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					  Community based
   opioid overdose
prevention: the role of
      naloxone
               Harm Reduction Coalition
               New York, NY
Drug poisoning death rates by
manner of death, US, 1979–2002

                                                                                        560



                                                             200



Source: adapted from Paulozzi Pharmacoepidemiology and Drug Safety, 2006; 15: 618–627
What is the most dispensed
prescription drug in the United
            States?
        (number of prescriptions filled;
    generic and branded products, 2004-06)




                                             3
       Chronic Pain Prevalence
   30% ages 45-64 years reported problems
    with pain that lasted more than 24 hours in
    duration in the prior month
   Among adults who reported pain
    problems, 42% had pain last more than a
    year

Sources: CDC, Chartbook on Trends in the Health of Americans, Health, 2006



                             source + more info at projectlazarus.org
       Top 10 Drugs Dispensed in
                 2006
                  1.          Hydrocodone/Acetaminophen
                  2.          Lipitor®
                  3.          Amoxicillin
                  4.          Lisinopril
                  5.          Hydrochlorothiazide
                  6.          Atenolol
                  7.          Zithromax®
                  8.          Furosemide
                  9.          Alprazolam
                  10.         Toprol-XL®

Source: http://www.rxlist.com/script/main/hp.asp          5
    Heroin Overdose Epidemiology
–   About 1.24-3.3 % of heroin users are estimated
    to die each year, many from heroin overdose
–   Heroin users experience a loss of 18 years of
    potential life, at least 25% due to overdose
–   Up to 2/3s of heroin users experience at least 1
    nonfatal overdose
–   Example 1999: most common cause of death
    men age 25-54 in Portland OR
–   Sporer 2002, Galea 2003, Smythe 2006, Coffin 2007
    Drug Overdoses Are Common
        and Kill Many Users
   Among heroin users, 20-40% report an
    overdose in the past year.
   About 1% of heroin users die of overdoses
    for every year they use.
Prescription pain KILLERs
  involved in fatal drug
        overdoses
      Oxycodone
      Hydrocodone
      Methadone
      Fentanyl
What is the most dispensed
prescription drug in the United
            States?
      (number of prescriptions filled;
      generic and branded products)
                   Chronic Pain Prevalence
            30% ages 45-64 years reported problems
             with pain that lasted more than 24 hours in
             duration in the prior month
            Among adults who reported pain
             problems, 42% had pain last more than a
             year

            Norway: 24.4% (mail survey)
            Australia: 17.1-20.0% (general population)
Sources: CDC, Chartbook on Trends in the Health of Americans, Health, 2006 Rusben T. Eur J Pain Dec 2004, 8(6); Blyth FM. Pain Jan 2001
                                                               89(2-3).
source + more info at projectlazarus.org
      National Survey of Drug Use &
                  Health
   In 2005, among 18-25 year-olds (4.0 million respondents),
    non-institutionalized population
   Prevalence of nonmedical use of pain relievers: 12.4%
   Source of pain relievers for nonmedical use %
      Got Them from a Friend or Relative for Free   37.5
      Bought from a Friend or Relative                    19.9
      Prescriptions from One Doctor                 13.6
      Bought from a Drug Dealer or Other Stranger 12.5
      Took from a Friend or Relative without Asking 6.3
      Prescriptions from More Than One Doctor       2.8
      Got them Some Other Way                       2.3
      Bought on the Internet                        1.3
      Other Unknown or Invalid Source                     1.9


                                    Source: SAMHSA, OAS. 2006, NSDUH Report, Issue 39.
           Physiology of overdose
   Generally happens over course of 1-3
    hours- the stereotype “needle in the arm”
    death is only about 15%
   Opioids depress the urge to breath –
    decrease response to carbon dioxide -
    leading to respiratory depression and
    death
Sporer Ann Emerg Med 2007
                 Who overdoses?
   Most often dependent long term users who
    are not in treatment with 5- 10 years of
    experience rather than new users- about
    17% occur among new users




Sporer Ann Emerg Med 2006
       Overdoses are often witnessed
But what to do?
 Fear of police may prevent calling 911

   Abandonment is the worst response

 Witnesses may try ineffectual things first

   Salt & milk shots

  Tracy, Drug Alcohol Depend 2005
            Naloxone (Narcan)

   Quick acting
   Reverses opioid
    overdose
   Works for 30-90
    minutes
   Narcan®
   Delivered via injection
    (IM, SC, IV) or nasal

