OVERDOSE SOLUTIONS 2013
ADDRESSING OPIOID OVERDOSE
WITH COMMUNITY-BASED EDUCATION AND
NALOXONE RESCUE KITS
Alexander Walley, MD MSc
Medical Director, Massachusetts Dept. of Public Health Opioid Overdose Prevention Pilot
Addressing opioid overdose
with community-based education and naloxone rescue kits
Alexander Y. Walley, MD, MSc
Boston University School of Medicine
Boston Medical Center
Allegheny County Overdose Prevention Coalition
Wednesday, July 24th, 2013
9:15am-10:45am
Disclosures –
Alexander Y. Walley, MD, MSc
•
The following personal financial relationships with commercial interests relevant to this presentation
existed during the past 12 months:
–
•
My presentation will include discussion of “off-label” use of the following:
–
–
•
Consultant for Social Sciences Research Inc. which is developing a training module for first responders
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 1R21CE001602-01
Learning objectives
At the end of this session, you will know:
1. Epidemiology of overdose, the rationale and history of the MA OEND
program
2. The scope of the MA OEND program
3. Effectiveness of OEND: INPEDE OD Study
4. Venues and models
5. How to incorporate OEND into medical settings
6. To acknowledge and address
overdose stigma
More Opioid Overdose Deaths than MVA Deaths in Massachusetts
1200
Poisoning Deaths vs. Motor Vehicle-Related Injury Deaths,
MA Residents (1997-2008)
1000
Deaths per year
800
600
400
200
0
1997
1998
1999
2000
All Poisoning Deaths
2001
2002
2003
2004
2005
2006
2007
2008
Motor Vehicle-Related Injury Deaths
The source of the data is: Registry of Vital Records and Statistics, MA Department of Public Health
2009
2010
More Opioid Overdose Deaths than MVA Deaths in Massachusetts
1200
Poisoning Deaths vs. Motor Vehicle-Related Injury Deaths,
MA Residents (1997-2008)
1000
Deaths per year
800
600
400
200
0
1997
1998
All Poisoning Deaths
1999
2000
2001
2002
2003
2004
Opioid-related Poisoning Deaths
2005
2006
2007
2008
2009
2010
Motor Vehicle-Related Injury Deaths
Rate of opioid-related fatal overdoses in MA in 2006 was 9.9 per 100K
The source of the data is: Registry of Vital Records and Statistics, MA Department of Public Health
Motor vehicle traffic, poisoning, drug poisoning, and unintentional drug poisoning death rates: United
States, 1999--2010
Motor vehicle traffic
18
Deaths per 100,000 population
16
Poisoning
14
12
Drug poisoning
10
Unintentional drug
poisoning
8
6
4
2
0
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
NOTES: Drug poisoning deaths are a subset of poisoning deaths. Unintentional drug poisoning deaths are a subset of drug poisoning deaths.
SOURCE: 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
Allegheny County Trends in Accidental Drug Overdose
Deaths
2000-2012*
350
Heroin
300
250
Cocaine
200
150
Prescription Opioids
100
50
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Total Overdose
Deaths
*Data is from Allegheny County Medical Examiners Annual Reports and includes all overdose deaths where these drugs were
present at time of death, not necessarily cause of death.
Opioid overdose costs
• $20.4 billion per year in 2009
– $2.2 billion direct costs
• inpatient, ED, MDs, ambulance
– $18.2 billion indirect costs
• lost productivity from absenteeism and mortality
• $37,274 cost per opioid overdose event
Inocencio TJ et al. Pain Medicine 2013
What is Driving the Increase in Overdose?
