Anne Arundel County Overdose Prevention Plan  

JinleneChan,M.D.,M.P.HActingHealthOfficer

AnneArundelCountyDepartmentofHealth

June2013

AnneArundelCountyOverdosePreventionPlan June2013

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Introduction  Theopioiddrugsarethosethatbindtoopioidreceptorsinthecentralandperipheralnervoussystemandgastrointestinaltract.Opiumhaslongbeenrecognizedasbothapotentpainrelieverandadrugthatcauseseuphoria.Heroinisamoremoderndrugderivedfromopium.WithintheUnitedStates,ratesofprescriptionopioiddeathhaverisensharplysince1999andheroindeathshavebeenontheincreasesince2006.1WithinthestateofMaryland,significanteffortstocurtailprescriptiondrugabuseseemtobepayingoffwithadropinprescriptionopioidoverdosesinthefirstsevenmonthsof2012vs.2011.However,thisappearstobecomingwithatradeoffofanincreaseinheroindeathsinthesametimeperiod.Therateofheroindeathsinthefirstsevenmonthsof2012exceededtherateofprescriptionopioiddeaths(6.0per100,000vs.5.2per100,000).1AnneArundelcountyhasseenasimilarpatternwitha35%dropinprescriptionopioidoverdose,buta31%increaseinheroinoverdose(SeeTable1).aThispatternisbeingrepeatedacrossthecountry,withthegeneralhypothesisforthechangethattheprescriptionopioidsarebecomingmoredifficultandmoreexpensivetoobtainthanheroinsecondarytothesuccessfulcampaignsagainstdiversionandabuseofprescriptionopioids.

Maryland Anne Arundel

County County Change 2011 2012 2011 2012

Total Opioid Overdoses 307 334 27 26 -3.70%

Prescription Opioid 208 177 17 11 -35.30%

Heroin 145 205 13 17 30.80% Table1:Countsofopioidrelateddeaths1January‐31July2011and2012.a

WhileaslightdeclineinopioidoverdoserateswasnotedintheStatefrom2007‐2011,anincreasehasbeendetectedin2012.Becauseoftheconcerningincreaseindeathrates,theStateofMarylandhasdevelopedacomprehensiveopioidoverdosepreventionplanandaskedthateachjurisdictiondevelopaplanbasedonlocalneeds.Theplanshouldbringtogetherbothpublicandprivateresourcesandcontainthefollowingelements:

1. Reviewandanalysisofdata2. Educationoftheclinicalcommunity3. Outreachtohigh‐riskindividualsandcommunities4. PerformanceMetrics

Background  Inanopioidoverdose,anindividualwillloseconsciousnessandtheirrespiratoryratewilldecreasebelowalife‐sustainingrate(about12breathsperminute).Theirlipsandfingersmayturnblueandtheywillnotbeabletobearoused.Eveniftheindividualsurvivestheevent,long‐termconsequencescanincludebraindamagefromlackofoxygentothebrainorlungdamagefromfluidfillingthelungsorfromaspiratingvomitwhile

1DataderivedfromcountsprovidedbytheOfficeoftheChiefMedicalExaminer.December2012.

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unarousable.Theoverdoselookssimilarregardlessofthetypeofopioidused.Eachopioidhasaspecificlengthoftimeitshouldlastinthebody.Heroinisfastacting,producingaquickhigh,whilemethadoneisverylongacting,leadingtoitslackofa“high.”Otherprescriptionopiateshaveanintermediatelengthoftimetheycontinueworking.Opiateoverdosescanhappenatlowerthanexpecteddoseswhentheopiatesarecombinedwithalcoholandotherdrugs,particularlybenzodiazepinesandcocaine.Itisimportantthatindividualsonlongeractingopiatesunderstandhowlongthedrugswillremainintheirsystemssothattheydonotinadvertentlyoverdose,thinkingthedrugwillnolongerhaveaneffect.

