Opioid overdose-related emergency department visits have increased in the last several decades, prompting concern from providers about how to respond to patients experiencing opioid overdoses who arrive in private vehicles. In this study, our research team developed and utilized an iBook intervention to teach nursing staff how to safely attend to opioid overdoses that occur outside of the department. We discuss our study methods and aims, including development of the Be-SAFE© iBook content with the input of an interprofessional team of key stakeholders. Fifteen training sessions were delivered to 89 ED nursing personnel across five regional hospitals. Nurses (n=69) completed knowledge pre-and post-surveys and a Be-SAFE© Response Program Evaluation. Our results indicate that the Be-SAFE© iBook was useful to ED nursing staff and significantly increased the specific areas of knowledge regarding risk factors and actions related to opioid overdoses that occur in private vehicles.
Key Words: Opioid, emergency nursing, emergency department, opioid epidemic resources, opioid overdose response
Opioid overdose deaths have increased exponentially across the United States in the past several decades.Opioid overdose deaths have increased exponentially across the United States in the past several decades. Deaths attributed to opioid overdoses nearly quadrupled from 1999 to 2017; approximately 130 fatalities now occur on a daily basis (Hedegaard et al., 2019; Scholl et al., 2019). With this increase has come an upsurge in the number of people who seek overdose-related care in emergency departments (ED). The rate of visits attributed to heroin overdose increased more than 30% per year from 2010 to 2014, and by 2015 over 140,000 ED visits nationwide were designated as opioid overdose-related (Guy et al., 2018; Centers for Disease Control and Prevention [CDC], 2018).
Cluster overdoses can happen at the rate of dozens per day for multiple days at a time, overwhelming ED staff.Another issue impacting ED management of opioid overdoses is the number of overdose events that can occur at one time. Cluster overdoses can happen at the rate of dozens per day for multiple days at a time, overwhelming ED staff. In the summer of 2016, Cincinnati police reported 60 overdose cases in a two-day period, including 16 in 90 minutes; Huntington, WV reported 26 overdoses in a 4-hour period the previous week (Jacobs, 2016). It is challenging to predict when another cluster event may occur, and patients suffering from overdoses may not be diagnosed as such due to varying presenting issues and provider subjectivity. However, when a “bad batch” is reported, it is usually noted by local law enforcement or emergency medical services due to increased activity.
Nurses are being required to step into the role of first responder, tending to overdoses in parking lots...The most common outcome of opioid overdose is respiratory distress leading to respiratory failure, which can ultimately lead to death but may be resolved by use of naloxone (Narcan®) (Sporer & Kral, 2007). A variety of community-based overdose prevention and naloxone-use programs exist, which can aid in preventing overdose fatalities; however, those who are present during an overdose event may not call 911 for a variety of reasons, such as improvement in the patient’s condition or a poor community relationship with the police (Bennett et al., 2011; Doe-Simkins et al., 2009; Tobin et al., 2009; Wheeler et al., 2012). This has resulted in an increased number of patients experiencing overdose who arrive at emergency departments in personal vehicles. Nurses are being required to step into the role of first responder, tending to overdoses in parking lots and other areas outside of the physical confines of the emergency department.
Many ED nurses have not been trained in the particular risks associated with this role, placing them in unpredictable, potentially unsafe situations (Clark et al., 2019). Nurses in Cincinnati, OH, a region heavily impacted by the opioid crisis, have experienced an influx of these private vehicle overdose scenarios in recent years. Before naloxone distribution in Cincinnati communities began, those who arrived to the emergency department for acute respiratory distress associated with opioid overdose arrived via emergency medical services (EMS). After naloxone distribution began, more patients began arriving in personal vehicles. However, EDs have not tracked this finding and accounts are based on subjective reports from nurses who have expressed concern for their safety and that of their peers.
