74
We Are Not Unique: The National Picture
Taken from The Economist, March 6 2017.
Western New York
ERIE COUNTY
DEPARTMENT OF HEALTH
Monday, February 26, 2018
Welcome & Thank You
Introduction of Trainers
Cheryll Moore
Erie County Department of Health
Monday, February 26, 2018
WHY ARE WE HERE?
Learning Objectives
The Opioid Epidemic in Erie County today –what happened?
Signs and symptoms of an opioid overdose
Good Samaritan Law
ESAP and SEP
Use of Narcan (naloxone) to reverse an overdose
Reporting and follow up
103 101
127
256 301
200
0
50
100
150
200
250
300
350
2012 2013 2014 2015 2016 2017*
2012 – 2017* OPIOID DEATHS
ERIE COUNTY
SOURCE: ERIE COUNTY MEDICAL EXAMINERS OFFICE, *CLOSED CASES REPORTED THRU
1/23/2018
119 PendingCases
SOURCE: ERIE COUNTY MEDICAL EXAMINERS OFFICE, *CLOSED CASES REPORTED THRU 1/23/2018
2014 – 2017* ERIE COUNTY OPIOID DEATHS
BY GENDER
85187 233 152
4269 68 48
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2014 2015 2016 2017
Female
Male
N=127 N=256 N=301 N=200 (119 Pending)
2014-2017* ERIE COUNTY OPIOID DEATHS BY RACE
N=127 N=256 N=301 N=200
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2014 2015 2016 2017
White Black Hispanic Other2014 106 8 8 52015 221 17 14 42016 246 28 20 72017 168 19 10 3
WhiteBlackHispanic Other
SOURCE: ERIE COUNTY MEDICAL EXAMINERS OFFICE, *CLOSED CASES REPORTED THRU 1/23/2018
0
10
20
30
40
50
60
70
80
90
100
UNDER 20 20-29 30-39 40-49 50-59 60+
7
72 74
50
39
14
3
92
86
55
40
25
7
56 57
3433
13
AGE (YEARS)
2015 N=2562016 N=3012017 N=200
(119 Pending)
2015 – 2017* ERIE COUNTY OPIOID DEATHS
BY AGE AND YEAR
Nu
mb
er o
f D
eath
s
SOURCE: ERIE COUNTY MEDICAL EXAMINERS OFFICE, *CLOSED CASES REPORTED THRU 1/23/2018
2016 CENSUS ESTIMATES FOR ERIE COUNTY, NEW YORK
Number PercentTotal Population 921,046 100Race
White 744,511 80.8
Black or African American 133,536 14.5Asian or Pacific Islander 35,375 3.8
American Indian or Alaska Native 7,624 0.8Ethnicity
Hispanic or Latino 49,008 5.3Not-Hispanic or Latino 872,038 94.7
GenderFemale 474,770 51.5Male 446,276 48.5
Age15-19 59,656 6.520-29 132,818 14.430-39 112,221 12.240-49 108,139 11.750-59 135,275 14.760-69 112,730 12.270+ 106,279 11.5
76% of Opioid Deaths are Male
83% of Opioid Deaths are White10% of Opioid Deaths are Black
57% of Opioid Deaths are between 20-39 years of age
2017 Opioid Statistics
39.0%
44.5%
15.0%
1.5%
2014 Fatal Opioid Overdoses
by Residence of Victim
unknown
BUFFALOSUBURBS
RURAL
Amherst
Cheektowaga
Depew
Hamburg
Kenmore
Lackawanna
Lancaster
Orchard Park
SloanTonawanda
West Seneca
Akron
Alden
Angola
Colden
Derby
East Aurora
Eden
Lakeview
Marilla
Newstead
North Collins
Springville
Source: Erie County Medical Examiners Office, Complete 2014 Data, Closed Cases; Reporting date 09/29/2015
43.8%
41.0%
8.6%
6.6%
BUFFALO
SUBURBS
RURAL
AMHERST
BLASDELL
CHEEKTOWAGA
CITY OF TONAWANDA
CLARENCE
DEPEW
GRAND ISLAND
HAMBURG
KENMORE
