Law as Barrier to and Facilitator of Opioid Overdose Prevention

Corey Davis, JD, MSPH

Cross-System Collaboration to Respond to the Prescription Drug Epidemic

November 12, 2012

Required Disclosure

I have no disclosures to report.

Objectives Provide an overview of legal and

regulatory barriers to naloxone access

Describe interventions to reduce opioid overdose death via Increased access to naloxone (“naloxone

access laws”) Increased access to emergency

responders (“Good Samaritan laws”) Other promising legal and regulatory

strategies

Overview Fatal opioid overdose is at epidemic levels

Opioid overdose death is largely preventable Long period in which reversal is possible Reversal easily accomplished w/ naloxone

Law and regulation are a barrier to naloxone access

Amending law and regulation to improve naloxone access is an effective and cost-effective intervention

Law as barrier to naloxone access Barrier 1: Civil/Regulatory

Prescription status Not a controlled substance No abuse potential Extremely good risk profile

Patients can only receive prophylacticallyfrom professional w/ prescription privileges Prescribers are in short supply Physician visits can be prohibitively expensive,

particularly for uninsured/underinsured

Law as barrier to naloxone access Barrier 1: Civil/Regulatory

In Ohio, patients in acute overdose can receive only from AEMT or EMT-Ps EMR or EMT-Bs may be first

responders, particularly in rural areas Lack of availability may increase stigma and

reduce knowledge

Law as barrier to naloxone access Barrier 1: Civil/Regulatory

Prescriber concerns re: civil and professionalliability Evidence suggests risk is extremely low, but

perceived risk is real barrier

Samaritan concerns re: civil liability In general, existing Good Samaritan laws

provide protection, but perceived risk may

affect action

Law as barrier to naloxone access Barrier 2: Criminal

Bystanders w/ naloxone may fear criminal sanctions for its use Unauthorized practice of medicine Possession of prescription drug (naloxone) w/o prescription

Bystanders w/o naloxone may fear calling 911 Fear arrest for drug possession, outstanding warrants or other

reasons Lots of evidence that this fear is both real and justified

Existing evidence mainly from heroin, but no reason to believe any different for prescription opioids

Removal of law as barrier All of these legal/regulatory barriers are

unintended consequences of attempts to address other problems

Unfortunately, they have an extraordinarily severe side effect: thousands of preventable deaths per year

Luckily, they can be easily modified to remove that side effect while maintaining original intent of laws/regulations

Critical Opportunity: Increase access Remove the possibility of civil and professional

penalties for prescribers and administrators acting in good faith

Remove the possibility of criminal penalties for prescribers and administrators acting in good faith

Explicitly endorse 3rd party prescription

As of Oct. 15, 2012, 8 states (NM, NY, IL, WA, CA, RI, CT and MA) have explicitly amended law to increase access

Example Language Naloxone or other opioid antagonist may lawfully be

prescribed and dispensed to a person at risk of experiencing an opiate-related overdose or a family member, friend or other person in a position to assist a person at risk of experiencing an opiate-related overdose. For purposes of this chapter and chapter 112 [governing professional licensing and registration], any such prescription shall be regarded as being issued for a legitimate medical purpose in the usual course of professional practice.

2012 Mass. Acts 192 (2012)

Example Language (a) A person may administer an opioid antagonist

to another person if: 1) He or she, in good faith, believes the other person is experiencing a drug overdose; and (2) He or she acts with reasonable care in administering the drug to the other person. (b) A person who administers an opioid antagonist to another person pursuant to this section shall not be subject to civil liability or criminal prosecution as a result of the administration of the drug.

2012 R.I. Pub. Laws 251 (2012)

States w/ naloxone access laws

Critical Opportunity: Good Sam Existing Good Samaritan laws provide protection

from civil liability But overdose bystanders are mainly

worried about criminal penalties

Enter the overdose Good Samaritan law Modeled after alcohol Good Sam policies

now enacted on many college campuses

As of Oct. 15, 2012, ten states (NM, WA, NY, CT, IL, CO, RI, FL, MA and CA) have passed

overdose Good Sam laws

Example Language (1) A person acting in good faith who seeks medical assistance for an

individual experiencing a drug-related overdose may not be charged, prosecuted, or penalized pursuant to this chapter for possession of a controlled substance if the evidence for possession of a controlled substance was obtained as a result of the person’s seeking medical assistance.

(2) A person who experiences a drug-related overdose and is in need of medical assistance may not be charged, prosecuted, or penalized pursuant to this chapter for possession of a controlled substance if the evidence for possession of a controlled substance was obtained as a result of the overdose and the need for medical assistance.

(3) Protection in this section from prosecution for possession offenses under this chapter may not be grounds for suppression of evidence in other criminal prosecutions.

2012 Fla. Laws 36 (2012)

States w/ drug overdose Good Sam laws

Discussion Changes are popular and have seen rapid

uptake Almost no organized opposition, good deal of law enforcement

support

Discussion “[Good Samaritan] laws are cost effective because they save

investigative resources in the long run…The fact is that when most people witness an overdose, they’ll try all kinds of bizarre, dangerous ways to revive a person, sometimes based off things they saw on TV. We want them to call 911 and Good Samaritan laws remove the fear of calling for help in most cases…Addiction can happen to anyone – your brother, daughter, sister, son…if we can save one life, it’s worth it.”   - Det. Gary Martin, Palm Beach County Sheriff's Office

"Let's say two teens are sniffing spray paint and one has adverse reaction and goes into shock. Do you want that other child to ignore them for fear of arrest because of sniffing misdemeanor? Allowing them to call 911 [through Good Samaritan laws] is not condoning their behavior, it's just letting them get help." – Assistant Chief Jim Pugel, Seattle Police Dep’t.

Discussion Related promising regulatory changes

Permitting EMT-Bs to carry and administer naloxone Talk about low-hanging fruit!

Standing orders for lay dispensing Currently in place in CA, MA

Co-prescription as standard of care State medical/pharmacy board

Changing law is not magic bullet Change requires engagement with and action from

public health and elected officials, the medical and treatment communities, law enforcement, clergy, community groups, etc.

Conclusion Common sense and emerging evidence suggest

that laws that make it easier for lay people to access naloxone, administer naloxone, and summon emergency assistance in the event of overdose can save lives and resources

Since such laws have possibility to save thousands of lives annually and no readily apparent downside, they should be enacted widely and with haste

As with all policy interventions, results should be independently and rigorously evaluated

Questions?

Corey Davis, JD, MSPHStaff Attorney

Network for Public Health Lawcdavis@networkforphl.org