OVERDOSE PREVENTION AND EDUCATION OVERDOSE MANAGEMENT

OVERDOSE PREVENTION AND EDUCATION OVERDOSE MANAGEMENT 1

OBJECTIVES Discuss basics of opioid overdose epidemiology and physiology To share accurate information about overdose prevention and education including potential impact to polices & procedures To discuss attitudes towards drug users and their processes of change. To practice skills to create more effective working relationships with persons at risk for overdose. Texas Data SB 1462 Offer a 10-20 minute overdose prevention training to other staff and clients Next Steps HEATH INDICATORS The opioid epidemic is one of the largest public health challenges facing the United States. In 2015, more than 52,000 people died from drug overdoses, more than in any other time in history. Drug overdose is the leading cause of accidental death in the country and is now responsible for more deaths than motor vehicle accidents and gun homicides combined. Today, at least 2 million Americans are suffering from substance use disorders related to prescription opioids and 591,000 are dependent on heroin, costing the United States $78.5 billion per year in healthcare and treatment costs, criminal justice costs, and lost productivity. 2

HEATH INDICATORS One of the most important causes of the epidemic is the rising prescribing rate of opiate pain relievers. The United States consumes more opioids than any other country, with some states reporting more opioid prescriptions than there are people. This is a rapidly growing threat, with the rate of opioid prescribing nearly quadrupling from 1999-2014, even while reported levels of pain remained constant. TREATMENT LAST THE STATE OF TEXAS IS LAST IN THE ACCESS TO TREATMENT BEDS. Maternal mortality rates in Texas are higher than any other state in the country. Texas experienced an 86% increase in maternal mortality while the rest of the country witnessed a 26% increase 3

INCREASE IN FENTENYL According to the Houston Section of the Texas DEA and HIDTA there has been a 250% increase in Fentanyl seizures in the State of Texas in last 18 months. National Overdose Deaths Number of Deaths from All Drugs 60,000 Total Female Male 50,000 40,000 30,000 20,000 10,000 0 4

National Overdose Deaths Number of Deaths from Opioid Drugs 35,000 Total Female Male 30,000 25,000 20,000 15,000 10,000 5,000 0 Source: National Center for Health Statistics, CDC Wonder National Overdose Deaths Number of Deaths from Prescription Opioid Pain Relievers (excluding non-methadone synthetics) 20,000 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 Total Female Male Source: National Center for Health Statistics, CDC Wonder 5

14,000 National Overdose Deaths Number of Deaths from Heroin Total Female Male 12,000 10,000 8,000 6,000 4,000 2,000 0 Source: National Center for Health Statistics, CDC Wonder National Overdose Deaths Number of Deaths from Heroin and Non-Methadone Synthetics (captures illicit opioids) 25,000 Total Female Male 20,000 15,000 10,000 5,000 0 Source: National Center for Health Statistics, CDC Wonder 6

10,000 9,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 National Overdose Deaths Number of Deaths from Benzodiazepines Total Female Male Source: National Center for Health Statistics, CDC Wonder 8,000 National Overdose Deaths Number of Deaths from Cocaine Total Female Male 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 Source: National Center for Health Statistics, CDC Wonder Source: National Center for Health Statistics, CDC Wonder 7

Opioid involvement in cocaine overdose 8,000 Total Cocaine and opioids Cocaine without Opioids 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 Source: National Center for Health Statistics, CDC Wonder Opioid involvement in benzodiazepine overdose 10,000 9,000 8,000 7,000 6,000 5,000 4,000 3,000 2,000 1,000 0 Total Benzodiazepines and Opioids Benzodiazepines without Opioids Source: National Center for Health Statistics, CDC Wonder 8

SOCIETAL COSTS Overdoses have become the leading cause of accidental deaths in this country. Nearly 53,000 deaths in 2015. FAMILIES AND COMMUNITIES DESTROID COSTS TO TEXAS The cost of one overnight admission for an opioid overdose episode in Texas is $35,908 (AHRQ HCUP 2013) considering the average stay for such events is 3.8 days according to Presentation of Prescription and Nonprescription Opioid Overdoses US Emergency Departments (JAMA 2014). With a cost of $136,450 per person. Texas healthcare cost and lives which is posed to skyrocket due to opioid related overdoses. Driven by the highest rate of uninsured (20%) and the second highest premium rates in the nation, many Texans, especially young opioid users, turn to hospitals for access to care. This practice increases uncompensated care and hospital cost. Currently, Texas providers rely on federal "1115 Waivers" that reimburses them for uncompensated care. This looks like it will drastically change in September of 2016 when the federal government has indicated they will no longer allow the use of the "1115 Waiver" to reimburse care that could have been paid for if Texas had expanded Medicaid as a part of the ACA. 9

TOTAL HEALTHCARE COSTS ASSOCIATED WITH OPIOID MISUSE 10

140 Americans die each day from drug overdose More than half are from prescription drugs alone Loss of Life from Overdose = Plane Crash Every 4 Days 11

