REDUCING OPIOID OVERDOSE DEATHS IN NEW MEXICO4

Running head: REDUCING OPIOID OVERDOsE DEATHS IN The United States & NEW MEXICO

REDUCING OPIOID OVERDOsE DEATHS IN The United States & NEW MEXICO

By Timothy L. Hallford, MPA

“Rarely do we find men who willingly engage in hard, solid thinking. There is an almost universal quest for easy answers and half-baked solutions. Nothing pains some people more than having to think.”

Reverend Martin Luther King, Jr.

STOP OD, INC.89 MOYA ROAD

SANTA FE, NM 87508505-469-5319

[email protected] (under construction)

http://www.StopODNM.com/

REDUCING OPIOID OVERDOsE DEATHS IN The United States & NEW MEXICO 2

TABLE OF CONTENTS

Abstract………………………………………………………………………………….. Page 3

Definitions/Organizations……………………………………………………………….. Page 4

Introduction ……………………………………………………………………………... Page 6

Target Population………………………………………………………………………… Page 8

Opioid Abusers…………………………………………………………………... Page 8

Opioid Overdose Citizens………………………………………………………... Page 10

Where are the Opioid Overdose Deaths?................................................................ Page 12

Synthetic Opioids & Fentanyl……………………………………………………. Page 22

Cost Benefit Analysis of Opioid Overdose Deaths……………………………………….. Page 28

Statewide Naloxone Distribution…………………………………………………………. Page 30

Naloxone Cost…………………………………………………………………….. Page 64

Naloxone Distribution Partners…………………………………………………… Page 68

What Should We Research & Study?................................................................................... Page 69

Critical Thinking & Analysis……………………………………………………………… Page 72

Findings……………………………………………………………………………………. Page 81

Strategic Action Plan………………………………………………………………………..Page 86

Editorial……………………………………………………………………………………. Page 89

References………………………………………………………………………………….. Page 94

About Timothy L. Hallford………………………………………………………………… Page 101

Appendix…………………………………………………………………………………… Page 102

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Abstract

This paper’s premise is that opioid overdose deaths in the United States, and in New Mexico have not meaningfully

reduced despite all of the research, financial resources, organizations, campaigns, legislation, political statements, and

community participation efforts. In fact, this paper describes a microcosm of the macrocosm of the current situation of

opioid overdose deaths in the United States-in almost all communities, they are unfortunately increasing. This paper offers

a strategy that will reduce opioid overdose deaths almost immediately. It is a call to action, with the already plentiful

resources targeted for this epidemic, and while making it a real emergency priority as portrayed by our leadership.

Keywords: Opioid Overdose, Opioid Abuse, Overdose Deaths, Naloxone, NARCAN, Harm Reduction, New Mexico

(Please note: While this paper is at least partly, in APA style format, bold type words are mine, they are there for emphasis and importance, please forgive me for the violation of the style.)

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DEFINITIONS AND RELATED STATE AGENCIES:

1. Epidemic -affecting or tending to affect a disproportionately large number of individuals within a population,

community, or region at the same time.

2. Epidemiology - a branch of medical science that deals with the incidence, distribution, and control of disease in a

population; the sum of the factors controlling the presence or absence of a disease or pathogen

3. Naloxone -a potent synthetic antagonist of narcotic drugs (as morphine and fentanyl) that is administered

especially in the form of its hydrochloride C19H21NO4·HCl. Naloxone is typically administered by injection to

reverse the effects of opioids and especially in the emergency treatment of opioid overdose. It is also administered

in combination with buprenorphine in the form of a dissolvable tablet placed under the tongue or a film placed

inside the cheek to treat opioid dependence. Trademarks for preparations containing naloxone include Bunavail,

Evzio, Narcan, Suboxone, and Zubsolv.

4. Reversal – term used by the New Mexico Department of Health to mean that a citizen who is overdosing does not

die because of the use of the drug, Naloxone or other antagonist of narcotic drugs which revives them.

5. Emergency Declaration - Emergency clause, meaning the law takes effect immediately.

6. Opioid Overdose - Opioid overdoses happen when there are so many opioids or a combination of opioids and other

drugs in the body that the victim is not responsive to stimulation and/or breathing is inadequate. This happens because

opioids fit into specific receptors that also affect the drive to breathe. If someone cannot breathe or is not breathing

enough, the oxygen levels in the blood decrease and the lips and fingers turn blue- this is called cyanosis. This oxygen

starvation eventually stops other vital organs like the heart, then the brain. This leads to unconsciousness, coma, and

then death. Within 3-5 minutes without oxygen, brain damage starts to occur, soon followed by death. With opioid

overdoses, surviving or dying wholly depends on breathing and oxygen.

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https://www.merriam-webster.com/dictionary/disproportionate


ORGANIZATIONS:

NEW MEXICO DEPARTMENT OF HEALTH

Mission Statement:

“Our mission is to promote health and wellness, improve health outcomes, and assure safety net services for all people in New Mexico.”

Public Health Division:“Coordinated system of community based public health services focusing on disease prevention and health promotion.”

Epidemiology & Response Division:“Tracks infectious diseases, injury and health statistics, trains organizations in disease control, injury prevention, responds to public health emergencies and provides vital records services. We also issue 228,000 birth and death certificates and register 28,000 births and 14,000 deaths each year.”

Environmental Health Epidemiology Bureau:“Reduce the prevalence of environmentally-related adverse health outcomes by:

Conducting surveillance of relevant, prioritized health outcome Identifying environmental exposures of concern Implementing public health promotion through evidence-based

approaches Evaluating program activities to further develop and improve effectiveness”

NEW MEXICO DEPARTMENT OF HUMAN SERVICES

Mission Statement: “To reduce the impact of poverty on people living in New Mexico by providing support services that help families break the cycle of dependency on public assistance.”

Behavioral Services Division Mission Statement: “The Behavioral Health Services Division (BHSD) primary role is to serve as the Mental Health and Substance Abuse State Authority for the State of New Mexico. The Authority's role is to address need, services, planning, monitoring and continuous quality systemically across the state.”

UNIVERSITY OF NEW MEXICO

Health Sciences Center Division:“Our mission is to provide an opportunity for all New Mexicans to obtain an excellent education in the health sciences. We will advance health sciences in the most important areas of human health with a focus on the priority health needs of our communities. As a majority-minority state, our mission will ensure that all populations in New Mexico have access to the highest quality health care. In order to realize our Vision and Mission, we will achieve the following goals:

Improve health and health care to the populations we serve with community-wide solutions Build the workforce of New Mexico by providing a premier education and transformative experience that prepares

students to excel in the workplace Foster innovation, discovery and creativity; and translate our research and discoveries into clinical or educational practice;

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Provide the environment and resources to enable our people and programs to do their best Deliver a well-integrated academic health center that provides high quality of care and service while being accessible to all

New Mexicans Nurture and embrace an environment of diversity, integrity and transparency

Project Echo Program:Mission Statement:

“Project ECHO is a lifelong learning and guided practice model that revolutionizes medical education and exponentially increases workforce capacity to provide best-practice specialty care and reduce health disparities. The heart of the ECHO model™ is its hub-and-spoke knowledge-sharing networks, led by expert teams who use multi-point videoconferencing to conduct virtual clinics with community providers. In this way, primary care doctors, nurses, and other clinicians learn to provide excellent specialty care to patients in their own communities.”

INTRODUCTION

New Mexico, consistently has always been at the top of the list for opioid overdose deaths in the United States,

currently #2 (although recent unclear data is indicating we are #9 for all overdose deaths), per capita. As it is in the United

States, it is a true epidemic. We, as a nation, and in New Mexico, were, and are still not ready, to focus ourselves on this

specific issue, marshaling the available resources to reduce this quite manageable problem. It’s actually been going on for

a long time in some parts of the United States, including New Mexico, and our government officials, law enforcement,

politicians, criminal justice, social services, treatment agencies, churches, and community organizations have

strategies in place. What has changed significantly, in the last 5 years, is that now it is epidemic everywhere in the

United States, across all age groups and races, in rural and metropolitan areas, in wealthy, middle class, and poor

communities, among the educated and the illiterate, among the young, adult, and elderly population. Substance

abuse has always been a huge challenge for policymakers, treatment agencies, the medical community, emergency services

personnel, law enforcement, judicial, social services and now suddenly they are asked to deal with this epidemic which has

reached its tentacles out into the whole United States. Frankly, it is unfair to ask them, by themselves, to now address

what was already a huge problem turned epidemic. I submit that, if it is affecting all states, all communities, all

Americans, then we all must stand up together to address it. My daughter, Ashley Seidner, D.O. is a physician in

residency at a hospital in Ohio, she reports that overdoses coming into the emergency room there are now routine. Ohio,

in the middle of the conservative Midwest, now leads the nation in overdose deaths:

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Ohio leads the nation in deaths due to heroin and other opioid overdoses. According to the Kaiser Family Foundation, the toll climbed from 2,106 in 2014 to 3,050 last year, with an even higher number projected for 2016. Ohio outpaces New York and California, states with much larger populations… Epidemic is the fitting description, and state lawmakers, along with Gov. John Kasich, have responded with additional resources for communities. The recent lame-duck session produced stronger regulations for opioid prescriptions, improved access to naloxone (medication to reverse overdoses) and support for treatment programs… Ohio law gives the governor and lawmakers the authority to declare emergencies. That is what the heroin and opioid epidemic presents. Will they respond adequately in the new year? {74}

While research (already completed en masse) on education, prevention, and treatment are critical factors to address the

problem, I submit that we must first address keeping opioid abuse citizens alive otherwise the rest of these strategies

mean nothing to that citizen for they are, needlessly, unfortunately already deceased. Several government agencies, even

the Governor’s office, have received significant federal funding to augment state resources for this expressed purpose.

This paper’s premise is that some, in fact, a relatively small amount of these financial resources, already available,

need to be redirected toward reducing opioid overdose deaths in New Mexico and exponentially in the United

States.

The Good News

There is good news about the possibilities of reducing opioid overdose deaths significantly in New Mexico. We

have the drug Naloxone, available to reverse immediately the citizen who is overdosing on opioids, no matter what the

reason – accidental overdose, illicit drug use, or suicide attempt. The cost of the drug is infinitesimal considering all the

available resources, the significant medical, legal, criminal justice, and societal costs of opioid overdose deaths, and the

cost to families, friends, emergency responders, doctors, hospitals, and innocent witnesses to an opioid overdose death.

And finally, the cost of deceased New Mexico citizen themselves-literally their life. New Mexico has garnered a great deal

of grant monies to address opioid abuse and overdose deaths. Federal and state resources are at multi-million dollars each

year, every year. And now there is even more with President Obama’s recent signature of the bill directing $1.8B

expressly for opioid drug abuse and overdose deaths. In New Mexico, we have passed and signed innovative legislation

that includes a standing order for the prescription of the drug Naloxone where it can be distributed by all pharmacies in

New Mexico without an individual prescription. We have a new Good Samaritan Law, passed in 2016 (which actually

already had one years before), signed by Governor Martinez, which provides that there can be no civil liability or criminal

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penalties for any citizen administering Naloxone in good faith, to an overdosing citizen in New Mexico. We have at least

some supply (the number of which I cannot determine) of the drug Naloxone, currently under control of the New Mexico

Department of Health, which can be, and is, distributed to a small number of pharmacies in New Mexico and to some

community organizations and treatment centers. We even have some big pharmaceutical companies willing to donate for

free or at a reduced cost, Naloxone to our State. And yet we remain, #2 in the nation for overdose deaths. Why? Because

it time that we think critically now, analyze what we have done, are doing, efficiency and effectiveness, and what can be

done immediately to reduce this death rate epidemic. And we must do it now, for, as I write this paper, a few more New

Mexico citizens have died from an opioid overdose.

Target Population. So, who are we targeting in this mission? Any New Mexico citizen who may accidentally, abuse,

or purposely overdose on opioids-legal or illegal. There is a strong belief that most of these citizens are at the street

level, homeless, lifelong drug abusers, and for some, lost causes. And as if, somehow, their lives are worth less than those

who are not overdosing. If they were treated the same as any New Mexico citizen, then why are they still dying at the

same rate? Why aren’t more resources not dedicated towards stopping their deaths? And what if, let’s say, half of the

overdose citizens, get help for the problem, and change their lives. And maybe they then become Naloxone advocates

themselves, saving others like they were saved, exponentially, Suddenly, we have someone still alive saving at least one

more life in New Mexico. Are these “reversal citizens” worth it now? What do we know about opioid overdose citizens?

A plethora of data, studies, and presentations continue to say the same things:

Opioid abusers. The first population to consider is those who accidentally take too many opioids or choose to abuse

opioids but do not actually overdose. They are the potential overdose citizens. They are not just street level addicts, they

are people who may be in chronic pain, have an injury requiring opioids for pain, handicapped, elderly, etc. What do we

know about them? While I could not find demographics for New Mexico for all opioid users, including illicit users (except

for youth), here are the demographics for prescribed opioids by participating pharmacies in Department of Health

program (please note this was from a presentation in 2014 using data only through 2012) a small percentage of

pharmacies, less than 20% of the 300 pharmacies in New Mexico:9


The age group for those filling prescription opioids is wide with the highest rate for New Mexicans age 85+. Males are

more prevalent than females. Significant usage begins at age 15 and increases in every age group through age 85+.

While this is eye opening, I still do not have more detailed demographics (race, location, prescribed reason, etc.) on

the legal use of opioids that I could find. Perhaps the answer is that opioid prescriptions are crossing all

demographics at an epidemic rate? I suspect the latter. Anyway, I digress… {1}

Total Opioid Prescribing in New Mexico:

Assuming there are

approximately 2 million people in our state, this user group alone equals having one opioid prescription for every New

Mexican, men, women, and children. And this is similar to the national rate for America.

Of these citizens, above, it appears that the average number of opioid prescriptions prescribed is 2 prescriptions each.

And this is every year. So, we seem to have little problem getting opioids prescribed in New Mexico, how do we get

Naloxone in every New Mexican’s medicine cabinet?

2016Q32016Q22016Q12015Q4

Total number of Controlled Substance patientsNumber of patients receiving opioidsNumber of opioid prescriptions filled (excluding buprenorphine/naloxone)

2015Q3

200,950190,752187,159

283,253271,822269,069

423,026410,940406,259450,000400,000350,000300,000250,000200,000150,000100,00050,000

-

Controlled Substance and Opioid Prescribing by Year andQuarter

389,865 377,087

264,097 258,836

181,278 175,839

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{75}

Opioid Overdose Citizens. Let’s look at the demographics for those who overdose, for there is no lack of research or data

in this data set in the United States and specifically, New Mexico:

“In NM, the rate of ED visits due to opioid overdose increased almost 30% between 2010 and 2013 The rate increased approximately 36% for men between 2010 (50.3 visits per 100,000 population) and 2013 (68.5 visits per 100,000 population). For women, the increase was approximately 21% (2010: 42.8 visits per 100,000 population; 2013: 51.8 visits per 100,000 population.) By age group, the rate was highest among men aged 25-34 (146.5 visits per 100,000 had the highest rate. In 2013, there were a total of 2,506 ED visits due to drug overdose, for a rate of 122.8 visits per 100,000 population. The rate of opioid overdose related ED visits was 60.4 visits per 100,000 population and the rate of heroin overdose-related ED overdose-related ED an was 70%. Among women, those aged 35-44 (80.5 visits per 100,000 population), representing 57% of all opioid overdose-related ED visits and 27% of total drug overdose-related ED visits. Both men and women between the ages of 15-54 had high rates of opioid overdose-related ED visits. However, men between the ages of 15-34 had higher rates compared to females, with the highest rate among men between the ages of 25-34 (146.5 visits per 100,000 population) being 48% higher than women in the same age group (70.9 visits per 100,000 population). visits per 100,000 population) was almost 27% higher visits per 100,000 population) was almost 27% higher than that for heroin overdose, representing 57% of all opioid overdose-related ED visits and 27% of total drug overdose-related ED visits. Poisoning was the leading cause of unintentional injury death from 2007 through 2014, followed by motor vehicle traffic-related injury and fall-related injury. About 90% of unintentional poisoning deaths in NM are due to drug overdose.” [1}

Mr. Saavedra, form the New Mexico Department of Health, further states:

“The data presented are worrisome since the most affected age group corresponds to the working age population, re-emphasizing the toll substance abuse imposes on society. Furthermore, the age groups among women correspond to their reproductive ages, which may explain the increasing trends in rates of neonatal abstinence syndrome that have been observed nationally.” [1]

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Opioid Overdose Citizens Data Conclusions:

So, lets sum this up in a few sentences.: Opioid overdose emergency visits have increased 30% and are increasing in both

sexes. Both men and women between the ages of 15-54 have the highest rates of opioid overdoses with men ages 25-34 the

highest, women 35-44 the highest, and these women are in reproductive age thus increasing the neonatal abstinence

syndrome. Now one overdose can kill or seriously harm two New Mexicans.

Overdose Deaths. This is the hardest part of the research, the ones who have already died from opioid overdose, many

needlessly, where I believe many could have still been here today. Perhaps their sacrifice will save others yet to come.

How bad is the death now in America? Well, heroin overdoses only have surpassed the homicide rate for guns in

America:

{70}

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This data represents those who died from opioid overdoses in New Mexico. What we know about this data: Substance

abuse is ravaging the Native American reservations and unfortunately it is no different for deaths from opioids.

