1. Presented by: Praxis Opiate Overdose Prevention

2. Understanding Opioids Opioid Overdose: Physiology and Risk Factors Opioid Overdose: Signs and Symptoms Responding to an Overdose Overdose Intervention and Prevention Strategies Agenda

3. Heroin Cocaine 38,329 drug overdose deaths in 2010 National Vital Statistics System, http://wonder.cdc.gov Year Unintentional Drug Overdose Deaths United States, 1970–2007

4. Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over) SOURCE: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Treatment Episode Data SET (TEDS). Data received through 11.03.10 < 8 8 – 14 15 – 18 19 – 44 45 or more Incomplete data 1999 ( range 1 – 50 )

5. SOURCE: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Treatment Episode Data SET (TEDS). Data received through 11.03.10 < 8 8 – 14 15 – 18 19 – 44 45 or more Incomplete data 2001 ( range 1 – 71 ) Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)

6. SOURCE: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Treatment Episode Data SET (TEDS). Data received through 11.03.10 < 8 8 – 14 15 – 18 19 – 44 45 or more Incomplete data 2003 ( range 2 – 139 ) Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)

7. SOURCE: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Treatment Episode Data SET (TEDS). Data received through 11.03.10 < 8 8 – 14 15 – 18 19 – 44 45 or more Incomplete data 2005 ( range 0 – 214 ) Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)

8. SOURCE: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Treatment Episode Data SET (TEDS). Data received through 11.03.10 < 8 8 – 14 15 – 18 19 – 44 45 or more Incomplete data 2007 ( range 1 – 340 ) Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)

9. SOURCE: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Treatment Episode Data SET (TEDS). Data received through 11.03.10 < 8 8 – 14 15 – 18 19 – 44 45 or more Incomplete data 2009 ( range 1 – 379 ) Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over)

10. 1999 Opioid Analgesic OD Death Rates Drug Poisoning AADR ( per 100,000) 0 - 2 3 - 5 6 - 8 12 - 14 9 - 11 15+ 1999 Opioid Analgesic Overdose Death Rates

11. 0 - 2 3 - 5 6 - 8 12 - 14 9 - 11 15+ Drug Poisoning AADR ( per 100,000) 2001 Opioid Analgesic OD Death Rates

12. 2003 Opioid Analgesic OD Death Rates 0 - 2 3 - 5 6 - 8 12 - 14 9 - 11 15+ Drug Poisoning AADR ( per 100,000) 2003 Opioid Analgesic Overdose Death Rates

13. 2005 Opioid Analgesic OD Death Rates 0 - 2 3 - 5 6 - 8 12 - 14 9 - 11 15+ Drug Poisoning AADR ( per 100,000) 2005 Opioid Analgesic Overdose Death Rates

14. 2007 Opioid Analgesic OD Death Rates 0 - 2 3 - 5 6 - 8 12 - 14 9 - 11 15+ Drug Poisoning AADR ( per 100,000) 2007 Opioid Analgesic Overdose Death Rates

15. 2009 Opioid Analgesic OD Death Rates 0 - 2 3 - 5 6 - 8 12 - 14 9 - 11 15+ Drug Poisoning AADR ( per 100,000) 2009 Opioid Analgesic Overdose Death Rates

16. 2001 to 2014 U.S. Prescription Opioid Analgesic Overdose Death Rates

17. The Problem SOURCES: National Vital Statistics System, 1999-2008; Automation of Reports and Consolidated Orders System (ARCOS) of the Drug Enforcement Administration (DEA), 1999-2010; Treatment Episode Data Set, 1999-2009 Rates of prescription painkiller (opioid pain reliever, or OPR) sales, deaths and drug and alcohol treatment admissions (1999-2010) Close Relationship

18. Significant Changes in the Landscape

19. National Overdose Death Rates from Heroin Use

20. Prescription Writing in the Bay State

21. Mass Opiate Overdose Death Rates 2000 to 2014

24. Mass Opiate Overdose Death Rates 2000 to 2014

25. Mass Opiate Overdose Death Rates by Gender 2015

26. What Do We Know? 3 out of 4 prescription drug overdoses are caused by painkillers. 300% increase in prescription painkiller sales since 1999. Prescription painkillers involved with more overdose deaths in 2008 than heroin and cocaine combined. PainKILLERS

27. Mass Opiate Overdose Death Rates 2000 to 2014

28. Opioids Opiates: Semi-Synthetic Synthetic Opium Morphine Codeine Heroin Hydrocodone Hydromorphone Oxycodone Oxymorphone Buprenorphine Fentanyl Methadone Tramadol

29. DrugDurationPotency Methadone24-32 hours**** Heroin6-8 hours***** Oxycontin3-6 hours***** Codeine3-4 hours* Demerol2-4 hours** Morphine3-6 hours*** *Fentanyl2-4 hours*****(*****) Chart from OOD Prevention & Reversal Trainers Manual-BPHC Opioids Differ *Fentanol has become a designer drug and potency can vary depending on the chemist who created the formula

30. How Do Opioids Get to My Community? Coastal state Direct pipeline through I-95 Borders other states with opioid problems Drug trafficking Improperly disposed prescription medication

