Seven Hills Behavioral Health Opioid Overdose Prevention Pilot Program

1. Seven Hills Behavioral Health Opioid Overdose Prevention Pilot Program Connie Rocha-Mimoso, L.A.D.C I License Alcohol & Drug Counselor Director Of HIV & Naloxone Services

2. Objectives Of Narcan • Enhance community knowledge in relation to Opioid Overdose • Pilot initiatives in the community • Enhance community resources to connect individuals to appropriate treatment

3. Narcan Pilot program Goals • Education and training to: • Opioid Active users • Family Members of active users • Friends of active users • Partners of active users • Staff of Substance abuse programs • Other human services providers who work with Opioid users • Law Inforcement • Emergency Response • County Jails • Shelters • Methadone Clinics • Connecting clients with treatment programs • Inpatient Treatment Facilities • Outpatient Services • Mental Health Services

4. Connecting Individuals with Pilot Program

5. Education Individuals / Group • Signs of Overdose • What are the signs of overdose • What to do and what not do in case of an overdose • Call 911 • Empowering individuals to call 911 • The importance of calling 911 • How to call 911 • Leaving an individual alone if you call 911 • A & B of Life- Airway and breath • Teaching individuals how to • Rescue breathing • Position of Rescue breathing • Leaving someone alone • How to administer Narcan • Put together the kit • When to administer Narcan • Return of Overdose • How to recognize the return of an overdose • Education on different Opioids and Benzos that cause overdoses

6. How is Narcan Distributed Through 1-3 hour training sessions to address death prevention and distribution to the following: • After the training is completed individuals must demonstrate his or her knowledge and skills learned of death prevention and the capability of assembly of the device and administration of the Narcan • After successful completing the training individuals are given the option of signing up for a Narcan Kit which includes • Substance Abuse assessment • Substance Abuse Plan • Two doses of Narcan • Each dose contains 2mg of Narcan • Community Resource guide

7. Overdose Prevention and Naloxone Pilot Structure • Bureau of Substance Abuse Services and Office of HIV/AIDS • Steering Committee • Data Subcommittee • Medical Director • Registered Program • Program Director • Master Trainer • Approved Trainer • Approved Responder

8. Implementing the Massachusetts public health pilot: December 2007 Pilot program conducted under DPH/Drug Control Program regulations (M.G.L. c.94C & 105 CMR 700.000) Medical Director issues standing order for distribution Naloxone may be distributed by public health workers

9. Massachusetts DPH standing order • Authorizes Registered Programs to maintain supplies of nasal naloxone kits • Authorizes Approved Opioid Overdose Trainers to possess and distribute nasal naloxone to approved Responders • Authorizes Approved Opioid Overdose Responders who are trained by Approved Opioid Overdose Trainers to possess and administer naloxone to a person experiencing a drug overdose

10. MA Timeline: Key events & players • 2000-2004: underground & 1 CBO • 2005: underground, 2 CBO

11. MA Timeline: Key events & players • 1999-2004: underground & 1 CBO • 2005: underground, 2 CBO • 2006: underground suspended= incorporated(?), Boston and Cambridge • 2007: MDPH starts an Opioid Overdose Prevention Pilot via standing order • 2009: expansion to more CBOs and outreach • 2010: first responders – police and fire • 2011: parents organizations • 2012: legislature passed good sam and limited liability protection

12. Program Components Approved staff enroll people in the program and distribute naloxone Curriculum delivers education on OD prevention, recognition, and response Referral to treatment available Reports on overdose reversals are collected as enrollees return for refills Enrollment and refill forms submitted to MDPH Kits include instructions and 2 doses naloxone (supplied by MDPH) Medical Director available for consultation, if necessary

13. Enrollments and Rescues: 2006-2013(first half) • Rescues • >2,100 reported • >1 per day • Enrollments • >19,000 individuals • >12 per day • AIDS Action Committee • AIDS Project Worcester • AIDS Support Group of Cape Cod • Brockton Area Multi-Services Inc.  (BAMSI) • Bay State Community Services • Boston Public Health Commission • Greater Lawrence Family Health Center • Holyoke Health Center • Learn to Cope • Lowell House/ Lowell Community Health Center • Manet Community Health Center • Northeast Behavioral Health • Seven Hills Behavioral Health • Tapestry Health • SPHERE

14. Pilot Programs in The State AIDS Action Committee Seven Hills Behavioral Health Tapestry Health AHOPE - Boston Public Health Commission MAPS – Health Innovations AIDS Support Group of Cape Cod Brockton Area Multi-Services Inc. (BAMSI) Statewide Partnership for HIV Education in Recovery Environments (SPHERE) Lowell Community Health Center Lowell House Lawrence Family Health Center Holyoke Health Center AIDS Project Worcester ED SBIRT Hospitals Learn to Cope Manet Community Health Center Quincy Police Department Revere Fire Department Gloucester Police Departments Weymouth Fire Department Saugus Fire Department New Bedford Police and Fire Departments

15. Adopted by ASAM Board of Directors April 2010 • “ASAM supports the increased use of naloxone in cases of unintentional opioid overdose, in light of the fact that naloxone has been proven to be an effective, fast-acting, inexpensive and non-addictive opioid antagonist with minimal side effects... Naloxone can be administered quickly and effectively by trained professional and lay individuals who observe the initial signs of an opioid overdose reaction.”

