Naloxone: Preventing Opioid Overdose in the Community. Sharon Stancliff, MD Medical Director Harm Reduction Coalition

Transcription

1 Naloxone: Preventing Opioid Overdose in the Community Sharon Stancliff, MD Medical Director Harm Reduction Coalition

2 DISCLOSURES Sharon Stancliff MD has nothing to disclose

3 LEARNING OBJECTIVES 1. Discuss the epidemiology of opioid overdose including recent shifts to heroin and illicit fentanyl. 2. Describe the steps in recognizing and responding to an opioid overdose. 3. Understand the role of pharmacy in dispensing naloxone.

4 Deaths related to prescription opioids and heroin drug poisoning United States, *Age-Adjusted Rates Compton et al. NEJM 2016;374:154-63

5 Opioid-Related Deaths in NYS LIMITATIONS OF THESE DATA Known underreporting Data only as good as certificates Variability among counties in thoroughness of tox screens and reporting

6 Harm Reduction Responses to Fentanyl Have naloxone at hand Do a tester shot or slow shot Start low and go slow Take turns: stories of people going out at the same time Don't use alone Don t delay calling 911 (Good Samaritan Laws)

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9 Fentanyl & Overdose Deaths Fentanyl was relatively uncommon in overdose in NYC with fewer than 3% of deaths involving fentanyl in the past ten years Of the 886 drug overdose deaths in 2015, 136 (15%) involved fentanyl Second half of 2016 over half the overdose deaths involved fentanyl

10 Strategies to address overdose Increase access to naloxone Good Samaritan laws Prescription monitoring programs Prescription drug take back events Safe opioid prescribing education Supervised injection facilities Expansion of opioid agonist treatment

11 Opioid Overdose Opioid Overdose Characteristics Opioid Overdose Toxidrome Develops Over Minutes to Hours Opioid receptors are in the respiratory center in the medulla Reduced sensitivity to changes in O 2 and CO 2 outside of normal ranges Decreased tidal volume and respiratory frequency Respiratory failure and death due to hypoventilation Decreased respiratory rate, Unresponsiveness Blue/gray lips and nails White JM, Irvine RJ. Mechanism of fatal opioid overdose. Addiction Jul;94(7):

12 Naloxone Reverses overdose and prevents fatalities Mu opioid receptor antagonist - No clinical effect in absence of opioid agonists - Displaces opioids from receptors Takes effect in 2-5 minutes - May cause withdrawal - Lasts for minutes (longer for newest formulation) Hepatic metabolism; renal excretion

13 Formulations

14 Risk Factors for Opioid Overdose Reduced Tolerance Using Alone (risk factor for fatal OD) Illness Depression Unstable housing Mixing Drugs Changes in the Drug Supply History of previous overdose Doses 100 mg morphineequivalent doses

15 Lowered tolerance Tolerance- repeated use of a substance may lead to the need for increased amounts to product the same effect Abstinence decreases tolerance increasing overdose risk - Incarceration - Hospitalization - Drug treatment/ Detox/ Therapeutic communities - Sporadic patterns of drug use Sporer 2007, Binswanger 2013

16 Overdose deaths in New York City involve multiple drugs: % of overdose deaths involved more than one substance. Approximately eight in ten (79%) overdose deaths involved an opioid. Benzodiazepines were found in 54% of overdose deaths involving opioid analgesics, 41% of deaths involving heroin, and 55% of deaths involving methadone NYCDOHMH 2015

17 Context of Opioid Overdose The majority of heroin overdoses are witnessed (gives an opportunity for intervention) The circumstances of prescription drug overdoses are less well characterized Fear of police may prevent calling 911 Witnesses may try ineffectual things - Myths and lack of proper training - Abandonment not uncommon Tracy 2005

18 NYS Public Health Law 2006 Allows the medical provider to provide naloxone for secondary administration. Naloxone must be prescribed by MD, DO, PA, or NP either in person Offers some liability protection 2014 amendments to the PHL made naloxone accessible through non-patient specific prescriptions ( standing order )

19 Training Essentials What does naloxone do? Overdose recognition - Sternal rub/grind Action - Call EMS and administer naloxone Recovery position

20 Training recommendations in most settings Risk factors for overdose/overdose death Loss of tolerance Mixing drugs Using alone Good Samaritan Law Hands on practice with device Resuscitation Rescue breathing and/or Chest compressions

21 Shake and shout Sternal rub/grind

22 Call AND Naloxone 22 Tell the dispatcher, I think someone has overdosed. - Give the address and location AND Give the Naloxone DO FIRST, whichever is closer at hand

23 Give naloxone

24 Give naloxone

25 Give naloxone Narcan Leave in plastic pack until ready to use Do NOT test before inserting in nostril

26 Rescue breathing or full CPR or chest compressions

27 Second dose If the person does not respond in 2-3 minutes, give a second dose of naloxone. Do not wait more than 5 minutes to give a second dose if person is not responding

28 After You Give Naloxone Explain what happened. Tell them not to take any more drugs because that could cause another overdose. Naloxone wears off in 30 to 90 minutes. Stay with the person until they go to the hospital, or until the naloxone wears off, to make sure they do not overdose again. If you do not seek medical care, stay with the person for at least 3 hours Call 911 if the person is not OK when they wake up or take them to the emergency Room yourself. When the ambulance arrives, tell them that naloxone has been given.