Native Americans are dying at rate double or triple the rate of the rest of the population. {2} White, Black, and Hispanic New Mexicans have very similar overdose death rates. So, opioid pain reliever overdose deaths occurred 89.2% of the time with those with chronic medical conditions. And almost 70% of the time they occurred in the home and with bystanders yet only 20% of the heroin users were given

Naloxone and only 10% of the opioid pain reliever overdose deaths received Naloxone. {3}

Who is dying of opioid overdoses? Native American citizens at rate 2 or 3 times the rest of the New Mexico population.

Hispanic, Black and White New Mexicans are dying at about the same rate. So, those who overdose from prescription

opioids, almost 90% of them have chronic medical conditions. Overdoses predominantly occur at home and with

somebody else there. Only 20% of heroin users received Naloxone and only 10% prescription users received Naloxone,

therefore less than 80% of overdose opioid deaths received Naloxone. And I suspect that rural New Mexicans are

dying at disproportionate rates over more populated areas.

Where Are the Deaths in New Mexico? Now that we know the “Who” of opioid overdose New Mexican citizen deaths, the next important determination is where they are most happening per capita? First, given the rural considerations of New Mexico, it is important to see that opioid overdose deaths are happening at a rate 45% higher than in rural areas and that there is rarely any help for substance abuse treatment services nearby when they do not die from an overdose: {4}

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Recently, Governor Suzanna Martinez and the Department of Health announced a reduction in overdose deaths in New

Mexico and this was spread across the United States media as a triumph. {5} While, we must applaud any and all deaths

saved in New Mexico, and we must thank each and every person who had any involvement in that reduction, 69 New

Mexicans stayed alive in 2015 and total overdose deaths declined by 9% statewide. Yet, we must also think critically

about this newest data. The article, entitled, “Overdose Deaths Decline in Nearly Two-Thirds of New Mexico’s 33

Counties,” we must look closer and think critically about these results. First, this is all overdoses which would include

alcohol, other drugs, etc. Second:

What is the opioid overdose rate for 2015?

The heroin overdose death rate increased although it is not stated by how much?

The drug overdose rate declined by 7.5%, not 9%.

The prescription opioid overdose rate death rate decreased but we do not know by how much?

If we look at where the decreases were, 36% of the death reduction happened in 3 more populated counties:

Valencia, Sandoval, and San Juan counties. If we count in Rio Arriba County’s reduction, 53% of the death

reduction were in these 4 counties. What might have changed in these counties to reflect the decrease? The

drug supply on the street through interdiction by law enforcement, excellent pharmacy participation, better EMS

resources, Naloxone distribution, well-staffed hospital emergency rooms, new and effective education and

prevention programs? We should be studying these 4 counties right now with an eye for things like: what kind

of abusers are overdosing still here and what kind aren’t (prescription, illicit, heroin, age, sex, race, location of

overdoses, changes in local programs, law enforcement interdiction, supply of drugs on the street, interviews of

overdosed citizens, etc.)

How many of these 69 people were reversals using Naloxone?

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Rio Arriba County, Ground Zero:

Rio Arriba County has steadily remained beyond epidemic for too many years leading New Mexico, and America in opioid overdose deaths. Opioid abuse is almost acceptable, endemic, in the community:

,

February 2000

“Beautiful Land, Ugly Addictions”

Comparison of heroin overdose death rates per 100,000 people per year from 1996-1998:US national rate: 2.2

New Mexico Rate: 9.4Rio Arriba County rate: 35.5

Chimayo is the "heroin capital" of Rio Arriba County, a rural region of 34,000 people with one of the highest rates of drug overdose in the United States… {6}

And this very insightful, although parts are questionable, article:

New Mexico has not stood by as fatal overdoses skyrocketed in Rio Arriba County — from 7 in 1990 to 40 in 2014, according to state health department data — and statewide, from 131 to more than 500. The state boasts one of the most sweeping harm reduction programs in the nation. Rio Arriba County is home to a nationally recognized doctor who prescribes proven anti-addiction medications, several local drug treatment centers, and an anti-overdose strategy that puts lifesaving drugs into the hands of law enforcement. Drug-ridden towns elsewhere are just discovering strategies Española has been practicing for decades.

So why, given New Mexico’s pioneering efforts, hasn’t the situation improved?

“Fernando Espinoza has known dozens of people killed by addiction to drugs and other substances. An aunt. An uncle. A cousin. Too many friends and fellow inmates to count. Espinoza, 32, has spent 14 consecutive birthdays in jail. When he’s out, he lives with his mother at her home in Española. He has two daughters, a GED, and an addiction to heroin that feels like something scratching inside his brain. Here in Rio Arriba County, where one in five residents lives in poverty, people overdose and die more often than almost anywhere else in the country. Over the past five years, the county’s overdose rate was three times the statewide average, and more than five times the national rate. According to a 2013 survey of 969 Española teenagers, nearly 5 percent of high school students had used heroin within the last month, as opposed to 2.9 percent statewide.

Attempts to treat addiction here have been undermined by a failure to focus on prevention, a lack of resources and an unanticipated boom in prescription drug sales. And for all the state and county have tried, their efforts have not changed the factors that drive people here to addiction in the first place. Among them: generations of poverty and a lack of jobs that leave people with few good alternatives. The Naloxone program:

Five days a week Fiuty and harm reduction program manager Dave Koppa drive the streets of Española, visiting homes, stopping in parking lots and open fields, and pulling over when people wave at them from sidewalks. They offer tips on how to shoot heroin without creating infected abscesses. They explain the dangers of mixing pills and alcohol, and give out for free an overdose reversal drug called Naloxone…. In the past year alone, the Santa Fe Mountain Center’s

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https://nmhealth.org/data/view/behavior/870/

https://nmhealth.org/data/view/behavior/870/


needle exchange programs collected over 1 million needles, gave away more than 3,000 doses of Naloxone, and recorded more than 700 successful overdose reversals.

…That such recidivism persists despite the state’s efforts haunts Salazar and other advocates. For one thing, the community’s need has always exceeded its resources. Except for pregnant women, Hayes, the buprenorphine-prescribing doctor, has hardly taken a new patient in three years. A local residential treatment center, Hoy Recovery, has nearly 50 beds – eight of them for detox – but they are regularly full of people from around the state. On a recent afternoon at Hoy, the waitlist for men was 28 people long.

“The services that are available work,” said Lauren Reichelt, head of the department of health and human services in Rio Arriba County. “Just not at a scale to meet the need.” {7}

Kudos to the Santa Fe Mountain Center and its efforts to distribution Naloxone, 3,000 units and 700 recorded

reversal, in one year. That means that four every 4 doses of Naloxone given out, 1 reversal was achieved. The death

rate did go down here some in 2016, perhaps because of their efforts. And yet it remains now 16 years later, by far, the

highest in New Mexico…This county has suffered long enough and if anywhere, why don’t we begin here?

“Sanches, still a certified paramedic, joined Rio Arriba County Sheriff James Lujan, U.S. Attorney Damon Martinez and other law enforcement leaders at a news conference in Albuquerque on Monday, announcing a program to help local agencies get funding to start carrying the overdose-reversing drug Narcan, also known by its generic name, naloxone. “Law enforcement is sworn to protect life, limb and property, and amongst that is dealing with the opiate crisis that is so prevalent right now,” Sanches said, highlighting the need for officers to carry and administer Narcan.

The antidote wasn’t around when he first started as a medical technician and the awareness surrounding the issue is long overdue. All 28 Rio Arriba County deputies have been `…. Despite the week presenting an opportunity for Rio Arriba County to highlight the fact that its people suffer from overdose rates well above national averages, the County did not participate in these events, did not host any events or make any official announcements…. “Every week is Heroin Awareness Week for Rio Arriba County government and has been for several decades,” Health and Human Services Director Lauren Reichelt wrote in an email Tuesday. “We’re glad everybody else in the country has caught up and realized.” She said her Department is working to develop a local diversion program and a provider network to get Narcan on the streets. In June, she started purchasing goods and services that will become the backbone of the Behavioral Health Investment Zone, paid for through the first installment of a five-year, $2.5 million grant from the state of New Mexico, meant to address behavioral health problems associated with drug abuse in the County…

Sanches said, at a minimum, and as soon as possible, the County needs a 100-bed in-house recovery facility. He said the entire north central region of the state has no recovery services after a program in Taos closed this summer, and the state as a whole, does not have enough space available for recovering addicts. “No change is ever going to occur until the people in power empower those who can make change,” he said.” {8}

Kudos to Ms. Reichelt and Officer Sanches, they get it…This story is not about Ms. Reichelt not attending the

promotional awareness week efforts. She has been on the front lines of this epidemic in the worst county in the

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state. Maybe she is tired of hearing all the pronouncements, proclamations, promises, and poor strategies that have not

worked. When everyone goes home after the awareness week, she faces more deaths. This story is about her seeing

that Naloxone needs to be on the streets of Rio Arriba County. And it is about a law enforcement officer who has

seen all the deaths and equipping the department with Naloxone. The story is about the fact that deputies just

started using the Narcan a month ago, in September 2016, in the worst epidemic at the county level in the United

States. It is about them already using it 5 times in a month, which would be 60 lives saved in a year’s time. And it

is about the fact that there is no safety net and treatment for these citizens after they overdose at ground zero in

New Mexico. That means they will be back and more Narcan is used to save their lives, again or they may just die.

I do not know why, with the money we have allotted for this state, that there are not construction companies

building a recovery hospital in the heart of Rio Arriba County right now, where it belongs, with the American and

New Mexican flags flying in front of it? All of these questions are really what needs to be studied, so why aren’t we?

Wouldn’t we want to know this most immediately, then fund and export these strategies to the rest of New Mexico? All we

know is what Cabinet Secretary Designate of the Department of Health, Lyn Gallagher states:

“We are working hard to reduce overdose deaths in New Mexico. The recent decrease shows we’re making progress, but we still have a lot more work to do,” said Department of Health Secretary Designate Lynn Gallagher. “The fact is, our state continues to suffer from drug abuse. One overdose death is one too many. And until we have zero fatalities related to drugs, we’re going to continue to do all that we can to address the issue with our partners.” {5}

The truth is the Department of Health does not really know why and I know more about what is not working in

the voluminous data than what does. But at least we have the same goal, “zero fatalities.”

The Behavioral Health Collaborative, headed by Wayne Lindstrom, PhD, who also an employee of the New

Mexico Human Services Division indicates in his annual report:

The Behavioral Health Collaborative administers a yearly $1M dollar federal grant:

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Mr. Lindstrom’s organization had to withdraw some initiatives that would have also been helpful for

opioid abuse reduction in general in New Mexico.

{9}

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The Rest of New Mexico: We also know where else there are serious issues with drug overdose deaths: {10}

Why this is 2014 data presented in 2016, I don’t understand? In any event, I suspect that the rates are similar

now unless there has been a community suddenly hit (like Lincoln County, see below) {} So, in the concern for

total overdose deaths, I am very concerned that Bernalillo and Santa Fe Counties are above the state average.

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This shows that Lomas/Broadway in Bernalillo County, the Agua Fria Neighborhood in Santa Fe County, McKinley

County, for example, are problem areas which will allow more targeting of efforts by area. This is very

important and excellent data, well done Dr. Landen and staff. I am also interested that Dona Ana

County, the second largest county in population in the state, and so near El Paso (see below) and the

Mexican Border, would have much lower rates, why? That’s worth a study…

The Native American Reservations. As with most every other Native American issue in the United States,

the Native American community is often forgotten and/or marginalized. For a culture and people who were in

New Mexico before most of the rest of New Mexicans by many generations, and only had illicit substances that

have turned into addictions in the last few generations, we must devote resources here if they are dying at rate

2 to 3 times the rest of us. And not that it should matter, but many Native Americans reservations are within or

near metropolitan areas where there is not a reservation hospital. So, they are often taken to New Mexican

hospitals, if we want to just look at the economic impact. There are some promising efforts: {73}

HHS Secretary Sylvia M. Burwell has made addressing opioid abuse, dependence and overdose a priority and through an evidence-based initiative focused on three promising areas: informing opioid prescribing practices, increasing the use of naloxone and using medication-assisted treatment to move people out of opioid addiction. The Obama administration is also committed to combatting the prescription drug and heroin epidemic, proposing significant investments to intensify efforts to reduce opioid use disorder…. The new agreement formalizes the partnership between IHS and BIA to reduce opioid overdoses among American Indians and Alaska Natives. In 2016, the more than 90 IHS pharmacies will dispense naloxone to as many as 500 BIA Office of Justice Services officers and will train these first responders to administer emergency treatment to people experiencing opioid overdose. The partnership will be reviewed annually by IHS and BIA and will continue as long as the agencies agree it is delivering the desired results. “I am deeply grateful to the IHS for working with us to create another level of safety throughout Indian Country for those trapped by the vicious cycle of drug addiction," said BIA Director Michael S. Black. "Law enforcement officers are usually the first responder to a drug overdose situation in a tribal community. This partnership greatly strengthens our public safety mission by enabling our BIA officers to take immediate action to save a life endangered by an overdose. ….an immediate action to save a life endangered by an overdose."

While I continue to stress within this paper that giving Naloxone to BIA officers is still not going to reach the users

themselves as effectively, it is much better than no Naloxone at all, and as first responders, it will, definitely, save

some lives. And again, we see the belief that the pharmacies should be the gatekeepers for Naloxone, based on an

assumption that is not working.

22

https://www.whitehouse.gov/ondcp/news-releases/2016-budget-opioid-resources

http://www.hhs.gov/news/press/2015pres/03/20150326a.html

http://www.hhs.gov/news/press/2015pres/03/20150326a.html


Also, critical to understand is exactly where the overdose death occurred and how often Naloxone was given by drug

type. Here is a study completed in 2012, by The Center For Disease Control, in New Mexico, by using the records of the

Office of Medical Examiner death records: {13}:

Of the 489 overdose deaths reviewed, 49.3% involved OPR, 21.7% involved heroin, 4.7% involved a mixture of OPR and heroin, and 24.3% involved only non-opioid substances. The majority of OPR-related deaths occurred in non-Hispanic whites (57.3%), men (58.5%), persons aged 40–59 years (55.2%), and those with chronic medical conditions (89.2%). Most overdose deaths occurred in the home (68.7%) and in the presence of bystanders (67.7%). OPR and heroin deaths did not differ with respect to paramedic dispatch and CPR delivery, however, heroin overdoses received naloxone twice as often (20.8% heroin vs. 10.0% OPR; p < 0.01).

•Most unintentional overdose deaths were due to prescription opioids or heroin.•Most overdose deaths occurred in the home, often in the proximity of family.•Decedents most often had a known history of drug dependency or prior overdose.•Heroin overdoses received naloxone twice as often as prescription opioid overdoses.

