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Disclosures-Traci C. Green

Traci C. Green, PhD, MSc Assistant Professor of Emergency Medicine & Epidemiology The Warren Alpert School of Medicine at Brown University, Rhode Island Hospital.

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Disclosures-Traci C. Green

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  1. Traci C. Green, PhD, MScAssistant Professor of Emergency Medicine & EpidemiologyThe Warren Alpert School of Medicine at Brown University, Rhode Island Hospital Community Approaches to the Opioid Overdose EpidemicAssociation for Medical Education and Research in Substance Abuse 36th Annual National ConferenceBethesda, MD

  2. Disclosures-Traci C. Green • The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: • Employment at Inflexxion, Inc. • My presentation will include discussion of “off-label” use of the following: • Naloxone is FDA approved as an opioid antagonist • Naloxone delivered as an intranasal spray with a mucosal atomizer device has not been FDA approved and is off label use • Funding: CDC National Center for Injury Prevention and Control, 5R21CE001846-02 and 1R21CE002165-01; National Institute on Drug Abuse, 1R21DA029201-02A1

  3. Roadmap • define the scope of national & state-level epidemiologic trends in prescription opioid abuse & overdose • identify factors influencing unintentional opioid poisoning using the Haddon Matrix • conceptualize a community based participatory research approach for understanding unintentional opioid poisonings in the community • describe community-based interventions for reduction of opioid overdose

  4. Poisoning: Leading cause of injury death

  5. Prescription opioids driving death trends • More poisoning deaths involve prescription opioids than heroin, other illicit drugs • CDC has declared this an epidemic Source: http://www.cdc.gov/nchs/data/databriefs/db81.htm

  6. Impacts on Life Expectancy? Olshansky et al., Health Affairs 2012

  7. Opioid/opiate substances: all can be prescribed legally except for heroin • Oxycodone • OxyContin • Percodan • Percocet • Hydrocodone • Vicodin • Hydromorphone • Dilaudid • Heroin • Morphine • Codeine • Methadone • Fentanyl Availability, access, & potency of prescription opioids is unprecedented

  8. Endemicity of Opioid Problem: DEA Drug Threat Assessment, 2011

  9. Who is using prescription opioids non-medically? Difficult to summarize & contrast these disparate groups, Let alone plan effective interventions • Young people (Partnership for Drug-Free America, 2005) • College students (McCabe et al., 2005) • Elderly (SAMHSA, 2005) • Women (Manchikanti,2006; Green et al., 2008) • Chronic pain patients (Butler et al., 2004, 2008; Passik et al.,2006) • Street drug users (Davis & Johnson, 2008) • Exhibits geographic patterns: greater in rural areas, also seen among street-based users in large cities (Paulozzi et al., 2009; Brownstein et al., 2009)

  10. ASI-MV Prescription opioid use latent class analysis (n=26,384)

  11. Opioidoverdose| Opioid poisoning • Pinpoint pupils • Respiratory depression (shallow/no breathing) • Blue or grayish lips/fingernails • No response to stimulus • Gurgling/ heavy wheezing or snoring sound • Occurs over 1-3 hours - the stereotype “needle in the arm” death is rare (15%) • Opioids repress the urge to breathe, decrease the body’s/brain’s response to carbon dioxide, leading to respiratory depression (decrease rate of breathing) and death

  12. Where are overdoses highest? Drug overdose death rates by state per 100,000 people (2008)

  13. Painkillers sold by state per 10,000 people (2010)

  14. Risk Factors for Unintentional Opioid Poisoning • Change in TOLERANCE • using ALONE, by oneself • MIXING opioids with other central nervous system depressing substances (alcohol, benzodiazepines) • ILLNESS • (Sporer 2007, Binswanger 2007, Green 2012)

  15. Haddon Matrix HOST • Method for conceptualizing injury • Pre-eventEventPost-event • Tackle problems identified with each factor during each phase TIME + + = AGENT ENVIRONMENT

  16. RARx Study: Unintentional poisoning deaths involving Rx opioids in RI & CT • 2-year CDC funded project • Collaborations with state medical examiners, departments of health, consumer safety, mental health & addiction services, corrections • 4-part study: Forensic case review, inter-agency data linkage (ME,PMP, DOC, SA/MH agencies), provider & pharmacist surveys, & community based rapid assessment field study in heavily affected cities

  17. RI statistics • Rhode Island had the highest rate of past month illicit drug use in the nation among people 12 or older, according to national surveys conducted in 2008,2009, & 2010 • 5.93%of Rhode Islanders 12 or older report non-medical use of opioids, ranking 7thin the nation • Nationally: 4.9% • Drug poisonings outrank motor vehicle crashes as leading cause of injury death, since 2005 Sources: National Survey on Drug Use and Health, SAMHSA 2010, 2011, 2012; CDC WISQARS 2012

