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Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis

BMJ 2013; 346 doi: (Published 31 January 2013) Cite this as: BMJ 2013;346:f174
  1. Alexander Y Walley, assistant professor of medicine, medical director of Massachusetts opioid overdose prevention pilot13,
  2. Ziming Xuan, research assistant professor2,
  3. H Holly Hackman, epidemiologist3,
  4. Emily Quinn, statistical manager4,
  5. Maya Doe-Simkins, public health researcher1,
  6. Amy Sorensen-Alawad, program manager1,
  7. Sarah Ruiz, assistant director of planning and development3,
  8. Al Ozonoff, director, design and analysis core56
  1. 1Clinical Addiction Research Education Unit, Section of General Internal Medicine, Boston University School of Medicine, Boston, MA, USA
  2. 2Department of Community Health Sciences, Boston University School of Public Health, USA
  3. 3Massachusetts Department of Public Health, USA
  4. 4Data Coordinating Center, Boston University School of Public Health, USA
  5. 5Design and Analysis Core, Clinical Research Center, Children’s Hospital Boston, USA
  6. 6Department of Biostatistics, Boston University School of Public Health, USA
  1. Correspondence to: A Y Walley Boston Medical Center, Section of General Internal Medicine, 801 Massachusetts Avenue, 2nd Floor, Boston, MA 02118, USA awalley{at}
  • Accepted 31 December 2012


Objective To evaluate the impact of state supported overdose education and nasal naloxone distribution (OEND) programs on rates of opioid related death from overdose and acute care utilization in Massachusetts.

Design Interrupted time series analysis of opioid related overdose death and acute care utilization rates from 2002 to 2009 comparing community-year strata with high and low rates of OEND implementation to those with no implementation.

Setting 19 Massachusetts communities (geographically distinct cities and towns) with at least five fatal opioid overdoses in each of the years 2004 to 2006.

Participants OEND was implemented among opioid users at risk for overdose, social service agency staff, family, and friends of opioid users.

Intervention OEND programs equipped people at risk for overdose and bystanders with nasal naloxone rescue kits and trained them how to prevent, recognize, and respond to an overdose by engaging emergency medical services, providing rescue breathing, and delivering naloxone.

Main outcome measures Adjusted rate ratios for annual deaths related to opioid overdose and utilization of acute care hospitals.

Results Among these communities, OEND programs trained 2912 potential bystanders who reported 327 rescues. Both community-year strata with 1-100 enrollments per 100 000 population (adjusted rate ratio 0.73, 95% confidence interval 0.57 to 0.91) and community-year strata with greater than 100 enrollments per 100 000 population (0.54, 0.39 to 0.76) had significantly reduced adjusted rate ratios compared with communities with no implementation. Differences in rates of acute care hospital utilization were not significant.

Conclusions Opioid overdose death rates were reduced in communities where OEND was implemented. This study provides observational evidence that by training potential bystanders to prevent, recognize, and respond to opioid overdoses, OEND is an effective intervention.


  • We thank the Massachusetts OEND program staff, participants, and advocates and the leadership and staff of the Bureau of Substance Abuse Services and Office of HIV/AIDS at the Massachusetts of Department of Public Health for their cooperation and support, including John Auerbach, Andy Epstein, Michael Botticelli, Barry Callis, Grant Carrow, and Leonard Young; Christine Chaisson for her data management support; Jeffrey Samet, Leonard Paulozzi, and Sharon Stancliff for providing input on earlier versions of this manuscript; and Courtney Pierce for managing this project in its early stages. Preliminary data from this study were presented at the American Public Health Association conference on 1 November 2011, Association of Medical Education and Research on Substance Abuse conference on 5 November 2011, and at the US Food and Drug Administration on 12 April 2012.

  • Contributors: AYW, AO, and HHH developed the original study design and all authors contributed to additional model development. HHH developed the definitions for fatal and non-fatal opioid overdose outcome. EQ managed the data and she and ZX and AO performed data analysis. All authors contributed to data interpretation and had full access to the de-identified dataset in the study and take responsibility for the integrity of the data and accuracy of the data analyses. AYW, MD-S, and AS-A wrote the first draft of the manuscript and all authors contributed to editing. AYW is the guarantor.

  • Funding: This study was funded by the Center for Disease Control and Prevention- 1R21CE001602 (principal investigator AYW).The funder played no role in study design, data collection, analysis, interpretation of data, writing of the report, or the decision to submit. The researchers had independence from the funder.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: AYW, ZX, EQ, MDS, AS-A, and AO had support from the Center for Disease Control and Prevention grant 1R21CE001602-01 for this study; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: This study was approved by the institutional review boards of Boston University Medical Center (H-28736) and the Massachusetts Department of Public Health (249874-3). Because this study used de-identified data previously collected, informed consent was not required.

  • Data sharing: No additional data available.

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