Building Capacity in Overdose Prevention

1. Building Capacity in Overdose Prevention • Sharon Stancliff, MD Harm Reduction Coalition

2. Accidental overdose, homicide, and suicide deaths, New York City, 1990-2001 S. Galea

3. Physiology of overdose • Generally happens over course of 1-3 hours- the stereotype “needle in the arm” death is only about 15% • Opioids depress the urge to breath – decrease response to carbon dioxide -leading to respiratory depression and death Sporer Ann Emerg Med 2006

4. Who overdoses? • Most often dependent long term users who are not in treatment with 5- 10 years of experience rather than new users- about 17% occur among new users Sporer 2006

5. Overdoses are often witnessed But what to do? • Fear of police may prevent calling 911 • Abandonment is the worst response • Witnesses may try ineffectual things first • Salt & milk shots Tracy Drug Alcohol Depend 2005

6. Antidote • Naloxone (Narcan), an injectable opioid antagonist will reverse the effects of opioids potentially preventing a fatal overdose.

7. Rationale for overdose prevention programs • Overdoses are rarely instant • There are often bystanders • Naloxone is a safe and effective antidote Many overdoses are preventable with prompt recognition and treatment

8. At least 2,642 overdose reversals How many lives saved? NPR.org

9. New York: a grassroots beginning 2004 • A syringe exchange program (SEP) initiated a pilot overdose program • Injection Drug Users Health Alliance lobbied successfully for NYC funds to provide overdose prevention services with naloxone at the SEPs 2005 • Physician hired to initiate overdose prevention at SEPs; New York Academy of Medicine hired for evaluation

10. New York State law 8/05:A bill approving provision of naloxone to trained lay persons passed unanimously NYSDOH, AIDS Institute charged with crafting regulations April 2006: Law took effect

11. Implementation: NYS • Creation of regulations: NYSDOH called a consultation of large programs: Chicago, New Mexico, San Francisco, Baltimore, NYC • NYS providing overdose kits,sample curriculum, policies and procedures, fact sheets etc • Joint letter from AIDS Institute and OASAS to all drug treatment programs • Outreach to state SEPs, AIDS organizations, drug treatment programs • Funding of evaluation at a methadone program

12. Implementation NYC Continued funding medical staff at the Harm Reduction Coalition to: • Prescribe naloxone at SEPs • Provide training and technical assistance to SEPs and other agencies implementing overdose prevention programs • Provide education to medical providers • Evaluate program

13. Get the SKOOP: Skills and Knowledge on Overdose Prevention

14. The training: 10-20 minutes • Prevention understanding the role of: • mixing drugs • reduced tolerance • using alone • Overdose recognition • Actions • Call 911 • Rescue breathing- using dummy • Naloxone administration

15. Major risk factors • Use following a period of abstinence • Incarceration • Hospitalisation • Drug treatment/detox • Mixing classes of drugs • Primarily other CNS depressants • Cocaine is involved in nearly 40% of NYC overdoses Sporer 2006, Chan Acad Emerg Med 2006

16. Death following incarceration Washington State Corrections: 30,237 inmates released • Overall mortality:777/100,000= 2.5x expected • First 2 weeks: 12.7x expected with overdose rate of 1840/100,000 (x=27) • 60% involved opioids: 60% • 74% involved cocaine and other stimulants Bingswanger NEJM 2007

17. + + + + + - + - + - + + + - - - + - - - + - - - Drug combinations, accidental overdose deaths, New York City, 1990-2001 (n= 10,091) 1-2 deaths each day Alcohol Opiates Cocaine S. Galea

18. Identifying those at risk • Injectors higher risk than nasal insufflators • History of previous overdose is a major predictor of future overdose- may be a key screening question Wines 2007, Coffin 2007

19. Other risk factors • Overdose is more likely in the presence of significant illness: cirrhosis, AIDS, coronary disease, pulmonary disease • Major changes in opioid supply: >1000 deaths USA 2006 with fentanyl • Depression • Wang AIDS 2005, Wines Drug Alcohol Depend 2007 Sporer 2006, http://www.whitehousedrugpolicy.gov/news/fentnyl%5Fheroin%5Fforum,

20. Messages for trained overdose responders Try to use with others who know what to do if an overdose happens Be careful using alone especially if • Using after abstinence • Mixing different classes of drugs Watch out for your friends, particularly under risky circumstances

21. Recognition Overdose responders are taught to be aware of possible signs of overdose • Nodding versus unresponsive • Blue lips and nail beds • Slow breathing, gurgling Act: Call name, sternal rub: rub knuckles hard up and down breast bone

22. Not a replacement for EMS Trainees are counselled • Call 911- “My friend is • unconscious/not breathing” • Give location. No need to say heroin or overdose • Police may come

23. Rescue breathing Many agencies teach mouth to mouth

24. Naloxone (Narcan) • Opioid antagonist which reverses opioid related sedation and respiratory depression and may cause withdrawal • Displaces opioids from the receptors, then occupies the receptor for 30-90 minutes • No psychoactive effects • Over the counter in Italy • Routinely used by EMS

25. Administration • Inject into muscle but subcutaneous and intravenous are also effective • Acts in 2-8 minutes • If no response in 2-5 minutes repeat • Lasts 30-90 minutes

26. Naloxone preparations • Injectable • Inexpensive-$0.25- 1.00 per dose • Well-documented effectiveness • Requires injection • Intranasal • More expensive $6-9.00 per dose • Less well-documented • Easier to use

