Journal Club: Naloxone Programs in the Community and Their Success to Decrease Overdoses from Opioids

Transcription

1 Journal Club: Naloxone Programs in the Community and Their Success to Decrease Overdoses from Opioids Emily Junck, MD Hayes Wong, MD Paul Freeman, MD Special Guest: Caleb Banta-Green, PhD, MPH, MSW

2 Special thanks to Lauren Whiteside, MD, MS Steve Anderson, MD, FACEP

3 Background Format #1: Albert et al. Project Lazarus: Community-Based Overdose Prevention in Rural North Carolina. Pain Medicine 2011; 12: S77- S85. #2: Walley et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ 2013; 346:f174. Comments by Caleb Banta-Green, PhD, MPH, MSW Discussion

4 Objectives To better understand the current medical, social and legal context of naloxone distribution To explore current evidence of community naloxone programs on reducing opioid overdoses To discuss pros and cons to naloxone distribution by EPs

5 Background Drug poisoning (overdose) is the #1 cause of injury-related deaths in US 43,982 deaths in 2013 Today, 120 people/day die from overdose 44/day prescription painkiller Centers for Disease Control, National Center for Health Statistics. Underlying Cause of Death on CDC WONDER Online Database.

6 Background 6,700 people/day are treated in the ED for misuse or abuse of drugs 2.5 million/year Cost: 55.7 billion from prescription opioid abuse in 2007 Birnbaum HG, White AG, Schiller M, Waldman T, Cleveland JM, and Roland CL. Societal costs of prescription opioid abuse, dependence, and misuse in the United States. Pain Medicine 2011; 12:

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9 Drug-poisoning deaths in US, ,235 8,257

10 Naloxone (Narcan ) Competitive opioid antagonist Safe, Schedule 0 Theoretical allergy IM vs IN no difference Effects last 30-90min

11 Naloxone: Intranasal Used off-label Most commonly used by first responders Cost ~$50/kit

12 Naloxone: Auto-injector April 2014: Evzio FDA approved Provides verbal instructions ~$400/kit

13 : 53,032 trainees 10,171 reversals

14 Who Has Statements of Support for Take-Home Naloxone? Washington State Board of Pharmacy

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16 ACEP No policy statement yet Bedard L, Bukata R, Hoffman J, et al. Naloxone Prescriptions by Emergency Physicians. ACEP Resolution 39(14), RESOLVED, That ACEP develops a clinical policy on the clinical conditions for which it is appropriate for emergency physicians to prescribe naloxone.

17 Unique Legal Challenges Third-party prescribing prescription of drugs to a person other than the intended recipient Prescription via standing order prescription to a person the physician has not personally examined

18 Washington State June 2010: Wash. Rev. Code The administering, dispensing, prescribing, acquisition, possession, or use of naloxone shall not constitute unprofessional conduct June 2010: Wash Rev. Code Good Samaritan Law Removes criminal liability for lay administration

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20 Who can prescribe? In Washington State: any physician, NP, or PA

21 Who can prescribe? In California: +pharmacists as of 4/10/15 Approved by California State Board of Pharmacy

22 Where can you find it?

23 ` Emily Junck MD

24 Wilkes County, North Carolina Population 66,500 Poverty, limited education Unemployment, physically-demanding industries One hospital for the county Some of the highest drug overdose rates in the country: 46.6 deaths per 100,000 population per year (2009) Mostly prescription opiates

25 Project Lazarus Non-profit organization with role to: Coordinate efforts Wilkes County Health Department Northwest Community Care Network, Chronic Pain Initiative Wilkes Health Carolinians Council, Substance Abuse Task Force Develop strategic plans Train community organizers Raise awareness

26 Overdose Prevention Strategy Community organization and activation Evaluating project components Prescriber education Overdose prevention Supply reduction Monitoring and surveillance

27 Overdose Prevention Strategy Community organization and activation Evaluating project components Prescriber education Overdose prevention Supply reduction Monitoring and surveillance

28 Overdose Prevention Strategy Community organization and activation Town hall meetings, task forces Presentations at schools and community centers Advertising against medication sharing

