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Get the SKOOP: Skills and Knowledge on

Overdose PreventionBill Matthews, RPA-C Harm Reduction CoalitionNovember 2012

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Objectives

Participants will be able to:

• Discuss the epidemiology and physiology of overdose; risk factors and response

• Offer a 10-20 minute overdose prevention training to other staff and clients

Number of drug poisoning deaths involving opioid analgesics by opioid analgesic category, heroin and cocaine: United States, 1999--2010

NOTES: Opioid analgesic categories are not mutually exclusive. Deaths involving more than one opioid analgesic category shown in this figure are counted multiple times. Natural and semi-synthetic opioid analgesics include morphine, oxycodone and hydrocodone; and synthetic opioid analgesics include fentanyl. SOURCE: CDC/NCHS, National Vital Statistics System; and Warner M, Chen LH, Makuc DM, Anderson RN, Miniño AM. Drug poisoning deaths in the United States, 1980–2008. NCHS data brief, no 81. Hyattsville, MD: National Center for Health Statistics. 2011. http://www.cdc.gov/nchs/data/databriefs/db81.htm

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Motor-Vehicle & Poisoning Death Rates, 2005- 2006

• Among adults aged 34-56 years, poisoning death rates were higher than motor –vehicle traffic death rates.

• 92% of poisoning deaths involved drugs.

National Vital Statistics System, mortality data,  

http://www.cdc.gov/nchs/deaths.htm.

Motor vehicle traffic, poisoning, drug poisoning, and unintentional drug poisoning death rates: United States, 1999--2010

NOTES: Drug poisoning deaths are a subset of poisoning deaths. Unintentional drug poisoning deaths are a subset of drug poisoning deaths. SOURCE: CDC/NCHS, National Vital Statistics System; and Warner M, Chen LH, Makuc DM, Anderson RN, Miniño AM. Drug poisoning deaths in the United States, 1980–2008. NCHS data brief, no 81. Hyattsville, MD: National Center for Health Statistics. 2011. http://www.cdc.gov/nchs/data/databriefs/db81.htm. Intercensal populations http://www.cdc.gov/nchs/nvss/bridged_race/data_documentation.htm

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Opioid treatment admissions: 1999-2009 ages 12-24

0

2000

4000

6000

8000

10000

12000

14000

16000

NYC NYS

199920042009

NYS OASAS Data Warehouse

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Opioid treatment admissions: 1999-2009 ages 12-24

0

500

1,000

1,500

2,000

2,500

3,000

Nassau Erie Suffolk

199920042009

NYS OASAS Data Warehouse

Counties Reporting Increases in Heroin-Related Overdoses, 2008–2010

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National Drug Threat Assessment 2011

Percentage of patients and prescription drug overdoses, by risk group

MMWR / January 13, 2012 / Vol. 61 / No. 1

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Initial route of opioid abuse versus route of abuse at admission in a substance abuse treatment center.

Katz, Am J of Drug and Alcohol Abuse, 2011

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What is the most dispensed prescription drug in the United

States?

(number of prescriptions filled;generic and branded products, 2004-06)

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Top 10 Drugs Dispensed in 2010

1. Hydrocodone/Acetaminophen (Vicodin)2. Amoxicillin3 Hydrocodone/Acetaminophen (Lortab)4. Lipitor5. Levothyroxine 6. Lisinopril7. Simvastatin8. Plavix8. Nexium10. Singulair

Source: http://www.rxlist.com/script/main/hp.asp 13

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Opioid pain reliever (OPR) death rates, sales, and substance abuse treatment admission

rates increased in parallel

National Vital Statistics System (99-09); Automated Reports Consolidated Orders System (99-10); Treatment Admissions Data Set (99-09)Age-adjusted rates per 100,000 population for OPR deaths, crude rates per 10,000 population for OPR abuse treatment admissions, and

crude rates per 10,000 population for kilograms of OPR sold.

