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Sarz Maxwell MD FASAM sarzmaxmd @yahoo.com. www. AnyPositiveChange.org “… he was nodding and then I looked over and he was … well, there’s a smell, you know? I knew he was dead. And I didn’t know what to do, I just parked the car and got on the bus. He was dead. What could I do?” 500 450 400 350 300 250 200 150 100 50 0 1996 1997 1998 1999 2000 1996 1997 1998 1999 2000 The diagnosis and management of anaphylaxis. SOURCE(S): J Allergy Clin Immunol 1998 Jun;101(6 Pt 2):S465-S528 [337 references] MAJOR RECOMMENDATIONS: Patient education may be the most important preventive strategy. Patients should be carefully instructed about hidden allergens, crossreactions to various allergens, unforeseen risks during medical procedures and when and how to use self-administered epinephrine. Standards of medical care for patients with diabetes mellitus. SOURCE(S): Diabetes Care 2001 Jan;24(Suppl 1):S33-S43 [32 references] MAJOR RECOMMENDATIONS:Family members and close associates of the patient who uses insulin should be taught to use glucagon. Pure opiate antagonist >40 years experience by emergency personnel for OD reversal Only effect is blockade of opiate receptor Not addictive; no potential for abuse No side effects except precipitation of withdrawal Dose- and delivery-sensitive Options Advantages Disadvantages Single-dose Pre-measured pre-loaded No add’l syringe equipment Cost (~$15 USD /dose) Fragile apparatus Single dose Intranasal atomizer No needles Premeasured Cost (~10 USD /dose) Slightly less efficacy Single dose Multi-dose multi-use 10cc vial Cost (~$0.27 /dose) Need add’l needles Multiple doses ?contamination? Very portable / durable Average heroin user has witnessed 4 OD’s, at least 1 of them fatal Deaths of peers & personal experience with OD do not ‘teach’ actively-using heroin addicts to stop using heroin Heroin addicts are interested in helping other addicts in trouble Participants definitely motivated to intervene in OD situations Participant focus groups informed program development Low threshold Multi-dose vial formulation 89% approve the idea 92% express willingness to attend training session Concerns: Police harrassment & legality of naloxone possession Fear of dopesickness Dose- and delivery-sensitive Wright et al 2006 UK Kerr et all 2008 Australia “I was just freakin’ out, thinking: ‘I wish I knew how to do CPR’… and I was like, ‘Oh, why don’t I know this?’” Death of CRA co-founder in 1997 Begin distributing naloxone in 1997 2000 actively expanding program Train all CRA operatives to educate and distribute US law allows a prescription to be written when a doctor-patient relationship exists Chart Documentation of education RE prescription Medical director trained CRA operatives to educate & distribute Intake form developed with brief history, checklist for education, and standing order OEND occurred at all 22 weekly SEP sites plus cell phone on-call Participants quickly became distributors OD Prevention Early Recognition › Unresponsive › Before cyanosis Rescue Breathing Naloxone administration › 1 cc (0.4 mg) IM › > 1” needle › Multi-use vial Aftercare › Do not use more opiate! High will return in 30-40 min › › Return of OD Transport for medical f/u Age > 34 Using in combination with other drugs Alcohol Cocaine PONS Respiratory Centre Opiates depress respiratory drive MEDULLA Cardiac Centre Cocaine stimulates heartbeat, blood pressure Mixing drugs Using alone Recent period of abstinence – as brief as 3 days will decrease tolerance Detox program Incarceration “He got out of the joint… came back, thought he had the same tolerance… but he didn’t… … I put myself in detox and I got out, shot up a bag … and he was with me, thank god, because I went out.” Drug Duration potency Methadone 24 hr ++++ Heroin 6 – 8 hr +++++ Oxycodone 3 – 6 hr +++++ Codeine 3 – 4 hr + Demerol 2 – 4 hr ++ Morphine 3 – 6 hr +++ Fentanyl 2 - 4 hr ++++++++ ++++++++ ++++++++ 500 450 400 350 300 250 200 150 100 50 0 1996 2000 2004 2007 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 NALOXONE Empowerment + New Message: “it matters if you live or die” community, altruism Hope Future-orientation “I did something that made a difference. The whole world can’t see it but I know it made a difference. And that’s important… to me.” Statewide program supported by state DPH Operating in 13 communities SEPs, drop-in centers, treatment programs ( detox, OTP, residential tx, inpt), ER, home visits, street outreach >9000 enrolled, ~1000 reversals (11%) Top 3 most common sites for OTP patient naloxone refills: Needle Exchange Program (40%) Drop-in Center (30%) Methadone Clinic (9%) Slide courtesy Maya Doe-Simkins 70 patients with opioid dependence syndrome in abstinence-based program trained & given naloxone 6 mos later, participants had retained knowledge, still had the naloxone, but none had used it Transportability Stigma Fear of police Harm Reduct J, 2009 Sep 24; 6:26 Low threshold – on demand, easily accessible, minimal paperwork Education – duration; by whom Venue – user-friendly Formulation – simple, durable Doses and Refills – multiple doses OD relapse Multiple simultanerous victims Abundance >> Confidence “It used to be, overdose, you always talked about it in past tense: ‘I HAD a friend who OD’d.’ Now, overdose is in the present tense: ‘I HAVE a friend who OD’d last week’. Naloxone did that.” Dan Bigg Karen Stanczykiewiz Greg Scott Suzanne Carlberg – Racich John Gutenson Susie Gualtieri Sharon Sereda Esther, Cheryl, Cliff, Andrew … All of our courageous participants, who make this program work the end(s) www. AnyPositiveChange .org sarzmaxmd @ yahoo.com