To call 911 or not to call 911?
Overdose help-seeking
Alexander Y. Walley and Maya Doe-Simkins
Co-authors: Ziming Xuan, Emily Quinn, Amy SorensenAlawad, Holly Hackman, Al Ozonoff
Harm Reduction Conference 2012 – Portland, OR
Friday, November 16, 2012
Disclosures
•
The following personal financial relationships with
commercial interests relevant to this presentation
existed during the past 12 months:
– None to disclose
•
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 1R21CE001602-01
Help-seeking rates
• Range among OEND trainees
– 28%-74%
• Range among untrained bystanders
– 23%-68%
• Before & after OEND training
– 65% pre-OEND and 49% post-OEND
• Help not sought because victim regained consciousness or
bystander felt OD could be managed without help
– Tobin et al. Int J Drug Policy 2009: 20; 131-6
Known help-seeking factors
• Among untrained, more likely to seek help when
– Victim does not respond
• Davidson et al. Addiction. 2002;97:1511-6
– Bystander’s last OD resulted in hospital visit
• Tracy et al. Drug Alcohol Depend. 2005;79:181-90
– Bystander witnessed fatal OD
• Tobin et al. Addiction 2005;100:397-404
– Female bystander
• Tobin et al. Addiction 2005;100:397-404
– OD is fatal
• Bohnert et al. Ann Emerg Med 2009;54:618-24.
Known help-seeking factors
• Among untrained, less likely to seek help
when
– Bystander is confident in skills
• Tracy et al. Drug Alcohol Depend. 2005;79:181-90 & Baca et
al. J Addict Dis. 2007;26:63-8
– 4 or more bystanders present
• Tobin et al. Addiction. 2005;100:397-404
– Fear of police/ arrest
• Darke et al. Addiction. 1996; 91:413-417 & Davidson et al.
Addiction. 2002;97:1511-6 & Tracy et al. Drug Alcohol
Depend. 2005;79:181-90
Outcomes for OD victims who are
not transported to hospital following
naloxone administration
• Refused transport AMA
– 0.0% of 998 died of rebound toxicity (Vilke et
al. Acad Emer Med 2003; 10: 893-896)
• Discharge-on-scene policy
– 0.13% of 2241 died from rebound toxicity
(Rudolph et al. Resuscitation 2011; 82: 14141418)
Study Objective
• Identify factors associated with help
seeking among opioid overdose
bystanders who report a witnessed
overdose to OEND programs in
Massachusetts
Methods
Population: Program data from the Massachusetts Department of Public
Health Opioid Overdose Prevention Pilot Program implemented at
community-based agencies from 2006 to 2010.
Data Collection: Overdose rescue questionnaire completed by staff when
program enrollee requested more naloxone
Outcome: Help-seeking defined by affirmative response to either of the
questions:
– “Was 911 called?”
– “Were police/EMTs/firefighters present?”
Independent variables:
– bystander age, gender, race/ethnicity, drug using status, setting (public vs. private),
time for naloxone to work, number of substances used by victim
Analyses: Multivariable logistic regression model
Results
• 2006-2010
– 8667 participants
• 483 participants reported 762 overdose rescues
Bystanders who used naloxone
during and overdose rescue
Age, median (IQR)
Female and MtF
White
Hispanic
Black/ African American
No substance use
Primarily heroin user
Primarily Rx opioid user
Non-opioid user
Previously trained
N=483
33 (26-45)
40%
81%
10%
6%
11%
54%
14%
22%
84%
Bystanders who used naloxone
during and overdose rescue
Witnessed overdose, lifetime
Previous overdose, lifetime
Any homelessness, past year
Incarceration, past year
Emergency department visit, past year
Detoxification program, past year
Reported >1 reversal
N=483
87%
64%
22%
28%
60%
56%
31%
Overdose rescue events
Sternal rub
Sought help
Rescue breathing
Stayed with the person
Public setting
Polysubstance use by victim
Time to work
N=762
62%
28%
48%
89%
22%
59%
Less than 1 minute
15%
1-3 minutes
39%
3-5 minutes
29%
More than 5 minutes
17%
Help-seeking factors I
Age in years
Female or MtF rescuer
Race/ ethnicity
White
Black/ African American
Hispanic
Other
Adjusted
odds ratio
1.01
1.30
(1.00-1.03)
(0.91-1.85)
Ref
0.45
1.43
1.79
Ref
(0.17-1.14)
(0.81-2.52)
(0.55-5.78)
95%CI
Help-seeking factors II
User Status
Primarily heroin user
Primarily Rx opioid user
Non-opioid user
Non-user
Previously trained
Public setting
Adjusted
odds ratio
95%CI
Ref
1.02
1.26
5.13
0.99
1.86
Ref
(0.66-1.56)
(0.73-2.16)
(2.87-9.17)
(0.58-1.70)
(1.26-2.75)
Help-seeking factors III
Polysubstance use
Time for naloxone to work
Less than 1 minute
1-3 minutes
3-5 minutes
More than 5 minutes
Adjusted
odds ratio
1.09
(0.77-1.56)
Ref
1.57
1.88
2.94
Ref
(0.82-2.99)
(1.01-3.49)
(1.48-5.81)
95%CI
Summary
• OEND enrollees were more likely to seek
help if:
1.they were non-users
2.the overdose occurred in public
3.the victim’s response to naloxone was
longer
Limitations
• Program data collected based on
participant refills, not systematic
• Not all variables that are likely to be
important were collected
– fear of police
– bystander confidence
– order of the actions
– number of people present
– rationale for adhering or not adhering to the
OEND training algorithm
Where do we go from here?
