1 OPIOID OVERDOSE PREVENTON Zena Hyman, DNS, ANP-BC October 4, 2015 2 Special Thanks and Recognition to: Office of Alcoholism and Substance Abuse Services New York State Department of Health Harm Reduction Coalition PART ONE EPIDEMIOLOGY 1
4 Heroin Overdose Deaths (prior to 2006) About 2% of heroin users died each year- many from heroin overdose 1990-98: 5,506 deaths in NYC Average of 1-2/day in NYC Up to 2/3 of heroin users experience at least one nonfatal overdose 2006: 979 OD deaths in NYC (70% due to opioids) = ~ 685 opioid deaths Coffin, 2007; Galea, 2003; Sporer, 2003. HRC Overdose Rates Increase 5 Between 2002 and 2013, heroin-related overdose deaths nearly quadrupled. Greater than 8,200 people died in 2013, with higher rates in the Northeast and Midwest. CDC, 2015 Top Medicines by Prescriptions (IMH, National Prescription Audit, Dec., 2011) Name 2007 2011 1 Hydrocodone/acetaminophen 120.9 136.7 2 Levothyroxine sodium 97.4 104.7 10 Alprazolam 41.4 49.1 15 Oxycodone/acetaminophen 31.3 38.8 22 Tramadol HCL 20.6 33.9 2
Drug Trend in the U.S.: Opioid Epidemic Rx Opioid availability Rx Opioid exposure Rx Opioid misuse IVDU/Heroin ) OVERDOSE DEATHS IN NYC INVOLVING MULTIPLE DRUGS (2008) HRC Nearly all unintentional drug overdose deaths (98%) involve more than one substance, including alcohol. Opioids were the most commonly noted drug type (74%). Types of opioids included heroin, methadone, and prescription pain relievers. (No mention of fentanyl.) Other drugs commonly found were: cocaine (53%), benzodiazepines (35%), antidepressants (26%), and alcohol (43%). Consider trends in drugs over time. NYC VITAL SIGNS Volume 9, No. 1, NYCDOHMH 3
10 Who overdoses? 11 Historically users with 5-10 years of experience (Sporer, 2003, 2006) Past hx OD, male gender, sexual abuse, pain (Britton, Wines, Connerb, 2009). Fatal OD are common in older individuals (CDC, 2011) and individuals prescribed immediate release formulations (Hirsh, Proescholdbell, Bronson, Dasgupta, 2014). Unstable housing, serious illness, Drug poisoning death rates by age: United States, 1999 2010 45 54 35 44 25 34 55 64 15 24 65 and over CDC/NCHS, National Vital Statistics System; and Warner M, Chen LH, Makuc DM, Anderson RN, Miniño AM. Drug poisoning deaths in the United States, 1980 2008. NCHS data brief, no 81. Hyattsville, MD: National Center for Health Statistics. 2011. http://www.cdc.gov/nchs/data/databriefs/db81.htm Intercensal populations http://www.cdc.gov/nchs/nvss/bridged_race/data_documentation.htm 4
Loss of Tolerance Regular use of opioids leads to greater tolerance, i.e., more needed to achieve the same result Overdose occurs often when people start using again following a period of not using (abstinence) Common situations leading to loss of tolerance include: Incarceration, detox, Drug Free treatment, or self imposed breaks from use Take Away: Tolerance can decrease in as little as 72 hours MIXING DRUGS Nearly all people who used heroin also used at least 1 other drug. Most used at least 3 other drugs (NSDUH, 2011-2013). Mixing opioids with other drugs, especially depressants such as benzodiazepines or alcohol can lead to an overdose. Most OD occur in 1-3 hours but the peak action and duration of the substances influence the sequence. GUIDANCE FOR PATIENTS Don t use alone or tell someone to check in on you Don t mix drugs Know the strength or purity of what you are using Don t be greedy 5
PART TWO PHARMACOLOGY Opioids (Lagos,2008) FULL morphine oxycodone fentanyl PURE naloxone naltrexone tramadol PARTIAL butorphanol pentazocine buprenorphine nalbuphine 17 AMSP OPIOIDS Fully Synthetic OPIATES Lagos, 2008) Bind to opioid receptors Morphine-like action DSM-IV: OPIOIDS 18 AMSP 6
Opioid Receptors µ (mu): Activated by morphine: analgesia Primary action site of all opioids Distribution: CNS and GI Linked to abuse/dependence κ (kappa): analgesia, endocrine changes and dysphoria δ (delta): for endogenous peptides 19 AMSP (Lagos,2008) PHARMACODYNAMICS 20 Desirable Analgesia Cough suppressant Antidiarrheal Inhibit peristalsis Undesirable Euphoria Decrease respiration Sedation Endocrine effects Constipation PHARMACOKINETICS ARE VARIABLE ROUTES OF ADMINISTRATION Swallowed whole or crushed Crushed and snorted Crushed and smoked, inhaled Crushed, dissolved, and injected Sublingual, buccal, recital, vaginal Transdermal, spinal, intrathecal, epidural 7
