Drug use in Colorado: New Ideas, New Partnerships, New Outcomes

Transcription

1 Drug use in Colorado: New Ideas, New Partnerships, New Outcomes Presented by: Lisa Raville, Executive Director Harm Reduction Action Center Rick Brandt, Chief, Evans PD and Past President, CACP Thanks to... Scope of the problem

2 How did we get here? The perfect storm! 1990 s: Aggressive opioid prescribing practices! Many new users! Widespread opioid availability! 2000 s: Spread of heroin to new markets! No longer limited to coastal metropolitan areas! Nearly 19,000 Opioid medication deaths! 1.9 million users! 10,000 heroin overdose deaths! 580,000 users Overdose Death Rates: U.S. Colorado overdose death rate Colorado Health Institute Report 2016

3 Colorado Counties: Highest overdose death rates: 2002 Colorado Counties: Highest overdose death rates: 2014 Colorado Health Institute Report County ( *Denotes first-responders already naloxoneequipped) Adams Baca Bent Boulder* Clear Creek Costillo* Conejos* Crowley Delta Denver* Dolores Fremont Huerfano Jackson Las Animas Mesa Otero Ouray Phillips Pueblo Rio Grande* Sedgwick

4 WHAT ARE OPIOIDS? HOW DO OPIOID USERS BECOME ADDICTED? WHY DO THEY OVERDOSE? How addiction hijacks the brain Koob, 2003 Opioids! Drugs that bind to opioid receptors! Effects:! Pain relief! Decreased anxiety! Relaxation! Sleepiness! Euphoria! Over time, tolerance develops to many of these effects! Tolerance to some physical effects are incomplete! Constipation! Respiratory depression

5 What is an opioid? Drugs derived from opium, also called opiate Opioid includes semi-synthetic and synthetic opiates Examples: Heroin Increasingly cut with illicitly produced synthetic opioids including fentanyl, carfentanyl Morphine, codeine, hydrocodone (Vicodin, Lorcet), oxycodone (Percocet, Roxicet), OxyContin, oxymorphone (Opana) hydromorphone (Dilaudid), meperidine (Demerol), Fentanyl, methadone How are opioids used? Oral Inhaled/smoked Intranasal/insufflation/sniffed/snorted Absorbed through the rectal mucosa Transdermal (skin) through patches Injected intravenously, intramuscularly, or subcutaneously Overdose risk factors Quality Mixing Tolerance: after detoxification, hospitalization, incarceration Using Alone Health Problems Others: Increasing dose (milligrams morphine equivalents) Psychiatric and substance use disorders Doctor-shopping: more than 4 clinicians Dunn, Ann Intern Med 2011; Bohnert, Am J Psychiatry, 2011; Bohnert, Jama, 2011; Hall, Jama, 2008 Binswanger, NEJM, 2007; Cornish R BMJ 2010; Merrall, Addiction, 2010 & 2012; Lim S. American J Epidemiol,; Albert Pain Med, 2011; Boyer, NEJM, 2012

6 Mixing Drugs: Benzodiazepines! Overdoses often involve more than one drug! Other drugs that suppress the respiratory system are especially dangerous! Most commonly abused benzos:! Clonazepam (Klonopin, K-pin )! Alprazolam (Xanax, Xannie bars )! Diazepam (Valium, V s ) Opioid Overdose Pinpoint pupils Respiratory depression (shallow/no breathing) Blue or grayish lips/ fingernails No response to stimulus Gurgling/ heavy wheezing or snoring sound Occurs over 1-3 hours - the stereotype needle in the arm death is rare REALLY HIGH Muscles become relaxed Speech is slowed/ slurred Sleepy looking Nodding Will respond to stimulation like yelling, sternal rub, pinching, etc. Normal pulse OVERDOSE Deep snoring or gurgling (death rattle) Very infrequent or no breathing Pale, clammy skin Heavy nod, not responsive to stimulation No or minimal response to pain Slow heart beat/ pulse Overdoses in Colorado Colorado Coalition for the Homeless. (2013, December). We Will Remember 2013: Homeless Death Review. Retrieved from userfiles/library/homeless%20death%20review % pdf. Colorado overdoses Total drug overdose deaths: 10,544 Opioid-related deaths: 3,537 Denver 2016: 174 Denver 2015: 129