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Heroin Overdose Epidemiology

About 2% of heroin users die each year- many from heroin overdose

• 1990-98: 5,506 deaths in NYC• Average of 1-2/day in NYC• Up to 2/3 of heroin users experience at least

one nonfatal overdose• 2006: 979 OD deaths in NYC (70% due to

opioids) = ~ 685 opioid deaths

Sporer BMJ 2003, Galea 2003, Coffin Acad Emerg Med 2007

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What do we know about overdose?

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Who overdoses?

• Happens most often in dependent long term users with 5- 10 years of experience rather than new users

Sporer 2003, 2006

Drug poisoning death rates by age: United States, 1999--2010

CDC/NCHS, National Vital Statistics System; and Warner M, Chen LH, Makuc DM, Anderson RN, Miniño AM. Drug poisoning deaths in the United States, 1980–2008. NCHS data brief, no 81. Hyattsville, MD: National Center for Health Statistics. 2011. http://www.cdc.gov/nchs/data/databriefs/db81.htmIntercensal populations http://www.cdc.gov/nchs/nvss/bridged_race/data_documentation.htm

15-24

25-34

35-44

45-54

55-64

65 and over

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Physiology

• Generally happens over course of 1-3 hours- the stereotype “needle in the arm” death is only about 15%

• Opioids repress the urge to breath – decrease response to carbon dioxide -leading to respiratory depression and death

Slow breathing>Breathing stops>Heart stops>Circulation of blood to the brain stops

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Context of Opioid Overdose

• The majority of overdoses are witnessed (gives an opportunity for intervention)

• Fear of police may prevent calling 911

• Witnesses may try ineffectual things– Myths and lack of proper training– Abandonment is the worst response

Tracy 2005

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An Antidote exists

• Naloxone (Narcan), an injectable opioid antagonist will reverse the effects of opioids preventing a fatal overdose.

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Many opioid overdoses are preventable!

Get the SKOOP!

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Legal Status- New Overdose Law in New York State (Effective April 1,

2006)• Protects the non-medical person who administers

naloxone in setting of overdose from liability.– “shall be considered first aid or emergency

treatment”.– “shall not constitute the unlawful practice of a

profession”.• Allows the medical provider to provide naloxone for

secondary administration.• NYSDOH created regulations for implementation of

opioid overdose prevention programs.• Naloxone must be dispensed by MD, PA, NP by

federal regulation

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Components of Opioid Overdose Prevention Training

• What is naloxone?• What are opioids?• Prevention and understanding risk factors:• Overdose recognition• Action Call 911

– Rescue breathing- using dummy– Naloxone administration and how it works– Recovery position

• Report and get refill• Legality

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What is Naloxone?

• Naloxone (Narcan) is an injectable opioid antagonist which reverses the effects of opioids preventing fatal overdose

• What else will it do?

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Naloxone (Narcan)

• Opioid antagonist which reverses opioid overdose

• Pushes most other opioids off the receptors, then sits on the receptor preventing it from being activated for 30-90 minutes

• Analogy- getting the wrong key stuck in a lock

NOP Opioid Receptor binding pockethttp://www.nature.com/nature/journal/v485/n7398/fig_tab/485314a_F1.html

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Naloxone preparations

• Injectable – Inexpensive: $4.50 per dose – Well-documented efficacy – Requires injection, drawing from a medical

vial into a syringe

• Intranasal– More expensive: $19.25 per dose– Less well-documented efficacy– Requires assembly of spay device with nasal

adaptor and naloxone capsule

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Intramuscular naloxone

• A face mask for rescue breathing

• Two safety syringes

• 2 pre-filled vials of Naloxone

• 2 alcohol swabs

• 2 latex gloves

• 1 brochure reviewing OD and rescue steps.

• Contact information for program

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Papaver Somniferum“Poppy Plant”

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WHAT ARE OPIOIDS?

