Overdose Crisis: A harm reduction approach

Transcription

1 Overdose Crisis: A harm reduction approach CAPA Conference, Ottawa October 29, 2017 Stan Kupferschmidt Joanna Binch

2 Objectives Describe the current landscape of opioid use in Canada. Discuss the dangers of fentanyl use. Review effective responses to opioid overdose. Review the current use of safer consumption sites in Canada. Describe the evidence used to support the use of supervised injection sites in harm reduction.

3 Disclosures No pharmaceutical disclosures/ conflicts of interest Our NESI peer program/ volunteers with lived experience contributed to this presentation Although opioids are prescribed for many patients across this lifespan, the focus of this presentation is relating to IDU and/or those using opioids not as prescribed

4 Myth or Fact Drug overdoses are a new problem for Canada.

5 Myth While statistics show a dramatic rise in overdose deaths in the last two years (2,458 for 2016 alone), overdoses among people who inject drugs is common As long as drugs are unregulated and produced in clandestine labs, there will always be overdoses.

6 Myth or Fact SIS: Safe injection Service

7 Myth There is no safe injection service. SIS: Supervised Injection Service. This is a Best Practices Harm Reduction Strategy.

8 Myth or Fact 911 is called in over 80% of overdoses.

9 Myth is called in less than 50% of overdoses. OPH 2016; PROUD 2016

10 Myth or fact? Fentanyl is the issue

11 Myth The issue as it has always been is trauma, violence, poverty and stigma, mental illness For people who use, drugs are not the problem, they are the answer Moral panic around a particular drug is a common narrative Mark Tyndall, 2017

12 Myth or Fact People are aware they are taking Fentanyl.

13 Truth With the delisting of Oxycontin in 2012, the currency of diverted prescriptions change to a more toxic drug. Prohibition leads to more toxic drugs Most people know they are taking Fentanyl, the dose is just more difficult to manage.

14 Myth or Fact Fentanyl is being cut into all kinds of drugs nothing is safe

15 Myth Toxicology from overdose victims usually shows multiple drugs including fentanyl because many people use multiple drugs Confiscated drugs purchased as cocaine or crystal meth that contain fentanyl are mostly due to a processing mistake Fentanyl is being sold because it is profitable for the suppliers, cheaper for the users, and readily available

16 Myth or fact The supply of Fentanyl can be stopped by tougher enforcement

17 Myth If we can t stop massive bags of heroin, how do we stop tiny envelopes of fentanyl? The focus needs to be on the demand side, addressing the social drivers that lead to addiction and supporting those who are addicted.

18 Trump declares opioid epidemic a national public health emergency Current Landscape

19 Scope of the Problem 2,458 overdose deaths in 2016 in all of Canada Approximately seven Canadians die of overdose each day. Highest rates of death in Western Canada opioidrelated death rates of over 10 per 100,000 population Serious fear of police response if call % of people who use drugs OD d in the previous 6 months Average lifetime number of OD s: 5 Opioid Crisis - Fentanyl / Carfentanil Emergency Depart ment Visit s for Drug Overdoses in Ot t awa June 2017 Report This report provides available monthly trend data on drug overdoserelated emergency department visits. It provides information on the overdose-related emergency department visit trends relating to overdoses in the last 6 months. What are the emergency department (ED) overdose trends in the last 6 months? The diagram on the right shows weekly counts of drug overdose-related emergency visits in Ottawa for the past 6 months among those aged 10 to 64. It only captures emergency department visits with life-threatening or potential life-threatening circumstances. It does not include people who overdose and do not access an emergency department. Key points: Drug overdose-related emergency department visits with life-threatening or potential life-threatening circumstances Emergency department visits by week were stable in December 2016 An increase started in January 2017, and returned to pre-2017 levels in late March 2017 An increase started in early April 2017, and has continued into May May year to date 2016 Total This product was developed in partnership with the Ottawa Overdose Prevention and Response Task Force. For more information visit: 127 visits 549 visits 1,122 visits The data used in this report is from: Drug overdose-related emergency department data Ottawa Paramedic Service naloxone administration data This data is updated monthly with additional data and indicators added as they become available. Data may change slightly between monthly reports based on updates to historical data. The reporting periods for the data sources used in this report may not align exactly with calendar months, as it is based on weekly data. NALOXONE May year to date Ottawa Paramedic Service Data: January 2017 to May # of patients administered naloxone by paramedics for suspected opioid overdose 72 # of patients administered naloxone by paramedics for suspected opioid overdose An OVERDOSEis a medical emergency. Anyone that suspects or witnesses an overdose should immediately CALL 9-1-1, even if Naloxone has been given.

