Journal Club: Naloxone Programs in the Community and Their Success to Decrease Overdoses from Opioids Emily Junck, MD Hayes Wong, MD Paul Freeman, MD Special Guest: Caleb Banta-Green, PhD, MPH, MSW
Special thanks to Lauren Whiteside, MD, MS Steve Anderson, MD, FACEP
Background Format #1: Albert et al. Project Lazarus: Community-Based Overdose Prevention in Rural North Carolina. Pain Medicine 2011; 12: S77- S85. #2: Walley et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ 2013; 346:f174. Comments by Caleb Banta-Green, PhD, MPH, MSW Discussion
Objectives To better understand the current medical, social and legal context of naloxone distribution To explore current evidence of community naloxone programs on reducing opioid overdoses To discuss pros and cons to naloxone distribution by EPs
Background Drug poisoning (overdose) is the #1 cause of injury-related deaths in US 43,982 deaths in 2013 Today, 120 people/day die from overdose 44/day prescription painkiller Centers for Disease Control, National Center for Health Statistics. Underlying Cause of Death 2000-2010 on CDC WONDER Online Database. http://www.cdc.gov/drugoverdose/epidemic/index.html
Background 6,700 people/day are treated in the ED for misuse or abuse of drugs 2.5 million/year Cost: 55.7 billion from prescription opioid abuse in 2007 Birnbaum HG, White AG, Schiller M, Waldman T, Cleveland JM, and Roland CL. Societal costs of prescription opioid abuse, dependence, and misuse in the United States. Pain Medicine 2011; 12: 657-667.
https://www.whitehouse.gov/sites/default/files/ondcp/fact_sheets/opioids_fact_sheet.pdf
Drug-poisoning deaths in US, 2000-2013 16,235 8,257
Naloxone (Narcan ) Competitive opioid antagonist Safe, Schedule 0 Theoretical allergy IM vs IN no difference Effects last 30-90min
Naloxone: Intranasal Used off-label Most commonly used by first responders Cost ~$50/kit
Naloxone: Auto-injector April 2014: Evzio FDA approved Provides verbal instructions ~$400/kit
1996-2010: 53,032 trainees 10,171 reversals
Who Has Statements of Support for Take-Home Naloxone? Washington State Board of Pharmacy
ACEP No policy statement yet Bedard L, Bukata R, Hoffman J, et al. Naloxone Prescriptions by Emergency Physicians. ACEP Resolution 39(14), 2014. RESOLVED, That ACEP develops a clinical policy on the clinical conditions for which it is appropriate for emergency physicians to prescribe naloxone.
Unique Legal Challenges Third-party prescribing prescription of drugs to a person other than the intended recipient Prescription via standing order prescription to a person the physician has not personally examined
Washington State June 2010: Wash. Rev. Code 18.130.345 The administering, dispensing, prescribing, acquisition, possession, or use of naloxone shall not constitute unprofessional conduct June 2010: Wash Rev. Code 69.50.315 Good Samaritan Law Removes criminal liability for lay administration
https://www.networkforphl.org/_asset/qz5pvn/network-naloxone-10-4.pdf
Who can prescribe? In Washington State: any physician, NP, or PA
Who can prescribe? In California: +pharmacists as of 4/10/15 Approved by California State Board of Pharmacy
Where can you find it?