Physiology of an Overdose 22 Opioid receptors are found in the brain, including the respiratory center in the medulla Opioid overdose Represses the urge to breathe Decrease response to carbon dioxideleads to respiratory depression Death Overdose Opioid overdose is preventable and, if witnessed, treatable (reversible) (WHO, 2013). Generally happens over a period of 1 3 hours where there is suppression of the urge to breath and oxygen levels fall below the level needed to transfer oxygen to vital organs. Non-fatal overdose leads to brain damage, cardiac arrhythmia, pulmonary edema. Fatal overdose occurs with cessation of breathing. HOW NALOXONE WORKS OPIOIDS, AGONISTS BIND TO THE RECEPTORS NALOXONE, ANTAGONIST DISPLACES OPIOIDS OFF RECEPTORS Naloxone temporarily holds receptors, time varies depending on the opioid OPIOID OPIOID OPIOID OPIOID OPIOID OPIOID NALOXONE NALOXONE NALOXONE 24 OPIOID RECEPTORS IN THE BRAIN 8
NALOXONE IN ACTION 25 Reverses opiate effects of sedation and respiratory depression Causes sudden withdrawal unpleasant feeling Lowers potential for abuse not addictive Wakes the person who is overdosing in 3-5 minutes Work for approx., 30-90 minutes Analogy: wrong key stuck in a lock Safe, highly effective Routinely used by EMS (larger doses) No harm if an opioid is not present Sold over the counter in Italy since 1988 No potential for abuse 26 Adverse Reactions Related to Withdrawal Sympathetic excess- cardiovascular, CNS Reversal opioid analgesia and sedation- CNS, neuromuscular and skeletal excitement, restlessness Increased gastrointestinal motility 9
28 29 OVERDOSE RESCUE KIT 30 Intramuscular (IM) Naloxone 2 safety syringes 2 vials of Naloxone Alcohol swabs Intranasal (IN) Naloxone 2 Luer-Lock pre-filled syringes 2 doses of Naloxone (Narcan ) 10
Con t: OVERDOSE RESCUE KIT 31 In addition, both kits are supplied with: A face mask for rescue breathing 2 latex gloves Directions for administering IM and intranasal Program contact information to seek refills, etc. Drug treatment/counseling resources (as per PH Law Section 3309, 10 NYCRR 80.138) Taking care of naloxone 32 Storage: o Attach naloxone to delivery device when ready to use. o Store naloxone in original package at room temperature; avoid exposure to light. o Keep in a safe place away from children & pets, but easy to access in case of emergency. Expiration: o Naloxone loses its effectiveness over time. o DoD data indicate naloxone is hardier than manufacture guidance. Opioid maintenance and mortality Overdose deaths in Baltimore Adjusting for heroin purity and the number of methadone patients, there was a statistically significant inverse relationship between heroin overdose deaths and patients treated with buprenorphine (P =.002). Schwartz et al AJPH 2013 11
Overdose Prevention Programs that distribute naloxone: 2010 2010 survey of programs known to the Harm Reduction Coalition 189 local programs in 16 states ranging from statefunded to underground 1996-2010: 53,339 individuals received kits 10,194 overdose reversals reported CDC MMWR February 17, 2012 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6106a1.htm PART THREE HISTORY AND THEORETICAL FRAMEWORK History Since the 1996 community-based programs have offered opioid overdose prevention services to persons who use drugs, their families and friends, and service providers. NYS legislation and regulations have passed giving sanction to overdose prevention programs and protection to Samaritans who respond to an overdose. During 1996 2010, these programs reported training and providing naloxone kits to 53,032 persons, resulting in 10,171 drug overdose reversals using naloxone Wheeler et al., 2012, Community-based opioid overdose prevention programs providing naloxone: United States, 2010, Morbidity and Mortality Weekly Report, 61( 6), p. 101-105. 12