27. Potential Harm? • Sinking back into overdose when it wears off • Study of 998 OD patients who were administered naloxone by EMS and refused to go to the hospital- none died in the next 12 hours • Using more heroin- naloxone as safety net • Risks unpleasant abrupt withdrawal Vilke Acad Emerg Med 2003

28. Safety in the field Over 3,500 kits distributed 319 overdose reversals reported • 1 unsuccessful revival • 1 seizure • 1 vomited • Only 5 cases with more than 1 injection • No cases of re-treatment after naloxone wore off Maxwell J Addict Dis 2006

29. Harm Reduction • Emergency Medical Services give 1.2- 1.6 milligrams of naloxone which precipitates severe withdrawal in the dependent person • Overdose prevention services recommend starting with 0.4 with an additional dose readily available

30. Results: awake and breathing Narcan wears off in 30-90 minutes • Overdose responder is counselled to remain with the overdoser and reassure the overdoser if s/he is drug sick- the naloxone will wear off- don’t use more heroin to feel better!!

31. Opioid maintenance as prevention • Methadone maintenance may decrease the risk of overdose by up to 75% • Since the institution of buprenorphine and methadone maintenance in 1996 in France heroin overdose has dropped by 79% Caplehorn 1996, Sporer BMJ 2003, Auriacombe Am J Addict 2004

32. 1996 Subutex and methadone 600 500 400 of deaths 300 No. 200 100 0 1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999 Year Substitution therapy prevents overdose French population in 1999 = 60,000,000 Patients receiving buprenorphine (1998): N= 55,000 Patients receiving methadone (1998): N= 5,360 Auriacombe et al., 2001

33. Opioid maintenance • Methadone and buprenorphine act to keep tolerance up- harder to get high but harder to overdose • Both may increase risk of overdosing on other depressants if taken in high doses

34. Syringe exchange/ access sites: rationale • SEPs serve a high risk population • SEPs have trusting relationships with drug users and have expertise in working with drug users including peer education

35. Challenges • Competition with existing programs for staff and resources Syringe exchange programs funding and staff is stretched and has a lot of turnover • Peer educators can be excellent trainers • Reinforcement of message often possible • SEPs usually do not have medical personnel able to prescribe medications on staff • Sharing paid medical staff, use of volunteer clinicians

36. Status of programs 14 syringe distribution programs offering overdose prevention Over over 2,600 syringe exchange participants, trained at 14 syringe access sites • Reports of overdose reversals using naloxone: over 250 SKOOP 3/08

37. Drug treatment programs New York City Department of Health is promoting naloxone training and distribution in: • Detoxification units • Methadone programs • Buprenorphine programs

38. Rationale • Recently detoxified patients are at high risk of overdose • Methadone & buprenorphine patients go in and out of treatment • These patients are in contact with other drug users

39. Challenges May be interpreted as condoning/expecting drug use • Address it as a community issue- points of contact Staff may not see drug users as capable of such an intervention • Education, drug users may be used to describe their own experiences Staff often invested in abstinence model

40. Status • 6 programs have registered all City Hospitals and several more are preparing to register • 1 methadone program has distributed over 200 kits

41. HIV service providers: rationale Ryan White funding can be used to provide overdose services in NYC • 42% of cumulative AIDS cases in NYS have injection drug use or sex with an IDU as a risk factor • People with advanced disease are at higher risk of overdose death • Overdose is a major cause of death among PLWHIV in New York City NYSDOH, Wang 2005, Sackoff 2006

42. Challenges • Clients possibly not willing to disclose drug use • Staff lack of experience and knowledge around drug use issues, discomfort discussing it. • Not all organizations have medical personnel on staff

43. Status of programs • 6 programs in NYS have registered • 4 have initiated services

44. Shelters for the homeless • In NYC, leading cause of death among homeless 2005-2006 was OD (23%) (*) NYC plan: • In 240 city funded shelters, one staff member on every shift will be trained in overdose response • In 81 facilities with medical providers, will offer training and intranasal naloxone to all interested clients • Initial training of medical staff completed • Training of staff as overdose responders imminent

45. Challenges • Creation of policies and procedures for large agency with wide diversity in settings • Medical providers not present in all facilities to dispense naloxone • Needles are not allowed in all shelters • Fear of repercussions of disclosing drug use

46. Status • 1 shelter implemented training of staff immediately after legislation passed • Initial training of medical staff completed • Training of staff as overdose responders imminent

47. Hospitals • Hospitals see patients admitted with drug related illnesses • Overdose prevention training not only addresses overdose risk but can build patient-provider relationship • Program is new with low volume but very acceptable to medical residents

48. Decreasing overdose rates Chicago: 1999-2003 opioid overdose deaths decreased 34% coinciding with start up of first naloxone distribution program • Peak 2000: 310 • 2003: 205 • Naloxone distribution scaled up 200 Baltimore: 2004 overdose rate down San Francisco: 2004 overdose rate down while statewide is up 42% Scott J Urban Health 2007, 3/28/05 Baltimore Sun, SFDOH Commission meeting 2005

49. Evaluation • Data is clear that overdose prevention is feasible, safe and acceptable • Data is emerging that overdose prevention is effective • Data on how best to reach a wider variety of users, how best to train and what preparations are best in different settings

50. Early evaluation of SKOOP Interviews March 2005- December 2005 • Interviewed 389 of 789 trained OD responders • Interviewed 122 trained OD responders who returned for a naloxone refill Piper, TM et.al. 2007, SKOOP Data