Opioid Safety Phillip Coffin, MD, MIA Director of Substance Use Research San Francisco Dept. of Public Health Assistant Clinical Professor University of California San Francisco

Heroin vs. Opiate Analgesic Deaths: Heroin InvolvedRx Opioid Only p-value N=22N=215 Age Mean42 (36-49)49 (47-51)0.030 Sex Male77.3%67.9%0.367 Race Hispanic18.2%3.3%0.012 Opioids Present at Death Methadone22.7%46.5%0.032 Morphine0.0%27.4%0.005 Oxycodone0.0%27.4%0.005 Other substances present at death Cocaine54.5%34.4%0.061 Antidepressant0.0%23.3%0.009 Benzodiazepines18.2%32.1%0.133 Amphetamines22.7%12.6%0.184 Location of Death Public Space36.4%6.0%0.000 Private Residence (All)54.5%80.5%0.005 San Francisco Resident68.2%85.1%0.041

Heroin-related Deaths, San Francisco, *Heroin death data (left axis) compiled from San Francisco Medical Examiner Reports, fitted to tailing fiscal year, no data for ; Naloxone data (right axis) from DOPE Project enrollments and refillswww.sfgsa.org

Opioid Safety Model in Clinical Care Reducing morbidity/ mortality Modify prescribing practice Reduce diversion Manage substance use Non-medication pain management

Prescribing restrictions initiated Naloxone distribution initiated

California Law: AB635 Allows naloxone prescription/distribution throughout state. Protects licensed health care professionals from civil & criminal liability when they prescribe, dispense, or oversee distribution via a standing order of naloxone via an overdose prevention program or standard medical practice. Permits individuals to possess and administer naloxone in an emergency and protects these individuals from civil or criminal prosecution for practicing medicine without a license. Clarifies that licensed prescribers are encouraged to prescribe naloxone to individual patients on chronic opioid pain medications to address prescription drug overdose.

Naloxone provided in SF County VenueStart-date# Prescriptions Reported reversals DOPE (syringe exchange, jail, other sites) 2003>4,500>1,100 Primary care3/2013-3/2014 (staged) >400(not collected) Mental Health12/201224(not collected) Opioid agonist treatment12/ SRO units(May 2014)-- SFGH inpatients at discharge (May 2014)--

Naloxone Pilot in SF County Jail VariableMen’s Re- entry Pod Women’s Pod # trainings done113 # trained9156 % accepted naloxone kit6759 % used opioids <30d before incarceration 4344 % Prior overdose2645 % Seen overdose7956 % Used naloxone before166

Patient Interviews Feelings about opioid use after getting naloxone “It made me think that I was playing with my life” “I’ve probably been a little more cautious. Just being careful to take the right amount, count the hours, you know, think more cautiously about dosing” How it feels to be offered naloxone by primary care provider “It just reassures me that if I do have a breathing problem, that drug is there to solve the problem” “It’s a great idea … There have been at least 1 or 2 times where I’ve been the one to go ‘oh wait, I just took a pill 20 minutes ago and I just took another – oops!’ it does happen, even to young people who aren’t fuzzy …” “I’m kind of a suspenders and belt person when it comes to safety and backups and life preservers or whatever”