Abstract

Opioids lethal overdose scales in the US and globally in the recent past has been consistently on the rise. Consequentially, the injection overdose deaths have grown tremendously making it a paradoxical phenomenon among medical scholars and scholars. The underlying causal factors remain relatively unclear because prevalence rates are high even in areas with sufficient supply of Naloxone survival kits. In the context of nursing practice, Opioids overdose deaths is preventable using Naloxone kits, with survival 99 % survival rates for victims. Therefore, it poses a disciplinary paradox among health professionals in the nursing field. On this note, the primary objective of this study is to critically examine the perceived benefits and risks of Naloxone survival kits in the communities with high prevalence of overdose deaths. Primarily, establish the underlying causal factors that prevent the use of the kit among individuals in Kentucky area. The project will adopt a logic model that will use a quasi-experimental approach with pre and post tests to evaluate the changes in the participants perception during the Overdose Education and Naloxone Distribution (OEND) patient feedback survey. The study will use multiple sources of evidence including peer-reviewed sources, scholarly publications, and news reports, government reports on the topic and survey questionnaires from respondents.

 

Section 1: Nature of the Project

Introduction

The rates of emergency visits in the American health institutions in the US have been on a tremendous increase since 2010. Statistics from FDA and the US Department of health indicate a double growth of the reported cases between the 2010 and 2016; down from 21,089 to 42,246. There are varying scholarly perspectives on the causal agents of the increase. While some attribute the upsurge to the proliferation of new drugs in the market that are highly synthetic, others support a legislature fail view. However, there is a consensus among the scholarly opinions on the critical role that the increased use of heroin plays a central role in this observed phenomenon. Recent studies also reveal that the current trends of many users and dealers mixing heroin and other synthetic opioids also account for the increase in the overdose cases. In the same period, between 2010 and 2016, the price and availability of painkiller prescription medication went high and reduced respectively. This trend was mainly due to changes in the policy rules and regulatory framework. Pain medication such as Oxycodone has gone up, making it unaffordable for most middle-class users(Cicero, Inciardi, & Surratt, 2007, p. 117). Subsequently, the users turn into the street opioids a solution to their physiological needs, a transition that leads to addictions. Legislation and laws on illegal substances in a similar trend has gone up with government agencies putting in place enforcement agencies to fight the trade. As such, the illegal trade is very unpredictable with the probability of overdose being high due to high heroin content in the pills.

Accidental overdose, according to several medical reports of the fatal cases registered in the hospitals shows that the patients did not know about the overdose(Bohnert et al., 2012, p. 66). The fact that most of the dealers in the street lack any medical knowledge on the use of these prescriptions put the consumers even at a higher risk of accidental overdose. Anxiety and sleep medication pills have also been on the increase in the recent past. Most of the drugs bought on the streets are not FDA approved making them unfit for human consumption. The sudden increase in the use of street opioids in place of pharmacy medication led upward surge of overdose deaths (Oquendo & Volkow, 2018, p. 1569). In the United States, NCSA (National Center on Addiction and Substance Abuse) report (2015) revealed that the problem is the leading cause of death among people under the age of 50 years as illustrated by figure 1 below.

Figure 1: Annual death rates classified as ICS-10 (Drug Poisoning) Source NCHS- (National Vital Statistics Mortality)

In the year that followed, more than 11.8 million individuals aged 12 years were reported to be users of the opioids. However, recent statistics reveal that the new addictions cut across all the demographic groups as shown by the deaths tolls in the past years. As shown in figure 1 above, the opioids deaths between 2000 and 2015 have been on a constant increase. However, the issue of overdose deaths is preventable manageable, and most importantly it can be reversed. Therefore, it is essential to establish whether there is a correlation between the increase in death rates and the reduced use of available Naloxone kits. The kits act as an antagonist agent that temporarily reverse overdose allowing medical intervention.

The antidote elements in the Naloxone make it easy to use and highly effective. However, the availability of the kits among communities where overdose cases are highly prevalent is relatively high, and therefore the reduced usage among victims is paradoxical. In the Kentucky faith-based community, there is an underlying issue of reduced usage. In this regard, this project will undertake a study to establish the causal factors that explain this phenomenon. Available research shows that the availability of Naloxone kits reduces the probability of overdose deaths. One of the most recent studies reveals a direct correlation between high availability and reduced overdose deaths.

However, public awareness among the target population is a critical component that helps to advance usage among users. Most cases of overdose reports show an immediate response by family members or close relatives in these communities. Essentially, identifying instances of at-risk overdose is of great importance to reverse the current trends of high death rates. Laws and statutory regulation governing the administration and handling of the Naloxone may shed light on the phenology of the potential benefits and risks of naloxone. Usage authorization is limited to police officers, first aid responders and non-medical community workers dealing with opioid overdose. Few community members are either unaware of the existence or the potential positive impact of using Naloxone as a response strategy in overdose cases.

