Opioid Overdose Prevention-Role of Naloxone in the Community

Sharon Stancliff, MDHarm Reduction CoalitionJanuary 2015

ObjectivesParticipants will be able to:• Summarize the incidence and demographics of opioid

use and over dose in the United States.• Recognize the characteristics, risk factors and

symptoms associated with opioid overdose. • Explain the New York State DOH’s Opioid Overdose

Prevention Program and the ESAP programs.• Describe the role of first responders in managing an

overdose.

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100

2,000

4,000

6,000

8,000

10,000

12,000

Natural and semi-synthetic opioid analgesic

Methadone

Cocaine

Heroin

Synthetic opioid analgesic, excluding methadone

Num

ber o

f dea

ths

Number of drug poisoning deaths involving opioid analgesics by opioid analgesic category, heroin and cocaine: United States, 1999--2010

NOTES: Opioid analgesic categories are not mutually exclusive. Deaths involving more than one opioid analgesic category shown in this figure are counted multiple times. Natural and semi-synthetic opioid analgesics include morphine, oxycodone and hydrocodone; and synthetic opioid analgesics include fentanyl. SOURCE: CDC/NCHS, National Center for Health Statistics. 2011. http://www.cdc.gov/nchs/data/databriefs/db81.htm

5% decrease

35% increase

Opioid related deaths 2011-2012Increased 2.9%

In 2011~25% of drug-poisoning were unspecified drugs

2010 2011 20120%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

13.821.4

34.9

86.278.6

65.1

Role of Heroin as Cause of Death Among All Drug-Related Deaths

Heroin Non-Heroin

2010 2011 20120%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

54.1 50 47.6

45.9 50 52.4

Role of Opioid Analgesics as Cause of Death Among All Drug-Related Deaths

Opioid Analgesics Other Drugs

Physiology

• Generally happens over course of minutes to hours- the stereotype “needle in the arm” death is only about 15%

• Opioids decrease response to rising carbon dioxide and falling oxygen levels leading to respiratory depression and death generally over the course of 1-3 hours

Who overdoses?

• Among heroin users it has generally been those who have been using 5-10 years

• Less is known about prescription opioid users• Anecdotal reports of youth dying suggest that

many of those have been in drug treatment and relapse

Sporer 2003, 2006

Heroin User Experiences

About 2% of heroin users die each year- many from heroin overdose1/2 heroin users experience at least one nonfatal overdose 80% have observed an overdose

Sporer BMJ 2003, Galea 2003, Coffin Acad Emerg Med 2007

Overdose risk of those with prescriptions

MMWR / January 13, 2012 / Vol. 61 / No. 1

Context of Opioid Overdose

• The majority of heroin overdoses are witnessed (gives an opportunity for intervention)

• The circumstances of prescription drug overdoses are less well characterized

• Fear of police may prevent calling 911• Witnesses may try ineffectual things

– Myths and lack of proper training– Abandonment is the worst response

Tracy 2005

Risk Factors for Opioid Overdose

• Reduced Tolerance• Using Alone (risk

factor for fatal OD)• Illness• Depression• Unstable housing

• Mixing Drugs• Changes in the Drug

Supply• History of previous

overdose

Overdose deaths in New York City involve multiple drugs (2012)

Nearly all unintentional drug overdose deaths (95%)involve more than one substance, including alcohol.2008 Opioids were the most commonly noted drug type(74%). Types of opioids included heroin, methadone, and prescription pain relievers.

Other drugs commonly found were: cocaine (53%), benzodiazepines (35%), antidepressants (26%),and alcohol (43%).

NYC VITAL SIGNS Volume 9, No. 1, NYCDOHMH

Unintentional drug poisoning deaths by drug type involved (not mutually exclusive), New York City, 2000-2012

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0 Heroin

Cocaine

Methadone

Benzodiazepines

Opioid Analgesics

Ag

e A

dju

ste

d R

ate

pe

r 1

00

,00

0

Source: NYC Office of the Chief Medical Examiner & NYC DOHMH Bureau of Vital Statistics

Lowered tolerance

• Tolerance- repeated use of a substance may lead to the need for increased amounts to product the same effect

• Abstinence decreases tolerance increasing overdose risk– Incarceration– Hospitalization– Drug treatment/ Detox/ Therapeutic communities– Sporadic patterns of drug use

• Sporer 2007, Binswanger 2007

Post release mortality

76,208 people released from Washington State Department of Corrections 1999-2009Overdose was the leading cause of death; opioids were involved in 14.8% of deathsBinswanger et al Annals of Med 2013

From: Mortality After Prison Release: Opioid Overdose and Other Causes of Death, Risk Factors, and Time Trends From 1999 to 2009

Ann Intern Med. 2013;159(9):592-600. doi:10.7326/0003-4819-159-9-201311050-00005

Mortality rate, by week since release, for overdose and all other (nonoverdose) causes of death.

