LifeWon’t Wait:Reducing Fatal Drug OverdosesIn British Columbia

Jordan WestfallThesis DefenseApril 2nd, 2015.10:00 A.M.

299 British Columbians died of unintentional, illicit drug overdoses in

2013. The largest yearly total since 1998.

Too Many British Columbians are Dying of Drug Overdoses..

What happened?

OxyContin, a prescription drug is taken off the market.Fentanyl sold as OxyContin or heroin illicitly. Led to worst weekend in Insite’s history for overdoses (31).

Prescription pain killer overdoses are also increasing.Chronic Pain, 22% of BC adults (Corneil, 2014).

Interior Region- 25, 000 people on opioid medications (Corneil, 2014).

Overdose Prevention in British Columbia• Take home naloxone program.

• Provides Overdose Education and Naloxone Training (OENT).

• OENT consists of:• Prevention of OD • Recognition/Response to OD.

Challenges:• Available by physician’s prescription only.• Must take training course.• Must have a history of opioid use.

How is policy is practiced?

Knowledge Gaps

• Barriers to enhancing overdose prevention.

• Drug user awareness of current policy.• Good practices from other jurisdictions.

Purpose of Research

• AIM: To develop policy at the provincial level to reduce drug overdose fatalities. • What role can public policy play in reducing fatal drug

overdoses in BC?• How can provincial legislation reduce fatal drug overdoses in

BC? • How have other jurisdictions reduced fatal drug overdoses?• Are drug users in Vancouver aware of the VPD’s overdose

prevention policy?

Methodology1) Case Studies:• Ontario – document analysis• North Carolina- 2 interviews with NCHRC• Massachusetts –Document analysis and

interview with Learn2Cope

2) Stakeholder Interviews: • British Columbia

• VPD• BCCDC• Ministry of Justice• Pivot Legal

• United States• Harm Reduction Coalition• National Alliance for Model State Drug

Laws• Columbia University

3) Survey: • 28 respondents• Street-level People who use drugs• Sampled from Vancouver Network of

Drug Users• Questionnaire asks about their

awareness of the Vancouver Police Department’s overdose prevention policy

Case StudiesJurisdiction Distribution

MethodNaloxone Kits Dispensed

Kits per 1,000 persons

Overdose

Reversals

Highlights

Massachusetts

Standing Order

2,444/year

22, 000 (total)

0.36 kits per 1000 people

1,300 • Uses intranasal naloxone.

• Learn2cope provides OENT to family members.

• Police carry naloxone

Ontario Directive (similar to standing order)

665/year

1,330 (total)

0.10 kits per 1000 people

120 • Restricted Access• Implementation

issues stopped program.

North Carolina

Standing Order

2700/year

5400 (total)

0.54 kits per 1000 people

 350 • Cost-effective• Broadest access

to naloxone.

British Columbia

Physician’sprescription

650/year1300

(total)

0.30 kits per 1000 people

125 • Comparative purposes only.

Stakeholder interviews

British Columbia:• More

education/destigmatization:• Friends, family, illicit, and

licit drug users.• Lack of prescribing

directive.• Inefficiency.• Naloxone by pharmacist’s

prescription.• Good Samaritan Law.

United States:• Misconceptions persist.• Public endorsements

increase acceptability.• Celebrities, police. • No evaluation or awareness

$ for Good Sam laws.

Were you aware of this policy?

YES 27%

(n) = 6• 50% (n=3) suggested that

awareness didn’t make them more likely to call 911 because the police arrived at the most recent overdose they witnessed.

• 50% (n=3) weren’t concerned about the police arriving at the scene.

• “It’s an emergency.”

NO 73%

(n) = 22• 63% (n=12) suggested they were

very likely to call 911 the next time they witness an overdose.

• 37% (n=7) said that they would call 911 regardless, no change in opinion.

• 21% said that VPD arrived at the last overdose they witnessed.

• 10% (n=2) stated specifically that awareness made them feel more comfortable to call 911.

Other policy considerations

Both VPD and drug users need to be considered. • Why not implement a Good Samaritan

law?

• Out of scope.

Intranasal naloxone.• Federal restrictions.

Staggered welfare cheque distribution.• No evidence thus far.

IM naloxone- cost effective

Policy Options are divided into two categories:1.) Overdose Education and Naloxone Training (OENT)2.) Naloxone Distribution

Policy Options- OENT

Findings

9.8% of trainings are for friends & family.

Only those with a history of opioid use can be prescribed naloxone.

“Licit” drug users need OENT

Findings

Most of the province’s methadone clinics don’t provide OENT.

Administering naloxone is empowering for drug users.

Option A

OENT for “laypeople” friends, family members, & licit drug users.

Option B

Dual-incentive recruitment for illicit PWUDs.

OENT at methadone clinics & detox centres.

Criteria and Measures

Effectiveness- Can bystanders respond appropriately to an overdose.

Equity- increase in representativeness for non-illicit drug users.

Policy Options- Naloxone Distribution

Findings

Having a physician prescribe naloxone is inefficient.

Licit drug users are overdosing at an increasing rate.

Adding naloxone to provincial formulary would make it free for Blue Cross members.

Findings

Overdose is leading cause of death among homeless in BC.

Jurisdictions that have liberalized access to naloxone have higher amounts of OD reversals.

Option A

Naloxone available by pharmacist’s prescription.

Option B

Nurse’s Decision Support Tool. (DST)

Criteria and Measures

Health & Safety- # of overdose reversals.

Effectiveness- # of naloxone kits dispensed.

OENT Option AStrengths• OENT for underrepresented

groups (family and friends).• Provides an access point

for support services• Addresses licit ODs.• Effective under current

regulations. when laypersons cannot receive naloxone kit.

Weaknesses• No support for illicit drug

users.

OENT Option B

Strengths• Empowerment for drug

users.• Reduced “enacted” and

“self-stigma”• Methadone clinics• Secondary trainings

Weaknesses• PWUDs already well represented

under current efforts (less of an impact)• Ideological resistance from

detox centres.

Naloxone Distribution Option A

Strengths• Convenience.

• Access for licit drug users and methadone patients.

• Easy to get follow-up kits.

• Reduces prescribing burden on physicians.

• Added to Blue Cross

• No need to use Telehealth in rural regions.

Weaknesses • Pharma Net.

• Negative externalities.

• Licit drug users have to make separate trips for OENT and kit.

Naloxone Distribution Option B

Strengths

• Cohesion with OENT options.

• Reduces physician prescriber burden.

• Outreach efforts (street nurses, etc)

Weaknesses

• Cost inefficiencies

• Clinic or other healthcare visit required.

• Follow up kits require healthcare visit.

Recommendations• OENT efforts should be expanded to

focus on friends, family members and licit drug users.

• Nurse’s DST: helpful for homeless populations.

• Naloxone distribution by pharmacist’s prescription for the rest of the population.

• Each naloxone distribution option is cost effective.

Future Considerations

• Reduce waitlists for drug rehabilitation services.

• Drug reformulations can increase overdoses.

• Instruct police departments not to respond to overdose 911 calls.

Conclusions

BC is leading Canada toward a rational, scientific drug policy.

Naloxone is not a “magic-bullet”.

But we’re losing ground

to the United States. Liberal access to naloxone.

Good Samaritan Laws.

Housing, employment training, rehab services.

These things help people stay

off of drugs.