29 New York State s Good Samaritan Law Protects: - Individual who experience an overdose and - Person who summons EMS (calls 9-1-1) Prevents prosecution for: - Possession of up to 8 Oz of a controlled substance - Alcohol (for underage drinkers) - Marijuana (any amount) - Paraphernalia offenses - Sharing of drugs (in NY sharing can be a sales offense) There are several exclusions

30 Evaluations of Overdose Education and Naloxone Distribution Programs Feasibility Piper et al. Subst Use Misuse 2008: 43; Doe-Simkins et al. Am J Public Health 2009: 99: Enteen et al. J Urban Health 2010:87: Bennett et al. J Urban Health. 2011: 88; Walley et al. JSAT 2013; 44: (Methadone and detox programs) Increased knowledge and skills Green et al. Addiction 2008: 103; Tobin et al. Int J Drug Policy 2009: 20; Wagner et al. Int J Drug Policy 2010: 21: No increase in use, increase in drug treatment Seal et al. J Urban Health 2005:82: Doe-Simkins et al. BMC Public Health :297. Reduction in overdose in communities Maxwell et al. J Addict Dis 2006:25; Evans et al. Am J Epidemiol 2012; 174: Walley et al. BMJ 2013; 346: f174. Cost-effective $438 (best) $14,000 (worst ) per quality-adjusted life year gained Coffin and Sullivan. Ann Intern Med Jan 1;158(1):1-9.

31 Massachusetts Massachusetts compared interrupted time series of towns by enrollment in Opioid Education and Naloxone Distribution programs 2912 kits distributed 327 rescues, 87% by drug users; 98% effective EMS revived the other 3 Walley et al BMJ 2013

32 Community results Fatal opioid OD rates compared no implementation Program enrollment per 100k population (ARR: 0.73) Program enrollment >100 per 100,000 (ARR:0.54) No differences were found in nonfatal opioid OD rates. Walley et al BMJ 2013

33 Increase drug use? Of the 325 with 2 points of data on drug use: No increase in reported use of opioids, alcohol, cocaine or number of substances used Significant increase in reported use of benzodiazepines: 30% increased use 23% decreased use Doe-Simkins et al BMC Public Health 2014

34 New York City Longitudinal Cohort Study Recruitment at trainings provided by 6 syringe exchange programs June January 2014 Interviewed at baseline, 3 months, 6 months and 12 months 351 were recruited 299 (85%) were interviewed at least once in the follow up period (Sept Dec 2014) Siegler A et al 2016 NYC Department of Health and Mental Hygiene

35 Results 128 (43%) study participants witnessed at least one opioid overdose, with 66% of these participants witnessing more than one overdose A total of 326 overdoses were observed Naloxone was administered by the study participant in 188 (62%) of cases and by another lay person in an additional 53 (18%) of cases In 12 months, of 351 trained individuals, 53 used naloxone Siegler A et al NYC Department of Health and Mental Hygiene

36 Implementation in NY State Over 300 sites have registered to distribute free kits provided by the New York State Department of Health Syringe exchange/syringe access providers Drug treatment providers Agencies focused on homeless populations Law enforcement agencies Local health departments Educational institutions School Districts NYS Department of Corrections and Community Supervision Primary care HIV services

37 September 2016 Expanding Community Program Special Focuses Nearly 300 programs currently active or recently registered 185 in 2014 & 2015; Basic Life Support Permissible scope of practice now includes IN naloxone. Law enforcement Firefighters Corrections School Settings Pharmacy Frequently first on the scene of an OD- over 3000 uses outside NYC since 5/14 As with police, firefighters are often first on the scene Pilot in 10 State prison facilities being expanded to others over 4000 formerly incarcerated individuals carry naloxone Began in August 2015 with changes in Public Health and Education laws Pharmacy dispensing pursuant to standing orders is now underway. Patient specific prescriptions as well

38 Role of the Community Pharmacist

39 Pharmacy Pharmacies are now carrying naloxone Dispense with a patient specific order Dispense per an non-patient specific (standing) order - Work with registered opioid overdose programs - Register as an opioid prevention program

40 Non-patient specific orders Available to all pharmacies who do not have a prescribers on staff Includes: Protocol CPE module Training materials Reporting information

41 Pharmacy 1,983 pharmacies throughout New York State able to dispense naloxone under standing orders including 111 independents 713 in New York City 1,270 in rest of state All chains with greater than 20 stores are required to dispense

42 Insurance coverage All Medicaid plans must cover at least one formulation of naloxone for people at risk of overdose Medicaid covers naloxone under standing orders at pharmacies Little information on private insurance If a patient cannot afford the naloxone and/or copay, they should be directed to listing of NYS Opioid Overdose Prevention Programs

43 Opioid-Related ED Visits by Receipt of Naloxone Prescription Among Primary Care Patients with Chronic Pain In a population with a rate of opioid-related emergency department visits of 7/100 person-years, prescribing naloxone to 29 patients would avert 1 opioid-related visit in the subsequent year.

44 Participate! Discuss naloxone with patients: On higher doses of opioids (> 100 morphine mg equivalents/day) Concurrent alcohol or benzodiazepine use Using opioids illicitly or with a history of use ESAP consumers Patients on buprenorphine or naltrexone

45 Opioid Maintenance & Mortality In Baltimore, researchers found: Statistically significant inverse relationship between heroin OD deaths and patients treated with buprenorphine (P =.002) (Adjusting for heroin purity and # of methadone patients) Schwartz et al AJPH 2013

46 Conclusions Provision of naloxone to patients and community members is feasible and efficacious Pharmacists can train, prescribe, refer to programs depending and local resources An addition to, not a replacement for evidence based treatment!

47 Acknowledgments New York State Department of Health New York City Department of Health and Mental Hygiene Opioid Safety with Naloxone Network Injection Drug Users Health Alliance

48 Resources NYSDOH: List of programs; registration information; calendar of trainings and more NYCDOH&MH List of NYC pharmacies and more HRC: Updates, videos, soon lists of independent pharmacies in NYS

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50 QUESTIONS? To set up training on HIV or Hepatitis C, please contact Terri Wilder at