• New Drug Use Patterns
– New Initiates to prescription drugs
– Vicodin/Percocet/oxycodone >>> heroin
• Heroin Availability/Purity/Lethal Mixture
– Heroin is the leading drug threat in New England
– From ‘93-’10 Heroin reported as primary drug increased from 20% - 40% of treatment admissions in
MA
• Prescribing Patterns
– Schedule II Opioid prescriptions more than doubled since the 1990s
Strategies to address overdose
• Prescription monitoring programs
– Paulozzi et al. Pain Medicine 2011
• Prescription drug take back events
– Safe disposal
• Safe opioid prescribing education
– Albert et al. Pain Medicine 2011; 12: S77-S85
• Expansion of opioid agonist treatment
– Clausen et al. Addiction 2009:104;1356-62
• Safe injection facilities
– Marshall et al. Lancet 2011:377;1429-37
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 OD takes minutes to hours and is reversible with naloxone
• Bystanders are trainable to recognize OD
• Fear of public safety
Overdose Education and Naloxone Rescue Kits
2010
States w/ OENDs
15
Programs
188
People enrolled
53,032
OD rescues
10,171
Wheeler E et al. Morb Mortal Wkly Rep 2012;61:101-5.
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
naloxone ≠ Suboxone ≠ naltrexone
Evaluations of OEND programs
• Feasibility
–
–
–
–
–
Piper et al. Subst Use Misuse 2008: 43; 858-70
Doe-Simkins et al. Am J Public Health 2009: 99: 788-791
Enteen et al. J Urban Health 2010:87: 931-41
Bennett et al. J Urban Health. 2011: 88; 1020-30
Walley et al. JSAT 2013; 44:241-7 (Methadone and detox programs)
• Increased knowledge and skills
– Green et al. Addiction 2008: 103;979-89
– Tobin et al. Int J Drug Policy 2009: 20; 131-6
– Wagner et al. Int J Drug Policy 2010: 21: 186-93
• No increase in use, increase in drug treatment
– Seal et al. J Urban Health 2005:82:303-11
• Reduction in overdose in communities
– Maxwell et al. J Addict Dis 2006:25; 89-96
– Evans et al. Am J Epidemiol 2012; 174: 302-8
– Walley et al. BMJ 2013; 346: f174
MA Timeline: Key events & players
• 2000-2004: 1 CBO underground
• 2005: 2 CBO underground
– Boston EMTs equipped with IN via special project waiver
MA Timeline: Key events & players
• 2000-2004: 1 CBO underground
• 2005: 2 CBO Boston underground
– Boston EMTs equipped with IN via special project waiver
•
•
•
•
•
•
2006: underground suspended >> incorporated, 2 city governments
2007: city, state government, CBOs
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
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
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
an overdose
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
Staff Training and Support
Staff complete:
• 4 hour didactic training
• At least 2 supervised bystander
training sessions
Sites participate in:
• Quarterly all-site meetings
• Monthly adverse event phone
conferences
Prefilled naloxone ampule
Mucosal Atomization Device
(MAD)
Luer-lock syringe
Intranasal
Administration
Pro
• 1st line for some local EMS
• RCTs: slower onset of action but milder
withdrawal
• Acceptable to non-users
• No needle stick risk
• No disposal concerns
Con
• Not FDA approved
• No large RCT
• Assembly required, subject to breakage
• High cost:
– $40-50+ per kit
Program data
Enrollments and Rescues:
2006-2012
• Enrollments
– 16,379 individuals
– >10 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
• Rescues
– 1,741 reported
– >1 per day
Enrollee characteristics:
2006-2012
User n=11,002
Witnessed overdose ever
Lifetime history of overdose
75%
49%
Received naloxone ever
Inpatient detox, past year
41%
64%
Incarcerated, past year
28%
Reported at least one overdose rescue
7.5%
Non-User
n=5,377
42%
2.0%
Program data
Enrollee past 30 day use: 2006-2012
Data only from people with current use or in treatment n = 10,589
OEND program rescues:
2006-2012
Active use, in
treatment, in
recovery N=1,132
Non-User (family,
friend, staff)
N=123
911 called or public safety present
30%
59%
Rescue breathing performed
Stayed until alert or help arrived
32%
90%
31%
94%
Program data
Adverse Events:
Sept 2006-Dec 2012
N=1,741
Deaths
7 / 1729
0.4%
72 / 1604
4%
Recurrent overdose
3/1741
0.2%
Withdrawal symptoms after naloxone
107/219
49%
Difficulty with device
11/1741
0.6%
Negative interactions with public safety
114/ 466
24%
205 / 5271
4%
OD requiring 3 or more doses
Confiscations
Program data
Withdrawal symptoms after naloxone
Symptoms
None
Irritable or angry
Dope sick
Physically combative
Vomiting
Other
N=219
51%
21%
20%
4%
3%
13%
Confused, Disoriented, Headache, Aches and chills, cold, crying, diarrhea, happy,
miserable
Program data
Do trained rescuers perform differently than
untrained rescuers?
