ACOPC
Allegheny County Overdose Prevention Coalition
Presents
PERMEATING
BORDERS
OVERDOSE PREVENTION
Summer Conference 2014
July 24, 2014
Overdose Prevention:
National Perspectives
Melinda Campopiano von Klimo, MD
Medical Officer
Center for Substance Abuse Treatment
(CSAT)
Overdose Prevention: National
Perspectives
Allegheny County Overdose
Prevention Coalition
Pittsburgh, PA
July 24th 2014
Melinda Campopiano, MD
Substance Abuse & Mental Health
Services Administration
Objectives
• Be able to integrate the SAMHSA Opioid Overdose
Prevention Toolkit into local prevention efforts.
• Be familiar with community overdose prevention
implementation strategies.
• Understand the role of medication assisted treatment
in overdose prevention.
Opioid pain reliever-related overdose deaths increasing
at a faster rate than deaths from any major cause
% change in number of deaths, United States, 2000-2010
Rx opioid overdose
Alzheimer's
Hypertension
Parkinson's Disease
Nephritis
Suicide
Liver Disease
Chronic Lower Respiratory disease
Septicemia
HIV
Malignant Neoplasms
Pneumonitis
Diabetes Mellitus
0%
Homicide
-3%
Perinatal Period
-14%
Heart disease
-16%
Motor vehicle traffic
-22%
Cerebro-vascular
-23%
Influenza & Pneumonia -23%
Aortic Aneurysm
-34%
-50%
276%
68%
47%
40%
36%
31%
20%
13%
11%
7%
4%
2%
0%
50%
100%
WISQARS, 2000 and 2010; CDC/NCHS, National Vital Statistics System
150%
200%
250%
300%
Opioid Overdose Toolkit
• Community
Members
• First Responders
• Patients and family
• Prescribers
• Overdose survivors
Preventing Opioid Overdoses & Deaths
 All five booklets feature clear explanations and
simple strategies that are based on current scientific
evidence and clinical experience.
 They answer questions such as the following:
• What are opioids?
• Why do opioids cause overdose?
• Who is at risk?
• What are the signs of overdose?
• How can overdose be prevented?
7
Booklet 1, Facts for Community Members:
• Educates local governments, community
organizations, and private citizens about the risks
of opioid overdose.
• Helps them develop sound policies and practices
to prevent opioid overdoses and deaths.
Substance Abuse and Mental Health Services Administration (SAMHSA). SAMHSA Opioid Overdose
Toolkit: Facts for Community Members. HHS Publication No. (SMA) 13-4742. Rockville, MD: SAMHSA,
2013.
Booklet 2, Five Essential Steps for First Responders,
describes:
• Five steps that should be taken by
paramedics, EMS personnel, police, and
other helpers when they respond to an opioid
overdose.
• How to use naloxone and provide other lifesaving assistance.
Substance Abuse and Mental Health Services Administration (SAMHSA). SAMHSA Opioid
Overdose Toolkit: Five Essential Steps for First Responders. HHS Publication No. (SMA) 134742. Rockville, MD: SAMHSA, 2013.
Booklet 3, Information for Prescribers, provides
physicians and other health care professionals with:
• Reliable information on how to assess each
patient’s risk of opioid overdose.
• Clinically sound strategies for educating and
monitoring patients to reduce the risk of
overdose.
Substance Abuse and Mental Health Services Administration (SAMHSA). SAMHSA Opioid
Overdose Toolkit: Information for Prescribers. HHS Publication No. (SMA) 13-4742. Rockville,
MD: SAMHSA, 2013.
Booklet 4, Safety Advice for Patients, empowers
patients who are prescribed opioids by:
• Helping them learn how to use opioids safely so as to minimize
the risk of overdose.
Substance Abuse and Mental Health Services Administration (SAMHSA). SAMHSA Opioid Overdose Toolkit: Safety Advice for
Patients. HHS Publication No. (SMA) 13-4742. Rockville, MD: SAMHSA, 2013.
Booklet 5, Recovering from Opioid Overdose, assists
overdose survivors and their family members by:
• Offering resources to help them recover from
the trauma of overdose, provide support to
the survivor, and become advocates for
prevention.
Substance Abuse and Mental Health Services Administration (SAMHSA). SAMHSA Opioid
Overdose Toolkit: Recovering from Opioid Overdose. HHS Publication No. (SMA) 13-4742.
Rockville, MD: SAMHSA, 2013.
Preventing Opioid Overdoses & Deaths
 STRATEGY 1: Encourage health care professionals, persons at high risk,
family members and others to learn how to prevent and respond to
opioid overdose.
• Practitioners should be encouraged to update their knowledge of evidencebased practices for the use of opioid analgesics to manage pain, as well as
specific steps to prevent and manage opioid overdose.
• www.opioidprescribing.com,
13
Preventing Opioid Overdoses & Deaths
 STRATEGY 2: Ensure access to treatment for individuals who are
misusing or addicted to opioids or who have other substance use
disorders.
• Effective medication-assisted treatment of substance use disorders
reduces the risk of overdose and helps overdose survivors attain a
healthier life.
