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Overdose Solutions 2013. Addressing Opioid Overdose with Community-based Education and Naloxone Rescue Kits Alexander Walley, MD MS c Medical Director, Massachusetts Dept. of Public Health Opioid Overdose Prevention Pilot. - PowerPoint PPT Presentation
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OVERDOSE SOLUTIONS 2013
ADDRESSING OPIOID OVERDOSE WITH COMMUNITY-BASED EDUCATION
AND NALOXONE RESCUE KITSAlexander Walley, MD MSc
Medical Director, Massachusetts Dept. of Public Health Opioid Overdose Prevention Pilot
Addressing opioid overdose with community-based education and naloxone rescue kits
Alexander Y. Walley, MD, MScBoston University School of Medicine
Boston Medical Center
Allegheny County Overdose Prevention CoalitionWednesday, July 24th, 2013
9:15am-10:45am
Disclosures –Alexander Y. Walley, MD, MSc
• The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months:– Consultant for Social Sciences Research Inc. which is developing a training module for first responders
• 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
Learning objectivesAt the end of this session, you will know:1. Epidemiology of overdose, the rationale and history of the MA OEND
program2. The scope of the MA OEND program3. Effectiveness of OEND: INPEDE OD Study4. Venues and models5. How to incorporate OEND into medical settings6. To acknowledge and address
overdose stigma
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100
200
400
600
800
1000
1200
All Poisoning Deaths Motor Vehicle-Related Injury Deaths
Deat
hs p
er y
ear
The source of the data is: Registry of Vital Records and Statistics, MA Department of Public Health
Poisoning Deaths vs. Motor Vehicle-Related Injury Deaths, MA Residents (1997-2008)
More Opioid Overdose Deaths than MVA Deaths in Massachusetts
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100
200
400
600
800
1000
1200
All Poisoning Deaths Opioid-related Poisoning Deaths Motor Vehicle-Related Injury Deaths
Deat
hs p
er y
ear
The source of the data is: Registry of Vital Records and Statistics, MA Department of Public Health
Poisoning Deaths vs. Motor Vehicle-Related Injury Deaths, MA Residents (1997-2008)
More Opioid Overdose Deaths than MVA Deaths in Massachusetts
Rate of opioid-related fatal overdoses in MA in 2006 was 9.9 per 100K
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100
2
4
6
8
10
12
14
16
18Motor vehicle traf -fic
Poisoning
Drug poisoning
Unintentional drug poisoning
Deat
hs p
er 1
00,0
00 p
opul
ation
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
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 20120
50
100
150
200
250
300
350
Heroin
Cocaine
Prescription Opioids
Total Overdose Deaths
Allegheny County Trends in Accidental Drug Overdose Deaths
2000-2012*
*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.
Opioid overdose costs
• $20.4 billion per year in 2009– $2.2 billion direct costs
• inpatient, ED, MDs, ambulance– $18.2 billion indirect costs
• lost productivity from absenteeism and mortality
• $37,274 cost per opioid overdose event
Inocencio TJ et al. Pain Medicine 2013
What is Driving the Increase in Overdose?
• New Drug Use Patterns– New Initiates to prescription drugs– Vicodin/Percocet/oxycodone >>> heroin
• Heroin Availability/Purity/Lethal Mixture– Heroin is the leading drug threat in New England– From ‘93-’10 Heroin reported as primary drug increased from 20% - 40% of treatment admissions in
MA
• Prescribing Patterns– Schedule II Opioid prescriptions more than doubled since the 1990s
Strategies to address overdose
• Prescription monitoring programs– Paulozzi et al. Pain Medicine 2011
• Prescription drug take back events– Safe disposal
• Safe opioid prescribing education– Albert et al. Pain Medicine 2011; 12: S77-S85
• Expansion of opioid agonist treatment– Clausen et al. Addiction 2009:104;1356-62
• Safe injection facilities– Marshall et al. Lancet 2011:377;1429-37
Rationale for overdose education and naloxone distribution
• Most opioid users do not use alone• Known risk factors:
– Mixing substances, 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
2010
States w/ OENDs 15
Programs 188
People enrolled 53,032
OD rescues 10,171
Wheeler E et al. Morb Mortal Wkly Rep 2012;61:101-5.
