Opioid Prescription and Illicit Drug Overdoses: On the Rise Cindy Haynes, MSA-PA, CHES Chronic Pain Program Coordinator Northern Piedmont Community Care Duke Division of Community Health
Objectives Define Opioids and how they work Define Opioid Overdoses as a Public Health Issue Review national and state trends on opioid overdoses Explain and review Naloxone Prescribing Review legal and policy environment related to prescribing and administering naloxone 2
Background & Scope of the Problem
What are Opioids Illegal drugs such as heroin Prescription medications to treat pain such as morphine, codeine, methadone, oxycodone (OxyContin, Percodan, Percocet); hydrocodone (Hydrocodone, Lortab, Norco); fentanyl (Duragesic, Fentora); hydromorphone (Dilaudid, Exalgo); and buprenorphine (Subutex, Suboxone) 4
Leading Cause of Injury Deaths US Drug Overdoses have surpassed motor vehicle crashes as the leading cause of injury death in the U.S. Source: CDC Wonder, Detailed Mortality File, National Vital Statistics System, NCHS at http://wonder.cdc.gov/
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North Carolina & Durham County Data
Substances Contributing to Medication or Drug Overdose Deaths North Carolina Residents, 1999-2014 900 800 700 Prescrip on Opioid Cocaine Heroin 684 Number of deaths 600 500 400 300 200 100 246 202 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 1999-2014 Analysis by Injury Epidemiology and Surveillance Unit 8
Heroin Hosp. and ED Overdoses: 2008-2014 1200 1000 800 600 From 2010 to 2014 a 429% increase for ED visits 474 643 1,127 400 200 252 213 213 76 75 58 311 101 122 195 0 2008 2009 2010 2011 2012 2013 2014 ED Hosp Source: N.C. State Center for Health Statistics, Vital Statistics-Hospital Discharge 2008-2013 NC DETECT- Statewide ED Visit data, 2008-2014 Analysis by Injury Epidemiology and Surveillance Unit 9
Overdoses and Reversals in Durham County Durham County, 2015: 53 opioid overdoses were reported 5 naloxone kits were administered in the ED Caveats ICD codes changed during October 2015, which may have caused some underreporting There may be additional underreporting in Durham due to the way data are being aggregated. The Carolina Center for Health Informatics is currently investigating this issue. 10
Naloxone
Naloxone Naloxone is an antidote for an opioid overdose. It is an opioid antagonist that is used to reverse the effects of opioids Naloxone blocks the opiate receptor sites It only effective in treating overdoses of opioids, it doesn t work on benzodiazepines (i.e., valium) or stimulants (i.e., cocaine & ecstasy) 12
Policy in Action 13
NC Good Samaritan Law Anyone who uses naloxone is immune from civil & criminal lability as long as they do so in good faith Medical providers who prescribe and pharmacies who dispense are also immune To date there are 95 law enforcement departments carrying naloxone (http://www.nchrc.org/lawenforcement/us-law-enforcementwho-carry-naloxone/) 14
NC Naloxone Standing Order June 2016, the State Health Director, Dr. Randall Williams, MD authorized pharmacies to dispense naloxone to those who meet the standing order criteria http://www.naloxonesaves.org/ 15
Project Lazarus 16
Coalitions & Partnerships VIBRANT (Vance Initiates Bringing Resources & Naloxone Training) Lincoln Community Health Center (FQHC) DUHS Opioid Safety Task Force 3-Region Partnership Chronic Pain Telephone Consultation for Primary Care Providers Partnership for a Healthy Durham (Substance Use/Mental Health Committee) Durham Crisis Collaborative Durham TRY Pharmacy Naloxone Outreach 17
Progress NPCC has been working with Sheriff s department to consider to carrying naloxone Duke Bass Connections Opiate Outreach team has submitted a letter to the Durham Police Chief to consider carrying naloxone Durham TRY has submitted a letter to Durham Police Chief to encourage officers to carry naloxone Duke Opioid Safety Task Force is conducting a pilot with identified clinics with high volume prescribing Lincoln Community Health Center is dispensing naloxone (new MAT program) Local pharmacies in the community dispensing naloxone Standing order at Gurley s Partnership for a Healthy Durham s Substance Use and Mental Health Committee working on DPH Naloxone grant from the state for outreach and education NC Harm Reduction Coalition dispensing naloxone in community 18
Next Steps Continue provider and community education on opioid overdose prevention Naloxone outreach and education to Durham County Law Enforcement to be trained to carry naloxone Encourage providers to use the Controlled Substance Reporting System to monitor misuse or abuse of prescription medication Identify and increase access to community-wide resources for alternative therapies and treatment Establish policies within the emergency departments to opioid overdose prevention 19
DCoDPH Program Naloxone kits are provided directly to opiate or heroin users, family members, friends, or domestic partners of active users to provide greater access to naloxone and reduce overdoses. Anyone 18 years of age or older can present to DCoDPH Registration and request a naloxone kit. The Pharmacy dispenses the kit after the registration process is completed. Clients receiving clinical services from a provider can also request naloxone.
Naloxone Information Patients who self-report current opiate or heroin use will receive education and a prescription for a naloxone kit from the clinic provider. Each clinic provides the Naloxone brochure and information on how to obtain a naloxone kit from the health department. Each clinic has Naloxone brochures which are given to patients and family members. Clinics exam rooms have naloxone flyers posted which states the clients may ask questions regarding Naloxone or request a Naloxone kit for a friend or family member.
Naloxone Distribution Over the 2015 calendar year, 9 naloxone kits were prescribed by clinic providers at DCoDPH. Since 1/1/16, 2 kits have been prescribed by clinic providers. 90% of the naloxone kits given were prescribed by the STD clinic providers. 10% of the kits were provided to walk in clients who requested kits.
Durham County Pharmacy Dr. Sena has approved the move to nasal for FY2017 Updates to policies and patient education materials are in the works Pharmacy is reaching out to other facilities to determine how they are implementing the new state wide changes
Sheriff Department Activities Meeting June 14 th with EMS, Sheriff s Office, Public Health and Durham City Manager representative. EMS Director Skip Kirkwood state the EMS Medical Director could write the standing order for Deputies to give Naloxone to suspected opioid overdose victims Sheriff Andrews endorses deputies carrying and giving Naloxone when indicated. Will need to obtain the resources for sustaining this project. Will look in NC Harm providing initial start up resources. Will need to be a county and city law enforcement effort.
Sheriff Department Activities City manager representative will take information to the City manager and Police Chief. Brian Jones from the Sheriff s Office will look at NC Harm Reduction for initial start up funds and funds in the Sheriff s budget to sustain the project Brian will also contact the local University Police about carrying and using Naloxone. Public Health endorses the project for all LEOs to carry and use Naloxone according to policy. Follow- up meeting to be scheduled.