Figure Legend:

Copyright © American College of Physicians. All rights reserved.

From: Mortality After Prison Release: Opioid Overdose and Other Causes of Death, Risk Factors, and Time Trends From 1999 to 2009

Ann Intern Med. 2013;159(9):592-600. doi:10.7326/0003-4819-159-9-201311050-00005

Copyright © American College of Physicians. All rights reserved.

Strategies to address overdose• Increase access to naloxone• Good Samaritan laws• Prescription monitoring programs

– Paulozzi et al. Pain Medicine 2011

• Prescription drug take back events• Supervised injection facilities• Safe opioid prescribing education

– Albert et al. Pain Medicine 2011; 12: S77-S85

• Expansion of opioid agonist treatment– Clausen et al. Addiction 2009:104;1356-62

Reverses clinical and toxic effects of opioid overdoseReverses respiratory depression, hypotension, sedationRestores breathingReverses analgesiaPatients can experience withdrawal after naloxone administration

Naloxone

Models of increasing access to naloxone

• Community prescribing/distribution to drug user and/or social networks

• Increasing access among uniformed first responders- eg police, fire, Basic EMTs

• Prescribing in outpatient care• Pharmacy collaborative agreements

Legal Status- New Overdose Law in New York State (Effective April 1, 2006)

• Protects the non-medical person who administers naloxone in setting of overdose from liability.– “shall be considered first aid or emergency treatment”.– “shall not constitute the unlawful practice of a

profession”.• Allows the medical provider to provide naloxone for

secondary administration.• Naloxone must be prescribed by MD, DO, PA, or NP either

in person or through designated representative via standing order

Who may offer an OpioidOverdose Prevention Program?

• Licensed health care facilities :– Hospitals– Diagnostic & Treatment

Centers• Drug treatment programs• Colleges, universities and

trade schools• Public safety agencies• CBOs with the services of a

clinical director

• Pharmacies• Health care practitioners:

– Physicians– Physician assistants– Nurse practitioners

• Local health departments• Other local and state

agencies

Available resources• Naloxone kits (free from NYSDOH)• Sample policies and procedures• Approved curriculum• Fact sheets• Sample medical history• Certificates of completion• OD reporting form

Non-patient specific order

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.

Training

Everyone being furnished or dispensed naloxone should have training in opioid overdose recognition and response. Mechanisms for pharmacist and patient training are still being explored.

27

Essential Knowledge

• What does naloxone do?• Overdose recognition• Action

– Call EMS– Administer naloxone

• Hands on practice with device if possible• Recovery position

? Report?

28

Painful stimulation

If no response to calling and shaking:Sternal grind (make a fist and rub the sternum with the knucles)• Assessment of level of consciousness• May make the overdoser breath a bit even if

he or she doesn’t wake up

Action

• Activate emergency medical services (911) “my friend is overdosing and not breathing”

And • Administer naloxoneWhich ever is closer at hand

Naloxone Instructions

• Inject into a muscle or spray up the nose• If no response in 2-5 minutes, give 2nd

naloxone injection • Lasts for 30 – 90 minutes – recipient must

be observed, preferably by medical staff for at least 2 hours

31

Results: awake and breathing

Narcan wears off in 30-90 minutes• Reassure the survivor if s/he is in withdrawal

the naloxone will wear off- don’t use more opioids to feel better!!

• Encourage survivor to go to the hospital, either by ambulance or other transportation

Implementation in NY StateOver 200 sites registered including:• Syringe exchange/syringe access sites• Hospitals/clinic• Drug Treatment Programs• HIV programs• Homeless shelters• Government agencies e.g. police• Local health departments• Educational institutions

Over 1000 reversals reported

States with legislation allowing 3rd party administration

Now addOther states with programs include:Wisconsin, Minnesota and small programs in a variety of places

Uniformed first responders

Initial responders vary by community• Basic Emergency Medical Technicians

are now able to carry naloxone in NYS• Fire fighters being trained• Law enforcement/peace officers

– NYC homeless shelters– CUNY and SUNY campus police

Law enforcement

Following a successful pilot in Suffolk County an initiative to train police across NYS began 4/14As of January 8, 2015• Over 2,400 officers have been trained outside

of NYC • Naloxone has been used 112 times, 77

recipients had a clear response

Opioid maintenance and mortality

Overdose deaths in BaltimoreAdjusting for heroin purity and the number of methadonepatients, there was a statistically significant inverse relationship between heroin overdose deaths and patients treated withbuprenorphine (P = .002).