Overdose Education and Naloxone Rescue Kits
About Naloxone
• Naloxone reverses opioid-related sedation and respiratory depression = pure opioid antagonist– Not psychoactive, no abuse potential– May cause withdrawal symptoms
• May be administered IM, IV, SC, IN• Acts within 2 to 8 minutes• Lasts 30 to 90 minutes, overdose may return • May be repeated• Narcan® = naloxone• naloxone ≠ Suboxone ≠ naltrexone
Evaluations of OEND programs• Feasibility
– Piper et al. Subst Use Misuse 2008: 43; 858-70– Doe-Simkins et al. Am J Public Health 2009: 99: 788-791– Enteen et al. J Urban Health 2010:87: 931-41– Bennett et al. J Urban Health. 2011: 88; 1020-30– Walley et al. JSAT 2013; 44:241-7 (Methadone and detox programs)
• Increased knowledge and skills– Green et al. Addiction 2008: 103;979-89– Tobin et al. Int J Drug Policy 2009: 20; 131-6– Wagner et al. Int J Drug Policy 2010: 21: 186-93
• No increase in use, increase in drug treatment– Seal et al. J Urban Health 2005:82:303-11
• Reduction in overdose in communities– Maxwell et al. J Addict Dis 2006:25; 89-96– Evans et al. Am J Epidemiol 2012; 174: 302-8– Walley et al. BMJ 2013; 346: f174
MA Timeline: Key events & players
• 2000-2004: 1 CBO underground• 2005: 2 CBO underground
– Boston EMTs equipped with IN via special project waiver
MA Timeline: Key events & players
• 2000-2004: 1 CBO underground• 2005: 2 CBO Boston underground
– Boston EMTs equipped with IN via special project waiver
• 2006: underground suspended >> incorporated, 2 city governments• 2007: city, state government, CBOs• 2009: expansion to more CBOs and outreach • 2010: first responders – police and fire• 2011: parents organizations• 2012: legislature passed good sam and limited liability protection
Implementing the Massachusetts public health pilot: December 2007
• Pilot program conducted under DPH/Drug Control Program regulations (M.G.L. c.94C & 105 CMR 700.000)
• Medical Director issues standing order for distribution
• Naloxone may be distributed by public health workers
Massachusetts DPH standing order
• Authorizes Registered Programs to maintain supplies of nasal naloxone kits• Authorizes Approved Opioid Overdose Trainers to possess and distribute nasal naloxone to
approved responders• Authorizes Approved Opioid Overdose Responders who are trained by Approved Opioid
Overdose Trainers to possess and administernaloxone to a person experiencingan overdose
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• At least 2 supervised bystander
training sessionsSites participate in:• Quarterly all-site meetings• Monthly adverse event phone
conferences
Prefilled naloxone ampule
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:
– $40-50+ per kit
Mucosal Atomization Device (MAD)
Luer-lock syringe
Program data
Enrollments and Rescues: 2006-2012
• Enrollments– 16,379 individuals – >10 per day
• Rescues– 1,741 reported – >1 per day
• AIDS Action Committee• AIDS Project Worcester • AIDS Support Group of Cape Cod• Brockton Area Multi-Services Inc. (BAMSI) • Bay State Community Services• Boston Public Health Commission• Greater Lawrence Family Health Center• Holyoke Health Center• Learn to Cope• Lowell House/ Lowell Community Health Center• Manet Community Health Center• Northeast Behavioral Health• Seven Hills Behavioral Health• Tapestry Health• SPHERE
Enrollee characteristics: 2006-2012
User n=11,002 Non-User n=5,377
