1. To call 911 or not to call 911? Overdose help-seeking Alexander Y. Walley and Maya Doe-Simkins Co-authors: Ziming Xuan, Emily Quinn, Amy Sorensen- Alawad, Holly Hackman, Al Ozonoff Harm Reduction Conference 2012 – Portland, OR Friday, November 16, 2012

2. Disclosures The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: –None to disclose My presentation will include discussion of “off-label” use of the following: –Naloxone is FDA approved as an opioid antagonist –Naloxone delivered as an intranasal spray with a mucosal atomizer device has not been FDA approved and is off label use Funding: CDC National Center for Injury Prevention and Control 1R21CE001602-01

3. Help-seeking rates Range among OEND trainees –28%-74% Range among untrained bystanders –23%-68% Before & after OEND training –65% pre-OEND and 49% post-OEND Help not sought because victim regained consciousness or bystander felt OD could be managed without help –Tobin et al. Int J Drug Policy 2009: 20; 131-6

4. Known help-seeking factors Among untrained, more likely to seek help when –Victim does not respond Davidson et al. Addiction. 2002;97:1511-6 –Bystander’s last OD resulted in hospital visit Tracy et al. Drug Alcohol Depend. 2005;79:181-90 –Bystander witnessed fatal OD Tobin et al. Addiction 2005;100:397-404 –Female bystander Tobin et al. Addiction 2005;100:397-404 –OD is fatal Bohnert et al. Ann Emerg Med 2009;54:618-24.

5. Known help-seeking factors Among untrained, less likely to seek help when –Bystander is confident in skills Tracy et al. Drug Alcohol Depend. 2005;79:181-90 & Baca et al. J Addict Dis. 2007;26:63-8 –4 or more bystanders present Tobin et al. Addiction. 2005;100:397-404 –Fear of police/ arrest Darke et al. Addiction. 1996; 91:413-417 & Davidson et al. Addiction. 2002;97:1511-6 & Tracy et al. Drug Alcohol Depend. 2005;79:181-90

6. Outcomes for OD victims who are not transported to hospital following naloxone administration Refused transport AMA –0.0% of 998 died of rebound toxicity (Vilke et al. Acad Emer Med 2003; 10: 893-896) Discharge-on-scene policy –0.13% of 2241 died from rebound toxicity (Rudolph et al. Resuscitation 2011; 82: 1414- 1418)

7. Study Objective Identify factors associated with help seeking among opioid overdose bystanders who report a witnessed overdose to OEND programs in Massachusetts

8. Methods Population: Program data from the Massachusetts Department of Public Health Opioid Overdose Prevention Pilot Program implemented at community-based agencies from 2006 to 2010. Data Collection: Overdose rescue questionnaire completed by staff when program enrollee requested more naloxone Outcome: Help-seeking defined by affirmative response to either of the questions: –“Was 911 called?” –“Were police/EMTs/firefighters present?” Independent variables: –bystander age, gender, race/ethnicity, drug using status, setting (public vs. private), time for naloxone to work, number of substances used by victim Analyses: Multivariable logistic regression model

9. Results 2006-2010 –8667 participants 483 participants reported 762 overdose rescues

10. Bystanders who used naloxone during and overdose rescue N=483 Age, median (IQR)33 (26-45) Female and MtF40% White81% Hispanic10% Black/ African American6% No substance use11% Primarily heroin user54% Primarily Rx opioid user14% Non-opioid user22% Previously trained84%

11. Bystanders who used naloxone during and overdose rescue N=483 Witnessed overdose, lifetime87% Previous overdose, lifetime64% Any homelessness, past year22% Incarceration, past year28% Emergency department visit, past year60% Detoxification program, past year56% Reported >1 reversal31%

12. Overdose rescue events N=762 Sternal rub62% Sought help28% Rescue breathing48% Stayed with the person89% Public setting22% Polysubstance use by victim59% Time to work Less than 1 minute15% 1-3 minutes39% 3-5 minutes29% More than 5 minutes17%