  18. Overdose Consequences: RI Emergency Department visits & Hospitalizations Green TC & Donnelly E. Preventable Death: Accidental Drug Overdose in Rhode Island. RI Med Health, Nov 2011

  19. Injury-related1 Deaths: Rhode Island 2005-2009, all ages *Unintentional Data Source: 2005 to 2009 Rhode Island Vital Record Death Data, Rhode Island Department of Health, Center for Health Data and Analysis. 1Injury was listed as primary cause of death. 2Age-adjusted to the year 2000 U.S. standard population

  20. Overdose deaths in CT over time Since 2005, leading cause of adult injury death, more than car crashes, fire, firearms deaths TC Green, LE Grau, HW Carver, M Kinzly, R Heimer. Epidemiologic and geographic trends in fatal opioid intoxications in Connecticut, USA: 1997-2007. Drug and Alcohol Dependence (2011).

  21. RARx: Rapid Assessment & Response • Ethnographic tool, used widely in public health: HIV/AIDS • Investigate who, what, when, where, & why abuse/ deaths occurring • Suggest ways to intervene locally • Two, 10-person Community Advisory Boards Data collection over 12-week period • Review publicly available data, media, online • Existing local data sources (ambulance run data) • 143 Key informant interviews • 52 Brief surveys

  22. Overdose deaths: Forensic Case review • Two-thirds involved a prescription opioid • Deaths occur among 35-54 age range, primarily non-Hispanic Whites, increasingly female, die at home • Involve other pharmaceuticals: anti-depressants, sedatives/hypnotics

  23. Overdose deaths: Forensic Case review themes Drug &/or alcohol abuse/dependence, SA/MH treatment, domestic violence, past suicide attempts, previous overdose, incarceration, other chronic diseases or conditions (diabetes, obesity, back problems, chronic pain), recent acute events-surgery, work injury

  24. Factors contributing to overdose epidemic in Rhode Island • Availability, accessibility of pain pills • Endemic opioid problem • Proliferation of pills in the home, community • Age distribution • “Complicated” patient • Constrained & isolated drug treatment resources • Poor awareness of overdose risk, recognition • Stigma of addiction, chronic pain care, pill use • Fear of police, calling 911

  25. Ambulance runs & Decedent locations Warwick, RI 2009 Calling 911: • Delay or don’t call 911 • Want to protect script doctor, fear of getting into trouble, stigma of drug use, they/ others have record • Failure to recognize overdose symptoms

  26. Recommendations

  27. PMP Survey Findings: prescribers Green et al., How Does Use of a Prescription Monitoring Program Change Medical Practice? Pain Medicine in press • Most use PMP reports to screen for abuse, complement patient care • When concerned about “dr. shopping”/diversion, PMP users significantly more likely than non-users to: • Screen for drug abuse, conduct urine screens, refer to another provider, refer to substance abuse treatment • Revisit pain treatment agreements • Less likely to do nothing (ignore it) • Fewer calls to law enforcement to intervene • Indirect not direct influence on overdose risk

  28. Prevention: Alter demand, supply, & harm MANY OPIOID OVERDOSES ARE PREVENTABLE

  29. Community-Based Prevention

  30. Community-Derived Responses Developed safer prescribing materials for RI, CT on Poison control website, Dept of Health, PMP; mailings to local providers Created, printed, distributed English, Spanish overdose awareness posters for treatment centers, community organizations, clinics; wallet cards Medication assisted therapy (MMT, Suboxone) expanded to two study sites Targeted continuing medical education on safer prescribing + overdose for study area health professionals Medication drop boxes installed in one study site

  31. Clinician Resourcesmaripoisoncenter.com/prescription

  32. Community-Derived Responses Developed safer prescribing materials for RI, CT on Poison control website, Dept of Health, PMP; mailings to local providers Created, printed, distributed English, Spanish overdose awareness posters for treatment centers, community organizations, clinics; wallet cards Medication assisted therapy (MMT, Suboxone) expanded to two study sites Targeted continuing medical education on safer prescribing + overdose for study area health professionals Medication drop boxes installed in one study site RI, CT Good Samaritan, Naloxone laws enacted, dissemination strategy

  33. Law as problem & solution • Prescribing naloxone • As of Aug 1, 2012, 8 states amended laws to make it easier for health professionals to provide naloxone & for lay administrators to use it without fear of legal repercussions (NM, NY, IL, WA, CA, RI, CT and MA) • Good Samaritan laws to encourage calling 9-1-1 • As of Oct 1, 2012, exist in 10 states (NM, WA, NY, RI, CT, IL, CO, FL, MA and CA)