After naloxone distribution began, more patients began arriving in personal vehicles.A literature search found that very little evidence was available to guide ED nurses in the safe removal of persons overdosing on opioids from privately owned vehicles. This lack of knowledge caused our research team to determine a process that would assist nurses to focus on their personal safety in addition to the urgent need to provide care in this increasingly prevalent clinical situation. To better prepare nurses to respond to the increased challenges of the opioid epidemic in our community, an interprofessional team developed an innovative educational intervention for emergency departments to increase knowledge about how to safely respond to a victim in a private vehicle during an overdose.
Our aims were: 1) to develop an educational intervention that prepared ED staff to respond safely to an opioid overdose event outside the traditional walls of the department to decrease risk factors associated with victims arriving in personal vehicles; 2) to determine if nurses who received the intervention could then deliver it to others with a high degree of fidelity; and 3) to determine the intervention effect size and knowledge change of participants. With stakeholder input, we developed an iBook entitled, Be-SAFE©: A Guide for Nurses Responding to Opioid Overdoses Outside the Emergency Department (Be-SAFE©). This article will discuss the process of developing and implementing the iBook educational intervention, and the outcomes of the Phase Ia/Ib feasibility study of the Be-SAFE© iBook in the group setting.
To develop the Be-SAFE© educational intervention, our interprofessional team of five key stakeholders convened to determine the critical components.Aim 1: Development and Content of the Be-SAFE© iBook
Aim 1 considered the development and specific content of the intervention. To develop the Be-SAFE© educational intervention, our interprofessional team of five key stakeholders (clinical nurse educators, ED nurses, paramedics, emergency medical technicians, and security personnel) convened to determine the critical components of the curriculum. An outline of the Be-SAFE© curricula was created and supplemented with content from the literature. We determined early in the process that there was not a practice case available to use for the intervention. The first three authors (AC, JB, RJ) created an original case study based on clinical experiences and troubleshooting that would best prepare nurses and ED staff members to safely remove an opioid victim from a personal vehicle.
The Be-SAFE© program was created using the iBooks platform. This format was chosen because it can easily be delivered via iPad and allows for dissemination through electronic efforts for future users. Previous educational interventions completed by the principal investigator (PI) have yielded that iPads can provide quick access to research protocols; utilize video and photo capture for iBook development; record interventions for training and fidelity purposes; and collect and simultaneously transfer data.
The Be-SAFE© program was created using the iBooks platform.After a first draft of the iBook was developed, the second author delivered the intervention in the group setting to ED nurses in a grand rounds-style presentation (n=9). Evaluations from this pilot intervention group were used to modify the iBook to its final version, and indicated that nurses appreciated the overdose review and were interested in further education about responding to overdose victims. The ultimate outcome of our efforts resulted in the final version of the innovative Be-SAFE© iBook.
Introduction to the iBook. The Be-SAFE© iBook includes two chapters with a total of 14 sections of information. The goal of Chapter 1 was to provide all necessary information required to safely respond to an opioid overdose outside of the emergency department. Chapter 2 includes the original case study for participants to apply their knowledge of the Be-SAFE© content. An overview of sections and topics is included in Table 1.
Table 1. Be-SAFE© iBook Content
Instructions on how to use iBook.
1.2 Learning Outcomes
Learning outcomes of the Be-SAFE intervention.
1.3 Overdoses and the Emergency Department
An original video that describes the impact of the opioid epidemic and provides epidemiological data related to the increase in opioid overdoses, ED visits, and complications such as cluster overdoses. The video describes how nurses have been trained to quickly provide care for patients, but due to risks associated with responding outside of the ED, the practice needs to change.
1.4 A Brief Review
A review of how opioids work in the body. The specific mechanisms of opioids binding to mu-opioid receptors is described so that a connection to opioid half-lives can be related to the substances that overdose victims are using. A picture from the New Hampshire State Police Forensic Department depicts a comparison of vials of lethal doses of heroin, Fentanyl, and Carfentanil. Finally, an animation of naloxone competitively binding to opioid receptor sites is provided to depict the concept that, depending on the opioids used, the half-life of naloxone is less than that of opioids, so multiple doses may be needed in the ED.