Rescues after training (N=508)
Rescues before training (N=91)
Friend of OD victim
67% (341/508)
69% (63/91)
OD setting: Public
20% (100/498)
29% (26/89)
> 1 naloxone dose used
48% (23/468)
39% (33/85)
911 called or EMS present
23% (119/508)
27% (25/91)
Rescue breathing
47% (166/350)
52% (34/66)
Stayed with victim
89% (445/498)
89% (78/88)
Sternal rub
63% (222/350)
62% (41/66)
Doe-Simkins et al. Under review
INPEDE OD
(Intranasal Naloxone and Prevention EDucation’s Effect on OverDose)
Study
Objective:
Determine the impact of opioid overdose education with intranasal naloxone
distribution (OEND) programs on fatal and non-fatal opioid overdose rates in
Massachusetts
Co-authors:
Ziming Xuan
H Holly Hackman
Emily Quinn
Maya Doe-Simkins
Amy Sorensen-Alawad
Sarah Ruiz
Al Ozonoff
Opioid Overdose Related Deaths:
Massachusetts 2004 - 2006
OEND programs
2006-07
2007-08
2009
Towns without
Number of Deaths
No Deaths
1-5
6 - 15
16 - 30
30+
Design, population and setting
• Design:
– Quasi-experimental interrupted time series
• Population:
– 19 Massachusetts cities and towns with 5 or more opioid-related unintentional
or undetermined poison deaths in each year from 2004-2006
• Setting:
– MA OEND programs were implemented by 8 community-based programs starting
in 2006
OEND program data collection
• Enrollment form:
– program staff collect potential bystander
demographics and OD risk factors
• Refill form:
– Upon return to program for more naloxone,
staff collect data on use of naloxone, including
overdose rescues
Analyses
Poisson regression to compare opioid-related overdose rates
among cities/towns with no vs. low and high implementation
between 2002 and 2009
– Natural interpretations as rate ratios (RRs) calculated by
exponentiating the beta coefficents
Fatal opioid OD rates by
OEND implementation
Cumulative enrollments per 100k
RR
ARR*
95% CI
No enrollment
Ref
Ref
Ref
Low implementation: 1-100
0.93
0.73
0.57-0.91
High implementation: > 100
0.82
0.54
0.39-0.76
Absolute model:
* Adjusted Rate Ratios (ARR) All rate ratios adjusted for the city/town population rates of age under 18,
male, race/ ethnicity (hispanic, white, black, other), below poverty level, medically supervised inpatient
withdrawal treatment, methadone treatment, BSAS-funded buprenorphine treatment, prescriptions to
doctor shoppers, and year
Walley et al. BMJ 2013; 346: f174.
Fatal opioid OD rates by
OEND implementation
Naloxone coverage per 100K
Opioid overdose death rate
250
100%
90%
200
80%
27% reduction
46% reduction
70%
150
60%
50%
100
No coverage
40%
30%
50
1-100 ppl
20%
10%
0
100+ ppl
0%
Walley et al. BMJ 2013; 346: f174.
