Prescription Opioid Overdose Prevention
in Clinical Settings:
New Mexico Department of Health Naloxone
Co-prescription Pilot Project Friday, June 6, 2014
New Mexico Health Resources
22nd Annual Health Provider Retreat
LEARNING OBJECTIVES
Provide epidemiologic data overview on drug overdose death in New Mexico (NMDOH)
Provide prescription opioid sales data in New Mexico (DEA)
Provide prescription writing (dispensing) data overview from New Mexico Prescription Drug Monitoring Program
Describe other policy efforts and community-based opioid overdose prevention projects in New Mexico
Describe the planning and implementation for 4 co-prescription pilots in Taos, Santa Fe, Roswell and Albuquerque
Report summary data and preliminary evaluation from first 15 months of co-prescription pilot projects
Drug Overdose:
The Epidemic in New Mexico
• In 2012, New Mexico’s age-adjusted drug overdose death rate was 24.2 per 100,000 persons. The CDC reports that New Mexico had the second highest drug overdose death rate in the nation in 2010, nearly double the U. S. rate.
• Since 2001, New Mexico’s drug overdose death rate has increased 79.9%. Since 1990, almost 300%.
• On average, one New Mexican dies of a drug overdose every 17 hours. In 2012, 486 New Mexicans died from drug overdose.
The Prescription Drug Overdose Epidemic
in New Mexico
• Prescription opioids have driven the increase in overall overdose death during the past decade in our state.
• More than half of the drug overdose deaths in New Mexico involve prescription drugs.
• Nearly 10 years ago deaths involving prescription drugs overtook deaths involving heroin.
• Deaths involving prescription drugs now outnumber deaths due to heroin by 60%.
• Between 2001 and 2011, oxycodone sales in the state more than tripled.
Source: United States (CDC Wonder); New Mexico (NMDOH BVRHS: SAES, 1990-1998, 2012; NM-IBIS, 1999-2011)
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5.0
10.0
15.0
20.0
25.0
30.0
199
0
199
1
199
2
199
3
199
4
199
5
199
6
199
7
199
8
199
9
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
De
ath
s p
er
10
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00
pe
rs
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s
Year
Drug Overdose Death Rates New Mexico and United States, 1990-2012
New Mexico
United States
Source: New Mexico Office of the Medical Investigator. Note: Groups are not mutually exclusive.
0
5
10
15
20
25
3019
90
199
1
199
2
199
3
199
4
199
5
199
6
199
7
199
8
199
9
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
20
12
Ag
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dju
ste
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ate
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r 1
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,00
0
po
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lati
on
Total Overdose Death Rates by Type of Drug,
New Mexico, 1990-2012
Total Prescription Illicit
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
0.0
5.0
10.0
15.0
20.0
25.0
30.0
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Sa
les
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r 1
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De
ath
s p
er
10
0,0
00
Rates of Drug Overdose Deaths and OPR Sales, New Mexico 2001-2012
drug deaths/100,000
opioid sales kg/10,000
Source: BVRHS, NMDOH; ARCOS, DEA.
Source: NMDOH BVRHS; CDC Wonder
0 10 20 30 40 50 60 70 80
USCibolaCurry
McKinleyRoosevelt
LunaLos Alamos
LeaSan Juan
Dona AnaSandoval
OteroChavesLincolnSocorro
ColfaxNew Mexico
TorranceValenciaSanta Fe
EddyBernalillo
TaosGrant
San MiguelQuay
SierraMora
Rio Arriba
Age-adjusted death rate per 100,000 population
Drug Overdose Death Rates by County New Mexico, 2008-2012 and US, 2010
Statewide Opioid Sales Fell in 2012
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
1,600,000
1,800,000
2,000,000
2001 20022003200420052006200720082009 2010 2011 2012
Mo
rp
hin
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qu
iva
len
t g
ra
ms
Total Morphine Equivalents of Opioids Sold, NM 2001-2012
Source: DEA ARCOS sales data
Statewide Opioid Sales by Drug
0
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
Mo
rp
hin
e E
qu
iva
len
t g
ra
ms
Morphine Equivalents of Opioids Sold, NM 2001-2012
OXYCODONE
FENTANYL
METHADONE
HYDROCODONE
MORPHINE
BUPRENORPHINE
Source: DEA ARCOS sales data
Opioid Prescription Rate
0
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
90,000
