1. Sarz Maxwell MD FASAM sarzmaxmd @yahoo.com. www. AnyPositiveChange.org

2. “… he was nodding and then I looked over and he was … well, there’s a smell, you know? I knew he was dead. And I didn’t know what to do, I just parked the car and got on the bus. He was dead. What could I do?”

3. 1996 1997 1998 1999 2000

4. Medical Precedent

5.  Pure opiate antagonist  >40 years experience by emergency personnel for OD reversal  Only effect is blockade of opiate receptor  Not addictive; no potential for abuse  No side effects except precipitation of withdrawal  Dose- and delivery-sensitive

6. OptionsAdvantagesDisadvantages Single-dose pre-loaded syringe Pre-measured No add’l equipment Cost (~$15 USD /dose) Fragile apparatus Single dose Intranasal atomizer No needles Premeasured Cost (~10 USD /dose) Slightly less efficacy Single dose Multi-dose multi-use 10cc vial Cost (~$0.27 /dose) Multiple doses Very portable / durable Need add’l needles ?contamination?

7.  Average heroin user has witnessed 4 OD’s, at least 1 of them fatal  Deaths of peers & personal experience with OD do not ‘teach’ actively-using heroin addicts to stop using heroin  Heroin addicts are interested in helping other addicts in trouble

8.  Participants definitely motivated to intervene in OD situations  Participant focus groups informed program development  Low threshold  Multi-dose vial formulation

9.  89% approve the idea  92% express willingness to attend training session  Concerns:  Police harrassment & legality of naloxone possession  Fear of dopesickness  Dose- and delivery-sensitive Wright et al 2006 UK Kerr et all 2008 Australia

10. “I was just freakin’ out, thinking: ‘I wish I knew how to do CPR’… and I was like, ‘Oh, why don’t I know this?’”

11.  Death of CRA co-founder in 1997  Begin distributing naloxone in 1997  2000 actively expanding program  Train all CRA operatives to educate and distribute

12.  US law allows a prescription to be written when a doctor-patient relationship exists  Chart  Documentation of education RE prescription  Medical director trained CRA operatives to educate & distribute  Intake form developed with brief history, checklist for education, and standing order  OEND occurred at all 22 weekly SEP sites plus cell phone on-call  Participants quickly became distributors

13.  OD Prevention  Early Recognition › Unresponsive › Before cyanosis  Rescue Breathing  Naloxone administration › 1 cc (0.4 mg) IM › > 1” needle › Multi-use vial  Aftercare › Do not use more opiate!  High will return in 30-40 min › Return of OD › Transport for medical f/u

14.  Age > 34  Using in combination with other drugs  Alcohol  Cocaine

15. PONS Respiratory Centre Opiates depress respiratory drive MEDULLA Cardiac Centre Cocaine stimulates heartbeat, blood pressure

16.  Mixing drugs  Using alone  Recent period of abstinence – as brief as 3 days will decrease tolerance  Detox program  Incarceration

17. … I put myself in detox and I got out, shot up a bag … and he was with me, thank god, because I went out.” “He got out of the joint… came back, thought he had the same tolerance… but he didn’t…

18. DrugDurationpotency Methadone24 hr++++ Heroin6 – 8 hr+++++ Oxycodone3 – 6 hr+++++ Codeine3 – 4 hr+ Demerol2 – 4 hr++ Morphine3 – 6 hr+++ Fentanyl2 - 4 hr++++++++ ++++++++ ++++++++

19. 1996 2000 2004 2007

20. low self esteem + stigma nihilism + hopelessness for the future

21. stigmaHopeFuture-orientation NALOXONEEmpowerment+ New Message: “it matters if you live or die” community, community,altruism

22. “I did something that made a difference. The whole world can’t see it but I know it made a difference. And that’s important… to me.”

23.  Statewide program supported by state DPH  Operating in 13 communities  SEPs, drop-in centers, treatment programs ( detox, OTP, residential tx, inpt), ER, home visits, street outreach  >9000 enrolled, ~1000 reversals (11%)

24.  Top 3 most common sites for OTP patient naloxone refills:  Needle Exchange Program (40%)  Drop-in Center (30%)  Methadone Clinic (9%) Slide courtesy Maya Doe-Simkins

25.  70 patients with opioid dependence syndrome in abstinence-based program trained & given naloxone  6 mos later, participants had retained knowledge, still had the naloxone, but none had used it  Transportability  Stigma  Fear of police Harm Reduct J, 2009 Sep 24; 6:26

26.  Low threshold – on demand, easily accessible, minimal paperwork  Education – duration; by whom  Venue – user-friendly  Formulation – simple, durable  Doses and Refills – multiple doses  OD relapse  Multiple simultanerous victims  Abundance >> Confidence

27. “It used to be, overdose, you always talked about it in past tense: ‘I HAD a friend who OD’d.’ Now, overdose is in the present tense: ‘I HAVE a friend who OD’d last week’. Naloxone did that.”

28.  Dan Bigg  Karen Stanczykiewiz  Greg Scott  Suzanne Carlberg – Racich  John Gutenson  Susie Gualtieri  Sharon Sereda  Esther, Cheryl, Cliff, Andrew …  All of our courageous participants, who make this program work

29. the end(s) www. AnyPositiveChange.org sarzmaxmd @ yahoo.com