7 Anatomy of opioid addiction Borrowed with permission from NOPE-RI Colorado Harm Reduction Legislation What is Harm Reduction?! Strategies designed to keep people alive and healthy until they can access treatment and recovery! HR proven to prevent disease while saving lives and money! Naloxone is a key part of the harm reduction strategy! Naloxone reversals have been shown to:! Reduce fatal overdose! Increase enrollment in drug treatment! Naloxone is not a solution to the opioid epidemic, but it gives some the chance for recovery and has not been shown to promote drug use

8 Colorado Harm Reduction Legislation Senate Bill 14 for Third Party Naloxone distribution Passed Colorado Legislature May, 2013 Allows medical providers to prescribe Naloxone to 3rd parties likely to witness an overdose Including: Friends and family members of opiate users Law enforcement Public health agencies To date, 610 lives have been saved so far under this legislation by HRAC alone Colorado Harm Reduction Legislation Senate Bill 20, the 911 Good Samaritan law Senate Bill 20, signed into law in May of 2012, provides legal immunity from prosecution for small amounts of drugs and paraphernalia to individuals who call 911 in response to an overdose emergency. Prohibits the arrest and criminal prosecution of anyone, including the individual who experiences an emergency drug or alcohol overdose, for certain offenses when the person or persons (Sec. 2): Report an emergency drug or alcohol overdose to law enforcement or 911 Stay at the scene of the overdose until law enforcement or an emergency medical responder arrives Identify themselves and cooperate with law enforcement or the emergency medical responder. Establishes that the individuals who experience or report an overdose are immune from prosecution for any of the following offenses, if the offense arose from the same course of events as the overdose (Sec. 2): Possession of a controlled substance, except for: Any mixture more than 4 grams of ketamine, flunitrazepam, or any schedule I or II drug; or Any mixture more than 2 grams of methamphetamines; Defines emergency drug or alcohol overdose as including, but not limited to, the following conditions (Sec. 2): Physical illness, coma, mania, hysteria, or death that results from the consumption or use of: A controlled substance; Alcohol; Another substance with which a controlled substance or alcohol was combined; and That a layperson would believe to be a drug or alcohol overdose requiring medical attention. Colorado Harm Reduction Legislation! SB Needlestick Prevention! 1 out of 3 law enforcement will experience a needle stick injury in their career. 2/3 of that 1/3 will experience multiple sticks. This law will prevent needle stick injuries to law enforcement.! SB creates an exception to ticketing, arrest, and filing of charges for the crime of possession of drug paraphernalia if the person prior to being searched by a peace officer informs the peace officer that he or she has a needle or syringe on his or her person or in his or her vehicle or home that is subject to a search. For a 2:30 video to train officers - harmreductionactioncenter.org/law-enforcement/

9 Senate Bill : Standing Orders A standing order allows a physician or any medical professional with prescriptive authority to write an order for a medication that can be dispensed by other designated individuals under certain conditions, such as harm reduction organizations and pharmacies. Currently 400 pharmacies offer access to naloxone through standing orders! Scales' Pharmacy 1999 Pennsylvania St, Denver, CO (303) Good Day Pharmacies 1925 Mountain View Ave., Longmont, CO (303) N Boise Ave., Loveland, CO (970) Flatirons Family 603 Ken Pratt Blvd, Longmont, CO (303) Pharmacy! Go to stoptheclockcolorado.org 4500 E 9th Ave for an #180, interactive Denver, map CARES CO (303) Mental Health Partners 1333 Iris Ave. Boulder, CO (303) King Soopers/City Many CVS/Target Many Walgreens Many First responder Naloxone programs Law Enforcement Training Nationally Quincy, MA 2010: first municipal PD to equip all officers >400 reversals since implementation Staten Island, New York Began January 2014 NY Office of the Attorney General $1.2 million used to supply 20,000 kits to NYC PD NOPE-Rhode Island >25% of all law enforcement trained >2000 Police and Sheriff s Departments >131 Colorado Departments

