Steve Alsum The Grand Rapids Red Project steve@redprojectgr.org (616) 456-9063
Red Project: Mission/History/Programs Epidemiology of Overdose Overdose Prevention in Grand Rapids National Efforts Moving Forward in Michigan
501c3 non-profit Founded in 1998 to bridge gaps in communities infected and affected by HIV A grassroots community based organization Funded by private foundations and community giving Annual budget: historically approximately $100,000/yr, but 2013/2014 approximately $200,000/yr
In 1998 Mayor John Logie convened a Task Force on Drug Policy Reform in GR Recommended the establishment of a syringe access program to reduce the spread of HIV Red Project chooses to address this issue August 2000: Permission from GR City Commission to open the doors of our Clean Works program
Improve Health, Reduce Risk, Prevent HIV Provide access to the knowledge, tools and support people need to stay healthy Empower individuals to begin making positive changes in their own lives and in their communities Health Issues: HIV, HCV, and OD
Clean Works Syringe access OD prevention & intervention trainings HIV & HCV testing and referrals Safer sex/safer shots Wound care Risk reduction counseling Mobile Health Unit
Positive Choices Peer run HIV support & educational group Highly Targeted Rapid HIV CTR Overdose Prevention and Response Training Hepatitis C Counseling, Testing and Referral Bar/Community/Street Outreach Condom Distribution Community Referrals
1998 Drug Policy Task Force Recommendation At this time 25% of all HIV/AIDS infections in Kent County related to injection drug use Open our doors in August of 2000, operating a fixed site, 2 days a week As of Jan 2014, 8% of current HIV/AIDS infections are among IDU or MSM/IDU, according to MDCH Extremely successful in addressing HIV/AIDS among people who inject drugs
Sept 2011- City Commission votes to allow operation throughout entire city Address HIV, AND Hepatitis C and Overdose Addition of our Mobile Health Unit Now opened 6 days a week from 5 different locations
Harm Reduction is a set of practical strategies that reduce negative consequences of drug use, incorporating a spectrum of strategies from safer use, to managed use, to abstinence. Harm reduction strategies meet drug users where they re at, addressing conditions of use along with the use itself. HRC We all practice Harm Reduction: Seat Belts
Meeting people where they re at Client Centered Low Threshold & Accessible Non Judgmental and Non Coercive Providing a range of options Holistic A continuum not a dichotomy Supportive and encouraging Positive Empowering
HIV HCV & Overdose
HIV/AIDS Estimated 1,100 people living with HIV/AIDS in Kent County 8 % IDU and MSM/IDU Still increasing on the whole, but decreasing among people who inject- what about other drug users? Hepatitis C Estimated 10,000 people living with Hepatitis C in Kent County Roughly 1 person diagnosed with chronic HCV everyday 70% baby boomers, but huge increases among young and new injectors Overdose 60-70 deaths per year in Kent County Primarily caused by opiates, both licit and illicit Very common among people who inject
Kent County Mortality Rates Deaths / 100,000 Living 8 7 6 5 Narcotic Overdose 4 3 Viral Hepatitis 2 HIV/AIDS related 1 0 1999 2001 2003 2005 2007 2009 2011 Year
Michigan Mortality Rates 6 Deaths/ 100,000 living 5 4 3 2 Narcotic Overdose Viral Hepatitis HIV/AIDS related 1 0 1999 2001 2003 2005 2007 2009 2011 Year
Most immediate health concern of the people we serve Kills more people in Kent County each year than HIV and HCV combined Kills more people than are in infected with HIV each year Leading cause of accidental death of ALL people aged 0-65 From 1994 to 2012 fatalities increased sixfold from about 15 deaths to 97 Where is the public health outcry?