31. Heroin Use Injected, snorted, or smoked May inject up to 4x/day Intravenous injection – greatest intensity rapid onset (7 to 8 seconds) Intramuscular (5 – 8 minutes) Sniffed or smoked (5 – 15 minutes)

32. What is an overdose? When a person’s body has more drugs than it can handle and someone slowly stops breathing (opioids) Opioid overdose deaths are from lack of oxygen. which results from taking too much drug (opioid) or dangerous combination of drugs (opioids plus) When a person’s body has more drugs than it can handle and someone slowly stops breathing (opioids) Opioid overdose deaths are from lack of oxygen. which results from taking too much drug (opioid) or dangerous combination of drugs (opioids plus)

33. From MA BSAS OOD Prevention & Reversal Trainers Manual - BPHC Opioid Receptors

34. Opioid Receptors in the Brain

35. Why Overdoses Happen Overdose happens when a person takes too much of a drug OR a combination of drugs They often happen in the context of relapse Many drug users don’t know the risks of mixing drugs and alcohol Some combinations can be deadly Anyone who uses drugs can overdose Many overdose deaths happen because people who witness ODs don’t know how to respond Overdose happens when a person takes too much of a drug OR a combination of drugs They often happen in the context of relapse Many drug users don’t know the risks of mixing drugs and alcohol Some combinations can be deadly Anyone who uses drugs can overdose Many overdose deaths happen because people who witness ODs don’t know how to respond

36. When Overdoses Happen 1-3 hours after use, instantaneous is rare Relapse After periods of abstinence (after treatment stay, hospitalization, incarceration) New city/residential location New dealer Post incarceration New route of administration

37. Overdoses Are Often Witnessed Research shows that: About 60% of OD deaths occur in the presence of others Sudden death immediately after injecting is rare (15% of cases) Some research shows that in 79% of the cases there is no intervention by bystanders before death. Because overdoses are usually witnessed and are rarely instantaneous, there is often an opportunity to intervene.

38. Who Overdoses? Experienced users, usually not “new users” People who have overdosed in the past and survived Overdoses may be intentional

39. Top Overdose Risk Factors: Using drugs alone Not knowing or misjudging body tolerance (relapse after period of abstinence) Mixing drugs and alcohol Physical health Variation of substance Using an opioid with other depressants such as alcohol or benzodiazepines increases the risk Cocaine is a stimulant but can have significant OD risk A history of recent drinking is a risk factor

40. What are benzodiazepines? Class of prescription drugs that depress central nervous system and commonly used to treat anxiety and insomnia Used in alcohol detox 30 different types - tablets or capsules Known by different generic and brand names of benzodiazepines Principal risk is from withdrawal, leading to seizure

41. Distinguishing Intoxication from Overdose Blue skin tinge- usually lips and fingertips show first/ Graying of skin and lips on brown or black skinned people with very white nail beds Body very limp Face very pale Pulse (heartbeat) is slow, erratic, or not there at all Throwing up Passing out Choking sounds or a gurgling/snoring noise Breathing is very slow, irregular or has stopped Eyes open, but unable to respond Signs of an Opioid Overdose

42. 2 Ways to Identify an Overdose Call name loudly 1 Sternal rub: rub knuckles hard up and down breast bone 2 2 Ways to Identify an Overdose

43. The most important considerations: Responsiveness to stimulation Breathing-shallow and slow or not breathing at all The most important considerations: Responsiveness to stimulation Breathing-shallow and slow or not breathing at all

44. Responding to OD: Actions Call 911 Rescue breathing Recovery position Administer Naloxone Stay with the person

45. Call 911 Give location Say, “My friend is unconscious or not breathing.” No need to say heroin or overdose. Emergency response may differ by community Stay with the person Call 911 Give location Say, “My friend is unconscious or not breathing.” No need to say heroin or overdose. Emergency response may differ by community Stay with the person

46. 911 Good Samaritan Law Passed in August 2012 Good Samaritan provision: Protects people who overdose or seek help for someone overdosing from being charged or prosecuted for possession of a controlled substance –Protection does not extend to trafficking or distribution charges A person acting in good faith may receive a naloxone prescription, possess naloxone and administer naloxone to an individual appearing to experience an opiate-related overdose. Prescriber protection: The result of this protection is that many communities have standing orders, written by physicians at their pharmacies, empowering citizens to obtain naloxone at pharmacies using their personal insurance coverage. 911 Good Samaritan Law Passed in August 2012

47. Rescue Breathing Make sure there is nothing in the mouth Tilt head back, lift chin, pinch nose Give a breath every 5 seconds. Illustration from the Harm Reduction Coalition Rescue Breathing

48. Recovery Position If you must leave the person who is overdosing, put them into the recovery position so they won’t choke on their own vomit. Illustration from the Harm Reduction Coalition Recovery Position

50. Massachusetts Experience Nasal Naloxone Pilot Program is in effect statewide pilot programs (approved trainers) in effect to instruct people to become naloxone (Narcan) responders. A Naloxone responder is a non- medical person who can administer naloxone (Narcan) to someone else in order to treat a potentially fatal overdose. Massachusetts Experience

