1. Sharon Stancliff, MD Caroline Rath, PA-C Harm Reduction Coalition New York, NY USA

2. Overdoses are rarely instant There are often bystanders Naloxone is a safe and effective antidote Many overdoses are preventable with prompt recognition and treatment Sporer 2006

3. Overdose prevention: Makes drug user health a priority in diverse settings Endorses idea of drug users as capable and concerned with their community Expands benefits from harm reduction intervention to other medical populations

4. Prevention: understanding the role of: mixing drugs reduced tolerance using alone Overdose recognition Actions Call emergency services Rescue breathing- using dummy Naloxone administration

5. Syringe exchange/syringe access sites Homeless Shelters Hospitals Inpatient Public Clinics Drug Treatment Methadone/Buprenorphine Detoxification programs HIV programs Jails/ Prisons and with the formerly incarcerated

6. SEPs serve a high risk population SEPs have trusting relationships with drug users and have expertise in working with drug users including peer educators

7. Competition with existing programs for staff and resources Syringe exchange programs funding and staff is stretched and has a lot of turnover Peer educators can be excellent trainers Reinforcement of message often possible SEPs usually do not have medical personnel able to prescribe medications on staff Sharing paid medical staff, use of volunteer clinicians

8. 14 syringe distribution programs offering overdose prevention Over over 2,600 syringe exchange participants, trained at 14 syringe access sites Reports of overdose reversals using naloxone: over 260 SKOOP 5/08

9. New York City Department of Health is promoting naloxone training and distribution in: Detoxification units Methadone programs Buprenorphine programs

10. Rationale: Drug treatment Recently detoxified patients are at high risk of overdose Methadone & buprenorphine patients go in and out of treatment These patients are in contact with other drug users Use of other sedatives associated with death of opioid maintained patients Wines 2007, Sporer 2006

11. May be interpreted as condoning/expecting drug use Address it as a community issue- points of contact Staff may not see drug users as capable of such an intervention Staff often invested in abstinence model

12. 6 programs including detoxification units, methadone and buprenorphine programs have registered. All City Hospitals and several more are preparing to register 1 methadone program has distributed over 200 kits

13. Being homeless is associated with risk of OD In NYC, leading cause of death among homeless 2005-2006 was OD (23%) Associated factors may be: Social and economic stress Lack of safe, familiar place to inject Using alone and rushing injection Less access to opioid maintenance treatment Driscoll 2001,NYCDOHMH

14. Creation of policies and procedures for large agency with wide diversity in settings Medical providers not present in all facilities to dispense naloxone Needles are not allowed in all shelters Fear of repercussions/ stigma around disclosing drug use

15. NYC plan for homeless shelters: One staff member on every shift trained in overdose response. Initial training of medical staff completed Training of staff as overdose responders imminent Medical providers will offer training and intranasal naloxone to all interested clients in city funded shelters 1 shelter implemented training of staff immediately after legislation passed

16. 42% of cumulative AIDS cases in NYS have injection drug use or sex with an IDU as a risk factor People with advanced disease are at higher risk of overdose death In impoverished areas of NYC, OD is leading cause of non-HIV death in persons with AIDS. NYSDOH, Wang 2005, Sackoff 2006

17. Clients may be reluctant to disclose drug use May be a bridge to further discussion of drug use Serving DU needs may still be controversial Staff lack of experience and knowledge about harm reduction and drug use issues Lack of medical personnel on staff for naloxone

18. 6 programs in NYS have registered 4 have initiated services

19. Post incarceration is major risk factor for death from OD (10) Study of deaths in first 2 weeks post incarceration among 30,237 released inmates 129 times greater likelihood of dying of OD vs. other WA state residents Bingswaner 2007

20. Gaining entrée to system Inability to give naloxone, must arrange for follow up after release Institutional discomfort with the harm reduction model Persons on parole are forbidden to access harm reduction services

21. NYC Department of Health: Plan to include OD prevention education with all intakes for opioid maintenance or detoxification at the city jail Some OD training done of NYCDOH counselors working jail settings Outreach : Harm Reduction Coalition working with 3 service organizations working with the formerly incarcerated

22. Hospitals see patients admitted with drug related illnesses Overdose prevention training not only addresses overdose risk but can build patient-provider relationship Program is new with low volume but very acceptable to medical residents

23. Implementation of overdose prevention programs appears to be more acceptable to many agencies than provision of syringes Core elements of the training can be adapted to many settings Discussion of overdose prevention can contribute to patient/provider relationship & lead to discussions of drug treatment

24. Injection Drug Users Health Alliance New York City Department of Health and Mental Hygiene New York State Department of Health