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Opioid Overdose Prevention -Role of Naloxone in the Community Sharon Stancliff, MD Harm Reduction Coalition January 2015 Objectives Participants will be able to: • Summarize the incidence and demographics of opioid use and over dose in the United States. • Recognize the characteristics, risk factors and symptoms associated with opioid overdose. • Explain the New York State DOH’s Opioid Overdose Prevention Program and the ESAP programs. • Describe the role of first responders in managing an overdose. Number of drug poisoning deaths involving opioid analgesics by opioid analgesic category, heroin and cocaine: United States, 1999--2010 12,000 Natural and semisynthetic opioid analgesic Number of deaths 10,000 Methadone 8,000 6,000 Cocaine 4,000 Heroin 2,000 Synthetic opioid analgesic, excluding methadone 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 NOTES: Opioid analgesic categories are not mutually exclusive. Deaths involving more than one opioid analgesic category shown in this figure are counted multiple times. Natural and semi-synthetic opioid analgesics include morphine, oxycodone and hydrocodone; and synthetic opioid analgesics include fentanyl. SOURCE: CDC/NCHS, National Center for Health Statistics. 2011. http://www.cdc.gov/nchs/data/databriefs/db81.htm Opioid related deaths 2011-2012 Increased 2.9% 5% decrease 35% increase In 2011~25% of drug-poisoning were unspecified drugs Role of Heroin as Cause of Death Among All Drug-Related Deaths 100% 90% 80% 70% 60% 65.1 78.6 86.2 50% 40% 30% 20% 10% 34.9 21.4 13.8 0% 2010 2011 Heroin Non-Heroin 2012 Role of Opioid Analgesics as Cause of Death Among All DrugRelated Deaths 100% 90% 80% 45.9 50 52.4 54.1 50 47.6 2010 2011 2012 70% 60% 50% 40% 30% 20% 10% 0% Opioid Analgesics Other Drugs Physiology • Generally happens over course of minutes to hours- the stereotype “needle in the arm” death is only about 15% • Opioids decrease response to rising carbon dioxide and falling oxygen levels leading to respiratory depression and death generally over the course of 1-3 hours Who overdoses? • Among heroin users it has generally been those who have been using 5-10 years • Less is known about prescription opioid users • Anecdotal reports of youth dying suggest that many of those have been in drug treatment and relapse Sporer 2003, 2006 Heroin User Experiences • About 2% of heroin users die each year- many from heroin overdose • 1/2 heroin users experience at least one nonfatal overdose • 80% have observed an overdose Sporer BMJ 2003, Galea 2003, Coffin Acad Emerg Med 2007 Overdose risk of those with prescriptions MMWR / January 13, 2012 / Vol. 61 / No. 1 Context of Opioid Overdose • The majority of heroin overdoses are witnessed (gives an opportunity for intervention) • The circumstances of prescription drug overdoses are less well characterized • Fear of police may prevent calling 911 • Witnesses may try ineffectual things – Myths and lack of proper training – Abandonment is the worst response Tracy 2005 Risk Factors for Opioid Overdose • Reduced Tolerance • Using Alone (risk factor for fatal OD) • Illness • Depression • Unstable housing • Mixing Drugs • Changes in the Drug Supply • History of previous overdose Overdose deaths in New York City involve multiple drugs (2012) Nearly all unintentional drug overdose deaths (95%) involve more than one substance, including alcohol. 2008 • Opioids were the most commonly noted drug type(74%). Types of opioids included heroin, methadone, and prescription pain relievers. • Other drugs commonly found were: cocaine (53%), benzodiazepines (35%), antidepressants (26%),and alcohol (43%). • NYC VITAL SIGNS Volume 9, No. 1, NYCDOHMH Unintentional drug poisoning deaths by drug type involved (not mutually exclusive), New York City, 2000-2012 8.0 Heroin Cocaine Age Adjusted Rate per 100,000 7.0 6.0 Methadone Benzodiazepines Opioid Analgesics 5.0 4.0 3.0 2.0 1.0 0.0 Source: NYC Office of the Chief Medical Examiner & NYC DOHMH Bureau of Vital Statistics Lowered tolerance • Tolerance- repeated use of a substance may lead to the need for increased amounts to product the same effect • Abstinence decreases tolerance increasing overdose risk – – – – Incarceration Hospitalization Drug treatment/ Detox/ Therapeutic communities Sporadic patterns of drug use • Sporer 2007, Binswanger 2007 Post release mortality 76,208 people released from Washington State Department of Corrections 1999-2009 Overdose was the leading cause of death; opioids were involved in 14.8% of deaths Binswanger et al Annals of Med 2013 From: Mortality After Prison Release: Opioid Overdose and Other