Opioid-related ED visits and hospitalization rates by OEND
implementation
Cumulative enrollments per 100k
RR
ARR*
95% CI
No enrollment
Ref
Ref
Ref
Low implementation: 1-100
1.00
0.93
0.80-1.08
High implementation: > 100
1.06
0.92
0.75-1.13
Absolute model:
* Adjusted Rate Ratios (ARR) All rate ratios adjusted for the city/town population rates of age under 18,
male, race/ ethnicity (hispanic, white, black, other), below poverty level, medically supervised inpatient
withdrawal treatment, methadone treatment, BSAS-funded buprenorphine treatment, prescriptions to
doctor shoppers, and year
Walley et al. BMJ 2013; 346: f174.
INPEDE OD Study
Summary
1. Fatal OD rates were decreased in MA cities-towns where OEND was
implemented and the more enrollment the lower the reduction
2. No clear impact on acute care utilization
Cost-effectiveness of distributing naloxone to heroin users
for overdose reversal
In a simulation model:
• One heroin overdose death prevented for every 164 kits distributed
• Cost for naloxone distribution would range between:
–
$438-$14,000 (best-worst case scenario) for every quality-adjusted life year gained
• Generally accepted threshold is $50,000/year
– For dialysis: recently calculated as $129,000
•
Lee et al. Value Health 2009;12(1): 80-7.
– For primary care-based SBIRT: recently calculated as $6960
•
Tariq et al. PLoS One 2009;4(5)
Coffin and Sullivan. Ann Intern Med. 2013; 158: 1-9.
Venues and Models
Enrollment locations: 2008-2012
Using, In Treatment, or In Recovery
Non Users (family, friends, staff)
Detox
Syringe Access
Drop-In Center
Community Meeting
Other SA Treatment
Methadone Clinic
Inpatient/ ED/ Outpatient
Home Visit/ Shelter/ Street Outreach
0
500
1,000
1,500
2,000
2,500
3,000
3,500
4,000
Number enrolled
Program data
Data from people with location reported: Users: 9,824 Non-Users: 4,818
Implementing OEND in MMT and detox
Among 1553 OEND participants who reported taking methadone, 47% were trained in detox, 25% at HIV prevention programs, and
17% in MMT. Previous overdose, recent inpatient detox or incarceration, and polysubstance use were OD risks common among
all groups.
Model
Advantages
Disadvantages
1. Staff provide OEND on-site
•
•
Good access to OEND
OD prevention integrated
•
Patients may not disclose risk
2. Outside staff provide OEND onsite
•
•
•
OD prevention integrated
Interagency cooperation
Low burden on staff
•
Community OEND program needed
3. OE provided onsite, naloxone
received off-site
•
•
OD prevention integrated
Interagency cooperation
•
Increased patient burden to get
naloxone
4. Outside staff recruit near MMT or
detox
•
Confidential access to OD prevention
•
OD prevention not re-enforced in
treatment
Not all patients reached
•
Among 29 MMT and 93 detox staff who received OEND, 38% and 45% respectively reported witnessing and overdose in their
lifetime.
Walley et al. JSAT 2013; 44:241-7.
Other venues and models
• First responder OEND
– Quincy, Revere, Gloucester
• Emergency Department (ED) SBIRT
• Post-incarceration
• Prescription naloxone
– Prescribetoprevent.org
Quincy P.D. Statistics
• May 2009 – October 2010 (17 months)
– 47 Fatal Overdoses
• October 2010 – December 2012 (26 months)
– 206 Non-Fatal Overdoses
– 19 Fatal Overdoses
– 134 Naloxone Administrations
• 131 Successful Reversals (98%)
• 2 Deceased (1.5%)
• 1 No Effect (probably not an opioid O.D.)
Incorporating overdose education and naloxone
rescue kits into medical and addiction practice
1. Prescribe naloxone rescue kits
•
PrescribeToPrevent.org
2. Work with your OEND program
Challenges for community
programs
• Prescription and prescriber typically
required
• Naloxone cost is increasing, funding is
minimal
• Missing people who don’t identify as
drug users, but have high risk
• CBOs target IDU, people w/ substance
use disorders, HIV prevention
Opportunities for prescription
naloxone
• Co-prescribe naloxone with opioids for
pain
• Co-prescribe with methadone/
buprenorphine for addiction
• Insurance should fund this
• Increase patient, provider & pharmacist
awareness
• Universalize overdose risk
Practical Barriers to Prescribing Naloxone
1.