1.5 A Review of Opioid Overdose
A discussion on the characteristics of overdose and respiratory depression. A diagram of the cyanotic pathway with an original photograph shows on the main screen to highlight the importance of a “quick response” to prevent respiratory depression from progressing to coma or death. The final activity is a group prompt asking participants to discuss the question, “How has the opioid epidemic changed your nursing practice?”
A brief introduction to the gap in training and the need to promote nurse and patient safety during opioid overdose events.
1.7 Be-SAFE© Response Kit
An original 53-second video of the Be-SAFE© overdose response technique. The video highlights the need for an organized team approach to the response, and introduces the contents of the Be-SAFE© Response Kit. Each response kit item was discussed at length and agreed upon by the team of stakeholders. Each item included in the Be-SAFE© response kit is introduced in this section: Flashlight, Bag-Valve Mask, Gloves, Sharps-Resistant Gloves, Masks, Naloxone hydrochloride (Narcan®), and Lift-Transfer Device (such as the MegaMover®).
1.8 The Be-SAFE© Sequence, Part 1
A full video demonstration of a team responding to an opioid overdose victim with removal from a personal vehicle.
1.9 The Be-SAFE© Sequence, Part 2
The Be-SAFE© sequence is explained by highlighting the five steps of “Scene Safety”. This content includes, “Always respond to the scene with caution. Scan the area for sights, sounds and smells that may signify danger. Make sure that there isn’t other suspicious activity such persons or vehicles. If it’s nighttime, make sure to bring a flashlight. Remain alert and attentive at all times. If security assistance is available contact immediately.” (“Be-SAFE©_v14 (1).iba.” iBooks.)
1.10 The Be-SAFE© Sequence, Part 3
The importance of getting information from bystanders to provide insight on the amount, time, and type of substance used; if there are sharps or needles in the car; and if the victim has been treated with naloxone. Because there has been widespread dissemination of nasal naloxone to lay persons, a video demonstration of nasal naloxone administration is provided.
1.11 The Be-SAFE© Sequence, Part 4
How to strategically choose a team at the beginning of each shift to streamline response time and involving security whenever possible. The stakeholder team recommended use of an assistive lift or transfer device (e.g., the MegaMover®), so key tips for transfer from the personal automobile are provided during an original 58-second video.
1.12 The Be-SAFE© Sequence, Part 5
Highlights of exposure risks, such as inhalation, needle sticks, or mucous membrane contact, with a pop-out of a newspaper article about a first-responder event in Massillon, OH. Other considerations for equipment during an overdose response, especially if Fentanyl is expected or powder is visualized, include long sleeves, a gown, and a powered air purifying respirator (PAPR) (CDC, 2018).
2.1 Be Safe: A Case Study
The author developed case study based on real-life clinical experience that details the arrival of a patient in a private vehicle to the emergency department:
At 7:30 in the evening, a triage nurse is asked by the driver of the vehicle to assist with an unresponsive passenger. The nurse approaches the vehicle and sees that there is a middle-aged woman in the passenger seat who appears to be experiencing an acute opioid overdose. The nurse also sees another passenger in the backseat who appears to be attempting to hide from view. The nurse attempts to ask questions about the patient but does not receive answers. The nurse ultimately releases the patient’s seatbelt, places her left arm behind the patient, her right arm over the patient’s chest, drags the patient out of the vehicle, and places her on the ground. When the patient is out of the car, the driver pulls the car away with the passenger door still open, at which time the nurse is able to see that there was a gun on the floor of the vehicle.
