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, 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

5% decrease 35% increase Opioid related deaths Increased 2.9% In 2011~25% of drug-poisoning were unspecified 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 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, 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 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): doi: / Mortality rate, by week since release, for overdose and all other (nonoverdose) causes of death. Figure Legend: Copyright © American College of Physicians. All rights reserved.American College of Physicians

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): doi: / Copyright © American College of Physicians. All rights reserved.American College of Physicians

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;

Reverses clinical and toxic effects of opioid overdose Reverses respiratory depression, hypotension, sedation Restores breathing Reverses analgesia Patients can experience withdrawal after naloxone administration Naloxone

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.

27 Essential Knowledge What does naloxone do? Overdose recognition Action – Call EMS – Administer naloxone Hands on practice with device if possible Recovery position ? Report?

28 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

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 2 nd naloxone injection Lasts for 30 – 90 minutes – recipient must be observed, preferably by medical staff for at least 2 hours

31 Results: awake and breathing Narcan wears off in 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

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 3 rd 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 Clausen T. et al. Drug and Alcohol Dependence, 2008, Mortality prior to, during and after opioid maintenance treatment (OMT) % pr year Pre-treatmentIn treatmentPost treatment Overdose Non-overdose ,789 subjects followed for up to 7 years

Syringe Access: Syringe Exchanges Pharmacies Medical providers

Figure 1: Proportion of HIV and AIDS Cases* by Risk and Year of Diagnosis, NYS, ** AIDSNewly Diagnosed HIV

Newly reported cases of hepatitis C Kim A Y et al. J Infect Dis Of those with reported risk: IDU 74% Of those heroin was the most common drug. Massachusetts 2002 n = 6368) 2011n = 5194).

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 , 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,

Figure 1 Number of methadone maintenance treatment program admissions over time by route of administration (inhalation versus injection) Des Jarlais et al Addiction 2010 Does syringe access increase injection?

Acknowledgements New York State Department of Health New York City Department of Health Opioid Safety Naloxone Network