2.
3.
Prescriber knowledge and comfort
How to write the prescription?
Does the pharmacy stock rescue kits?
•
•
4.
Rescue IN kit with MAD?
Rescue IM kit with needle?
Who pays for it?
•
•
•
Insurance in Massachusetts covers naloxone, but not the atomizer yet
The MAD costs $3 each>> $6-7 per kit
Work with your pharmacy to see if they will cover it
Legal Barriers to Prescription Model
“Prescribing naloxone in the USA is fully consistent with state and federal laws
1.
2.
regulating drug prescribing. The risks of malpractice liability are consistent
with those generally associated with providing healthcare, and can be
further minimized by following simple guidelines presented.”
Only prescribe to a person who is at risk for overdose
Ensure that the patient is properly instructed in the administration and risks
of naloxone
Burris S at al. “Legal aspects of providing naloxone to heroin users in the United States. Int J of Drug Policy 2001: 12; 237248.
Massachusetts - Passed in August 2012:
An Act Relative to Sentencing and Improving Law Enforcement Tools
Good Samaritan provision:
•Protects people who overdose or seek help for someone overdosing from being charged or prosecuted for drug
possession
–
Protection does not extend to trafficking or distribution charges
Patient protection:
•A person acting in good faith may receive a naloxone prescription, possess naloxone and administer naloxone to an
individual appearing to experience an opiate-related overdose.
Prescriber protection:
•Naloxone or other opioid antagonist may lawfully be prescribed and dispensed to a person at risk of experiencing an
opiate-related overdose or a family member, friend or other person in a position to assist a person at risk of
experiencing an opiate-related overdose. For purposes of this chapter and chapter 112, any such prescription shall be
regarded as being issued for a legitimate medical purpose in the usual course of professional practice.
Overdose Education in Medical Settings
• Where is the patient at as far as overdose?
– Ask your patients whether they have overdosed, witnessed an overdose or received training to prevent,
recognize, or respond to an overdose
• Overdose history:
1. Have you ever overdosed?
1.
2.
What were you taking?
How did you survive?
2. What strategies do you use to protect yourself from overdose?
3. How many overdoses have you witnessed?
1.
2.
Were any fatal?
What did you do?
4. What is your plan if you witness an overdose in the future?
1.
2.
Have you received a narcan rescue kit?
Do you feel comfortable using it?
Overdose Education in Medical Settings
What they need to know:
1.Prevention - the risks:
–
–
–
–
–
–
Mixing substances
Abstinence- low tolerance
Using alone
Unknown source
Chronic medical disease
Long acting opioids last longer
2.Recognition
– Unresponsive to sternal rub with slowed breathing
– Blue lips, pinpoint pupils
3.Response - What to do
•
•
•
•
Call for help
Rescue breathe
Deliver naloxone and wait 3-5 minutes
Stay until help arrives
Prescribetoprevent.org
Stigma Related to Overdose
These articles appeared in the same paper, one in
police reports the other in the obituary
Woodland Avenue resident dies of an apparent overdose
A 44-year-old Woodland Avenue man is believed to have overdosed on
heroin and died as a result last Thursday morning at a Cooledge
Avenue home.
The man, William SmithJones, of Woodland Avenue, was found by a
friend in the bathroom after he went in to shower and shave around 8
a.m. After spending more time than usual in the bathroom, the friend
pushed her way inside and found him on the floor, purple colored.
EMTs from Cataldo Ambulance administered Narcan to Anderson and
rushed him to Whidden Hospital, where he died later.
William SmithJones, 44
Worked for Acme
William SmithJones died unexpectedly at the Whidden Memorial Hospital in Everett on
March 5, after
at his Oak Island home in Revere. He was 44 years old.
Born in Lynn, he was a lifelong resident of Oak Island, attended Revere schools and was
employed by Acme Company of Revere until his untimely death.