13. Help-seeking factors I Adjusted odds ratio 95%CI Age in years1.01(1.00-1.03) Female or MtF rescuer1.30(0.91-1.85) Race/ ethnicity WhiteRef Black/ African American0.45(0.17-1.14) Hispanic1.43(0.81-2.52) Other1.79(0.55-5.78)

14. Help-seeking factors II Adjusted odds ratio 95%CI User Status Primarily heroin userRef Primarily Rx opioid user1.02(0.66-1.56) Non-opioid user1.26(0.73-2.16) Non-user5.13(2.87-9.17) Previously trained0.99(0.58-1.70) Public setting1.86(1.26-2.75)

15. Help-seeking factors III Adjusted odds ratio 95%CI Polysubstance use1.09(0.77-1.56) Time for naloxone to work Less than 1 minuteRef 1-3 minutes1.57(0.82-2.99) 3-5 minutes1.88(1.01-3.49) More than 5 minutes2.94(1.48-5.81)

16. Summary OEND enrollees were more likely to seek help if: 1.they were non-users 2.the overdose occurred in public 3.the victim’s response to naloxone was longer

17. Limitations Program data collected based on participant refills, not systematic Not all variables that are likely to be important were collected –fear of police –bystander confidence –order of the actions –number of people present –rationale for adhering or not adhering to the OEND training algorithm

18. Where do we go from here? Good Samaritan protection may increase help-seeking among both users and non- users

19. Passed in August 2012: An Act Relative to Sentencing and Improving Law Enforcement Tools Good Samaritan provision: Protects people who overdose or seek help for someone overdosing from being charged or prosecuted for drug possession –Protection does not extend to trafficking or distribution charges Patient protection: 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: Naloxone or other opioid antagonist may lawfully be prescribed and dispensed to a person at risk of experiencing an opiate-related overdose or a family member, friend or other person in a position to assist a person at risk of experiencing an opiate-related overdose. For purposes of this chapter and chapter 112, any such prescription shall be regarded as being issued for a legitimate medical purpose in the usual course of professional practice.

20. Where do we go from here? Should the response to overdose be like cardiac arrest or like choking? –Cardiac Arrest: Call for help, then intervene vs. –Choking: Intervene, then discretionary call for help

21. Thanks – awalley@bu.edu M DPH John Auerbach Andy Epstein Michael Botticelli Kevin Cranston Dawn Fakuda Sarah Ruiz Barry Callis Kyle Marshall Office of HIV/AIDS Bureau of Substance Abuse Services BU/BMC Courtney Pierce Dan Hovelson Christine Chaisson Jeffrey Samet Peter Moyer Ed Bernstein BPHC Adam Butler Program sites, staff and participants

22. Intranasal Administration Pro 1 st line for some local EMS RCTs: slower onset of action but milder withdrawal Acceptable to non-users No needle stick risk No disposal concerns Con Not FDA approved No large RCT Assembly required, subject to breakage High cost: –$30+ per kit Current national shortage

23. Program Components Approved staff enroll people in the program and distribute naloxone Curriculum delivers education on OD prevention, recognition, and response Referral to treatment available Reports on overdose reversals are collected as enrollees return for refills Enrollment and refill forms submitted to MDPH Kits include instructions and 2 doses

24. Staff Training and Support Staff complete: 4 hour didactic training knowledge test At least 2 supervised bystander training sessions Sites participate in: Quarterly all-site meetings Monthly adverse event phone conferences

25. The source of the data is: Registry of Vital Records and Statistics, MA Department of Public Health Poisoning Deaths vs. Motor Vehicle-Related Injury Deaths, MA Residents (1997-2008) More Opioid Overdose Deaths than MVA Deaths in Massachusetts

26. Enrollments and Rescues: 2006-2012 Enrollments –>15K individuals –300 per month Rescues –>1500 reported –30 per month AIDS Project Worcester AIDS Support Group of Cape Cod Brockton Area Multi-Services Inc. (BAMSI) Bay State Community Services Boston Public Health Commission CAB Health and Recovery Cambridge Cares About AIDS Greater Lawrence Family Health Center Holyoke Health Center Learn to Cope Lowell Community Health Center Seven Hills Behavioral Health Tapestry Health SPHERE

27. Overdose Education in Medical Settings Where is the patient at as far as overdose? –Ask your patients whether they have overdosed, witnessed an overdose or received training to prevent, recognize, or respond to an overdose Overdose history: 1.Have you ever overdosed? 1.What were you taking? 2.How did you survive? 2.What strategies do you use to protect yourself from overdose? 3.How many overdoses have you witnessed an overdose? 1.Were any fatal? 2.What did you do? 4.What is your plan if you witness an overdose in the future? 1.Have you received a narcan rescue kit? 2.Do you feel comfortable using it?