LACKAWANNA
LANCASTER
ORCHARD PARK
TOWN OF TONAWANDA
WEST SENECA
HOMELESS OR UNKNOWN
AKRON
ALDEN
ANGOLA
AURORA
CHAFFEE
COLLINS
CONCORD
EAST AURORA
EDEN
ELMA
EVANS
GLENWOOD
GOWANDA
HOLLAND
MARILLA
NEWSTEAD
NORTH COLLINS
SARDINIA
SPRINGVILLE
N=256
2015 ERIE COUNTY OPIOID OVERDOSE DEATHS BY RESIDENCE
SOURCE: ERIE COUNTY MEDICAL EXAMINERS OFFICE, CLOSED CASES; REPORTED 05/13/2016
43.8%
39.2%
9.6%
7.3%
BUFFALO
SUBURBS
HOMELESS/
UNKNOWN
SUBURBAN TOWNS:
AMHERST
CHEEKTOWAGA
CLARENCE
GRAND ISLAND
HAMBURG
LACKAWANNA
LANCASTER
ORCHARD PARK
TONAWANDA
WEST SENECA
N=296
RURAL
RURAL TOWNS:ALDEN
AURORA
COLDEN
COLLINS
CONCORD
EDEN
ELMA
EVANS
GOWANDA
HOLLAND
MARILLA
NEWSTEAD
NORTH COLLINS
SARDINIA
2016 ERIE COUNTY OPIOID DEATHS BY RESIDENCE
SOURCE: ERIE COUNTY MEDICAL EXAMINERS OFFICE, CLOSED CASES REPORTED THRU 8/7/2017
28% of persons who live in Erie County reside in the
City of Buffalo
44%
44%
9%
3%
HOMELESS/UNKNOWN
BUFFALO
SUBURBS
SUBURBAN TOWNS:AMHERST
CHEEKTOWAGA
CLARENCE
GRAND ISLAND
HAMBURG
LACKAWANNA
LANCASTER
ORCHARD PARK
TONAWANDA
WEST SENECA
N=200 (119 Pending)
RURAL
RURAL TOWNS:ALDEN
AURORA
COLDEN
COLLINS
CONCORD
EDEN
ELMA
EVANS
GOWANDA
HOLLAND
MARILLA
NEWSTEAD
NORTH COLLINS
SARDINIA
2017* ERIE COUNTY OPIOID DEATHS BY RESIDENCE
SOURCE: ERIE COUNTY MEDICAL EXAMINERS OFFICE, *CLOSED CASES REPORTED THRU 1/23/2018
28% of persons who live in Erie County reside in the
City of Buffalo
Residence 2016 2017
Buffalo 44% 44%
Suburbs 40% 44%
Rural 10% 9%
Other 7% 3%
¹ NO FENTANYL; POSSIBLE OTHER DRUGS INVOLVED
² NO HEROIN; POSSIBLE OTHER DRUGS INVOLVED
³ NO FENTANYL OR HEROIN; POSSIBLE OTHER DRUGS INVOLVED4 POSSIBLE OTHER DRUGS INVOLVED
FENTANYL
RELATED2
23%
HEROIN
RELATED1
21%
FENTANYL
& HEROIN
RELATED4
8%
OTHER OPIOID3
48%
SOURCE: ERIE COUNTY MEDICAL EXAMINERS OFFICE, CLOSED CASES
2014
N=127
ERIE COUNTY OPIOID RELATED DEATHS BY TYPE OF OPIOID
¹ NO FENTANYL; POSSIBLE OTHER DRUGS INVOLVED
² NO HEROIN; POSSIBLE OTHER DRUGS INVOLVED
³ NO FENTANYL OR HEROIN; POSSIBLE OTHER DRUGS INVOLVED4 POSSIBLE OTHER DRUGS INVOLVED
FENTANYL
RELATED²43%
HEROIN
RELATED¹12%
FENTANYL & HEROIN
RELATED4
19%
OTHER
OPIOIDS³26%
SOURCE: ERIE COUNTY MEDICAL EXAMINERS OFFICE, CLOSED CASES REPORTED THRU 8/7/2017
2015 ERIE COUNTY OPIOID RELATED DEATHS
BY TYPE OF OPIOID
2015N=256
¹ NO FENTANYL; POSSIBLE OTHER DRUGS INVOLVED
² NO HEROIN; POSSIBLE OTHER DRUGS INVOLVED
³ NO FENTANYL OR HEROIN; POSSIBLE OTHER DRUGS INVOLVED4 POSSIBLE OTHER DRUGS INVOLVED
SOURCE: ERIE COUNTY MEDICAL EXAMINERS OFFICE, *CLOSED CASES REPORTED THRU 1/23/2018
2016 AND 2017* ERIE COUNTY OPIOID RELATED DEATHS
BY TYPE OF OPIOID
2016N=301
Fentanyl Related²
59%
Heroin Related¹
5%
Fentanyl & Heroin
Related4
21%
Other Opioids³16%
Fentanyl Related²
59%
Heroin Related¹
8%
Fentanyl & Heroin Related4
17%
Other Opioids³16%
2017N=200
(119 pending)
CPS= Central Police Services
• Opium poppy cultivated in Mesopotamia in 3400 BC.