Causes of Death, Risk Factors, and Time Trends From 1999 to 2009 Ann Intern Med. 2013;159(9):592-600. doi:10.7326/0003-4819-159-9-201311050-00005 Figure Legend: Mortality rate, by week since release, for overdose and all other (nonoverdose) causes of death. Copyright © American College of Physicians. All rights reserved. From: Mortality After Prison Release: Opioid Overdose and Other Causes of Death, Risk Factors, and Time Trends From 1999 to 2009 Ann Intern Med. 2013;159(9):592-600. doi:10.7326/0003-4819-159-9-201311050-00005 Copyright © American College of Physicians. All rights reserved. Strategies to address overdose • Increase access to naloxone • Good Samaritan laws • Prescription monitoring programs – Paulozzi et al. Pain Medicine 2011 • Prescription drug take back events • Supervised injection facilities • Safe opioid prescribing education – Albert et al. Pain Medicine 2011; 12: S77-S85 • Expansion of opioid agonist treatment – Clausen et al. Addiction 2009:104;1356-62 Naloxone • Reverses clinical and toxic effects of opioid overdose • Reverses respiratory depression, hypotension, sedation • Restores breathing • Reverses analgesia • Patients can experience withdrawal after naloxone administration Models of increasing access to naloxone • Community prescribing/distribution to drug user and/or social networks • Increasing access among uniformed first responders- eg police, fire, Basic EMTs • Prescribing in outpatient care • Pharmacy collaborative agreements Legal Status- New Overdose Law in New York State (Effective April 1, 2006) • Protects the non-medical person who administers naloxone in setting of overdose from liability. – “shall be considered first aid or emergency treatment”. – “shall not constitute the unlawful practice of a profession”. • Allows the medical provider to provide naloxone for secondary administration. • Naloxone must be prescribed by MD, DO, PA, or NP either in person or through designated representative via standing order Who may offer an Opioid Overdose Prevention Program? • Licensed health care facilities : – Hospitals – Diagnostic & Treatment Centers • Drug treatment programs • Colleges, universities and trade schools • Public safety agencies • CBOs with the services of a clinical director • Pharmacies • Health care practitioners: – Physicians – Physician assistants – Nurse practitioners • Local health departments • Other local and state agencies Available resources • • • • • • • Naloxone kits (free from NYSDOH) Sample policies and procedures Approved curriculum Fact sheets Sample medical history Certificates of completion OD reporting form Non-patient specific order Allows Approved Overdose Trainers to train community members on overdose treatment with naloxone and to furnish the naloxone under the supervision of a doctor, nurse practitioner or physician assistant when the prescriber is not present. Training • Everyone being furnished or dispensed naloxone should have training in opioid overdose recognition and response. Mechanisms for pharmacist and patient training are still being explored. Essential Knowledge • What does naloxone do? • Overdose recognition • Action – Call EMS – Administer naloxone • Hands on practice with device if possible • Recovery position ? Report? 27 Painful stimulation If no response to calling and shaking: Sternal grind (make a fist and rub the sternum with the knucles) • Assessment of level of consciousness • May make the overdoser breath a bit even if he or she doesn’t wake up 28 Action • Activate emergency medical services (911) “my friend is overdosing and not breathing” And • Administer naloxone Which ever is closer at hand Naloxone Instructions • Inject into a muscle or spray up the nose • If no response in 2-5 minutes, give 2nd naloxone injection • Lasts for 30 – 90 minutes – recipient must be observed, preferably by medical staff for at least 2 hours Results: awake and breathing Narcan wears off in 30-90 minutes • Reassure the survivor if s/he is in withdrawal the naloxone will wear off- don’t use more opioids to feel better!! • Encourage survivor to go to the hospital, either by ambulance or other transportation 31 Implementation in NY State Over 200 sites registered including: • • • • • • • • Syringe exchange/syringe access sites Hospitals/clinic Drug Treatment Programs HIV programs Homeless shelters Government agencies e.g. police Local health departments Educational institutions Over 1000 reversals reported States with legislation allowing 3rd party administration Now add Other states with programs include: Wisconsin, Minnesota and small programs in a variety of places Uniformed first responders Initial