OPIOID OVERDOSE PREVENTON

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OPIOID OVERDOSE

PREVENTON

Zena Hyman, DNS, ANP-BC October 4, 2015

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Office of Alcoholism and Substance Abuse Services New York State Department of Health

Harm Reduction Coalition

Special Thanks and Recognition to:

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EPIDEMIOLOGY

PART ONE

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Heroin Overdose Deaths

(prior to 2006)

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About 2% of heroin users died each year- many from heroin overdose

1990-98: 5,506 deaths in NYC

Average of 1-2/day in NYC

Up to 2/3 of heroin users experience at least one

nonfatal overdose

2006: 979 OD deaths in NYC (70% due to opioids)

= ~ 685 opioid deaths

Coffin, 2007; Galea, 2003; Sporer, 2003. HRC

Overdose Rates Increase

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Between 2002 and 2013, heroin-related overdose deaths nearly quadrupled.

Greater than 8,200 people died in 2013, with higher rates in the Northeast and Midwest.

CDC, 2015

Top Medicines by Prescriptions

(IMH, National Prescription Audit, Dec., 2011)

Name 2007 2011 1 Hydrocodone/acetaminophen 120.9 136.7 2 Levothyroxine sodium 97.4 104.7 10 Alprazolam 41.4 49.1 15 Oxycodone/acetaminophen 31.3 38.8 22 Tramadol HCL 20.6 33.9

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Rx Opioid

availability Rx Opioid exposure Rx Opioid misuse IVDU/Heroin

Drug Trend in the U.S.:

Opioid Epidemic

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OVERDOSE DEATHS IN NYC INVOLVING

MULTIPLE DRUGS (2008) HRC

Nearly all unintentional drug overdose deaths (98%) involve more than one substance, including alcohol.

Opioids were the most commonly noted drug type (74%). Types of opioids included heroin, methadone, and prescription pain relievers. (No mention of fentanyl.)

Other drugs commonly found were: cocaine (53%), benzodiazepines (35%), antidepressants (26%), and alcohol (43%).

Consider trends in drugs over time.

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Who overdoses?

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Historically users with 5- 10 years of experience

(Sporer, 2003, 2006)

Past hx OD, male gender, sexual abuse, pain (Britton,

Wines, Connerb, 2009).

Fatal OD are common in older individuals (CDC,

2011) and individuals prescribed immediate release formulations (Hirsh, Proescholdbell, Bronson, Dasgupta, 2014).

Unstable housing, serious illness,

Drug poisoning death rates by age: United States, 1999‐‐2010

CDC/NCHS, National Vital Statistics System; and Warner M, Chen LH, Makuc DM, Anderson RN, Miniño AM. Drug poisoning deaths in the United States, 1980–2008. NCHS data brief, no 81. Hyattsville, MD: National Center for Health Statistics. 2011. http://www.cdc.gov/nchs/data/databriefs/db81.htm Intercensal populations http://www.cdc.gov/nchs/nvss/bridged_race/data_documentation.htm 15‐24 25‐34 35‐44 45‐54 55‐64 65 and over

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Loss of Tolerance

Regular use of opioids leads to greater tolerance, i.e., more needed to achieve the same result Overdose occurs often when people start using

again following a period of not using (abstinence) Common situations leading to loss of tolerance

include: Incarceration, detox, “Drug Free” treatment, or self imposed breaks from use

Take Away: Tolerance can decrease in as little as

72 hours

MIXING DRUGS

Nearly all people who used heroin also used at least 1 other drug. Most used at least 3 other drugs (NSDUH, 2011 -2013). Mixing opioids with other drugs, especially depressants such as benzodiazepines or alcohol can lead to an overdose. Most OD occur in 1 - 3 hours but the peak action and duration of the substances influence the sequence.

GUIDANCE FOR PATIENTS

Don’t use alone or tell someone to check in on you Don’t mix drugs

Know the strength or purity of what you are using Don’t be greedy

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PHARMACOLOGY

PART TWO

Opioids

(Lagos,2008) FULL • morphine • oxycodone • fentanyl FULL • morphine • oxycodone • fentanyl PARTIAL butorphanol pentazocine PARTIAL butorphanol pentazocine PURE naloxone PURE naloxone naltrexone naltrexone buprenorphine buprenorphine nalbuphine nalbuphine tramadol tramadol © AMSP 18

OPIOIDS

Fully Synthetic

OPIATES

Lagos, 2008)

