PROTOCOL AND STANDING ORDER

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Bertha Welch
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1 Clark County Public Health 1601 E. Fourth Plain Blvd. PO Box 9825 Vancouver, WA (360) PROTOCOLANDSTANDINGORDER SUBJECT:NaloxoneDistributionatHarmReductionCenter UNIT:HIVPrevention POLICYNO:PSO030 EFFECTIVEDATE:November23,2013 ORIGINALDATE:November23,2013 SIGNATUREOFDEPARTMENTDIRECTOR/HEALTHOFFICER:ALANMELNICK,MD,MPH,CPH COPIESDISTRIBUTEDTO:HIV/STDPrevention;HarmReduction CenterSyringeExchangeServicesStaff&Volunteers;HDrive REFERENCES:RCW REVIEW:November23,2014 NEXTREVIEW:November23,2014 POLICY: InanefforttoreduceoverdosemortalityinClarkCounty,ClarkCountyPublicHealth ssyringeexchange programwillprovideoverdosepreventioneducationanddistributenaloxonetopersonsatriskfor havingorwitnessinganopioidoverdose.thispolicyservesasastandingorderforclarkcountypublic HealthstaffandvolunteerswhoworkatthesyringeexchangeclinicattheHarmReductionCenterto administernaloxonetoclientswhoareexperiencinganopioidoverdose.italsoservesasastanding ordertoprovideoverdosepreventioneducationandnaloxonekitstosyringeexchangeclientswhoare atriskofhavingorwitnessinganopioidoverdose. OVERVIEW: OpioidoverdoseistheleadingcauseofaccidentaldeathinWashingtonState.Opioidrelateddeathsin WashingtonStateandClarkCountyhavesignificantlyincreasedoverthepastdecade,andare preventablethrougheducationandnaloxoneintervention.washingtonstategoodsamaritanlaw (RevisedCodeofWashington(RCW) )passedin2010legalizestheadministering,dispensing, prescribing,purchasing,acquisition,possession,anduseofnaloxoneforpersonsatriskofexperiencing orwitnessinganopioidrelatedoverdose. 1 Additionally,theWashingtonStateBoardofPharmacyis supportiveofmakingnaloxoneavailabletohighriskpopulationssuchassyringeexchangeclients,and collaborativedrugtherapyagreementsthatallowpharmaciststoeducate friends ofpotentialopioid overdosevictimsandprovidethemwithnaloxone.naloxonedistributionisrecommendedbythe CentersforDiseaseControlandWashingtonStateDepartmentofHealthasapromisingstrategyto preventoverdosedeaths. 2,3 TheAmericanMedicalAssociationandtheAmericanPublicHealth Associationbothhavepoliciessupportingtheavailabilityoftakehomenaloxone. 4 Nationwide, naloxonedistributionprogramshavereportedover10,000overdosereversals, 3 andeconomic evaluationsshowthatnaloxonedistributiontoheroinusersarehighlycosteffective. 5 OverdosePrevention&Naloxone Policy&StandingOrderPage1of6

2 DEFINITIONOFTERMS: Administer:Directapplicationofaprescriptiondrugtothebodyofapatientbyapractitioner CCPH:ClarkCountyPublicHealth Dispense:Theinterpretationofaprescriptionororderforalegenddrugand,pursuanttothe prescriptionororder,theproperselection,labeling,orpackagingnecessarytopreparethatprescription ororderfordelivery.practitionerswithprescriptiveauthoritysuchasphysiciansandadvanced RegisteredNursePractitionersareauthorizedtodispensethedrugswhichtheyprescribe Distribute:Todelivermedicationsotherthanbyadministeringordispensingalegenddrug Legend:Drugswhicharerequiredbystatelaworregulationofthestateboardofpharmacytobe dispensedonprescriptiononlyorarerestrictedtousebypractitionersonly Naloxone:Prescriptionmedicinethatreversestheeffectofanopioidoverdose OverdosePreventionEducator:HarmReductionCenterstaffandvolunteerswhohavecompletedthe overdosepreventioneducation,underthedirectionofthehealthofficer,andarequalifiedtodeliverthe OverdosePreventionandNaloxoneTrainingcurriculumtoindividualsatriskofexperiencingorwitnessing anopioidoverdose OverdoseResponder:Individualswhoareatriskofexperiencingorwitnessinganopioidoverdose,have attendedtheoverdosepreventionandnaloxonetraining,andareeligibleforpossessionand administrationoftakehomenaloxonetotreatanopioidoverdose RCW:RevisedCodeofWashington STANDINGORDER Naloxoneisindicatedforreversalofopioidoverdoseinthesettingofrespiratorydepressionor unresponsiveness. 1. Naloxonemaybegivenintramuscularly(IM)bytrainedClarkCountyPublicHealthstaffand volunteers(overdosepreventioneducators)toapersonwhoisexperiencingadrugoverdose,as describedinthe Procedure Guidelines sectionbelow.naloxonemaybegiven subcutaneouslyorintravenously,however,ccphwillteachandusetheimroute,unlessan urgentsituationrequirestheotherroutes. 2. SuppliesofNaloxoneHydrochlorideInjectionshallbemaintainedfordistributionaspartofthe CCPHOverdosePreventionProgramforthepurposeofreducingopioidrelatedoverdosedeaths. 3. TrainedOverdosePreventionEducatorsshallpossessanddistributetakehomenaloxonekitsto OverdoseResponderswhohavecompletedtheOverdosePreventionandNaloxoneTraining. 4. OverdoseResponders,trainedbyOverdosePreventionEducators,whoaretrainedemployeesand volunteersofccph sharmreductioncenter,shallbeauthorizedtopossessandadminister naloxonetoapersonwhoisexperiencingadrugoverdose. 5. Pregnancy&NursingMothers:PregnancyCategoryB.Therearenoadequateandwell controlledstudiesinpregnantwomenanditisnotknownwhethernaloxoneisexcretedin humanmilk.naloxoneshouldonlybegiventopregnantandnursingmothersifclearlyneeded. 6. Overdosage:Thereisnoclinicalexperiencewithnaloxoneoverdosageinhumans. OverdosePrevention&Naloxone Policy&StandingOrderPage2of6