Referred to as the “joy plant”
• 1803: Active ingredient of opium identified-morphine
• 1895: Heroin, diacetylmorphine is synthesized
and marketed by Bayer as a medication
with less side effects than morphine
• Early 20th century: increases in morbidity
• associated with opioids leads to many
countries passing laws restricting their use
• Harrison Narcotics Tax Act 1914
Courtesy of Dr. Paul Updike, Catholic Health
Readily available in WNY area- Comes in various forms – usually a beige or
white powder
Low Price- Average $5-10 per bag ($50-100 per
“bundle”)
- Less expensive than Prescription pills such
as OxyContin, Opana, or Vicodin which sell
for $10, $20, $40, $60, or $80 per pill
($1/mg)
High Purity & Deadly Combination
with Synthetic Fentanyl- Powerful Opioid Leads to Overdose Deaths
- Can be Snorted/Inhaled or Injected
Fentanyl
&
Courtesy of John Flickinger, DEA
Heroin Forms
Courtesy of John Flickinger, DEA
2/26/2018* Evidence of Drug Use in Community Locations
TODAY
Lethal Amounts of Heroin vs Fentanyl
Source: PBS.org Photo from New Hampshire State Police Forensic Lab
*
Source: New Hampshire Public Radio/ New Hampshire State Police
Complete refresher training at least every 2 years
Contact Emergency Medical Services (EMS)- Call 911- if there is a suspected drug overdose.
Advise if naloxone was used on victim
Report all opioid overdose responses/ naloxone administrations to your OOP program director and get a refill
About 2% of heroin users die each year- many
from heroin overdoses
1/2 to 2/3 of heroin users experience at least
one nonfatal overdose
80% have observed an overdose
Sporer BMJ 2003, Coffin Acad Emerg Med 2007
Among heroin users it has generally been those
who have been using 5-10 years
After rehab
After incarceration
Less is known about prescription opioid users
Anecdotal reports of youth dying suggest that
many of those have been in drug treatment and
relapse are now overdose victims
Sporer 2003, 2006
•Generally happens over course of 1-3 hours
•When stronger opiates such as fentanyl are added to the
mix it is much more immediate
•The stereotypical “needle in the arm” death may be
only about 15% but with the addition of
pharmaceutical grade fentanyl to the heroin mix this
is becoming more common
•Opioids repress the urge to breath – decrease
response to carbon dioxide – leading to respiratory
depression and death
Slowed breathing Breathing stops Heart stops
Overdose is rarely immediate – can happen over 1-3 hours
Heavy/ Uncontrollable Noddinghttps://www.youtube.com/watch?v=0noHSly8YFo
https://www.youtube.com/watch?v=StMcYCBcjOs
Still arousable
Snoring or loud breathing
May have excess drooling
Overdose
Not responsive
Very shallow breathing, gurgling
Skin changes, blue lips and nails
Fatal Overdose Death
The majority of heroin overdoses are witnessed
Provides opportunity for intervention
Fear of police may prevent calling 911“Don’t run, call 911!”