Bind to opioid receptors

Morphine-like action

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Opioid Receptors

µ (mu):

Activated by morphine: analgesia Primary action site of all opioids Distribution: CNS and GI Linked to abuse/dependence

κ(kappa): analgesia, endocrine changes and dysphoria

δ(delta): for endogenous peptides

PHARMACODYNAMICS

Analgesia Cough suppressant Antidiarrheal Inhibit peristalsis Euphoria Decrease respiration Sedation Endocrine effects Constipation 20 Desirable Undesirable

PHARMACOKINETICS ARE VARIABLE

ROUTES OF ADMINISTRATION

Swallowed whole or crushed

Crushed and snorted Crushed and smoked, inhaled Crushed, dissolved, and injected Sublingual, buccal, recital, vaginal Transdermal, spinal, intrathecal, epidural

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Physiology of an Overdose

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Opioid receptors are found in the brain, including the respiratory center in the medulla

Opioid overdose

 Represses the urge to breathe  Decrease response to carbon

dioxide-leads to respiratory depression  Death

Opioid overdose is preventable and, if witnessed, treatable (reversible) (WHO, 2013).

Generally happens over a period of 1 – 3 hours where there is suppression of the urge to breath and oxygen levels fall below the level needed to transfer oxygen to vital organs.

Non-fatal overdose leads to brain damage, cardiac arrhythmia, pulmonary edema.

Fatal overdose occurs with cessation of breathing.

Overdose

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HOW NALOXONE WORKS

 OPIOIDS, AGONISTS BIND TO THE

RECEPTORS

 NALOXONE, ANTAGONIST

DISPLACES OPIOIDS OFF RECEPTORS

OPIOID

RECEPTORS

IN

THE

BRAIN

OPIOID OPIOID OPIOID NALOXONE NALOXONE NALOXONE OPIOID OPIOID _OPIOID

Naloxone temporarily holds receptors, time varies depending on the opioid

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Wakes the person who is

overdosing in 3-5 minutes

 Work for approx., 30-90 minutes

 Analogy: ‘wrong key stuck in a lock’

 Safe, highly effective

NALOXONE IN ACTION

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• Reverses opiate effects of

sedation and respiratory depression

• Causes sudden

withdrawal– unpleasant feeling

• Lowers potential for abuse

– not addictive •• Routinely used by EMS (larger doses)No harm if an opioid is not present

• Sold over the counter in Italy since 1988

• No potential for abuse

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Adverse Reactions Related to

Withdrawal

Sympathetic excess- cardiovascular,

CNS

Reversal opioid analgesia and

sedation- CNS, neuromuscular and skeletal excitement, restlessness

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OVERDOSE RESCUE KIT

2 safety syringes 2 vials of Naloxone Alcohol swabs 2 Luer-Lock pre-filled syringes 2 doses of Naloxone (Narcan ®)

Intramuscular (IM) Naloxone Intranasal (IN) Naloxone 30

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Con’t: OVERDOSE RESCUE KIT

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In addition, both kits are supplied with:

A face mask for rescue breathing 2 latex gloves

Directions – for administering IM and intranasal Program contact information– to seek refills, etc. Drug treatment/counseling resources (as per PH Law Section

3309, 10 NYCRR 80.138)

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Storage:

o Attach naloxone to delivery device when ready to use. o Store naloxone in original package at room temperature;

avoid exposure to light.

o Keep in a safe place away from children & pets, but easy to access in case of emergency.

Expiration:

o Naloxone loses its effectiveness over time.

o DoD data indicate naloxone is hardier than manufacture guidance.

Taking care of naloxone

Opioid maintenance and mortality

Overdose deaths in Baltimore

Adjusting for heroin purity and the number of methadone patients, there was a statistically significant inverse relationship between heroin overdose deaths and patients treated with buprenorphine (P = .002).

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Overdose Prevention Programs that distribute

naloxone: 2010

2010 survey of programs known to the Harm Reduction Coalition

 189 local programs in 16 states ranging from

state-funded to underground 1996 - 2010:

 53,339 individuals received kits  10,194 overdose reversals reported

CDC MMWR February 17, 2012

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6106a1.htm

HISTORY AND THEORETICAL FRAMEWORK

PART THREE

 Since the 1996 community-based programs have offered opioid

overdose prevention services to persons who use drugs, their families and friends, and service providers.

 NYS legislation and regulations have passed giving sanction to

overdose prevention programs and protection to Samaritans who respond to an overdose.