14
Preventing Opioid Overdoses & Deaths
 STRATEGY 3: Ensure ready access to naloxone:
• Opioid overdose deaths can be prevented when
naloxone is administered in a timely manner.
• As an opioid antagonist, naloxone blocks the
effects of opioids on the brain and reverses
respiratory depression, which usually is the cause
of overdose deaths.
• Naloxone has no psychoactive effects and thus no
potential for abuse.
15
Preventing Opioid Overdoses & Deaths
 STRATEGY 3 (continued):
• It is important that local EMS personnel and other
first responders be trained to care for overdose,
and that they are allowed to stock naloxone in
their drug kits.
• Physicians should consider prescribing naloxone
to their patients who are receiving long-term pain
treatment with opioids.
16
Preventing Opioid Overdoses & Deaths
 STRATEGY 4: Encourage the public to call 911:
• A person who is experiencing opioid overdose needs
immediate medical attention.
• An essential first step is to get help from someone with
medical expertise as quickly as possible.
• Therefore, members of the public should be educated to
call 911.
• All they need to say is, “Someone is not breathing” and
give a clear address or description of the location.

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Preventing Opioid Overdoses & Deaths
 STRATEGY 5: Encourage prescribers to use state
Prescription Drug Monitoring Programs (PDMPs):
• State Prescription Drug Monitoring Programs (PDMPs) are
a key strategy for addressing the misuse and abuse of
prescription opioids and thus preventing opioid overdoses
and deaths.
• Through the PDMP, a prescriber can access a state
database to determine whether a patient is filling the
prescriptions provided and/or obtaining prescriptions for
the same or similar drugs from multiple physicians.
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Preventing Opioid Overdoses & Deaths
Where is SAMHSA’s Opioid Overdose Toolkit available?
• The information outlined here and more can be viewed at or
downloaded from SAMHSA's website at www.samhsa.gov.
• The toolkit also refers readers to other reliable sources of
information, including those offered by the CDC, ONDCP, and private
sector organizations.
19
HOW TO GET NALOXONE TO THOSE WHO NEED
IT.
20
Block Grant Funds
 Primary prevention set-aside
funds may be used to support
overdose prevention education
and training
 Other SABG funds may be
utilized to purchase naloxone
and the necessary materials to
assemble overdose kits and
cover the cost of dissemination
of these kits
21
Discretionary Grant Recipients
 May repurpose portions of current grants to purchase
naloxone and the
necessary materials to assemble overdose kits.
 Must revise and resubmit a proposed budget
22
Individual Providers and Programs
 For prescribers to routinely prescribe naloxone:
• Naloxone must be covered by public and private OUTPATIENT
pharmacy benefits.
• Pharmacists need to be aware of plans to routinely prescribe
naloxone to stock an adequate supply
• Pharmacists need to know how the patient will be trained.
23
Standing Orders
 Order issued by health department physician
 Overdose prevention
training and naloxone may be provided
• in pharmacy
• in existing community sites (treatment, medical and behavioral
health clinics)
24
Cooperative Practice Agreement
 Formal agreement to cooperatively manage a patient
 Specific to diseases and/or medications
 Specific to physician(s)
and pharmacist(s)
25
MEDICATION ASSISTED TREATMENT
26
A key driver of the overdose epidemic is underlying substance use disorder…
Expanding access to MATs is a crucial component
of the effort to help patients recover.
27
Increased access to opioid agonist therapy was
associated with a reduction in heroin overdose
rates.
28
Benefits of MAT
 Reduces all cause mortality
 Reduces HIV seroconversion
 Improves adherence to medical treatment
 Improves social function
 Decreases criminal behaviors
 Decreases drug use
29
Opioids were involved in 14.8% of all deaths. Overdose was the leading cause of death…
and overdose deaths in former prisoners accounted for 8.3% of the overdose deaths
among persons aged 15 to 84 years.
30
31
Pretreatment and After Care Interventions
to Reduce Mortality
 Naloxone and ER injectable naltrexone
 Detainees
 Detox
 Discharge
32
PRESCRIBER EDUCATION
33
JAMA 2011;305:1315-1321
34
Opioid pain reliever prescribing rates vary by state
CDC Vital Signs, July 2014. Rates per 100 people in 2012
35
Opioid prescribing rates correlate with
drug overdose death rates
Kg of opioid pain
relievers used per
10,000
Age-adjusted rate
per 100,000
Death rate, 2008, National Vital Statistics System. Opioid pain reliever sales rate, 2010, DEA’s Automation of Reports and Consolidated Orders System
36
Patients receiving high doses of opioid pain relievers
account for disproportionate share of overdoses
100%
multiple doctors,
high doses
90%
one doctor, high dose
multiple doctors,
high doses
one doctor, lower dose
one doctor, high dose
80%
70%
Percent
60%
50%
40%
30%
20%
one doctor, lower dose
10%
0%
patients receiving opioid pain relievers
patients overdosing with opioid pain relievers
CDC Grand Rounds: Prescription Drug Overdoses — a U.S. Epidemic. MMWR Weekly. January 13, 2012 / 61(01);10-13.
37
38
Where next?
 Widen availability of training and naloxone
• New formulations/delivery systems
 Expand access to medication assisted treatment
 Prepare for community crisis response to closure of “pill mills.”
39