Availability of naloxone survival kits within the geographical area of this projective initiative has provided the possibility to reverse overdose situations, although there are still many debates concerning the process at both the local, state and national level. According to most medical scholars, it is crucial for community members to carry around the naloxone antidote if they know that there are individuals who meet the criteria of at-risk persons. According to the National Center for Substance Abuse, there are four points that a community member may use to determine whether an individual qualifies as a vulnerable person to overdose, namely:

• A person who abuse prescription opioids or heroin-lased substances such as fentanyl or carfentanil
• A medically diagnosed patient with opioid use disorder currently undergoing a detoxification program using medication such as methadone or naltrexone. They may not necessarily be taking medication as long as they have in the recent past finished treatment.
• A recently discharged individual from emergency care treatment due to an overdose.
• An individual diagnosed with a history of opioid overdose or misuse.
• Any patient with active prescriptions of using opioids for the chronic pain management or any other sedative.

Community members who meet these criteria mentioned above are vulnerable to an overdose, and therefore it is essential for them or individuals close to them always to carry naloxone medication. The main reason for taking this cautionary strategy is to ensure that in case of an emergency, it is easier for the first responders to administer the antidote. However, the arising ethical debates that arise on the validity of this evaluation and the role it plays towards reduced opioid use in the community. Following the rise in these trends, most states across the USA constituted laws that legally protect pharmacists selling of naloxone over the counter without a prescription. The initiative was primarily an effort to increase the accessibility of the antidote and consequentially lead to reduced cases of death due to an overdose. Critics to the laws assert that the punitive laws have a negative impact on the efforts to reduce usage among the population as opposed to contributing to reduced deaths.

The most compelling argument cites the reduced risk of death as an incentive of users to increase consumption. In their view, elimination of the risk of death presents users with psychological confidence to increase their usage because they are no fear of the negative consequences. In the opinion of this doctoral study, it is illogical to reduce access to medication that positively reverses a social problem in society. The ethical issue, therefore, is the consequence of the death or emergency admission due to unavailability of the antidote. The paper will present a project proposal surrounding naloxone survival kit administration through identification and analysis to the evaluation stage.

1.2 Structure

This dissertation is drafted in a series of sections as outlined below

• The introduction section one will present the problem statement, purpose, nature of the doctoral project and significance sections as the main subheadings. Typically, the chapter will provide an exhaustive overview of the current issue backed by evidence that proves the existing problem of overdose deaths. Literary analysis will seek to put the question in an advanced nursing context, practice and offer a justification of the merits of the study. The section aims to pursue an explorative approach that will help to construct evidence-based theories that challenge the preconceived notions on the matter. Within, the section methodological approaches applied in the data analysis will also be comprehensively explained to validate the theoritical conclusions therein.
• Section two of the study will focus on the data research methodology used in the paper. It will offer the reader an explanation of the pros of the identified methods in correspondence to its objectives. In essence, the section will show the rationale used to determine participants, research instruments and study methodology. One of the critical components is the analysis of data collected during the study. The section will in-depth support the validity of these analytical tools used thereby revealing their role in formulating the theoretical conclusions of the findings. It will also offer how the methods relate to nursing practice utilizing the background information provided.
• Section three provides insights on the collection of the evidence gathered from the focus groups, literary reviews and educational seminars employed by the study. The perspectives of the community members will be an integral part of the research because it helps to advance the understanding of the individual. The section will closely correlate the perceptions of the Kentucky Baptist community on Naloxone use during an overdose and connect findings with the existing literature. It will also evaluate the sources of the evidence used by the study to determine their validity.
• Section four will critically examine the finding of the research as provided for by the respondents to uncover an underlying thematic connection. The connection between these themes will reveal a relationship that will create a link between the views of the participants and the existing literature that supports or critiques their point of view. Further, the section will conduct an in-depth review of the resulting analysis and subsequently formulate recommendations that will guide the resolution of the problem statement. It will closely relate the projects main strengths and scholarly contributions to the field of advanced nursing practice. In the last subsection, it will critically discuss the limitations faced in the course of the study and ways the lessons future may refer. In a nutshell, the section will primarily focus on reviewing the findings of the research and subsequently provide recommendations for increased accessibility of Naloxone medication among at-risk opioid users.
• Section five will outline a clear dissemination plan of the dissertation findings and recommendations to an institution within the Kentucky community with the highest prevalence rates of overdose mortality. In the project, it will propose an implementation outline to be used by the community-based faith organizations that characterize the study area.

1.3 Problem Statement

Opioid overdose cases have seen a substantial increase in the Central Kentucky area. Since 2007, annual occurrences of fatal overdose in Lexington have increased from one to an average of twenty-two (Kentucky Office of Drug Control Policy, 2017). The prevalence of the problem hit record high levels since 2011 with a market survey by National Health statistics indicating an increase of 371 million new users in the same period. Last year, there was an 11.5 % increase in the usage among the residents of the area according to the Office of the Drug control. The figure below shows a summary of the increasing trends of overdose deaths in the state of Kentucky in comparison to the US national rates.