` Emily Junck MD
Wilkes County, North Carolina Population 66,500 Poverty, limited education Unemployment, physically-demanding industries One hospital for the county Some of the highest drug overdose rates in the country: 46.6 deaths per 100,000 population per year (2009) Mostly prescription opiates
Project Lazarus Non-profit organization with role to: Coordinate efforts Wilkes County Health Department Northwest Community Care Network, Chronic Pain Initiative Wilkes Health Carolinians Council, Substance Abuse Task Force Develop strategic plans Train community organizers Raise awareness
Overdose Prevention Strategy Community organization and activation Evaluating project components Prescriber education Overdose prevention Supply reduction Monitoring and surveillance
Overdose Prevention Strategy Community organization and activation Evaluating project components Prescriber education Overdose prevention Supply reduction Monitoring and surveillance
Overdose Prevention Strategy Community organization and activation Town hall meetings, task forces Presentations at schools and community centers Advertising against medication sharing
Overdose Prevention Strategy Prescriber education Face to face interviews CME didactics Toolkit
Overdose Prevention Strategy Supply reduction Prescription limits, CSRS checked for all ED visits ED case manager for Medicaid patients, facilitate specialized pain referrals Unused medication takeback events, fixed medication disposal sites Mandatory patientprescriber agreements and pharmacy homes
Overdose Prevention Strategy Monitoring and surveillance Tracking of ED visits for substance abuse and accidental poisonings Tracking of Medical Examiner overdose cases Controlled Substances Reporting System North Carolina State Center for Health Statistics
Overdose Prevention Strategy Overdose prevention Chronic pain support groups Detox programs, drug treatment clinics Lay-person naloxone administration
Overdose Prevention Strategy Evaluating Project Components
Overdose mortality rate dropped from 43 to 29 per 100K population (2008 to 2010) Decreased prescribing Overdose fatalities that had received a prescription for the implicated substance dropped from 82% 10% Results Increased provider enrollment in the Controlled Substances Reporting System (CSRS) to 70% - Revised ED Policies for narcotic dispersal - CSRS accessed for all narcotics prescriptions - Decreased ED visits for pain
Limitations Does not evaluate impact of each intervention Not adjusted for confounders Difficult to replicate Setting Large-scale effort with many coordinated resources
Opioid OD Rates and Implementation of OEND in Massachusetts: Interrupted Time Series Analysis Paul Freeman, MD, EM R2 Madigan Army Medical Center, WA April 24, 2015
Study Objective Evaluate the effect of overdose education and nasal naloxone distribution (OEND) on rates of opioid related deaths from overdose (OD) and acute care utilization Design Interrupted time series analysis of OD death and acute care utilization 2002-2009
Massachusetts 19 cities/towns At least 5 opioid related deaths 2002 2009 Increasing number of OEND programs from 2006 Nonmedical public health workers Opioid users, social service staff, friends, family Also providing HIV education and prevention
What is OEND? Decrease polysubstance misuse Accounting for reduced tolerance after abstinence Not using alone Recognizing OD by alertness assessment and decreased breathing Providing rescue breathing Engaging EMS Administering nasal naloxone (2x 2mg atomizers) Staying with person until EMS arrives
1 Outcome - OD death rates decreased Absolute Low - 0.73 High - 0.54 Relative Low - 0.85 High - 1.0 2 outcome no significant difference Results
Strengths - Interrupted time series approach - Comparison to cancer death ratios and nonfatal traffic accident ratios - Three lives saved - Adjustment for demographic variables
Limitations - OD may have occurred in clusters (increased drug potency, misrepresent a trend ) - Underreporting (survey of OEND participants) - Measures of OEND implementation not validated - Acute care utilization based on discharge coding - Interrupted time series approach (RCT better)
Caleb Banta-Green PhD, MPH, MSW
Discussion Should EPs prescribe naloxone? To whom? Will this enable more high-risk behavior? More will die because they will refuse transport to the hospital and the naloxone will wear off. Is naloxone the panacea or is it a Band-Aid to opioid overdoses? If fewer opioid overdoses present to the ED, isn t this a good thing? What follow-up/drug education is or should be available in your community?
Maine Governor Paul LePage [Naloxone] would make it easier for those with substance abuse problems to push themselves to the edge, or beyond. It provides a false sense of security that abusers are somehow safe from overdose if they have a prescription nearby."
More High Risk Behavior? No data to support this (yet) Survey of 82 IDUs in San Francisco in 2000 Majority 65% said would not use more
Slide credit: Dr. Paul Charlton
Who is at risk? ANY heroin user Prescription opioids: Multiple prescribers Co-prescribing with sedatives, antidepressants Co-morbid psychiatric illness and/or substance abuse High morphine equivalent dose (>100 morphine equivalents/day*) Concurrent methadone use #1 predictor of overdose: PRIOR OVERDOSE *Dunn KM, Saunders KW, Rutter CM et al. Opioid Prescriptions for Chronic Pain and Overdose. Annals of Internal Medicine. 2010;152:85-92
Resources www.prescribetoprevent.org www.stopoverdose.org http://www.samhsa.gov/ http://www.cdc.gov/drugoverdose/
Thank You