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

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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

• 8/05A bill approving provision of naloxone to
  trained lay persons passed unanimously
• NYSDOH, AIDS Institute charged with crafting
  regulations
• April 2006 Law took effect

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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

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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

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Get the SKOOP Skills and Knowledge on Overdose
Prevention

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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

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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

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Death following incarceration

• Washington State Corrections 30,237 inmates
  released
• Overall mortality777/100,000 2.5x expected
• First 2 weeks 12.7x expected with overdose rate
  of 1840/100,000 (x27)
• 60 involved opioids 60
• 74 involved cocaine and other stimulants
• Bingswanger NEJM 2007

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

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Other risk factors

• Overdose is more likely in the presence of
  significant illness cirrhosis, AIDS, coronary
  disease, pulmonary disease
• Major changes in opioid supply gt1000 deaths USA
  2006 with fentanyl
• Depression
• Wang AIDS 2005, Wines Drug Alcohol Depend 2007
  Sporer 2006, http//www.whitehousedrugpolicy.gov/n
  ews/fentnyl5Fheroin5Fforum,

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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

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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

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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

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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

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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

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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

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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

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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

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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- dont
  use more heroin to feel better!!

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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

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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
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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

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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

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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

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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

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Drug treatment programs

• New York City Department of Health is promoting
  naloxone training and distribution in
• Detoxification units
• Methadone programs
• Buprenorphine programs

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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

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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

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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

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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

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Status of programs

• 6 programs in NYS have registered
• 4 have initiated services

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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

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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

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Status

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

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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

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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

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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

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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

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Characteristics of 389 SKOOP participants
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SKOOP evaluation

• Of 759 trainees from March December 2005
• 71 reported witnessing an overdose
• 50 used naloxone for a total of 82 uses
• 68 were known to have lived 14 unknown outcomes
• 75 reported calling an ambulance
• Markham, in press

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Overdose responders knowledge

• Methods Evaluated 10 current or former opioid
  users recruited from each of 6 sites with
  naloxone training programs
• Baltimore, Maryland San Francisco, California
• Chicago, Illinois New York (Bronx Manhattan)
• New Mexico
• Used validated, reliable knowledge assessment
  tool presenting 16 putative overdose scenarios
  (Green et al., 2005)
• Compared responses of opioid users to those of 11
  medical experts in overdose
• Green, Heimer, Grau 2007 (under review)

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Overdose responders knowledge

• Naloxone training programs in the US improve
  participants recognition response to opioid
  overdoses compared to those untrained (plt.001)
• Fewer opioid overdoses were missed by trained
  participants (plt.05)
• Fewer overdoses responded to inappropriately by
  trained participants (plt.001)
• Trained respondents were as skilled as medical
  experts in recognizing opioid overdose situations
  (weighted kappa0.85) when naloxone was
  indicated (kappa1.0).

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Challenges common in many settings

• Concerns that overdose prevention condones drug
  use
• Injectable medication not acceptable in all
  settings

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Lessons learned

• Implementation of overdose prevention programs
  appears to be more acceptable to many agencies
  than provision of syringes
• Core elements of the training can be adapted to
  many settings
• Discussion of overdose prevention can contribute
  to patient/provider relationship lead to
  discussions of drug treatment

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Goals/wish list

• Over the counter status for naloxone
• Overdose prevention training as standard of care
  for all at risk of opioid overdose
• Inexpensive, effective, intranasal delivery system

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Conclusions

• Overdose prevention training consists of a few
  basic components
• Overdose prevention by non medical persons is
  feasible, safe and probably effective

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Acknowledgements

• Injection Drug Users Health Alliance
• New York City Department of Health and Mental
  Hygiene
• New York State Department of Health