Fig. 2 Annual Death rates per 100,000 people in Kentucky ( Source S. Slavova et al. / International Journal of Drug Policy 46 (2017) 120–129

These findings reveal how the rates of deaths in Kentucky is increasingly becoming a health crisis. According to Ellis & Harney (2015), the increased usage is due to the annual growth of heroin sales in the state and great marketing by “Opioid Mills.” Pure heroin in the market has significantly reduced, and most of the individuals are quickly opting for street heroin. Adulterated heroin is more highly addictive, and users are susceptible to an accidental overdose (Ciccarone, Ondocsin, & Mars, 2017, p. 149). Most of the users are likely to inject more of the drugs to satisfy their addiction levels. Ideally, impure heroin is laced with opioids thereby making it highly dangerous to the users. The extent of the problem has significantly increased in recent years with statistics revealing an annual increase of 21 % in 2015 and deaths during the period almost doubling (Gladden et al., 2016).  The Kentucky police department in the same year almost doubled their normal drug bust for opioids, especially in the Lexington and Richmond areas. The numbers coincide with statewide trends of narcotic seizures mainly attributed to the increase in narcotic legislation and the difficulty of obtaining prescription pain medication. The pharmaceutical companies in Kentucky according to the statistics provided by the FDA show that most of in the year 2015, 95 per in every 100 had prescribed to some opioid painkillers. In comparison to the national scales (70 per 100), it is evident that Kentucky has a higher rate of consumption. As earlier stated in the introduction part, most users of opioids on a regular basis are vulnerable to an accidental overdose which may lead to death.

In most cases, mild users have a biased perception of the use of Naloxone. Studies reveal that most of the users are functional middle-class people with normal lives and perceive overdose as a problem for “Junkies.” For clarity, “Junkies” refers to addicts medically diagnosed to overly on the heroin to function normally. As the statistics indicate, the increasing rates of usage lead to an increase in the likelihood of an overdose that results in the death of the victims.  These facts show that usage among the people is relatively higher than in previous years. Similarly, the deaths have significantly increased as illustrated in the figure above. Individuals using illegal narcotic medications range in age; from 20 to 60 years old. Regardless of age, all heroin users are at high risk of overdose due to staggered use, concurrent administration of addictive agents such as alcohol and suboxone, and height and weight variances that affect metabolism (Honeycutt, 2015). The usage of take-home Naloxone kits is relatively low in Kentucky despite the high rate of overdose.

Research indicates that there is reluctance among members of the faith-based community in Kentucky against the kits as a preventive measure to curb the increasing rates of overdose death. The underlying problem is that even community members living with or in proximity with individuals who meet the criteria of at-risk individuals do not put efforts to acquire the kit until when there is an emergency (Bixler et al., 2018, p. 529). On this note, it clear that the low levels of public awareness on the importance of the kit among the individuals play a significant role in the increased number of deaths in the state. According to preliminary research, the underlying perception of the faith-based community applys interpersonal beliefs with no backing of scientific evidence or rationale. While from a medical point of view having the kit is seen as a precautionary measure there is a different perception from a religious point of view.

Earlier on, I stated of the looming ideological conflict on the morality of increased access of the antidote. It is a similar case scenario that makes the problem more prevalent in the Kentucky population. Understanding addiction and susceptibility of an overdose as a more of a medical condition rather than a moral failure on the part of the person are imminent to stimulate a change in perception. Heroin or opioid addiction, like any other form of diagnosed addition, is a medical condition. As such, carrying a take-home naloxone kit will be regarded as an act of prevention by the patient rather than anticipation for the worst case scenario. More so, the perception of the kit as a “Ticket free from Jail” for the users but rather an intervention to reduce the high rates of death caused by the overdose. In this regard, the underlying problem that this study seeks to address is the low usage of the kit among resident due to the lack of awareness.

Reaching this population of patients is difficult due to the perception of potential legal ramifications if their addiction is known. Family members who often have the greatest impact toward obtaining treatment for the individual are often unaware of the addictive process, local resources, and availability of naloxone survival kits. Recent state legislation has established guidelines for the procurement of these survival kits that enables individuals to obtain them if the local pharmacy has a medical provider and a pharmacist who agrees to dispense; otherwise, their name is recorded on a list of individuals who have possession of a reversal kit (Dhanda, O’Connor, McGuire, Knox, & Ruth, 2018). Anonymity is essential in this area of need.  Allowing open availability of reversal kits has the potential to save thousands of lives. The project aims to evaluate individual perceptions of community members related to the identification of addictive behavior, local resources and administration of naloxone survival kits following educational training.

1.4 Purpose

The substance abuse focus in Healthy People 2020 will be the basis of my chosen problem. “Although progress has been made in substantially lower rates of substance abuse in the United States, the use of mind- and behavior-altering substances continues to take a major toll on the health of individuals, families, and communities nationwide. In 2005, an estimated 22 million Americans struggled with a drug or alcohol problem.” (U.S. Department of Health and Human Services, 2010, p.1). The focus of opioid overdose has been identified as a public health problem, and I am choosing to focus on this aspect concerning naloxone survival kit availability. The purpose of this project is to evaluate individual perceptions of community members related to the identification of addictive behavior, local resource availability and proper administration of naloxone survival toolkits following educational training.