Kent County Overdose Fatalities by Drug of First Mention 100 Overdose Fatalities 80 60 Total Total Opioid ODs 40 Narcotic Analgesic 20 Methadone Heroin/Morphine 0 1994 1998 2002 2006 2010 Year
Unpublished data from the Kent County Medical Examiner 74% of all fatalities involve an opiate Of the opiate fatalities 40% involve Methadone 38% involve Morphine/Heroin 35% involve some other opiate 41% of opiate overdoses involve a multi-drug combination 22% Cocaine, 15% Alcohol, Benzos are also implicated
Mean age: 41 years Kent County Overdose Fatalities 50 40 Total Deaths 30 20 10 0 <25 25 to 34 35 to 44 45 to 54 >54 Age Group
Overdose History: The average client has: Personally overdosed 2.3 times Witnessed 5.87 overdoses, of which only 1.98 have resulted in 911 being called, and 0.6 where someone has died Drug Intake Opiates: 93% use heroin, 46% use methadone, 41% use another opiate Uppers: 39% use cocaine, 16% use speed Downers: 49% use alcohol, 37% use benzos Clean Works clients are at risk for OD, furthermore they are at risk for opiate OD
Naloxone HCl is an unscheduled prescription medication both federally and in the state of MI. Naloxone is a medication used solely for the prevention and reversal of opiate overdoses. Naloxone is pretty much a pure antidote for opiates. It will have little or no effect on people without opiates in their system. Naloxone is so safe and effective that often when someone presents unresponsive medical personnel will administer Naloxone without knowing whether or not an overdose has occurred. Naloxone was FDA approved in 1971 for first responders to use to respond to overdose situations
Red Project Program Data October 2008 January 2014 Over 650 individuals trained Our average client has witnessed 5.87 overdoses, of which only 1.98 have resulted in a 911 call Since 2000 many programs have shown that lay-people (people who use opioids, their families & friends) can be trained in safely and effectively responding to opioid overdoses with naloxone hydrochloride
Clean Works Program- October 2008 Cherry St Health Methadone Clinic- 2012 Network 180 and SUD Treatment- 2013 SA Turning Point, Arbor Circle IOP, Our Hope, Jellema House, Freedom House, Cherry St Health Methadone Clinic, Degage Open Door Women s Shelter, Network 180 Access Center, etc Results (as of 08/30/2014) 936 individuals trained which has led to 177 reported reversals The Future Increased collaboration/partnerships Multiple points of distribution
Methadone Maintenance Intensive Out-Patient Detox Facilities 90-day Programs Emergency Shelters/Drop In Centers Recovery Housing/Housing First Referral Relationships Medical Community
What is an overdose? Why do people overdose? Recognizing an overdose Responding to an overdose Recognizing and acknowledging experience, pain and trauma Confidentiality
NYDOH Training Video
Multi-Drug Use Alcohol Consumption Period of Abstinence Decreased Health Decreased Breathing Function Prior History of Overdose Unregulated drugs/unfamiliar medications Using alone
Stimulation Call for Help Airways Rescue Breathing Evaluation Muscular Injection Evaluate/Support
Naloxone Hydrochloride 4 IM Syringes Training DVD & Instructions Rescue breathing barrier, alcohol pads, gauze, rubber gloves Information on our program all in a recognizable bag
As of 08/30/2014 Over 900 individuals trained in how to prevent and respond to overdose situations and issued a rescue kit Over 175 overdoses reported reversed as a result Individual Level: Success! Community Level: OD rates are beginning to stabilize
American Medical Association http://www.ama-assn.org/ama/pub/news/news/2012-06-19-ama-adopts-newpolicies American Society of Addiction Medicine http://www.asam.org/advocacy/find-a-policy-statement/view-policystatement/public-policystatements/2011/12/15/use-of-naloxone-for-theprevention-of-drug-overdose-deaths Office of National Drug Control Policy http://www.whitehouse.gov/ondcp/drugpolicyreform US Conference of Mayors http://www.usmayors.org/resolutions/76th_conference/chhs_16.asp National Coalition Against Prescription Drug Abuse http://leginfo.ca.gov/pub/13-14/bill/asm/ab_0601-0650/ab_635_cfa_20130617_134746_sen_comm.html American Public Health Association http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1443 United Nations Office on Drugs and Crime http://www.unodc.org/documents/commissions/cnd-res-2011to2019/cndres- 2012/Resolution_55_7.pdf National Alliance of State and Territorial AIDS Directors http://www.nastad.org/docs/014907_nastad%20statement%20of%20commitment%20drug%20user%20he alth%20august%205%202011.pdf Source: NOPE Model Naloxone legislation Guide
Strategies to Reduce Overdose Death STRATEGY 1: Encourage providers, persons at high risk, family members and others to learn how to prevent and manage opioid overdose. STRATEGY 2: Ensure access to treatment for individuals who are misusing or addicted to opioids or who have other substance use disorders. STRATEGY 3: Ensure ready access to naloxone. STRATEGY 4: Encourage the public to call 911. STRATEGY 5: Encourage prescribers to use state Prescription Drug Monitoring Programs (PDMPs). ***SAMSHA Block Grant Funds Can Support OD Prevention