Schwartz et al AJPH 2013

Mortality before, during and after OMT in Norway

Clausen T. et al. Drug and Alcohol Dependence, 2008, Mortality prior to, during and after opioid maintenance treatment (OMT)

% pr year

Pre-treatment In treatment Post treatment

Overdose

Non-overdose

0

0.5

1

1.5

2

2.5

3

3.5

4

1998-20033,789 subjects followed for up to 7 years

Syringe Access:

Syringe Exchanges Pharmacies Medical providers

Trends in HIV and AIDS Cases*New York State, 1984 - 2012

0

20,000

40,000

60,000

80,000

100,000

120,000

140,000

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

1984 1986 1988 1990 1992 1994 1996 1998 2000^ 2002 2004 2006 2008 2010 2012

Nu

mb

er of P

LWD

HI

Nu

mb

er o

f A

IDS

Dia

gn

ose

s an

d D

eath

s

People living withHIV (non-AIDS) atthe end of each yearNumber

diagnosed eachyear with AIDS

Number of deaths each year among AIDS cases

People living withAIDS at the end of

each year

*Data as of April 2014^HIV named reporting began in NYS in 2000;deaths among HIV and AIDS cases are reported starting in 2000. NYSDOH/AI/BHAE

Number of deathsamong HIV & AIDScases each year

19851986

19871988

19891990

19911992

19931994

19951996

19971998

19992001

20022003

20042005

20062007

20082009

20102011

20120

10

20

30

40

50

60

Perc

ent o

f Cas

es**

*

*AIDS Cases are shown for 1985-1999 Source: NYSDOH/AI/BHAE**Data as of December 6, 2013***Percentages are based on the total number of new HIV diagnoses for each year, regardless of transmission category.

MSM/IDU

MSM

IDU

Figure 1: Proportion of HIV and AIDS Cases* by Risk and Year of Diagnosis, NYS, 1985-2012**

AIDS Newly Diagnosed HIV

Newly reported cases of hepatitis C

Kim A Y et al. J Infect Dis. 2013

Of those with reported risk: IDU 74%Of those heroin was themost common drug. Massachusetts

2002 n = 6368)2011n = 5194).

Expanded Syringe Access

• Proven public health intervention• Reduces the transmission of blood-borne

pathogens• Expands options for persons with diabetes and

others who self-inject• Promotes self disposal of syringes

Expanded Syringe Access Program (ESAP)

New York State law allows for sale or furnishing of hypodermic syringes or needles by registered: • Pharmacies• Article 28 health care facilities• Health care practitioners

Selling of Syringes by Pharmacies

During 2011-2012, the ESAP pharmacies distributed an estimated 4,059,048 syringes

Research and Evaluation on ESAP

• Evaluations of ESAP by the New York State Department of Health, the National Development and Research Institutes, Beth Israel Medical Center and the New York Academy of Medicine found the program to be an effective means of increasing access to sterile syringes for self-injectors in New York State

• Pharmacy experiences: Based on the results of three statewide surveys of ESAP-registered pharmacists, the vast majority of ESAP registered pharmacists report very positive experiences with ESAP and this has not changed over time

• Criminal Activity: Implementation of ESAP did not appear to increase heroin use, drug injection, or criminal activity in New York State

Syringe Exchange in NYS

24 syringe exchange in New York State with multiple sites

• Storefronts• Mobile vans• Delivery in single room occupancy hotels• Walking about with supplies• Peer delivery

Not just syringes at syringe servicesOther services include:CounselingDrug treatment referralDrug treatmentOverdose preventionHepatitis servicesAcupunctureFood

Syringe prescription• Prescription of syringes to injection drug users

is legal in New York State• Endorsed by the AMA• Recommended in NYSDOH AIDS Institute

guidelines

Burris, Annals Int Med 8/1/00, www.hivguidelines.org

Figure 1 Number of methadone maintenance treatment program admissions over time by route of administration (inhalation versus injection) Des Jarlais et al Addiction 2010

Does syringe access increase injection?

AcknowledgementsNew York State Department of Health New York City Department of Health Opioid Safety Naloxone Network