                    Source: adapted from slides of Nab Dasgupta
      Overdose Prevention

   Community-based, public health OD
    prevention programs are spreading
    (Chicago, New York, Boston, San
    Francisco, Philadelphia, Pittsburg)
   Involve training users about how to
    recognize ODs and what to do
   Provide naloxone to reverse opioid ODs
Rationale for overdose prevention
                programs
   Overdoses are rarely instant
   There are often bystanders
   Naloxone is a safe and effective antidote

Many overdoses are preventable with
 prompt recognition and treatment
           The training: 10-20 minutes
   Prevention understanding the role of:
     mixing drugs
     reduced tolerance
     using alone
   Overdose recognition
   Actions
     Call 911
     Rescue breathing- using dummy
     Naloxone administration
                       Major risk factors
   Use following a period of abstinence
     Incarceration
     Hospitalisation
     Drug treatment/detox
   Mixing classes of drugs
     Primarily other CNS depressants
     Cocaine is involved in nearly 40% of
      NYC overdoses
    Sporer 2006, Chan Acad Emerg Med 2006
      Death following incarceration
Post incarceration is major risk factor for
 death from OD
   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
   60% involved opioids

   74% involved cocaine and other stimulants


  Bingswanger NEJM 2007
            Identifying those at risk
   Injectors higher risk than nasal insufflators
   History of previous overdose is a major
    predictor of future overdose- may be a key
    screening question



Wines Drug Alcohol Depend 2007, Coffin Acad Emerg Med 2007
                         Other risk factors
   Overdose is more likely in the presence of
    significant illness: cirrhosis, AIDS,
    coronary disease, pulmonary disease
   Major changes in opioid supply: >1000
    deaths USA 2006 with fentanyl
   Depression



   Wang AIDS 2005, Wines Drug Alcohol Depend 2007 Sporer 2006,
    http://www.whitehousedrugpolicy.gov/news/fentnyl%5Fheroin%5Fforum,
Messages for trained overdose responders

Try to use with others who know what to do
  if an overdose happens
Be careful using alone especially if
 Using after abstinence

 Mixing different classes of drugs

Watch out for your friends, particularly under
  risky circumstances
             Recognition

Overdose responders are taught to be
  aware of possible signs of overdose
 Nodding versus unresponsive

 Blue lips and nail beds

 Slow breathing, gurgling

Act: Call name, sternal rub: rub knuckles
  hard up and down breast bone
    Stimulate the person overdosing
   Shake, call name loudly
   Sternal rub: rub knuckles hard up and
    down breast bone (it hurts!)

     Ice   can work but this is easier
    Drug User Responses to an
            Overdose
   Have limited information on what to do;
    most of it coming from peers
   Do not call 9-1-1 quickly or at all, because
    of fear of police and possible arrest
   Walk around
   Inflict pain
   Ice in groin
   Inject salt water
        Not a replacement for EMS
Trainees are counselled
 Call 911- “My friend is

unconscious/not breathing”
 Give location.

 No need to say heroin or
  overdose
 Police may come
Teaching “rescue breathing” and how to
 position a person who has overdosed
               Naloxone (Narcan)
   Opioid antagonist which reverses opioid
    related sedation and respiratory
    depression and may cause withdrawal
   Displaces opioids from the receptors, then
    occupies the receptor for 30-90 minutes
   No psychoactive effects
   Over the counter in Italy
   Routinely used by EMS
             Administration

   Inject into muscle but subcutaneous and
    intravenous are also effective
   Intranasal
   Acts in 2-8 minutes
   If no response in 2-5 minutes repeat
   Lasts 30-90 minutes
            Nasal Naloxone


   2 mL pre-loaded
    syringes (1
    mg/mL)
   Nasal adaptor
   Spray into nose
   No needles
          Naloxone preparations
   Injectable
      Inexpensive- $0.25- 1.00 per dose
      Well-documented efficacy
      Requires injection
   Intranasal
      More expensive $6-9.00 per dose
      Less well-documented efficacy
      Easier to use
                       Role of EMS

