Naloxone Distribution for Opioid Overdose Prevention

Naloxone Distribution for Opioid Overdose Prevention Caleb Banta-Green PhD, MPH, MSW Alcohol and Drug Abuse Institute, University of Washington Alan Melnick, MD, MPH Clark County Public Health Chris Humberson, RPh Washington Pharmacy Association www.nwcphp.org/hot-topics Washington State s Opioid Overdose Epidemic Caleb Banta-Green PhD, MPH, MSW Senior Research Scientist, Alcohol and Drug Abuse Institute Affiliate Associate Professor, School of Public Health, University of Washington Affiliate Faculty, Harborview Injury Prevention & Research Center 1

Outline Epidemiology Prescribing of opioids Police, treatment and mortality data Rx to heroin Overdose and naloxone Background Distribution models Resources Opioid Prescribing in Washington State Hydrocodone (e.g. Vicodin) and Oxycodone (e.g. OxyContin and Percocet) most common Huge increase from mid- 90 s through ~ 08-09 2009 onward most opioid types leveled off or declined In 2013 Prescription Monitoring Program data for Washington, opioids were prescribed to: 1,299,513 acute (90 days or less ) 212,609 chronic (120+days/10+ Rx s) 2

State-Wide Crime Lab Cases with Opiate Results Data source: WA State Patrol- Forensic Lab Services Bureau Washington State Treatment Admits Primary Drug Data source: DSHS/DBHR TARGET 3

Washington First Time in Treatment Heroin Primary Drug Data source: DSHS/DBHR TARGET Opioid-Involved Deaths By Type and Source Heroin Rx-type Opioids Not- prescribed Rx-type Opioids Prescribed Proportions approximate In WA and nationally, approximately 1/3 of deaths fall into each of the opioid use groups in recent years Most deaths involve other drugs as well 4

Drug Overdoses Washington 1999-2013 Age-adjusted Rate per 100,000 12 10 8 6 4 2 0 Total Opioid Overdose Prescription Opioid Overdose Heroin Overdose (estimated) 1999 2001 2003 2005 2007 2009 2011 2013 Year of Death King County data indicate recent heroin increases mostly <30 years of age Data source: WA State Dept of Health Opioid Deaths by County 2000-2013 Total deaths = 7834 1 Dot = death attributed to any opiate in the 14-year period Data suppressed when count is 1-4 Residents who died outside Washington excluded. Dots are randomly allocated within counties. Data from Center for Health Statistics, Washington Department of Health. Map created by Alcohol & Drug Abuse Institute, Univ. of Washington. 5

Pills to Heroin Use more Heroin Smoke, snort, inject Like Try 2013 Syringe Exchange Survey King County Heroin Users by Age *Statistically significant Source: Public Health- Seattle & King County, Emily Cederbaum analyses 6

Public Health and Medical Interventions Careful opioid prescribing Prevent in appropriate initiation Dampen illicit supply Drug treatment Medication Assisted Treatment Buprenorphine/Methadone agonist therapy Syringe exchange, infectious disease prevention Overdose prevention Washington s 2010 Good Samaritan Overdose/Naloxone Law RCW 69.50.315 Medical Immunity Prescriber may prescribe naloxone to a person at risk for having or witnessing an overdose They may carry and administer naloxone Legal Immunity Overdose victim and bystander who seeks medical aid gets immunity from prosecution for drug possession 7

Opioid overdoses Medical Due to respiratory depression Usually several hours until death Social Often others present Low overdose knowledge Fear of calling police for some Therefore a window of opportunity exists to prevent an overdose from becoming fatal What is Naloxone (Narcan )? Prescription medicine to reverse opioid overdose (not used to get high) No effect on person who has not used opioids Safe and effective (in use for decades) Lay person can recognize and respond to an overdose Typically administered into a muscle or intranasally Takes effect in 2-3 minutes and lasts 30-90 minutes 8

Evidence and Support for Overdose Education & Naloxone Support from health-related associations and organizations (ONDCP, CDC, DOJ, Medical/Pharmacy/Public Health Assoc. s) According to research, distribution to heroin users saves lives and is cost effective Current research occurring to learn how education and naloxone impact overdose: risk, occurrence, response, fatality Current research occurring on how to adapt for different populations (chronic pain, primary care) Reduction in population death rate when 150 per 100,000 population were trained BMJ 2013;346:f174 9

Reduction in population death rate when 150 per 100,000 population were trained BMJ 2013;346:f174 Doctors should educate patients about overdose risk and prescribe naloxone J Fam Pract. 2012 October;61(10):588-597 Reduction in population death rate when 150 per 100,000 population were trained BMJ 2013;346:f174 Doctors should educate patients about overdose risk and prescribe naloxone J Fam Pract. 2012 October;61(10):588-597 Distributing naloxone to heroin users saves lives and is cost effective Ann Intern Med. 2013;158(1):1-9. 10