2009 2010 2011 2012 2013*
Pr
es
cr
ipti
on
s f
ille
d p
er
10
0,0
00
po
p
Opioid Prescriptions per 100,000 population
New Mexico
Source: NM Prescription Monitoring Program 2013 population estimated
Total Quantity of Opioids Dispensed
0
20,000,000
40,000,000
60,000,000
80,000,000
100,000,000
120,000,000
1 2 3 4 5
MM
E p
er
10
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00
po
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on
Total MME of Opioids Dispensed per 100,000 population
New Mexico
MME is Morphine Milligram Equivalents Source: NM Prescription Monitoring Program 2013 population estimated
Quantity per Prescription
0
200
400
600
800
1,000
1,200
1,400
2009 2010 2011 2012 2013*
MM
E p
er
pr
es
cr
ipti
on
fil
l
Morphine Milligram Equivalents per Prescription
New Mexico
Source: NM Prescription Monitoring Program 2013 population estimated
Policy and Board Responses to the Drug
Overdose Epidemic in New Mexico
• Overdose Death as NM Department of Health Priority Indicator (1 of 9)
• Board of Pharmacy and the Prescription Drug Monitoring Program (PDMP) in 2012
• Professional Health Care Provider Boards Rules Changes (2012-13)
• Governor’s Prescription Drug Misuse and Overdose Prevention and Pain Management Advisory Council (SB215 out of 2012 Legislative Session)
• Board of Pharmacy: Expansion of Naloxone Prescriptive Authority
• Human Services Department/Medical Assistance Division: Naloxone Rescue Kit now on Centennial Care Formulary
NM Department of Health
Overdose Prevention Efforts
• Naloxone distributed to injection drug users and their
friends/family at syringe exchange sites since 2001
• Collaboration with city/county government in Bernalillo,
Taos, Rio Arriba, Santa Fe and San Miguel, including:
1. Overdose prevention and naloxone rescue kits to
detainees upon release from adult detention facilities
2. Public overdose prevention education sessions
3. EMTs and overdose prevention training and naloxone
• Naloxone Co-Prescription Pilots (Taos, Santa Fe,
Roswell and Albuquerque) beginning December 2012
What is NALOXONE?
Naloxone (brand name Narcan) is a prescription
drug that reverses the effects of an opioid overdose by blocking the opioid’s action on the brain and restoring breathing.
Naloxone’s only purpose is to reverse opioid overdose; it is not a “recreational” drug and does not cause a “high.” The use of naloxone, in combination with rescue breathing, can save a life.
Naloxone only works if a person has opioids in their system; otherwise it has no effect
Has been used for decades by emergency responders and in hospital settings to revive persons experiencing overdose of opioids.
Can be administered intravenously, intra-muscularly or intra-nasally. The NM Department of Health programs use the intra-nasal version.
Guide to Developing and Managing Overdose Prevention and Take-Home
Naloxone Projects, Harm Reduction Coalition
Fall 2012
WHY Provide Overdose Prevention and Naloxone Rescue
Training to Patients (and their caregivers) in a Clinic Setting?
Opportunity to reach patients at point of care and explain
risk of opioid pain medication – and include family member
or care giver in medication therapy planning
Opportunity to educate patients on importance of careful
and responsible use of opioids – to include possibility of
unintentional overdose
Opportunity to provide overdose prevention education and
response (administration of naloxone) as standard of care
for chronic pain treatment
NMDOH Naloxone Co-Prescription Pilots
Based on Project Lazarus from North Carolina (Wilkes
County and 69% reduction in prescription opioid overdose
death rate after 2 years)
Provision of naloxone and overdose prevention education
to risk-identified patients and their rescue persons
Partners: NMDOH + Pharmacy + Medical Provider
NMDOH reimburses Pharmacy for Naloxone Rescue Kits
(cost of drug, nasal adaptor, patient educational materials)
as prescribed by Medical Provider
Taos in January of 2013, Roswell in February of 2013,
Santa Fe in June of 2013
Overdose Prevention Education
as Patient Service
Medical Provider identifies risk of misuse or
overdose (patients on opioid pain medication or
opioid replacement therapy)
Internal Referral for Overdose Prevention Education
by identified staff (Nurse/Pharm Tech/Medical
Assistant/Social Worker/Community Health Worker)
Naloxone Rescue Kit dispensed directly to patient at
clinic OR from participating community-based
Pharmacy
