Community based opioid overdose prevention: the role of naloxone. William Matthews, Physician Assistant Harm Reduction Coalition New York, NY

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1 Community based opioid overdose prevention: the role of naloxone William Matthews, Physician Assistant Harm Reduction Coalition New York, NY

2 Drug poisoning death rates by manner of death, US, Source: adapted from Paulozzi Pharmacoepidemiology and Drug Safety, 2006; 15:

3

4 What is the most dispensed prescription drug in the United States? (number of prescriptions filled; generic and branded products, ) 4

5 Top 10 Drugs Dispensed in Hydrocodone/Acetaminophen(Vicodin) 2. Lipitor 3. Amoxicillin 4. Lisinopril 5. Hydrochlorothiazide 6. Atenolol 7. Zithromax 8. Furosemide 9. Alprazolam (Xanax) 10. Toprol-XL Source: 5

6 Heroin Overdose Epidemiology About % of heroin users are estimated to die each year, many from heroin overdose Heroin users experience a loss of 18 years of potential life, at least 25% due to overdose Up to 2/3s of heroin users experience at least 1 nonfatal overdose Sporer 2002, Galea 2003, Smythe 2006, Coffin 2007

7 Drug Overdoses Are Common and Kill Many Users Among heroin users, 20-40% report an overdose in the past year. About 1% of heroin users die of overdoses for every year they use.

8 Physiology of overdose Generally happens over course of 1-3 hours- the stereotype needle in the arm death is only about 15% Opioids depress the urge to breath decrease response to carbon dioxide - leading to respiratory depression and death Sporer Ann Emerg Med 2007

9 Who overdoses? Most often dependent long term users who are not in treatment with 5-10 years of experience rather than new users- about 17% occur among new users Sporer Ann Emerg Med 2006

10 Overdoses are often witnessed But what to do? Fear of police may prevent calling 911 Abandonment is the worst response Witnesses may try ineffectual things first Salt & milk shots Tracy, Drug Alcohol Depend 2005

11 Naloxone (Narcan) Quick acting Reverses opioid overdose Works for minutes Narcan Delivered via injection (IM, SC, IV) or nasal Source: adapted from slides of Nab Dasgupta

12 Overdose Prevention Community-based, public health OD prevention programs are spreading (Chicago, New York, Boston, San Francisco, Philadelphia, Pittsburg) Involve training users about how to recognize ODs and what to do Provide naloxone to reverse opioid ODs

13 The training: minutes Prevention understanding the role of: mixing drugs reduced tolerance using alone Overdose recognition Actions Call 911 Rescue breathing- using dummy Naloxone administration

14 Major risk factors Use following a period of abstinence Incarceration Hospitalisation Drug treatment/detox Mixing classes of drugs Primarily other CNS depressants Cocaine is involved in nearly 40% of NYC overdoses Sporer 2006, Chan Acad Emerg Med 2006

15 Death following incarceration Post incarceration is major risk factor for death from OD Study of deaths in first 2 weeks post incarceration among 30,237 released inmates 129 times greater likelihood of dying of OD vs. other WA state residents 60% involved opioids 74% involved cocaine and other stimulants Bingswanger NEJM 2007

16 Identifying those at risk Injectors higher risk than nasal insufflators History of previous overdose is a major predictor of future overdose- may be a key screening question Wines Drug Alcohol Depend 2007, Coffin Acad Emerg Med 2007

17 Other risk factors Overdose is more likely in the presence of significant illness: cirrhosis, AIDS, coronary disease, pulmonary disease Major changes in opioid supply: >1000 deaths USA 2006 with fentanyl Depression Wang AIDS 2005, Wines Drug Alcohol Depend 2007 Sporer 2006,

18 Messages for trained overdose responders Try to use with others who know what to do if an overdose happens Be careful using alone especially if Using after abstinence Mixing different classes of drugs Watch out for your friends, particularly under risky circumstances

19 Recognition Overdose responders are taught to be aware of possible signs of overdose Nodding versus unresponsive Blue lips and nail beds Slow breathing, gurgling Act: Call name, sternal rub: rub knuckles hard up and down breast bone

20 Stimulate the person overdosing Shake, call name loudly Sternal rub: rub knuckles hard up and down breast bone (it hurts!) Ice can work but this is easier

21 Not a replacement for EMS Trainees are counselled Call 911- My friend is unconscious/not breathing Give location. No need to say heroin or overdose Police may come

22 Step Two: Rescue breathing Rescue breathing alone can sustain someone until EMS arrives Mouth to mouth is using a dummy for practice (if available) Chest compressions not included (unless Responder is trained in CPR)

23 Naloxone (Narcan) Opioid antagonist which reverses opioid related sedation and respiratory depression and may cause withdrawal Displaces opioids from the receptors, then occupies the receptor for minutes No psychoactive effects Over the counter in Italy Routinely used by EMS

24 Administration Inject into muscle but subcutaneous and intravenous are also effective Intranasal Acts in 2-8 minutes If no response in 2-5 minutes repeat Lasts minutes

