Overdose Education and Naloxone Distribution (OEND) Saves Lives

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1 Overdose Education and Naloxone Distribution (OEND) Saves Lives Utah Fall Substance Abuse Conference St George, Utah Chris Stock, PharmD, BCPP VA Mental Health/Substance Use Disorders

2 Workshop Description Ten Utahns die every week from drug overdose. Many more are treated in EDs and survive Prescription pain relievers account for more than half of these. Family or friends are nearby during most of these deaths. Safe Use, Safe Storage and Safe Disposal of prescription pain medications is critical. Having naloxone available to give to a loved one in the event of an overdose can save some of these lives. Participants will learn how to recognize and respond to an overdose. Naloxone administration will be practiced. Participants will learn how and where naloxone can be obtained.

3

4 Nearly 10 Utahns die as a result of drug overdose each week! Utah DOH

5 How Did We Get Here?

6 160, , ,000 Opioid Events in ED for every 1 death 135, ,000 80,000 60,000 40,000 20,000 0 ED visits 46 people die from an rx opioid overdose every day 16,651 Rx deaths NALOXONE COULD/SHOULD BE USED IN EVERY CASE! Sources: Yokell, JAMA Int Med, Dec 2014; NIDA News Release April 24, 2014

7

8 VETERANS

9 Over 50% of all deaths and approximately 80% of all Rx overdose deaths

10 CDC rate of heroin-related overdose deaths nearly quadrupled, > 8,200 people died in 2013.

11 2002-8: 1,234 Accidental Opioid Deaths Porucznik, Christina A., et al. "Studying adverse events related to prescription opioids: the Utah experience." Pain medicine 12.s2 (2011): S16-S25.

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13 Collateral exposures CONCLUSIONS: Increasing adult drug prescriptions are strongly associated with rising pediatric exposures and poisonings, particularly for opioids and among children 0 to 5 years old. Pediatrics 2013;132:18 27

14 28% had doses <50mg/d MED 48% had concurrent sedative prescriptions 44% had chronic opioid use Medical Care Volume 53, Number 8, August 2015 Study of non-fatal overdoses at SLC VA: 34% had doses < 50mg/d MED were older than U.S. average victim s age many did not have SUDD many had UDSs reflective of prescribed medications

15 Who is at risk of Overdose Death? Veterans Children in the home if opioids present Prescribed high dose opioids (over mg MED) or ANY DOSE History/vulnerability for substance abuse Current or history of psychiatric illness With benzodiazepine and opioid in their hands!!! Mis-using their medications! Taking more than prescribed Drinking alcohol with meds Taking benzos, Z drugs, sedatives With medical co-morbidities Lung disease, heart disease, hepatic/renal over 50 years of age Past history of overdose, currently in ED for overdose. After release from prison, treatment, etc.

16 Accidental Rx drug overdose (prescribed or not) Intentional drug overdose (i.e. suicide by drug) Accidental Street drug overdose (heroin, cocaine, meth)

17 What do we do now? Call to Action and Resources

18 Naloxone Access laws n=37

19 Utah Law Updates HB Overdose Reporting Amendments Encourages people to call 911 to summon rescue of an overdose victim Utah Code > Opiate Overdose Emergency Treatment Allows 3rd party prescribing of naloxone and offers civil, criminal and health care liability for prescribing, dispensing and lay person administration of naloxone for overdose rescue

20 Title: Emergency Administration of Opiate Antagonist Definitions. As used in this chapter: (4) "Opiate antagonist" means naloxone hydrochloride or any similarly acting drug Voluntary participation. does not create a duty or standard of care to prescribe or administer naloxone Immunity from liability. (1) a person administering naloxone is not liable for any civil damages (b) health care provider: (i) does not have immunity from liability when acting within their professional scope; and (ii) does have immunity from liability if they are under no legal duty to provide care. (2) they may, without a prescriber-patient relationship, prescribe or dispense naloxone without liability, to: (a) any one at increased risk of overdose; or (b) a family member, friend, or other person who can assist (3) health care providers shall provide education that includes instructions to take the person who received naloxone to an emergency care facility for a medical evaluation (i.e. call 911) Enacted by Chapter 130, 2014 General Session

21 Why DISTRIBUTE Naloxone? Even after calling 911, help might not arrive in time to save the individual who has overdosed. Naloxone is an antagonist/blocking medication that can quickly reverse overdose from opioids (i.e. heroin, oxycodone, methadone) and prevent death. Naloxone is: very safe not a controlled substance approved by the FDA to reverse opioid overdoses

22 Naloxone Mechanism of Action: Pure opioid antagonist that competes and displaces opioids at opioid receptor sites Onset of action: Intramuscular: 2-5 minutes Intranasal: 2-5 minutes Duration: ~ minutes depending on route of administration Half-life elimination: Adults: hours Naloxone.Lexicomp

