Overdose%20Education%20and%20Naloxone%20Rescue%20in%20Massachusetts

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Overdose Education and Naloxone Rescue in
Massachusetts

• Alexander Y. Walley, MD, MSc
• Assistant Professor of Medicine
• Boston University School of Medicine
• Medical Director, Opioid Overdose Prevention
  Pilot, Massachusetts Department of Public Health
• Cross-System Response to the Opioid Epidemic
• Monday, November 12, 2012

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Disclosures A Walley

• 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

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More Opioid Overdose Deaths than MVA Deaths in
Massachusetts
Poisoning Deaths vs. Motor Vehicle-Related Injury
Deaths, MA Residents (1997-2008)
The source of the data is Registry of Vital
Records and Statistics, MA Department of Public
Health
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More Opioid Overdose Deaths than MVA Deaths in
Massachusetts
Poisoning Deaths vs. Motor Vehicle-Related Injury
Deaths, MA Residents (1997-2008)
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
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Strategies to address overdose

• Prescription monitoring programs
• Paulozzi et al. Pain Medicine 2011
• Prescription drug take back events
• Safe opioid prescribing education
• Albert et al. Pain Medicine 2011 12 S77-S85
• Expansion of opioid agonist treatment
• Clausen et al. Addiction 20091041356-62
• Safe injection facilities
• Marshall et al. Lancet 20113771429-37

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Rationale for bystander overdose education and
naloxone distribution

• Most opioid users do not use alone
• Known risk factors
• polydrug, 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

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The Massachusetts OEND model

• Standing order
• Intranasal naloxone

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Massachusetts OEND pilot Standing order model

• Pilot program conducted under state Drug Control
  Program regulations (M.G.L. c.94C 105 CMR
  700.000)
• Medical Director issues standing order for
  distribution to potential bystanders
• Traditional prescription not needed
• Naloxone distributed by public health workers who
  are trained, but nonmedical staff
• gtgt access to populations at highest risk

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OEND Program Components - Massachusetts

• Community program staff enroll, train and
  distribute naloxone
• Kit includes 2 doses and instructions
• Curriculum delivers education on OD prevention,
  recognition, and response
• Referral to treatment available
• Reports on overdose rescues are collected when
  enrollees return for refills
• Each overdose report reviewed by data committee

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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

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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 per kit
• Insurance does not typically cover the atomizer
• Subject to shortage

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Scope of OEND in Massachusetts
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Enrollments and Rescues 2006-2012

• Rescues
• gt1500 reported
• 30 per month

• Enrollments
• gt15K 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

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Enrollment locations 2008-2012
Program data
Data from people with location reported Users
7,220 Non-Users 3,522
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Other venues

• First responder OEND
• Quincy, Revere, Gloucester
• Boston Police Academy e-training module
• Emergency Department (ED) SBIRT
• Post-incarceration
• Prescription naloxone
• Prescribetoprevent.org

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OEND program rescues 2006-2012
Active use, In treatment, In recovery N1004 Non-User (Family, friend, staff) N108
911 called or public safety present 29 64
Rescue breathing performed 33 33
Stayed until alert or help arrived 90 91
Program data
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Adverse Events Sept 2006- Jan 2012
OD Reports N1346 OD Reports N1346
Deaths 7 / 1346 0.5
OD requiring 3 or more doses 52 / 1226 4
Recurrent overdose 1/1346 0.1
Precipitated withdrawal 4/1346 0.3
Difficulty with device 7/1346 0.7
Negative interactions with public safety 82 / 332 25
Confiscations 158 / 3594 4
Program data
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Impact of OEND on overdose rates in Massachusetts
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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
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INPEDE OD (Intranasal Naloxone and Prevention
EDucations 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
Supported Center for Disease Control and
Prevention 1R21CE001602
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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

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Fatal opioid OD rates by OEND implementation
2002-09

• Compared to towns in years when there was no OEND
  enrollment, the rate of overdose deaths was
• 27 lower in towns in years when 1-100 people per
  100K were enrolled
• 50 lower in towns in years when gt100 people per
  100K were enrolled
• Rates were adjusted for age, gender,
  race/ethnicity, poverty level, detox treatment
  slots, methadone slots, state-funded
  buprenorphine slots, prescriptions to
  doctor-shoppers, and year
• Total OEND enrollments through 2006-09 in 19
  selected towns 2912

Under review
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Opioid-related ED visits and hospitalization
rates by OEND implementation 2002-09

• Compared to towns in years when there was no OEND
  enrollment, the rate of overdose ED visits and
  hospitalizations was
• Not significantly different for towns in years
  with OEND enrollment
• Rates were adjusted for age, gender,
  race/ethnicity, poverty level, detox treatment
  slots, methadone slots, state-funded
  buprenorphine slots, prescriptions to
  doctor-shoppers, and year
• Total OEND enrollments through 2006-09 in 19
  selected towns 2912

Under review
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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

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Implication

• Naloxone should be made more widely available to
  trained laypersons in an effort to reduce deaths
  due to opioid overdose

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Considerations

• Intranasal works and is popular
• It could be improved with a one-step, affordable
  FDA-approved intranasal delivery device
• 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
• Fear of police is a barrier to help seeking
• Good Samaritan laws would address in part

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Next steps for policy

• Expand number of sites and venues
• Good Samaritan law for bystanders
• Passed in August of 2012
• Liability protection for prescribers
• Passed in August of 2012
• Target incarcerated and ED patients
• Facilitate co-prescription of naloxone with
  chronic pain medication

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Passed in August 2012An 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.