Witnessed overdose ever 75% 42%Lifetime history of overdose 49%
Received naloxone ever 41%Inpatient detox, past year 64%Incarcerated, past year 28%
Reported at least one overdose rescue 7.5% 2.0%
Program data
Data only from people with current use or in treatment n = 10,589
Enrollee past 30 day use: 2006-2012
OEND program rescues: 2006-2012
Active use, in treatment, in
recovery N=1,132
Non-User (family, friend, staff)
N=123
911 called or public safety present 30% 59%
Rescue breathing performed 32% 31%Stayed until alert or help arrived 90% 94%
Program data
Adverse Events: Sept 2006-Dec 2012
N=1,741
Deaths 7 / 1729 0.4%
OD requiring 3 or more doses 72 / 1604 4%
Recurrent overdose 3/1741 0.2%
Withdrawal symptoms after naloxone 107/219 49%
Difficulty with device 11/1741 0.6%
Negative interactions with public safety 114/ 466 24%
Confiscations 205 / 5271 4%
Program data
Withdrawal symptoms after naloxone
Program data
Symptoms N=219None 51%Irritable or angry 21%Dope sick 20%Physically combative 4%Vomiting 3%Other 13%
Confused, Disoriented, Headache, Aches and chills, cold, crying, diarrhea, happy, miserable
Do trained rescuers perform differently than untrained rescuers?
Doe-Simkins et al. Under review
Rescues after training (N=508) Rescues before training (N=91)
Friend of OD victim 67% (341/508) 69% (63/91)
OD setting: Public 20% (100/498) 29% (26/89)
> 1 naloxone dose used 48% (23/468) 39% (33/85)
911 called or EMS present 23% (119/508) 27% (25/91)
Rescue breathing 47% (166/350) 52% (34/66)
Stayed with victim 89% (445/498) 89% (78/88)
Sternal rub 63% (222/350) 62% (41/66)
INPEDE OD (Intranasal Naloxone and Prevention EDucation’s 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
Co-authors: Ziming XuanH Holly HackmanEmily QuinnMaya Doe-SimkinsAmy Sorensen-AlawadSarah RuizAl Ozonoff
Opioid Overdose Related Deaths: Massachusetts 2004 - 2006
No Deaths1 - 56 - 1516 - 3030+
Number of Deaths
OEND programs2006-072007-08
2009Towns without
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
OEND program data collection
• Enrollment form: – program staff collect potential bystander
demographics and OD risk factors
• Refill form:– Upon return to program for more naloxone,
staff collect data on use of naloxone, including overdose rescues
Analyses
Poisson regression to compare opioid-related overdose rates among cities/towns with no vs. low and high implementation between 2002 and 2009 – Natural interpretations as rate ratios (RRs) calculated by
exponentiating the beta coefficents
Fatal opioid OD rates by OEND implementation
Cumulative enrollments per 100k RR ARR* 95% CI
Absolute model:No enrollment Ref Ref Ref
Low implementation: 1-100 0.93 0.73 0.57-0.91High implementation: > 100 0.82 0.54 0.39-0.76
* Adjusted Rate Ratios (ARR) All rate ratios adjusted for the city/town population rates of age under 18, male, race/ ethnicity (hispanic, white, black, other), below poverty level, medically supervised inpatient withdrawal treatment, methadone treatment, BSAS-funded buprenorphine treatment, prescriptions to doctor shoppers, and year
Walley et al. BMJ 2013; 346: f174.
Naloxone coverage per 100K
0
50
100
150
200
250Opioid overdose death rate
0%10%20%30%40%50%60%70%80%90%
100%
No coverage
1-100 ppl
100+ ppl
27% reduction46% reduction
Fatal opioid OD rates by OEND implementation
Walley et al. BMJ 2013; 346: f174.