He was the father of Brendan SmithJones and Krysti SmithJones, both of Salem, NH; son
of Cheryl SmithJones of Malden and the late Harold SmithJones; brother of Lori
SmithJones of Tewksbury, Harold SmithJones of Fremont, NH, Annie SmithJones of
Medford and Robert SmithJones of Somerville. He is also survived by the mother of his
children, Heidi SmithJones of Salem, NH, Mildred SmithJones, his maternal
grandmother, Ruth Smith of Revere; a cousin, Jonathan A. SmithJones of Revere; and
several nieces, nephews and other cousins. He was also the grandson of the late Robert
SmithJones and Oswell and Anna SmithJones.
Funeral arrangements were entrusted to the Vertuccio Home for Funerals of Revere.
Remembrances may be made to the American Heart Association, 20
Speen St., Framingham, MA 01701.
Reduce the Stigma
• Talk about it!!!
• Information DOES NOT = “enabling”
• Denying access increases risk
• Open up the issue like any other
• Chance for intervention
• Discuss overdose information along with
use/recovery/treatment etc.,
• Listen and talk with users/nonusers/politicians/community
Next steps
• Sustain existing programs
• Expand sites and venues
• Target incarcerated and ED patients
• Facilitate wider prescribing of naloxone
– Chronic pain and addiction practices
– Family members of opioid users
Lessons Learned
• Standing order facilitates expansion
• Nasal naloxone helps acceptability
• Use existing networks to reach high risk people and build out
from there
• Both grass roots and top down leadership are useful
• Prescription naloxone takes patience and perseverance
• Parents and public safety can be powerful advocates
• Overdose can bring people together on common ground
Learning objectives
At the end of this session, you will know:
1. Epidemiology of overdose, the rationale and history of the MA OEND
program
2. The scope of the MA OEND program
3. Effectiveness of OEND: INPEDE OD Study
4. Venues and models
5. How to incorporate OEND into medical settings
6. To acknowledge and address
overdose stigma
Thank you!
awalley@bu.edu
MA DPH
• Sarah Ruiz
• John Auerbach
• Andy Epstein
• Holly Hackman
• Michael Botticelli
• Kevin Cranston
• Dawn Fakuda
• Barry Callis
• Grant Carrow
• Len Young
• Kyle Marshall
• Office of HIV/AIDS
• Bureau of Substance Abuse Services
Helpful Websites:
Prescribetoprevent.org
Overdosepreventionalliance.org
Naloxoneinfo.org
BU/BMC
• Gregory Patts
• Chris Chaisson
• Jeffrey Samet
• Ed Bernstein
Program sites, staff and participants
NOPE group
Considerations
• Intranasal works and is popular
– It could be improved with a one-step, affordable FDA-approved intranasal
delivery device
– Intramuscular may be more affordable and implementable
• Nonmedical community health workers provide effective OEND
– Broad dissemination to high risk groups and their families
– Facilitated by state-supported standing order
• Prescription status is a barrier
Limitations
• True population at risk for overdose is not known
– Adjusted for demographics, treatment, PMP, and year
• Cause of death subject to misclassification
– One medical examiner for all of MA
• Non-fatal overdose measure >> Diagnostic codes are subject to
misclassification
– No reason bias should be in one direction
• Overdoses may occur in clusters
– Study conducted over wide area and several years
• Measures of OEND implementation have not been validated
How does drug use change after OEND?