SB 1462 Third party prescription Standing orders and individual prescriptions Prescriptions written for medical purposes Protection from criminal and civil liability as well as professional disciplinary action, so long as they act in good faith 12

OVERDOSES HAVE BECOME THE LEADING CAUSE OF UNINTENTIONAL DEATHS IN THE UNITED STATES. SAMHSA, CDC, NIDA, AMA,ONDCP, HHS, DEA AND MANY OTHERS HAVE CALLED THIS THE EPIDEMIC OF OUR GENERATION UNDERSTANDING DRUG USE EXPLORE PREJUDICES ASSOCIATED WITH DRUG USE AND DRUG USERS HOW STIGMAS PLAY A ROLE IN HOW WE ADDRESS THE ISSUE 13

BASIC DEFINITION OF A DRUG A common definition of the word drug is any substance that in small amounts produces significant changes in the body, mind or both. --Andrew Weil, M.D. WHY DO PEOPLE USE DRUGS? Religious Practices Social interaction Boredom Despair Treat disease Artistic Enlightenment Escape Relaxation 14

DRUG, SET, AND SETTING DRUG SET SETTING BREAK 15 MINUTES 15

WHAT S AN OVERDOSE/WHAT TO DO? CAUSE RECOGNIZE RESPONSE EVALUATION NALOXONE ONLY WORKS TO REVERSE AN OPIOID OVERDOSE Opioids include: heroin, morphine, codeine, methadone, oxycodone (Oxycontin, Percodan, Percocet), hydrocodone (Vicodin) fentanyl (Duragesic), and hydromorphone (Dilaudid) Naloxone does not work for- Non-opioid sedatives: Valium, Xanax, Clonopin, Clonidine, Elavil, alcohol Stimulants: cocaine, amphetamines 16

ARE ALL OPIATES CREATED EQUAL? IN SOME WAYS ALL OPIATES ARE THE SAME AND IN OTHER WAYS THEY ARE DIFFERENT: ALL OPIATES ARE THE SAME IN THAT THEY COME FROM THE OPIUM POPPY OR ARE CHEMICALLY CREATED TO BE LIKE A DRUG WHICH COME FROM THE POPPY; HAVE THEIR EFFECT ON THE SAME PART OF THE BRAIN CAUSE OVERDOSE IN THE SAME WAY IF TOO MUCH IS USED--THIS OVERDOSE COMES IN THE FORM OF STOPPED BREATHING ARE ALL OPIATES CREATED EQUAL? IN SOME WAYS ALL OPIATES ARE THE SAME AND IN OTHER WAYS THEY ARE DIFFERENT: OPIATES ARE DIFFERENT IN THAT THEY: HAVE DIFFERENT CONCENTRATIONS OR STRENGTHS HAVE VARYING DURATIONS OF ACTION SUCH AS.. 17

DURATION OF EFFECTS Methadone: 24 32 hours Heroin: 6 8 hours Oxycodone: 3 5 hours, except extended release formulations Codeine: 3 4 hours Demerol: 2 4 hours Morphine: 3 6 hours Fentanyl: 2 hours, however, more often available as a patch, which lasts 3 days PAIN RELIEF AND EUPHORIA 18

Heroin Sources and Supply Routes Mexican Black Tar Heroin Mexican Brown Heroin & SW Asian South American Heroin, SE Asian, & new Mexican White Heroin 19

Overdose: opioids on brain http://www.copeaustralia.com.au/overdose/ 20

High Risk Factors: People experiencing homelessness: #1 cause of death People experiencing incarceration: #1 cause of death People entering and exiting treatment for opioid use disorder (OUD) Persons with COPD and other respiratory morbidity People living with HIV/AIDS: 74% higher if HIV+ Many people who overdose have just come out of jail or detoxification programs. These individuals should be especially careful if they were to use. Not only has their tolerance gone down, but the strength of illicit drugs may have risen. 21

More Risk Factors Loss of Tolerance: Regular use of opioids leads to tolerance- more is needed to achieve the same effect (same high). Overdoses occur when people start to use again, following a period of abstinence such as incarceration, detox or drug free drug treatment. Mixing Drugs: Mixing opioids with other drugs, especially depressants such as benzodiazepines (Xanax, Clonopin) or alcohol. They are synergistic - the effect of taking mixed drugs is greater than the effect one would expect if taking the drugs separately or together. Cocaine is a stimulant but in high doses it can also depress the urge to breath. Using alone: When using drugs alone there is no one present to see signs of overdose. As noted above, users are at greater risk of overdosing if recently abstinent or mixing drugs and should try to avoid doing that when alone. Variation in strength of street drugs Street drugs may vary in strength and effect based on the purity of the heroin (or other opioid) and the amount of other ingredients used to cut the drug. Users can use small amounts of new batches or inject slowly enough to get a feel of the quality. Possible Causes of Drug Overdose What happens when someone overdoses depends on the kind of drugs they have taken. 22