Fentanyl and Synthetic Opioids. As if it isn’t bad enough, new, even more dangerous and addictive, synthetic opioids

are being sold on the street of the United States, and New Mexico:

“…officials are investigating the deaths of at least 20 people who overdosed on the powerful painkiller fentanyl in New Mexico this year, apparently after taking what they thought was black-market oxycodone. The victims ranged in age from 17 to 63; 17 of the 20 were men. The price of oxycodone is normally $1 per milligram, or $30 for one 30-milligram pill, but the fentanyl pills have been sold for as little as $5 a pill around the country. The counties of residence of those who died were Bernalillo, Chaves, Lea, Lincoln, Colfax, Eddy, Guadalupe, Otero, Sandoval, San Miguel, Santa Fe, Valencia and one unknown. Fentanyl has long been prescribed for people suffering from chronic pain, often associated with cancer, but in recent years, fentanyl has shown up on the illegal drug market, leading to many overdose deaths in New England and mid-Atlantic states. There, the drug is often mixed with heroin by dealers to give their product an extra kick or to cheaply produce more usable heroin. Now the odorless white powder is being made into pills and passed off as another drug.” {14}

“…Drug Enforcement Agency agents say the pills were likely manufactured in Mexico using fentanyl powder from China that can cost a few thousand bucks for a kilogram and be turned into counterfeit oxycodone pills that can net traffickers millions of dollars. Toxicology tests in the 20 New Mexico deaths showed fentanyl and slightly different chemical versions of it, called analogs, which can be stronger than legally produced fentanyl and may take more naloxone (Narcan) to counter than it would to counter a heroin overdose…. If that scares you, and it should, consider the growing use of carfentanil, a synthetic anesthetic designed to tranquilize elephants and other large animals. It is not approved for use in humans, but drug traffickers are mixing it with heroin and it has become popular in some states among addicts looking for ever stronger highs. It has caused hundreds of overdoses and several deaths in states like Ohio, which has been particularly hard hit. Carfentanil is 10,000 times more potent than morphine and 100 times stronger than fentanyl, as reported by columnist Diane Dimond in a recent Albuquerque Journal article. So, we have Chinese chemists and Mexican drug pushers, to thank for introducing even more powerful ways to make obscene profits at American addicts. But part of the solution must lie with slowing the demand on the U.S. side of the border for high-risk drugs that damage and destroy lives and families. Which is why the HOPE (Heroin and Opioid Prevent and

23


Education) Initiative of the U.S. Attorney’s Office for the District of New Mexico and the University of New Mexico’s Health Sciences Center is so important. In addition to prosecution, its focus is on diversion, rehabilitation and re-entry programs and it is working with community organizations, such as the Bernalillo County Opioid Accountability Initiative. The fact that people are so addicted that they are willing to turn to knock-off drugs or buy pills they think – hope – are the real thing says a lot about how serious the drug epidemic has become. This is a new kind of drug war.” {15}

Well said, Albuquerque Journal, you get it. And these new drugs are inherently dangerous to everybody:

“Right now we’re seeing the emergence of a new class — that’s fentanyl-type opioids,” Dye’s boss, Jill Head, explained. “Based on the structure, there can be many, many more substitutions on that molecule that we have not yet seen. “Entrepreneurial” chemists have been creating designer alternatives to cannabis, amphetamine, cocaine and Ecstasy for years. But this new class of synthetics is far more lethal. Back in 2012 and 2013, when reports of fentanyl derivatives started coming in to the U.N. Office on Drugs and Crime in Vienna, chemists chucked them in the “other” category. Today those “other” substances are one of the fastest-growing groups of illicit chemicals tracked by the agency. “New opioids keep emerging,” said Martin Raithelhuber, an expert in illicit synthetic drugs at the U.N. They deserve their own category, he added, but that will take time. Once, forensic chemists like Dye confronted a familiar universe of methamphetamine, cocaine and heroin. Drug dealers, users and DEA agents generally knew what substance they were handling. Today, things are different. This is a golden age of chemical discovery — and subterfuge. Dealers may not know that the high-purity heroin from Mexico they’re selling has been laced with fentanyl. Users may not realize the robin’s-egg-blue oxycodone tablets they’re taking are spiked with acetylfentanyl. If field agents bust a clandestine drug lab and see a cloud of white powder in the air, they no longer assume it’s cocaine. They run.” {16}

So, our law enforcement personnel are themselves in danger of accidental poisoning and possible death in busting

these labs. If we are to be so unlucky as to come into a place with unknown white powder floating around, we can die on

the spot and we may not even be users at all. And here is China’s role with a link to our neighboring state, Utah, using the

internet to buy fentanyl:

“Baer said the DEA is actively investigating U.S.-based vendors who use dark net markets to sell fentanyl and related compounds, as well as Chinese companies that use U.S. servers to sell carfentanil. But the extent to which those U.S. companies are merely retailing made-in-China drugs is not clear. Baer said the DEA doesn’t believe fentanyl is mass-produced in the U.S., though authorities have uncovered mom-and-pop pill press operations. One of them was run by a 28-year-old in Utah, who was busted late last month with a pill press, piles of powder and cash, and nearly 100,000 pills laced with suspected fentanyl in his Cottonwood Heights home. According to the criminal complaint, the young man hired people to accept packages shipped to their homes, which they’d hand over, unopened. The packages came from China.” {16}

And the newest study, just released, from the Center for Disease Control on opioid overdose deaths, using 2015, data: {17}

“During 2015, drug overdoses accounted for 52,404 U.S. deaths, including 33,091 (63.1%) that involved an opioid. There has been progress in preventing methadone deaths, and death rates declined by 9.1%. However, rates of deaths involving other opioids, specifically heroin and synthetic opioids other than methadone (likely driven primarily by illicitly manufactured fentanyl) (2,3), increased sharply overall and across many states. A multifaceted, collaborative public health and law enforcement approach is urgently needed. Response efforts include implementing the CDC Guideline for Prescribing Opioids for Chronic Pain (4), improving access to and use of prescription drug monitoring programs, enhancing naloxone distribution and other harm reduction approaches, increasing opioid use disorder treatment capacity, improving linkage into treatment, and supporting law enforcement strategies to reduce the illicit opioid supply.

24


TABLE 1. Number and age-adjusted rate of drug overdose deaths* involving natural and semisynthetic opioids† and methadone,§,¶ by sex, age group, race/ethnicity, ** U.S. Census region, and selected states†† — United States, 2014 and 2015

Natural and semisynthetic opioids Methadone

2014 2015 % change in rate,

2014 to 2015

2014 2015 % change in rate,

2014 to 2015Characteristic No. (Rate) No. (Rate) No. (Rate) No. (Rate)

Overall 12,159 (3.8) 12,727 (3.9) 2.6§§ 3,400 (1.1) 3,301 (1.0) -9.1§§

SexMale 6,732 (4.2) 7,117 (4.4) 4.8§§ 2,009 (1.3) 1,939 (1.2) -7.7§§

Female 5,427 (3.3) 5,610 (3.4) 3.0 1,391 (0.9) 1,362 (0.8) -11.1§§

Age group (yrs)0–14 42 (0.1) 48 (0.1) 0.0 14 –¶¶ 13 –¶¶

–¶¶15–24 726 (1.7) 715 (1.6) -5.9 241 (0.5) 201 (0.5) 0.025–34 2,115 (4.9) 2,327 (5.3) 8.2§§ 796 (1.8) 735 (1.7) -5.635–44 2,644 (6.5) 2,819 (6.9) 6.2§§ 768 (1.9) 739 (1.8) -5.345–54 3,488 (8.0) 3,479 (8.1) 1.3 854 (2.0) 843 (2.0) 0.055–64 2,437 (6.1) 2,602 (6.4) 4.9 629 (1.6) 642 (1.6) 0.0≥65 706 (1.5) 736 (1.5) 0.0 98 (0.2) 127 (0.3) 50.0§§

Sex/Age group (yrs.)Male15–24 529 (2.3) 493 (2.2) -4.3 173 (0.8) 149 (0.7) -12.525–44 2,869 (6.8) 3,139 (7.4) 8.8§§ 969 (2.3) 926 (2.2) -4.345–64 3,015 (7.4) 3,095 (7.5) 1.4 808 (2.0) 777 (1.9) -5.0Female15–24 197 (0.9) 222 (1.0) 11.1 68 (0.3) 52 (0.2) -33.325–44 1,890 (4.5) 2,007 (4.8) 6.7§§ 595 (1.4) 548 (1.3) -7.145–64 2,910 (6.8) 2,986 (6.9) 1.5 675 (1.6) 708 (1.6) 0.0Race/Ethnicity**White, non-Hispanic 10,308 (5.0) 10,774 (5.3) 6.0§§ 2,845 (1.4) 2,725 (1.4) 0.0Black, non-Hispanic 814 (2.0) 878 (2.1) 5.0 256 (0.6) 247 (0.6) 0.0Hispanic 727 (1.4) 780 (1.5) 7.1 228 (0.5) 235 (0.5) 0.0U.S. Census region of residenceNortheast 1,851 (3.3) 2,095 (3.6) 9.1§§ 587 (1.0) 643 (1.1) 10.0Midwest 2,205 (3.3) 2,302 (3.4) 3.0 675 (1.0) 673 (1.0) 0.0South 5,101 (4.2) 5,374 (4.4) 4.8§§ 1,298 (1.1) 1,228 (1.0) -9.1§§

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TABLE 1. (Continued) Number and age-adjusted rate of drug overdose deaths* involving natural and semisynthetic opioids† and methadone,§,¶ by sex, age group, race/ethnicity, ** U.S. Census region, and selected states†† — United States, 2014 and 2015

Natural and semisynthetic opioids Methadone

2014

2015

% change in rate,

2014 to 2015

2014

2015

% change in rate,

2014 to 2015Characteristic No. (Rate) No. (Rate) No. (Rate) No. (Rate)

Selected states††

States with very good or excellent reporting (n = 21)Alaska 40 (5.6) 51 (6.5) 16.1 12 –¶¶ 10 –¶¶

–¶¶

Connecticut 157 (4.3) 183 (4.8) 11.6 50 (1.4) 72 (1.9) 35.7

Iowa 81 (2.7) 75 (2.5) -7.4 16 –¶¶ 24 (0.8) –¶¶

Maine 80 (6.1) 102 (7.7) 26.2 29 (2.2) 36 (2.8) 27.3

Maryland 388 (6.2) 398 (6.5) 4.8 153 (2.4) 182 (2.9) 20.8

Massachusetts 178 (2.6) 225 (3.3) 26.9§§ 88 (1.3) 82 (1.2) -7.7

Nevada 224 (7.4) 259 (8.6) 16.2 64 (2.2) 57 (1.9) -13.6

New Hampshire 81 (5.8) 63 (4.4) -24.1 29 (2.3) 25 (1.9) -17.4

New Mexico 223 (10.9) 160 (8.1) -25.7§§ 45 (2.3) 33 (1.6) -30.4

New York 608 (3.0) 705 (3.4) 13.3§§ 231 (1.1) 246 (1.2) 9.1

North Carolina 462 (4.7) 554 (5.5) 17.0§§ 131 (1.4) 108 (1.1) -21.4

Oklahoma 370 (9.6) 277 (7.2) -25.0§§ 67 (1.7) 62 (1.7) 0.0

Oregon 137 (3.2) 150 (3.6) 12.5 59 (1.4) 70 (1.7) 21.4

Rhode Island 70 (6.7) 95 (8.3) 23.9 24 (2.2) 30 (2.4) 9.1

South Carolina 319 (6.5) 322 (6.5) 0.0 77 (1.6) 57 (1.2) -25.0

Utah 367 (13.6) 357 (12.7) -6.6 47 (1.7) 45 (1.6) -5.9

Vermont 21 (3.4) 25 (3.9) 14.7 –¶¶ –¶¶ –¶¶ –¶¶ –¶¶

Virginia 323 (3.9) 276 (3.3) -15.4§§ 105 (1.2) 67 (0.8) -33.3§§

Washington 288 (3.8) 261 (3.5) -7.9 115 (1.5) 111 (1.4) -6.7

West Virginia 363 (20.2) 356 (19.8) -2.0 35 (2.0) 29 (1.7) -15.0

Wisconsin 279 (4.8) 249 (4.3) -10.4 78 (1.4) 73 (1.3) -7.1

States with good reporting (n = 7)Colorado 259 (4.6) 259 (4.5) -2.2 51 (0.9) 34 (0.6) -33.3

Georgia 388 (3.8) 435 (4.2) 10.5 124 (1.2) 115 (1.1) -8.3

Illinois 253 (1.9) 271 (2.0) 5.3 106 (0.9) 99 (0.8) -11.1

Minnesota 102 (1.9) 125 (2.2) 15.8 81 (1.6) 55 (1.0) -37.5

Missouri 237 (4.0) 237 (3.9) -2.5 53 (0.9) 62 (1.0) 11.1

Ohio 618 (5.4) 690 (6.1) 13.0§§ 107 (0.9) 109 (1.0) 11.1

Tennessee 554 (8.6) 643 (9.7) 12.8§§ 71 (1.1) 67 (1.0) -9.1

TABLE 2. Number and age-adjusted rate of drug overdose deaths* involving synthetic opioids other than methadone† and heroin,§,¶ by sex, age group, race/ethnicity,** U.S. Census region, and selected states†† — United States, 2014 and 2015

Synthetic opioids other than methadone Heroin

2014

2015

% change in rate,

2014 to 2015

2014

2015

% change in rate,

2014 to 2015

Characteristic No. (Rate) No. (Rate) No. (Rate) No. (Rate)

Overall 5,544 (1.8) 9,580 (3.1) 72.2§§ 10,574 (3.4) 12,989 (4.1) 20.6§§

Sex

Male 3,465 (2.2) 6,560 (4.2) 90.9§§ 8,160 (5.2) 9,881 (6.3) 21.2§§

Female 2,079 (1.3) 3,020 (1.9) 46.2§§ 2,414 (1.6) 3,108 (2.0) 25.0§§


Synthetic opioids other than methadone Heroin2014

2015

% change in rate,

2014 to 2015

2014

2015

% change in rate,

2014 to 2015

Characteristic No. (Rate) No. (Rate) No. (Rate) No. (Rate)

Selected states††

States with very good or excellent reporting (n = 21)Alaska 14 –¶¶ 14 –¶¶

–¶¶ 25 (3.3) 37 (4.7) 42.4

Connecticut 94 (2.7) 211 (6.1) 125.9§§ 299 (8.9) 390 (11.3) 27.0§§

Iowa 29 (1.0) 44 (1.5) 50.0 37 (1.3) 45 (1.6) 23.1

Maine 62 (5.2) 116 (9.9) 90.4§§ 38 (3.1) 52 (4.5) 45.2

Maryland 230 (3.8) 357 (5.8) 52.6§§ 313 (5.2) 405 (6.6) 26.9§§

Massachusetts 453 (6.9) 949 (14.4) 108.7§§ 469 (7.2) 634 (9.6) 33.3§§

Nevada 32 (1.0) 32 (1.1) 10.0 64 (2.2) 82 (2.7) 22.7

New Hampshire 151 (12.4) 285 (24.1) 94.4§§ 98 (8.1) 78 (6.5) -19.8

New Mexico 66 (3.3) 42 (2.1) -36.4 139 (7.2) 156 (8.1) 12.5

New York 294 (1.4) 668 (3.3) 135.7§§ 825 (4.2) 1,058 (5.4) 28.6§§

North Carolina 217 (2.2) 300 (3.1) 40.9§§ 266 (2.8) 393 (4.1) 46.4§§

Oklahoma 73 (1.9) 93 (2.4) 26.3 26 (0.7) 36 (1.0) 42.9

Oregon 33 (0.8) 34 (0.9) 12.5 124 (3.2) 102 (2.5) -21.9

Rhode Island 82 (7.9) 137 (13.2) 67.1§§ 66 (6.8) 45 (4.3) -36.8

South Carolina 110 (2.3) 161 (3.3) 43.5§§ 64 (1.4) 100 (2.2) 57.1§§

Utah 68 (2.5) 62 (2.3) -8.0 110 (3.8) 127 (4.3) 13.2

Vermont 21 (3.6) 33 (5.6) 55.6 33 (5.8) 33 (5.8) 0.0

Virginia 176 (2.1) 270 (3.3) 57.1§§ 253 (3.1) 353 (4.3) 38.7§§

Washington 62 (0.8) 65 (0.9) 12.5 289 (4.1) 303 (4.2) 2.4

West Virginia 122 (7.2) 217 (12.7) 76.4§§ 163 (9.8) 194 (11.8) 20.4

Wisconsin 90 (1.6) 112 (2.1) 31.3 270 (4.9) 287 (5.3) 8.2

States with good reporting (n = 7)Colorado 80 (1.5) 64 (1.2) -20.0 156 (2.9) 159 (2.8) -3.4

Georgia 174 (1.7) 284 (2.8) 64.7§§ 153 (1.6) 222 (2.2) 37.5§§

Illinois 127 (1.0) 278 (2.2) 120.0§§ 711 (5.6) 844 (6.7) 19.6§§

Minnesota 44 (0.8) 55 (1.0) 25.0 100 (1.9) 115 (2.2) 15.8

Missouri 109 (1.9) 183 (3.1) 63.2§§ 334 (5.8) 303 (5.3) -8.6

Ohio 590 (5.5) 1,234 (11.4) 107.3§§ 1,208 (11.1) 1,444 (13.3) 19.8§§

Tennessee 132 (2.1) 251 (4.0) 90.5§§ 148 (2.3) 205 (3.3) 43.5§§

Source: CDC. National Vital Statistics System, Mortality. CDC WONDER. Atlanta, GA: US Department of Health and Human Services, CDC; 2016.

26


https://wonder.cdc.gov/.* Rates are for the number of deaths per 100,000 population. Age-adjusted death rates were calculated using the direct method and the 2000 standard

population. Deaths were classified using the International Classification of Diseases, Tenth Revision (ICD–10). Drug overdose deaths were identified using underlying cause-of-death codes X40–X44, X60–X64, X85, and Y10–Y14.

† Drug overdose deaths, as defined, that have synthetic opioids other than methadone (T40.4) as contributing causes.§ Drug overdose deaths, as defined, that have heroin (T40.1) as a contributing cause.¶ Categories of deaths are not exclusive because deaths might involve more than one drug. Summing categories will result in a number greater than

the total number of deaths in a year.** Data for Hispanic ethnicity should be interpreted with caution; studies comparing Hispanic ethnicity on death certificates and on census surveys

have shown inconsistent reporting.†† Analyses were limited to states meeting the following criteria. For states with very good to excellent reporting, ≥90% of drug overdose death

certificates mention at least one specific drug in 2014, with the change in percentage of drug overdose deaths mentioning at least one specific drug differing by <10 percentage points from 2014 to 2015. States with good reporting had 80% to <90% of drug overdose death certificates mention at least one specific drug in 2014, with the change in the percentage of drug overdose deaths mentioning at least one specific drug differing by <10 percentage points from 2014 to 2015. Rate comparisons between states should not be made because of variations in reporting across states.

§§ Statistically significant at p<0.05 level. Gamma tests were used if the number of deaths was <100 in 2014 or 2015, and z-tests were used if the number of deaths was ≥100 in both 2014 and 2015.

¶¶ Cells with nine or fewer deaths are not reported, and rates based on <20 deaths are not considered reliable and not reported.

I am unsure why this data is showing a 25% reduction in opioid overdose deaths for New Mexico, when our data and press

conferences indicate 7.5% (?) I also note the 12% increase in heroin overdose deaths in New Mexico. I submit to you

again, we are at a real war, and we are being attacked by increasingly more insidious, habit-forming, overdose death

risk heightened, drugs, brought from around the world and within our country.