The significance of the issue rests on the realization that non-fatal overdoses result in physiological damage including pulmonary edema, necrotizing fasciitis, and cardiac anomalies. Opioid abuse has been identified as a “middle-class” addiction and has non-discriminatory appeal to all ages and affluence. These conditions result in fiscal impact related to expensive treatment and loss of any potential individual profitability. In central and Eastern Kentucky, opioid addiction affects the economy and community health status considerably as; the region is prone to impoverished areas and high drug use and trafficking. My most significant concern with this project is the impact on the faith communities in Kentucky. Legislative action is imperative to the support of public support. Currently, there are varying attempts to obtain availability of naloxone survival toolkits in several states, some related to attachment with needle exchange programs.

The practice-focused question is, will there be an increase of knowledge surrounding addiction resources and administration of naloxone survival kits (intranasal Narcan) in 75% of participants as measured by the Overdose Education and Naloxone Distribution (OEND) Patient Feedback Survey? The project will require the development and planning of an educational program aimed at impacting current knowledge surrounding addiction recognition, local resources, and behavioral response during overdose situations.

The community of participation for this project lives in a rural eastern Kentucky faith-based organization. Opioid addiction and overdose have affected this area by changing the familial group as grandparents are now the principal guardians of children as a direct result of the addition of parental generation. The suffering socioeconomic status has directly impacted drug use as a result of the cause of hopelessness for many within this population. The disappearance of the coal industry has increased family utilization of faith-based organizations and outreach for many of the affected individuals.

1.5 Nature of the Doctoral Project

The project will be conducted in the community setting of South Eastern Kentucky and will, to include the population of Sutton Baptist Ministries, an (A member of the Southern Baptist Convention).  Education aimed at the public, as well as volunteer emergency response professionals, will be essential in optimizing utilization of local resources and reversal kits while impacting public opinion. Every community is affected by addiction and heroin has become a popular drug that has daily addiction maintenance costs of approximately $150; Disney stars are overdosing, but these survival kits save them. The incidence that drove the selection of this topic was caring for seven overdose victims in the emergency room of Kentucky One Health in Lexington, KY. Brought in by a “friend,” these patients spoke no English and were found to have taken Heroin procured from the same dealer; later found to be laced with methamphetamine, creating a street drug called “blue ice.”  In one week, five overdose deaths occurred in very similar circumstances.

Situations involving opioid overdose and reversal are published in local news outlets and are subject to individual inflection.  These stories, such as the northern Kentucky nurse who experienced overdose and currently does not advocate for open availability, can affect education programs negatively. (Ungar, 2015) The overwhelming public opinion has thwarted legislation regarding the open availability of naloxone survival kits that having the survival kit will increase drug utilization because it represents a “get out of jail free card.”  Changing public opinion begins with community education about resources, signs of addiction and availability of naloxone survival kits (including proper administration of intranasal medication).

This project will include education related to the identification of addictive behaviors, community resources for impacted individuals and the proper administration of the naloxone survival kits. The overdose Education and Naloxone Distribution (OEND) patient feedback survey and teach-back demonstration will be utilized to identify participant competency. The educational sessions are voluntary and will focus on recognizing addiction, treatment of overdose and utilization of naloxone survival kits. Community resources that the project will use include educational space and advertisement provision through local media and other faith-based groups. Community populations involved in this program are addicted individuals, family members, and concerned community members. No age requirements have been identified, and each participant will receive a naloxone survival kit upon completion.

1.6 Sources of Evidence

The study will use multiple primary sources of evidence including peer-reviewed scholarly articles, government agencies publications, Kentucky Police reports, Emergency Medical Reports, Toxicology Reports and focus group survey questionnaires. However, the study will not be limited to the use of only these sources and will supplement information using an online-based research on credible sources. In essence, the study will integrate quantitative, qualitative and mixed methodological approaches to accumulate a wide range of information. These sources will construct the foundation upon which this study is anchored. Peer-reviewed articles will be considered based on their relevance to the study topic. Most of the government agencies publication will provide statistical data to either support or refute the philosophical arguments that presented by the peer-reviewed sources. Such publications include CDC reports on the use of Opioids and overdose rates in the Kentucky state and the national level.

Moreover, the releases will also help identify the current trends in the consumption rates of heroin and other opioids at state and federal levels. Police reports will offer substantial information on the illegal heroin drugs and reported deaths with the department. ED reports are a vital source of reported cases of overdose that was either successfully treated or eventually resulted in a severe health condition. The quantitative-based sources will mainly rely on questionnaire data from the focus group meeting conducted within in the target community. Primarily, the question will be open-ended to provide a detailed perspective of the respondent on the issue under review. A comprehensive analysis of the evidence presented in the sources will be undertaken to ensure that all the underlying themes are identified in correlation with the project goals and objectives.

1.7 How to Obtain the Sources of Evidence

Peer-reviewed sources will gotten from virtual library and physical libraries in the Kentucky area. Most of the government agencies publications are now available in electronic form in most government websites. However, for those only available in hard copy, the researcher will seek relevant approval from the government archives to access them and use the data. In essence, the research will gain authorization pertinent to use all sources of evidence throughout the study. All the individuals engaged in the survey questionnaire, the review will ensure that it is conducted purely on a volunteer basis without any monetary incentive offered to the respondent. In contrast, the project team will provide an in-depth explanation to the individuals on the potential benefit that it has on the community to contribute towards reduced mortality rates. All the participating persons will fill consent form giving the project team authority to use any information collected in a way that guarantees full confidentiality and anonymity. Data privacy and confidentiality will be upheld at every phase of the research.