WHAT DOES AN OVERDOSE LOOK LIKE? Most overdoses is more likely 1-2 hours after using rather than just after injection most overdoses are witnessed Signs: Deep, slow snoring or gurgling Heavy nod, not responsive to stimulation teach sternal rub (rub breastbone hard with knuckles) Slowed breathing Cyanotic- bluish lips and nail beds/graying skin STEP 1: CHECK RESPONSIVENESS 1. FIRST TAP THE PERSON S SHOULDER. IF THAT DOESN T WORK TRY PINCHING AN EARLOBE OR FINGERTIP. 2. ASK ARE YOU OK? SHOUT THE PERSON S NAME; SHOUT WAKE UP! IF NO RESPONSE, CONTINUE. 23

WHAT TO DO : UNDERSTANDING HEROIN OVERDOSE THE PRIMARY BARRIER TO SEEKING HELP DURING AN OVERDOSE IS FEAR OF POLICE INVOLVEMENT. REAL OR PERCEIVED, THE THREAT OF ARREST GREATLY IMPACTS DECISION-MAKING AT THE SCENE OF AN OVERDOSE. WHAT TO DO? FIRST CALL 911 WHATEVER IS GOING ON WITH THEM-- THE MORE HELP THE BETTER. RESCUE BREATHING IS HARD TO KEEP UP FOR LONG PERIOD OF TIME!!!!!!!!! 24

ROLL PERSON ONTO BACK 1. DO THIS AS GENTLY AS POSSIBLE TO AVOID INJURY. OPEN AIRWAYS USE HEAD-TILT/ CHINLIFT METHOD 1. TILT HEAD BACK WITH YOUR NEAREST HAND BY APPLYING BACKWARD PRESSURE TO PERSON S FOREHEAD. 2. PLACE FINGERS OF OTHER HAND UNDER CHIN BONE AND LIFT. DO NOT USE YOUR THUMB TO LIFT THE CHIN. 3. TILT HEAD BACK WITHOUT CLOSING MOUTH. 25

OVERDOSE THE CURE FOR A OPIOID/HEROIN OVERDOSE IS OXYGEN, BREATHING SUPPORT AND AIRWAY CONTROL. If you have to leave scene give first aid put them in the recovery position. 26

NALOXONE IS ALSO CALLED NARCAN IS A PURE ANTIDOTE TO OPIATES INCLUDING OPIOIDS/HEROIN-- IT REVERSES THE EFFECTS OF OPIOIDS/HEROIN FOR ABOUT AN HOUR Overdose: Treat Narcan/naloxone high affinity! http://www.copeaustralia.com.au/naloxone/ 27

Naloxone Nasal Naloxone intranasal spray 28

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NALOXONE HAS NO EFFECTS OF ITS OWN- USING IT WITHOUT HAVING OPIATES IN YOU IS LIKE INJECTING WATER. IS NOT A SCHEDULED DRUG- IT HAS NO POTENTIAL FOR ABUSE 30

NALOXONE CAN CAUSE WITHDRAWAL IN A PERSON USING OPIOIDS. WITHDRAWAL CAN HARM SOMEONE. MORE THAN ONE SHOT MAY BE NEEDED TO STOP OD AND IF OD RETURNS WHEN NALOXONE WEARS OFF. VIDEOS www.getnaloxonenow.org www.prescribetoprevent.org www.operationnaloxone.org 31

HOW CAN WE BEST ACCESS NALOXONE/NARCAN TO DISTRIBUTE IN THE STATE OF TEXAS????? TTOR Philanthropy Medicaid reimbursement Federal Funding Standing Order Pharmacy Access Pharmaceutical Donation Block Grant Dollars AGENCY POLICY AND PROCEDURE TEXAS CURRENT STANDING ORDERS Naloxone Trained Overdose Responder Enrollment Form ADAPT record of Use Form 32

In Conclusion POLICY AND PROCEDURES FOR YOUR AGENCY Doctors can educate patients & partners on naloxone, champion naloxone prescribing Contact funding sources to advocate to use unspent dollars for the purchase of naloxone In Conclusion We ve given some valuable ideas in dealing with an overdose. There are consequences to our actions, whether they re good or bad actions. Calling 911 can be the best option as trained professionals can intervene on sight. Doing all that one can for the person who has overdosed can help one remember that even if the victim died, we did all we could do. 33

Contact Information Texas Overdose Naloxone Initiative www.texasoverdosenaloxoneinitiative.com Mark Kinzly 860-724-5339; markkinzly022@gmail.com Charles Thibodeaux 512-517-9566; cmego46@sbcglobal.net 34

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Contact Information Texas Overdose Naloxone Initiative www.texasoverdosenaloxoneinitiative.com TONI Charles Thibodeaux Mark Kinzly Mark Kinzly 860-724-5339; markkinzly022@gmail.com Charles Thibodeaux 512-517-9566; cmego46@sbcglobal.net 37