• Good Samaritan protection may increase
help-seeking among both users and nonusers
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.
Where do we go from here?
• Should the response to overdose be like
cardiac arrest or like choking?
– Cardiac Arrest: Call for help, then intervene vs.
– Choking: Intervene, then discretionary call for help
Thanks – awalley@bu.edu
M DPH
• John Auerbach
• Andy Epstein
• Michael Botticelli
• Kevin Cranston
• Dawn Fakuda
• Sarah Ruiz
• Barry Callis
• Kyle Marshall
• Office of HIV/AIDS
• Bureau of Substance Abuse
Services
BU/BMC
• Courtney Pierce
• Dan Hovelson
• Christine Chaisson
• Jeffrey Samet
• Peter Moyer
• Ed Bernstein
BPHC
• Adam Butler
Program sites, staff and
participants
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:
– $30+ per kit
• Current national shortage
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
• knowledge test
• At least 2 supervised bystander training
sessions
Sites participate in:
• Quarterly all-site meetings
• Monthly adverse event phone conferences
More Opioid Overdose Deaths than MVA
Deaths in Massachusetts
1200
Deaths per year
1000
Poisoning Deaths vs. Motor Vehicle-Related Injury Deaths,
MA Residents (1997-2008)
800
600
400
200
0
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
All Poisoning Deaths
Motor Vehicle-Related Injury Deaths
The source of the data is: Registry of Vital Records and Statistics, MA Department of Public Health
Enrollments and Rescues:
2006-2012
• Enrollments
– >15K individuals
– 300 per month
•
•
•
•
•
•
•
•
•
•
•
•
•
•
AIDS Project Worcester
AIDS Support Group of Cape Cod
Brockton Area Multi-Services Inc. (BAMSI)
Bay State Community Services
Boston Public Health Commission
CAB Health and Recovery
Cambridge Cares About AIDS
Greater Lawrence Family Health Center
Holyoke Health Center
Learn to Cope
Lowell Community Health Center
Seven Hills Behavioral Health
Tapestry Health
SPHERE
• Rescues
– >1500 reported
– 30 per month
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 an overdose?
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?
Practical Barriers to Prescribing
Naloxone
1.
2.
3.
Prescriber knowledge and comfort
How to write the prescription?
Does the pharmacy stock it? Naloxone?
•
•
4.
Rescue IN kit with MAD? Boston Medical Center and Mass
General Hospital
Rescue IM kit with needle?
Who pays for it?
•
•
•
Insurance in Massachusetts covers naloxone, but not the
atomizer
The MAD costs $2.50 each
Work with your pharmacy to see if they will cover it
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
• Refills: None
More Opioid Overdose Deaths than MVA
Deaths in Massachusetts
1200
Deaths per year
1000
Poisoning Deaths vs. Motor Vehicle-Related Injury Deaths,
MA Residents (1997-2008)
800
600
400
200
0
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
All Poisoning Deaths
Opioid-related Poisoning Deaths
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
Help-seeking rates
• Range among OEND trainees
–
–
–
–
28% (Doe-Simkins et al. Am J Public Health 2009;99:788-91)
30% (Seal KH et al. J Urban Health 2005;82:303-11)
49% (Tobin et al. Int J Drug Policy 2009;20:131-6)
74% (Piper et al. Subst Use Misuse 2008;43:858-70)
• Range among untrained bystanders
– 23% (Tobin et al. Addiction 2005;100:397-404)
– 44% (Bennett et al. Addiction 1999;94:1179-89 & Strang et al. Int
J Drug Policy 2000;11:437-45)
– 53% (Davidson et al. Addiction 2002;97:1511-6)
– 68% (Tracy et al. Drug Alcohol Depend. 2005;79:181-90)
• Before & after OEND training
– 65% pre- OEND and 49% post- OEND (Tobin et al. Int J Drug
Policy 2009: 20; 131-6)
• Help not sought because victim regained consciousness or bystander felt
OD could be managed without help
Overdose Education
1.Prevention - the risks:
•
•
•
•
•
•
Mixing substances
Abstinence & other tolerance changing events
Using alone
Unknown source
Chronic medical disease & previous overdose
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 then continue rescue breathing
If no response after 3-5 minutes, deliver 2nd dose
Post naloxone support
Stay until help arrives
Rationale for bystander overdose
education and naloxone distribution
• Most opioid users do not use alone
• Known risk factors:
– Polysubstance use, abstinence, using alone,
unknown source, previous OD
• Opportunity window:
– opioid OD takes minutes to hours and is reversible
with naloxone
• Bystanders are trainable to recognize OD
• Fear of public safety
Evaluations of OEND programs
• Feasibility
–
–
–
–
Bennett et al. J Urban Health 2011:88; 1020-1030
Enteen et al. J Urban Health 2010:87; 931-41
Doe-Simkins et al. Am J Public Health 2009: 99; 788-791
Piper et al. Subst Use Misuse 2008: 43; 858-70
• Increased knowledge and skills
– Wagner et al. Int J Drug Policy 2010: 21; 186-93
– Tobin et al. Int J Drug Policy 2009: 20; 131-6
– Green et al. Addiction 2008: 103;979-89
• No increase in use, increase in drug treatment
– Seal et al. J Urban Health 2005:82; 303-11
• Reduction in overdose in some communities
– Maxwell et al. J Addict Dis 2006:25; 89-96.