   Overdose responders are trained to call
    EMS
   What if they don’t?
     Study of 998 OD patients who were
      administered naloxone by EMS and
      refused to go to the hospital- a review of
      coroner records revealed no deaths in
      the sample within 12 hours of the
      encounter
    Vilke Acad Emerg Med 2003
                   Safety in the field
Over 3,500 kits distributed
319 overdose reversals reported
 1 unsuccessful revival
 1 seizure
 1 vomited
 Only 5 cases with more than 1 injection
 No cases of re-treatment after naloxone
  wore off
Maxwell J Addict Dis 2006
           Intramuscular Dose
   Emergency Medical Services give
    1.2- 1.6 milligrams of naloxone which
    precipitates severe withdrawal in the
    dependent person
   Overdose prevention services recommend
    starting with 0.4 with an additional dose
    readily available
  Results: awake and breathing

Narcan wears off in 30-90 minutes
 Overdose responder is counselled to
  remain with the overdoser and reassure
  the overdoser if s/he is drug sick- the
  naloxone will wear off- don’t use more
  heroin to feel better!!
       Syringe exchange/ access sites:
                rationale
   SEPs serve a high risk population
   SEPs have trusting relationships with drug
    users and have expertise in working with
    drug users including peer education
                    Challenges
   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
       Drug Treatment: Rationale
   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
                  Challenges
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
     Education, drug users may be used to
      describe their own experiences
Staff often invested in abstinence model
             Homeless shelters
 Being    homeless is associated with risk of
  OD
 Associated factors may be:
  Socialand economic stress
  Lack of safe, familiar place to inject
      Using alone and rushing injection
  Less    access to opioid maintenance treatment

 O’Driscoll AJPH 2001
             Challenges
 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 of disclosing
  drug use
                  Hospitals
   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
   One emergency department is planning to
    offer naloxone
                  National Experience




http://www.npr.org/templates/story/story.php?storyId=17578955
       Decreasing overdose rates

Chicago: 1999-2003 opioid overdose deaths
  decreased 34% coinciding with start up of first
  naloxone distribution program
 Peak 2000: 310 2003: 205
 Naloxone distribution scaled up 2000
Baltimore: Decreasing rates prior to and with OD
  program
San Francisco: 2004 overdose rate down while
  statewide is up 42%
Scott J Urban Health 2007, Baltimore DOH 2008 , SFDOH Commission
   meeting 2005
Heroin overdoses dropping
Allegheny County Trends in Accidental Drug Overdose Deaths
                       2000-2006*




   *Data is from Allegheny County Medical Examiners Annual Reports and includes all
   overdose deaths where these drugs were present at time of death, not necessarily cause of
   death.
Heroin Use in Allegheny County by
           Fiscal Year




*Data from Pennsylvania Department Of Health
    The LESHRC naloxone program
   The Overdose Prevention and Reversal Program was launched in
    June 2004 by the Lower East Side Harm Reduction Center
    (LESHRC) with the following goals
        to reduce overdose-related deaths through the distribution of
         naloxone hydrochloride to injection drug users in NYC
        to build evidence of the effectiveness of take-home naloxone in
         harm reduction settings
        to create wider support for the inclusion of naloxone in harm
         reduction, methadone, and other public health programs
        to establish pilot data in anticipation of a city-wide distribution of
         naloxone through other SEPs in NYC
   Pilot study taught 25 habitual drug users about use of naloxone,
    distributed naloxone, and assessed responses to overdose over a
    three month period
   Galea S, Addict Beh 2005
Demographic characteristics
        (N=25)
                          N     %
 Total                    25   100
 Gender
  Male                    23   92.0
  Female                  2    8.0
 Race/ethnicity
  White                   16   64.0
  Black                   4    16.0
  Hispanic                5    20.0
 Homeless last 6 months
  Yes                     12   52.2
 Jail/prison ever
  Yes                     5    21.7
Experience with overdose (N=25)
                             N     %
    Total                    25   100
    Ever overdosed
     Yes                     17   68.0
    If overdose, number of
    time
     0-1                     12   48.0
     2-4                     7    28.0
     5-9                     3    12.0
     10-29                   3    12.0
    Ever witnessed an
    overdose
     0                       4    17.4
     1                       1    4.4
     2-4                     8    34.8
     5+                      10   43.5
Baseline when witnessing last overdose at
       baseline and follow up visits
                                        Baseline    Follow-up
                                         (n=19)      (n=11)
                                                                McNemar's
                                        N     %     N     %        test
Called ambulance                        11   57.9   9    81.8    0.1025
Took to hospital                        1    5.3    3    27.3    0.0833
Placed in rescue position (on their
side)                                   1    5.3    2    18.2    0.3173
Mouth to mouth/ Heart massage, CPR      1    5.3    3    27.3    0.0833
Called their name to try to wake them
up                                      10   52.6   8    72.7     1.000
Tried to wake person by causing pain    14   73.7   5    45.5    0.3173
Injected w/ cocaine, water or
salt                                    3    15.8   0     0          -
Did Nothing                             4    21.0   0    0.0         -
Other                                   5    26.3   1    9.1      1.000
      Distribution and use of naloxone at
       most recent overdose witnessed
         during a three month period

