Transcript Get the SKOOP: Skills and Knowledge on Overdose Prevention

Opioid Overdose Prevention
-Role of Naloxone in the Community
Sharon Stancliff, MD
Harm Reduction Coalition
January 2015
Objectives
Participants 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.
Number of drug poisoning deaths involving opioid analgesics by opioid analgesic
category, heroin and cocaine: United States, 1999--2010
12,000
Natural and semisynthetic opioid
analgesic
Number of deaths
10,000
Methadone
8,000
6,000
Cocaine
4,000
Heroin
2,000
Synthetic opioid
analgesic, excluding
methadone
0
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 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
Opioid related deaths 2011-2012
Increased 2.9%
5% decrease
35% increase
In 2011~25% of drug-poisoning
were unspecified drugs
Role of Heroin as Cause of Death Among All Drug-Related
Deaths
100%
90%
80%
70%
60%
65.1
78.6
86.2
50%
40%
30%
20%
10%
34.9
21.4
13.8
0%
2010
2011
Heroin
Non-Heroin
2012
Role of Opioid Analgesics as Cause of Death Among All DrugRelated Deaths
100%
90%
80%
45.9
50
52.4
54.1
50
47.6
2010
2011
2012
70%
60%
50%
40%
30%
20%
10%
0%
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 overdose
• 1/2 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
8.0
Heroin
Cocaine
Age Adjusted Rate per 100,000
7.0
6.0
Methadone
Benzodiazepines
Opioid Analgesics
5.0
4.0
3.0
2.0
1.0
0.0
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 1999-2009
Overdose was the leading cause of death;
opioids were involved in 14.8% of deaths
Binswanger 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
Figure Legend:
Mortality rate, by week since release, for overdose and all other (nonoverdose) causes of death.
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
Naloxone
• Reverses clinical and toxic effects of opioid
overdose
• Reverses respiratory depression, hypotension,
sedation
• Restores breathing
• Reverses analgesia
• Patients can experience withdrawal after
naloxone administration
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 Opioid
Overdose 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.
Essential Knowledge
• What does naloxone do?
• Overdose recognition
• Action
– Call EMS
– Administer naloxone
• Hands on practice with device if possible
• Recovery position
? Report?
27
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
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Action
• Activate emergency medical services (911)
“my friend is overdosing and not breathing”
And
• Administer naloxone
Which 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
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
31
Implementation in NY State
Over 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 add
Other 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 4/14
As 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
Baltimore
Adjusting for heroin purity and
the number of methadone
patients, there was a statistically
significant inverse relationship
between heroin overdose deaths
and patients treated with
buprenorphine (P = .002).
Schwartz et al AJPH 2013
Mortality before, during and after
OMT in Norway
% pr year
3,789 subjects followed for up to 7 years
1998-2003
4
3.5
3
Overdose
2.5
Non-overdose
2
1.5
1
0.5
0
Pre-treatment
In treatment
Post treatment
Clausen T. et al. Drug and Alcohol Dependence, 2008,
Mortality prior to, during and after opioid maintenance treatment (OMT)
Syringe Access:
Syringe Exchanges
Pharmacies
Medical providers
Trends in HIV and AIDS Cases*
New York State, 1984 - 2012
16,000
12,000
Number
diagnosed each
year with AIDS
People living with
HIV (non-AIDS) at
the end of each year
120,000
100,000
10,000
80,000
8,000
6,000
4,000
Number of
deaths each
year among
AIDS cases
People living with
AIDS at the end of
each year
2,000
60,000
Number of PLWDHI
Number of AIDS Diagnoses and Deaths
14,000
140,000
40,000
Number of deaths
among HIV & AIDS
cases each year
20,000
0
0
1984 1986 1988 1990 1992 1994 1996 1998 2000^ 2002 2004 2006 2008 2010 2012
*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
Figure 1: Proportion of HIV and AIDS Cases* by Risk and Year of Diagnosis,
NYS, 1985-2012**
AIDS
60
Newly Diagnosed
HIV
50
Percent of Cases***
IDU
40
MSM
30
20
10
MSM/IDU
0
1985 1987 1989 1991 1993 1995 1997 1999 2001 2003 2005 2007 2009 2011
*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.
Newly reported cases of hepatitis C
Massachusetts
2002 n = 6368)
2011n = 5194).
Of those with reported
risk: IDU 74%
Of those heroin was the
most common drug.
Kim A Y et al. J Infect Dis. 2013
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 services
Other services include:
• Counseling
• Drug treatment referral
• Drug treatment
• Overdose prevention
• Hepatitis services
• Acupuncture
• Food
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
Does syringe access increase injection?
Figure 1 Number of methadone maintenance treatment program admissions
over time by route of administration (inhalation versus injection)
Des Jarlais et al Addiction 2010
Acknowledgements
• New York State Department of Health
• New York City Department of Health
• Opioid Safety Naloxone Network