Most commonly used opioids • Heroin• Codeine• Demerol• Morphine• Darvocet • Fentanyl • Dilaudid • Methadone• Opium

• Hydrocodone • Oxycodone • Levorphanol • Vicodin • OxyContin • Tylenol 3• Tylox • Percocet• Percodan

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Boston Public Health Commission

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Naloxone does not work for substances that are not opioids

• Alcohol• Benzodiazepines

– Xanax, Valium, Klonopin

• Tricyclics– Elavil (amitriptylene)

• GBH• Ketamine

• Cocaine• Amphetamines• Methamphetamine• Ecstasy

Overdose deaths in New York City involve multiple drugs

(2008)Nearly all unintentional drug overdose deaths (98%)involve more than one substance, including alcohol.

Opioids were the most commonly noted drug type(74%). Types of opioids included heroin,

methadone, and prescription pain relievers.

Other drugs commonly found were: cocaine (53%),benzodiazepines (35%), antidepressants (26%),

and alcohol (43%).

NYC VITAL SIGNS Volume 9, No. 1, NYCDOHMH

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What are the Risk Factors for Opioid Overdose?

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Risk Factors for Opioid Overdose

• Reduced Tolerance• Illness• Depression• Unstable housing

• Mixing Drugs• Changes in the Drug

Supply• History of previous

overdose• Using in a new

environment

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Mixing Drugs: Major Risk for Overdose

• Using an opioid with other depressants such as alcohol or benzodiazepines

• Cocaine is a stimulant but:– High doses can reduce the respiratory drive– Wears off sooner than heroin in a speedball– Involved in about 53% of opioid overdose

deaths in NYC

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Major risk factor: Lowered tolerance

• Tolerance- repeated use of a substance may lead to the need for increased amounts to product the same effect

• Abstinence decreases tolerance increasing overdose risk– Incarceration– Hospitalization– Drug treatment/ Detox/ Therapeutic communities– Sporatic patterns of drug use

– Sporer 2007, Binswanger 2007

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Risk factor: Overdose Death following Incarceration

Cause of Death in the 2 weeks post-incarceration

Washington State Corrections – studied 30,237 inmates released (7/99-12/03)

Former Inmates were:– 12.7 times more likely to die vs. WS residents of same

age, race, and sex– 129 times more likely to die of overdose vs WS residents

• Opioids: 60%• Cocaine and other stimulants: 74%

• Binswanger et al., 2007

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Illness and overdose

Overdose is more likely in the presence of significant illness

• Liver disease: notably cirrhosis• Advanced AIDS• Coronary disease• Pulmonary disease: notably pneumonia

• Wang 2005, Darke 2006

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Other risk factors • Major changes in opioid supply/

Variations in strength of street drugs >1000 deaths USA 2006 with

fentanyl • Depression• History of previous overdose• Injection drug use

Sporer 2006, Wines 2007, Pollini 2006http://www.whitehousedrugpolicy.gov/news/fentnyl%5Fheroin

%5Fforum,

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Prevention Messages

• Use with others who know what to do if an overdose happens – make a plan

• Be aware of companions at all times when using• Be careful if using alone, especially if:

– Mixing different classes of drugs– Using after abstinence– (And watch out for others in these situations)

• Use a trusted source – one that you know• “Taste” (test) your shot• Control your own shot

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What does an Opioid Overdose Look Like?

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Continuum of Overdose

• Overdose is rarely immediate – can happen over 1-3 hours

• Heavy/ Uncontrollable Nodding– Still arousable– Snoring or loud breathing– May have excess drooling

• Overdose– Not responsive– Very shallow breathing, gurgling– Skin changes, blue lips and nails

• Fatal Overdose

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Recognizing a Stimulant Overdose(Naloxone won’t be effective unless an

opioid is also present)

• Fever

• Profuse sweating

• Rapid, (maybe irregular) heart beat

• Chest pain

• Seizures

• Heart attack, Stroke

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Stimulate the person overdosing

• Shake, call name loudly

• Sternal rub: rub knuckles hard up and down breast bone (it hurts!)

