Overdose Prevention and Response and Relay, a post-overdose initiative
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1 Overdose Prevention and Response and Relay, a post-overdose initiative Emily Winkelstein, Community Engagement Manager Bureau of Alcohol and Drug Use Prevention, Care and Treatment
2 Agenda How overdose is affecting New Yorkers DOHMH responses Opioid overdose Naloxone and overdose response Expanding access to naloxone Relay: A model for post-overdose engagement Questions
3 Key terms Opioids: pain relievers, including prescription painkillers, heroin and fentanyl Opioid Overdose: respiratory depression or death as a result of using opioids Naloxone: a medication that reverses the effects of an opioid overdose
4 Opioids Heroin Tramadol (Ultram, Ryzolt ) Methadone Oxycodone (Oxycotin, Percocet ) Hydrocodone (Vicodin, Lortab ) Oxymorphone (Opana ) Fentanyl (Duragesic ) Morphine Not opioids Cocaine or Crack Methamphetamines Benzos (Valium, Xanax, Klonopin ) Alcohol Muscle Relaxers (Soma, Flexeril ) Seroquel Gabapentin (Neurontin )
5 HOW OVERDOSE IS AFFECTING NEW YORKERS 5
6 Number of overdoses Overdose Rate Overdose deaths have increased for six consecutive years in NYC 1600 Number of unintentional drug poisoning deaths (overdoses), New York City, ** Confirmed drug overdoses Estimated number of pending deaths Overdose Rate Source: New York City Office of the Chief Medical Examiner & New York City Department of Health and Mental Hygiene * *Data for 2015 and 2016 are preliminary and subject to change.
7 Rate of overdose deaths, by neighborhood of residence, 2016 Rate of unintentional drug poisoning (overdose) deaths (per 100,000 residents), New York City, Crotona Tremont High Bridge Morrisania Hunts Point Mott Haven East Harlem Top 5 neighborhoods South Beach Tottenville
8 Age-Adjusted Rate per 100,000 Source: New York City Office of the Chief Medical Examiner & New York City Department of Health and Mental Hygiene * *Data for 2016 are provisional and subject to change. (June 13, 2017) Number 2016: Highest Rate among Staten Island residents; Largest Number among Bronx residents Rate of drug overdose death, Number of drug overdose deaths, by borough of residence, by borough of residence,
9 Heroin Or Fentanyl Involved In Nearly All Opioid Overdoses In 2016 Any Opioid 82% Heroin or Fentanyl 72% Cocaine 46% Benzodiazepines 33% Opioid Analgesics 18% Methadone 14% Source: NYC Office of the Chief Medical Examiner & NYC DOHMH Bureau of Vital Statistics *Data for 2016 are provisional and subject to change. (June 13, 2017)
10 Fentanyl in NYC drug supply Fentanyl is times > morphine Illicitly manufactured fentanyl (IMF) - Not patches or lollipops - Produced in illicit laboratories Showing up in heroin, as well as cocaine, and counterfeit street pills (e.g., marked as Xanax or opioid analgesics) - Cut or pressed in before purchase No reliable way to detect if fentanyl is present by sight, taste, or smell
11 Number of overdoses Percent involving fentanyl Increase in Fentanyl Driving Increases in Overdose Deaths Number of unintentional drug poisoning deaths (overdoses), by quarter, New York City, % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Confirmed drug overdoses Estimated number of pending deaths Percent involving fentanyl Source: New York City Office of the Chief Medical Examiner & New York City Department of Health and Mental Hygiene * *Data for 2015 and 2016 are provisional and subject to change (June 13, 2017)
12 Number of overdoses Source: New York City Office of the Chief Medical Examiner & New York City Department of Health and Mental Hygiene * *Data for 2015 and 2016 are provisional and subject to change (June 13, 2017) Percent involving fentanyl Fentanyl increasingly present in cocaine-involved overdoses Number of unintentional drug poisoning deaths (overdoses) involving cocaine without heroin, by quarter, New York City, % 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Overdose deaths involving cocaine, no heroin Percent involving fentanyl
13 DOHMH Response to Opioid Epidemic 1. Rapid Assessment and Response (RAR) 2. Judicious opioid prescribing 3. Buprenorphine access 4. Naloxone expansion 5. Public awareness campaigns 6. Relay: Non-fatal overdose response system
14 DOHMH Response to Opioid Epidemic 1. Rapid Assessment and Response (RAR) 2. Judicious opioid prescribing 3. Buprenorphine access 4. Naloxone expansion 5. Public awareness campaigns 6. Relay: Non-fatal overdose response system
15 Public health approach Sometimes people engage in behaviors that are harmful to themselves or others. People may engage in behaviors even knowing they re harmful, illegal, unhealthy, or cause harm to others. People may be willing and able to make some changes to decrease the risk of harm to themselves and their community. Individual goals may or may not involve abstaining from substance use.