29 Overdose Prevention Strategy Prescriber education Face to face interviews CME didactics Toolkit

30 Overdose Prevention Strategy Supply reduction Prescription limits, CSRS checked for all ED visits ED case manager for Medicaid patients, facilitate specialized pain referrals Unused medication takeback events, fixed medication disposal sites Mandatory patientprescriber agreements and pharmacy homes

31 Overdose Prevention Strategy Monitoring and surveillance Tracking of ED visits for substance abuse and accidental poisonings Tracking of Medical Examiner overdose cases Controlled Substances Reporting System North Carolina State Center for Health Statistics

32 Overdose Prevention Strategy Overdose prevention Chronic pain support groups Detox programs, drug treatment clinics Lay-person naloxone administration

33 Overdose Prevention Strategy Evaluating Project Components

34 Overdose mortality rate dropped from 43 to 29 per 100K population (2008 to 2010) Decreased prescribing Overdose fatalities that had received a prescription for the implicated substance dropped from 82% 10% Results Increased provider enrollment in the Controlled Substances Reporting System (CSRS) to 70% - Revised ED Policies for narcotic dispersal - CSRS accessed for all narcotics prescriptions - Decreased ED visits for pain

35 Limitations Does not evaluate impact of each intervention Not adjusted for confounders Difficult to replicate Setting Large-scale effort with many coordinated resources

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37 Opioid OD Rates and Implementation of OEND in Massachusetts: Interrupted Time Series Analysis Paul Freeman, MD, EM R2 Madigan Army Medical Center, WA April 24, 2015

38 Study Objective Evaluate the effect of overdose education and nasal naloxone distribution (OEND) on rates of opioid related deaths from overdose (OD) and acute care utilization Design Interrupted time series analysis of OD death and acute care utilization

39 Massachusetts 19 cities/towns At least 5 opioid related deaths Increasing number of OEND programs from 2006 Nonmedical public health workers Opioid users, social service staff, friends, family Also providing HIV education and prevention

40 What is OEND? Decrease polysubstance misuse Accounting for reduced tolerance after abstinence Not using alone Recognizing OD by alertness assessment and decreased breathing Providing rescue breathing Engaging EMS Administering nasal naloxone (2x 2mg atomizers) Staying with person until EMS arrives

41 1 Outcome - OD death rates decreased Absolute Low High Relative Low High outcome no significant difference Results

42 Strengths - Interrupted time series approach - Comparison to cancer death ratios and nonfatal traffic accident ratios - Three lives saved - Adjustment for demographic variables

43 Limitations - OD may have occurred in clusters (increased drug potency, misrepresent a trend ) - Underreporting (survey of OEND participants) - Measures of OEND implementation not validated - Acute care utilization based on discharge coding - Interrupted time series approach (RCT better)

44 Caleb Banta-Green PhD, MPH, MSW

45 Discussion Should EPs prescribe naloxone? To whom? Will this enable more high-risk behavior? More will die because they will refuse transport to the hospital and the naloxone will wear off. Is naloxone the panacea or is it a Band-Aid to opioid overdoses? If fewer opioid overdoses present to the ED, isn t this a good thing? What follow-up/drug education is or should be available in your community?

46 Maine Governor Paul LePage [Naloxone] would make it easier for those with substance abuse problems to push themselves to the edge, or beyond. It provides a false sense of security that abusers are somehow safe from overdose if they have a prescription nearby."

47 More High Risk Behavior? No data to support this (yet) Survey of 82 IDUs in San Francisco in 2000 Majority 65% said would not use more

48 Slide credit: Dr. Paul Charlton

49 Who is at risk? ANY heroin user Prescription opioids: Multiple prescribers Co-prescribing with sedatives, antidepressants Co-morbid psychiatric illness and/or substance abuse High morphine equivalent dose (>100 morphine equivalents/day*) Concurrent methadone use #1 predictor of overdose: PRIOR OVERDOSE *Dunn KM, Saunders KW, Rutter CM et al. Opioid Prescriptions for Chronic Pain and Overdose. Annals of Internal Medicine. 2010;152:85-92

50 Resources

51 Thank You