(Ice can work but this is easier)

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What NOT to do if a person is overdosing

• Leave without calling 911• Salt shots• Milk shots• Cocaine shots• Ice on genitals/ Shower• Hitting or burning feet or fingertips

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RESPONDING TO AN OPIOID OVERDOSE

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Step One: Get Help

• Call 911- “My friend is overdosing and not breathing”

• This phrase is more likely to bring paramedics with naloxone than EMT, who don’t carry it

• Give location

• Police may come

• New 911 law

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Check for breathing

• Chest rising and falling

• Nostrils moving in and out

• Mirror or glass by nose or mouth will fog up

• Touch moistened finger next to nostrils, feel for cool draft of inward breathing

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Step Two: Rescue breathing

Rescue breathing alone can sustain someone until EMS arrives

Mouth to mouth isusing a dummy for practice (if available)

Chest compressions notincluded (unlessResponder is trainedin CPR)

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Rescue Breathing

• Tilt back head to open airway

• Hold nose, lift chin

• Make a seal over the mouth with your mouth

• Start with 2 quick breaths then one breath about every 5 seconds until EMS arrives or person breathes on their own.

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Intramuscular naloxone

• A face mask for rescue breathing

• Two safety syringes

• 2 pre-filled vials of Naloxone

• 2 alcohol swabs

• 2 latex gloves

• 1 brochure reviewing OD and rescue steps.

• Contact information for program

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Administration:Naloxone Injection

• Inject into a muscle (subcutaneous and intravenous are also effective)

• Acts within 2-8 minutes• If no response in 2-5 minutes, give 2nd

naloxone injection • Lasts for 30 – 90 minutes• (reminder that if 911 has not been called

do it now!!)

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Injection Technique

• Inject into muscle of upper arm or front of thigh• Inject straight in, not at an angle• Rapidly push needle through skin into muscle

and then push syringe to inject the medication• Depth of whole needle is fine (maybe less

deep if person is skinny)• DON’T INJECT INTO THE CHEST, even if

you saw Pulp Fiction…

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Disposing of the Used Syringe

• If safety syringe, engage sheath

• Ask EMS to dispose of the needle or:

• Take to any SEP, hospital or nursing home for disposal, call first!

• Sharps accepted by some pharmacies and health care facilities

• Call DOH for disposal site near you (800-522-5006)

• Contact local Dept. of Public Works

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Recovery Position

• If you must leave the overdoser even for

a few minutes put them into the

recovery position so they won’t

choke on vomit

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Results: awake and breathing

Narcan wears off in 30-90 minutes

• Don’t leave the overdoser alone as sedation may return

• Reassure the overdoser if s/he is drug sick- the naloxone will wear off- don’t use more heroin to feel better!!

• Encourage survivor to go to the hospital

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Next Steps

• Report use of Naloxone to the program• Anonymous report of date, place, drugs

used and outcome

• Get a refill of the Naloxone• Even if just one dose was used• If kit is lost• If kit is confiscated• If naloxone is nearing expiration date

TIME FOR HANDS ON SKILLS PRACTICE

Practice these skills: 1. Rescue Breathing

2. Injection/intranasal Technique

3. Training a Partner

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Naloxone in Action

• Reverses opiate effect of sedation and respiratory depression

• Causes sudden withdrawal in the opioid dependent person – an unpleasant experience

• No psychoactive effects – low potential for diversion, is not addictive

• Routinely used by EMS (but in larger doses)• Has no effect if an opiate is not present• Sold over the counter in Italy since 1988

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More about Naloxone

• It is regulated but not a controlled substance

• Need to obtain from a licensed prescriber

• Should be stored at room temperature and away from direct light (in kit is OK)

• Has a limited shelf life. Note expiration date and obtain replacement

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More about Naloxone cont.