Witnesses may try ineffectual thingsMyths and lack of proper training
Abandonment is the worst response
Tracy 2005
Opioid antagonist which
reverses opioid overdose
injectable or intranasal
Has a higher affinity for
opioid receptors than most
opioids
occupy and block the
receptors for 30-90
minutes
“getting the wrong key
stuck in a lock”
Monday, February 26, 2018
Causes sudden withdrawal in the opioid dependent person – an unpleasant experience
No psychoactive effects – low potential for diversion, is not addictive
Routinely used by EMS (but often in larger doses)
Has no effect if an opiate is not present
Sold over the counter in Italy since 1988
The Opiate Epidemicand Narcan Usage
Erie County Department of Health
September 2017
0 5 10 15 20 25 30 35 40 45
0000 to 0059
0100 to 0159
0200 to 0259
0300 to 0359
0400 to 0459
0500 to 0559
0600 to 0659
0700 to 0759
0800 to 0859
0900 to 0959
1000 to 1059
1100 to 1159
1200 to 1259
1300 to 1359
1400 to 1459
1500 to 1559
1600 to 1659
1700 to 1759
1800 to 1859
1900 to 1959
2000 to 2059
2100 to 2159
2200 to 2259
2300 to 2359
Unknown
Time (1 hr), 2016 only
Overdose Reversals and Time of Day• Low in the mornings. We think many individuals with substance use disorders (SUDs) have regular jobs, and are
self-medicating before they start their day. • Spike from Noon – 1 PM: people self-medicating on their lunch break?• Slight lull in evening; we think that’s when people are heading home or preparing/eating dinner.
0 50 100 150 200 250
Midnight to 12:59
1:00 - 1:59 AM
2:00 - 2:59 AM
3:00 - 3:59 AM
4:00 - 4:59 AM
5:00 - 5:59 AM
6:00 - 6:59 AM
7:00 - 7:59 AM
8:00 - 8:59 AM
9:00 - 9:59 AM
10:00 - 10:59 AM
11:00 - 11:59 AM
Noon - 12:59 PM
1:00 - 1:59 PM
2:00 - 2:59 PM
3:00 - 3:59 PM
4:00 - 4:59 PM
5:00 - 5:59 PM
6:00 - 6:59 PM
7:00 - 7:59 PM
8:00 - 8:59 PM
9:00 - 9:59 PM
10:00 - 10:59 PM
11:00 - 11:59 PM
Unknown
Time of OD Reversal, N = 1,345
Deaths vs. Overdoses, 2016
0 20 40 60 80 100 120 140 160 180
Under 10
10 to 14
15 to 19
20 to 24
25 to 29
30 to 34
35 to 39
40 to 44
45 to 49
50 to 54
55 to 59
60 to 64
65 to 69
70 to 74
75 to 79
80+
2016 ODs 2016 Deaths
Deaths vs. Overdoses, 2017
0 10 20 30 40 50 60 70 80
Under 10
10 to 14
15 to 19
20 to 24
25 to 29
30 to 34
35 to 39
40 to 44
45 to 49
50 to 54
55 to 59
60 to 64
65 to 69
70 to 74
75 to 79
80+
2017 ODs 2017 Deaths
ZIP Code of Overdoses, Police/Fire Forms
0
20
40
60
80
100
120
140
12
01
5
13
08
4
14
00
4
14
00
6
14
01
2
14
02
5
14
02
7
14
03
1
14
03
4
14
04
3
14
04
7
14
05
5
14
05
7
14
05
9
14
06
7
14
07
0
14
07
2
14
07
5
14
08
1
14
08
5
14
08
6
14
09
4
14
09
6
14
10
5
14
10
8
14
11
1
14
12
0
14
12
7
14
12
9
14
13
1
14
13
2
14
14
1
14
17
2
14
20
1
14
20
2
14
20
3
14
20
4
14
20
6
14
20
7
14
20
8
14
20
9
14
21
0
14
21
1
14
21
2
14
21
3
14
21
4
14
21
5
14
21
6
14
21
7
14
21
8
14
21
9
14
22
0
14
22
1
14
22
2
14
22
3
14
22
4
14
22
5
14
22
7
14
22
8
14
30
4
14
44
5
ZIP Code, Excluding Unknowns, N = 1,402
Erie County New YorkResponse After Overdose
Pilot Project Utilizing ODMap
Immediate Response to Overdoses
Immediate Follow-up After Overdose
Long Term Follow-up
Outcomes to Date
• September 1, 2017 – December 31, 2017
• 19 clients total identified through ODMap after overdose and direct referrals from law enforcement officers
• 10 individuals identified after overdose using ODMap
– Of this cohort, 4 remained connected to care at 30 day interval
• 9 individuals identified through direct referral from law enforcement when identified through associated crimes
– Of this cohort, 5 remained connected to care at 30 day interval
Monday, February 26, 2018
Over 500 registered sites, including:
Syringe exchange/syringe access sites
Hospitals
Drug Treatment Programs
HIV prevention programs
Homeless shelters
Reduced Tolerance
Post-rehab
Using Alone
risk factor for fatalOD
Illness
Depression
Unstable housing
Mixing Drugs
Changes in the
Drug Supply
History of
previous overdose
Heroin
Morphine
Fentanyl
Dilaudid
Demerol
Norco
Vicodin
Opana
Codeine
Methadone
Hydrocodone
Oxycodone
Oxycontin
Lortab
Percocet
Suboxone
Overdose is rarely immediate – can happen over 1-3 hours
Heavy/ Uncontrollable Nodding
Still arousable
Snoring or loud breathing
May have excess drooling
Overdose
Not responsive, lack of response to sternal rub, painful stimuli
Very shallow breathing, gurgling
Skin changes, blue lips and nails
Fatal Overdose ⇒Death
Call 911
Rescue Breathing
Narcan Administration
Recovery Position
Nose is easy access
point for medication
and delivery
Painless
Eliminates risk of a
contaminated needle
stick
2/26/2018
PEEL
PLACE
2/26/2018
PRESS
2/26/2018
Lie individual on back, making sure neck is
extended, chin is lifted and air way is clear.
