Overdose prevention in criminal justice settings

The NEXT Study

David Showalter1,2, Eliza Wheeler3, Lynn Wenger1, Andrea Lopez4, Ingrid Binswanger5, Barrot Lambdin1 and Alex Kral1

1RTI International, 2 University of California, Berkeley, 3 Harm Reduction Coalition, 4 University of Maryland, College Park, 5 Kaiser Permanente, Institute for Health Research

Drug overdose deaths in the US

• In 2014, there were 47,055 drug overdose deaths in the US, more than motor vehicle accident deaths, and a 6.5% increase from 2013.

• Among these, 28,647 (61%) involved opioids including heroin. Heroin deaths increased by 26% since 2013. Fentanyl deaths doubled from 2013. Rx opioid deaths increased 9%. Methadone stayed the same since 2013.

What puts people at risk for overdose?• Mixing Drugs

• Variation in strength and content of ‘street’ drugs (purity), or strength of pharmaceuticals

• Switching mode of admin (snorting to injecting, eating pills to snorting, etc.)

• Tolerance changes (getting out of jail, leaving treatment, relapsing)

• New or experimenting users, no tolerance or dependence

• Using alone

• Physical Health (liver functioning, weight loss, asthma, immune system problems, dehydration, malnutrition, etc.)

Recognizing a depressant OD

REALLY HIGH OVERDOSE

Muscles become relaxed Deep snoring or gurgling (death rattle) or wheezing

Speech is slowed/slurred Blue skin tinge- usually lips and fingertips show first

Sleepy looking Pale, clammy skin

Will respond to stimulation like yelling, sternum rub, pinching, etc.

Heavy nod, will not respond to stimulation

Nodding out Breathing is very slow, irregular, or has stopped/faint pulse

• Opioids repress the urge

to breathe

• Carbon dioxide levels

increase

• Oxygen levels decrease

• Process takes time

• There is time to respond,

but no time to waste

1 • Slow breathing

2 • Breathing stops

3• Lack of oxygen may cause brain

damage

4 • Heart stops

5 • Death

How the overdose occurs

Next steps – overdose response

• Stimulation (call name, foot tap, sternum rub). If no response:

• Administer naloxone (also known as Narcan®)

• Call 911

• Clear the airway, preform rescue breathing and/or chest compressions

• Recovery position if you have to leave the person

• Administer second dose of naloxone after 2-3 minutes if no response

• Opioid antagonist (“blocker”) which reverses opioid overdose

• Can be administered intravenously, intramuscularly,

subcutaneously or intranasally

• Only works for about 20-90 minutes

• Causes sudden withdrawal in the opioid dependent person –

an unpleasant experience

• Doesn’t get a person “high” and is not addictive

• Has no effect if an opioid is not present

Naloxone (Narcan®)

Available forms of naloxone

The wake-up

• People wake up from an overdose differently

• Violent reactions to waking up from an overdose are rare, and associated with being given too much naloxone, or waking up in disorienting environments (ER, first responders/police presence, etc.)

• Often, the person does not realize that they had overdosed, keep them calm and explain what happened

• Make sure they do not try to ingest more of any drug

Community based overdose education and naloxone distribution (OEND)

• Since 1996, 644 programs in the U.S. trained 152,283 laypersons1

• The programs that collect reversal data documented 26,463 overdose reversals1

• Studies show that communities with OEND programs have lower fatal overdose rates than communities without OEND programs2

1Wheeler, E. et al. (2015). Opioid overdose prevention programs providing naloxone to laypersons -United States, 2014.

MMWR 64(23), 631-635. 2 Walley, A.Y. et al. (2013). Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ 346, f174

Naloxone access models

1. Provider writes prescription and directly dispenses pre-assembled naloxone kit to patient

2. Provider writes prescription, patient fills at pharmacy• Setting: clinic with insured patients, pharmacies alerted to prescribing plans, may need to have atomizers on-

site for intranasal formulation, consider providing informational brochure www.prescribetoprevent.org

3. Pharmacy directly dispenses from “behind the counter” without prescription (AB 1535 authorized this in California as of 2015)

4. Prescriber writes non-patient specific standing order for community-based program or treatment program, program staff provide the education and distribute pre-assembled kits• Setting: “Overdose prevention programs”, commonly located at programs like syringe exchanges, drug

treatment programs, drop-in centers, jails/corrections, etc.

Overdose risk and re-entry

• Research from Washington State shows:

• Former inmates had 129 times the risk of overdose death during the 2 weeks immediately following release from prison than the general population.3

• Overdose was the leading cause of death among former prisoners.3

• Opioid overdose was most common during the first two weeks following release from jail or prison.4

3Binswanger I.A., et al. (2007). Release from prison—a high risk of death for former inmates. NEJM356(2), 157-165;4 Binswanger IA et al. (2013). Mortality after prison release: opioid overdose and other causes of death, risk factors, and time trends from 1999 to 2009. Ann Intern Med159(9), 592-601.

Why are former inmates at high risk of overdose?

• Limited access to drug treatment and lack of social support following release

• Inadequate services to support integration into the community

• Opioid relapse is common after release from prison or jail

• Abstinence and infrequent use during incarceration lowers opioid tolerance, increasing risk of overdose in the event of relapse

OEND in Criminal Justice settings

• San Francisco

• Collaboration between Jail Health Services, DPH, Harm Reduction Coalition, Adult Probation and the Sheriff’s Department

• Since implementation in 2013, 289 inmates have received naloxone kits upon release

• New York State

• Pilot program launched at a minimum security prison in February 2015 with the goal of expanding to all NY State correctional facilities

• More than 700 inmates have been trained and approximately 200 have received naloxone kits

• Seattle, Washington

• Jail pharmacist has provided trainings since March 2014; more than 200 inmates have been trained

In this 3/21/2016, photograph, inmate Eric Burton examines a naloxone dose while conferring with a doctor at the Denver County Jail in downtown Denver. (AP Photo/David Zalubowski)

The “next” study: an overview

• OEND programs in Criminal Justice settings are an effective tool to prevent overdose

• Criminal Justice settings pose unique challenges to OEND implementation

• The goal of this NIH-funded research is to identify barriers and facilitators and develop solutions for the implementation of OEND programs in Criminal Justice settings

Study methods and goals

• Four San Francisco Bay Area counties, including Alameda County.

• Interviews with key stakeholders in health care services, corrections, and re-entry programs.

• Implementation of OEND in two pilot venues – existing programs targeting people exiting incarceration

• Development of a manual to address the key factors and lessons learned

What we’ve learned: barriers

• Insufficient county level data overdose death data

• Lack of knowledge about OEND programs

• Competing priorities for providing services to people exiting Criminal Justice settings

• Lack of countywide harm reduction services

• Institutional fragmentation and budgetary limitations

What we’ve learned: facilitators

• Local champions who are committed to OEND

• Existing partnerships within the county systems of care

• CBOs committed to the population and interested in adding OEND services

• Data that indicate OEND saves lives without adverse consequences

Next steps

• We need your help. You are the experts!

• We would like to set up interviews with you

• We are looking for partners who are interested in piloting OEND services

• What we can do for you:

• Train service providers

• Provide on-going technical support

• Monitor the implementation process

• Develop county-wide recommendations for OEND programming

Contact information

• David Showalter, Research Associate dshowalter.Contractor@rti.org

• Lynn Wenger, Project Director lynndee@rti.org

• Alex Kral, Principal Investigator akral@rti.org