At the end of the case study, participants are challenged to demonstrate concepts such as safely removing a victim from a vehicle, using role-play, and simulation
Aim 2: Determine if Nurses Could Deliver the Intervention with Fidelity in the Group Setting
Due to our team’s desire to more widely disseminate the Be-SAFE© intervention, for Aim 2 we assessed whether nurses who had received training could deliver the intervention with a high level of implementation fidelity in the group setting. Fidelity monitoring provides researchers with a way to evaluate and enhance research interventions. A high level of fidelity establishes confidence and credibility in findings, and provides feedback for the research team (Bellg et al., 2004; Resnick et al., 2005). Creating intervention manuals and guidelines for research is one way to improve the fidelity of the intervention and potentially prevents local adaptations of the intervention that would allow dissemination of misinformation. iPads and iBooks are useful to eliminate some of the threats associated with intervention fidelity, and enhance nursing research by allowing a variety of educational strategies to disseminate information.
The overall outcome of the fidelity monitoring indicated that the educational intervention was delivered with a high level of fidelity...To determine fidelity, we used an iPad to video-capture each educational intervention. The videos were uploaded to box.com by the co-investigator. The PI developed a fidelity checklist that included two scales: adherence and competence. Two research assistants were trained about how to use the fidelity checklist. Each assistant watched the videos separately and completed the checklist. Results from the completed checklists were transferred to REDCap™ database and downloaded into a spreadsheet for data analysis. Item reliability on the Be-SAFE© Modified Fidelity Checklist was determined using percent agreement. The overall outcome of the fidelity monitoring indicated that the educational intervention was delivered with a high level of fidelity across each of the 15 interventions, as well as by each trainer.
Group-Based Educational Learning. Social Interdependence Theory states that promotive interaction and positive interdependence between group members results in a stronger drive towards achievement. In promotive interaction, individuals encourage and assist each other to achieve a group goal; this variable can be measured by the Classroom Life Measure (CLM) cooperative learning subscale. Positive interdependence, where the actions of individuals move the group toward the joint goal, can be assessed by the CLM positive goal interdependence and resource interdependence subscales. The outcome of these variables is “effort to achieve,” which can be noted through such behaviors as use of high-level reasoning strategies, internally-based motivation, creation of new ideas, ability to transfer learning from one situation to another, and actual achievement (Johnson & Johnson, 2013; Johnson & Johnson, 2008). In this project, effort to achieve was assessed by measuring actual achievement via the change in knowledge score from the Knowledge Pre- and Post-Tests.
Sample Recruiting. The PI and co-investigator received Institutional Review Board approval before study initiation. We recruited a convenience sample of participants by approaching ED nursing staff individually or in non-study-related group settings.
Sample Size and Program Implementation. Three clinicians, an ED nursing supervisor, a clinical nurse educator, and an ED staff nurse, were trained to deliver the Be-SAFE© iBook educational intervention. An in-person training was conducted by the first author, who attended virtually to troubleshoot iBook questions, and the second author, who led the training.
Fifteen trainings across four regional EDs were delivered from February to June 2018. A total of 89 ED nursing personnel, 69 of whom were nurses, received the educational intervention. On average, each group educational intervention lasted 40.19 minutes. While other ED staff, such as security officers and paramedics, completed the training, only nurses completed the pre- and post-tests due to their role as direct responders during an overdose event that occurs immediately outside of the ED and higher relevance of training materials to their everyday responsibilities.
Design and Data Collection. The research team proposed the hypothesis that the Be-SAFE© group educational intervention would increase actual knowledge. Our study used a one-group pre-test/post-test design (Allen, 2017). Participants completed the Knowledge Survey Pre-test before the group educational intervention. After the intervention, participants completed the Knowledge Survey Post-test and the Be-SAFE© Response Program Evaluation.
To develop the pre- and post-tests, the key stakeholders determined mastery items and knowledge items based on the intervention content and developed test items accordingly. Pre- and post-test items covered knowledge of risk factors, symptoms, mechanism of action of opioids and naloxone, and general knowledge. The program evaluation assessed confidence of skills and practice, perceived safety, and perceptions of ability (personal and unit/department) to respond to an opioid overdose. Data collected from the participants were entered into REDCap™ database and imported into Statistical Analysis Software (SAS®) for analysis.