Taos Co-Prescription Pilot
Taos Alive + Holy Cross Hospital Pharmacy + Taos Medical Group
Development of Policy, Enrollment Forms and Patient Education Materials
Rescue Kits are packaged by Holy Cross Pharmacy and provided to Medical Practice for dispensing to patients onsite
Patient education provided at clinic site by medical provider, nurse, medical assistant, counselor, community educator
Taos Co-Prescription Pilot, cont
Expanded to 6 Provider Sites: Taos Medical Group
Tri-County Community Services (suboxone case load)
El Centro Family Health Clinic/Taos
Holy Cross Peñasco Clinic
Family Practice Associates of Taos
Holy Cross In-Patient (patients sent home with kits)
Further expansion in planning stages: Holy Cross Hospital Emergency Department
Presbyterian Medical Services in Peñasco
Taos County Adult Detention Center
73 Kits dispensed since launching in JAN of 2013 with 2 reported saves to date
Santa Fe Co-Prescription Pilot
Santa Fe Opioid Safe (SOS) + Medicap Pharmacy +
La Familia Medical Center
Revised Policy, Enrollment Form and Patient
Education Materials
Same model as Taos: Pharmacy directs Rescue Kits
to Pharmacy Room/Drug Shelf and dispensed to
patients onsite
35 Kits dispensed since June 2013 launch with 1
reported save (use) to date
Plans to expand to more sites
Roswell Co-Prescription Pilot
NMDOH Regional Public Health Office + Primm Drug + small family medicine practice
Revised Policy, Enrollment Form and Patient Education Materials
Pharmacy Dispensing Model: Patients fill prescription for Naloxone Rescue Kit with Primm Drug and pharmacists provide patient/rescue person education and training
Launched in February of 2013 and expanded by 2 clinic sites in June of 2013
32 kits dispensed – No reported use to date
University of New Mexico School of Medicine
Chronic Pain Clinic
Human subject study of overdose prevention
education and naloxone rescue kit dispensing in
chronic pain clinic setting
No risk screen: all chronic pain patients on opioid
therapy will be offered the training and rescue kit
Pilot set to launch mid-June
Descriptive Data from
Pilot Sites
32 35
73
0
10
20
30
40
50
60
70
80
Roswell Santa Fe Taos
Kit
s D
isp
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se
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County of Service
Naloxone Rescue Kits Dispensed by County of Service
44% 56%
Naloxone Kits Dispensed by Sex
MaleFemale
1
18
32
21
49
19
0
10
20
30
40
50
60
0-14 18-24 25-34 35-44 45-64 65+
Kit
s D
isp
en
se
d
Age-Groups
Naloxone Kits Dispensed by Age-Group
0
4
11 10
23
12
1
13
20
11
25
7
0
5
10
15
20
25
30
35
40
45
50
0-14 18-24 25-34 35-44 45-64 65+
Kit
s D
isp
en
se
d
Age-Group
Naloxone Kits Dispensed, by Gender and Age-Group
Male
Female
NMDOH Naloxone Co-Prescription Pilot Risk Indicators
Frequency (as of
April 2014)
Prescribed opioids or opioid use greater than 30 days 65
A high daily dose of opioid prescribed (>50 mme/day) 58
Prescribed long-acting opioid 55
Suspected or known history of substance abuse, regardless if currently abstinent 42
Concurrent prescription or OTC medication that could potentiate the CNS and respiratory
depressant properties of opioid medications 36
Households with people at risk of overdose 28
Opioid use with certain concurrent diseases 27
History of or current polyopioid use 22
History of emergency medical care for intoxication or overdose 20
Elderly (>65) 15
Known or suspected substance use such as alcohol or marijuana 14
Patients who may have difficulty accessing emergency medical services 6
Just released from incarceration or institutionalization with history of opioid addition 6
Known severe psychiatric illness or history of suicide attempt 5
Teens receiving an opioid prescription 3
137 Enrollees • 3 enrollees have two
enrollment forms each, one for each kit received
126 Identified Rescue Person
• 91 Family Member
• 23 Friend
• 10 Other
• 2 Missing Information in Enrollment Form
79 Rescue persons
present at training
Evaluation of Co-Prescription Pilots
NMDOH Substance Abuse Epidemiology Section
Completed Enrollment Forms from Each Practice
Site (2013-2014)
Re-Fill data capture
Emergency Department and Hospitalization Data
OMI data (Overdose Death Rate by County and
State)
Opioid Prescribing Behavior by County/State
Online Patient Naloxone Training Video
http://prescribetoprevent.org/video/
Contact Information
Melissa Heinz, MPH
New Mexico Department of Health
Office of Injury Prevention