                                                        Naloxone
                                                         used 10
                                                        times; all
                                                           lived
     25             22            11       17 most
  baseline      follow-up     witnessed     recent
participants   participants       an      overdose
                              overdose    witnessed

                                                      Naloxone not
                                                      used 7 times;
                               26 total
                                                        5 lived, 1
                              overdoses
                                                         died, 1
                              witnessed
                                                        unknown
    Overdose responders knowledge
   Methods: Evaluated 10 current or former opioid users
    recruited from each of 6 sites with naloxone training
    programs
       Baltimore, Maryland   San Francisco, California
       Chicago, Illinois     New York (Bronx & Manhattan)
       New Mexico

   Used validated, reliable knowledge assessment tool
    presenting 16 putative overdose scenarios (Green et al.,
    2005)
   Compared responses of opioid users to those of 11 medical
    experts in overdose

Green Addiction 2007
    Overdose responders knowledge
   Naloxone training programs in the US improve
    participants’ recognition & response to opioid overdoses
    compared to those untrained (p<.001)

   Fewer opioid overdoses were missed by trained
    participants (p<.05)

   Fewer overdoses responded to inappropriately by
    trained participants (p<.001)

   Trained respondents were as skilled as medical experts
    in recognizing opioid overdose situations (weighted
    kappa=0.85) & when naloxone was indicated
    (kappa=1.0).
          More prevention
Opioid maintenance with methadone or
 buprenorphine reduces opioid overdoses
           Methadone and mortality

   A study of opioid dependent patients
    applying for methadone treatment in
    Norway
   3,789 subjects followed for up to 7 years

   Clausen Drug Alc Dep 2008
                           Results

                  Pre-treatment   In treatment        Post-treatment



Total mortality   1               0.5                 1.43
Odds ratio

Total overdose    1               0.20                1.40
Odds ratio

Percent           79%             27%                 61%
of deaths due
to overdose


                                                 Clausen Drug Alco Dep 2008
                      Maintenance therapy prevents
                               overdose
                •Since the institution of buprenorphine and methadone
                maintenance in 1996 in France heroin overdose has dropped by
                79%

                600


                500
                                                                                                    French population in
                                                                                                    1999 = 60,000,000
No. of deaths




                400

                300                                                                                 Patients receiving buprenorphine
                                                                                                    (1998): N= 55,000
                200
                                                                                                    Patients receiving methadone
                100                                                                                 (1998): N= 5,360
                 0
                  1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999

                                                   Year
                                                                                                                             62
                                                                                                         Auriacombe et al., 2001
    Good Samaritan Law – New
         Mexico – 2007
   OVERDOSE PREVENTION--LIMITED
    IMMUNITY. A person who, in good faith, seeks
    medical assistance for someone experiencing a
    drug-related overdose shall not be charged or
    prosecuted for possession of a controlled
    substance . . . If evidence for the charge . . . was
    gained as a result of seeking medical
    assistance.
                Lessons learned
   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
               Goals/wish list
   Over the counter status for naloxone
   Overdose prevention training as standard
    of care for all at risk of opioid overdose
   Inexpensive, effective, intranasal delivery
    system
                    Conclusions
   Overdose prevention training consists of a
    few basic components
   Overdose prevention by non medical
    persons is feasible, safe and probably
    effective
If you ever get in a meeting with some
professional-type people, tell ‘em that,
you know, people like us–no, we’re not
professionals, but if we have it at hand we
can save somebody’s life with this stuff
[naloxone] . . . it’s a lifesaver, there’s no
question.*



          *quote collected by Suzanne Carlberg-Racich, Chicago
       Participant Perspective
  I did SOMETHING, you know, that made a
  difference. The whole world can’t see it but
  I know it made a difference. And that’s
  important . . . to me.*

* quote collected by Suzanne Carlberg-Racich
        Slide Acknowledgements
   Alice Bell
   Melinda Campopiano
   Nabarun Dasgupta
   Sandro Galea
   Traci Green
   T. Steve Jones
   Sharon Stancliff

				
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