Administer 2 rescue breaths
Administer vial of Narcan in one nostril
Observe individual for 2 min, continuing rescue
breathing, if no response administer second vial
of Narcan in other nostril.
If there is a response after administration of
first vial, turn individual on their side and prop
in the recovery position until additional help
arrives
Nausea, Vomiting, Diarrhea
Hypertension, Tachycardia
Unmasking of other ingestions
Lowers seizure thresholds
All side effects pale in comparison
to the danger of not breathing!
Yes, but you should have some
suspicion of opiate overdose
Situational
Pinpoint pupils, hypoventilation
No, both may cause respiratory
depression, and both can be
reversed using naloxone (Narcan)
Naloxone only affects
patients with opiates in
their system
“do no harm” drug
New York State
911 Good Samaritan Law
1. A person who, in good faith, seeks health care for someone
who is experiencing a drug or alcohol overdose or other life
threatening medical emergency shall not be charged or
prosecuted for a controlled substance offense under article
two hundred twenty or a marihuana offense under article two
hundred twenty-one of this title, other than an offense
involving sale for consideration or other benefit or gain, or
charged or prosecuted for possession of alcohol by a person
under age twenty-one years under section sixty-five-c of the
alcoholic beverage control law, or for possession of drug
paraphernalia under article thirty-nine of the general business
law, with respect to any controlled substance, marihuana,
alcohol or paraphernalia that was obtained as a result of such
seeking or receiving of health care.
2. A person who is experiencing a drug or alcohol overdose or
other life threatening medical emergency and, in good faith,
seeks health care for himself or herself or is the subject of
such a good faith request for health care, shall not be
charged or prosecuted for a controlled substance offense
under this article or a marihuana offense under article two
hundred twenty-one of this title, other than an offense
involving sale for consideration or other benefit or gain, or
charged or prosecuted for possession of alcohol by a person
under age twenty-one years under section sixty-five-c of the
alcoholic beverage control law, or for possession of drug
paraphernalia under article thirty-nine of the general business
law, with respect to any substance, marihuana, alcohol or
paraphernalia that was obtained as a result of such seeking or
receiving of health care.
Offers protection from charge and
prosecution for possession of:
Drugs up to an A2 felony offense (possession of
up to 8oz of narcotics)
Alcohol (for underage drinkers)
Marijuana (any amount)
Paraphernalia offenses
Sharing of drugs (in NYS sharing constitutes a
“sales” offense)2
Does NOT offer protection for:
People in possession of A1 felony amounts of narcotics (not marijuana), meaning 8oz or more of narcotics;
Arrest or charge for drug or alcohol possession for individuals with an open warrant for their arrest or are currently on probation/parole.2
2/26/2018
• Naloxone needs to be kept at room
temperature.
• Do not keep in your car
• Do not allow medication to freeze
• If medication becomes corrupted, please turn
in for a replacement
2/26/2018
Complete reporting from to the best of your ability
Important fields to complete:
Time of response
Time of EMS arrival
Age
Gender
How much naloxone was used
Outcome if you know
Return form to contact on last slide to receive new
kit
2/26/2018
*This is why we do this….
Mark C. Poloncarz
County Executive
Dr. Gale Burstein
Commissioner of Health
www.erie.gov/health
Cheryll [email protected]
716-858-7695
John [email protected]
716-858-8142
Frank [email protected]
716-858-6137