N=325
Increased
Decreased
No change
Heroin
115 (35%)
122 (38%)
88 (27%)
Methadone
84 (26%)
70 (22%)
171 (52%)
Buprenorphine
73 (22%)
66 (20%)
186 (58%)
Other Opioids
59 (18%)
62 (19%)
205 (63%)
Cocaine
83 (26%)
96 (30%)
146 (44%)
Alcohol
69 (21%)
70 (22%)
186 (57%)
Benzo/Barbiturate
99 (30%)
74 (23%)
152 (47%)*
Number of substances** used
131 (40%)
125 (38%)
69 (21%)
*p < 0.05 - Wilcoxon signed rank test which compares the median difference between two repeated measures among the repeat enrollers
**Participants were asked about use of heroin, methadone, buprenorphine, other opioids, cocaine, alcohol, benzodiazepine/barbiturate,
methamphetamine, clonidine, and other substances
Doe-Simkins et al. Under review
Unadjusted unintentional opioid-related overdose death rates
in 19 communities with no, low and high OEND enrollment
in Massachusetts, 2002-2009
Opioid-related overdose deaths
per 100,000 population
20
15
10
No enrollment
Low enrollment (1-100 per 100,000)
High enrollment (>100 per 100,000)
5
0
2002
2003
2004
2005
2006
2007
2008
2009
Year
Walley et al. BMJ 2013; 346: f174.
Unadjusted unintentional opioid-related acute care hospitalization rates
in 19 communities with no, low and high OEND enrollment
in Massachusetts, 2002-2009
Opioid-related acute care rates
per 100,000 population
120
100
80
60
No enrollment
Low enrollment (1-100 per 100,000)
High enrollment (>100 per 100,000)
40
20
0
2002
2003
2004
2005
2006
2007
2008
2009
Year
Walley et al. BMJ 2013; 346: f174.
Control models of OEND implementation and ratio of opioid related overdose deaths
to cancer deaths
Cumulative enrollments per 100k
Adjusted β estimate*
P-value
Absolute model:
No enrollment
Ref
Low implementation: 1-100
-0.0222
0.01
High implementation: > 100
-0.0326
0.01
Relative model:
No enrollment
Ref
Low implementation: 1-100
-0.0238
<0.01
High implementation: > 100
-0.0183
0.07
* Adjusted Rate Ratios (ARR) All rate ratios adjusted for the city/town population rates of age under 18,
male, race/ ethnicity (hispanic, white, black, other), below poverty level, medically supervised inpatient
withdrawal treatment, methadone treatment, BSAS-funded buprenorphine treatment, prescriptions to
doctor shoppers, and year
Walley et al. BMJ 2013; 346: f174.
Control models of OEND implementation and ratio of opioid related to MV crash
related acute care hospitalizations
Cumulative enrollments per 100k
Adjusted β estimate*
P-value
Absolute model:
No enrollment
Ref
Low implementation: 1-100
-0.022
0.6
High implementation: > 100
0.0001
0.98
Relative model:
No enrollment
Ref
Low implementation: 1-100
-0.0044
0.3
High implementation: > 100
0.0027
0.5
* Adjusted Rate Ratios (ARR) All rate ratios adjusted for the city/town population rates of age under 18,
male, race/ ethnicity (hispanic, white, black, other), below poverty level, medically supervised inpatient
withdrawal treatment, methadone treatment, BSAS-funded buprenorphine treatment, prescriptions to
doctor shoppers, and year
Walley et al. BMJ 2013; 346: f174.
Learn2cope.org
Meeting Schedule
•
Every Monday evening 7 - 9 PM
–
Good Samaritan Medical Center, 235 North Pearl Street, Brockton, MA. 02301
• Every Tuesday at 7:00 pm
–
•
Gloucester Family Health Center, 302 Washington Street, Gloucester, MA.
Every Tuesday at 7:00 - 8:30 pm
–
Eastern Nazarene College, 180 Old Colony Avenue Quincy Mass.
• Every Wednesday evening 7 - 9pm
–
•
•
Saints Medical Center, One Hospital Drive, Lowell.
Every Thursday evening 7 PM
–
Salem Massachusetts at North Shore Childrens Hospital, 57 Highland Ave.
–
UMASS Community Healthlink Campus, 26 Queen Street, 5th Floor, Room 515, Worcester, MA 01610
Email for Dates
–
Mass General Hospital Boston in the Thier Research building first floor conference room. This meeting is new and room is subject to
change, email learntocope2001@yahoo.com for dates.