1.8 Approach to Organize and Analyze Evidence

The study will use the quantitative, qualitative and mixed methodology in organizing and analysis of the evidence throughout the research paper. The qualitative method will apply to all the face to face interviews conducted during focus group meetings with the respondent. In essence, it will form a critical element throughout the study to ensure validation of all collected data before analysis. On the other hand, the study will also apply quantitative methods of data collection and analysis. This methodology will mostly involve the use of questionnaires during the focus group interviews by the project team.  For verification of all the collected information, all the project team will subject a quasi-experiment through pre and post-tests for the data collected before and after the focus group meetings. The experiment will mainly be used to review and evaluate the accuracy of the information obtained before the education programs and after in the perspective of the all the users. In brief, the experiment will be used to determine whether the focus group meeting in any way has an impact on the perceptions and usage of naloxone survival kits by at-risk individuals.

1.9 Statement of Purpose of the Project / Significance

The significance of the naloxone education and utilization program is to enable the participant to effectively save lives if an overdose situation occurs, having been provided the tools to intervene (Honeycutt, 2015). Opioid overdose cases have seen a substantial increase, as reported by the Kentucky Office of Drug Control Policy, 2017. The marked increase in overdose cases has required additional staffing for emergency departments and has at times resulted in internal disaster situations. One outlying emergency department had 21 overdose cases within a 24-hour period during the first week of January 2017 (Kentucky One Health, 2017).  Local overdose numbers coincide with statewide trends and are being related to the increase in narcotic legislation that results in difficulty of obtaining prescription pain medication (Kerr, Dietz & Kelly, 2008). Contributions of the educational program will be to aid Church and community recognition of addiction, thus enabling them to act with purpose and positively impact the affected individuals’ state of health.

According to the Centers for Disease Control (CDC), people are using Heroin as well as other drugs at the same time, and the primary adjunct substance is a prescription opioid narcotic (Centers for Disease Control, 2015). In the United States, opioid use among the age group of 18-25 years has doubled within the past ten years. (Centers for Disease Control, 2015). Addictions to injection drugs can result in long-term viral infections, bloodstream infections, skin infections and Hepatitis C and B (Lin et al., 2017, p. 259). Educating the public around the recognition of addiction and utilization of naloxone survival kits in the occurrence of overdose will reduce morbidity and mortality through increasing monitoring ability and increased intervention. The healthcare industry is increasing responsible prescriptive practices and developing pain management medication that is less prone to abuse, incidences of opioid abuse and overdose will decrease in the future through advocacy and intervention. (Centers for Disease Control, 2015).

Understanding the need for Naloxone survival kit availability begins with analyzing overdose rates and narcotic addiction rates at local, state and national levels. Knowledge of the opioid overdose problem instigated the impetus for reversal options, which led to the creation of survival kits.  Processes are being implemented that are designed to streamline procurement and education of naloxone survival kits. The social implications of the community-based education project will result in an increased understanding and saved lives by enabling the participants to react appropriately in emergency situations and recognizing the signs and symptoms of addiction. The federal government is working through community resources to aid communities in this battle against opioid addiction through providing integrated prevention services. (Centers for Disease Control, 2015). The implemented programs include needle exchange from reliable sources; however, naloxone survival kit program distribution is limited. (Centers for Disease Control, 2015).

Providing education to the community at large will positively impact perceptions related to the disease of addiction; theoretically decreasing comorbidities that impact social well-being on a fundamental scale. Theoretically, a healthier population results in a stronger economy through more social productivity, and since addiction affects all age groups, the impact of minimizing its effects cannot be understated. Educating community members about the impact of addiction and providing the tools to intervene during emergency situations when needed is thought to result in lives saved. Changing perceptions of community members can prove to be greatly impactful of social well-being, notably because the typical drug addicted individual can often be your neighbor, a beloved actor or the CEO of a fortune 500 company. This epidemic knows no culture, race or socioeconomic status; no community is safe from the far-reaching effects of this disease. The provision of naloxone overdose survival kits and accompanying education will help to decrease overdose mortality. (Wheeler, et al., 2015).

Table 1.

Goals, Objectives and Activities

Goals	Objectives	Activities	Outcomes
Impact participant perceptions related to comfort of identifying addictive behaviors.	75% of participants will state that they better understand addictive behaviors following an educational session and evaluation of learning, utilizing the Overdose Education and Naloxone Distribution (OEND) Patient Feedback Survey.	Provide community education surrounding support and awareness related to opioid use and utilization of naloxone survival kits.	Greater than 75% of all participants will be able to state at least one addictive behavior.
Impact participant perceptions related to comfort of administration of naloxone survival kits.	75% of participants will state that they can administer an intranasal naloxone survival kit following an educational session and evaluation of learning, utilizing the Overdose Education and Naloxone Distribution (OEND) Patient Feedback Survey.	Provide community education surrounding support and awareness related to opioid use and utilization of naloxone survival kits.	At least 75% of participants will be able to demonstrate proper administration techniques for the Naloxone distribution kit.