3 PROCEDUREGUIDELINES 1. TheHarmReductionCoordinator,underdirectionoftheHealthOfficer,shallberesponsiblefor trainingstaffandvolunteersonoverdosepreventionandnaloxoneuse.ccphstaffand volunteerswhohavecompletedtrainingshallbequalifiedasoverdosepreventioneducators. 2. CCPHHarmReductionStaffshallberesponsibleforreceivingshipments,monitoringinventory, andmaintaininglogdetailsofdispensedkitsandclientenrollmentforms. 3. AllOverdosePreventionEducators(includingstaffandvolunteers)shallbeauthorizedtodeliver theoverdosepreventionandnaloxonetraining,anddistributetakehomenaloxonekits. 4. AllOverdosePreventionEducatorswillbeeligibleforadditionaltrainingwiththeHarm ReductionCoordinatortorecognizeoverdoseandadministernaloxonetoclientsexperiencing overdoseattheharmreductioncenter. 5. OverdosePreventionEducatorsshallidentifysyringeexchangeclientsatleast14yearsofage,at riskofexperiencingorwitnessingopioidoverdoseaseligibleoverdoserespondercandidates, whofulfillthefollowingcriteria: Currentopioidusers,individualswithahistoryofopioiduse,orsomeonewithfrequent contactwithopioidusers,age14yearsorolder Riskforoverdoseorlikelihoodofcontactwithsomeoneatrisk,byreportorhistory Abletounderstandandwillingtolearntheessentialcomponentsofoverdose prevention,management,andnaloxoneadministration 6. OverdosePreventionEducatorsshallberesponsiblefordeliveringthe OverdosePrevention andnaloxonetraining educationalcurriculumtooverdoserespondercandidates(overdose PreventionGuideandTrainingAppendixD&E attached).theoverdosepreventioneducator willcompleteanenrollmentformforeachparticipant(overdosepreventionprogram ParticipantFormAppendixFattached).Thetrainingwilltakefrom20minutesupto1hour, dependingonquestionsaskedbycandidates,andwillinclude: Overdosepreventiontechniques Recognizingsignsandsymptomsofoverdose Calling911andTheGoodSamaritanLaw Rescuebreathing Naloxonestorage,carrying,andadministration Postoverdosefollowupandcare 7. Uponcompletionofthetraining,theOverdosePreventionEducatorwillassessthecandidates ontheirunderstandingoftheinformationandtheircomfortwiththebasiccomponentsof overdoseresponse.successfulcandidatesshallbecertifiedasoverdoseresponders.atake homenaloxonekitwillbedispensedtooverdoseresponderswhoshallbeauthorizedto possessandadministernaloxonetoanypersons(friend,family,partner,etc)experiencingan opioidoverdose. OverdosePrevention&Naloxone Policy&StandingOrderPage3of6

OrdertoDispense: UponparticipantcompletionofOverdosePreventionandNaloxoneTrainingProgramand documentationofcompetency,dispenseforusebyatrainedprogramparticipant:

4 OrdertoDispense: UponparticipantcompletionofOverdosePreventionandNaloxoneTrainingProgramand documentationofcompetency,dispenseforusebyatrainedprogramparticipant: Two1ccNaloxoneHydrochloride(concentration0.4mg/ml)vialsandtwo3mlsyringeswith 22g11/2 needles. NaloxoneKitcontents: Two1ccvialsNaloxoneHydrochloride(concentration0.4mg/ml) Two3mlsyringeswith22g11/2 needles AlcoholPads Onepairofgloves Rescuebreathingmask Overdosepreventiontips&instructionstouseNaloxone NaloxoneAdministration: (PleaserefertoAppendixA,B,&Cfordetailedinstructions): 1. Ifthepersonisn tbreathing,call Dorescuebreathingforafewquickbreathsfirst. 3. Popofftheorangetopfromthevialofnaloxone. 4. Openoneintramuscularsyringewithneedleandtwisttheneedle componenttosecureittothesyringe. 5. Foradolescentsandadults,drawupentirecontentsofthe1ccvial ofnaloxone(0.4mg)intothesyringe.forchildrenlessthanorequal to20kg(44pounds)bodyweight,pleasecall Injectintoamuscle thighs,upper,outerquadrantofthegluteus, ordeltoidarebest.ifpossible,cleantheskinwhereyouaregoing toinjectwithanalcoholswabfirst.itisokaytoinjectdirectly throughclothingifnecessary.injectstraightintomakesuretohit themuscle. 7. Afterinjection,continuerescuebreathing3minutes. 8. Ifthereisnochangeinabout3minutes,administeranotherdoseofnaloxoneandcontinueto breathefortheperson. 9. Remainwiththepersonuntilheorsheisundercareofamedicalprofessional,likeaphysician, nurseoremergencymedicaltechnician. NaloxoneSecurity&Storage SyringeExchangeStaffshallensurethatallnaloxonekitsaresecurelystoredattheHarmReduction Centerunderconditionsconsistentwiththemanufacture sguidelines. AdaptedfromHarmReductionCoalition.org Refills QualifiedOverdoseResponderswillbeeligibletoreceivetakehomenaloxonerefillsuponcompletionof afollowupassessment.overdosepreventioneducatorswillcompletetheform, OverdosePrevention Project UseandRefill AppendixFattached. OverdosePrevention&Naloxone Policy&StandingOrderPage4of6

5 Evaluation TheHarmReductionCoordinatorandCCPHstaffepidemiologistwillreviewcompletedenrollmentand refillforms(appendixf)atleasteveryothermonth. EMPLOYEEEDUCATIONANDTRAINING: AllHarmReductionCenterstaffandvolunteersshallreceivetrainingonthispolicy,andarerecommended tocompleteoverdosepreventionandnaloxonetrainingcurriculumtoqualifyasanoverdoseprevention Educator. APPENDICES: AppendixA:NaloxonePackageInsert H\communicabledisease\hivprevention\overdoseprevention\naloxonepolicy\naloxonepackageinsert AppendixB:OverdoseRecognition H\communicabledisease\hivprevention\overdoseprevention\naloxonepolicy\overdoserecognition AppendixC:PatientInstructions H\communicabledisease\hivprevention\overdoseprevention\naloxonepolicy\patientinstructions AppendixD:TrainingGuide H\communicabledisease\hivprevention\overdoseprevention\naloxonepolicy\trainingguide AppendixE:OverdosePreventionandNaloxone(Narcan)TrainingProgram H\communicabledisease\hivprevention\overdoseprevention\naloxonepolicy\overdosepreventionand naloxonetrainingprogram AppendixF:Participant&NaloxoneRefillForm H\communicabledisease\hivprevention\overdoseprevention\naloxonepolicy\participant&naloxone refillform OverdosePrevention&Naloxone Policy&StandingOrderPage5of6

6 References 1. WA State Law. RCW (911 Good Samaritin Drug Overdose Law) Retrieved from Washington State Department of Health, Washington State Injury and Violence Prevention Guide, Injury and Violence Prevention Program, Editor Control Centers for Disease and Prevention, Community-based opioid overdose prevention programs providing naloxone - United States, MMWR Morb Mortal Wkly Rep, (6): p APHA Policy Statement LB Reducing Unintentional Prescription Drug Overdoses, Preventing Overdose Through Education and Naloxone Distribution, American Public Health Association, Editor P. O. Coffin and S. D. Sullivan, Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal. Ann Intern Med, (1): p OverdosePrevention&Naloxone Policy&StandingOrderPage6of6

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Washington State PMP Data Mapping Project

Washington State PMP Data Mapping Project 2014 Category 3 Grant Harold Rogers Category 3 Grantee Meeting February 25, 2015 Washington State BACKGROUND: OPIOID ISSUES AND PLANNING 2 WA Unintentional Opioid