Whenratesofopioidabuse,overdose,andfatalityareevaluated,thenumberstypicallyreportedwilllookatallopioidstogetherandthenheroin,prescriptionopioids,andmethadonespecifically.Theterm“prescriptionopioid”doesnotimplythatthedrugwasprescribedtotheindividualorthattheindividualwastakingitforthepurposeforwhichitwasintended(typicallypainrelief).Additionally,methadoneistypicallyaprescribedopioidandmaybeundercountedasacauseofoverdoseinhospitalrecords,butwilllikelybeascribedcorrectlyinmedicalexaminerreports.

Take‐homenaloxoneprograms:Manymodernopioidoverdosepreventionprogramsincludetheuseofnaloxone.Naloxonecanbeprescribedbyproviderstoindividualsreceivingopioidmedicationsforchronicpainorindividualsonmethadoneforeitherpainoropioidaddictiontreatment.Additionally,itmaybegiventoknownusersofillicitopioidsubstancesuchasdivertedprescriptionopioidsorheroin. Naloxoneisanopioidmedicationthatdisplacesthedrugsonthemureceptorsinthecentralnervoussystemthatcausea“high.”Naloxonehasveryfewserioussideeffectsexceptinthoseallergictoit.Allergyisrare.Itisunlikelytobedivertedforalternativeusesince,ratherthancausingahigh,itcauseswithdrawal,whichisveryunpleasant.Itisalsorelativelycheap(lessthan20dollarsperdose).Oncenaloxoneisadministered,withinafewminutes,thevictimshouldwakeupfromtheiroverdose.Itisgenerallyinjected,althoughsomeprogramshavedevelopedanintranasalformulationthatisnotcurrentlyFDAapproved(theyjustattachanatomizertoasyringe).Theintranasalformulationseeemstoworkaswellastheinjectable,buttakesalittlelongertowork.Naloxonewearsoffwithinanhourtoanhourandahalf,soifthedruglastsinthesystemlongerthanthat(mostprescriptionopioidmedicationsandmethadone),itneedstobereadministered.Primarydisadvantagesofnaloxonearethatitisaprescribed,scheduledmedicationandthereforeisonlytobeusedandadministeredbythepersontowhomtheprescriptionwaswritten.Asopposedtoanepipen,ifanindividualisoverdosing,theywon’tknowit,theywillbeasleep.Theycannotinjectthemselves.Someoneelsemustinjectthem.Otherprogramshaverecommendedtrainingboththeindividualbeingprescribedthenaloxone,theirfriendsandtheirfamilymembers.2 InBaltimore,57%ofIVdrugusers(IVDU)hadwitnessedanoverdoseintheirlifetime.Increaseriskofoverdosewasnotedinthehomeless,historyofinjectingalone,injectingheroinandcocainetogether,andlongerdurationofuse.3ASanFranciscostudyalsonotedthat68%offataloverdosevictimswerealoneatthetimetheyoverdosed,butencouragingindividualstohaveabuddyincreasesriskofneedle‐sharing.4Anadditionalriskfactorforfataloverdoseisrecentreleasefromprison.Individualswhowerewithin1‐2weeksofreleasefromprisonwere3.2to11timesmorelikelytodiefromanoverdose

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thanindividualswithin5to12weeksofreleasefromprison.Thisislikelyduetodecreasedtolerancetoopioidmedicationsandcanalsooccurafterdetoxification.Individualsforgetthattheirtoleranceisdecreasedandwhentheyagainreturntoopioiduse,theyusemorethantheycantolerate.5Potentiallyeffectivemethodsofrevivinganindividualfromanopioidoverdoseinadditiontonaloxone,includeCPRwithrescuebreathing,sternalrub,andcalling911.Witnessesareoftenreluctanttocall911duetofearofpoliceinvolvement,butthosefearsaregenerallyoverstatedasfewerthan3%ofindividualsinanyoftheevaluatedstudiesreportedanarrestoccuringatthesceneofanoverdosewhen911wascalledtosaveavictim.3 TheCDCreportsthat10,171reversalswithnaloxonewerereportedthroughJuneof2010fromlocalitiesthathavebegunaddingnaloxonetotheiropioidoverdosepreventionprograms.6Inunpublisheddata,thestateofMassachusettsreportsthattherehasbeenadecreaseinthedeathratefromopioidsincommunitieswithinthestatewithanaloxoneprogramvsthosewithout,howeverEDvisitsareunchanged.7Useofnaloxonebyabystanderhasbeenshowntodecreasethelikelihoodthattherescuerwillcall911inafewstudies.8,9Itisunclearifnaloxoneiscoveredbylocalinsurancecompanies,butgiventhatitisgenericandrelativelyinexpensive,itlikelywouldbecovered.ItiscoveredbyMedicarepartD.Afullnarcankitwithtwoinjectors,instructionsonuse,abarrierdeviseforrescuebreathing,andalcoholswabsgenerallycanbeassembledfor$36to$50.Theybecomemoreexpensiveforintranasalnaloxoneduetoneedforanatomizer.Kitsarenotavailableforpurchasebutareassembledbytheprogramsthatprovidethem.

