Download Overdose Prevention with Community Based Naloxone: An …

Overdose Prevention with
Community Based Naloxone
Sharon Stancliff, MD
Harm Reduction Coalition
Motor vehicle traffic, poisoning, drug poisoning, and unintentional drug
poisoning death rates: United States, 1999--2010
Motor vehicle
traffic
18
Deaths per 100,000 population
16
Poisoning
14
12
Drug poisoning
10
Unintentional
drug poisoning
8
6
4
2
0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
NOTES: Drug poisoning deaths are a subset of poisoning deaths. Unintentional drug poisoning deaths are a subset of drug poisoning deaths.
SOURCE: CDC/NCHS, National Vital Statistics System; and Warner M, Chen LH, Makuc DM, Anderson RN, Miniño AM. Drug poisoning deaths in the United
States, 1980–2008. NCHS data brief, no 81. Hyattsville, MD: National Center for Health Statistics. 2011. http://www.cdc.gov/nchs/data/databriefs/db81.htm.
Intercensal populations http://www.cdc.gov/nchs/nvss/bridged_race/data_documentation.htm
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 Vital Statistics System; and Warner M, Chen LH, Makuc DM, Anderson RN, Miniño AM. Drug poisoning deaths in the United
States, 1980–2008. NCHS data brief, no 81. Hyattsville, MD: National Center for Health Statistics. 2011. http://www.cdc.gov/nchs/data/databriefs/db81.htm
Inpatient admissions for heroin use
6
5
Rate Per 100,000
4
16-19
20-23
24-27
3
28-31
32-35
36-39
2
40-43
44-47
48-51
52-55
1
0
1993
1997
2001
2005
2009
Unick, GJ et al, 2013, PLOSONE, in press
Opioid overdoses
•
•
•
•
Overdoses evolve over 1-3 hours
There are often bystanders
Naloxone is a safe and effective antidote
Many overdoses deaths are preventable with
prompt recognition and treatment
Source: Sporer, K. 2006
Naloxone (Narcan)
• Prescribed opioid antagonist which rapidly reverses
opioid related sedation and respiratory depression
and may cause withdrawal
• Overdose victims wake up minutes after
administration
• Displaces opioids from the receptors for 30-90
minutes
• No pleasant psychoactive effects
• Routinely used by EMS
Naloxone preparations
• Injectable
– Less expensive: $6.50 per dose
– Well-documented efficacy
– Requires injection, drawing from a medical vial
into a syringe
• Intranasal
– More expensive: $21.00 per dose
– Less well-documented efficacy
– Requires assembly of spay device with nasal
adaptor and naloxone capsule
7
Models of increasing access to
naloxone
• Community prescribing/distribution to drug
user and/or social networks
• Prescribing in outpatient care
• Increasing access among first responders
• Pharmacy collaborative agreements
Legal issues
•
•
•
Most states allow for prescription of naloxone to
those at risk of overdose
Some states have passed legislation to allow for
prescribing to anyone potentially at risk of
witnessing an overdose (NY, NM, Il, WA, CA, RI,
MA, CT)
Other jurisdictions have passed local laws or
initiated pilot programs
Appropriate Settings for Naloxone Assess
• Syringe access
• Homeless shelters
programs
• Post-incarceration
• HIV programs
• Primary care and
• Drug treatment
other health care
– Methadone or
settings
Suboxone programs
• Parent support
– Detoxification
groups
– Residential or
outpatient treatment
Overdose prevention knowledge
• Preventionunderstanding the
role of:
– mixing drugs
– reduced tolerance
– using alone
• Overdose recognition
• Actions
–
–
–
–
Call 911
Rescue breathing
Naloxone administration
After-care
Reversing an overdose:
Program Support
• New York, New Mexico and Massachusetts operate state-wide
programs supported by State Departments of Public Health
• City Health Departments support programs in Baltimore, San
Francisco, Seattle, New York City
• Connecticut, Washington, New Mexico, New York, have
passed Good Samaritan laws to encourage calling 911 (NM,
WA, NY, CT IL
Overdose prevention programs: US
MMWR report based on survey of programs
known to the Harm Reduction Coalition
• As of 2010, there were 48 known programs,
representing 188 community-based sites in 15
states and DC.