10 Policy Development & Training Naloxone for releasing inmates! Inmates released from incarceration are 129 times more likely to die of drug overdose than the general population in the first 2 weeks! 3.5x more likely to die of any cause! Colorado Office of Behavioral Health supporting naloxone distribution from contracted county jails:! Arapahoe! Boulder! Denver! Douglas! Jefferson! >600 inmates who inject drugs trained so far Binswanger, et al.nejm 2007; 356: Opioid Overdose Deaths Are Preventable Since 2015 Narcan (Naloxone) has been distributed to numerous Colorado Law Enforcement Agencies. Safe Highly effective Having available before paramedics arrive saves lives and decreases possibility of brain damage Community programs and first responder access has been expanding across the country Since 2010, 183% increase in community organizations that provide naloxone to laypersons Giving naloxone to someone who has overdosed on other drugs or who is not an overdose victim will not hurt them Tens of thousands of lives have been saved nationally

11 Naloxone Opioid antagonist >40 years experience by emergency personnel for OD reversal Not addictive; no potential for abuse; no agonist activity Not a scheduled drug but RX needed No side effects except precipitation of withdrawal (dose-sensitive) Unmasking underlying medical problems Administer intramuscular and intranasal Naloxone Delivery Systems Intranasal Evzio autoinjector Injectable Nasal Narcan

12 How Naloxone Works RESPIRATORY 35 CENTER Naloxone in Action The Need For Medical Attention Duration of action of naloxone compared with common opioids Brenner GM, Stevens CW. Pharmacology. Philadelphia, PA: Saunders/Elsevier; Graphic: courtesy of NOPE-RI

13 Reporting an Overdose Reversal: The Opi-Rescue App

14 L.E.A.D. WHAT IS L.E.A.D.? LEAD is a pre booking diversion program. Divert low level, non violent crime offenders directly into treatment and social support to address the root cause of their criminal behavior Addiction. By diverting offenders into treatment an already overburdened criminal justice system is bypassed and allow it to handle more serious cases. Addiction is viewed as a medical issue and LEAD addresses three fundamental issues in our communities; Improve lives, reduce crime and save taxpayer dollars. COMMON FACTORS IN LAW ENFORCEMENT TODAY Manpower Issues Decreased Budgets Lack of Community Support Increased Crime Rates Mass Incarceration Reducing Recidivism Increased Safety to the Public and LE Changing Lives

15 L.E.A.D. Programs Across the Country MAKING A DIFFERERENCE By diverting low level drug offenders into treatment, LEAD provides immediate wrap around services to the individual to address their addiction. Wrap around services include: Immediate intensive case management. Emergency housing in DV and prostitution situations. Food Clothing Start addressing drug withdrawal and cravings. MAT Therapy Once the addiction component is addressed, the criminal behavior is either stopped or it is drastically reduced. Pre-Arrest Diversion Model Arrest Typically Criminal no services Justice System are given during adjudication to address drug addiction Adjudication Pre- Arrest Case Management LEAD MAT, Housing, Therapy, Educational incentives, Trade Training, Housing, etc.

16 New vs Traditional Education Incentives Trade Training Immediate Case Management Basic Necessities Drug Court Maybe MAT Harm Reduction Methadone IOP LEAD Emergency Housing, DV, Prostitution Human Trafficking CRIMINAL JUSTICE Medical Care More oversight Transportation to and from treatment OVERDOSE DEATH STATISTICS Death from drug overdose is the leading cause of accidental death in the United States. In 2015 in the US and Colorado, drug overdoses caused more deaths than firearms and traffic crashes. (Overdose: 904. Firearm: 698: Traffic Accident: 545) Everyday 144 people die in the United States from a drug overdose. Of those, 91 people die as a result of an opioid (heroin and/or prescription) overdose (CDC). In New Colorado: a) From , the number of heroin overdose deaths in CO doubled, from 69 to 160. b) Property Crime statistics are revealing a direct correlation to opiate use and abuse. Benefits of L.E.A.D