NewlegislationinMarylandwillrequireanindividualtoreceivestandardizededucationandtrainingandtoshowcertificationofhavingreceivedthistrainingbeforereceivingaNaloxoneprescriptionfromamedicalprovider.

Review and Analysis of Local Data  WhenthedeathdatapresentedinTable1isextrapolatedouttothefullyearandcomparedtoUSandStatedata,weseethatAnneArundelCountyhasaslightlylowerrateofprescriptionopioidoverdosethanboththeUSandtheStateofMaryland,butboththecountyandtheStatehaveamuchhigherrateofheroinrelateddeaths.

Opioid Overdose Rates Total

Opioid Rx

Opioid Heroin

United States 4.82 0.983

Maryland 9.92 5.26 6.09

Anne Arundel County 9.67 4.09 6.32 Table2:Annualizedratesofdeathextractedfrom2012StateandCountyJanuary‐Julydata.StateandCountypopulationsarebasedon2010Censusdata.Itshouldbenotedthatthenationaldataisbasedona2008estimateforprescriptionopioiddeathsanda2009estimateforheroindeaths.Allratesareper100,000personyears.

2“VitalSigns:OverdosesofPrescriptionOpioidPainRelievers—UnitedStates,1999‐2008.”MMWR.CDC2011;60(43).3EstimatefromNationalVitalstatistics2009whichstated“approximately3000heroindeaths.”

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Countyratesofdeathattributedtoasubstanceweresimilartostateratesfrom2007through2011.Figure1showstherateofdeathfromvarioussubstancesduringthistimeperiodintheStatevs.theCounty.Theratesareaveragedoverthe5‐yearperiodandbasedon2010censusdata.

Average Death Rates State vs. County by Substance, 2007-2011

02468

101214

Total

All Opio

id

Heroin

Rx Opio

id

Cocain

e

Met

hadone

Alcohol

Oxyco

done

Benzo

Fenta

nyl

Tram

adol

Substance

Rat

e p

er 1

00,0

00 p

-yrs

State

County

Figure1:Averagedeathrateper100,000personyearsbysubstanceStateofMarylandvs.AnneArundelCounty InFigure2weobservethatdeathsfromheroinandprescriptionopioidscontributedroughlyequallytotheoveralloverdosedeathrateinAnneArundelCounty.

Anne Arundel County Intoxication Deaths by Year and Type

0

2

4

6

8

10

12

14

16

2007 2008 2009 2010 2011

Rat

e p

er 1

00,0

00

Total

All Opioid

Heroin

Rx Opioid

Methadone

Figure2:RateofIntoxicationdeathsinAnneArundelCountybytypeofsubstanceimplicatedandyearfrom2007‐2011.

WecancurrentlyutilizeESSENCEtoevaluate“chiefcomplaints”foremergencydepartment(ED)visitsdatingbacktolate2009.SearchingESSENCEfor“overdose”or“drugabuse”chiefcomplaintswillyieldbothintentionalandunintentionaloverdosepatientspresentingtotheED.Unfortunately,atthistimeitisdifficulttostratifytheseresultsbytypeofdrugabused.Lookingatthedatafrom2009‐present,itappearsthat

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malesandfemalespresenttotheEDatsimilarratesforalloverdosesandthattheratehasbeenincreasingthroughoutthattimeperiod(Figure3).

