8/12/2013. Drug overdose death rates in the US have more than tripled since 1990 (CDC 2011).

Transcription

1 Age Adjusted Death Rate/100,000 p-y 8/12/2013 Jane A. Kennedy, D.O. Lisa Raville, B.A. Executive Director, Harm Reduction Action Center Slide presentation about opioids, overdose, and Naloxone Many thanks for slides from Dr. Ingrid Binswanger, Dr. Alice Bell, Harm Reduction Coalition, New Mexico Harm Reduction program, slide share sites Film about overdose and Naloxone used in training Review of trainings at HRAC Legislative accomplishments by HRAC Future goals in overdose prevention Q and A Drug overdose death rates in the US have more than tripled since 1990 (CDC 2011). According to CDC data (2009), drug overdose was the number one cause of injury death that year, exceeding motor vehicle accidents. At least 37,485 people died of drug overdose in the United States that year, and roughly half of these deaths involve opioids Source: NCHS Data Brief, December, 2011, updated with 2009 mortality data 4 9 National Overdose Death Rate by Substance: Year Pharmaceutical Opioids Cocaine Heroin Psychostimulants Like the rest of the nation, Colorado has seen an increase in deaths resulting from drug overdose over the past decade. In 2009, Colorado was one of only two states in which prescription drug overdose ranked as the leading cause of accidental death and prescription opioids are involved in an increasingly significant percentage of these cases. In 2003, Denver had 139 deaths from drug/alcohol overdose. Of these 139 deaths, 30 (21.6%) involved prescription opioids. In 2011, Denver had 190 deaths from drug/alcohol overdose. Of these 190 deaths, 84 (44%) involved prescription opioids. Calcaterra, et al., Drug and Alcohol Dependence, 2013 Bruce Mendelson et. al. 2012). 1

2 Drugs derived from opium, usually called opiate Opioid includes semi-synthetic and synthetic opiates, including: Heroin Morphine, codeine, hydrocodone (Vicodin, Lorcet), oxycodone (Percocet, Roxicet), OxyContin, oxymorphone (Opana) hydromorphone (Dilaudid), meperidine (Demerol), Fentanyl, methadone Oral Inhaled/smoked Intranasal/insufflation/sniffed/snorted Absorbed through the rectal mucosa Transdermal (skin) through patches Injected intravenously, intramuscularly, or subcutaneously Person becomes non-responsive May happen over a period of hours Breathing is inadequate or stops Opiates affect receptors in the brainstem that drive breathing Slowing or stopping breathing causes decrease in oxygen in our blood Lack of oxygen can cause organ failure, brain damage, coma, or death Presence of other depressants (alcohol, benzodiazepines) worsen situation 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 (15%) Opioids repress the urge to breathe decrease the body s/brain s response to carbon dioxide, leading to respiratory depression (decrease rate of breathing) and death Overdose is a cause of non-aids deaths in persons living with HIV Patients treated for pain and end-stage disease with opioids Can develop physical dependence, abuse, or addiction May take more than prescribed to relieve pain May have primary addiction to heroin or prescription opioid analgesics 2

3 More poisoning deaths involve prescription opioids than heroin, other illicit drugs Young people (Partnership for Drug-Free America, 2005) College students (McCabe et al., 2005) Elderly (SAMHSA, 2005) Women (Manchikanti,2006; Green et al., 2008) Chronic pain patients (Butler et al., 2004, 2008; Passik et al.,2006) Street drug users (Davis & Johnson, 2008) Exhibits geographic patterns: greater in rural areas, also seen among street-based users in large cities (Paulozzi et al., 2009; Brownstein et al., 2009) CDC has declared this an epidemic Source: Prescription Monitoring Programs: Reduce Diversion, not demonstrated to reduce overdose. Concern about increase in heroin use. Physician Prescribing Education when prescribing opioids for pain Methadone and Suboxone treatment: Very effective Abstinence-based drug treatment: Risk of overdose increases when relapse occurs. Community Based Education: Risk Factors, Identification of Symptoms, Effective Response, including Rescue Breathing, Calling 911 and Naloxone Administration We have the antidote: Naloxone (Narcan) Safe Highly effective Paramedics use Naloxone to immediately reverse the effects of opiate overdose Having Naloxone available before the paramedics arrive saves lives and decreases possibility of brain damage Effective opioid antidote FDA approved since 1971 via IM and IV routes Reverses signs of opioid intoxication Onset of action: usually less than 2-3 minutes Duration ~20-60 minutes Additional doses may be needed for long-acting opioids No abuse potential Prescription drug but not controlled drug Pure opiate antagonist >40 years experience by emergency personnel for OD reversal Only effect is blockade of opiate receptor Not addictive; no potential for abuse No side effects except precipitation of withdrawal Dose- and delivery-sensitive Boyer, NEJM,