 

• Summary (Each Section should be captured in the Summary)

The increased rate of medical emergencies and deaths due to heroin and opioid overdose has increased at an alarming rate as the evidence in this section shows. This phenomenon is preventable and manageable with the integration of right strategies such the use of naloxone survival kits. The double-digit growth in rates of deaths and overdose in the Kentucky state have had negative social impacts on the lives of the community members. However, it is important to critically examine the causal factors that lead to this phenomenon and put in place intervention mechanisms that guarantee the reversal of this behavioral pattern. On this note, the implementation of educational programs and utilization of naloxone survival kits with increased information helps to resolve fear and concern related to the reversal process. Proper education of clinicians, addicts, and family can result in saved lives and better outcomes for the productivity of society through decreasing negative consequences that will have a far-stretching reach.

The community will support the continuous evolution of this project for those involved (Family members, emergency medical technicians, and willing church members) for years to come.  The educational sessions will provide the measurement of acquisition of knowledge and the potential utilization of addiction assessment, community resources and naloxone survival kits for the participants. The 75 % of the participant population will be evaluated to determine the viability of the OEDC training program output conducted after the survey.

The varying sources of evidence to be used in the study will present a broad spectrum of information to support possible conclusions made by this paper. It is important to note that the study subscribes to the existing nursing research data collection and analysis standards as articulated in this section. The project team is bound by the code of ethical research only to use validated literary literature and to protect personal information as stipulated in the framework of confidentiality. Because different data sources will be used in the research requires that methodological approaches correspond to the type of date. Therefore, it becomes prudent to use a mixed method of collection and analysis.

In essence, the qualitative and quantitative data methods will supplement the mixed approaches in the application. The study will seek to fulfill both literary and institutional purposes. Preliminary research indicated that there exists a research gap on the scholarly understanding of naloxone survival kit usage in areas with a high frequency of overdose. To this end, it will fill the gap by providing the field of nursing with adequate information on the information. Besides, stakeholders working on issues related to opioid overdose and heroin-related deaths will have sufficient reference point when making policy decisions.

From an institutional point of view, this dissertation will offer institutions facing similar challenges an opportunity to implement evidence-based interventions that will be arrived at in subsequent sections. In a nutshell, it will strategically provide additional insight into the possible causal factors on low Naloxone usage in the community despite multi-agency efforts to increase access. This section presents an in-depth understanding of the topic and outlines the way that project team will go about implementing it and the geographical location. In conclusion, it offers the exposition of the project’s relevance in the scholarly spheres and society that introduces in details its natural value to the audience. Section 2: Background and Context

2.1 Introduction

Opioid overdose death and administration of naloxone survival kits are both case study scenarios of ultimate interest to advanced nursing practice. Drug and substance abuse as evidence showed in the previous section is quickly becoming a high-level health situation. The emergency cases being reported annually in hospitals across the country indicate that if the trend persists, soon they will take the lead in a majority of health facilities. The underlying paradox therein becomes if the desired changes will be achievable to reverse the opioid overdose death with the development of education programs for all the participants of the survey. The section sets outs a general overview of the background the project’s activities and approaches it employed help achieve a 75 % reduction rates of overdose deaths in the Kentucky area through increased availability of Naloxone kits by members.

Typically, the reversal mechanism of the problems lies in the increased usage of the survival kits by the general population of Kentucky area. The background presents a contextual analysis of the key concepts, models and theoretical perspective it adopted to accomplish its underlying objectives. The ambition of this section is to critically describe the rationale that conceptual frameworks that inform the project based on the point of various philosophical theories provided used in the doctoral project. Clarification on all complex terms used in the following sections will be explained in detail. Further, it will provide a historical analysis of the problem of Opioid use in American in the context of preventive treatment, emergency response, naloxone administration, and detoxification. In essence, it will show how the conducting this study correlates to nursing practice.

Moreover, the section will provide insight into possible strategic intervention to improve naloxone administration, detoxification using existing literature as a reference point. The evidence from previous studies will be used as tools for the identification of acceptable nursing practice standards that may be duplicated in the interventions practice and yield highly positive results. It will provide sufficient evidence indicating that OECD advance the current nursing practices by integrating community education approach as a practice with corresponding forms of practice employed during prevention of heroin overdose deaths.

In contrast to the previous section, this section will in detail present local evidence that accurately justifies the community education programs as effective ways of creating awareness among the Kentucky population. Also, it assesses the various community-based, Control agencies and legislative frameworks that Kentucky area has put in place a response mechanism to the problem of high death rate and increased opioid addiction.

Further it will highlight any Federal government initiatives put in place to create awareness of the use of naloxone kits a reliable way to reduce the rates of death. In the last part, I will contextualize my professional role in ensuring the scales of overdose death decline and usage of kits goes up. I will also provide information dissemination strategies to ensure that the project team is adequately informed of the goals and objectives of the project. In a nutshell, the section will ensure that the relevance of the project is clear both within the community setting and in the field of nursing practice.