28. Practical Barriers to Prescribing Naloxone 1.Prescriber knowledge and comfort 2.How to write the prescription? 3.Does the pharmacy stock it? Naloxone? Rescue IN kit with MAD? Boston Medical Center and Mass General Hospital Rescue IM kit with needle? 4.Who pays for it? Insurance in Massachusetts covers naloxone, but not the atomizer The MAD costs $2.50 each Work with your pharmacy to see if they will cover it

29. Prescription Directions Dispense: One naloxone rescue kit –2 prefilled syringes with 2mg/2ml naloxone –2 mucosal atomizer devices –Risk factor info and assembly directions Directions: For suspected opioid overdose, spray 1ml in each nostril. Repeat after 3 minutes if no or minimal response- include infosheet Refills: None

31. The source of the data is: Registry of Vital Records and Statistics, MA Department of Public Health Poisoning Deaths vs. Motor Vehicle-Related Injury Deaths, MA Residents (1997-2008) More Opioid Overdose Deaths than MVA Deaths in Massachusetts Rate of opioid-related fatal overdoses in MA in 2006 was 9.9 per 100K

32. Help-seeking rates Range among OEND trainees –28% (Doe-Simkins et al. Am J Public Health 2009;99:788-91) –30% (Seal KH et al. J Urban Health 2005;82:303-11) –49% (Tobin et al. Int J Drug Policy 2009;20:131-6) –74% (Piper et al. Subst Use Misuse 2008;43:858-70) Range among untrained bystanders –23% (Tobin et al. Addiction 2005;100:397-404) –44% (Bennett et al. Addiction 1999;94:1179-89 & Strang et al. Int J Drug Policy 2000;11:437-45) –53% (Davidson et al. Addiction 2002;97:1511-6) –68% (Tracy et al. Drug Alcohol Depend. 2005;79:181-90) Before & after OEND training –65% pre- OEND and 49% post- OEND (Tobin et al. Int J Drug Policy 2009: 20; 131-6) Help not sought because victim regained consciousness or bystander felt OD could be managed without help

33. Overdose Education 1.Prevention - the risks: Mixing substances Abstinence & other tolerance changing events Using alone Unknown source Chronic medical disease & previous overdose Long acting opioids last longer 2.Recognition Unresponsive to sternal rub with slowed breathing Blue lips, pinpoint pupils 3.Response - What to do Call for help Rescue breathe Deliver naloxone then continue rescue breathing If no response after 3-5 minutes, deliver 2 nd dose Post naloxone support Stay until help arrives

34. Rationale for bystander overdose education and naloxone distribution Most opioid users do not use alone Known risk factors: –Polysubstance use, abstinence, using alone, unknown source, previous OD Opportunity window: –opioid OD takes minutes to hours and is reversible with naloxone Bystanders are trainable to recognize OD Fear of public safety

35. Evaluations of OEND programs Feasibility –Bennett et al. J Urban Health 2011:88; 1020-1030 –Enteen et al. J Urban Health 2010:87; 931-41 –Doe-Simkins et al. Am J Public Health 2009: 99; 788-791 –Piper et al. Subst Use Misuse 2008: 43; 858-70 Increased knowledge and skills –Wagner et al. Int J Drug Policy 2010: 21; 186-93 –Tobin et al. Int J Drug Policy 2009: 20; 131-6 –Green et al. Addiction 2008: 103;979-89 No increase in use, increase in drug treatment –Seal et al. J Urban Health 2005:82; 303-11 Reduction in overdose in some communities –Maxwell et al. J Addict Dis 2006:25; 89-96.