US and MA Age-Adjusted All Poisoning and MA Opioid-related Death
Rates, 2000-2010
Age Adjusted Rate per 100,000 persons
18.0
16.0
14.0
12.0
10.0
8.0
6.0
4.0
U.S. All Poisoning
MA All Poisoning
MA Opioid-related Poisoning
2.0
0.0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
Year
99% increase in all poisoning death rate in MA from 2000-2006; 18% decrease in rate from 2006 to 2010.
Overall APC 2000-2010: 4.05 (p <.05)
73% increase in opioid-related poison death rate in MA from 2000-2006; 13% decrease in rate from 2006 to
2010. Overall APC 2000-2010: 4.06 (p<.05)
Sources: All- poisoning rates from CDC, WISQARS web-based query (Accessed 2/19/2013)
Opioid-related poisoning from Registry of Vital Records, MDPH.
Acts of 2012, Chapter 192, Sections 11 & 32
(d) Naloxone or other opioid antagonist may lawfully be
prescribed and dispensed to a person at risk of experiencing an
opiate-related overdose or a family member, friend or other
person in a position to assist a person at risk of experiencing an
opiate-related overdose. (emphasis added)
(a) A person who, in good faith, seeks medical assistance for someone
experiencing a drug-related overdose shall not be charged or prosecuted for
possession of a controlled substance under sections 34 or 35 if the evidence
for the charge of possession of a controlled substance was gained as a result
of the seeking of medical assistance.
(b) A person who experiences a drug-related overdose and is in need of
medical assistance and, in good faith, seeks such medical assistance, or is the
subject of such a good faith request for medical assistance, shall not be
charged or prosecuted for possession of a controlled substance under said
sections 34 or 35 if the evidence for the charge of possession of a controlled
substance was gained as a result of the overdose and the need for medical
assistance.
(c) The act of seeking medical assistance for someone who is experiencing a
drug-related overdose may be used as a mitigating factor in a criminal
prosecution under the Controlled Substance Act,1970 P.L. 91-513, 21 U.S.C.
section 801, et seq.
(d) Nothing contained in this section shall prevent anyone from being charged
with trafficking, distribution or possession of a controlled substance with
intent to distribute.
(e) A person acting in good faith may receive a naloxone prescription, possess
naloxone and administer naloxone to an individual appearing to experience an
opiate-related overdose.
Prescription Directions
• Dispense: One naloxone rescue kit
– 2 prefilled syringes with 2mg/2ml naloxone
– 2 mucosal atomizer devices
– Risk factor info and assembly directions
• Directions: For suspected opioid overdose, spray 1ml in
each nostril. Repeat after 3 minutes if no or minimal
response- include infosheet
Patient instructions
Education Videos:
• Overdose Prevention Video for chronic pain
patients
Patient Selection
•
•
•
•
•
•
After emergency medical care involving opioid intoxication or poisoning
Suspected hx of substance abuse or nonmedical opioid use
Patients taking methadone or buprenorphine
Any patient receiving an opioid prescription for pain and:
–
higher-dose (>50 mg morphine equivalent/day) opioid
–
rotated from one opioid to another= poss incomplete cross tolerance
–
Smoking, COPD, emphysema, asthma, sleep apnea, respiratory infection, or other respiratory illness or
potential obstruction.
–
Renal dysfunction, hepatic disease, cardiac illness, HIV/AIDS
–
Known or suspected concurrent heavy alcohol use
–
Concurrent benzodiazepine or other sedative prescription
–
Concurrent antidepressant prescription
Patients who may have difficulty accessing emergency medical services (distance, remoteness)
Voluntary request from patient or caregiver
Opioid OD conceptual model
OEND
Opioid addiction
prevention and
treatment
OD prevention
education
OD management
(naloxone, 911)
bystander
Heroin use
Non-fatal Opioid
OD
Rx Opioid misuse
Rx diversion
PMP, Prescriber
Education, Take Back
Days
OD risk factors
•
•
•
•
polydrug use
abstinence
using alone
unknown source
Fatal Opioid OD