Cost/Benefit Analysis of Opioid Overdose Death. When we think of resources to fight this epidemic, we must consider

what we have already. Millions of dollars are poured in annually to address the problem in New Mexico. Criminal justice

and drug treatment organizations, emergency responders, community groups and activists who care about this issue and

want it changed, agencies and organizations already existing who can better address this problem by coordination

and non-duplication of efforts, and finally, most importantly, we have the citizens of New Mexico – the fathers,

mothers, brothers, sisters, neighbors, and even strangers of the opioid overdose victim. And we have the saved

overdosed citizens, who are an untapped resource in the opioid overdose death epidemic. I will focus now on the

economic costs of opioid overdose death in New Mexico because, in the end, we cannot put a price on the amount of a

saved New Mexico citizen who overdosed – not to his or her family, his friends, his community, and not to all citizens of

New Mexico. And I wonder if we collectively have decided that the death of an opioid overdose citizen is somehow

expendable, deserved, or just the acceptable risk results of drug abuse that cannot be changed.

27


So, if we want to do a cost benefit analysis of saving opioid overdose citizens from death from a strictly economic

point of view, the numbers are as follows:

The hospital costs of opioid abuse in New Mexico is $192M ($25B in the United States) each year which

equates to a cost of $92.00 for every New Mexican citizen each year. And these are very conservative

estimates. More recent data shows it to be $28B in the United States. {18} And fatal overdoses alone

account for $21B a year. {19}

The average United States cost of every emergency room visit where the overdose victim was treated and

released is $3,640 and if admitted to the hospital, $29,497. 59% of all overdose patients are admitted to

the hospital. [69]

Other societal costs include $5B a year in criminal justice costs and another $25B per year in lost workplace

productivity. (While there is a whole plethora of data and studies in New Mexico, I could not find this data for some

reason, specifically related to New Mexico). Newer data now show criminal justice costs at $7B. [19]

And this is every year….

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Statewide Naloxone Distribution. I submit to you that the best strategy for the cost is widespread Naloxone distribution

in New Mexico where it is most effective, in the hands of the drug users themselves. And this cannot be done, alone, by

pharmacies for several reasons:

1. How many citizens overdose on opioids in the parking lot of the pharmacy?

2. How many overdose at risk citizens are willing to go into a pharmacy, talk to a pharmacist, and then provide their

information which is then provided to a government agency? And how many families and friends? How many

concerned citizens, who just want to have Naloxone in case they come across an overdosing citizen, will go into a

pharmacy and ask for it?

3. How many, especially rural, overdose prevention citizens can even get to a pharmacy before the person overdosing

dies? What if they are elderly, cannot drive, handicapped, mentally unstable?

4. One big pharmaceutical company, is willing to donate Naloxone kits to every high school in New Mexico.

Have we done this? Apparently not. In addition, they provide a cellular phone application, for both Android

and Apple phones, that tells how to administer the Naloxone, safety information, education, even a video, and 911

call button- Free. And they are offering substantially discounted Naloxone pricing to law enforcement and

government agencies.

5. Opioid overdose abuse victims often take the opioid with at least one other person(s). [2] Often by the time

law enforcement or emergency services personnel arrive, the other person(s) have left the scene, afraid of the

repercussions of being arrested or involved with an overdose victim, especially if they die. What if these other

person(s) had a Naloxone kit with them, could administer the drug, and then leave the scene after calling 911?

And what is really, well, disturbing is, we began a Naloxone program in 2001 in New Mexico, from a recent

presentation made by University of New Mexico Project Echo:

“To respond to the highest per capita heroin- related death rate in the nation, NM passed the 1st law which funded statewide OD prevention and Naloxone distribution (administered by the NM Dept. of Health). The law directs the NM Dept. of Health to: “Develop a program to train lay persons to administer Naloxone to another person in case of opiate overdose.” {20}

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And this article from 2001, when the program began under Governor Gary Johnson: {21}

…a controversial package of drug-policy reform legislation introduced by New Mexico Gov. Gary Johnson in January, one law that passed without much of a struggle was aimed at increasing use of naloxone…Fear of infection also plays a role in the aversion to naloxone use, according to speakers at the recent Lindesmith Center-Drug Policy Foundation annual conference, held in Albuquerque, N.M. For example, overdose victims who receive naloxone require rescue breathing immediately after the shot is administered — a dicey prospect for police or even emergency medical personnel, who may fear infection with HIV or hepatitis via blood, saliva, or other bodily fluids…. But experts at the conference said that using a protective mask equipped with a one-way breathing tube and a plastic shield can minimize these risks. “I think the cops will use it if given reassurance by Emergency Medical Services,” said Dr. Steve Jenison of the New Mexico Department of Health. “It gets the job done.” Harder to overcome may be simple prejudice against addicts. “What I hear in conversation is that those lives are not necessarily valuable,” according to Maureen Rule, clinical advisor to Albuquerque's Health Care for the Homeless. “The response I hear is, 'So what if they die?’” But New Mexico Secretary of Health J. Alex Valdez asserted, “[Naloxone is] used for one reason and one reason alone, and that's to save lives. You can debate the use of naloxone, but if you value the life of a person regardless of his addiction to heroin — if saving a life has value — then it's worth $1.50.

The New Mexico legislation also protects individuals from civil liability or criminal prosecution for using an opioid antagonist, as long as they act in “good faith” and with “reasonable care.” Rule noted that prior to the legislation, “Doctors were reticent about anything that was outside the standard care, but now the law provides legal protection.” New Mexico officials said they want to see naloxone distributed via police to injection-drug users and their family members and friends throughout the state. And speakers at the drug-policy reform conference said that making naloxone more readily available nationally would help fight an explosion in opioid overdose deaths. The New Mexico legislation was sparked by the state's alarming overdose death rate, centered in Albuquerque and in Rio Arriba, the huge rural country stretching north from Santa Fe to the Colorado border. Jenison reported that between 1996 and 1998, the statewide incidence of fatal overdose from illicit drugs, primarily heroin, was 7.8 deaths per 100,000, nearly four times the national average. Populated largely by Native Americans and Mexican-Americans, Rio Arriba experienced a catastrophic 35 deaths per 100,000 population in 1998, and had at least sixteen overdose deaths in 2000. Bigg added — with deliberate ambiguity — that his program has been distributing naloxone “for a while” in Chicago to about 300 drug users, doctors and others. “Some doctors were involved who didn't want to be known, but now we have an 'out' physician,” he said. Among his clients, he reports there are “forty-three people who were blue and unresponsive who are alive today.”

Jenison reported that since discussion about naloxone heated up in January, “a dozen or so private physicians” in New Mexico have been prescribing it to users and their families in and around Espanola, Rio Arriba County's biggest city.But physician involvement in prescribing the drug remains scant in Albuquerque, Jenison said. In rural settings, such as Rio Arriba, experts noted, users are more likely to have a home to store the drug and access to a doctor. They're also more likely to have an intact family structure to watch over them and administer the drug, since, as Wayne A. Salazar, Espanola's chief of police, stated, “Heroin use is somewhat socially acceptable in the Hispanic community in Rio Arriba.” With 24 overdoses — including 8 fatalities — in his jurisdiction in the prior four months, Salazar would like to see his officers carrying naloxone by mid-July. He says he's already gotten positive feedback. “There's nothing more frustrating during an OD then waiting that eight to 13 minutes for the EMTs to show up and not being able to do a lot, all the family and friends crying all around you,” said Salazar. Of course, police are as helpless as ever if no one calls 911. Fearful of arrest, some users will actually let a companion die rather than call for help. Harm-reduction specialists counsel users on techniques for safely calling 911, but even so, getting naloxone into users' hands remains a huge stumbling block.

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Heather Meschery, executive director of the Santa Cruz Needle Exchange, noted that 11 percent of her clients have been arrested in conjunction with an overdose. And Salazar said his is one of only two police departments in New Mexico that doesn't arrest overdose victims. Salazar's do officers confiscate personal-use amounts of heroin found on the scene, and will investigate anything that looks like potential distribution. To counter this problem, advocates want to make naloxone widely available in the user community. The New Mexico law currently applies to licensed professionals with prescription-writing authority, but Cliff Rees, a lawyer for the state health department, said the regulations could be broadened by mid-September to permit any person to administer the drug without fear of liability. “It’s a goal” to have it in users' homes, Rees said. Bigg stated that users “have to discuss, plan and prepare for” use of naloxone. “And you have to have it around — you can't be hunting it down,” he noted. One couple, for instance, keeps an 'OD box' with a red cross on it. Of course, Bigg said, all bets are off for users who persist in using alone. Asked if naloxone might give users a false sense of security and thus encourage reckless drug use, Rule said, “Absolutely not — it's really unpleasant. It initiates withdrawal with such symptoms as cramping, sweats, vomiting, chills, loose bowels, aching bones and joints. It's like turning a switch.”

Wait a minute, we have had this program since 2001? With Good Samaritan protections? We were giving it to law

enforcement departments? There was a belief that it was important to get Naloxone in the hands of the users and

the individual homes? And Naloxone was only $1.50? What, When, Where? What have been the results, how

many lives have been saved? How many have been distributed and what has been the cost? And how many “lay

persons” have been trained to administer Naloxone? For the life of me, I cannot find one comprehensive study, date,

public comment, or promotion of this program (?) I submit that everything in this article about Naloxone getting into

the hands of the opioid users remains true today, the only thing that have changed is that the overdose death rate has

skyrocketed, Naloxone distribution in New Mexico, and in America, has lagged behind or been non-existent, and that

there have been millions and millions of dollars poured into research, education, prevention, etc. that has not produced the

results intended.

“Approximately 3,000 opioid overdose reversals were reported to the New Mexico Department of Health Harm Reduction Program through 2013” In the United States – from 1996 through July 2010 – opioid overdose prevention programs in 15 states (including NM) and the District of Columbia reported training and providing naloxone to 53,032 persons, resulting in 10,171 drug overdose reversals using naloxone: {22}

Really? 3,000 lives saved with Naloxone in New Mexico, where are the press conferences? Where are the pats on the

back, much deserved? Oh, wait, read the small print, the key word is “through” 2013. Ok, so that is still an average

of 250 lives saved every year of the program. And this also indicates, that for every 19 people trained to administer 31


Naloxone, and assuming they had Naloxone available, they saved 1 life. And for every 5 doses of Naloxone

distributed a life was saved. Why didn’t we, as New Mexicans, or in the United States, expand this exponentially in

any of the last 15 years of this program? I cannot find this answer in New Mexico or in the United States. And

remember much of this time was before pharmaceutical companies jacked the price up, before millions and millions of

dollars, spent each and every year on often meaningless research as it relates to opioid overdose death reduction, and, still

today, without a meaningful injecting of funding for this important and proven program. Alright, now I am just

downright mad, frustrated, ashamed of us as Americans, that this has continued to epidemic proportions right

through today. And I think of my fellow New Mexico citizens, Native Americans dying each and every one of these years

at rates 2 or 3 times over the rest of us, innocent high school and college students with their whole life ahead of them gone,

the citizens of Rio Arriba County and the fallout of death in those communities, and in every other crack and crevice of

New Mexico and the United States.

And the use of real stories of people who survived an overdose, prominently told, has a power much needed now at the

community level, regional, state, and national levels. We can use the media to sell increasingly new and questionably

effective pharmaceuticals and we do not have a campaign that is killing us every year at over 50,000 people?: {20}

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I am reminded of HIV/AIDS, which remains a serious issue right through today. I remember, in Indiana, when the

HIV/AIDS crisis hit, and the stigmas that were associated with it: drug users, homosexuals, etc. I remember a brave boy

stood up with his family, right there in Indiana, his name was Ryan White. He became, at least for a while, the face of the

AIDS crisis. I also remember as a kid when Walter Cronkite would, every day, list the soldiers who died in Vietnam. Who

are the faces of the opioid overdose death epidemic? The users themselves who have avoided an overdose death. And

what if, every day, we listed on National and New Mexico news, everybody we lost that day to opioid overdose abuse? We

need these faces for they educate the world that opioid overdose death can happen to anyone.

And our own New Mexico Department of Health’s State Health Improvement Plan 2014-2016, states:

“A public health, pain medication overdose prevention model based upon multi-sector partnership (hospital EDs, County law enforcement, managed care organizations, county health department, public insurance brokers, boards of medicine and pharmacy) with following components: (1) community coalition building, (2) monitoring and epidemiologic surveillance, (3) provider education, (4) naloxone (5) project evaluation

Evidence Based 69% reduction in poisoning mortality rate from 2009 to 2011; 15% reduction in substance abuse and overdose-related ED visits from 2008 to 2010 in Wilkes County, NC

“Increase access to overdose prevention education and naloxone for persons at-risk of misuse or overdose of their prescribed pain medication (Co-prescription Pilots).” {23}

More recently (and finally at least some data on Naloxone distribution in New Mexico):

“We’re encouraged, but we need more naloxone than this,” said State Epidemiologist Dr. Michael Landen. “Our goal is to get all pharmacies to stock naloxone.” …Prescription opioids accounted for about half of overdose deaths. Another 154 died of heroin overdoses. Thirty-five pharmacies submitted 285 Medicaid claims for naloxone from Jan. 1 to March 31, up from just 59 claims in the first quarter last year. Landen noted that the 35 pharmacies that submitted Medicaid claims account for only a fraction of the state’s approximately 300 pharmacies. Those totals also pale in comparison with the 1.75 million prescriptions New Mexico clinicians wrote for opioid drugs in 2015, according to the Department of Health data. …The state is encouraging the state’s 300 pharmacies to dispense naloxone to anyone with a prescription for narcotic painkillers. Pharmacy chains Walgreens and CVS recently announced plans to stock and dispense naloxone in New Mexico. Some Albertsons and Smith’s Food and Drug stores stock naloxone, and the state is in negotiations with Walmart to encourage the company to follow suit, Landen said. The state also encourages clinicians to co-prescribe naloxone to anyone with a prescription for a narcotic painkiller. For heroin users, the Department of Health last year distributed 7,186 doses of naloxone to people enrolled in the agency’s syringe-exchange and harm-reduction programs.” {24}

“…That number shows the state needs to step up efforts to curb addiction, including better monitoring of prescription painkillers, according to state Epidemiologist Dr. Michael Landen. He said New Mexico also needs to expand the use of naloxone, a prescription drug that can counteract a drug overdose, by making it more widely available to law enforcement officers and the public. Far more New Mexicans could have died last year without Naloxone, which was used successfully in over 900 cases… Prescription opioids – narcotic painkillers such as hydrocodone and oxycodone – remained the leading cause of overdose deaths in 2014, accounting for nearly half the total. Back-to-back declines in overdose deaths in 2012 and 2013 may have led to complacency about the problem, Landen said. “There was a lot of focus for a couple of years, and I just think some of the focus has waned,” he

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said. “We now need to redouble our efforts.” {25}

And the New Mexico Department of Human Services launches a public service campaign in 2016:

“Those huge ads on Albuquerque buses soon will include a pitch for a drug that can save lives by reversing the effects of an overdose. Advertisements for the drug naloxone, also known by the brand-name Narcan, also will appear at other city-owned properties, including bus shelters and community centers. The purpose of the public awareness campaign is to encourage anyone who keeps narcotic painkillers around the house, or has a family member who uses heroin, to keep an emergency dose of Narcan on hand. “The lifesaving potential of naloxone has not been well publicized until just recently,” Albuquerque City Councilor Diane Gibson said at a news conference Tuesday to announce the effort. Narcan “is available in many drug stores right now here in Bernalillo County,” Gibson said. “One of my goals is that every pharmacy in Albuquerque will carry it very soon.” Narcan is available at 22 pharmacies in Bernalillo County, including eight Walgreens stores, five Smith’s Food and Drug Centers, and a several independent drug stores. The city effort is part of a statewide public awareness campaign developed by the New Mexico Department of Human Services…. Narcan “is very safe,” said Jennifer Weiss-Burke, who lost her son to a heroin overdose in 2011. “You don’t have to worry about administering it the wrong way. You get a few minutes training on how to use it and you are good to go.” …State officials Tuesday said they don’t know how many pharmacies stock naloxone statewide. Gov. Susana Martinez signed a bill into law last month that expands access to naloxone by making it readily available to opioid users as well as to their families, friends, community groups and programs. The law also shields people who administer naloxone from civil liability or criminal prosecution. “If you have an extra glass of wine one night with your pain meds, you might overdose,” Weiss-Burke said. “Your family needs to understand that and know what the signs are.” {26}

Well said and well done, Ms. Weiss-Burke, and Human Services Division, a substantial forward step, almost there to

the solution… Alarming is that our state government does not know how many naloxone kits are in pharmacies in

New Mexico? Why not, are you not the distributor? Only 22 pharmacies participating in Bernalillo County, and only

35 pharmacies out of 300 in New Mexico, filing Medicaid claims for Naloxone. That’s only 10%, perhaps this should

not be optional. Perhaps it should be mandatory, Governor Martinez and the legislature, it is time to step in again.