20 Context-How did this happen? War on drugs Stigma & discrimination Delisting of oxycotin in 2012 Recent provincial response to overdose crisis makes prescribers fear prescribing Fentanyl patches no longer covered by drug programs for people with social assistance Ease of supply of fentanyl from overseas

21 Objectives What is an opioid? What is fentanyl? Discuss the dangers of fentanyl use What is carfentanil?

22 What is an opioid?

23 What is Fentanyl? Developed in 1959, in 1990 s developed as transdermal patch for palliative care Around 50 to 100 times more potent than morphine. Available in both pharmaceutical and illicit forms. Illicit fentanyl is often made as a powder and mixed with other drugs Street names: fake oxy, greenies, green beans, green apple, shady eighties, etc. or for fentanyl-laced heroin include Apache, China Girl, China White, Dance Fever, Friend, Goodfella, Jackpot, Murder 8, TNT, and Tango and Cash.

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25 P.E.I. Police Photo Shows Just How Little Fentanyl and Carfentanil It Takes To cause a fatality

26 Carfentanil Used by vets for very large animals like elephants. 100 x more potent than fentanyl. 10,000 times more potent than morphine. Cut into some drugs like heroin & counterfeit pills made to look like prescription opioids There is no easy way to know if carfentanil is in drugs, you can t see it, smell it or taste it. It is extremely toxic and a very small amount can cause an overdose.

27 Opioid Overdose 1. What are the risks for overdose? 2. Message for your patients 3. How to recognize an overdose 4. What you should have in the clinic to manage 5. What harm reduction approach you could be a part of

28 Overdose risk factors DECREASED TOLERANCE You are at increased risk if you have not used in a few days because you were incarcerated, you just returned from treatment. MIXING DRUGS Danger = Use one drug at a time USING ALONE Have a plan and know your limit

29 Overdose risk factors DRUG QUALITY & POTENCY Drugs can have added ingredients HEALTH STATUS Use less if you are sick. ROUTE

30 Fentanyl Overdose Prevention Message Store medications safely Don t use alone Leave door unlocked Tell someone to check on you Start with a small amount Try to procure your drug from a familiar source, but alert if anything looks different Do testers to check strength Mixing drugs, including alcohol, increases risk of overdose If you do mix, choose to use drugs before alcohol (you can puke out the alcohol, but not the drug you shot up) Pace yourself Choose a safer route of taking drugs Be aware: using drugs while on prescribed medications can increase overdose risk Call 911 right away if someone overdoses [e.g. has difficulty breathing or loses consciousness] Use less if you are sick Use where help is easily available (e.g. most importantly around people you trust) Make a plan/know how to respond in case of OD. Be prepared to give breaths and/ or administer naloxone (Narcan) until help arrives Overdose response training and naloxone kits are available for free!

