Opportunities for Opioid Safety and Community-Based Overdose Management DANTE COLLINS ERICA C. ERNST MAYA DOE-SIMKINS SEPTEMBER 13, 2013
Overview Prevalence & data Overdose prevention Making an overdose plan Recognizing & responding to an overdose Experiences talking with drug users Additional organizational strategies
Some vocabulary Narcan = naloxone hydrochloride naloxone is NOT naltrexone (Vivitrol, Revia ) Suboxone = buprenorphine + naloxone naloxone -> discourage people from injecting Subutex = buprenorphine
Prevalence & data
NCHS, 2012
Mortality, overdose & homeless people Homeless people overall mortality rate 25 to 44-9x 45 to 64-4.5x Deaths from (comparable demographic) Homeless men- 16x higher Homeless women- 24x Baggett et al. JAMA Intern Med 2013
Macro strategies to address overdose Prescription monitoring programs (Paulozzi et al. Pain Medicine 2011) Prescription drug take back events (Gray et al. AIM 2012) Abuse deterrent formulations (Cicero et al. NEJM 2012) Safe opioid prescribing education (Albert et al. Pain Medicine 2011) Expansion of opioid agonist treatment (Clausen et al. Addiction 2009) Supervised injection facilities (Marshall et al. Lancet 2011) Take home naloxone (OEND) (Walley et al. BMJ 2013)
Tailoring the content We want to make sure we touch on questions & thoughts you have- what would you like to make sure we discuss today?
Preventing an overdose
Increased Risk Of Overdosing Mixing drugs Variation in strength and content of street drugs (purity) Tolerance changes (coming out of jail/tx) Using alone Physical health (liver function, weight loss, smoking, etc.) Transient living new dealers/new product Thinking you know everything Switching from sniffing/swallowing to injection
How Can You Lower Your Personal Risk Of Overdose? Stop using Engage in treatment Know your tolerance If relapse, start low and go slow Avoid mixing substances Use when others are around Train your network to call for help, rescue breathe, and administer naloxone Encourage your network to get a naloxone rescue kit Keep a kit where you use Tailor this plan to the client s situation
Sample Prevention Messages I want to remind you that (BECAUSE OF) your tolerance is very low, you are at high risk for an overdose Do you have an overdose plan? Do you and your friends know about naloxone? I don t want anything to happen to you If you relapse please do not do it alone People, places & things have a way of reappearing- it is my responsibility to make sure you have access to the skills & information to survive, no matter what happens
Strategies for preventing overdose Always use with someone else Always get your drugs from the same person Taste or use a smaller amount if a new provider Taste or use a smaller amount if you have been clean for a period (voluntary, hospitalization, incarceration) Don t mix with other drugs or ETOH Keep an overdose kit wherever you use Have an overdose plan
Making an overdose plan CHALLENGES PERSONAL PROCESS
OD plans affect: Individuals People around individuals http://www.youtube.com/watch? v=_a_1qrohxw8u1frpjowtkw# action=share http://www.youtube.com/watch? v=_a_1qrohxw8
Recognizing really high vs overdose Really high Pupils pinned Nodding, but arousable Responds to sternal rub Speech is slurred Sleepy, intoxicated, but breathing 8 or more times per minute Overdose Pupils pinned Not arousable No response to sternal rub Breathing slow or stopped Less than 8 times per minute May hear choking sounds or a gurgling/snoring noise Blue lips, blue fingertips >> Stimulate and observe >> Rescue breathe + give naloxone
Responding to an overdose
How do opioids affect breathing? Opioid Receptors, brain Opioid
If an overdose happens 1. Call 911 (you don t have to say that it is an OD) 2. Rescue breathing 3. Give naloxone 4. Keep breathing for the person?another dose of naloxone? (3-5 min) Rescue position
Rescue Position
How does naloxone affect overdose?
Experiences talking with fellow drug users
Some people are very interested in hearing more about overdose prevention Some people are not
More organizational strategies
Materials Referrals More ways to address overdose Ask clients/stakeholders what they want 911 Good Samaritan Make public space for overdose & join in
Message: Alive is more important than abstinent! Program restroom
PUD take care of each other: Drug using status of responders Enrollments Nondrug Users 31% Nondrug Users 13% Overdose rescues Drug Users* 69% Drug Users* 87% *Active + in treatment + in recovery Walley, BMJ, 2013
More ways to address overdose Address OD in counseling Mental health SUD Tx Upon entry Discharge planning Relapse prevention Screen for overdose risk Organize Rx disposal event Develop an organizational overdose policy Support dialogue & activism
Public displays; collective grief; tangible activism Lobbying for 911 Good Sam in MOquilt- 400
Public displays; collective grief; tangible activism Quilt detail
Public displays; collective grief; tangible activism International Overdose Awareness Day, Schaumberg
Public displays; collective grief; tangible activism Terri preparing for vigil
Public displays; collective grief; tangible activism OD vigil, Yarmouth
Public displays; collective grief; tangible activism Overdose Awareness Day, Gloucester
Public displays; collective grief; tangible activism 911 Good Samarian advocacy, NY
Ongoing remembrance; Increased awareness
Ongoing remembrance; Increased awareness
Ongoing remembrance; Increased awareness
Ongoing remembrance; Increased awareness
Ongoing remembrance; Increased awareness
Take home points Addressing overdose: Life affirming Enhances provider-patient relationship Response to fatalism Activates and soothes community members Creates community Sample policies? Email me: mdoesimkins@heartlandalliance.org
MAYA DOE-SIMKINS MDOE-SIMKINS@HEARTLANDALLIANCE.ORG ERICA C. ERNST ERICA.ERNST@THRESHOLDS.ORG DANTE COLLINS (773) 668-2048
Overdose Education and Naloxone Distribution Program Reach 2010 States w/ OENDs 15 Programs 188 People enrolled 53,032 OD rescues 10,171 Wheeler E et al. Morb Mortal Wkly Rep 2012
Evaluations of OEND programs Feasibility Walley et al. JSAT 2013; 44:241-7 (Methadone and detox programs) Bennett et al. J Urban Health. 2011: 88; 1020-30 Enteen et al. J Urban Health 2010:87: 931-41 Doe-Simkins et al. Am J Public Health 2009: 99: 788-791 Piper et al. Subst Use Misuse 2008: 43; 858-70 Increased knowledge and skills Wagner et al. Int J Drug Policy 2010: 21: 186-93 Tobin et al. Int J Drug Policy 2009: 20; 131-6 Green et al. Addiction 2008: 103;979-89 No increase in use, increase in drug treatment Seal et al. J Urban Health 2005:82:303-11 Wagner et al. Int J Drug Policy 2010: 21: 186-93 Reduction in overdose in communities Maxwell et al. J Addict Dis 2006:25; 89-96 Evans et al. Am J Epidemiol 2012; 174: 302-8 Walley et al. BMJ 2013; 346: f174 Cost effective Coffin & Sullivan Ann Internal Med 2013; 158: 1-9
Reduction in community OD death rate Naloxone coverage per 100K 250 200 150 100 50 0 Opioid overdose death rate 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 27% reduction 46% reduction No coverage 1-100 ppl 100+ ppl Funding: CDC National Center for Injury Prevention and Control 1R21CE001602-01 Walley, BMJ 2013