Overdoses are rarely instant

1
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
• Sporer 2006

2
Related benefits

• Overdose prevention
• Makes drug user health a priority in diverse
  settings
• Endorses idea of drug users as capable and
  concerned with their community
• Expands benefits from harm reduction intervention
  to other medical populations

3
The training 10-20 minutes

• Prevention understanding the role of
• mixing drugs
• reduced tolerance
• using alone
• Overdose recognition
• Actions
• Call emergency services
• Rescue breathing- using dummy
• Naloxone administration

4
Opioid Overdose Prevention Implementation New
York City

• Syringe exchange/syringe access sites
• Homeless Shelters
• Hospitals
• Inpatient
• Public Clinics
• Drug Treatment
• Methadone/Buprenorphine
• Detoxification programs
• HIV programs
• Jails/ Prisons and with the formerly incarcerated

5
Rationale Syringe exchange/access sites

• SEPs serve a high risk population
• SEPs have trusting relationships with drug users
  and have expertise in working with drug users
  including peer educators

6
Challenges Syringe exchanges

• 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

7
Status Syringe exchange

• 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 260
• SKOOP 5/08

8
Drug treatment programs

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

9
Rationale Drug treatment

• 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
• Use of other sedatives associated with death of
  opioid maintained patients
• Wines 2007, Sporer 2006

10
Challenges Drug treatment

• 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
• Staff often invested in abstinence model

11
Status Drug treatment

• 6 programs including detoxification units,
  methadone and buprenorphine programs have
  registered. All City Hospitals and several more
  are preparing to register
• 1 methadone program has distributed over 200 kits

12
Rationale Homeless populations

• Being homeless is associated with risk of OD
• In NYC, leading cause of death among homeless
  2005-2006 was OD (23)
• Associated factors may be
• Social and economic stress
• Lack of safe, familiar place to inject
• Using alone and rushing injection
• Less access to opioid maintenance treatment
• Driscoll 2001,NYCDOHMH

13
Challenges Homeless shelters

• 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/ stigma around disclosing
  drug use

14
Status Homeless populations

• NYC plan for homeless shelters
• One staff member on every shift trained in
  overdose response. Initial training of medical
  staff completed Training of staff as overdose
  responders imminent
• Medical providers will offer training and
  intranasal naloxone to all interested clients in
  city funded shelters
• 1 shelter implemented training of staff
  immediately after legislation passed

15
Rationale HIV service providers

• 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
• In impoverished areas of NYC, OD is leading cause
  of non-HIV death in persons with AIDS.
• NYSDOH, Wang 2005, Sackoff 2006

16
Challenges HIV care

• Clients may be reluctant to disclose drug use
• May be a bridge to further discussion of drug use
• Serving DU needs may still be controversial
• Staff lack of experience and knowledge about harm
  reduction and drug use issues
• Lack of medical personnel on staff for naloxone

17
Status of programs HIV care

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

18
Rationale Incarcerated and formerly incarcerated
populations

• Post incarceration is major risk factor for death
  from OD (10)
• Study of deaths in first 2 weeks post
  incarceration among 30,237 released inmates
• 129 times greater likelihood of dying of OD vs.
  other WA state residents
• Bingswaner 2007

19
Challenges Jail/ prison settings

• Gaining entrée to system
• Inability to give naloxone, must arrange for
  follow up after release
• Institutional discomfort with the harm reduction
  model
• Persons on parole are forbidden to access harm
  reduction services

20
Status Incarcerated populations

• NYC Department of Health
• Plan to include OD prevention education with all
  intakes for opioid maintenance or detoxification
  at the city jail
• Some OD training done of NYCDOH counselors
  working jail settings
• Outreach
• Harm Reduction Coalition working with 3 service
  organizations working with the formerly
  incarcerated

21
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

22
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

23
Acknowledgements

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