Overdose Education & Naloxone Distribution OEND

1. Overdose Education & Naloxone DistributionOEND Sarz Maxwell MD FASAM sarzmaxmd @yahoo.com. www. AnyPositiveChange.org

2. “… he was nodding and then I looked over and he was … well, there’s a smell, you know? I knew he was dead. And I didn’t know what to do, I just parked the car and got on the bus. He was dead. What could I do?”

3. Opiate Overdose Deathsin Cook County (Chicago IL) 1996 1997 1998 1999 2000

4. Medical Precedent

5. Naloxone • Pure opiate antagonist • >40 years experience by emergency personnel for OD reversal • Only effect is blockade of opiate receptor • Not addictive; no potential for abuse • No side effects except precipitation of withdrawal • Dose- and delivery-sensitive

6. Formulations

7. Dead Addicts Never Recover • Average heroin user has witnessed 4 OD’s, at least 1 of them fatal • Deaths of peers & personal experience with OD do not ‘teach’ actively-using heroin addicts to stop using heroin • Heroin addicts are interested in helping other addicts in trouble

8. Participant Input • Participants definitely motivated to intervene in OD situations • Participant focus groups informed program development • Low threshold • Multi-dose vial formulation

9. Attitudes of Drug Users to NDP • 89% approve the idea • 92% express willingness to attend training session • Concerns: • Police harrassment & legality of naloxone possession • Fear of dopesickness • Dose- and delivery-sensitive • Wright et al 2006 UK • Kerr et all 2008 Australia

10. “I was just freakin’ out, thinking: ‘I wish I knew how to do CPR’… and I was like, ‘Oh, why don’t I know this?’”

11. “Motivated more by loss than by brilliance” • Death of CRA co-founder in 1997 • Begin distributing naloxone in 1997 • 2000 actively expanding program • Train all CRA operatives to educate and distribute

12. “Standing Order” Model • US law allows a prescription to be written when a doctor-patient relationship exists • Chart • Documentation of education RE prescription • Medical director trained CRA operatives to educate & distribute • Intake form developed with brief history, checklist for education, and standing order • OEND occurred at all 22 weekly SEP sites plus cell phone on-call • Participants quickly became distributors

13. OD Prevention • Early Recognition • Unresponsive • Before cyanosis • Rescue Breathing • Naloxone administration • 1 cc (0.4 mg) IM • > 1” needle • Multi-use vial • Aftercare • Do not use more opiate! • High will return in 30-40 min • Return of OD • Transport for medical f/u

14. Risk Factors Identified by Medical Examiner Data • Age > 34 • Using in combination with other drugs • Alcohol • Cocaine

15. PONS Respiratory Centre Opiates depress respiratory drive MEDULLA Cardiac Centre Cocaine stimulates heartbeat, blood pressure

16. Risk Factors Identified by our Partipants’ Reports • Mixing drugs • Using alone • Recent period of abstinence – as brief as 3 days will decrease tolerance • Detox program • Incarceration

17. … I put myself in detox and I got out, shot up a bag … and he was with me, thank god, because I went out.” “He got out of the joint… came back, thought he had the same tolerance… but he didn’t…

18. Comparison of Some Opiates

19. >22,000 multi-dose vials >15,000 participants >1500 successful reversal reports NDP begun 1996 2000 2004 2007

20. low self esteem+stigmanihilism+hopelessness for the future

21. stigma NALOXONE Empowerment + New Message: “it matters if you live or die” community, altruism Hope Future-orientation

22. “I did something that made a difference. The whole world can’t see it but I know it made a difference. And that’s important… to me.”

23. 2010: Multiple Venues in Massachusetts • Statewide program supported by state DPH • Operating in 13 communities • SEPs, drop-in centers, treatment programs ( detox, OTP, residential tx, inpt), ER, home visits, street outreach • >9000 enrolled, ~1000 reversals (11%)

24. OEND in Addictions Treatment Programs • Top 3 most common sites for OTP patient naloxone refills: • Needle Exchange Program (40%) • Drop-in Center (30%) • Methadone Clinic (9%) Slide courtesy Maya Doe-Simkins

25. 2009, Birmingham Gaston et al • 70 patients with opioid dependence syndrome in abstinence-based program trained & given naloxone • 6 mos later, participants had retained knowledge, still had the naloxone, but none had used it • Transportability • Stigma • Fear of police Harm Reduct J, 2009 Sep 24; 6:26

26. Significant Factors in Program Success • Low threshold – on demand, easily accessible, minimal paperwork • Education – duration; by whom • Venue – user-friendly • Formulation – simple, durable • Doses and Refills – multiple doses • OD relapse • Multiple simultanerous victims • Abundance >> Confidence

27. “It used to be, overdose, you always talked about it in past tense: ‘I HAD a friend who OD’d.’ Now, overdose is in the present tense: ‘I HAVE a friend who OD’d last week’. Naloxone did that.”

28. Thanks toChicago Recovery Alliance • Dan Bigg • Karen Stanczykiewiz • Greg Scott • Suzanne Carlberg – Racich • John Gutenson • Susie Gualtieri • Sharon Sereda • Esther, Cheryl, Cliff, Andrew … • All of our courageous participants, who make this program work

29. the end(s) www. AnyPositiveChange .org sarzmaxmd @ yahoo.com