Headlines Decline in Drug Overdose Deaths After State Policy Changes Florida, 2010 2012 MMWR July 4, 2014 / 63(26);569-574 THEORETICAL CONCEPTS: DIFFUSION OF INNOVATIONS Diffusion: process by which an innovation is communicated through certain channels over time among the members of a social system (Rogers, 2003). Innovation: an idea, practice, or object perceived as new by an individual or other unit of adoption. Diffusion Process: involves mass media and interpersonal, communication channels. CHARACTERISTICS OF AN INNOVATION (ROGER CLARK, 1991, 1994, 1999) Relative advantage - the degree to which it is perceived to be better than what it supersedes Compatibility - consistency with existing values, past experiences and needs Complexity - difficulty of understanding and use Trialability - the degree to which it can be experimented with on a limited basis Observability - the visibility of its results 13
CONCEPTS OF PREVENTION Primary Prevention aims to decrease incidence and prevalence of a disease. (Protection) Secondary Prevention aims to discover disease before the development of symptoms and to intervene before consequences occur. (Screening) Tertiary Prevention aims to prevent further damage from occurring as a consequence of disease. What is NYS s Opioid Overdose Program? 41 April 2006, PHL Section 3309, 10 NYCRR 80.138 Eligible, registered entities provide training to individuals in the community on how to respond to an overdose Health care facilities Drug treatment programs Health care practitioners (MD, DO, NP, PA) Community-based organizations Local health departments Police and EMT Colleges, universities and trade schools Local and state agencies Pharmacies 42 New York State s Good Samaritan law Sept. 18, 2011 Protects: Individual who experience an overdose Person who summons EMS (calls 9-1-1) Protections from: Arrest in the presence of misdemeanor possession and/or underage drinking Prosecution in felony possession 14
More on Good Samaritan 43 Offers protection from charge and prosecution for possession of: Drugs up to an A2 felony offense (possession of up to 8oz of narcotics); Alcohol (for underage drinkers); Marijuana (any amount); Paraphernalia offenses; Sharing of drugs (in NYS sharing constitutes a sales offense). Limitations 44 Does not offer protection for drug offenses involving: Sales for consideration or other benefit or gain People in possession of A1 felony amounts of narcotics (not marijuana), meaning 8oz or more of narcotics Arrest or charge for drug or alcohol possession for individuals with an open warrant for their arrest Parole is neither expressly covered or singled out for non-coverage. Parole encourages carrying kits and use is not necessarily a violation 45 Logistics and Paperwork 15
All trainings will address at a minimum (NYSDOH) Risk factors for opioid overdose: Loss of tolerance Mixing drugs Using alone Signs of an overdose: Lack of response to sternal rub Shallow or no breathing Bluish lips or nail beds Actions: Call 911 Rescue breathing Using naloxone Rescue position Brief education increases recognition of OD among heroin users. (Jones, Roux, Standcliff, Matthews, & Comer, 2014) Documentation 47 Policies and procedures Clinician agreements and non-patient specific orders Log: name or record number, date, trainer, naloxone dispenser, prescriber, type of kit Add a section for people receiving training (blue card) but not naloxone Inventory records Reversal reports Logistics 48 May be carried by people 16 years or older. Need to obtain from a licensed prescriber or authorized trainer. Should be stored at room temperature and away from direct light (in kit is OK). Has a limited shelf life. Note expiration date and obtain replacement. 16
Label 49 Name of recipient Naloxone preparation and formulation Date of receipt Name of program Name of prescriber Name of person furnishing naloxone (not required) Things Needed to Do the Training 50 A naloxone kit for demonstration Blue Certification Cards Informational materials: device assembly instructions, fact sheets, brochures Optional: Dummy to demonstrate rescue breathing. Optional: Orange for injection Practice if using IM naloxone. 51 Trained Overdose Responder Responsibilities Complete refresher training at least every 2 years Contact EMS if suspected drug overdose and advise if naloxone was used Report all naloxone administrations to program director and get a refill 17
Non-patient specific order 52 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. 18