2.2 Concepts, Models, and Theories

The complexity of the underlying problem of high rates of overdose deaths due to biased perception on the use of naloxone drugs requires community-based education programs. Lack of vital information among the residents and opioid users account for the high prevalence rates experienced in the area. Following this observation, I believe that the logic model is the most appropriate because it involves a conceptual framework that integrates aspects of evaluation of the inputs and following outputs that drive outcomes.

In nursing practice, is essential for the health officers to provide services in a way that matches the underlying needs of the patients or rather the case scenarios. The logic model takes various forms, but the most common model is the patient model that helps the practicing nurses to identify interventions centered on the unique educational needs of the patients (Sousa, Shoemaker, Do Nascimento, Costa, & Ramalho de Oliveira, 2017, p. 254). The figure 3 below illustrates the key aspects of the model that this study chose to helps address the high rates of death among the drug’s users

Figure 4: Logic Model

 

This decision was arrived at after the determination of the fact that it was ultimately necessary to undertake serious training for the community to reduce mortality by increasing survival kit usage. Therefore, there are two fundamental aspects in projected in the utilization of the logic model: The current issue of high rates of overdose and the need to increase the open availability of naloxone kits among the community. Input is the process of organizing community action surrounding kit availability; legislation and actions for change will involve time, money, stakeholder involvement, and legislative support through lobbying and community partnership. Identified Output includes Community education through utilization of developed informational publications and festival involvement. The process comprises of increased legislative support due to constituent lobbying along with increased kit utilization achieved through increased training on the potential benefit of the naloxone survival kit. Participants include the Hope over Heroin Program, affected families, patients and the community at large. The outcome of change will occur over the short, medium and long-term future.

Growth will occur from changing knowledge, attitudes, and awareness to impact behaviors, practice, and policy. Increased legislative support for the open availability of naloxone survival kits and reported overdose reversal due to the utilization of survival kits would have a long-term effect on the overall environment through social, political and economic change. In the first aspect, the increased overdose death, it is virtually impossible for the nurse to intervene in these cases because mostly these persons do not make it receive personalized treatment. The proposition by the study to undertake a community training eliminates the theoretical components of the two of the four nursing meta-paradigms. In nursing practice, it employs four fundamental foci of patient-based care. While the phenomenon of Nursing conceptually involve all forms of technical actions that all nurse undertakes to care for a patient, the person paradigm focuses on the care subjected to an individual with physical, emotional and biological characteristics (Sitzman & Eichelberger, 2017, p. 403).

Therefore, the application of the logic model in this model eliminates the meta-paradigms mentioned above of nursing. According to Nola Panda, the main focus of the person phenomenon in model nursing practice primarily focuses on the recipient of the care. In the case of community-based education awareness programs, the focus shifts from the individual to their immediate environment. On this note, it is therefore clear that the remaining two conceptual frameworks apply in the practice models adopted by this study. The paradigm of the environment, one of the least used nursing practices involves any form of alteration or adjustment to the external environment of an individual leading to the advancement of natural health. The activities of the nurse or practitioner mainly focus on the external environment of the individual based on the fact that most of the external factors form a dimension in the health of the individuals (Koy, Yunibhand, Angsuroch, & Fisher, 2015, p. 1829). The legal ramifications are one of the causal factors that cause most of the individuals at-risk not carry naloxone survival kits. In this regard, through increased awareness and community support, most of the addicted and vulnerable individuals openly declare their condition allowing them access to the naloxone in case of an overdose.

It is clear that the social contexts in Kentucky play a significant role in the low rates of usage of Survival kits among residents. Different present diverse views on the conceptual perspectives that offer explanations of the phenomenon. According to Imogene King, any process in nursing practice that is conducted with an ultimate goal of helping them achieve their goals. Similarly, Dorothea Orem asserts that any therapeutic supportive-educative initiatives undertaken to supplement self-care systems fall under the environment paradigm of nursing. All these theories reflect the conceptual frameworks that the paper uses to accomplish its aims and goals.

Also, critically evaluating the principle of the phenomenon of health indicate that the study also uses the concept in its theoretical framework. Under this concept, the definition of one’s health differs based on individual perceptions of what amounts to the quality of life. Theoretical evidence shows that the emergency response technicians, police and nurse in ER units understand the treatment capability of Naloxone. In their view, it is useful and helps to reduce the high rates of overdose.  However, in the cases of the population under study, most of the individuals do not hold a similar point of view hence the reluctance to acquire naloxone.

It is a biased view that explains the aspect of high death rates. Moreover, the legal limitations by the policymakers on the opioid users prevent an intensive public awareness program. According to research, most of the policymakers perceive naloxone negatively, arguing it gives users a: free ticket from jail” for their actions. The approach in the county seeks to reduce the distribution networks that exist in the state. However, evidence shows that most getting opioids or heroin out of the streets do prevent intake but rather raises illegal uptake which has more adverse effects on the consumers. As preliminary research also revealed, most of the middle-class users did perceive themselves as being at-risk of overdose, therefore ignoring the risk of accidental deaths. On this note, the education program has an underlying goal to increase access to the naloxone as a principal resource in the reduction of fatal deaths caused by overdose.