23 Is there any debate? Benefits Reduce overdose deaths Faster than waiting for EMS (may save brain cells) Increased awareness of dangers of medications and illicit drugs Promotes self-care Possible Risks Increase in drug use Several published studies disprove this Increase in risky use, i.e. higher doses, naloxone parties No valid, verified reports Naloxone reversal can be miserable so repeated exposure not desirable Successful rescue will discourage seeking medical attention or treatment

24 TAILOR EDUCATION TO RISK FACTORS Substance use disorder (addiction) Don t Use Alone, harm reduction model Have naloxone available in case of overdose Medication misusers Use Only as Directed Have naloxone available for respiratory side effects Adherent patients on high opioid doses Just In Case Have naloxone in case your dose becomes too strong

25 Training/Education: Recognizing an Opioid Overdose Really High (stay and arouse) Muscles become relaxed Speech is slowed/slurred Sleepy looking Will respond to stimulation like yelling, sternum rub, pinching, etc. Nodding out Wolfe T. Safe Injection Intranasal Drug Delivery. Online available at: Intranasal.net Overdose (call 911 and give naloxone) Deep snoring or gurgling (deep rattle) or wheezing Blue skin tinge- usually lips and fingertips show first Pale, clammy skin Heavy nod, will not respond to stimulation Breathing is very slow, irregular, or has stopped/faint pulse

26 Intranasal Naloxone Rescue Kit 2 x 2 ml pre-filled needless syringes of naloxone 1 mg/ml 2 mucosal atomization devices micron particle size

27 Intramuscular (IM) Naloxone Rescue Kit 2 x 1 ml single-dose vials of naloxone 0.4 mg/ml 2 x 3 ml IM syringes

28 Naloxone auto-injector (Evzio TM ) Approved in 2014 Each package comes with a trainer 0.4 mg/0.4 ml naloxone in a pre-filled auto-injector; 2 auto-injectors per package Trainer and auto-injectors are equipped with electronic voice instruction system May not be readily available in all pharmacies due to cost Pharmacy may choose to special order Evzio based local prescriber/patient needs

29 Naloxone Kit Availability Intermountain Health Community Pharmacies 28 throughout most of Utah IN kits < $60 if paying cash! The Apothecary Shoppe at SL Regional Using a Collaborative Practice Agreement (CPA), prescription is not needed St Marks Community pharmacy UofU HealthCare Greenwood Health Center VA Medical Center 6 clinics throughout Utah Other retail outlets are working on availability Ogden, Associated Food Stores

30 Naloxone Kits Rescue kits are available in either intranasal or intramuscular forms Costs range from $35-$100+ Commercial auto-injector is available but very expensive There are patient assistance programs available that could make this free if you qualify Check the Evzio website Most insurance plans (including medicaid) cover the cost of the kit Free kits available from Department of Pediatrics program

31 VIDEOS

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33

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35 Intranasal Naloxone Rescue Kit Instructions

36 IM Naloxone Rescue Kit Instructions

37 Naloxone auto-injector (Evzio TM ) Instructions

38 Summary: Have: Utah Law authorizing 3 rd party prescribing Naloxone available on Utah Medicaid formulary Need: Including Evzio Nasal adapter (for IN), syringe (for IM), and other materials may require additional orders/purchases Broader access and distribution mechanisms Pharmacists can use CPA s to prescribe/dispense naloxone kits Use for access to prescriber, pharmacist, training resources and materials Collaboration (there is a working group including: Pharmacists, Utah Department of Health, Utah Poison Control Center, Utah Division of Substance Abuse Services, Utah Department of Corrections, and representatives of UPhA, USHP, UMA, Smith s, Walgreens and others

39 Save a life! Be aware Educate Naloxone

40 Community Management of Opioid Overdose, World Health Organizationhttp://apps.who.int/iris/bitstream/10 665/137462/1/ _eng.pdf?ua=1&u a=1 Substance Abuse and Mental Health Services Administration (SAMHSA) Opioid Overdose Toolkit, Prescription Drug Abuse Prevention Toolkit for downtown Ogden

41 Thank you Questions? Let s go and save a life!

42 Opioid Overdoses by Small Area 62 areas determined by population size, political boundaries of cities and towns, economic similarity Highest prescription pain medication overdoses ( UTDOH data) Carbon/Emery counties: 37.8 per 100,000 South Salt Lake: 34.8 per 100,000 Downtown Ogden: 29.6 per 100,000 Prescription opioid deaths per 100,000 populations ages 18+ by small area, Fondario, UTDOH, 09/2014

43 ENDORSEMENTS SAMHSA Opioid Overdose Toolkit * Federal Guidelines for Opioid Treatment Programs Position Statements American Medical Association (AMA) American Pharmacists Association (APhA) American Society of Addiction Medicine (ASAM) * American College of Medical Toxicology & AACT and AAPCC Office of the National Drug ControlPolicy (ONDCP) National Commission on Correctional Health Care American Public Health Association American Academy of Pain Medicine * * Recommends co-prescribing naloxone with opioid prescriptions

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