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All of this effort towards the management of opioid prescriptions but not much participation and even worst results:

Percent Change in Filled Prescriptions, 2015 vs 2014Opioid Products

%Rank State Change

1 South Dakota -0.7%2 New Mexico -1.9%3 New York -2.7%4 Nevada -3.0%5 New Jersey -3.2%6 Arizona -4.5%7 Colorado -4.6%8 Washington -4.7%9 Georgia -5.1%10 Florida -5.3%11 Utah -5.3%12 Tennessee -5.3%13 New Hampshire -5.4%14 Iowa -5.6%15 North Carolina -5.6%16 Delaware -5.6%17 Wyoming -5.6%18 Wisconsin -5.7%19 Mississippi -5.7%20 Maryland -5.8%21 Pennsylvania -5.8%22 North Dakota -5.9%23 Arkansas -6.0%24 Illinois -6.0%

{27}

It appears to me that until all pharmacies are required to participate they are not going to participate. Well, so the

past is the past, I’m sure now there is better participation, now right? So, I thought I would find out in my own backyard,

Santa Fe, New Mexico. On January 3, 2017, I went to 4 pharmacies with the following results;

Walgreen’s – Cerrillos Road

I approached the pharmacy technician and said I needed some Naloxone. The technician and two others did not know what this was or what it was for. I educated them about opioid overdose and what this life-saving drug was for. The pharmacist on duty stepped in and stated that there was a standing order for the drug correctly and showed the technician how to write a prescription for it. I was next asked for my insurance coverage and I asked if I had to have insurance to get the drug. They said it could be sold to me without insurance so I presented my Presbyterian insurance card and was told that I could have 10 units for $10 or 1 unit for $10 (?) I indicated that I might as well take 10! (I will be donating the Naloxone to the best local distribution, in my judgement, to get it in the hands of users themselves.) I talked with the pharmacist and asked, “So if I had a guy overdosing in the car outside, would I have to go through this process before I could get the Naloxone. The pharmacist stated that he could administer it in an emergency. I then asked how many people have come in and requested it, either in an emergency, or for their family, friend, or as a concerned citizen, or for themselves. The answer was never and obviously there had not been even one case of an overdosed citizen being saved by coming to Walgreens. The pharmacist commented that he thought that the stigma of drug use prevents those who need it to come and ask for it. The pharmacist indicated that the only time it is distributed is when the referring physician who prescribes Naloxone along with an opioid prescription. He said that sometimes the customer will not take the Naloxone because they do not want to pay the co-pay from their insurance. I was given 10 one-dose vials of Naloxone and 9 nasal attachments form Amphastar Pharmaceuticals. I told the pharmacist that the new synthetic opioids are on the streets now and that it often required 2 doses of Naloxone to save the overdosed citizen. I asked if they were given any information to give the person requesting the Naloxone and he said there was none. I note the Amphastar box has some directions on usage but it does not say to

35


call 911 and get an ambulance there before or after the overdose citizen has revived. I asked what the cost would be for the 10 vials without insurance and was told it would be $370.00 which indicates that one vial would be $37.00.

CVS – Cerrillos Road

I went in to this CVS and asked the same questions at this pharmacy. They indicated that they had some and produced a box containing two vials with nose attachments within it, by Adapt Pharma (I note they only had one more box in the stock in the back of the pharmacy desk. The pharmacy technician looked up the directions on how to do the Narcan purchase. She indicated if I had insurance the cost of the Naloxone would be $37.50 but if not, $116.00. I asked if they had anybody asked for Naloxone for a family member friend, or as concerned citizen and they said they did not. I asked what would happen if I had an overdose victim outside in the car, could they just give me a vial to save his life? The pharmacist indicated that he would be able to administer the Naloxone in an emergency but I either had to buy it with or without insurance. The pharmacy technician said they had just started the program and were not familiar with it. I asked if they were given any information to provide with the Naloxone and they said they did not. I note the Amphastar box had much better instructions, including calling 911. I again educated them about opioid abuse and the new more powerful synthetic opioids that are hitting the streets. They indicated that their CVS instructions sell the two-vial set at $109.00 without insurance and that they had a coupon for $35.00 if I had insurance (?). When I tried to use my Presbyterian Hospital in their system, she indicated that the Naloxone was not an approved medication under my plan (?).

Highland Pharmacy (Across from Saint Vincent’s Hospital)

I went to this pharmacy and they said they had Naloxone. The technician indicated that they did not have any in stock but she could get it the next day. She indicated that they used the Alpha Pharma naloxone two-pack. She indicated that she has never had anyone request Naloxone for themselves or others and that if there was someone needing it overdosing outside, that the St. Vincent’s Emergency Room was across the street.

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Del Norte Pharmacy – Galisteo Street

The pharmacy staff here know the most about Naloxone and the pharmacist indicated that they did not have any in stock because the pharmaceutical provider, Amphastar, had defective sprayers, and the company removed all of them from the market. She stated that their order has been back ordered for months and they have none. Again, I educated them about the need for two vials per kit and they indicated that the Amphastar box has two vials, showing me a box. Unfortunately, they are incorrect, there is only a single vial in the Amphastar boxes. They gave me instructions for the Naloxone, a one page copied sheet of paper, which they said they received from the Southwest Care Center in Santa Fe. They have no idea when they will be getting any more Naloxone.

Smith’s Pharmacy – Pacheco Street

I talked with the pharmacy technician here who indicated that they had Naloxone ‘samples” which were provided by the Southwest Care Center in the summer of 2016 but they had to destroy these samples because they expired in January 2017. They have not received any more naloxone, have none available, and had not ordered any from any source. She indicated that they have nobody asking for it and have had nobody approach them with an overdose emergency either. {28}

Southwest Care Center is funded by the Behavioral Health Division of the Department of Human Services to:

“The Behavioral Health Services Division (BHSD) contracts with SW CARE to provide technical assistance to pharmacies related to naloxone. The goal is to increase access to naloxone by increasing the number of pharmacists credentialed to dispense naloxone, increase patient outreach and education about naloxone, and reduce pharmacy barriers to dispensing and billing for naloxone. Increasing access to naloxone is a strategy recommended by the Centers for Disease Control and Prevention (http://www.cdc.gov/vitalsigns/heroin/).

In addition to other community prevention efforts BHSD Office of Substance Abuse and Prevention (OSAP) also oversees two public awareness campaigns: Increasing public awareness of, and access to naloxone through a media campaign consisting of radio public service announcements, newsprint ads, billboards, and a resource website (http://doseofrealitynm.com/2015/08/31/more-info-aboutnaloxone/) Increasing public awareness of the dangers of prescription drug abuse through “A Dose of Reality” media campaign consisting of radio public service announcements, TV ads, newsprint ads, billboards, social media, movie theater ads, and resource website ( http://www.nmprevention.org/Dose-of-Reality/Home.html).” And they are award-winning for their “Dose of Reality” campaign, an award, really?

“The New Mexico Human Services Department’s (HSD) campaign to raise awareness of prescription drug abuse, called, A Dose of Reality, has been awarded the 2015 Silver Cumbre Award for public service campaigns from the New Mexico chapter of the Public Relations Society of America.”

As part of the campaign, three commercials designed to capture teens’ attention appear on youth-oriented programming on Comcast, YouTube, movie theaters, malls, billboards and gas pumps. Additionally, weekly posts are aimed directly at teens on Instagram with combinations of common hashtags kids use to research and share information about getting high. Advertisements on pharmaceutical drug bags promote safe storage and proper disposal, as well as a parent resource toolkit. All materials are available for download at Susana Martinez, Governor Brent Earnest, Secretary at http://www.adoseofrealitynm.com for use by parents and community members working on prevention. The campaign will also be featured in an upcoming “Better Call Saul” episode. The campaign is being funded by a grant from the federal Substance Abuse and Mental Health Administration (SAMHSA) Center for Substance Abuse Prevention (CSAP). The Cumbre Awards recognize outstanding strategic public relations campaigns and tactics by New Mexico’s communications professionals. {29}

While I understand the need to educate our youth about prescription overdoses, and their rate, especially among

females is rising, the mass amount of prescription overdoses is not with youth. Why wasn’t this campaign aimed at

the 75%+ of the New Mexico population who are overdosing? And again, has it been effective, have the overdose

death rates gone down? And how many Naloxone units did they actually distribute? Are they ever planning on

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http://www.nmprevention.org/Dose-of-Reality/Home.html)

http://doseofrealitynm.com/2015/08/31/more-info-aboutnaloxone/)

http://www.cdc.gov/vitalsigns/heroin/)


distributing some more? For Santa Fe pharmacies, and perhaps all 300 New Mexico pharmacies, certainly need

some along with education about what Naloxone is even for.

Southwest Care’s main thrust appears to be HIV/AIDS/Hepatitis, prevention and treatment. While, of course, related to

opioid abusers who contract these conditions as well, their website has no information on Naloxone, anywhere, yet they

are funded by the New Mexico Human Services Division for this purpose. {30}

I found they offered a training session in 2016:

Southwest CARE Center, with funding from the Behavior Health Services Division in New Mexico:Invite you and your Staff …

“A Dose of Rxeality - You Can Be Part of the Solution! Campaign”

Presented by: Karen Clark, PharmD, Staff Pharmacist, Southwest CARE Center, Albuquerque, NMCarly Cloud Floyd, PharmD, PhC, CACP, AAHIVP, Pharmacy Manager, Clinical Pharmacist, Southwest CARE Center, Albuquerque, NMKate Morton, PharmD, Director of Pharmacy, Southwest CARE Center, Santa Fe, NMCraig Schaefer, CPhT, Pharmacy Specialist, Southwest CARE Center, Santa Fe, NM

Date: Monday, May 2, 2016

Place: Southwest CARE Center – 649 Harkle Rd. NE, Santa FeTimes: Call or email to confirm times or to schedule future training dates.

RSVP: Contact Kate Morton @ 505-989-8154 or [email protected]

* Pre-Registration is required to guarantee your seat.

RPh Objectives # 0104-9999-16-028-L01-P CPhT Objectives # 0104-9999-16-028-L01-T

By the end of this presentation, pharmacists will be able to: Review the 2016 updated law regarding pharmacist naloxone prescriptive authority and Department of Health standing order

By the end of this presentation, pharmacy technicians will be able to:

Review the 2016 updated law regarding pharmacist naloxone prescriptive authority and Department of Health standing order and how this affects technicians in an outpatient pharmacy setting

Describe the different groups of people that come into the pharmacy who should receive naloxone

Identify good candidates for naloxone at the drop-off and pick-up windows, or by reviewing prescription profiles

Properly and efficiently adjudicate a claim for naloxone Properly and efficiently adjudicate a Medicaid claim for naloxone

Effectively and efficiently counsel a patient and family members on harm reduction strategies and naloxone use by using the demo kit(s) provided

Identify appropriate vendors for naloxone and mucosal nasal adaptors

The New Mexico Pharmacists Association is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a provider of continuing pharmacy education. This program provides 2.0 contact

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hours (0.2 CEUs) of continuing pharmacy education credit. The knowledge-based program is designed for pharmacists & pharmacy technicians. Participants are required to turn in a completed program evaluation form to receive the designated CEUs. Your CPE credits will be submitted into the CPE Monitor Database within 60 days based on the information provided.

ACPE Program # 0104-9999-16-028-L01-P/T / Initial Release Date: 5/02/16

And they are recognized as innovative in Naloxone distribution expansion:

“The increase in naloxone access can be attributed in large part to a novel pharmacist-initiated naloxone program. Since April, a group of pharmacists who are part of a nonprofit HIV/Hepatitis C clinic in New Mexico has been traveling to pharmacies in the state to train pharmacists to operate a naloxone program. “Even though we have this law in New Mexico, we didn’t see claims increase for naloxone, so we felt we needed hands-on training for pharmacists and technicians,” said Kate Morton, PharmD, director of Pharmacy Services of Southwest CARE Center, the nonprofit that provides the onsite training. She said many pharmacists intended to take advantage of the law but didn’t know how to develop a program or were too strapped for time to get one started. Providing hands-on, peer-to-peer training seemed like the most effective tactic, according to Morton. “People are really appreciative that we’ve come to them and taken the time, especially in the more rural towns,” Morton told Pharmacy Today.” {31}

And Ms. Morton writes, in her own editorial:

“Since April, nearly 200 outpatient pharmacists and their staff, representing more than 43 pharmacies in 20 communities throughout the state, have been trained on how to use patient demonstration kits and how to prescribe lifesaving naloxone to patients with an opioid painkiller prescription or their family members. New laws allowing for easier distribution of naloxone, including the naloxone prescription order from New Mexico’s Department of Health, have seen an increase in the number of Medicaid claims for naloxone. More than 77 pharmacies and 160,000 patients received their prescriptions in pharmacy bags with the Dose of Reality campaign message to promote the lifesaving benefit of naloxone. Collaboration must continue at the local and state level. The New Mexico Behavioral Health Services Division and the state Department of Health have received four federal grants to raise awareness about the dangers of sharing prescription drugs and reducing opioid overdose deaths, and expanding naloxone distribution and training first responders in high-need communities. This is the right direction for all of us. Accidental opioid overdose can happen to anyone. Protect your family by asking your pharmacist today about naloxone. {32}

It is apparent that the Naloxone distribution strategy providing it in pharmacies, is an utter failure and always has been, I

note the following problems and considerations with this strategy:

1. There appears to be no continuous source to even get Naloxone stocked in 3 out of the 5 pharmacies in Santa Fe,

with another pharmacy only having two boxes available. One pharmacy could get in 24 hours; another had been

given samples that expired 6 months later with no replenishment of their inventory. And no pharmacy had any

examples of anyone coming and wanting it as an emergency with someone overdosing nearby. If that did happen,

the pharmacists agreed that they could administer the Naloxone themselves.

2. The fact that a person must have insurance to get Naloxone meant a copay anywhere from a $1 a single dose vial

up to $37.00 for a single use vial. For a double-vial pack, one pharmacy had it for $37.00 with insurance and

$116.00 without insurance. So, the cost per 2 does vial ranges from $2 to $37.00 if you have insurance. They only

apparent time that it has been distributed was as a separate prescription by a prescribing doctor who was giving the

39


patient an opioid prescription in tandem. And it appears that at least some of these customers have refused to pay

the copay for the Naloxone, taking only the opioid prescription.

3. There has been little to no education of the pharmacy staff on the problem of overdose death in New Mexico nor

about the synthetic opioids requiring two vials to revive the overdosing citizen.

4. There is no marketing of Naloxone with any signs or indication that Naloxone is even available. So, nothing

like a poster that might say “Have a friend with an opioid problem?” and a description of the various opioids

including heroin and fentanyl, and the need for two vials. And some information about the cost of it with Medicaid

and conventional insurance coverage would also be important.

5. Nobody is coming in and asking for Naloxone, for those that have it prescribed and have insurance, at least some

won’t even pay a copay for Naloxone. Few claims for Medicaid for Naloxone are being filled. There is a stigma

with asking for Naloxone in a pharmacy setting.

6. There is no tracking and distribution management of the Naloxone. For example, if some of the Naloxone was

expiring in 6 months, that should be pulled from the shelves, and immediately distributed at the street level, where

it could be used the fastest, and before it expired.

7. There is some conflicting information about the storage of the Naloxone. None of the pharmacies had the drug in

any special temperature controlled container. The Amphastar box indicates it must be protected from light, stored

at 77 degrees Fahrenheit, that in transporting it, the range can be between 59 degrees and 86 degrees Fahrenheit. It

appears, however that, studies show that it is fine at room temperature and has been proven to be effective in high

heat and in very cold, Norway.

I cannot find how much Southwest Care receives annually for their Naloxone distribution and education program, as well

as their “Dose of Reality” campaign. It appears that there is grant for over $300,000 per year (see below, under “New

Mexico Funding”).

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Law Enforcement Agency Distribution. And expanding law enforcement agency availability of Naloxone, surprisingly

does not show a lot of “push back” from police personnel:

“The drug will even be distributed free at a health fair in Española on Saturday. Police agencies are getting on board, equipping officers with Narcan. Our goal is to ensure that all persons at high risk from prescription opioid overdose have access to naloxone and this can occur in many different ways,” said state epidemiologist Dr. Michael Landen of the state Department of Health.… But if your mental picture of New Mexico’s overdose problem is that of a junkie shooting up in an alley, you’re only partly right. Landen stresses that heroin overdoses are just the tip of the iceberg. “Heroin overdose deaths are a part, but not the largest part, of overdose deaths in New Mexico,” he said. Prescription opioids “are the major cause of our drug overdose epidemic in New Mexico at this time,” he said. The prescription drugs that most often are the cause of overdose deaths are painkillers like morphine, oxycodone and hydrocodone… We need to reduce the misuse of prescription opioids and assure that naloxone is available to persons at risk of overdosing, said Landen. Prescription drug users “are a different population than heroin users,” said Landen, but an overdose is an overdose...”

…A health fair Saturday sponsored by the Rio Arriba County Health Department will focus on gun violence prevention and include several classes “on how to recognize and intervene in a drug overdose,” said county health and human services director Lauren Reichelt. The classes are “for anybody concerned about a loved one in their environment at risk of overdose,” said Reichelt. The anti-overdose drug Narcan will be distributed free to attendees. “They just need to come” and no affidavit or application is required, said Reichelt. {33}

First, I have to say, that I would not like the job of Dr. Landen or Ms. Reichelt at ground zero of the problem in Rio

Arriba County, having to address and respond to this issue. Kudos to him and to Ms. Reichelt for also moving in the right

direction, yet you are not quite there…

“…State Police Chief Pete Kassetas has been studying the issue and sees no downside. A dozen or more years ago, some of the agency’s officers carried the drug but then there was a problem with temperature stabilization that has now been solved. “We are getting funding in place, training, then deployment,” said Kassetas. “So I foresee within the next three to six months we’ll be live in at least the first two counties and I want to make it a statewide initiative. “There is a cost to all of this stuff, but I think it is well worth it to give us the ability, because usually we are the first ones on scene….”