Table 2: Definition of Terms

Term	Meaning
Naloxone Survival Kit	A prescription medication that is used for treatment of an opioid emergency or overdose. Administration should occur when unresponsiveness is established, severe lethargy is noted or breathing difficulty is occurring (Anova Pharma, 2017). Pieces of equipment provided in the kit include naloxone 0.4mg vial, an atomizer, one pair of gloves and two alcohol swabs. (Kerr, Dietz & Kelly, 2008)
Opioid	A pain relieving medication that resembles Morphine in class pharmacological properties; also known as an opioid analgesic. This class of medication is absorbed rapidly and results in respiratory depression.  (Kerr, Dietz & Kelly, 2008)
Addiction	A psychological or physiological habit that causes severe trauma with attempted cessation; as seen with narcotics, specifically Heroin. (Kerr, Dietz & Kelly, 2008)
Overdose	An excessive dose of medication resulting in physiological oversaturation. Overdose is the leading cause of death among intravenous drug users with Heroin being the most commonly used drug. (Kerr, Dietz & Kelly, 2008)
Public opinion	The collective opinion of a community at large relating to a common decision, issue or problem. Overdose treatment can be expedited with public action or response to individual occurrence; public opinion is paramount in implementing bystander response programs. (Kerr, Dietz & Kelly, 2008).

 

2.3 Relevance to Nursing Practice

The opioid health crisis witnessed in the health care system correlates with a similar epidemic that rocked the American health care system in the 1840’s. The scales are lower because, at the time, the addiction rates were at 0.72 per 1,000 individuals. During this time the rates did make a high impact on the American healthcare systems. However, in the next fifty years that followed the addiction rates grew by more than 538 % in the mid-1980. At the time, medical treatment of overdose was still at very early stages, and most cases died at home. In 2000, the rates of addiction surged with the increased availability of heroin and other opioids in the American market.

Consequentially, the high rates of overdose registered in the hospitals during this time resulted in a new scholarly shift on the treatment methodology in nursing practice. Nursing professions should help all people with a medical condition. As such as soon as the high rates of addition started being recorded in hospitals the role of the nurse rapidly changed. Research studies indicate that these changes led to the integration of treatment of opioid overdose medication became an integral element of nursing practice at the same time when the prevailing rates began to surge upwards. Over the years, overdose deaths have slowly become a significant menace among healthcare professionals. In nursing theory practice, any medical conditions that threaten the physical, emotional or psychological balance of a person require prompt intervention to ensure a timely response. In the years after 2006, most of the medical scholar started to shift their focus on the advancing existing knowledge on the best ways to treat the condition using a multi-dimensional approach that apply the four meta-paradigms of nursing. Overdose cases epidemic intrinsically connect with nursing practices in most emergency cases, there are the first to responders.

The overdose cases fall under the category of nursing practitioners because it is classified as an ICD-10 condition whose treatment only requires detoxification and recovery phase. The field of nursing has tremendously expanded both theoretical data and practice standards to help deal with the increased addiction. On this note, preventive measures such as the use of naloxone have transformed the way that nursing help to reduce the effects of opioids. The conceptual framework of nursing has a variety of treatment options for the opioid addiction depending on the level of addition. For example, for mild users without a history of overdose; they may undergo treatment that eliminates the psychological dependence of the drug. However more advanced case require intervention through the use of lesser strong opioids.

 

References

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Bohnert, A. S., Ilgen, M. A., Ignacio, R. V., McCarthy, J. F., Valenstein, M., & Blow, F. C. (2012). Risk of Death From Accidental Overdose Associated With Psychiatric and Substance Use Disorders. American Journal of Psychiatry, 169(1), 64-70. doi:10.1176/appi.ajp.2011.10101476

Ciccarone, D., Ondocsin, J., & Mars, S. G. (2017). Heroin uncertainties: Exploring users’ perceptions of fentanyl-adulterated and -substituted ‘heroin’. International Journal of Drug Policy, 46, 146-155. doi:10.1016/j.drugpo.2017.06.004

Cicero, T. J., Inciardi, J. A., & Surratt, H. (2007). Trends in the use and abuse of branded and generic extended release oxycodone and fentanyl products in the United States. Drug and Alcohol Dependence, 91(2-3), 115-120. doi:10.1016/j.drugalcdep.2007.05.008

Dhanda, A., O’Connor, S. S., McGuire, H., Knox, E., & Ruth, E. (2018). Patterns of opioid use during initial buprenorphine/naloxone treatment in relation to changes in opioid management laws in Kentucky. The American Journal on Addictions. doi:10.1111/ajad.12767

Koy, V., Yunibhand, J., Angsuroch, Y., & Fisher, M. (2015). Relationship between nursing care quality, nurse staffing, nurse job satisfaction, nurse practice environment, and burnout: literature review. International Journal of Research in Medical Sciences, 1825-1831. doi:10.18203/2320-6012.ijrms20150288

Lin, T., Ger, L., Pergolizzi, J. V., Raffa, R. B., Wang, J., & Ho, S. (2017). Long-term use of opioids in 210 officially registered patients with chronic noncancer pain in Taiwan: A cross-sectional study. Journal of the Formosan Medical Association, 116(4), 257-265. doi:10.1016/j.jfma.2016.10.015

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