25

26 Nasal Naloxone 2 ml pre-loaded syringes (1 mg/ml ml) Nasal adaptor Spray into nose No needles

27 Naloxone preparations Injectable Inexpensive: $ per dose Well-documented efficacy Requires injection, drawing from a medical vial into a syringe Intranasal More expensive: $19.25 per dose Less well-documented efficacy Requires assembly of spay device with nasal adaptor and naloxone capsule

28

29

30 Role of EMS Overdose responders are trained to call EMS What if they don t? Study of 998 OD patients who were administered naloxone by EMS and refused to go to the hospital- a review of coroner records revealed no deaths in the sample within 12 hours of the encounter Vilke Acad Emerg Med 2003

31 Safety in the field Over 3,500 kits distributed 319 overdose reversals reported 1 unsuccessful revival 1 seizure 1 vomited Only 5 cases with more than 1 injection No cases of re-treatment after naloxone wore off Maxwell J Addict Dis 2006

32 Intramuscular Dose Emergency Medical Services give milligrams of naloxone which precipitates severe withdrawal in the dependent person Overdose prevention services recommend starting with 0.4 with an additional dose readily available

33 Results: awake and breathing Narcan wears off in minutes Overdose responder is counselled to remain with the overdoser and reassure the overdoser if s/he is drug sick- the naloxone will wear off- don t use more heroin to feel better!!

34 Syringe exchange/ access sites: rationale SEPs serve a high risk population SEPs have trusting relationships with drug users and have expertise in working with drug users including peer education

35 Challenges Competition with existing programs for staff and resources Syringe exchange programs funding and staff is stretched and has a lot of turnover Peer educators can be excellent trainers Reinforcement of message often possible SEPs usually do not have medical personnel able to prescribe medications on staff Sharing paid medical staff, use of volunteer clinicians

36 Drug Treatment: Rationale Recently detoxified patients are at high risk of overdose Methadone & buprenorphine patients go in and out of treatment These patients are in contact with other drug users Use of other sedatives associated with death of opioid maintained patients

37 Challenges May be interpreted as condoning/expecting drug use Address it as a community issue- points of contact Staff may not see drug users as capable of such an intervention Education, drug users may be used to describe their own experiences Staff often invested in abstinence model

38 More prevention Opioid maintenance with methadone or buprenorphine reduces opioid overdoses

39 Methadone and mortality A study of opioid dependent patients applying for methadone treatment in Norway 3,789 subjects followed for up to 7 years Clausen Drug Alc Dep 2008

40 Results Pre-treatment In treatment Post-treatment treatment Total mortality Odds ratio Total overdose Odds ratio Percent of deaths due to overdose % 27% 61% Clausen Drug Alco Dep 2008

41 Year NB of OD Change/y % Change/y % % % % % %

42 Maintenance therapy prevents overdose Since the institution of buprenorphine and methadone maintenance in 1995 in France heroin overdose has dropped by 79% No. of deaths French population in 1999 = 60,000,000 Patients receiving buprenorphine (1998): N= 55,000 Patients receiving methadone (1998): N= 5,360 Year 42 Auriacombe et al., 2001

43 Homeless shelters Being homeless is associated with risk of OD Associated factors may be: Social and economic stress Lack of safe, familiar place to inject Using alone and rushing injection Less access to opioid maintenance treatment O Driscoll AJPH 2001

44 Challenges Creation of policies and procedures for large agency with wide diversity in settings Medical providers not present in all facilities to dispense naloxone Needles are not allowed in all shelters Fear of repercussions of disclosing drug use

45 National Experience

46 Decreasing overdose rates Chicago: opioid overdose deaths decreased 34% coinciding with start up of first naloxone distribution program Peak 2000: : 205 Naloxone distribution scaled up 2000 Baltimore: Decreasing rates prior to and with OD program San Francisco: 2004 overdose rate down while statewide is up 42% Scott J Urban Health 2007, Baltimore DOH 2008, SFDOH Commission meeting 2005

47 Heroin overdoses dropping Allegheny County Trends in Accidental Drug Overdose Deaths * *Data is from Allegheny County Medical Examiners Annual Reports and includes all overdose deaths where these drugs were present at time of death, not necessarily cause of death.

48 Heroin Use in Allegheny County by Fiscal Year *Data from Pennsylvania Department Of Health

49 Good Samaritan Law New Mexico 2007 OVERDOSE PREVENTION-- --LIMITED IMMUNITY. A person who, in good faith, seeks medical assistance for someone experiencing a drug-related related overdose shall not be charged or prosecuted for possession of a controlled substance... If evidence for the charge... was gained as a result of seeking medical assistance.

50 Conclusions Overdose prevention training consists of a few basic components Overdose prevention by non medical persons is feasible, safe and probably effective

51 If you ever get in a meeting with some professional-type people, tell em that, you know, people like us no, we re not professionals, but if we have it at hand we can save somebody s s life with this stuff [naloxone]... it s s a lifesaver, there s s no question.* *quote collected by Suzanne Carlberg-Racich, Chicago

52 Slide Acknowledgements Alice Bell Melinda Campopiano Nabarun Dasgupta Sandro Galea Traci Green T. Steve Jones Sharon Stancliff

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