1/23/2015. Disclosure. Overview. A National Response to a Public Health Crisis Opioid Overdose and the Changing Spectrum of Care

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1 A National Response to a Public Health Crisis Opioid Overdose and the Changing Spectrum of Care Michael W. Dailey, MD FACEP Chief, Division of Prehospital and Operational Medicine Associate Professor of Emergency Medicine Disclosure No academic conflict of interest No financial conflict of interest FDA Off-label use of a medication will be discussed 2 Overview Review the background of the current opioid crisis Describe the advancement of naloxone into the out-of-hospital arena to treat opioid overdoses Identify opportunities for increasing the distribution of naloxone into high-risk opioid overdose environments Specify the next steps in increasing use of naloxone for the treatment of opioid overdose in the community 3 1

2 If one of us dies of an If overdose, one of probably us dies 10 of an overdose, probably who were about 10 who to won t were about to won t Phillip Seymour Hoffman Hoffman (in Time reported (in Time reported by Aaron Sorkin) by Aaron Sorkin)

3 7 8 Why Do We Have an Opioid Overdose Epidemic? 3

4 10 Strategies to Address Overdose Prescription monitoring programs Paulozzi et al. Pain Medicine 2011 Prescription drug take back events Safe opioid prescribing education Albert et al. Pain Medicine 2011; 12: S77-S85 Expansion of opioid agonist treatment Clausen et al. Addiction 2009:104; Safe injection facilities Marshall et al. Lancet 2011:377;

5 13 Drug Treatment Options Inpatient vs. Outpatient Abstinence vs. Agonist Methadone Suboxone Insurance coverage Long term support Community services 14 Heroin User Experiences About 2% of heroin users die each year, many from heroin overdose 1/2 to 2/3 of heroin users experience at least one nonfatal overdose 80% have observed an overdose Sporer BMJ 2003, Coffin Acad Emerg Med

6 Who Overdoses? Among heroin users it has generally been those who have been using 5-10 years After rehab After incarceration Less is known about prescription opioid users Anecdotal reports of youth dying suggest that many of those have been in drug treatment and relapse Sporer 2003, Context of Opioid Overdose The majority of heroin overdoses are witnessed (gives an opportunity for intervention) Fear of police may prevent calling 911 Witnesses may try ineffectual things Myths and lack of proper training Abandonment is the worst response Tracy How Overdose Occurs Slow breathing Breathing stops Lack of oxygen may cause brain damage Heart stops Death 18 6

7 19 Models of Overdose Treatment Increasing Access to Naloxone Community prescribing/distribution to drug user and/or social networks Began in Chicago in 1992 Prescribing in outpatient care Increasing access among first responders Pharmacy collaborative agreements 21 7

8 Overdose Fatality Prevention Programs that Distribute Naloxone: USA, survey of programs known to the Harm Reduction Coalition 189 local programs in 16 states ranging from state-funded to underground : 53,339 individuals received kits 10,194 overdose reversals reported CDC MMWR February 17, States with 3 rd Party Naloxone Laws (Coffin, 2013) 23 Does Naloxone Distribution Help? 8

9 Naloxone Distribution Decreases Mortality Observational studies of overdose prevention programs find an association with reductions in overdose deaths: Massachusetts, New York City, San Francisco, Baltimore, Pittsburgh, Chicago Hard to tell how many new users there are (denominator) May only be the education of the users and not the naloxone More studies are in progress Banta-Green and others 25 Prevention Messages for Users Use with others who know what to do if an overdose happens make a plan Be aware of companions at all times when using Be careful if using alone, especially if: Mixing different classes of drugs Using after abstinence (And watch out for others in these situations) 26 Intramuscular Naloxone 27 9

10 Intranasal Naloxone

11 Implementation in NY State Hundreds of sites registered including: Syringe exchange/syringe access sites Drug Treatment Programs HIV programs Homeless shelters Hospitals (Albany Medical Center) 31 Public Safety Naloxone Access What is the scope across the country? All 53 jurisdictions permit Paramedics to administer naloxone Of the 48 jurisdictions with mid-level EMS personnel, all but one authorize those personnel to administer naloxone Only twelve jurisdictions explicitly permit EMTs to administer naloxone Five additional states permit some or all EMTs to administer the drug through pilot programs or agency medical director authority Davis, Walley, Dailey, Southwell, Neihaus, EMS Naloxone Access: A National Systematic Legal Review, Academic EM, August

12 Naloxone for Basic EMT Results Additional states may allow BLS personnel or other first responders to administer naloxone as part of a separately regulated community access program. At least four jurisdictions modified law or policy to expand EMS access to naloxone in Many others have changed since this review Davis, Walley, Dailey, Southwell, Neihaus, EMS Naloxone Access: A National Systematic Legal Review, Academic EM, August Disparity in Naloxone Administration NEMSIS search for overdose and naloxone initiated as a project by CDC injury prevention Naloxone administration is highest in SUBURBAN areas, but overdose is highest in RURAL areas Likely disparity because of certification of providers with BLS more likely in RURAL areas Scope of practice for basic EMT should add naloxone Faul M, Dailey MW, Sugerman DE, Sasser SM, Levy B, Paulozzi LJ, AJPH, publication pending 36 12

13 The New York Experience Why Our Program in NYS? Disaster opioid overdoses in areas of New York with little coverage by advanced EMS providers Medical providers from rural areas recognized problem with BLS response and overdose morbidity Laws that were conducive to the program Career fire department BLS-FR in Rochester Law enforcement in REMO and Suffolk County Volunteer ambulances in several regions 38 Review of NYS Law 13

14 Overdose Law in NYS (PHL 3309) Community Access Naloxone Law Allows the medical provider to provide naloxone for use as first aid on another person Protects the non-medical person who administers naloxone in setting of overdose from liability shall be considered first aid or emergency treatment shall not constitute the unlawful practice of a profession 40 NYS Good Samaritan 911 Intent: To encourage those present at an overdose to do the right thing and call for help This law protects an overdose victim and those who summon EMS: From arrest in the presence of misdemeanor drug possession and/or underage drinking From prosecution in felony possession unless there are aggravating circumstances, e.g. possession with intent to sell or outstanding warrants 41 Skills Addition Matrix High Reward Low Frequency Low Reward Low Frequency High Reward High Frequency Low Reward High Frequency 42 14

15 So what do we teach the police? When to Use Naloxone Overdose suspected Not responsive to painful stimuli Breathing status Normal or Fast Slow (<10x minute) No or Gasping Turn on side Naloxone Naloxone and CPR 44 Steps to Assemble Open box; remove yellow and purple caps Open and attach atomizer Screw medication into holder 45 15

16 Hands On Training

17 49 50 New York s Experience: BLS and Police Over 200 opioid overdose reversals in first year, 1 reversal for every 10 EMTs trained Currently >300 reversals by law enforcement Avg 7 minutes prior to arrival of EMS (max 29 minutes) No adverse events No significant hazards to EMS personnel Case of reduced hazard for EMS personnel One interesting unplanned complication with law enforcement 51 17

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20 What Did We Learn? Naloxone for first responders can be a phenomenal success Scope of practice expansion for ALL EMS providers is safe Training and equipping providers should be expanded where useful Law enforcement Fire first response Others 58 Last Thoughts This train has left the station Naloxone programs MUST have physician oversight to assure safety to patients and adequate training of providers Public safety naloxone programs should be managed through existing EMS systems We must work with politicians to assure these programs are safe, efficient, useful and well managed by us, THE EXPERTS IN EMS MEDICINE 59 Thank you daileym@mail.amc.edu 60 20