Opioid-related ED visits and hospitalization rates by OEND implementation
Cumulative enrollments per 100k RR ARR* 95% CI
Absolute model:No enrollment Ref Ref Ref
Low implementation: 1-100 1.00 0.93 0.80-1.08
High implementation: > 100 1.06 0.92 0.75-1.13
* Adjusted Rate Ratios (ARR) All rate ratios adjusted for the city/town population rates of age under 18, male, race/ ethnicity (hispanic, white, black, other), below poverty level, medically supervised inpatient withdrawal treatment, methadone treatment, BSAS-funded buprenorphine treatment, prescriptions to doctor shoppers, and year
Walley et al. BMJ 2013; 346: f174.
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
Cost-effectiveness of distributing naloxone to heroin users for overdose reversal
In a simulation model: • One heroin overdose death prevented for every 164 kits distributed• Cost for naloxone distribution would range between:
– $438-$14,000 (best-worst case scenario) for every quality-adjusted life year gained
• Generally accepted threshold is $50,000/year– For dialysis: recently calculated as $129,000
• Lee et al. Value Health 2009;12(1): 80-7.
– For primary care-based SBIRT: recently calculated as $6960 • Tariq et al. PLoS One 2009;4(5)
Coffin and Sullivan. Ann Intern Med. 2013; 158: 1-9.
Venues and Models
Enrollment locations: 2008-2012
Data from people with location reported: Users: 9,824 Non-Users: 4,818Program data
Implementing OEND in MMT and detox
Model Advantages Disadvantages
1. Staff provide OEND on-site • Good access to OEND• OD prevention integrated
• Patients may not disclose risk
2. Outside staff provide OEND on-site
• OD prevention integrated• Interagency cooperation• Low burden on staff
• Community OEND program needed
3. OE provided onsite, naloxone received off-site
• OD prevention integrated• Interagency cooperation
• Increased patient burden to get naloxone
4. Outside staff recruit near MMT or detox
• Confidential access to OD prevention • OD prevention not re-enforced in treatment
• Not all patients reached
Walley et al. JSAT 2013; 44:241-7.
Among 29 MMT and 93 detox staff who received OEND, 38% and 45% respectively reported witnessing and overdose in their lifetime.
Among 1553 OEND participants who reported taking methadone, 47% were trained in detox, 25% at HIV prevention programs, and 17% in MMT. Previous overdose, recent inpatient detox or incarceration, and polysubstance use were OD risks common among all groups.
Other venues and models
• First responder OEND– Quincy, Revere, Gloucester
• Emergency Department (ED) SBIRT• Post-incarceration• Prescription naloxone
– Prescribetoprevent.org
Quincy P.D. Statistics
• May 2009 – October 2010 (17 months)– 47 Fatal Overdoses
• October 2010 – December 2012 (26 months)– 206 Non-Fatal Overdoses– 19 Fatal Overdoses– 134 Naloxone Administrations
• 131 Successful Reversals (98%)• 2 Deceased (1.5%)• 1 No Effect (probably not an opioid O.D.)
Incorporating overdose education and naloxone rescue kits into medical and addiction practice
1. Prescribe naloxone rescue kits• PrescribeToPrevent.org
2. Work with your OEND program
Challenges for community programs
• Prescription and prescriber typically required
• Naloxone cost is increasing, funding is minimal
• Missing people who don’t identify as drug users, but have high risk
• CBOs target IDU, people w/ substance use disorders, HIV prevention
Opportunities for prescription naloxone
• 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
Practical Barriers to Prescribing Naloxone
1. Prescriber knowledge and comfort2. How to write the prescription?3. Does the pharmacy stock rescue kits?
• Rescue IN kit with MAD? • Rescue IM kit with needle?
4. Who pays for it?• Insurance in Massachusetts covers naloxone, but not the atomizer yet• The MAD costs $3 each>> $6-7 per kit• Work with your pharmacy to see if they will cover it
Legal Barriers to Prescription Model
“Prescribing naloxone in the USA is fully consistent with state and federal laws regulating drug prescribing. The risks of malpractice liability are consistent with those generally associated with providing healthcare, and can be further minimized by following simple guidelines presented.”