17 National Overdose Deaths by Gender REDUCING CRIME One of the central tenets with LEAD is to redirect officers to handle more pressing first responder duties rather than deal with low level drug offenses or criminal offenses. Officers can be released back into the street within 30 minutes rather than be stuck on a call for hours. A LEAD Case Manager can meet a LEAD Officer or a patrol officer/detective in the street or in the station to relieve them from the offender. An evaluation conducted on Seattle, Washington's LEAD program discovered that individuals who were engaged in their program were 58% less likely to be rearrested for another crime. COST SAVINGS Typically LEAD program funding is derived from city, county, state appropriations and foundation dollars. Rarely are programmatic costs removed from department budgets. Costs of incarceration vary between cities. In Colorado costs it approximately $30,374 per year to house a prisoner. Cost benefit analysis of LEAD.

18 Taxpayer Savings Cost of Incarceration vs. Treatment Harm Reduction Principles of Harm Reduction Harm reduction is a set of practical strategies aimed at reducing negative consequences associated with drug use: overdose, arrest, homelessness. A harm reduction approach: Accepts that licit and illicit drug use is part of our world and chooses to work to minimize its harmful effects. Understands drug use is a complex, multi-faceted phenomenon that encompasses a continuum of behaviors from severe abuse to total abstinence. Establishes quality of individual and community life and well-being not necessarily cessation of all drug use as the criteria for successful interventions and policies.

19 Principles of Harm Reduction Calls for the non-judgmental, non-coercive provision of services and resources to people who use drugs in order to assist them in reducing attendant harm. Affirms drugs users themselves as the primary agents of reducing the harms of their drug use. Does not attempt to minimize or ignore the real and tragic harm and danger associated with licit and illicit drug use. Examples of Harm Reduction Programs Needle Exchange Prevents used needles from being discarded in parks or on the street. Prevents officers from being stuck by a needle. 1 in 3 officers will be stuck by a needle. Persons unwilling and or unable to stop using drugs access social programs aimed at treating their addiction while they are obtaining clean needles. Reduces the amount of people who contract communicable diseases. HIV, Hepititis C Upon arrest, or pre-arrest, an officer will contact an individual on the street and determine, based on eligibility requirements, if they qualify as a candidate for LEAD. If they do qualify, the subject is handed over to a case manager immediately and the officer is released to continue his shift. If they do not qualify the subject is referred through the traditional criminal justice system. The subject is required to complete an intake assessment and is required to return to the treatment provider within 7 days to continue a more intense individualized treatment plan. The officers and case managers meet twice a month to discuss the progress of their client and learn about the services that are being provided to them. Officers also have a social referral component to the program.

20 Frequently asked questions Will naloxone work on other drug overdoses?! Naloxone only blocks the opioid receptor! No effect on alcohol, benzodiazepines, cocaine, etc.! Drug overdose deaths are often poly-drug! Giving naloxone to someone who has overdosed on other drugs or who is not an overdose victim will not hurt them What do I do with people asking for drug treatment? COLORADO CRISIS SERVICES TALK (8255) or text TALK to Walk-In Centers: Westminster: 2551 W 84th Avenue Westminster Lakewood: W. 2nd Place Lakewood Littleton: 6509 S. Santa Fe Drive Littleton Boulder: 3180 Airport Road Boulder Denver: 4353 E. Colfax Avenue Denver Aurora: 2206 Victor Street Aurora Fort Collins: 1217 Riverside Ave Fort Collins Greeley: th Street Greeley Grand Junction: /4 Road Grand Junction Pueblo: 1302 Chinook Lane Pueblo Colorado Springs: 115 S Parkside Drive Colorado Springs

21 What s Next?! Naloxone Efforts for drug users, drug treatment facilities, schools, primary care, jails, law enforcement, etc.! Safe Medication Disposal efforts! LEAD (Law Enforcement Assisted Diversion)! PAARI! $$ for Expanded Treatment! Overdose Prevention Sites HRAC and Law Enforcement

22 Colorado Law Enforcement & Jails today 133 Colorado Law Enforcement Departments are currently carrying Naloxone 5 Jails are currently training heroin injection drug users in jail and putting intranasal in their property upon release On The Horizon Fentanyl/Carfentanyl/Analogs Resurgence of other substances Thank you! Additional questions?