 During 1996–2010, these programs reported training and

providing naloxone kits to 53,032 persons, resulting in 10,171 drug overdose reversals using naloxone

Wheeler et al., 2012, Community-based opioid overdose prevention programs providing naloxone: United States, 2010”, Morbidity and Mortality Weekly Report,61( 6), p. 101-105.

History

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Decline in Drug Overdose Deaths After State Policy Changes — Florida, 2010–2012 MMWR July 4, 2014 / 63(26);569-574

Headlines

THEORETICAL CONCEPTS:

DIFFUSION OF INNOVATIONS

Diffusion:

process by which an innovation is communicated

through certain channels over time among the members of a social system (Rogers, 2003).

Innovation:

an idea, practice, or object perceived as new

by an individual or other unit of adoption.

Diffusion Process:

involves mass media and

interpersonal, communication channels.

CHARACTERISTICS OF AN INNOVATION

(ROGER CLARK, 1991, 1994, 1999)

Relative advantage - the degree to which it is perceived to be better than what it supersedes

Compatibility - consistency with existing values, past experiences and needs

Complexity - difficulty of understanding and use

Trialability- the degree to which it can be experimented with on a limited basis

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CONCEPTS OF PREVENTION

Primary Prevention aims to decrease incidence and prevalence of a disease. (Protection)

Secondary Prevention aims to discover disease before the development of symptoms and to intervene before consequences occur. (Screening)

Tertiary Prevention aims to prevent further damage from occurring as a consequence of disease.

What is NYS’s Opioid Overdose

Program?

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April 2006, PHL Section 3309, 10 NYCRR 80.138

• Eligible, registered entities provide trainingto

individuals in the community on how to respond to an overdose

• Health care facilities

• Drug treatment programs

• Health care practitioners (MD, DO, NP, PA)

• Community-based organizations

• Local health departments

• Police and EMT

• Colleges, universities and trade schools

• Local and state agencies

• Pharmacies

New York State’s Good Samaritan

law

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Protects:

Individual who experience an overdose Person who summons EMS (calls 9-1-1)

Protections from:

Arrest in the presence of misdemeanor possession

and/or underage drinking

Prosecution in felony possession

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More on Good Samaritan

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Offers protection from charge and prosecution

for possession of:

• Drugs up to an A2 felony offense (possession

of up to 8oz of narcotics);

• Alcohol (for underage drinkers);

• Marijuana (any amount);

• Paraphernalia offenses;

• Sharing of drugs (in NYS sharing constitutes a

“sales” offense).

Limitations

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Does not offer protection for drug offenses involving:

Sales for consideration or other benefit or gain People in possession of A1 felony amounts of narcotics

(not marijuana), meaning 8oz or more of narcotics

Arrest or charge for drug or alcohol possession for

individuals with an open warrant for their arrest

Parole is neither expressly covered or singled out

for non-coverage. Parole encourages carrying kits and use is not necessarily a violation

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Risk factors for opioid overdose: Loss of tolerance Mixing drugs Using alone Signs of an overdose: Lack of response to sternal rub Shallow or no breathing Bluish lips or nail

beds Actions: Call 911 Rescue breathing Using naloxone Rescue position

Brief education increases recognition of OD among heroin users.

(Jones, Roux, Standcliff, Matthews, & Comer, 2014)

All trainings will address at a minimum (NYSDOH)

Documentation

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

Policies and procedures



Clinician agreements and non-patient

specific orders



Log: name or record number, date, trainer,

naloxone dispenser, prescriber, type of kit



Add a section for people receiving training

(blue card) but not naloxone



Inventory records



Reversal reports

Logistics

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May be carried by people 16 years or older. Need to obtain from a licensed prescriber or

authorized trainer.

Should be stored at room temperature and away from direct light (in kit is OK).

Has a limited shelf life. Note expiration date and obtain replacement.

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Label

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

Name of recipient



Naloxone preparation and formulation



Date of receipt



Name of program



Name of prescriber



Name of person furnishing naloxone (not

required)

Things Needed to Do the Training

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

A naloxone kit for demonstration



Blue Certification Cards



Informational materials: device assembly

instructions, fact sheets, brochures



Optional: Dummy to demonstrate rescue

breathing.



Optional: Orange for injection Practice if

using IM naloxone.

Trained Overdose Responder

Responsibilities

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Complete refresher training at least every 2 years Contact EMS if suspected drug overdose and