1. Only prescribe to a person who is at risk for overdose2. Ensure that the patient is properly instructed in the administration and risks
of naloxone
Burris S at al. “Legal aspects of providing naloxone to heroin users in the United States. Int J of Drug Policy 2001: 12; 237-248.
Massachusetts - 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.
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. What were you taking?2. How did you survive?
2. What strategies do you use to protect yourself from overdose?3. How many overdoses have you witnessed?
1. Were any fatal?2. What did you do?
4. What is your plan if you witness an overdose in the future?1. Have you received a narcan rescue kit?2. Do you feel comfortable using it?
Overdose Education in Medical SettingsWhat they need to know:1.Prevention - the risks:
– Mixing substances– Abstinence- low tolerance – Using alone– Unknown source– Chronic medical disease– 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 and wait 3-5 minutes • Stay until help arrives
Prescribetoprevent.org
Stigma Related to OverdoseThese articles appeared in the same paper, one in police reports the other in the obituary
Woodland Avenue resident dies of an apparent overdoseA 44-year-old Woodland Avenue man is believed to have overdosed on heroin and died as a result last Thursday morning at a Cooledge Avenue home.The man, William SmithJones, of Woodland Avenue, was found by a friend in the bathroom after he went in to shower and shave around 8 a.m. After spending more time than usual in the bathroom, the friend pushed her way inside and found him on the floor, purple colored.EMTs from Cataldo Ambulance administered Narcan to Anderson and rushed him to Whidden Hospital, where he died later.
William SmithJones, 44Worked for AcmeWilliam SmithJones died unexpectedly at the Whidden Memorial Hospital in Everett on March 5, after being stricken at his Oak Island home in Revere. He was 44 years old.Born in Lynn, he was a lifelong resident of Oak Island, attended Revere schools and was employed by Acme Company of Revere until his untimely death.He was the father of Brendan SmithJones and Krysti SmithJones, both of Salem, NH; son of Cheryl SmithJones of Malden and the late Harold SmithJones; brother of Lori SmithJones of Tewksbury, Harold SmithJones of Fremont, NH, Annie SmithJones of Medford and Robert SmithJones of Somerville. He is also survived by the mother of his children, Heidi SmithJones of Salem, NH, Mildred SmithJones, his maternal grandmother, Ruth Smith of Revere; a cousin, Jonathan A. SmithJones of Revere; and several nieces, nephews and other cousins. He was also the grandson of the late Robert SmithJones and Oswell and Anna SmithJones.Funeral arrangements were entrust ed to the Vertuccio Home for Funerals of Revere. Remembrances may be made to the American Heart Association, 20 Speen St., Framingham, MA 01701.
Reduce the Stigma• Talk about it!!!• Information DOES NOT = “enabling”• Denying access increases risk• Open up the issue like any other• Chance for intervention• Discuss overdose information along with
use/recovery/treatment etc.,• Listen and talk with
users/non-users/politicians/community
Next steps
• Sustain existing programs• Expand sites and venues • Target incarcerated and ED patients• Facilitate wider prescribing of naloxone
– Chronic pain and addiction practices– Family members of opioid users
Lessons Learned
• Standing order facilitates expansion • Nasal naloxone helps acceptability• Use existing networks to reach high risk people and build out
from there• Both grass roots and top down leadership are useful• Prescription naloxone takes patience and perseverance• Parents and public safety can be powerful advocates• Overdose can bring people together on common ground
Learning objectivesAt the end of this session, you will know:1. Epidemiology of overdose, the rationale and history of the MA OEND
program2. The scope of the MA OEND program3. Effectiveness of OEND: INPEDE OD Study4. Venues and models5. How to incorporate OEND into medical settings6. To acknowledge and address
overdose stigma
Thank you! [email protected]
MA DPH• Sarah Ruiz• John Auerbach• Andy Epstein• Holly Hackman• Michael Botticelli• Kevin Cranston• Dawn Fakuda• Barry Callis• Grant Carrow• Len Young• Kyle Marshall• Office of HIV/AIDS• Bureau of Substance Abuse Services
BU/BMC• Gregory Patts• Chris Chaisson• Jeffrey Samet• Ed BernsteinProgram sites, staff and participantsNOPE group
Helpful Websites:Prescribetoprevent.orgOverdosepreventionalliance.orgNaloxoneinfo.org
Considerations• Intranasal works and is popular
– It could be improved with a one-step, affordable FDA-approved intranasal delivery device
– Intramuscular may be more affordable and implementable• 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
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 >> 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
How does drug use change after OEND?