responders vary by community • Basic Emergency Medical Technicians are now able to carry naloxone in NYS • Fire fighters being trained • Law enforcement/peace officers – NYC homeless shelters – CUNY and SUNY campus police Law enforcement Following a successful pilot in Suffolk County an initiative to train police across NYS began 4/14 As of January 8, 2015 • Over 2,400 officers have been trained outside of NYC • Naloxone has been used 112 times, 77 recipients had a clear response Opioid maintenance and mortality Overdose deaths in Baltimore Adjusting for heroin purity and the number of methadone patients, there was a statistically significant inverse relationship between heroin overdose deaths and patients treated with buprenorphine (P = .002). Schwartz et al AJPH 2013 Mortality before, during and after OMT in Norway % pr year 3,789 subjects followed for up to 7 years 1998-2003 4 3.5 3 Overdose 2.5 Non-overdose 2 1.5 1 0.5 0 Pre-treatment In treatment Post treatment Clausen T. et al. Drug and Alcohol Dependence, 2008, Mortality prior to, during and after opioid maintenance treatment (OMT) Syringe Access: Syringe Exchanges Pharmacies Medical providers Trends in HIV and AIDS Cases* New York State, 1984 - 2012 16,000 12,000 Number diagnosed each year with AIDS People living with HIV (non-AIDS) at the end of each year 120,000 100,000 10,000 80,000 8,000 6,000 4,000 Number of deaths each year among AIDS cases People living with AIDS at the end of each year 2,000 60,000 Number of PLWDHI Number of AIDS Diagnoses and Deaths 14,000 140,000 40,000 Number of deaths among HIV & AIDS cases each year 20,000 0 0 1984 1986 1988 1990 1992 1994 1996 1998 2000^ 2002 2004 2006 2008 2010 2012 *Data as of April 2014 ^HIV named reporting began in NYS in 2000; deaths among HIV and AIDS cases are reported starting in 2000. NYSDOH/AI/BHAE Figure 1: Proportion of HIV and AIDS Cases* by Risk and Year of Diagnosis, NYS, 1985-2012** AIDS 60 Newly Diagnosed HIV 50 Percent of Cases*** IDU 40 MSM 30 20 10 MSM/IDU 0 1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011 *AIDS Cases are shown for 1985-1999 Source: NYSDOH/AI/BHAE **Data as of December 6, 2013 ***Percentages are based on the total number of new HIV diagnoses for each year, regardless of transmission category. Newly reported cases of hepatitis C Massachusetts 2002 n = 6368) 2011n = 5194). Of those with reported risk: IDU 74% Of those heroin was the most common drug. Kim A Y et al. J Infect Dis. 2013 Expanded Syringe Access • Proven public health intervention • Reduces the transmission of blood-borne pathogens • Expands options for persons with diabetes and others who self-inject • Promotes self disposal of syringes Expanded Syringe Access Program (ESAP) New York State law allows for sale or furnishing of hypodermic syringes or needles by registered: • Pharmacies • Article 28 health care facilities • Health care practitioners Selling of Syringes by Pharmacies During 2011-2012, the ESAP pharmacies distributed an estimated 4,059,048 syringes Research and Evaluation on ESAP • Evaluations of ESAP by the New York State Department of Health, the National Development and Research Institutes, Beth Israel Medical Center and the New York Academy of Medicine found the program to be an effective means of increasing access to sterile syringes for self-injectors in New York State • Pharmacy experiences: Based on the results of three statewide surveys of ESAP-registered pharmacists, the vast majority of ESAP registered pharmacists report very positive experiences with ESAP and this has not changed over time • Criminal Activity: Implementation of ESAP did not appear to increase heroin use, drug injection, or criminal activity in New York State Syringe Exchange in NYS 24 syringe exchange in New York State with multiple sites • Storefronts • Mobile vans • Delivery in single room occupancy hotels • Walking about with supplies • Peer delivery Not just syringes at syringe services Other services include: • Counseling • Drug treatment referral • Drug treatment • Overdose prevention • Hepatitis services • Acupuncture • Food Syringe prescription • Prescription of syringes to injection drug users is legal in New York State • Endorsed by the AMA • Recommended in NYSDOH AIDS Institute guidelines Burris, Annals Int Med 8/1/00, www.hivguidelines.org Does syringe access increase injection? Figure 1 Number of methadone maintenance treatment program admissions over time by route of administration (inhalation versus injection) Des Jarlais et al Addiction 2010 Acknowledgements • New York State Department of Health • New York City Department of Health • Opioid Safety Naloxone Network