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Incorporating overdose education and naloxone
rescue kits into medical and addiciton practice

• Prescribe naloxone rescue kits
• PrescribeToPrevent.org
• Work with your OEND program

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Challenges for community programs
Opportunities for prescription naloxone

• Naloxone cost is increasing, funding for is
  minimal
• Missing people who dont identify as drug users,
  but have high risk
• Missing people who may periodically misuse
  opioidsno tolerance

• 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

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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
• Have you ever overdosed?
• What were you taking?
• How did you survive?
• What strategies do you use to protect yourself
  from overdose?
• How many overdoses have you witnessed an
  overdose?
• Were any fatal?
• What did you do?
• What is your plan if you witness an overdose in
  the future?
• Have you received a narcan rescue kit?
• Do you feel comfortable using it?
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

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Overdose Education in Medical Settings

• What they need to know
• Prevention - the risks
• Mixing substances
• Abstinence- low tolerance
• Using alone
• Unknown source
• Chronic medical disease
• Long acting opioids last longer
• Recognition
• Unresponsive to sternal rub with slowed breathing
• Blue lips, pinpoint pupils
• Response - What to do
• Call for help
• Rescue breathe
• Deliver naloxone and wait 3-5 minutes
• Stay until help arrives
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  
  

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Practical Barriers to Prescribing Naloxone

• Prescriber knowledge and comfort
• How to write the prescription?
• Does the pharmacy stock rescue kits?
• Rescue IN kit with MAD?
• 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

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Thank you! awalley_at_bu.edu

• BU/BMC
• Maya Doe-Simkins
• Amy Alawad
• Ziming Xuan
• Al Ozonoff
• Emily Quinn
• Gregory Patts
• Chris Chaisson
• Jeffrey Samet
• Peter Moyer
• Ed Bernstein
• BPHC
• Adam Butler
• Program sites, staff and participants
• NOPE group

• MA DPH
• John Auerbach
• Andy Epstein
• Holly Hackman
• Michael Botticelli
• Kevin Cranston
• Dawn Fakuda
• Sarah Ruiz
• Barry Callis
• Grant Carrow
• Len Young
• Kyle Marshall
• Office of HIV/AIDS
• Bureau of Substance Abuse Services
• RTI Alex Kral

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(No Transcript)
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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

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Enrollee characteristics 2006-2012
Active use, In treatment, In recovery N8476 Non-User (Family, friend, staff) n4079
Witnessed overdose ever 75 43
Lifetime history of overdose 50
Received naloxone ever 44
Inpatient detox, past year 65
Incarcerated, past year 28
Reported OD reversal 7.5 2.1
Program data
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Enrollee past 30 day use 2006-2012
Data only from people with current use or in
treatment N 8476
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Learn2cope.org Meeting Schedule

• Every Monday evening 7 - 9 PM
• Good Samaritan Medical Center, 235 North Pearl
  Street, Brockton, MA. 02301
• Every Tuesday at 700 pm
• Gloucester Family Health Center, 302 Washington
  Street, Gloucester, MA.
• Every Tuesday at 700 - 830 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_at_yahoo.com for
  dates.

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Outcomes
Variable Element Source
Outcome Fatal opioid OD per town population per year Registry of Vital Records and Statistics
Defined as unintentional or undetermined intent opioid poisoning (X40-X44, Y10-Y14) in the underlying COD field and a T code of T40.0 T40.4 and/or T40.6 in any of the multiple COD fields Defined as unintentional or undetermined intent opioid poisoning (X40-X44, Y10-Y14) in the underlying COD field and a T code of T40.0 T40.4 and/or T40.6 in any of the multiple COD fields
Outcome Opioid-related ED or hospital discharges per town population per year MA Div. of Health Care Finance and Policy Discharge Database
Defined as hospital and emergency department discharges with codes for opioid intoxication and poisoning ICD-9-CM 965 (.00, .01, .02, .09) or E code E850 (.0, .1, .2) Defined as hospital and emergency department discharges with codes for opioid intoxication and poisoning ICD-9-CM 965 (.00, .01, .02, .09) or E code E850 (.0, .1, .2)
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Analyses

• Poisson regression to compare annual
  opioid-related overdose rates among cities/towns
  by OEND implementation
• Natural interpretations as rate ratios (RRs)
• Models adjusted for the city/town population
  rates of
• age under 18
• Male
• race/ ethnicity
• below poverty level

• inpatient detox treatment
• methadone treatment
• DPH-funded bup treatment
• prescriptions to doctor shoppers
• year

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INPEDE OD 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 gtgt 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