Doe-Simkins et al. Under review
N=325 Increased Decreased No change
Heroin 115 (35%) 122 (38%) 88 (27%)
Methadone 84 (26%) 70 (22%) 171 (52%)
Buprenorphine 73 (22%) 66 (20%) 186 (58%)
Other Opioids 59 (18%) 62 (19%) 205 (63%)
Cocaine 83 (26%) 96 (30%) 146 (44%)
Alcohol 69 (21%) 70 (22%) 186 (57%)
Benzo/Barbiturate 99 (30%) 74 (23%) 152 (47%)*
Number of substances** used 131 (40%) 125 (38%) 69 (21%)
*p < 0.05 - Wilcoxon signed rank test which compares the median difference between two repeated measures among the repeat enrollers**Participants were asked about use of heroin, methadone, buprenorphine, other opioids, cocaine, alcohol, benzodiazepine/barbiturate,
methamphetamine, clonidine, and other substances
2002 2003 2004 2005 2006 2007 2008 20090
5
10
15
20
No enrollmentLow enrollment (1-100 per 100,000)High enrollment (>100 per 100,000)
Year
Opi
oid-
rela
ted
over
dose
dea
ths
per 1
00,0
00 p
opul
ation
Unadjusted unintentional opioid-related overdose death rates in 19 communities with no, low and high OEND enrollment
in Massachusetts, 2002-2009
Walley et al. BMJ 2013; 346: f174.
Unadjusted unintentional opioid-related acute care hospitalization rates in 19 communities with no, low and high OEND enrollment
in Massachusetts, 2002-2009
2002 2003 2004 2005 2006 2007 2008 20090
20
40
60
80
100
120
No enrollment Low enrollment (1-100 per 100,000)
High enrollment (>100 per 100,000)
Year
Opi
oid-
rela
ted
acut
e ca
re ra
tes
per 1
00,0
00 p
opul
ation
Walley et al. BMJ 2013; 346: f174.
Control models of OEND implementation and ratio of opioid related overdose deaths to cancer deaths
Cumulative enrollments per 100k Adjusted β estimate* P-value
Absolute model:No enrollment Ref
Low implementation: 1-100 -0.0222 0.01High implementation: > 100 -0.0326 0.01
Relative model:No enrollment RefLow implementation: 1-100 -0.0238 <0.01High implementation: > 100 -0.0183 0.07
* Adjusted Rate Ratios (ARR) All rate ratios adjusted for the city/town population rates of age under 18, male, race/ ethnicity (hispanic, white, black, other), below poverty level, medically supervised inpatient withdrawal treatment, methadone treatment, BSAS-funded buprenorphine treatment, prescriptions to doctor shoppers, and year
Walley et al. BMJ 2013; 346: f174.
Control models of OEND implementation and ratio of opioid related to MV crash related acute care hospitalizations
Cumulative enrollments per 100k Adjusted β estimate* P-value
Absolute model:No enrollment Ref
Low implementation: 1-100 -0.022 0.6
High implementation: > 100 0.0001 0.98Relative model:
No enrollment RefLow implementation: 1-100 -0.0044 0.3High implementation: > 100 0.0027 0.5
* Adjusted Rate Ratios (ARR) All rate ratios adjusted for the city/town population rates of age under 18, male, race/ ethnicity (hispanic, white, black, other), below poverty level, medically supervised inpatient withdrawal treatment, methadone treatment, BSAS-funded buprenorphine treatment, prescriptions to doctor shoppers, and year
Walley et al. BMJ 2013; 346: f174.