Reduction in population death rate when 150 per 100,000 population were trained BMJ 2013;346:f174 Distributing naloxone to heroin users saves lives and is cost effective Ann Intern Med. 2013;158(1):1-9. Doctors should educate patients about overdose risk and prescribe naloxone J Fam Pract. 2012 October;61(10):588-597 64% of police at opiate OD past year, arrests uncommon, low knowledge about Good Sam law J Urban Health. 2013 Dec;90(6):1102-11. Naloxone Access, Examples Who dispenses How To Whom Where Examples Prescriber Prescription Patient, police officer, Other Office, mobile health van, police department Pharmacist Collaborative Practice Agreement with prescriber Customer, client/inmate college staff Pharmacy, clinic, jail, syringe exchange Health Educator Standing order by prescriber (some counties) Client Syringe exchange 11

Considerations for Prioritizing Naloxone Distribution Risk level of target population (heroin, chronic pain) Setting of intervention (community, jail, shelter) Timing of intervention (at time of discharge from detox or jail) Speed of OD Response- medical response (artificial respirations, naloxone administration) Naloxone Distributed to Bystanders or Carried by Police 12

StopOverdose.org www.stopoverdose.org Email: info@stopoverdose.org Opioid Trends Across Washington State adai.uw.edu 13

Opiate Overdose in Clark County Alan Melnick, MD, MPH, CPH Director and Health Officer Clark County Public Health Introduction The Opioid Overdose Problem Overdose Prevention in Clark County: Program Development & Implementation Challenges & Evaluation Discussion & next Steps 14

Opiate-Related Hospitalizations Clark County vs. Washington State 250 Age-Adjusted Rate per 100,000 200 150 100 50 20.9 111.8 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 WA State Clark County Opiate-Related Deaths Clark County vs. Washington State 10 Age-Adjusted Rate per 100,000 9 8 7 6 5 4 3 2 1 4.7 8.7 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 WA State Clark County 15

Overdose Risk Assessment, 2012 Drug Use 70% clients primarily use heroin 30% use methamphetamines Most (62%) used prescription opiates before using heroin Less than half called 911 as OD witness Only 35% aware of Good Samaritan Law! Challenges and Opportunities in Policy Development Stigma associated with opiate use Good Samaritan Law Need for policy support from Board of Health Funding/sustainability Limited staff/resources 16

Clark County Public Health (CCPH) Policy Development Health Officer s standing order to authorize purchase & distribute naloxone Harm Reduction Center staff & volunteers are Overdose Prevention Educators Trained educators are authorized to distribute and administer naloxone Educators train clients using Overdose Prevention & Naloxone Training curriculum Overdose Prevention Training Students and interns helped develop curriculum Overdose prevention techniques How to recognize overdose Using Naloxone Good Sam Law Simplified curriculum to engage clients Call 911, rescue breathing, naloxone Help participants understand and feel confident in overdose response 17

Training Implementation & Evaluation Began overdose prevention education and naloxone distribution in April 2014 Evaluation data collected for participants using Enrollment and Refill forms Demographics Housing/homelessness Overdose risk factors Reversal incidents 18

190 Individuals Trained April-December 2014 >80% syringe exchange clients ~10% professional (staff, partner orgs, students) ~10% friends and family of opiate users >50% homeless, or temporary/unstable housing >25% aged 24 or younger Number & Percent of Enrolled Clients Reporting Overdose Risk Factors Took time off from opiate use in the last 12 months (detox, jail, shelter, ER visit, or other reason) 104 (55%) Drink alcohol with opioids 50 (32%) Use sedatives or downers with opioids 56 (36%) Use heroin or other opioids ALONE 122 (79%) Use drugs in a public setting: a park, alley, or public bathroom 89 (58%) 19

Overdose History Lifetime Overdoses 40% reported 1 overdose 25% reported 2 overdoses 86% used heroin the last time they overdosed (less than half received naloxone from medical professional) Witnessed Overdoses 46% witnessed 1 overdose 40% witnessed 2 overdoses Only 16% received medical attention Overdose Reversals 312 naloxone kits distributed in 2014 190 individuals enrolled 122 refills completed Other reasons for refills include: Confiscated/lost/stolen Gave away to friend/family Opened to use/false alarm 57 reversals reported between April & December 2014 20

Overdose Incidents Reported Half reported using 2 doses Most used on a friend All involved heroin Two-thirds didn t call 911 because Felt could handle without medical help (21%) No phone (16%) Afraid of police involvement (10%) Victim regained consciousness (10%) Overdose Incidents Reported Overdose Location Most took place in a private home (70%) Few in public/street/outside/park (23%) Outcomes Most reported person OK Police, EMS, or ER involvement (21%) No arrests reported 21

Community Response Community Partner Interest Law enforcement Chemical dependency treatment programs Local school intervention counselor Clark College Challenges Provider community engagement is a challenge No dedicated outreach staff Collaborative Drug Therapy Agreements Chris Humberson, RPh Executive Director Washington Pharmacy Commission 22