16 UNDERSTANDING OPIOID OVERDOSE 16
17 The process of overdose happens over the course of minutes to hours Fatal Overdose Too many opioids gradually suppress the involuntary drive to breathe Breathing slows down Heart Stops Important: The window to respond to an overdose may be shorter with fentanyl involved.
18 Common Risk Factors Risk Reduction Changes in Tolerance Mixing Drugs Drug Quality Previous Non-Fatal Overdose Using Alone Be careful if you take a break or miss doses, use less, go slow Think about the order of ingestion Go slow/do a slow shot, make an overdose plan, have a phone on hand to call 911 Assess for risk, carry naloxone Use with someone else, take turns: It s important to have someone to help Use of any opioids can put someone at risk
19 NALOXONE AND OVERDOSE RESPONSE
20 Naloxone Only function is to reverse opioid overdose Zero effect if opioids are not present Will not reverse overdoses caused by non-opioids No known negative effects Non-addictive No potential for abuse or dependence May cause withdrawal in opioid dependent person Not a controlled substance In NYS may be carried and administered by non medical people
21 Common naloxone products Nasal Sprays Single-step Nasal Spray (Narcan ) Multi-step Nasal Spray Injection Single-step Intramuscular Auto-Injector (Evzio )* Single-step Intramuscular Injection
22 How does naloxone work? Opioids Opioid receptors
23 How does naloxone work? Usually takes effect within 2-5 minutes to restore breathing Lasts for minutes Opioids Naloxone Opioid receptors
24 Overdose Response Steps 1. Check for responsiveness Shout and shake Sternum rub 2. Call 911 Good Samaritan Law 3. Administer naloxone 4. Rescue breaths 5. Rescue position 6. Aftercare
25 NALOXONE ACCESS
26 Who can carry naloxone? In NYS, trained laypersons can legally administer naloxone for overdose prevention NYS Public Health Law (April 2006) created the Opioid Overdose Prevention Program (OOPP) Community-based organizations, providers and other entities can register as OOPPs provide FREE naloxone to their clients or patients Dispensers and responders have liability protection
27 Who should carry naloxone? Any individual at risk of experiencing an opioid-related overdose, including anyone: High-dose opioid prescription (> 100 total MME/day) Chronic opioid therapy (>3 months) Current or past opioid misuse/illicit use Including people in treatment for Opioid Use Disorder Opioid overdose history Any individual at risk of witnessing an opioid related overdose This may include persons who use drugs other than opioids Family members, friends or others in social networks of people using drugs
28 Naloxone distribution in NYC DOHMH has distributed over 80,000 kits to OOPPs since 2009 FY17: 30,000 kits FY18: 62,000 kits FY19: 100,000 kits Over 1,400 reversals reported INITIAL ADOPTERS Syringe exchange AIDS service organizations Drug treatment Homeless shelters RECENT SETTINGS Rikers Island Visit House NYPD Primary care Emergency Departments Pharmacies FUTURE EXPANSION Probation & parole Courts Consistency across drug treatment Additional clinical settings
29 Each DOHMH overdose rescue kit includes: 2 doses of Narcan Nasal Spray A face mask for rescue breathing 2 alcohol swabs 2 gloves A brochure reviewing overdose risk, recognition and rescue steps
30 Common questions Does naloxone make people use more drugs (provide a safety net )? No evidence of riskier use Some studies suggest reductions in drug use Does giving naloxone send the message that it s okay to use drugs? Sends the message that we care about community members Builds trust and increases dialogue Seal KH, Thawley R, Gee L, et al. 2005; Wagner KD, Valente TW, Casanova M, et al. 2010; Jones, Jermaine D., et al. 2017; Doe-Simkins M, Quinn E, Xuan Z et al. 2014
31 Common questions Why would someone who isn t currently using drugs need or want naloxone? Relapse is often a part of the recovery process Periods of abstinence increase risk To protect friends and others If we give out naloxone, people won t call 911 for help. Hasn t proven true in practice Training encourages people to call 911 Good Samaritan legislation to encourage 911