Learn2cope.org Meeting Schedule
• Every Monday evening 7 - 9 PM– Good Samaritan Medical Center, 235 North Pearl Street, Brockton, MA. 02301
• Every Tuesday at 7:00 pm– Gloucester Family Health Center, 302 Washington Street, Gloucester, MA.
• Every Tuesday at 7:00 - 8:30 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 [email protected] for dates.
US and MA Age-Adjusted All Poisoning and MA Opioid-related Death Rates, 2000-2010
Sources: All- poisoning rates from CDC, WISQARS web-based query (Accessed 2/19/2013)Opioid-related poisoning from Registry of Vital Records, MDPH.
99% increase in all poisoning death rate in MA from 2000-2006; 18% decrease in rate from 2006 to 2010. Overall APC 2000-2010: 4.05 (p <.05)73% increase in opioid-related poison death rate in MA from 2000-2006; 13% decrease in rate from 2006 to 2010. Overall APC 2000-2010: 4.06 (p<.05)
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
U.S. All Poisoning MA All Poisoning MA Opioid-related Poisoning
Year
Age
Adj
uste
d R
ate
per 1
00,0
00 p
erso
ns
Acts of 2012, Chapter 192, Sections 11 & 32
(d) 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. (emphasis added)
(a) A person who, in good faith, seeks medical assistance for someone experiencing a drug-related overdose shall not be charged or prosecuted for possession of a controlled substance under sections 34 or 35 if the evidence for the charge of possession of a controlled substance was gained as a result of the seeking of medical assistance.
(b) A person who experiences a drug-related overdose and is in need of medical assistance and, in good faith, seeks such medical assistance, or is the subject of such a good faith request for medical assistance, shall not be charged or prosecuted for possession of a controlled substance under said sections 34 or 35 if the evidence for the charge of possession of a controlled substance was gained as a result of the overdose and the need for medical assistance.
(c) The act of seeking medical assistance for someone who is experiencing a drug-related overdose may be used as a mitigating factor in a criminal prosecution under the Controlled Substance Act,1970 P.L. 91-513, 21 U.S.C. section 801, et seq.
(d) Nothing contained in this section shall prevent anyone from being charged with trafficking, distribution or possession of a controlled substance with intent to distribute.
(e) 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.
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
Patient instructionsEducation Videos:• Overdose Prevention Video for chronic pain
patients
Patient Selection
• After emergency medical care involving opioid intoxication or poisoning• Suspected hx of substance abuse or nonmedical opioid use• Patients taking methadone or buprenorphine• Any patient receiving an opioid prescription for pain and:
– higher-dose (>50 mg morphine equivalent/day) opioid– rotated from one opioid to another= poss incomplete cross tolerance– Smoking, COPD, emphysema, asthma, sleep apnea, respiratory infection, or other respiratory illness or
potential obstruction.– Renal dysfunction, hepatic disease, cardiac illness, HIV/AIDS– Known or suspected concurrent heavy alcohol use– Concurrent benzodiazepine or other sedative prescription– Concurrent antidepressant prescription
• Patients who may have difficulty accessing emergency medical services (distance, remoteness)• Voluntary request from patient or caregiver
Opioid OD conceptual model
Fatal Opioid ODNon-fatal Opioid OD
Heroin use
Rx Opioid misuse
OD prevention education
OD management (naloxone, 911)
Opioid addiction prevention and
treatment
Rx diversion
bystander
OEND
OD risk factors• polydrug use• abstinence• using alone• unknown source
PMP, Prescriber Education, Take Back
Days