51. Overdose Reversal Naloxone (Narcan) will reverse the effects of opioids, reversing an overdose. Simple nasal spray No effect other than blocking the opioids No adverse reactions No potential for abuse No potential for overdose Naloxone (Narcan) will reverse the effects of opioids, reversing an overdose. Simple nasal spray No effect other than blocking the opioids No adverse reactions No potential for abuse No potential for overdose

52. What is Naloxone ? A prescription medicine that reverses an opioid overdose (may cause withdrawal) Injectable and intranasal applications Wakes a person who is overdosing in 3-5 minutes and lasts 30-90 minutes Does not have psychoactive effects – does not make a person “high” Cannot cause harm, even if the person is not overdosing Used routinely by EMS & ERs A prescription medicine that reverses an opioid overdose (may cause withdrawal) Injectable and intranasal applications Wakes a person who is overdosing in 3-5 minutes and lasts 30-90 minutes Does not have psychoactive effects – does not make a person “high” Cannot cause harm, even if the person is not overdosing Used routinely by EMS & ERs

53. Opiates: Narcan Opioid Opioid Receptor Naloxone has a stronger affinity to the opioid receptors than the heroin, so it knocks the heroin off the receptors for a short time and lets the person breathe again.

54. Naloxone Facts Benefits: awake and breathing Naloxone effects can last from 30-90 minutes After 90 minutes, effects of opioid may return if there is enough drug still in the system (bloodstream) Reassure person experiencing the OD that any withdrawal feelings will lessen Advise against using more opioid since Naloxone will cancel the effect. Also adding more heroin would be dangerous Harm: possibility of withdrawal symptoms and re- overdose Benefits: awake and breathing Naloxone effects can last from 30-90 minutes After 90 minutes, effects of opioid may return if there is enough drug still in the system (bloodstream) Reassure person experiencing the OD that any withdrawal feelings will lessen Advise against using more opioid since Naloxone will cancel the effect. Also adding more heroin would be dangerous Harm: possibility of withdrawal symptoms and re- overdose

55. Timing Is Everything: The Duration Of Naloxone & The Opioid DrugDuration Naloxone wears off in… Methadone24-32 hours30-90 mins Heroin6-8 hours30-90 mins Oxycontin3-6 hours30-90 mins Codeine3-4 hours30-90 mins Demerol2-4 hours30-90 mins Morphine3-6 hours30-90 mins Fentanyl2-4 hours30-90 mins Chart from OOD Prevention & Reversal Trainers Manual - BPHC Timing Is Everything: The Duration Of Naloxone & The Opioid

56. Myths: What NOT to do DON’T leave the person alone DON’T leave the person without calling 911 DON’T lock the door behind you DON’T put the person in a cold water bath or shower – they could drown! DON’T inject them with salt water, milk, or other drugs (like cocaine or speed) DON’T put ice on their genitals Ice won’t help. Neither will tea, coffee, or alcohol. DON’T make them vomit – they could choke! Myths: What NOT to do

57. Overdose Harm Reduction Understand risk factors Try not to use alone Make an overdose plan/partner contract Know tolerance Know supply Become a Naloxone responder Be aware of mixing drugs Give tips to clients Know how to recognize an overdose, call 911, rescue breathing, recovery position, Naloxone and wait with the person

58. Creating The Conversation: Risk Screening Talking to clients about their pattern of substance use and effects of mixing drugs (mixing, using alone or not) Talking to clients about their stay in treatment or recovery or jail and its impact on tolerance… Talking to clients about their experiences of witnessing overdoses… Talking to clients about their past history of surviving non-fatal overdose…

59. MA Statewide Overdose Prevention Information 1-800-383-2437 Massachusetts Substance Abuse Information and Education Helpline 800-327-5050 MA Clearinghouse- FREE EDUCATIONAL MATERIALS ON OVERDOSE www.maclearinghouse.org or call 1-800-952-6637 www.maclearinghouse.org Chicago Recovery Alliance www.anypositivechange.org www.anypositivechange.org Harm Reduction Coalition www.harmreduction.org www.harmreduction.org Learn to Cope (for families) www.learn2cope.org www.learn2cope.org On-line CASAC training & CEU [NYS] www.oasas.state.ny.us www.oasas.state.ny.us Physicians for Responsible Opioid Prescribing http://supportprop.org/index.html MA Statewide Overdose Prevention Information 1-800-383-2437 Massachusetts Substance Abuse Information and Education Helpline 800-327-5050 MA Clearinghouse- FREE EDUCATIONAL MATERIALS ON OVERDOSE www.maclearinghouse.org or call 1-800-952-6637 www.maclearinghouse.org Chicago Recovery Alliance www.anypositivechange.org www.anypositivechange.org Harm Reduction Coalition www.harmreduction.org www.harmreduction.org Learn to Cope (for families) www.learn2cope.org www.learn2cope.org On-line CASAC training & CEU [NYS] www.oasas.state.ny.us www.oasas.state.ny.us Physicians for Responsible Opioid Prescribing http://supportprop.org/index.html Resources

60. Center for Social Innovation Praxis@center4si.com Thank you