Figure3:Rateper100,000CountyResidentEDVisitsfor“Overdose”or“DrugAbuse,”September2009‐December2012(ESSENCE). MoredetailedinformationcanbeexaminedutilizingtheHealthServicesCostReviewCommision’s(HSCRC)database.ThedisadvantageofthisdatabaseoverESSENCEisthelagtimeinthedatacollectionanddisseminationtothecountiesandtheincreasedeffortsandknowledgerequiredtosearchthedatabase.HSCRCwasutilizedtoanalyzetrendsanddemographicsinEDdiagnosesforICD9specificcategoriesofopioidoverdose“ECodes.”Figure4showsthetrendsforoverdosefromfiscalyear2008‐2011.Theoveralltrendisanincreaseinoverdoseofalldrugs,withasteadyincreaseinprescriptionopioidoverdosediagnosesinthattimeperiod.However,heroinvisitswereonthedeclinefromFY2010throughFY2011.

Figure4:TrendinEDVisitsforopioidoverdosesFY2008‐2011(HSCRC).

Figure5showsthebreakdowninopiaterelatedEDvisitsbyagegroup.Youngadultshavethehighestratesofopiateoverdose‐relatedERvisits.Thedataalsoindicatethatwhileheroin‐relatedoverdoseEDvisitspredominateinyoungadults(18‐34years),prescriptionopiateoverdosevisitsareseenacrossalladultagegroupsaswellasinveryyoungchildren,presumablyduetoaccidentalingestions.

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Figure5:Rateper100,000personyearsofAnneArundelCountyresidentvisitstoemergencydepartmentsforopioidoverdoses(HSCRC). Lookingatthetrendsinraceandgender,weseethatwhitesandmalesinAnneArundelCountyhavehigherratesofopiateoverdoseEDvisitsthantheirblackandfemalecounterparts.Itshouldbenotedthatthedataonracearelackinganethnicityidentifier(Figures6and7).

Figures6and7:Rateper100,000personyearsofopiateoverdoseEDvisitbysexandrace(respectively),FY2009‐2011 Finally,whenwelookattheratesofpresentationtotheEDfromvariouszipcodes,weseethatthenorthernpartofthecountyaccountsforthevastmajorityofbothheroinandprescriptionopioidvisits.Themapbelow(Figure8)wasnotbrokendownbytypeofdrugduetothelownumbersineachzipcodeforeachdrug.Agrayshadedareadoesnotmeanthattherewerenopresentationsofresidentsfromthatpartofthecounty.Itsimplymeansthattherewerefewerthan5residentsoverthe3yearperiodthatpresentedfromthatregionofthecounty.

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Figure8:RatesofopioidoverdoseEDvisitsbyplaceofresidence,FY2009‐2011

County Data Summary DatafromtheOfficeoftheChiefMedicalExaminer(OCME)indicatesthatopioidoverdosedeathratesinAnneArundelCountyaresimilartostatewideratesandthatheroinandprescriptionopiatesappeartobecontributingroughlyequallytothetotaloverdosedeaths.ESSENCEdatashowanoverallincreasingtrendinAnneArundelcountyresidentvisitstotheemergencydepartmentsfor“overdose”or“drugabuse.”HSCRCdataalsoshowanoverallincreaseinEDvisitsduetoalldrugoverdosesandanincreasethroughFY2011inprescriptionopioidoverdoseEDvisits.Youngadultshavethehighestratesofopiateoverdose‐relatedEDvisits.Whileheroin‐relatedoverdoseEDvisitspredominateinthe18‐34yearsagegroup,prescriptionopiateoverdosevisitsarespreadmoreevenlyacrossalladultagegroupsandalsoinveryyoungchildren,presumablyduetoaccidentalingestions.ResidentsinthenorthernmostportionsofthecountyhavethehighestratesofEDvisitsforallopioidoverdoses.