CDC MMWR February 17, 2012
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6106a1.htm
Survey completed by Eliza Wheeler [email protected]
Overdose fatality prevention programs
that distribute naloxone: USA, 2010
2010 survey of programs known to the Harm
Reduction Coalition
• 189 local programs in 16 states ranging from
state-funded to underground
1996 - 2010:
• 53,339 individuals have received kits
• 10,194 overdose reversals reported
CDC MMWR February 17, 2012
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6106a1.htm
naloxone: USA, 2010
Implementation in NYS
Agencies register and use their own resources
0ver 80 so far
• Syringe exchange/syringe access sites
• Hospitals
• Drug Treatment: Methadone, detox, 28 day and
Therapeutic Community
• HIV programs
• Homeless shelters
• Primary care
Prescribing to those at risk
• Project Lazarus, North Carolina: A multifaceted
OD prevention program including provision of
naloxone to chronic pain patients
• Operation OpioidSafe, Ft Bragg: replicated
aspects of Project Lazarus including naloxone
• Brason, Replication of Project Lazarus comprehensive community based model to
reduce opioid medication overdoses among active duty soldiers determined to be at
risk within select US military bases by implementing the naloxone rescue component
as Standard Operating Procedure APHA 2011
Potential Indications/Populations
1. Patient release after emergency medical care involving opioid poisoning/intoxication
2. Suspected history of illicit or nonmedical opioid use
3. High-dose opioid prescription (> 50 mg of morphine equivalence/day)
4. Any methadone prescription to opioid naïve patient
Any opioid prescription and …
5. smoking/COPD/emphysema/asthma or other respiratory illness or obstruction
6. renal dysfunction, hepatic disease
7. known or suspected concurrent alcohol use
8. concurrent benzodiazepine prescription
9. concurrent SSRI or TCA anti-depressant prescription
10. Prisoner released from custody
11. Release from opioid detoxification or mandatory abstinence program
12. Voluntary request from patient
13. Patients in methadone or buprenorphine detox/maintenance (for addiction or pain)
14. Patient may have difficulty accessing emergency medical services (distance,
remoteness)
source + more info at projectlazarus.org
15. Other (specify): _______________________________________
Pharmacy Collaboration
NEW NEWS!
Collaborative Drug Therapy Agreement for Naloxone Medication in Opioid
Overdose Reversal
I, __________________, MD, a licensed health care provider authorized to prescribe
medication in the State of Washington, delegate prescriptive authority to
_______________________ Pharmacy and the pharmacists listed below to initiate drug
therapy for the treatment or prophylaxis of opioid overdose according to the protocol that
follows. The protocol provides written guidelines for the pharmacists to dispense
medication in accordance with the laws (RCW 18.64.011) and regulations (WAC 246‐
863‐100) of the State of Washington.


The pharmacists shall document all drug therapy initiated under this protocol.
As the authorizing prescriber, I or authorized staff under my supervision will be
available to review the drug therapy initiated by the pharmacists.
This protocol will be in effect for two years unless rescinded earlier in writing to the
Washington State Board of Pharmacy by either party. Any modification of the protocol
shall be treated as a new protocol and filed with the Washington State Board of
Pharmacy.
Creative strategies for preventing
overdose: Massachusetts
Source: Four Tales of Overdose Survival, Massachusetts Bureau of Substance Abuse Services, SA1069, 2009
Source: Four Tales of Overdose Survival, Massachusetts Bureau of Substance Abuse Services, SA1069, 2009
Source: Four Tales of Overdose Survival http://www.maclearinghouse.com/PDFs/SubstanceAbuse/SA1069.pdf
Source: Four Tales of Overdose Survival, Massachusetts Bureau of Substance Abuse Services, SA1069, 2009
Source: Four Tales of Overdose Survival, Massachusetts Bureau of Substance Abuse Services, SA1069, 2009
Role of EMS
Patients receiving naloxone, not being transported to
ER: deaths known to medical examiner
• 998 patients refused transport: none within 12 hours
• 552 patients refused transport: none within 48 hours
• 2241 patients discharged by EMS over 10 yrs: 3 died
(0.13%) of potential rebound overdose
Limitations: some medical evaluation, varying doses of
naloxone; all SKOOP responders instructed to call EMS
•
San Diego: Vilke Acad Emerg Med 2003; San Antonio: Wampler Prehosp Emerg Care 2011;
Copenhagen: Rudolph Rescusitation 2011
Incremental Cost Effectiveness Ratio
• ICER = Added cost of intervention divided by
increase in Quality adjusted life year
• Generally accepted threshold is $50,000/year
• Chlamydia screening, Problem drinking
screening both < $14,000
• Naloxone provision $438- $14,000 depending
on variables used
• Coffin 2013,
Outcomes per 1 million heroin users
Change if naloxone given to 20% of
heroin users
Baseline
OD
Increase by 60,000
OD death
Decrease by 10,000
Kits to prevent 1 death
164
Cost / QALY gained
$400
If naloxone reduces OD risk behaviors
OD
Decrease by 1,000,000
OD death
Decrease by 43,000
Kits to prevent 1 death
36
Cost / QALY gained
Cost-saving
Opioid Overdose Prevention:
Who Gets there first?