Kassetas agrees that administering Narcan appears to be a change in the law-enforcement mind-set. “Years ago, I think at least the State Police and law enforcement’s vision was that’s really not our job – we are law enforcement, we are not medical responders and we are not into treatment,” Kassetas said. “But I don’t believe that. We are there to employ life-saving measures, no matter what the situation is, and if we can be provided a tool, be it Narcan or the defibrillators we carry.” A month ago or so, Kassetas met with Health Department and community outreach folks from Taos and Rio Arriba counties. “They came to us and said we would like the State Police to carry this in Taos and Rio Arriba counties,” he said.”

The Santa Fe County Sheriff’s Office has never used Narcan before but, for the past couple of months, Capt. Adan Mendoza has been looking into it. “It’s a life-saving measure, it’s a life-saving tool,” he said. “Under very emergency type situations, extreme situations, Narcan can be a tool to save someone’s life that is possibly overdosing…” The pilot program would involve State Police officers carrying Narcan in Taos, Rio Arriba and Santa Fe counties, which is the state Department of Public Safety’s Region 7, said DOH’s Landen. But Kassetas doesn’t want half a solution. “I said, look, I think what is good for one county is good for all 33.” After

41


any liability and training issues are worked out, Capt. Mendoza of the sheriff’s office would like to see its widespread use in his jurisdiction. “I think our goal is to get it in the hands of every deputy that’s out on the streets,” said Mendoza. “At the minimum, we would want to start with maybe a pilot program with getting some kits out to part of our patrol teams, so a certain amount of individuals would have it. But our goal is to have every deputy have a kit while on duty.” The Santa Fe Police Department is also looking into whether its officers should have Narcan, and the associated cost and training issues, said an SFPD spokeswoman. {33}

And within 24 hours of the kits being handed out to the sheriff’s deputies, a life is saved:

“This incident is a real-life example of a situation that our deputies will be handling with this new program,” Santa Fe County Sheriff Robert A. Garcia said, “The overdose victim received the nasal spray dosage and within four minutes he became alert and communicated with Deputy Lopez, advising her that he had used heroin.” On Friday, the sheriff’s office announced deputies would start using Narcan when responding to drug overdoses.” {34}

Kudos to State Police Chief Kassetas, he sees the whole picture. The Santa Fe Sheriff’s Department and the Santa Fe

Police Department had never used Naloxone in the capital city, in a program that has been around since 2001? It took them

2 more additional years to get the program going at the Santa Fe Sheriff’s Department, not until 2016? And within 24

hours of implementation, a live is saved. Well, it is never too late, I guess….

Recently, in Lincoln County, where they suddenly had a rash of synthetic overdose deaths, the following statement

came from State Epidemiologist, Dr. Landen:

“…the standing order for pharmacists that was signed by Dr. Michael Landen, the State Epidemiologist on March 18, 2016, authorized pharmacists to dispense naloxone to “…any person who uses an opioid, regardless of how the opioid is used or obtained and any person in a position to assist a person at risk of experiencing an opioid overdose.” …Sheriff Robert Sheppard, who was in attendance, noted that the legislation was an unfunded mandate. Nevertheless, his department was looking into funding sources so that deputies and narcotics officers will be able to carry the drug in the field. In addition to the expense, there are other concerns including response time, shelf life and the fact that naloxone only works on opioid overdoses. “Narcan® is only good for three to four minutes after the overdose, so the timeframe is important,” Shepperd said. “We aren’t close enough to be right there. There are two or three agencies that have gone out and purchased this but they are in bigger populated areas, so their response time to these calls are a lot shorter than ours. They also have more people to cover [smaller] areas.” {35}

Sheriff Sheppard, while misinformed about the amount of time one can recover from an overdose using Naloxone (not

his fault), still gets it. It’s about response time, availability of Naloxone and who is going to pay for it (it is not an

unfunded mandate in my estimation), and the issue of large rural territories that must be covered. And why are

police agencies seeking out funding sources for Naloxone when it is available from the State Department of Health

and supposedly at some corporation and other pharmacies in New Mexico?

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And, in our second largest city, Las Cruces, well, not so much:

“Las Cruces Police Department spokesman Dan Trujillo said LCPD currently doesn’t carry naloxone. “We patrol within city limits, so it’s not necessarily something that would be a huge benefit for our officers to carry it, and the reason why is the (Las Cruces Fire Department) responds to nearly all medical calls as it is and are well-trained in the usage of it,” Trujillo said. Doña Ana County sheriff's deputies also do not carry the medication. Unlike paramedics and emergency medical technicians, deputies are not trained to administer medications, such as naloxone, department spokeswoman Kelly Jameson said. “Aside from that, we are usually the last to respond to a situation where Narcan (naloxone) would be necessary — fire and EMS are the first to arrive," Jameson said. Harrand said the majority of the state’s emergency medical services carry naloxone. “They are usually the ones that reverse an overdose in the field and then transfer patients over to emergency rooms, which are equipped with naloxone,” she said. “Our emergency departments are no strangers to treating opioid overdose.” {36}

It appears that Las Cruces Police and Sheriff departments are not definitely not on board. Dr. Herrand, from The New

Mexico Department of Mental Health, indicates here that a “majority” of emergency medical services agencies carry

naloxone, that can be anywhere from 51% - 99%, what is the percentage? It should be 100% (P.S. click the link for

this article and read the human-interest story {36})

Police budgets are already strapped and there is a shortage of police officers even on the job in New Mexico. Police

budgets are for law enforcement, not health issues. We need them for interdiction of these dangerous drugs, getting these

drugs off the street, and not responding to overdoses all over the territory when they could be responding to law

enforcement challenges in the community. I am not saying they should not have naloxone in their squad cars if they come

on to a scene with an overdosing victim. I’m saying we New Mexicans, at the community level, should be the ones

responding. “We are first responders.”

Other Organizations – Naloxone Distribution. It appears that New Mexico PMP program participation appears to be

minimal. And over 7,000 Naloxone doses distributed to program only participants. I’m not saying these participants are

not higher risk for overdose and they should not have Naloxone, they absolutely should. But if it has been being

distributed for years, and the death rate continues at the same rate, why? Because we are not addressing the ones

who are not in any programs and are not going into a pharmacy to ask for naloxone, ever. In our largest city,

Albuquerque, with a population of over 900,000, almost half or our state’s population, and we only have 22 participating

pharmacies? Perhaps it is time that participation by pharmacies is no longer optional. Naloxone was distributed to

heroin users who are enrolled in the Department of Health programs for syringe exchange and heroin reduction programs.

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We don’t know how many of these doses went to heroin users who have overdosed previously? By definition, these users

have to be already enrolled in the programs so these doses were given post, any overdoses or not, as a preventive measure

to stop a future overdose. A good start, but no indication how many Naloxone units were distributed in total in New

Mexico, with opioid prescriptions, or illicit opioids, where more than half of the opioid overdose deaths occur. And

Naloxone saved 900 lives in 2014, which lives we don’t know: where? what age, race, sex, what drug was used in the

overdose, were there any repeaters using Naloxone more than once, etc. Overdoses went down in 2012 and 2013 but we

don’t know why? And they went up in 2014 and 2015 and we don’t know why? The only answer we are given was

“complacency.” I’m not sure who Dr. Landen is referring to and I would like some research on that please, I am afraid he

might be right. And the health fair in Rio Arriba County, the ground zero of opioid overdose in New Mexico, where

Naloxone is, after a training class, distributed without any registration of who is receiving it is on the right track.

And even bigger step: Just hand them out to adults and teenagers who will take it with the instructions on how to

administer it in the kit including noting the cell phone application that has all the education and training on how to

administer it. You see, those abusing opioids, including heroin, are probably not going to sit through a class from a

government agency, just hand it out, no questions asked. And those whose family members, neighbors, partners,

etc. may not either because they are being seen sitting at health fair and taking a class on opioid overdose. Stigma is

stigma.

And it continues, now in Chaves County, part of the strategy, excellent, including a community consortium of individuals

and naloxone distribution, part of it very frustrating-why is the group having to find sources to procure Naloxone?, it

should be delivered by the New Mexico Department of Health in crates to these groups at that meeting, part of it is back to

what has not worked to meaningfully to reduce opioid overdose deaths, research, education and prevention, and finally

most of the grant funds will be used for youth prevention. Yes, don’t get me wrong, youth prevention of overdoses is

critical, but by far are not the age groups that are overdosing as delineated in this paper.

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“While the grant funds will focus on youth, health care professionals recognize that the problem of opioid deaths knows no age boundaries, and it has plagued the nation, state and county for decades. “Opioids cause the majority of overdose deaths,” said Landen, “and in New Mexico, most overdose deaths are due to prescription drugs.” {37}

One of the strategies shared with health care officials at the recent meeting was encouraging law enforcement,

health organizations and detention centers to obtain naloxone and distribute it or administer it to people they think are

either likely to overdose or in the midst of overdosing. The third strategy involves treatment and prevention, which has

many different aspects. Some efforts involve educating people about the risks of opioids and especially how dangerous

they can be when used in combination with alcohol or other substances.”

{20}

Taos Holy Cross Hospital has been distributing kits in the community:

John Hutchinson, PharmD, BCPS, is Director of Health Outreach for Holy Cross Hospital in Taos, NM. The 29-bed acute care rural hospital is the sole community provider and owns some physician practices. In 2008, New Mexico was the state with the highest overdose death rate, dropping to second highest in 2010 and third highest in 2012. North-central New Mexico, where Hutchinson lives, is the epicenter of drug overdose deaths in the state—most unintentional, and most from prescription opioids.

The whole community response, he explained, begins with limiting the volume of opioids in circulation through elements such as safe opioid prescribing (e.g., not concomitantly prescribing benzodiazepines and muscle relaxants, running a prescription drug monitoring report, urine testing for drugs); drop boxes and disposals strategically placed throughout the community; and prescribing guidelines in the emergency department. It continues with treatment and recovery, behavioral health, the courts, a strong 12-step community, and school-based drug prevention talks. “The solution has to extend beyond the walls of our institution, and so we’re trying to engage the community at large,” Hutchinson said.

In that big picture, naloxone can “keep people alive and get them referred to treatments, and get them help,” he continued. For more than a decade, the New Mexico Department of Health has dispensed intranasal naloxone as part of its needle exchange program. But in January 2013, Holy Cross Hospital started a community-based intranasal naloxone program that is funded by the state department of health. Led by Hutchinson,

45


the program aims to reduce prescription drug overdose deaths and to use the prescriptive authority for naloxone that New Mexico was first in the nation to grant to pharmacists.

In a collaboration among community pharmacy, hospital pharmacy, local physician practices, and clinics, intranasal naloxone kits are assembled by a pharmacist and dispensed to high-risk patients at the point of care. As Today went to press, approximately 130 kits had been dispensed since the program began, and four successful reversals had been reported—with none of the kits used on the person the kit was dispensed to. “When we’re dispensing these kits, these people are being educated,” Hutchinson emphasized. “The education piece is critical.” {38}

Kudos Mr. Hutchinson well said, he gets it. But even with this distribution, has the overdose deaths reduced in Taos

County? It does not appear so. The Colorado Consortium has a great program and they are currently raising funds to

provide Naloxone to law enforcement and first responders. Further research indicates they want to obtain $2,500 kits at

the cost of $187,500 which equals $75 per unit. {39}

The Harm Reduction Coalition is a consortium of agencies and individuals whose role is:

“The Harm Reduction Coalition is a national advocacy and capacity-building organization that promotes the health and dignity of individuals and communities impacted by drug use. Our efforts advance harm reduction policies, practices and programs that address the adverse effects of drug use including overdose, HIV, hepatitis C, addiction, and incarceration. Recognizing that social inequality and injustice magnify drug-related harm and limit the voice of our most vulnerable communities, we work to uphold every individual’s right to health and well-being and their competence to participate in the public policy dialogue.” {40}

This appears to be a very worthy organization and mission, and I am impressed with attendees at their International

Convention, these people are on the front lines of many issues which include opioid abuse, overdose, and overdose deaths

(see Appendix). They have devoted their lives to reducing these and many other issues and the stigma that comes with

substance abuse citizens. Says Ms. Tula:

“…in spite of all we’ve accomplished, we are seeing unprecedented rates of people dying from fatal opioid overdoses and people being ripped from their communities and incarcerated for drug-related crimes.”

Monique Tula, Executive Director {40}

As I read through the conference agenda and the workshops and panels at their recent national conference held in San Diego, CA, I saw the following:

New Mexico Naloxone Access: New Statutes to Increase Distribution by Non-Clinicians Dominick Zurlo, New Mexico Department of Health, Santa Fe, NMin November 2016, included New Mexico presentations on a panel entitled “Expanding Naloxone”:

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The Naloxone Buffet Phillip Fiuty, Santa Fe Mountain Center, Tesuque, New MexicoDave Koppa, Santa Fe Mountain Center, Tesuque, New Mexico {40}

The Santa Fe Mountain Center delivers over 3,000 units of Naloxone a year through a state grant at Ground Zero and on

the streets of Rio Arriba County communities. For them to speak about their experiences and effectiveness is without

question, and there has been death reduction there recently. And the Department of Health, with Mr. Zurlo, was speaking

about the new legislation which is innovative, but legislation with Naloxone distribution has no effect. I must say I am

troubled by our government presenting at national conferences as if we are leading the way on the issue of opioid abuse

and overdose death by how we have reduced its impacts but the previous year was the highest in New Mexico for opioid

overdose death. In 2015, the New Mexico Department of Health, presenting a Webinar where Naloxone is mentioned. It is

less than sterling about the Naloxone program itself, but the observations are very important – opioid abusers, when you

can even actually get them in a room somewhere, cannot and will not sit through education classes. {41}

Program started in 2001

Originally a 3-hour training – Some problems: ◦ Participants falling asleep ◦ Participants needing to use ◦ Too much information – cognitive overload!

In 2005-2006 the program started implementing a short 15-20 minute on the street curriculum – to meet people where they are!

◦ Basic information ◦ It is not overwhelming ◦ Handouts re-designed ◦More easily integrated into outreaches and clinics

And after that, in 2006, I find nothing in New Mexico about Naloxone as a strategy for years…. From “The Council of State and Territorial Epidemiologists” 2016 Conference in Anchorage, Alaska:

Monday, June 20, 2016: 11:15 AMTubughnenq' 5, Dena'ina Convention CenterSamuel L Swift, New Mexico Department of Health, Santa Fe, NMLuigi F Garcia Saavedra, New Mexico Department of Health, Santa Fe, NM

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BACKGROUND: From 2008 to 2012, American Indians and Alaskan Natives (AIANs) had the highest drug overdose mortality rate of any racial/ethnic group within the United States. However, there are counties in the United States where the AIAN drug overdose mortality rate is the lowest of any racial/ethnic group. We investigated the relationship between county-level demographics and drug overdose among AIAN peoples. County demographics may provide insight into potential protective or risk factors that are present in certain types of AIAN communities.

METHODS: We used an ecological study design linking county level demographics from the United States Census American Community Survey and the 2008-2012 national mortality file obtained from the National Center for Health Statistics (NCHS). Using four multivariable logistic regression models, we analyzed the impact of three county-level demographic variables on the drug overdose death rate among American Indians in the county: 1) the percent of AIAN persons living in a county, 2) the percent of persons living on tribal lands, 3) and classification as an Indian Health Service Area, and 4) all three variables together.

RESULTS: After adjustment for social and economic factors including poverty, educational attainment and Gini index, we found that percent of self-identified AIANs living within the county, percent of county population living on tribal lands were both associated with a reduction in the log transformed county level AIAN drug overdose death rates. CONCLUSIONS: The three measures we used to describe the types of counties that AIAN individuals live in are likely proxy measures for conditions in these communities. We believe that these measures may be proxies for community resilience, or community cohesiveness, which are things we are unable to measure with this type of study design. These proxies of social structure In AIAN communities (percent of AIAN living in a county and percent of county population living on tribal lands) were shown to be protective against drug overdose death. These results suggest that there may be factors in American Indian communities that may be protective from drug overdose. Further research is needed into the identification and bolstering of the protective factors intrinsic in AIAN communities. {42}

Wait, what? Protective factors from drug overdose in AIAN communities? And they are dying all through these

years at a rate of 2 or 3 to 1? And in 2016, one could argue convincingly that whatever “protective factors” they

have found in their study, are not working, period. Mr. Swift and Mr. Saavedra are using data that ends in 2012 (I tried

to find this presentation on the conference website and at the Department of Health, it is not available)? Have we even

studied what is happening NOW or even the last 2 years with Native Americans? Why didn’t you use the most

recent “New Mexico Substance Abuse Epidemiology Profile”? I think we know why, because the overdose rate

skyrocketed, including Native Americans, and they could not show that. The New Mexico Epidemiology Profile, Dated

January 2016, all the data is there through 2014,? Found at: https://nmhealth.org/data/view/substance/1862/ .