Data Analysis and Results
Aim 3: Determine the Intervention Effect Size Regarding Knowledge
Aim 3 was to determine the intervention effect size regarding knowledge about opioid overdoses and perceptions of personal safety and confidence. Nurses reported feeling significantly less confident (p<0.001, 95% CI) and significantly less safe (p<0.001, 95% CI) when responding to personal vehicles, as compared to patients arriving via EMS. In addition, there was a significant difference on the item “Worrying about personal injury when caring for patients experiencing an overdose who arrive via personal automobile” (p<0.001, 95% CI). The majority of nurses (88%, n=60) believed that addiction is a chronic disease, and wanted to learn more about addiction and opioid use disorder.
Emerging Themes. Three research team members analyzed the nurses’ open-ended responses using qualitative content analysis to identify themes. First, each team member reviewed the open-ended responses independently to formulate an overall idea of the content and identify potential categories. Next, the study team met to review the findings as a group and refine the categories by theme. The team decided upon initial categories, and reviewed the data again to further refine the categories. This process was repeated until the team was in consensus that they had identified categories that adequately described the responses of the nurses.
...emergency nurses already possessed a high degree of knowledge in the areas of overdose symptomology and naloxone administration.In regards to general attitude toward caring for patients experiencing opioid overdoses in the ED, we identified themes of Frustration (e.g., frequency of overdoses and repeat offenders); Ambivalence (“Here’s another one”); Safety (fear of physical violence, not knowing how patients will act); Comparison (other patients being overlooked); Compassion (patients deserve the same care); and Understanding (lack of effective long-term care). When asked what would benefit their practice related to responding to opioid overdose victims, the themes expressed these main concerns: Equipment (lifts, naloxone), Training (education, protocols), and Personnel (non-specific roles, more people capable of helping). The purpose of identifying these thematic categories was to be sure that there was not an unmet need or available resources that were not identified at earlier points in the research process.
Knowledge Change. A power analysis was completed before enrollment using an estimated sample size of 64 participants. This analysis yielded a power of 90% to detect a correlation coefficient of 0.45, and 86% power to detect an effect size of 0.45 to detect a change between Knowledge Survey Pre-test and Post-tests, using a paired t-test at a 5% significance level. This indicated that the sample size determination was met and sufficient power was present to detect significant findings.
Participants scored significantly higher on the Knowledge Post-test (M=85.07%, SD=10.29%) compared to the Knowledge Pre-test (M=71.32%, SD=14.81%), t(79) = -9.148, p<0.001. Dependent samples t-test analyses were also run on each subset of the Knowledge Test: Risk Factors, Symptoms, Actions, and Addiction/Narcan®. Significantly higher scores were noted on the Risk Factors Subset of the Knowledge Post-test (M=94.72%, SD=14.68%) compared to the Risk Factors Subset of the Knowledge Pre-test (M=85.56%, SD=25.09%), t(79) = -3.752, p<0.001, as well as the Actions Subset of the Knowledge Post-test (M=84.14%, SD=17.65%) compared to the Actions Subset of the Knowledge Pre-test (M=59.14%, SD=25.7%), t(79) = -8.648, p<0.001. This allows the conclusion that the Be-SAFE© intervention significantly improved ED staff knowledge.
There was no significant difference on the Symptoms Subset of the Knowledge Post-test (M=85.63%, SD=9.56%) compared to the Symptoms Subset of the Knowledge Pre-test (M=81.88%, SD=20.27%), t(79) = -1.658, p=0.101. Additionally, there was no significant difference on the Addiction/Naloxone Subset of the Knowledge Post-test (M=69.75%, SD=23.17%) compared to the Addiction/Naloxone Subset of the Knowledge Pre-test (M=67.75%, SD=22.61%), t(79) = -0.832, p=0.408. This indicates that emergency nurses already possessed a high degree of knowledge in the areas of overdose symptomology and naloxone administration.
