Overdose Prevention Pilot Project Cross Systems Collaboration. Naloxone Distribution
Opioid Overdose Prevention - Role of Naloxone in the Community Sharon Stancliff, MD Harm Reduction...
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Transcript of Opioid Overdose Prevention - Role of Naloxone in the Community Sharon Stancliff, MD Harm Reduction...
Opioid Overdose Prevention-Role of Naloxone in the Community
Sharon Stancliff, MDHarm Reduction CoalitionJanuary 2015
ObjectivesParticipants 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.
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100
2,000
4,000
6,000
8,000
10,000
12,000
Natural and semi-synthetic opioid analgesic
Methadone
Cocaine
Heroin
Synthetic opioid analgesic, excluding methadone
Num
ber o
f dea
ths
Number of drug poisoning deaths involving opioid analgesics by opioid analgesic category, heroin and cocaine: United States, 1999--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
5% decrease
35% increase
Opioid related deaths 2011-2012Increased 2.9%
In 2011~25% of drug-poisoning were unspecified drugs
2010 2011 20120%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
13.821.4
34.9
86.278.6
65.1
Role of Heroin as Cause of Death Among All Drug-Related Deaths
Heroin Non-Heroin
2010 2011 20120%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
54.1 50 47.6
45.9 50 52.4
Role of Opioid Analgesics as Cause of Death Among All Drug-Related Deaths
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 overdose1/2 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
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0 Heroin
Cocaine
Methadone
Benzodiazepines
Opioid Analgesics
Ag
e A
dju
ste
d R
ate
pe
r 1
00
,00
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 1999-2009Overdose was the leading cause of death; opioids were involved in 14.8% of deathsBinswanger 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
Mortality rate, by week since release, for overdose and all other (nonoverdose) causes of death.
Figure Legend:
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
Reverses clinical and toxic effects of opioid overdoseReverses respiratory depression, hypotension, sedationRestores breathingReverses analgesiaPatients can experience withdrawal after naloxone administration
Naloxone
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 OpioidOverdose 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.
27
Essential Knowledge
• What does naloxone do?• Overdose recognition• Action
– Call EMS– Administer naloxone
• Hands on practice with device if possible• Recovery position
? Report?
28
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
Action
• Activate emergency medical services (911) “my friend is overdosing and not breathing”
And • Administer naloxoneWhich 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
31
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
Implementation in NY StateOver 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 addOther 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 4/14As 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 BaltimoreAdjusting for heroin purity and the number of methadonepatients, there was a statistically significant inverse relationship between heroin overdose deaths and patients treated withbuprenorphine (P = .002).
Schwartz et al AJPH 2013
Mortality before, during and after OMT in Norway
Clausen T. et al. Drug and Alcohol Dependence, 2008, Mortality prior to, during and after opioid maintenance treatment (OMT)
% pr year
Pre-treatment In treatment Post treatment
Overdose
Non-overdose
0
0.5
1
1.5
2
2.5
3
3.5
4
1998-20033,789 subjects followed for up to 7 years
Syringe Access:
Syringe Exchanges Pharmacies Medical providers
Trends in HIV and AIDS Cases*New York State, 1984 - 2012
0
20,000
40,000
60,000
80,000
100,000
120,000
140,000
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
1984 1986 1988 1990 1992 1994 1996 1998 2000^ 2002 2004 2006 2008 2010 2012
Nu
mb
er of P
LWD
HI
Nu
mb
er o
f A
IDS
Dia
gn
ose
s an
d D
eath
s
People living withHIV (non-AIDS) atthe end of each yearNumber
diagnosed eachyear with AIDS
Number of deaths each year among AIDS cases
People living withAIDS at the end of
each year
*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
Number of deathsamong HIV & AIDScases each year
19851986
19871988
19891990
19911992
19931994
19951996
19971998
19992001
20022003
20042005
20062007
20082009
20102011
20120
10
20
30
40
50
60
Perc
ent o
f Cas
es**
*
*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.
MSM/IDU
MSM
IDU
Figure 1: Proportion of HIV and AIDS Cases* by Risk and Year of Diagnosis, NYS, 1985-2012**
AIDS Newly Diagnosed HIV
Newly reported cases of hepatitis C
Kim A Y et al. J Infect Dis. 2013
Of those with reported risk: IDU 74%Of those heroin was themost common drug. Massachusetts
2002 n = 6368)2011n = 5194).
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 servicesOther services include:CounselingDrug treatment referralDrug treatmentOverdose preventionHepatitis servicesAcupunctureFood
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
Figure 1 Number of methadone maintenance treatment program admissions over time by route of administration (inhalation versus injection) Des Jarlais et al Addiction 2010
Does syringe access increase injection?
AcknowledgementsNew York State Department of Health New York City Department of Health Opioid Safety Naloxone Network