16. About Naloxone • Naloxone reverses opioid-related sedation and respiratory depression = pure opioid antagonist • Not psychoactive, no abuse potential • May cause withdrawal symptoms • May be administered IM, IV, SC, IN • Acts within 2 to 8 minutes • Lasts 30 to 90 minutes, overdose may return • May be repeated • Narcan® = naloxone

17. Rationale for overdose education and naloxone distribution • Most opioid users do not use alone • Known risk factors: • Mixing substances, abstinence, using alone, unknown source • Opportunity window: • Opioid overdoses take minutes to hours and is reversible with naloxone • Bystanders are trainable to recognize and respond to overdoses • Fear of public safety

18. Evaluations of overdose education and naloxone distribution programs • Feasibility • Increased knowledge and skills • No increase in use, increase in drug treatment • Reduction in overdose in communities • Cost-effective

19. Opioids Semi-synthetic Natural Fully synthetic MorphineCodeine Fentanyl Methadone Buprenorphine Heroin Oxycodone

20. Overdose • Definition: • Excess of a substance leading to central nervous system and respiratory depression/apnea -- unresponsive and not breathing • Opioid overdoses is rarely instantaneous • happen as a process- breathing slows down before it stops • it takes minutes to hours after the drug was used • someone “found dead with a needle in their arm” is uncommon • ¾ of overdose deaths in MA are related to opioids • Of these, half involved another substance • Most often cocaine but benzodiazepines are also common http://www.mass.gov/eohhs/docs/dph/injury-surveillance/opioid-trends-2009.pdf

21. What is Narcan® (naloxone)? • Narcan knocks the opiate off the opiate receptor- it does nothing other than blocking opiate receptors • Temporarily takes away the “high,” giving the person the chance to breathe • Narcan works in 1 to 3 minutes and lasts 30 to 90 minutes • Narcan can neither be abused nor cause overdose, only contraindication is known sensitivity, which is very rare. • Too much Narcan can cause withdrawal symptoms such as: • nausea/vomiting • diarrhea • chills • muscle discomfort • disorientation • combativeness

22. Naloxone basics • Shelf life ~ 2 years • Half life • 28-55 minutes • Bioavailable • intravenous, intramuscular intranasal, • but not orally or under the tongue • Effective dose depends on opioid dose • Adverse effects are opioid withdrawal IPCS/CEC EVALUATION OF ANTIDOTES SERIES http://www.inchem.org/documents/antidote/antidote/ant01.htm#SectionNumber:2.6

23. High Affinity - No Activity • High Affinity – Naloxone sits down hard on the opioid receptor and knocks other opioids off • No Activity – Naloxone does not stimulate the opioid receptor at all

24. Naloxone components Prefilled ampoule of naloxone- comes in the box Mucosal Atomization Device (MAD)- nasal attachment, comes in bag separately Plastic delivery device- looks like barrel of a syringe, comes in the box

25. Can you hurt someone if you give them nasal Narcan? • Narcan’s only function is to block the receptors where opioids would be. If no opioids are present, there is no effect from having Narcan administered. • Narcan will not make a person feel high. • Narcan only treats the effects of opioids-it will not treat the effects of alcohol, cocaine, benzos, or others substances. • The only contraindicaton for Narcan is an allergy to naloxone, which is rare. • Because Narcan stops the effects of opioids, an opioid-dependent person may experience withdrawal symptoms. • The nasal dose provided by the DPH pilot likely results in milder withdrawal symptoms than the intravenous or intramuscular dose commonly used in settings such as ambulances and Emergency Departments.

26. What else? • Narcan last 30-90 minutes • Heroin overdose can last up to 2 hours • An overdose victim should get medical care, or at least be monitored by companions to ensure the OD doesn’t recur • OD victims w/ methadone should get to a hospital to be monitored- methadone lasts much longer than heroin • Taking more drugs right after being given Narcan won’t alleviate withdrawal symptoms • Could also cause OD to recur

27. Intranasal naloxone administration Delivery route has advantages: • Its easy and convenient • The nose is a very easy access point for medication delivery (even easier than the arm, especially in winter) • No shots are needed • It is painless • It eliminates any risk of a needle stick to you

28. Connecting Individuals • The Ultimate Goal of the Narcan Pilot Program: • Reduce the incidence of fatal and non-fatal overdose prevention overdoses from occurring. • Connect individuals to prevention/treament programs. • Improve access to treatment and reduce overdose risk with awareness and education.