Richard Cotroneo, Director
HIV Education and Training Programs
OMD, AIDS Institute
NYSDOH
• 1,250 EMT staff trained
• More than 50 overdose events
reversed
• Excellent news coverage
• No serious adverse events reported
Is naloxone distribution decreasing
mortality?
Observational studies in places with overdose
prevention programs find an association with
reductions in overdose deaths:
• Massachusetts, New York City, San Francisco,
Baltimore, Pittsburgh, Chicago
More studies are in progress
39
Heroin-related Deaths, San Francisco, 1993-2011
160
140
Naloxone distribution begins, 2003
120
100
Heroin-related deaths
80
60
40
20
0
19931994
19941995
19951996
19961997
19971998
19981999
19992000
20022003
*Data compiled from San Francisco Medical Examiner’s Reports, www.sfgsa.org
**no data available for FY 2000-2001
20032004
20042005
20052006
20062007
20072008
20082009
20092010
20102011
The DOPE Project 2003-2012
700
600
500
400
New Enrollments
Refills
300
Reversals
200
100
0
2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Unintentional drug poisoning deaths decreased by 37% in
NYC from 2005 to 2010
Number of unintentional drug poisoning deaths
12.3
14
12.9
800
12
10.5
700
9.4
9.3
Number
600
10
7.9
8
500
400
801
838
695
300
6
631
624
200
516
4
2
100
0
0
2005
2006
2007
2008
Year of death
Source: NYC OCME & NYC DOHMH- BADUPCT, 2005-2009
Age-adjusted mortality rate per 100,000
New Yorkers
900
Age-adjusted Rate
2009
2010
Cocaine and heroin rates decreased while
opioid analgesic rate increased
500
Number
400
300
Heroin
Cocaine*
Benzodiazepines*
Sedatives
200
Opioid Analgesics*
Anti-Depressants
Methadone
100
Anti-Psychotics
0
2005
* P-Value less than .05; (2005 vs. 2009)
2006
2007
2008
Year
Drugs are not mutually exclusive
2009
2010
43
Massachusetts
• Massachusetts compared towns by enrollment
in Opioid Education and Naloxone Distribution
programs determining Adjusted Rate Ratios
• Controlled for: city/town population rates of age
under 18, male, race/ ethnicity (hispanic, white, black,
other), below poverty level, medically supervised
inpatient withdrawal treatment, methadone treatment,
BSAS-funded buprenorphine treatment, prescriptions
to doctor shoppers, and year
A. Walley et al Is implementation of bystander overdose education and naloxone
distribution associated with lower opioid-related overdose rates in Massachusetts?
AMERSA 2011
Results
Fatal opioid OD rates were lower in citiestowns:
• Where program enrollment reached a density of
150 per 100k population (ARR: 0.74)
• Where drug user enrollment was high (ARR:0.78)
• Where there were high annual rates of reversals
reported (ARR: 0.74)
No differences were found in nonfatal opioid OD rates.
Federal Support
SAMHSA is finalizing an overdose prevention tool kit
to be sent to all Outpatient Treatment Programs
ONDCP participated in a webinar on the topic with
Safe States and CDC 12/12
FDA which held a workshop in collaboration with HHS,
NIDA and CDC on increasing access to naloxone 4/12
Italy
Rescheduled naloxone as an over the counter
medication in 1987
Medication not subject to
medical prescription.
International Support
UN Resolution: Promoting measures to
prevent drug, in particular opioid overdose
Encourages Member States to include effective drug overdose
prevention and treatment elements in national drug policies
... including the use of opioid receptor antagonists such as
naloxone;
Requests the UNODC & WHO, circulate best practices on drug
overdose treatment and emergency response and to provide
advice, guidance and capacity-building on preventing
mortality from drug overdose
Programs without Naloxone
Lack of naloxone should not deter overdose
prevention education and training
• Screening for risk of overdose and giving
information: risks, prevention, recognition, calling
911 and rescue breathing CAN HELP SAVE LIVES!
• Make OD screening and training a standard of
care
49
Conclusions
• Many overdoses can be prevented
• Ask about risk factors and educate patients
• Overdose training consists of a few basic components
• Integrate into intake, medical visits and patient care
• Drug users, friends, and family can learn to prevent and
safely treat overdose
• Goals:
• Overdose training as standard of care
• Naloxone available over the counter
50