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32 Signs of opioid overdose Can t be woken up ( no response to shake and shout ) Slow breathing or no breathing (<12 breaths/minute) X Blue lips and nails

33 Signs of opioid overdose Snoring or gurgling sounds Skin feels cold Very small pupils

34 Office Supplies Naloxone (multiple doses) Intranasal Intramuscular Oxygen Ambu-bag attached to the oxygen tank BP Cuff O2 Sat monitor Air ways Nasal Oral Snacks

35 What is Naloxone A Competitive Antagonist at Opioid Receptor Sites Naloxone is a medication that can temporarily reverse the effects of an overdose The goal of naloxone is to restore adequate breathing (required for life) The drug is still in the body. Image: Harm Reduction Coalition / Graphics by Maya Doe-Simkins

36 No Need to Fear Naloxone! Listed on WHO s list of essential It is a life-saving measure It works if someone has ingested opioids. It has no effect if someone has not ingested opioids The only reason not to give it is if someone has ever had an allergic reaction to naloxone previously Naloxone starts to work within 2-5 minutes, wears off as quickly as minutes Can be administered into a muscle via injection, or intranasal preparation. Used in Canada for over 40 years Do not need a prescription to use or obtain

37 What s in a Naloxone Kit? 2 vials of Naloxone and 2 syringes OR two intranasal sprays 1 breathing mask Gloves Step-by-step instructions

38 In case of an overdose 1. Shake at the shoulders & Shout their name (sternum rub) 2. Call 911 if unresponsive 3. Chest compressions 4. Naloxone

39 In case of an overdose 5. Better? If the person is not doing better after 3-5 minutes (not breathing, not waking up), give a second dose of Naloxone and continue CPR until paramedics arrive. 6. If you have to leave the person alone at any time, put them in the recovery position.

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41 Supervised Injection Service 1. Harm reduction philosophy 2. Approaches to harm reduction (opioids) 3. Test your knowledge 4. SIS

42 Harm Reduction Drug use as a human behaviour and complex social issue that should be approached from a health perspective, not a criminal perspective A set of practical strategies and ideas aimed at reducing negative consequences with drug use The more doors you have open for people to come in to get help, the greater the chance we have to save decades of their lives. - Ray Harrison, NESI peer

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44 Continuum of Substance Use SMI Chronic Non Use Abstinence Situational Use Regular/Man aged Use Problematic Use/ Addiction Complex Addiction We need to move towards social justice built on a belief in, and respect for the rights of people who use drugs.

45 Harm Reduction Approaches Peer involvement Talk to your patients and ask the right questions Naloxone & overdose prevention training Offer drug testing & checking Recognition consumption (include injection drug use and smoking) Opioid substitution therapy Managed opioid programs Drug Testing Overdose prevention sites

46 MYTH or FACT Supervised Injection Services have been proven effective.

47 MYTH There are 90 locations throughout Western Europe and Australia. SIS has proven to reduce overdoses, reduce the risk of HIV and Hep C transmission, and help drug users into addiction treatment services.

48 MYTH or FACT Abstinence based addiction treatment and short term detox is the priority

49 MYTH While addiction treatment in the form of inpatient beds has a role, the staggering numbers of people currently at risk will require a much broader response Short term rapid taper detox with no follow up can actually contribute to overdose deaths.

50 MYTH or FACT An agency/organization requires a federal exemption from the controlled drug & substances act in order to serve people who use drugs.

51 MYTH Needle exchange no exemption Administering naloxone no exemption Alley patrols/outreach no exemption Telling people to use with others no exemption Opening a supervised consumption site exemption required Mark Tydall, 2017

52 Supervised Consumption Sites

53 SIS The number one overdose intervention names by community groups and current drug users is supervised injection There has never been an overdose death at a supervised injection site. Currently, these services are quickly opening across Canada (Edmonton, Montreal, Ottawa, Vancouver, Kelowna, etc.) The local government and community groups play a critical role

54 Documented successes Reduced overdose deaths Reduced sharing of needles (reduced risks of HIV & Hep C) Reduced public injecting Increased use of detox & treatment services Decreased number of publicly discarded needles Health Care costs Increased safety & decreased stigma

55 Questions!

56 The Science! Published Science, Reports and Evaluations Insite for Community Safety