4 Narcan, also called Naloxone, is a drug used to counter the effects of opioid overdose, for example heroin or morphine overdose. Opiate receptor sites in the body prefer Narcan. While Narcan is binding to the receptors, the opiate has nowhere to bind to, so the opiate has no effect on the body. Once Narcan wears off (after minutes), the receptor sites will be free and the opiate will bind to them again. If there is still enough opiate in the body to cause an overdose, the person will go back into one. On the other hand if there is not enough opiate in the body, the person can start experiencing withdrawal symptoms. It is recommended to discuss these points when developing an OD response plan or training If someone has been given Narcan, they should not try to use again for several hours at a minimum due to possible changes in tolerance which can cause another overdose. Binswanger, Ingrid Patients: with history or suspected history of substance abuse treated for opioid poisoning or intoxication at ED beginning Methadone or Buprenorphine therapy for addiction with higher-dose opioid prescriptions (>50 mg morphine equivalent/day) rotated from one prescription opioid to another with opioid prescriptions and: Benzodiazepine prescription Anti-depressant prescription Smoking, COPD, asthma, or other respiratory illness Renal dysfunction, hepatic illness, cardiac disease, HIV/AIDS Concurrent alcohol use People who abuse opioids People whose friends abuse opioids Friends and families of users Shelters Mobile clinics Treatment centers Service providers Any potential bystander Increasing dose (milligrams morphine equivalents) Psychiatric and substance use disorders Multiple substances, e.g. benzodiazepines Doctor-shopping: more than 5 clinicians Release from jail or prison After detoxification After hospitalization 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 There is a higher risk of overdose with HIV seropositivity Not a clear reason why; controversial Biological Abnormal liver function impaired metabolism? Pulmonary problems exacerbate respiratory depression? Poor physical health Medical complications from injecting Low CD4+ counts immunosuppression Why is there increased risk of OD with HIV? Proposed but not specific to HIV Behavioral High risk lifestyle Psychiatric disorders Poor nutrition Structural and Environmental Factors Poor access to medication-assisted treatment Homelessness Neighborhood poverty Socioeconomic status Incarceration release Isolation and using alone 4

5 What could help reduce the increased risk? HAART Improve health status Educate on risk of drug interactions with medications and/or street drugs Medication-Assisted Treatment Reduces drug use, decreases risk behaviors, increases medication compliance Naloxone Saves lives Despite the heterogeneous pool of studies, the meta-analysis results suggest that people who use drugs have a 74% greater risk of overdose if they are HIV-infected compared to their counterparts who are not HIV-infected. HIV infection and risk of overdose: a systematic review and meta-analysis. TC Green, SK McGowan, MA Yokell, ER Pouget, and JD Rich. AIDS February 20; 26(4): View film describing overdose and response Varied films available (chronic pain patients versus addicts) Discuss risks of overdose and how to lessen risks How to recognize overdose Overdosing or just very intoxicated Response to overdose Call 911, rescue breathing, administer naloxone Mixing: Opioids (heroin or painkillers) with alcohol, benzos, cocaine, or speed Prevention: Use one drug at a time; put your opiate on board first Tolerance: After release from jail, hospital, detox, or after methadone detox Prevention: Use less than normal during these times. Quality: Street drug quality is unpredictable and can change daily Prevention: Tester shots, using reliable/consistent dealer. Using Alone: Behind closed or locked doors, where you cannot be found, especially in SROs Prevention: Use with a friend, leave the door unlocked, call someone and ask them to check on you if you don t call back in X amount of time Health: Breathing problems (asthma, COPD, emphysema, etc.), liver issues (i.e. HCV), compromised immune system (i.e. HIV/AIDS), active infections (i.e. abscess, cellulitis, endocarditis), lack of sleep, dehydration, malnourishment can all increase your risk of OD. Prevention: Take care of yourself! Eat, drink, sleep, see a doctor, carry your inhaler, treat infections, etc. Recovery Position: Put person on their side if you have to leave them alone to call 911. Check responsiveness Noise: Call name, yell cops! or I m going to Narcan you! Breathing: Is it slow, shallow, or irregular? Are they making a gurgling sound? Pain: Sternum Rub This is the hard line difference between someone who is just really high and someone who is in trouble; if they don t respond to pain, it s because they can t Calling 911: Say someone is not breathing, I need an ambulance at [address]. Do not say overdose until the paramedics arrive; when they arrive, tell them everything you know. Rescue Breathing: Remember, brain damage can occur with as little as 3-5 minutes without oxygen! If you re alone with the overdosing person, start rescue breathing and then go get Naloxone after you ve given a few breaths. If you re not alone, start rescue breathing while other person goes to get the Naloxone. Head tilt, chin lift Look, listen, feel: to see if chest rises/falls; listen/feel for breath. Two breaths: normal sized, not quick, not a hurricane! One breath every five seconds (count one-one thousand, two-one thousand...) Administering IM Narcan Assembling shot: remove cap on vial, draw up 1cc of Naloxone into muscling syringe. Site location: arm (deltoid), thigh, butt. Shoot into muscle, not vein, not abscess. Administering shot: clean with alcohol wipe (if available). Insert at 90 angle. Push in plunger. Aftercare: Takes several minutes to kick in; wears off in minutes Person won t remember overdosing; explain what happened Don t allow to do more opioids--will be wasting drugs, could OD again Need to watch person for at least an hour Could need to administer another dose of Naloxone 5

6 160 Survey of Overdose Prevention programs providing naloxone from overdose prevention programs across 15 states and the District of Columbia 53,032 naloxone kits distributed 10,171 reversals (lives saved) Naloxone distribution begins, 2003 Heroin-related deaths MMWR, Centers for Disease Control, February 17, 2012, Volume 61, No. 6. Los Angeles, Massachusetts, Mendocino County, CA, New Haven, New Mexico, New York City, Oakland, Pittsburgh, Rhode Island, San Francisco, Wilkes County, NC and more *Data compiled from San Francisco Medical Examiner s Reports, **no data available for FY Colorado s 911 Good Samaritan Law (SB ) Protects an individual who calls 911 for emergency assistance in the event of a drug overdose from prosecution for possession of small amounts of drugs (less than 4g heroin or cocaine, less than 2g methamphetamine) and drug paraphernalia. Third Party Naloxone (SB ) Authorizes third party individuals (family, friends, service providers) of opiate users to carry and administer Naloxone in the case of an opiate overdose. Overdose Prevention and Naloxone Distribution statewide Colorado syringe access programs (Boulder, Grand Junction, Fort Collins) Methadone Clinics Jails & prisons, especially release programs Detox facilities Homeless service providers 6