ACOPC Summer Conference 2016 “Anatomy of Recovery: Peaks and Valleys” July 28, 2016 We have a large number of participants today so please be courteous and fill in seats from the middle and from the front first.

A Harm Reduction Perspective: Preventing Overdose Death for People Actively Using Drugs Alice Bell, LCSW, Overdose Prevention Project Coordinator, Prevention Point Pittsburgh

Alice Bell, L.C.S.W. Overdose Prevention Project Prevention Point Pittsburgh

Rio Arriba County, New Mexico, population 40,000: Santa Fe Mountain Center gave out over 3,300 doses of naloxone with 752 reversals reported in FY16 !!!

“We had 234 reported (fentanyl overdose) reversals by drug users between June- August and only a couple of unfortunate deaths, about which we still have little information. There were two uses of naloxone by law enforcement in the same period and no noticeable uptick in EMS responses to overdoses. Essentially, this was handled expertly by the syringe exchanges and drug users and many, many possible deaths were averted.” -Eliza Wheeler, the DOPE Project, San Francisco

Allegheny County Trends in Accidental Drug Overdose Deaths * *Data from Allegheny County Medical Examiners Annual Reports. Includes all overdose deaths where these drugs were present at time of death, alone or in combination with other substances.

Safer Injection Facilities – reduce the spread of infectious diseases like HIV, AIDS and hepatitis C. Wherever there is street drug use, an SIF makes the area safer by diminishing open drug use and curtailing litter, such as used needles. Finally, they’ve been shown to reduce overdose deaths. There has not been a single overdose death in an SIF ever! Illicit drug overdose deaths in Vancouver's Downtown Eastside dropped by 35 per cent after the establishment of Insite, North America's first supervised injection facility, according a new study by researchers at the University of British Columbia and the British Columbia Centre for Excellence in HIV/AIDS.

Harm Reduction Services  Providing Sterile Injection Equipment for over 20 years!  Testing for HIV and Hepatitis C  Education on disease prevention, safer injection, how to avoid abscesses  Case Management, assistance to treatment  Crisis Intervention & Counseling  Overdose Prevention & Response Training  Naloxone Prescription for over 10 years!  Wound Consultation Clinic  All Services Free of Charge  Anonymous/Confidential  Low Threshold

Prevention Point Pittsburgh Naloxone CUMULATIVE DATA - July June 2016 Third Party Naloxone Law Implemented % of rescues were by individuals who use opioids themselves, In % of rescues were by individuals who use opioids themselves.

“the definition of addiction is continuing to do something despite negative consequences, so inherently negative consequences - i.e. punishment – is not going to be effective.” – Maia Szalavitz Neither jail nor treatment programs that employ harsh or punitive techniques, offer effective strategies to help people get control over dangerous, compulsive problematic patterns of drug use. Employing negative consequences is an illogical strategy for people who continue to use drugs despite negative consequences- the definition of addiction! If negative consequences worked, they would not be addicted in the first place.

Supply reduced by drug take-backs, prescription drug monitoring programs and changes in prescribing practices in recent years. In 2012, for first time, Prescription Opioid Overdose deaths down 5%; Heroin deaths up 35% In 2013, heroin deaths up 39% over heroin deaths increased by more than 300% Hepatitis C infections have increased 150% since 2010; primarily among adolescents/ young adults, white, living in non-urban areas. Rural states have seen Hep C increase of 364% – 188 injection-related HIV cases in rural, Scott County, Indiana Concern that we are likely to see this in other rural areas soon.

“Across the country that day, 182 people were arrested in a dozen cities in Operation Tar Pit. Agents seized relatively small quantities of drugs and cash: sixty pounds of heroin and two hundred thousand dollars. Yet Tar Pit remains the largest case-geographically and in terms of manpower used – the DEA and FBI have ever mounted jointly.” Despite massive arrests of all levels of management in the Sante Fe area, one heroin user there reported: “After Tar Pit,” he remembered, “there was no dope on Sante Fe streets for exactly one day.”

Maintenance therapy prevents overdose French population in 1999 = 60,000, Year No. of deaths Patients receiving methadone (1998): N= 5,360 Patients receiving buprenorphine (1998): N= 55,000 Auriacombe et al., 2001 Since the institution of physician prescribed buprenorphine and methadone maintenance in 1996 in France, heroin overdose dropped by 79% Medication assisted treatment also has resulted in reduced HIV and hepaitis by reducing needle sharing

Given the black market for this medication, what we have here is a Dallas Buyers Club situation for substance use disorder. Expanding legal access is the best way to reduce diversion. Even diverted medication is better than no medication there were only 2 documented overdose deaths in Allegheny County where toxicology report on person who died indicated they had taken buprenorphine. Buprenorphine keeps people alive! Buprenorphine/ Suboxone

ANXIETY TREATMENT GOALS  Develop strategies to reduce symptoms, or reduce anxiety and improve coping skills  Increase understanding of anxious feelings. DRUG TREATMENT GOALS  Be free of drug/alcohol use/abuse  Client will abstain from using substances and will manage withdrawal symptoms without relapsing Peaks and Valleys

Antidote for opiate overdose. Routinely used by EMS. Very safe and effective. No psychoactive effects

 Deaths from Opioid Overdose are almost entirely preventable if oxygen is maintained through rescue breathing.  In addition, we have a highly effective, very safe antidote.  Paramedics use naloxone to immediately reverse the effects of opiate overdose.  Standardized 5–10 min education is sufficient.  Online Trainings available at PrescribetoPrevent.org

Remember the guy who bought 80-proof vodka that turned out to be 190-proof Everclear and died from alcohol poisoning? Probably not, because that sort of thing almost never happens in a legal drug market, where merchants or manufacturers who made such a substitution, whether deliberately or accidentally, would face potentially ruinous economic and legal consequences. In a black market, by contrast, customers frequently get something different from what they thought they were buying: something weaker, something stronger, or some other substance entirely. As The Washington Post notes in a story about fentanyl-laced heroin, the results can be fatal.notes

 NUMBER ONE priority: Put naloxone in the hands of those most likely to be on the scene and first to respond, individuals who use opioids, themselves. Naloxone should be in every first aid kit.  How best to reach this population? By making naloxone available, free of charge in these settings: ▪ Syringe Exchange Programs ▪ Jails ▪ Methadone, Suboxone and Other Treatment Programs ▪ Hospital Emergency Departments ▪ Free Clinics  Simultaneously make effective treatment available and accessible to all who want and need it.  Work on addressing systemic societal problems that result in people seeking relief from pain.

Alice Bell, L.C.S.W. Overdose Prevention Project Prevention Point Pittsburgh

Co-Sponsors Thank you!!! Co-Sponsors Pyramid Healthcare, Inc. Greenbriar Treatment Center White Deer Run Treatment Network Summit BHC of PA Community Care Behavioral Health Organization University of Pittsburgh Thank you!!!