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Anne Arundel County Overdose Prevention Plan Overview TheAACountyDepartmentofHealthwillworkcloselywiththeCountyDrugandAlcoholAbuseCouncilandothercommunitystakeholderstorefinethecounty’splaninaniterativeprocess,particularlyinfinalizingatimelineanddeterminingresponsibilitiesforvariousplancomponents.Theproposedplanincorporatescommentsfromanumberofcouncilmembersandothercommunitymembersengagedinthisissue,andwewillcontinuetoseekandutilizethisfeedbackandsolicitcommitmentsfrommemberstoimplementactionstepswiththeDepartmentofHealthastheprimarycoordinatingbody.

PRESCRIPTION OPIOID OVERDOSE PREVENTION

HEROIN OVERDOSE PREVENTION

3. Take-home naloxone program

feasibility assessment and plan development

4. Treatment of opioid addiction

5. Diversion control and drug storage/security

1. Education of clinical Community

2. Education of patient/user community , with outreach

to high-risk groups

A. Coalition building and community engagement

B. Ongoing performance

evaluation

Opioid Overdose Prevention Plan Overview

OverallProgramGoalandOutcomePerformanceMetrics:Toreducethetotalnumberofoverdosedeathsbyanaverageof10%peryear(using2012asabaseline),fora30%reductionover3years:DecreasethetotalannualnumberofoverdosedeathsinAnneArundelCountyfrom26(2012)tolessthan18by2016.

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Strategies,ActivitiesandImplementationPerformanceMetrics

STRATEGY ACTIVITIES METRICS/TIMELINE1.Educationoftheclinicalcommunity

a. Draftemailandlettertobesenttoall clinicalproviders,hospitals,andpharmaciesinAACounty,toinclude:

i. Overviewofstateandcounty‐leveloverdosepreventionefforts

ii. Linkstoonlineresources,tobeavailableontheAACDHwebsite(AACDHOverdosePreventionResourceCenter)1. InformationabouttherecentlypassedMarylandSB0610OverdoseResponseProgramlawandDHMHOverdosePreventionPlan,specificallyaboutthecertificationprocessforindividualsinterestedinreceivingnaloxoneprescription

2. Toolsforidentifyingpatientsatincreasedriskforopioidoverdose

3. Informationonprescribingnaloxonetopatientsreceivinglong‐termopiates

4. Opioidprescribingpracticeguidelines(indevelopment)anduseofPDMP

5. ScreeningBriefInterventionandReferraltoTreatment(SBIRT)toolkit

6. Informationonlocaladdictiontreatmentoptionsandreferralprocesses

7. Patienteducationresources(see#2below)b. Academicdetailingofpracticesinhigh‐riskzipcodesi. SBIRTtrainingin‐servicesii. Additionalprovidereducationthroughgrand

rounds

AACDHOverdosePreventionResourceCenter(webresourceforprovidersandthepublic)operationalandlivebyJuly1,2014withon‐sitecontentandactivelinkstoexistingweb‐basedresources

90%ofprovidersand

pharmaciescontactedbyOctober1,2014

80%ofprovidersinhigh‐risk

zipcodestohavereceivedin‐personindividualorgroup‐basedSBIRTandoverdosepreventiontrainingbyJuly1,2015

2.Educationofpatient/usercommunity,withoutreachtohigh‐riskgroups

a. Developstandardizedopioidoverdosepreventionandresponseeducationalmaterials,drawingonmaterialsdevelopedbyDHMHandsuccessfuloverdosepreventionprogramsnationwide

b. Viaemailandletterstoallphysicianoffices,hospitals,andpharmacies,providelinkstoonlinepatienteducationmaterials

c. Outreachtohigh‐riskgroupsiii. Standardizeoverdosepreventionandresponse

clienteducationmaterialsinallAACDHoperatedandcontractedaddictiontreatmentprograms

iv. Reachoutviaemail/lettertopromoteoverdosepreventionandresponseclienteducationmaterialsandguidelinesavailableon‐lineattheAACDHOverdosePreventionResourceCenter1. AllmethadonetreatmentprogramsandSuboxoneproviders