32 How to talk about overdose/naloxone Not all patients will identify with the language of overdose or the need for naloxone Sample language: Bad reactions to opioids are rare, but it is important to be prepared if they happen Naloxone is like an epipen for opioids it s important to have it around just in case of an emergency We recommend naloxone for anyone that takes opioids or is around anyone that takes opioids for opioid safety
33 Opportunities for expanding access Encourage your organization to become an Opioid Overdose Prevention Program (OOPP) Directly dispense free naloxone supplied by DOHMH Tool for increased dialogue around drug use and risk Registration is easy and dispensing can often be easily integrated into existing work Submit two-page application to NYSDOH Identify key staff Develop policies and procedures for dispensing Training can be completed in as little as 5 minutes DOHMH can provide technical assistance
34 Naloxone prescribing guidance Providers with prescribing privileges can write patient-specific prescriptions for naloxone DOHMH offers clinical guidance based on known risk factors
35 Where else is naloxone available? Naloxone available via standing order (no prescription needed) NYC Health Commissioner provides standing order to pharmacist to dispense naloxone All major chain pharmacies carry naloxone Insurance required or ability to pay, co-pays may apply N-CAP program covers co-pays up to $40 Find a pharmacy on DOHMH Site Locator
36 Where else is naloxone available? At participating community-based organizations that have registered as an Opioid Overdose Prevention Program (OOPPs) Includes 14 harm reduction programs About 140 programs citywide - call ahead and make an appointment Best option for individuals without insurance coverage
37 Download the app: Stop OD NYC
38 RELAY: A MODEL POST-OVERDOSE SUPPORT PROGRAM
39 Relay Background Nonfatal overdose increases risk of future, frequently fatal, overdose The occasion of a nonfatal overdose is an opportunity for intervention Relay program model based on pilot program in Rhode Island Feasibility to engage and follow patients
40 Relay Overview: NYC DOHMH nonfatal overdose response system New hospital-based support system for overdose patients called Relay. Relay dispatches Wellness Advocates, trained peer workers, to collaborating emergency departments 24/7. Offer overdose risk reduction counseling; opioid overdose rescue training and naloxone; followup, referrals, and navigation to harm reduction, drug treatment, or other services.
41 Relay Sites June 5: NY Presbyterian/Columbia University Medical Center (NYP) June 26: Montefiore Medical Center (MMC) June 30: Richmond University Medical Center (RUMC) subcontracted through CHASI Over 3 years, expand to all boroughs, 10 hospitals
42 Relay Procedures 1. ED activates Relay by calling Poison Control Center (PCC) 2. PCC dispatches the on-call Wellness Advocate 3. Introductions 4. Wellness Advocate engages with patient Risk reduction counseling Opioid overdose rescue training with naloxone for patient + family/friends Referrals, navigation to harm reduction/other services 5. Follow up for up to 90 days
43
44 Relay Program Evaluation IRB approved program evaluation underway Will collect data via 4 and 9 month follow-up phone survey Will match to mortality and hospital records
45 Relay Engagement (as of 9/11/17) Number of patients referred from 3 hospitals Number of participants successfully engaged Number of overdose response kits distributed (MMC 24; NYP 26; RUMC 10) 87 (67 participants) Number of 24-hour follow-ups 29
46 Challenges Identifying appropriate staffing structure Hospital turnover requires weekly training Patients being held in ED for longer than expected Each hospital is unique and protocols must be adapted to work within their systems
47 What Relay participants are saying I ve overdosed three times in two days. What am I doing wrong? Will you stay and talk to me? You re the only one that listens. Thank you so much for coming today. One day I wanna be a Wellness Advocate like you.
48 Summary Opioid overdose has reached epidemic levels in NYC and are continuing to rise Naloxone is a safe, easy, legal, and evidence-based tool that can be made available to clients to help reduce risk of overdose death Providers can: Talk about fentanyl and od prevention Become an OOPP Refer to community-based OOPPs and/or Pharmacies Engage with patients who have had non-fatal overdoses
49 Questions? Emily Winkelstein Naloxone Technical Assistance Relay
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