose-associated morbidity and mortality.
Several statewide opioid epidemic interventions were implemented before and directly following the study period, including a concerted law enforcement effort to close “pill mills”.(17) However, these statewide policies should theoretically affect all counties equally and thus do not temporally explain Miami-Dade’s decline in overdose deaths as reported by the Florida Department of Law Enforcement Medical Examiners Commission (Figure 1). During the study period, the IDEA-SSP distributed 795 naloxone kits to participants and 387 reversals were reported. Between 2016-2017, opioid-related mortality in Miami-Dade County declined 5%, from 321 deaths to 305 deaths. Similar declines were not seen in neighboring counties. Considered together, these data suggest early impacts of the first legal SSP in the state, operating in Miami-Dade County.
More low-barrier SSPs are needed across Florida to increase naloxone access among PWID and reduce statewide opioid-related morbidity and mortality. Due to negative experiences PWID have when receiving services in traditional health care settings, they may be less likely to visit such settings to access naloxone; highlighting the importance of establishing naloxone distribution programs in low-barrier settings where PWID may feel more comfortable—namely SSPs and other harm reduction modalities. Recent modeling simulating the impact of 13 naloxone distribution modalities on overdose deaths estimated expanding naloxone distribution through a single SSP can reduce a community’s overdose deaths by 65%.(18)
Limitations to this study exist. The ICD-10 does not have diagnosis codes for injection drug use or sequelae. This study relied on a novel ICD-10 adaptation of an ICD-9-based algorithm using codes for drug use and infectious consequences.(16) Additionally, stigma associated with injection drug use remains widespread, and patients may not have reported use, resulting in under-documentation. Most importantly, our data do not imply causality between the establishment of the SSP and the decrease in opioid-associated admissions. Previous epidemiologic evaluations of SSPs describe lag times between community SSP implementation and decline in chronic infections.(19) An analysis of HIV rates among PWID in Baltimore only noted significant decline after five years of increasing SSP service coverage, with sustained decline demonstrated thereafter.(19) Future research should explore longitudinal effects of the IDEA-SSP.
Despite these limitations, this study reveals a significant decrease in overdose-associated admissions among PWIO at a county safety-net hospital following the implementation of the IDEA-SSP in the setting of the contemporary Florida overdose crisis. Taken alongside medical examiner data, this study demonstrates trends of decreasing opioid overdose-related morbidity and mortality in Miami-Dade County. SSPs and take-home naloxone may impact the number of overdose-associated hospital admissions and warrant further study.