2. Narcoticsanonymous,AA,CDA,andotheraddictionsupportgroups

3. Jails/policedepartments,halfwayhouses,andjuveniledetentionfacilities

4. Homelessshelters,veteransgroups

Overdosepreventionandresponseclient/communityeducationmaterialscompiled,synthesized,reviewed,andmadeavailableon‐lineontheAACDHOverdosePreventionResourceCenterbyJuly1,2014

90%ofclinicalprovidersand

localpharmaciescontactedviaemailand/orletterbyOctober1,2014

90%ofidentifiedhigh‐risk

programs/groupscontactedviaemailand/orletterbyDecember1,2014

AllAACDH‐affiliatedmethadone

treatmentprogramshavepoliciesandproceduresinplaceregardingoverdosepreventionandresponseeducationforclientsbyOctober1,2014

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STRATEGY ACTIVITIES METRICS/TIMELINE

3.Conductafeasibilityanalysisofatake‐homenaloxoneprogramoperatedbyAACDHBehavioralHealthAdultAddictionsProgram

a. CollaboratewithDHMHandAACountyCriminalJusticeCoordinatingCouncil(DrugandAlcoholAbuseCouncil)onimplementationofSB0610withregardtocertificationprocessrequiredforprescribingnaloxone

b. Modifycurrentquarterlyclientsurveystoincludequestionsabout:

v. Personalexperiencewithoverdosevi. Witnessedoverdosesorlossof

friends/familytooverdosevii. Knowledge/awarenessofoverdose

preventionandresponse,includingroleofnaloxone

viii. Interestinnaloxonetrainingandcertification

ix. Willingnesstopayfornaloxonekitsc. Explorationofpotentialcollaborationswithlocal

pharmacies/chainsd. Legal,risk‐managementreviewe. Reviewofexistingtake‐homenaloxoneprograms

f. Budgetaryanalysis

Naloxonecertificationprocessfinalizedandinformationavailableonlineforproviders/publicviaAACDHOverdosePreventionResourceCenterbyJuly1,2014

AdultaddictionsclientsurveyoverdosequestionsdevelopedbyJanuary1,2014

80%ofnewandongoingclientstohavecompletedoverdosesurveybyDecember1,2014

SurveyresponsescompiledandanalyzedbyJuly1,2015

TracknumberofAACountyresidentsreceivingcertificationfornaloxoneprescription

TracknumberofnaloxoneprescriptionsfilledinAACountypermonth

DraftAACCHtake‐homenaloxoneprogramproposalcompletedandsubmittedforlegal/financialreviewbyDecember1,2015

4.Treatmentofopioidaddiction

a. ContinueoperationofAACDHAdultAddictionsmethadone‐basedtreatmentprogramscurrentlyoperatedorcontractedtoprovideaddictiontreatmentservicesbytheBehavioralHealthdivisioninGlenBurnie,MD.ProgramsincludetheRoadtoRecoverymethadonemaintenanceprogrambasedattheOrdinanceRoadCorrectionalCenter,initiatedin2012.

b. ContinuetoeffortstoincreasereferralsthroughuseofSBIRTtoolkitandthrougheducationandtrainingoflocalEDandotherclinicalproviders

Tracknumberofclientsenteringtreatmentandremainingintreatmentfor6months,12months,18months,inLangleyRoadAdultAddictionsprogramandotherAAC‐contractedmethadonemaintenanceprograms

TracknumberofclientsreferredforSuboxonetreatment

Tracknumberofclientsreferredforinpatientrehab

TracknumberofeligibleinmatesatOrdinanceRoadCorrectionalCenterparticipatinginjail‐basedRoadToRecoverymethadonemaintenanceprogram:Goalistoincreaseparticipationfrom#/%to#/%

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STRATEGY ACTIVITIES METRICS/TIMELINE5.Diversioncontrolanddrugstorageandsecurity

a. ContinuepracticeofdruglockboxesforAACDH‐affiliatedmethadonetreatmentprogramsandworkwithotheraddictiontreatmentprogramstoexpanddruglockboxpractices

b. Educateclinicalprovidersandpatientsaboutuseofdruglockboxesforopioidpainmedications

c. Workwithpolicetopublicizeandpromotedrugtake‐backprogramsbasedatlocalpolicestationsthroughmediaannouncementsandpostersforclinics,publictransport,etc.