Deaths Rates*

CountyAmerican

Indian

Asian/ Pacific Islander

Black Hispanic WhiteAll

RacesAmerican

Indian

Asian/ Pacific Islander

Black Hispanic WhiteAll

Races

Bernalillo 19 9 23 456 396 918 14.0 9.2 23.0 29.1 26.4 26.9

Catron 0 0 0 2 5 7 0.0 0 0.0 83.3 49.4 56.3

Chaves 1 1 3 25 32 62 41.7 33.2 46.8 17.0 23.0 20.5

Cibola 2 0 0 6 9 17 4.2 0.0 0.0 11.7 27.9 11.8

Colfax 0 0 0 10 7 17 0.0 0.0 0.0 35.3 22.7 28.3

Curry 0 0 2 6 16 24 0.0 0.0 13.3 6.9 13.0 10.0

De Baca 0 0 0 1 0 1 0.0 0.0 0.0 40.4 0.0 18.6

Dona Ana 0 0 4 84 87 178 0.0 0.0 21.4 13.5 30.1 18.6

Eddy 0 0 0 19 37 56 0.0 0.0 0.0 17.0 27.1 22.1

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https://nmhealth.org/data/view/substance/1862/


Grant 0 0 0 16 17 33 0.0 0.0 0.0 27.0 28.3 26.7

Guadalupe 0 0 0 5 0 5 0.0 0.0 0.0 26.3 0.0 20.9

Harding 0 0 0 0 0 0 0.0 0.0 0.0 0.0 0.0 0.0

Hidalgo 0 0 1 2 6 10 0.0 0 1,344.0 17.1 71.4 46.1

Lea 0 1 5 13 39 58 0.0 57.3 37.2 8.8 28.6 18.7

Lincoln 1 0 0 9 20 30 27.9 0.0 0.0 33.4 31.3 31.8

Los Alamos 0 0 0 2 11 13 0.0 0.0 0.0 21.2 19.1 17.1

Luna 0 0 0 3 16 20 0.0 0.0 0.0 3.9 47.4 19.0

McKinley 29 0 1 8 7 45 12.5 0.0 45.1 19.2 16.4 14.0

Mora 0 0 0 13 0 13 0.0 0.0 0.0 80.0 0.0 67.9

Otero 4 0 3 19 39 66 17.6 0.0 28.1 19.5 21.5 20.7

Quay 0 0 0 8 5 13 0.0 0.0 0.0 45.9 23.1 32.0

Rio Arriba 10 0 1 126 10 147 35.5 0.0 116.3 95.2 35.2 78.4

Roosevelt 0 0 1 4 10 15 0.0 0.0 21.0 11.9 18.6 16.3

Sandoval 13 0 1 46 62 127 18.5 0.0 7.6 20.2 19.7 19.4

San Juan 29 0 2 17 63 111 14.1 0.0 53.4 16.4 21.1 18.2

San Miguel 0 0 0 46 7 53 0.0 0.0 0.0 41.5 24.7 37.1

Santa Fe 2 0 1 131 71 208 9.4 0.0 16.1 36.6 22.3 29.4

Sierra 1 0 0 5 20 26 96.0 0.0 0.0 31.0 53.6 44.6

Socorro 2 0 0 11 7 20 18.9 0.0 0.0 27.3 16.8 22.5

Taos 1 0 0 26 20 47 9.5 0.0 0.0 30.6 24.8 27.7Torrance 1 0 0 11 11 23 45.8 0.0 0.0 39.9 21.2 27.7Union 0 0 0 1 0 1 0.0 0.0 0.0 9.4 0.0 3.9Valencia 2 0 1 46 50 100 21.6 0.0 25.6 21.3 33.1 26.2New Mexico 117 11 49 1,177 1,080 2,464 14.1 6.2 22.7 26.0 24.7 24.3

I am all for collaboration around the country and finding out what others are doing to address this important subject. And

yes, New Mexico was the first to have a Naloxone program and had lead the way on other statutes which allow for more

Naloxone distribution. But that’s where it ends, there is no effective Naloxone distribution. And, let’s face it, if we

were #2 in the country in opioid overdose deaths in 2014, we should not be presenting at international conferences and in

an online Webinar, as if we had been successful in its distribution or the reduction of overdose deaths in New Mexico. It

analogous to NFL football coaches, the same coaches are moved around to different teams, paid astronomical salaries, and

they consistently have a losing record. I would much prefer our tax dollars be spent on Naloxone at the street level

instead of conference, airfare, and hotel costs.

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The New Mexico HOPE Initiative

Kudos to this community agency gathering of agencies in this effort:

“Increased Coordination among Law Enforcement Agencies, Improved Access to, and Onsite Delivery of Life-Saving Medication to be Announced-- First Event of National Heroin and Opioid Awareness Week to be held September 19

ALBUQUERQUE – U.S. Attorney General Loretta E. Lynch has designated the week of September 18, 2016, as National Heroin and Opioid Awareness Week, and U.S. Attorneys throughout the country are sponsoring events geared towards increasing awareness and developing solutions to the growing epidemic of heroin and opioid abuse in our country during the awareness week.

In New Mexico, the New Mexico Heroin and Opioid Prevention and Education (HOPE) Initiative, a partnership between the UNM Health Sciences Center and the U.S. Attorney’s Office, will host a series of education events during National Heroin and Opioid Awareness Week. Bruce G. Ohr, Associate Deputy Attorney General and Director of DOJ’s Organized Crime Drug Enforcement Task Force (OCDETF) Program, will participate in the HOPE Initiative’s events.One key component in the fight against addiction and overdose death is the availability of life-saving medications like Naloxone. Naloxone is a prescription drug that reverses the effects of an opioid overdose; it is easy to administer and safe to use. U.S. Attorney Damon P. Martinez and Dr. Joanna G. Katzman, Director of the UNM Pain Clinic, will launch the HOPE Initiative’s Naloxone Project during a press conference at 10:00 a.m. on Monday, September 19, 2016 at the Hotel Andaluz in Albuquerque, N.M. The goal of the Naloxone Project is to enlist law enforcement agencies throughout New Mexico to join HOPE’s life-saving efforts by implementing Naloxone protocols and carrying Naloxone. U.S. Attorney Martinez and Dr. Katzman will be joined by Bernalillo County Commissioner Maggie Hart Stebbins, Albuquerque City Council President Dan Lewis, Albuquerque City Councilor Diane Gibson, and representatives of law enforcement agencies that are carrying Naloxone, or are seeking to do so. Discussion details from this event will be posted to the NM HOPE Initiative website and available to the public at www.hopeinitiativenm.org [external link] .” {43}

While I also support all law enforcement agencies having Naloxone available in their cars, I still submit that they should

not be the ones on the front lines of its administration. It is us at the grass roots level.

The cost of Naloxone ranges from free to approximately $75 for a 2-nasal administration kit. There are also an

injectable Naloxone but it currently is at a far greater cost. It is not a controlled substance and cannot be used to get

high and is not poisonous. Safe administration applications, videos, pamphlets, and other advertisements abound.

And we have the Good Samaritan law to protect those who administer the drug to an overdose citizen.

New Mexico Funding. I guess, in the end, it always comes down to human and financial resources. In a time of shrinking

federal, state and local government budgets, there has been a great deal of funding for the opioid abuse and overdose death

epidemic to the State of New Mexico citizens. I know it must be someplace, but I cannot find in federal or state agency

online information on how these monies are spent in detail, nor any performance analysis of the use of these monies (?).

And I remind you, this is our tax dollars at work:

Federal dollars earmarked specifically for opioid overdose in New Mexico – $2,232,607. And this is supplementing funds from previous federal grants

also in New Mexico to the Department of Human Services, through the Behavioral Health Collaborative of $1M per year.

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http://www.hopeinitiativenm.org/


Federal dollars, the Center for Disease Control, 2015, earmarked specifically for opioid overdose in New

Mexico - $850,000 a year, for four years = $3,4000,000.

“This funding allows the New Mexico Department of Health to develop new partnerships with the Board of Pharmacy and the Workers Compensation Administration. It will increase our capacity to reach communities with a high overdose burden.” [44]

For the life of me, I cannot understand what opioid overdose death prevention has to do with the Worker’s Compensation

Administration, other than lost work time and productivity, but wait a minute, if they are already deceased, who cares

about lost work time and productivity? Perhaps, it’s more education…I need to be educated on this one.

Additional 2017 funding specifically for New Mexico, $2,500,000 +? “President Obama’s $1.8B package of additional funding to address Prescription Opioid Abuse and Heroin Abuse Epidemic, New Mexico,” [45], $5,000,000 +?

The State of New Mexico Funding:

While I have tried valiantly, I cannot find how much New Mexico tax dollars are spent each year on opioid abuse

and overdose death prevention, I tried the sunshine portal, I tried the Department of Finance Administration, etc.

but to no avail (if, and when, I find this information I will update this paper). However, with federal funding, I found

the following and I note I cannot find anywhere analysis of the effectiveness in the use of some this funding on the

TAGGS website {46}, Congressional Budget Office, etc. (not easy to find, wonder why?):

New Mexico Human Services Department Funding:

Prevent Prescription Drug/Opioid Overdose-Related Deaths (PDO)Organization: CENTER FOR SUBSTANCE ABUSE PREVENTION (Substance Abuse and Mental Health Services Administration)Type: Discretionary GrantAmount: $1,000,000

The New Mexico will implement the PDO program in high need communities in New Mexico. The project aims to prevent overdose death through the: 1) purchase and distribution of naloxone for overdose reversal, and; 2) training to a wide variety of first responders to administer naloxone. In this initiative, training of first responders will include not only law enforcement and EMT officials, but also family members, friends and social networks, and organizations that work with people with addiction and who may be a first responder in the event of an overdose, such as treatment providers and shelters. Strategies that integrate overdose prevention and naloxone as a harm reduction strategy into state and local treatment program strategies and settings, including the state's Medicaid managed care programs, will be used.

Great, earmarked for Naloxone! You know what? Let’s skip, “the strategies that integrate….” for that implies to

me more studies, data with no analysis, etc. The funding is discretionary. The harm reduction strategy is simple -

spend the money buying and distributing Naloxone and then studying the rate of overdose deaths over time given a

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continuous supply of Naloxone in New Mexico. The education on how to administer the naloxone is already

available to every New Mexican who has a cell phone. Not sure what the PDO Program is, but that is what it should

look like.

State of New Mexico SPF RxOrganization: CENTER FOR SUBSTANCE ABUSE PREVENTION (Substance Abuse and Mental Health Services Administration)Type: Cooperative AgreementAmount: $371,616

The New Mexico Human Services Department, will implement SPF Rx with the goal of increasing awareness of the dangers of sharing prescription opioids and of overprescribing prescription opioids. The purpose of this project is to significantly increase the awareness of the dangers of sharing prescription opioids and demonstrate how readily available they are in Bernalillo County. It aims to reduce the high volume of high-risk prescriptions dispensed in New Mexico, and work with a broad range of partners to develop recommendations about how to address the roughly 30,000 individuals in New Mexico who have a prescription for opioids for half of a year or more, putting themselves at high risk of addiction and increased risk of overdose. The state will expand its "A Dose of Reality" campaign, SAMHSA's Opioid Overdose Prevention Toolkit and the CDC Guidelines for Prescribing Opioids for Chronic Pain to further educate the public.

How many New Mexicans don’t already know about the opioid epidemic? How many do not know they can overdose on

prescription medication? What was the effectiveness of the “Dose For Reality” campaign we have already done on the

opioid overdose death rate (minimal to none…)? It reminds me of all the billboards telling us that DWI is wrong. I often

say, “Thanks for that billboard. It has reminded me that it is wrong to drink and drive, I had forgotten that.” And “The

Opioid Overdose Prevention Toolkit” is available online, downloadable to any computer or cell phone

http://store.samhsa.gov/shin/ .

New Mexico Department of Health and Environment (Department of Health) Funding:

NEW MEXICO PRESCRIPTION DRUG OVERDOSE PREVENTIONOrganization: NATIONAL CENTER FOR INJURY PREVENTION AND CONTROL (Centers For Disease Control)Type: KDA (KNOWLEDGE/DEVELOPMENT/APPLICATION)Funding: Administrative Supplement Discretionary or Block Grant - $953,074, 2016 Non-Competing Continuation - $856,313, 2016 Total: $1,809,387 (so far)

I could not find any abstract for the intention of this finding other than the title. The “Knowledge, Development,

Application” type implies to me more studies, research, with no analysis. Again, we have all the data we need, we know

who, when, where, and how they are dying of prescription opioids. If we want to stop overdoses, distribute

Naloxone.

New Mexico Project LAUNCH52

http://store.samhsa.gov/shin/content//SMA16-4742/SMA16-4742.pdf


Organization: CENTER FOR MENTAL HEALTH SERVICES (Substance Abuse and Mental Health Services Administration)Type: Substance Abuse & Mental Health Services: Projects of Regional and National Significance (Discretionary)Funding: $4,580,000 - 2009-2014

The State of New Mexico's Department of Health's Family Health Bureau proposes to develop and implement a demonstration project in the County of Santa Fe to promote wellness of children ages zero to eight years by coordinating key child-serving systems and integrating behavioral and physical health services. The project expects to significantly improve the outcomes of children from Santa Fe County's lowest-income highest-risk neighborhoods and advance the seven strategic goals of New Mexico's Early Childhood Action Network (ECAN): 1. FAMILY ENGAGEMENT: Strengthen the leadership of families with young children in policy development and implementation 2. HEALTH: All children, their parents, and all pregnant women have access to continuous preventative, acute, and chronic health care, including behavioral and oral health. 3. DEVELOPMENT: All developmental concerns of young children and their families are addressed prior to kindergarten. 4. EARLY LEARNING: High quality early learning and care meets the needs of all families and promotes optimum development and school readiness for children.5. INVESTMENT: Invest in young children and their families to promote healthy development and school readiness to improve the quality of life for all New Mexicans. 6. FAMILY FRIENDLY COMMUNITIES AND SERVICES: Family friendly policies and practices are implemented in communities, in business, in service, and in education systems. 7. PUBLIC ENGAGEMENT: The public actively embraces the importance of early childhood development and is engaged in supporting policies and programs at all levels that support children and families to thrive.

What? While the opioid abuse and overdose death rates skyrocketed in New Mexico, we spent $5.5M on one county

in New Mexico to implement “family friendly policies and practices.” Couldn’t find any effectiveness studies of the

project, but funding stopped in 2014, I wonder why?

The University of New Mexico Funding:

Let’s look at what the University of New Mexico receives in federal funding related to this issue:

Department of Psychiatry:

Comparing Interventions for Opioid Dependent Patients Presenting in Medical EDsOrganization: NATIONAL INSTITUTE ON DRUG ABUSETYPE: SCIENTIFIC/HEALTH RESEARCH (INCLUDES SURVEYS)FUNDING: $612,048 – 2013 $632,425 – 2014

$633,973 – 2015 $1,878, 446 TOTAL (So far…)

DESCRIPTION (provided by applicant): As addiction treatment becomes increasingly integrated into the medical care system, two models have rightly received a great deal of attention. The first is the use of SBIRT models to identify cases, provide therapeutic contact, and refer the more severe cases to longer-term care. The second is the treatment of addictions using medical models of treatment, including those that can be implemented in primary care settings. Much less attention has been paid to optimizing strategies for bridging the gap between SBIRT and more intensive/longer-term treatment for those on the severe end of the spectrum. This factor is of critical importance for opioid dependent patients, whose needs are not met by brief interventions or brief treatment. Emergency room interventions for substance use disorders have been largely limited to brief interventions/SBIRT models, and these have focused primarily on alcohol. Although there is a substantial literature documenting the value of case management in linking drug users to treatment, this approach has not been applied to drug users in the ED setting. In a sample of opioid dependent patients seen in a medical ED who are not currently engaged in treatment, this study will compare the effects of brief strengths-based case management (SBCM) and those of a brief intervention with booster sessions (BIB), based on Motivational Enhancement Therapy (MET), to the effects of screening, assessment and referral alone (SAR). These treatment models were selected because of their evidence base and because they are feasible to implement in the ED. Participants meeting DSM-IV criteria for opioid dependence will be randomly assigned (150 per group) to receive 1) the BIB intervention including a 30-minute motivational interviewing session in the ED, followed by two 20-minute booster phone sessions; 2) up to 6 sessions of SBCM based on the model previously implemented by Rapp and colleagues in prior studies; or 3) SAR. Staffs that are blinded to treatment condition will complete follow-up assessments at 3 and 6 months. Aims of the study are to identify the main effects of SBCM and BIB on substance abuse treatment initiation and engagement, use of opioids and other drugs, and broader measures of health and life functioning; to examine the interactions between treatment assignment and selected participant attributes in predicting treatment initiation, engagement, and substance use outcomes; and to examine effects

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of treatment involvement on substance use outcomes in the three treatment groups. The proposed study will be the first trial using a case management approach to link drug dependent patients presenting in EDs to longer-term addiction treatment. It will be one of the first trials focusing specifically on opioid dependent patients in medical EDs. A further innovative feature is that the case management approach will emphasize linkage to pharmacotherapy, and in particular will facilitate linkage to office-based buprenorphine for patients who desire this treatment.