CDC MMWR, February 17, 2012 Nationally there were 188 local overdose prevention programs that distribute Naloxone From 1996-2010 Trained 53,032 people 10,171 reported reversals Multiple Models For Successful Programming Syringe Access/Harm Reduction-Chicago Recovery Alliance, etc Point of Prescription/Medical Model-Project Lazarus State Health Department- Massachusetts, etc The Take Away: Finding ways to put tools in hands to save lives
Project Lazarus http://www.projectlazarus.org Prescribe to Prevent http://www.prescribetoprevent.org
Community Engagement 2008: Wilkes County, NC has 6 th highest OD mortality rate in nation Fatality is caused primarily by prescription opioids Work with doctors to train individuals receiving opioid prescriptions in how to respond to overdose with Naloxone OD deaths down 69% between 2009 and 2011 Less than 1% change in how many residents had a prescription for an opioid pain reliever in Wilkes County In 2008 82% of OD fatality victims had a prescription from a Wilkes County prescriber, in 2011 this decreased to 0%
Inclusion Criteria for a Naloxone Rescue Kit: The Short List Anyone using opioids medically or non-medically, and anyone with a history of non-medical opioid use The Long List Received emergency medical care involving opioid intoxication or poisoning Suspected history of substance abuse or nonmedical opioid use Prescribed methadone or buprenorphine Higher-dose (>50 mg morphine equivalent/day) opioid prescription
Inclusion Criteria (continued): Receiving any opioid prescription for pain plus: Rotated from one opioid to another because of possible incomplete cross tolerance Smoking, COPD, emphysema, asthma, sleep apnea, respiratory infection, or other respiratory illness or potential obstruction. Renal dysfunction, hepatic disease, cardiac illness, HIV/AIDS Known or suspected concurrent alcohol use Concurrent benzodiazepine or other sedative prescription Concurrent antidepressant prescription Patients who may have difficulty accessing emergency medical services (distance, remoteness) Voluntary request from patient or caregiver
Well coordinated statewide program utilizing standing order model for nasal naloxone Multiple points of distribution Harm reduction Substance abuse treatment First Responders Families groups Declaration of Public Health Emergency Community level reductions in OD fatality http://www.mass.gov/eohhs/gov/departments/dph/programs/substanceabuse/prevention/opioid-overdoseprevention.html#overdoseeducationandnaloxonedistributionprogram
Emergency Regulations Providers at state-licensed facilities must receive training on OD prevention & Naloxone Consumers must be offered kits upon discharge Pharmacy Collaborative Practice Agreements Naloxone kits can be procured on a walk-in basis at any Walgreens statewide
Will this encourage drug use? What does the data say? Anecdotal evidence.. Appropriateness within treatment/recovery? Benefits to clients Life is valued, rather than just treatment compliance A positive role in the community: that of life-saver and educator Benefits to staff Enhancing the therapeutic relationship Addressing OD-related trauma
Staff Buy In Prescription Status Unscheduled Relationship with a doc? Relationship with a pharmacy? Does this issue affect your clients? Moving beyond an abstinence only approach
No Good Samaritan legislation for calling 911 in an overdose situation Prescribing Naloxone to bystanders with no personal risk for overdose Administering Naloxone to someone for whom it has not been prescribed We are actively working to get legislation passed to address these barriers SB 0860
Integrating this into your SUD practice Starting the conversation: What could be the most important question Can your organization provide this to your at-risk clients? Do you have a referral relationship with an organization or doctor who can? What can you do? Find out how this is affecting your clients OD Prevention with and without naloxone Doctors in your area Suboxone and pain maintenance
Impeding [the IDU] population from obtaining or using sterile syringes amounts to prescribing death as a punishment for illicit drug use. Source: Human Rights Watch, Lessons Not Learned: Human Rights Abuses and HIV/AIDS in the Russian Federation, April 2004, Vol. 16, No. 5, p.3
1998 Grand Rapids Mayors Task Force on Drug Policy Reform Final Report Harm Reduction Coalition Michigan Department of Community Health Quarterly HIV Statistics Kent County Health Department Governors Hepatitis C Advisory Task Force Final Report Kent County Medical Examiner Clean Works Program Data Centers For Disease Control Wonder Mortality Database Chicago Recovery Alliance Centers For Disease Control Morbidity and Mortality Weekly Report The Network For Public Health Law Project Lazarus Prescribe to Prevent North Carolina Medical Board Human Rights Watch SAMSHA Opioid Overdose Toolkit NOPE Model Naloxone Legislation Guide http://ripr.org/post/agency-issues-emergency-rules-drug-overdose-crisis