• Emergency Medical Services give 1.2 to 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 – found to be effective in most instances

Role of EMSPatients receiving naloxone, not being transported to ER: deaths known to medical examiner•998 patients refused transport: none within 12 hours•552 patients refused transport: none within 48 hours•2241 patients discharged by EMS over 10 yrs: 14 within 48 hours; 3 (0.13%) of potential rebound overdoseLimitations: some medical evaluation, varying doses of naloxone; all SKOOP responders instructed to call EMS

•San Diego: Vilke Acad Emerg Med 2003; San Antonio: Wampler Prehosp Emerg Care 2011; Copenhagen: Rudolph Rescusitation 2011

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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 2006

2010 survey of programs known to the Harm Reduction Coalition

• 189 local programs in 16 states

• 1996 - 2010:

–53,339 individuals have received kits

–10,194 overdose reversals reported

Personal communication Eliza Wheeler, Harm Reduction Coalition

Overdose fatality prevention programs that distribute naloxone:

USA, 2010

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Cocaine and heroin rates decreased while opioid analgesic rate increased

* P-Value less than .05; (2005 vs. 2009)

Opioid Analgesics*

Benzodiazepines*

Methadone

Cocaine*Heroin

Anti-Psychotics

Sedatives

Heroin-related Deaths, San Francisco, 1993-2010

*Data compiled from San Francisco Medical Examiner’s Reports, www.sfgsa.org **no data available for FY 2000-2001

0

20

40

60

80

100

120

140

160

1993-1994

1994-1995

1995-1996

1996-1997

1997-1998

1998-1999

1999-2000

2002-2003

2003-2004

2004-2005

2005-2006

2006-2007

2007-2008

2008-2009

2009-2010

Heroin-related deaths

Naloxone distribution begins, 2003

Effect of naloxone on overdose death: Chicago, US

Heroin overdoses dropping

Allegheny County Trends in Accidental Drug Overdose Deaths 2000-2006*

*Data is from Allegheny County Medical Examiners Annual Reports and includes all overdose deaths where these drugs were present at time of death, not necessarily cause of death.

Heroin Use in Allegheny County by Fiscal Year

*Data from Pennsylvania Department Of Health

Opioid maintenance and mortality

• Prospective study of opioid dependent patients applying for methadone treatment in Norway

• 3,789 subjects followed for up to 7 years

• Clausen Drug Alc Dep 2008

Results

Pre-treatment In treatment Post-treatment

Total mortalityOdds ratio

1 0.5 1.43

Total overdoseOdds ratio

1 0.20 1.40

Percent of deaths due to overdose

79% 27% 61%

Clausen 2008

7777

Maintenance therapy prevents overdose

French population in 1999 = 60,000,000

1969 1971 1973 1975 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 1999

Year

No.

of

deat

hs

600

500

400

300

200

100

0

Patients receiving methadone (1998): N= 5,360

Patients receiving buprenorphine (1998): N= 55,000

Auriacombe et al., 2001

•Since the institution of buprenorphine and methadone maintenance in 1996 in France heroin overdose has dropped by 79%

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• "I did SOMETHING, you know, that made a difference. The whole world can’t see it but I know it made a difference.  And that’s important . . . to me."        --quote collected by Suzanne Carlberg-Racich, Chicago  “You get nervous, you know – someone’s blue, someone’s dying.  But you do it because we are all out here together and people are going out right and left.”           --Boston man, age 29

"If you ever get in a meeting with some professional type people, tell ‘em that, you know, people like us–no, we’re not professionals, but if we have it at hand we can save somebody’s life with this stuff [naloxone]. . . it’s a lifesaver, there’s no question."    --Program participant in Chicago; Maxwell S, et al. J Addict Dis. 2006;25(3):8996.

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RESOURCES

• Harm Reduction Coalition (harmreduction.org)

NYSDOH(www.health.state.ny.us - search for overdose)

• On-line CASAC training and credit– www.oasas.state.ny.us