We determined that there was need for emergency nurses to improve their competency when opioid overdose patients arrive to emergency departments in private vehicles. Due to the increase in this type of overdose event and the range of safety-related variables that can be present when patients arrive in this manner, we sought to develop a resource that nurses could use to improve their education in these areas. Our efforts resulted in the creation of an innovative and interactive iBook that was designed to provide education to nurses regarding opioid overdose risk factors, the impact of opioids on the body and how naloxone works to reverse these effects, and measures that can be taken to both ensure the safety of emergency nursing staff and appropriate patient care.
...the intervention was well-received and nursing staff increased their knowledge and confidence in multiple critical areas related to opioid overdose and personal safety.We found that the intervention was well-received and nursing staff increased their knowledge and confidence in multiple critical areas related to opioid overdose and personal safety. Despite concerns for safety and injury – and contrary to published literature (Elliott et al., 2019; Punches et al., 2020) about the negative attitudes of providers responding to opioid overdose victims – when asked about their general attitudes about providing care to these patients, responses were compassionate.
Implications for Emergency Nursing
With the recent rise in opioid overdose events, nurses are being placed in potentially hazardous situations when overdose patients arrive to EDs in private vehicles. While nurses are well-trained in overdose symptomology and naloxone administration, they do not currently possess adequate knowledge to act as first responders in regards to scene safety and protocols to follow outside the physical confines of the ED.
...[nurses] do not currently possess adequate knowledge to act as first responders in regards to scene safety and protocols to follow outside the physical confines of the ED.Through the dissemination of this study, we are able to bring awareness to the safety risks identified by nurses when approaching and assessing possible overdose patients who arrive in private vehicles. We have shown that the Be-SAFE© intervention improves nurses’ knowledge about how to approach and assess this type of possible overdose patient event, and suggest that this curriculum could be utilized by nurses in similar EDs to promote a safe working environment and optimal patient care. At this time, the full iBook is available on the Emergency Nurses Association (ENA) organization website for use by emergency nurses (ENA, 2019).
The goal of our work was to develop an educational intervention designed to improve emergency nursing knowledge and skills related to providing care for patients with a potential overdose who arrive to EDs in private vehicles. With the input of five key stakeholders, we created an instructional iBook intervention to provide relevant, focused training to nursing staff to mitigate risk associated with responding to such overdose events. Our results show that nursing knowledge was increased in the areas of focus as a result of participating in the Be-SAFE© program. The information included in this intervention is relevant to nursing practice and can be used to promote higher standards of emergency nursing care and staff safety in the context of care for patients with a potential opioid overdose.
This work was supported by the American Nurses Foundation grant number 1013791 and the Midwest Nursing Research Society.
Conflict of Interest Statement
The authors report no conflicts of interest.
Angela Clark, PhD, RN, CNE
Dr. Clark is an assistant professor at the College of Nursing, University of Cincinnati in Cincinnati, OH.
Jeannie Burnie, MS, APRN, AGCNS-BC, CEN, FAEN
Ms. Burnie is a clinical nurse specialist at Bethesda North Hospital, TriHealth, in Cincinnati, OH.
Randall Johann, MA, BS, NHDP-BC, FP-C, FF/Paramedic
Mr. Johann is the EMS Coordinator for Bethesda North Hospital, TriHealth, in Cincinnati, OH.
Rachel Baker, PhD, RN, CPN
Dr. Baker is an adjunct professor at the College of Nursing, University of Cincinnati, Cincinnati, OH.
Christine Hassert, BSN, RN, CEN
Ms. Hassert is a nurse at Bethesda North Hospital, TriHealth, and an adjunct instructor at Xavier University, both in Cincinnati, OH.
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