d. Collaboratewithlocalschoolsandcommunitygroupsoncommunityawarenessandeducationcampaignsforadolescentsregardingdrugdiversionandprescriptiondrugabuse

AllAACDH‐affiliatedmethadonemaintenanceclientstoutilizelock‐boxesfortakehomedosing

LinkonAACOverdosePreventionResourceCenterwebsiteonlock‐boxuseforallopioidprescriptionstobeactivebyJuly1,2014

Numberofposterspromotingdrugtake‐backdistributedtopharmacies,offices,ED’s,andotherpublicplaces

Holdatleast2meetingswithschoolhealthandAlcoholandDrugAbuseCouncilrepresentativesregardingpreventingdiversionofcontrolledsubstancesamongadolescents

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relatedoverdosedeathscomparedtoothersubstancerelatedoverdosedeaths:1999‐2009.DrugAlcoholDepend.Jan42013.

2. DarkeS,HallW.Thedistributionofnaloxonetoheroinusers.Addiction.Sep1997;92(9):1195‐1199.

3. ShermanSG,ChengY,KralAH.PrevalenceandcorrelatesofopiateoverdoseamongyounginjectiondrugusersinalargeU.S.city.DrugAlcoholDepend.May112007;88(2‐3):182‐187.

4. PJD,RLM,AHK,AAG,BRE,ARM.Fatalheroin‐relatedoverdoseinSanFrancisco,1997‐2000:acasefortargetedintervention.JournalofUrbanHealth.2003;80(2):261‐273.

5. MerrallEL,KariminiaA,BinswangerIA,etal.Meta‐analysisofdrug‐relateddeathssoonafterreleasefromprison.Addiction.Sep2010;105(9):1545‐1554.

6. Community‐basedopioidoverdosepreventionprogramsprovidingnaloxone‐UnitedStates,2010.MMWRMorbMortalWklyRep.Feb172012;61(6):101‐105.

7. WalleyAY.BystanderoverdoseeducationandnaloxonedistributioninMassachusetts.Paperpresentedat:RoleofNaloxoneinOpioidOverdoseFatalityPrevention;12April,2012;SilverSpring,MD.

8. BennettAS,BellA,TomediL,HulseyEG,KralAH.Characteristicsofanoverdoseprevention,response,andnaloxonedistributionprograminPittsburghandAlleghenyCounty,Pennsylvania.JUrbanHealth.Dec2011;88(6):1020‐1030.

9. LankenauSE,WagnerKD,SilvaK,etal.InjectionDrugUsersTrainedbyOverdosePreventionPrograms:ResponsestoWitnessedOverdoses.JCommunityHealth.Jul312012.

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Acknowledgements CompilationandTechnicalAssistanceProvidedby:

JanaMcAninch,MD,MPH.,MS

TammyServies,MD

SpecialthankstotheOverdosePreventionPlanningCommittee:

JinleneChan,MD,MPH,AnneArundelCountyDepartmentofHealth

WilliamRufenacht,MA,LCADC,AnneArundelCountyDepartmentofHealth

SandraO’Neill,LCPC,AnneArundelCountyDepartmentofHealth

BarbaraHatch,RN,AnneArundelCountyDepartmentofHealth

HildrethClagett,NCC,AnneArundelCountyDepartmentofHealth

BabakImanoel,DO,AnneArundelCountyDepartmentofHealth

HeatherEshleman,CPP,CHES,MPH,AnneArundelCountyDepartmentofHealth

ArleneHall,RN,MSN,CARN,BaltimoreWashingtonMedicalCenter

LeighRagan,LCADC,FirstStepRecoveryCenter

HelenReines,BA,RN,PathwaysatAnneArundelMedicalCenter

ShirleyKnelly,MS,CPHQ,LCADC,PathwaysatAnneArundelMedicalCenter