Naloxone

1. Andie Slivinski and Ruth Labardee Health Policy: Spring 2014 Naloxone

2. Naloxone • The Problem • 440% increase in drug overdose deaths over the past decade • Unintentional drug overdoses has become the leading case of injury-related deaths (surpassing MVA, suicides, and falls) • Approximately 1 death every 5 hours related to unintentional overdoses • Unintentional fatal poisonings cost 3.5 billion dollars a year, while non-fatal, hospital admitted poisonings cost an additional 31.9 million (include medical, work loss, and quality of life lost) • Late identification = Wait for EMS = prolonged downtime • Lengthy hospitalization and recoveries • Hugely resource intensive from the time patient hits the door until discharged • Community resources available to address the problem, but patient has to survive and have the “want”

4. The Solution • Naloxone Rescue Kit Programs • Kit contains education on overdose and rescue breathing, face mask, Mucosal Atomization Device (MAD), and 2 mg vial of Naloxone • Cost of kit approximately $40-50 • Have been documented in the literature for over 20 years • Patient can be prescribed naloxone, but more success when patient receives kit “to go” • Kits often distributed from clinics and safe needle houses • Grant funding to provide kits

5. Success Stories • 2 successful programs in Ohio (Scioto and Cuyahoga counties) as Project DAWN initiative • As of 2010, 194 sites distribute Naloxone in 15 states. • Between 1996 and June 2010, a total of 53,032 individuals have been trained and given Naloxone and programs have received reports of 10,171 overdose reversals using Naloxone.

6. Success cont… • Recently published findings in Massachusetts • Probablistic analysis shows distributing naloxone to heroin users in order to reverse unintentional overdose could significantly reduce overdose deaths and would be highly cost effective • One life would be saved for every 164 naloxone kits given out. • Based on more optimistic assumptions, naloxone could prevent as many as 43,000 deaths – one life for every 36 kits given out. • Naloxone distribution would cost about $400 for every quality-adjusted year of life gained. This value is well below the customary $50,000 cutoff for medical interventions.

7. Common Questions • Are we promoting users pushing themselves to the brink if giving them a safety net? • Qualitative studies have demonstrated this not to be true • No user wants their high to be reversed…so they will push themselves to the brink, but not trying to overdose • Studies suggest that increasing health awareness through training programs that accompany Naloxone distribution actually reduces the use of opioids and increases users’ desire to seek addiction treatment. • A 2006 study (Polloni et al) of injection drug users found that surviving an overdose may actually lead an individual to seek treatment. In fact, one in four drug users (26.2%) sought treatment within 30 days after their last overdose. • A 2005 (Seal et al) review of a Naloxone pilot in San Francisco found that during the six months following training in naloxone administration, participants had a statistically significant decrease in injection frequency. • How safe is the drug? • Sold over the counter in some countries • Have to take 260 grams/kg of body weight to cause harm • Violent behavior when high is reversed? • While absorption is almost as quick as intravenous when given intranasal, absorption is different in mucous membranes and there has been documentation of a more “gentle reversal” in the literature (no violent outburst or vomiting) • What if they refuse to come to hospital? • Vilke et al. (2003) reviewed 998 out-of-hospital patients who received Naloxone and refused further treatment and found that there were no cases in which a patient was treated by paramedics with Naloxone within 12 hour of being found dead of an opioid overdose.

8. Legislative Barriers to Solving the Opioid Problem • Lack of immunity • Liability for providers, peace officers, and community at large • 7 states (8 now including Ohio) have prescriber liability and layperson administration laws • Personal examination rule • Required to evaluate and prescribe to individual versus family/friend • 23 states allow APNs and 25 states allow PAs to dispense Naloxone with no significant dispensing restrictions.

9. HB 170 • Bipartisan Bill Sponsorship • Representatives Michael Stinziano (Attorney) and Terry Johnson (practicing DO) • Benefits of the bill • Accepted and went into affect March 11, 2014 • Eliminates liability and possibility of prosecution for providers, peace officers, and community laypersons • Eliminates need for personal examination and allows providers to prescribe to friends/family of known opiate user

10. Stakeholders • Ohio Board of Nursing • Ohio State Medical Association • Ohio Pharmacist Association • Ohio State Board of Pharmacy • Project DAWN • Metro Health • Ohio Ambulance and Medical Transportation Association • Ohio Osteopathic Association • Ohio Department of Mental Health and Addiction Services • Ohio Department of Public Safety • Patients at risk for overdose, and their families

11. Testimony of HB 170 • Many of the above stakeholder groups • Family of overdose victim and patient who was successfully treated w/ Naloxone *Presenters are not aware of any opponent testimony of the bill*

12. Policy Forces • Problem Stream • Opioid addiction is rampant which results in an risk of overdose and death • Policy Stream • The addiction issue is now well understood • Allows individuals and advocacy groups to gain ground • Political Stream • Governor Kasich has established task forces such as the Governor’s Cabinet Opiate Action Team (GCOAT), to address the opioid issue

13. Implications for Nursing Practice • HB 170 allows APRNs w/ prescriptive authority the ability to personally furnish naloxone or issue a prescription for the drug to any of the following…. • Friend • Family member • Other individual in a position to provide assistance • Duty to educate • APRN must instruct individual to whom the drug is furnished/prescribed to summon EMS immediately before or after administration • Documentation of actions and education into the medical record

14. Does this solve the real issue? • What are your thoughts?

15. Conclusion • Ohio is in the midst of a drug overdose epidemic • HB 170 is one way to decrease the number of opioid overdoses • It will take dedicate APRNs and other Healthcare professionals to work collaboratively with legislators and advocacy groups to solve the underlying issue of addiction What questions do you have for us?

16. References • 2011 Drug overdose data: General findings. (2012). Retrieved from http://www.healthyohioprogram.org/~/media/HealthyOhio/ASSETS/Files/injury%20prevention/2final2011_Bullets%20on%20drug%20related%20poisoning.ashx • CDC (February 2012). MMWR Community-Based Opioid Overdose Prevention Programs Providing Naloxone — United States. 61(06);101-105 • Coffin, P. & Sullivan, S. (2013 January). Cost-Effectiveness of Distributing Naloxone to Heroin Users for Lay Overdose Reversal. Annals of Internal Medicine, 158(1), pp. 1-9 • Opiate Action Team (2014). Public Children Services Association of Ohio Executive Meeting. Unpublished manuscript.