  34. Community-Derived Responses Developed safer prescribing materials for RI, CT on Poison control website, Dept of Health, PMP; mailings to local providers Created, printed, distributed English, Spanish overdose awareness posters for treatment centers, community organizations, clinics; wallet cards Medication assisted therapy (MMT, Suboxone) expanded to two study sites Targeted continuing medical education on safer prescribing + overdose for study area health professionals Medication drop boxes installed in one study site RI, CT Good Samaritan, Naloxone laws enacted, dissemination strategy Naloxone “train the trainer” pilots in CT and RI for 7 SA tx programs, MMT, recovery centers

  35. Naloxone: What is it? • Reverses opioid effects, restores breathing • Not scheduled, not controlled, not abuseable • Must be prescribed • Works only on opioids (heroin, methadone, pain pills) • Has no effect unless opioids are present • Standard antidote used by EMS to diagnosis & treat respiratory depression that causes overdose • Can be administered by laypeople, with training

  36. Existing Naloxone Programs • Since 1996, community-based programs operating overdose education and naloxone programs In the last 15 years: • 188 local programs, 15 US states, DC • 10,171 drug overdose reversals w/naloxone • 53,032 people trained and given naloxone • RI: 177 trainings through community-based organization pilot • CT: 1 MMT, underground programs with limited distribution • MA program trained >15,000 community lay people; >1,500 reversals. Protective effects seen with community saturation (Walley et al., under review)

  37. Community-based overdose prevention:Naloxone distribution models • One-to-one • Provider-patient: Prescribe naloxone to patients at high risk of opioid overdose • One-to-many • Standing order (state, institution) • Designate prescriber proxy • Collaborative Pharmacy Practice Model (flu vaccine)

  38. Project Lazarus, NC

  39. Remarks from G. Kerlikowske, Head of ONDCP: August 22, 2012 •  ”Drug prevention—especially overdose prevention—is a critical piece of our mission.” • “Naloxone is a tool of overdose intervention, and once used, can become a critical link to substance abuse treatment—a tool for long-term overdose prevention.”

  40. www.PrescribetoPrevent.org

  41. Who might benefit most from Narcan training & prescription? • Patients: • with history or suspected history of substance abuse • treated for opioid poisoning or intoxication at ED • beginning Methadone or Buprenorphine therapy for addiction • with higher-dose opioid prescriptions (>50 mg morphine equivalent/day) • rotated from one prescription opioid to another • with opioid prescriptions and: • Benzodiazepine prescription • Anti-depressant prescription • Smoking, COPD, asthma, or other respiratory illness • Renal dysfunction, hepatic illness, cardiac disease, HIV/AIDS • Concurrent alcohol use

  42. Community-Derived Responses Developed safer prescribing materials for RI, CT on Poison control website, Dept of Health, PMP Created, printed, distributed English, Spanish overdose awareness posters for treatment centers, community organizations, clinics; wallet cards Medication assisted therapy (MMT, Suboxone) expanded to two study sites Targeted continuing medical education on safer prescribing for study area health professionals Medication drop boxes installed in one study site RI, CT Good Samaritan, Naloxone laws enacted, dissemination strategy Naloxone “train the trainer” pilots in CT and RI for 7 SA tx programs, MMT, recovery centers RI adopts Poisoning as 1 of 5 priority areas for CDC injury prevention planning grant; CT DMHAS adopts naloxone as “Good Clinical Practice” RI Collaborative Pharmacy Practice Agreement for naloxone adopted by Pharmacy Board Naloxone Summit: Strategic Planning to improve naloxone access in RI

  43. Special Population: Prisoners • 129 times more likely to die of drug overdose during first 2 weeks following release • Tolerance altered by abstinence; physical isolation (using alone) • Since 2005, RI pilot trained 1000’s prisoners, refer to community program for naloxone upon release • <20 have ever presented for take-home naloxone • Similar outcomes in other locations, even with financial incentives

  44. Project SOON: Overdose prevention & take-home naloxoneat release • R21: NIDA grant (PI: Rich, Co-I: Green) started 4/11 • 19-minute overdose prevention & response DVD • Conceptual model: Social learning theory, peer stories • Prisoner-specific, highlighting unique risk & circumstances • Rescue breathing, naloxone (IM, IN) administration • Literacy challenges • N=125 soon-to-be-released prisoners: opioid users or likely to be around opioid users post-release • Naloxone mailed to known address or met at release

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