Don’t we already know this in many other studies? The answer is yes. And were going to study “30-minute motivational

interviewing session” and following up with 2 “phone booster” sessions for opioid dependent patients? Please, these

are opioid dependent patients! And we do not have even any preliminary data to work with to see what has been effective

for this overdose death epidemic after 3 years? Wait a minute, we have no substance abuse treatment facility in Rio Arriba

County, and we have spent $1.9M on this study already? I don’t think so…

Division of Health Sciences:

Epidemiology, Prevention and Treatment of HCV in Young Adult Persons who Inject Drugs in non-urban New MexicoOrganization: NATIONAL CENTER FOR PREVENTION SERVICES (Center For Disease Control)Type: Cooperative AgreementFunding: $899,906 (2014-2016)

DESCRIPTION (provided by applicant): The hepatitis C virus (HCV) epidemic in the U.S. is concentrated in people who inject drugs (PWID). Increasing reports of HCV including outbreaks of HCV in young adult PWID in non-urban locales have prompted concerns about an expanding epidemic. Several investigations suggest that that these spikes in HCV infection are linked to sharp increases in prescription opiate use that has been trending in the U.S, and which have resulted in young adults transitioning from prescription opiates to injection use, particularly heroin. Young adult PWID in non-urban areas may be at increased risk of infection, from the combination of high viral infectivity and high prevalence of HCV in injecting groups, together with a lack of knowledge regarding infection routes and effective prevention. New Mexico is one of the states leading recorded increases in HCV in young adults, ranking 2nd in the CDC's Emerging Infections Program (EIP), Hepatitis Surveillance Demonstration Sites project, in 2011 for the number and rate of HCV cases reported. Heroin, prescription opioids, and other drugs are also accounting for this state having one of the highest overdose rates in the country. Between October 2013 and March 2014, the New Mexico Department of Health recorded 211 cases of HCV among young adults in a pilot surveillance study, demonstrating the gravity of the problem. To address the need for prevention, care and treatment services against HCV in this population, we propose epidemiological and service uptake research in two regions of New Mexico where young adult PWID have been impacted by drug use and HCV. We will initiate a prospective cohort study of young adult non-urban PWID who will be recruited and followed in two health regions of New Mexico (the South West and North East) to: (1) gather epidemiologic data on risk behaviors, drug use patterns, injection networks, prevention needs, and health service utilization; (2) to refer young adult PWID to HCV care services, as well as other prevention and treatment opportunities including harm reduction and drug treatment, and assess rates of successful linkage, including the cascade of care; (3) to examine factors that may contribute to non-treatment, poor adherence, and failure to achieve SVR among young adult PWID with chronic HCV infection; and (4) assess reinfection events among young adult PWID who are treated for HCV and achieve SVR. Our proposal, which we refer to in this application as New Mexico H-TIPS, will also include testing and referrals for HIV and HBV co-infections as well. A collaborative group of public health and clinical specialists linked with a strong prevention and clinical service infrastructure in New Mexico will ensure successful implementation of this research. Results from this proposed research will impact a diverse young population disproportionately at risk for HCV and reduce health disparities in a region highly impacted by drug use and HCV.

Ok, by itself, without the opioid overdose deaths epidemic, this study would be somewhat worthwhile. But don’t we

already know this information from other studies? And there were 211 cases of HCV in six months, or 422 annually in

rural areas, wouldn’t this study garner more information to gather youths injecting opioids in their own backyard,

Albuquerque, where half the population resides?

Pilot Study of Combined Treatment for Veterans with Chronic Pain & Opiate Misuse

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Organization: CENTER FOR DRUG EVALUATION AND RESEARCH (National Institutes of Health) Type: SCIENTIFIC/HEALTH RESEARCH (INCLUDES SURVEYS)Funding: $228,333 – 2014 $209,114 – 2015 $209,354 - 2016 $627,822 – TOTAL (So far…)

DESCRIPTION (provided by applicant): Opioid prescription in the treatment of chronic pain is frequent and carries a consequent risk of poor treatment outcome, as well as higher morbidity and mortality in a clinically significant number of patients, particularly those who meet criteria or opioid dependence. Despite the alarming increases (140% increase from 1992 to 2003) in prescription opiate misuse, abuse, and dependence nationally in the United States, there are few treatment options available that target both pain-related interference and opioid dependence among patients with chronic pain. In military veterans, this issue is of particular importance as numerous reports indicate increasing use of opioids in the treatment of chronic pain, as well as increasing opioid-related problems, specifically in those who served in the Iraq and Afghanistan theatres [Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND)]. To date, there are no evidenced-based treatment options which aim to both maximize effective functioning in Veterans with chronic pain while simultaneously addressing problematic opioid use. The overall aim of the present study will be to determine the feasibility of an integrated psychosocial treatment in veterans with chronic pain, who also have evidence of opioid-related misuse. To examine this aim, we will utilize a randomized design to assess the feasibility of integrating two empirically supported interventions: Acceptance and Commitment Therapy for chronic pain and Mindfulness Based Relapse Prevention for substance use and misuse. Feasibility will be assessed by examining rates of recruitment and retention of participants through a six month follow-up. In addition, we will evaluate progress within-treatment on specific therapy targets to aid in the identification of potential treatment mechanisms. The results of this study will directly inform treatment of chronic pain patients and represents a significant advance in the growing and understudied problem of opiate misuse among chronic pain patients. In addition to addressing the question of whether the treatment is feasible, it will further examine issues of treatment mechanisms to better inform the design of a randomized and controlled trial assessing treatment efficacy.

If there is ever a population that deserves the best when they are struggling with opioids are Veterans with, and without,

chronic pain. These men and women risked their life for our country. However, ACT therapy and Mindfulness relapse

prevention has also been around for years. Does it work for this population, or doesn’t it? And how much does it cost,

really, to determine if it works? If the overdose death epidemic in Veteran’s is the same, or higher, then let’s spend

some money on saving them first, and then on unfunded community treatment programs where they live.

ORGANIZATION: CENTER FOR NATIVE AMERICAN ENVIRONMENTAL HEALTH EQUITY RESEARCH (NATIONAL INSTITUTES OF HEALTH)RESEARCH STUDY:FUNDING: $700,00 2016 (So far…)

DESCRIPTION (as provided by applicant): The integrated approach described in the UNM Center for Native Environmental Health Equity (Native EH Equity) will for the first time address, across multiple tribes, disparities in social determinants of health, and tribal cultural and traditional practices with the potential to provide resilience to reduce the effects of environmental disparities on the health of Native Americans. The Native EH Equity approach, also for the first time, provides an integrative understanding of the generalizability of risk and resilience factors across multiple tribes - Navajo Nation, Crow Nation, and the Cheyenne River Sioux Tribe (CRST) - to improve both our understanding of these relationships, and our ability to develop and prioritize evidence-based risk reduction and prevention strategies. The focus of Native EH Equity will be to develop common data sets that for the first time will standardize our approach to assessing these variables across multiple tribes. Achieving these goals requires a strong administrative structure to ensure consistency across all components of the Center, to ensure parallel data are collected from each of the partner tribes, and that data are managed in a structure that ensures integration and allows comparative analyses. The Administrative Core (AC) for Native EH Equity brings decades of experience working with Tribal communities, leadership, and agencies; of managing and analyzing large and complex datasets; of oversight of career development programs; of integrative analyses allowing replication of findings with multiple levels of data; and of successful translation of results to enhance understanding in communities, among researchers, to federal agencies, and to health care providers. The goal of the Administrative Core (AC) is to facilitate responsible management, resource allocation, integration and communication within the team; to foster successful career development for new investigators; to provide and manage pilot funding; and long-term to develop sustainable partnerships integrated within the institutional and tribal structures to ensure sustainability of research on Native Environmental Health Equity.

FAMILY LISTENING PROGRAM: MULTI-TRIBAL IMPLEMENTATION AND EVALUATION

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NATIONAL INSTITUTE ON DRUG ABUSERESEARCH STUDYFUNDING: $677,496 – 2014 $584,115 – 2015

$591,687 - 2016 $1,853,298 (So far…)

DESCRIPTION (provided by applicant): With substance abuse concerns plaguing tribal communities, health preventive approaches for American Indian (AI) children need urgent attention. Mainstream programs fall short by failing to speak to AI children on their own terms. Not so with the Family Listening/Circle Program (FL/CP) which integrates an evidence-based family-strengthening core, with cultural values and practices for 4th graders, their parents and elders? Through previous Native American Research Centers for Health funding (Indian Health Service & National Institutes of Health partnership) the FL/CP was created and piloted by community-based participatory research (CBPR) partnerships between the University of New Mexico Center for Participatory Research and three tribal communities: Pueblo of Jemez, Ramah Band of Navajo and Mescalero Apache Nation. FL/CP fills a gap in substance abuse prevention by recapturing historic traditions of cultural transmission, such as family dinner story telling where elders connect with children, supporting enhanced child-family communication and psycho-social coping through traditional dialogue, indigenous languages and empowerment where children and families create community action projects addressing community substance abuse. With initial FL/CP pilot and feasibility research completed, Tribal Research Teams (TRTs) from the Pueblo of Jemez, Ramah Band of Navajo and Mescalero Apache Nation are now in place for full program implementation and effectiveness testing through a longitudinal quasi-experimental design involving a long-term, multi-tribal/academic research partnership. Under this five-year R01 effectiveness trial, tribal partners are committed to assessing the program's effectiveness and disseminating the approach and intervention within Indian Country as a best practice in reducing substance abuse health disparities, with TRTs collaborating on all research activities, implementation, interpretation/analysis, and dissemination plans. Three specific aims are 1) To rigorously test effectiveness of FLCP; with a comparative longitudinal design within and across the tribes, with 4th graders to prevent substance initiation/use and strengthen families; 2) Through CBPR, support TRTs to transform their research capacities into local prevention research infrastructures and partnering; 3) To assess additional program effects on other health/education programs and leadership within the tribes. In sum, this multi-tribal/academic partnership builds on accomplishments to test the effectiveness of an innovative intervention. This grant provides an unparalleled opportunity to reduce substance abuse in three tribal communities, strengthen tribal research capacities, and impact substance abuse prevention research designs nationally, by illustrating how CBPR processes can integrate evidence-based and cultural-centered practices to create effective programs that generate community ownership and sustainability.

Again, Native American communities, if not more than others, deserve our consideration and concern for the

“environmental disparities” on their health. And we have countless studies on their environmental disparities of

poverty, substance abuse, unemployment, effect of their incarceration in U.S. jails and prisons, threats to their

culture, etc. And now we are going to study Native American children communications on substance abuse… This

assumes that first, that Native Americans, aren’t already discussing substance abuse with their children and

grandchildren “at the dinner table” and in many other settings. And it assumes, I guess, that there is a better way to

communicate substance abuse issues to the children of Native Americans? I doubt it, and I find it insulting and

condescending that the University of New Mexico thinks they do. If Native Americans had real support on the myriad

of issues which cause endemic substance abuse and overdose deaths, then perhaps these conversations with their children

wouldn’t be needed. Oh, and it’s a five-year study, so expect to add at least $1M more. How about we do a study on

why they are dying 2 or 3 times the rate of other New Mexicans from opioid overdoses? How about funding

Naloxone distribution specifically on the tribal reservations and studying its effects? There will be more Native

56


Americans “to listen to” if they are alive! How about we provide funding to build treatment centers on the

reservation, run by Native Americans, using proven therapies, where they are taking care of their own people?

New Funding:

“In addition, the Department of Health and the Human Services Department announced in September that it had secured more than $11 million in grants to reduce opioid-related deaths, strengthen prevention efforts, and improve opioid surveillance data. DOH’s Epidemiology and Response Division also received two grants from the US Centers for Disease Control and Prevention, totaling $3.7 million over three years to aid in preventing prescription drug overdoses and to enhance tracking and reporting of overdoses; this is in addition to $3.4 million received in September 2015 over four years for preventing prescription drug overdoses” {47}

THE PRESCRIPTION DRUG OPIOID OVERDOSE PREVENTION GRANTS WILL PROVIDE UP TO $11 MILLION TO 12 STATES to reduce opioid overdose-related deaths. Funding will support training on prevention of opioid overdose-related deaths as well as the purchase and distribution of naloxone to first responders. Awardees are Alaska, Arkansas, Illinois, Missouri, New Jersey, New Mexico, Oklahoma, South Carolina, Washington, West Virginia, Wisconsin, and Wyoming. (SAMHSA) {12}

If my math is right, that is over $35M over the next four years, or almost $9M a year, and at least a part of that is

earmarked specifically for reducing opioid related deaths

Naloxone Distribution Support. I am not alone in this recommendation to increase Naloxone distribution, and in many

cases, it has been recommended for years:

Our own New Mexico Department of Human Services promotional information states:

“INCREASE ACCESS TO NALOXONE: Naloxone (also known as Narcan®) is a medication used to reverse an opioid overdose.

Naloxone Facts: Naloxone is FDA approved, since 1971. Naloxone is not a controlled substance. Naloxone is non-addictive. Naloxone can be administered repeatedly without harm. Naloxone has no potential for abuse. Naloxone could meet over the counter specifications” [22]

The New Mexico Department of Public Health also has a link to YouTube for a Narcan video, apparently from a Chicago

program. I wonder why we do not have our own video with the incredible amount of resources for opioid overdose

prevention already funded? [48]

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National Naloxone Programming. Let’s look are national research on Naloxone distribution studies and programs, and

perhaps, if we just did this, we would not have to spend any more resources on studies and research, it has already

been done and paid for by all American tax payers:

Our own New Mexico Department of Health in 2016:

“Increasing Naloxone Availability Helps Prevent Opioid Overdose Deaths” …In 2016, legislation passed that eases restrictions on possession, storage, distribution, and prescribing and administration of Naloxone, [49]

The National Institutes for Health in 2015:

“Existing research suggests that people who are at risk for overdose and other bystanders are willing and able to be trained to prevent overdoses and administer naloxone. Counseling patients about the risks of opioid overdose and prescribing naloxone is an emerging clinical practice that may reduce fatalities from overdose while enhancing the safe prescribing of opioids.” [50]

“Findings indicate a positive association between injection of prescription opioids and public health indicators suggesting a need for prescription opioid formulations that may inhibit injection of these medications.” [51]

The Journal for Substance Abuse

‘The highest levels of burnout, fatigue, and stigma regarding naloxone and opioid overdose were among nurses, EMTs, other health care providers, and physicians. In contrast, individuals who self-identified as “naloxone-trained” had the highest optimism and the lowest amount of burnout and stigma. Conclusions: Provider training and refinement of naloxone administration procedures are needed to improve treatment outcomes and reduce provider stigma. Social networking sites such as Twitter may have potential for offering psychoeducation to health care providers.” [52]

So, lay people who administer Naloxone have high optimism and low burnout rates. Wow, it is actually an optimism inducing act!

“Confidence improved significantly from pre- to post-training across both routes of administration (ps < .001). However, confidence was higher among those who were trained using the intranasal naloxone compared to those who were trained using the intramuscular injection naloxone at pre- (p = .011) and post-training (p < .001). Confidence increased from pre- to post-training in each of the participant types (ps < .001). Post-hoc tests revealed that confidence was higher among providers and friends/family members compared to “other” participants, such as first responders, only at post-training (p < .05). Conclusions: Opioid overdose trainings are effective in increasing knowledge and confidence related to opioid overdose situations. Findings suggest that trainees are more confident administering naloxone via intranasal spray compared to injection. Future research should attempt to identify other factors that may increase the likelihood of trainees' effectively intervening in opioid overdose situations.” [53]

And there are many, many, more, just do a Google Search….

And in Baltimore, another opioid war zone:

“BALTIMORE — After two decades of sending a needle exchange van around this city, officials here last year started doing something new. They wouldn’t just hand out clean syringes; they would distribute the antidote to the opioid overdoses ravaging local communities. When the van rolls through Baltimore these days, a member of the city’s health department teaches newcomers how to deliver naloxone, the life-saving medication that can reverse the effects of an opioid overdose, and gives them a free kit

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https://www.statnews.com/feature/opioid-crisis/dope-sick/

https://www.statnews.com/2016/06/03/narcan-naloxone-overdose-opioid/


containing two doses. Similar scenes are playing out at recovery centers, school orientations, and town meetings around the country as communities try to prevent fatal opioid overdoses, which quadrupled in the past decade and a half. Once a tool found mainly in ambulance and emergency departments, naloxone is increasingly being offered to the masses without prescriptions. Some advocates liken knowing how to use naloxone to knowing how to perform CPR, granting someone the opportunity to save another’s life. For at least two decades, advocates have pushed to get naloxone to people with drug addictions and their families, and in recent years, campaigns have focused on equipping police forces with the antidote. Those groups remain the main audiences for the efforts. But some initiatives are also trying to reach people regardless of whether they use opioids or know someone who does, just in case they find an overdose victim passed out in a car, unconscious in a restaurant bathroom, or dying on their own front lawn. Training sessions now include security guards, parking enforcement, and ordinary community members.

Here in Maryland, a change in state law allowed municipalities to issue their own standing orders, and Dr. Leana Wen, Baltimore’s health commissioner, signed one last year. Since the order took effect last October, the city has conducted about 15,000 training sessions for lay people, Wen said. The city also has an online training program. “I have Narcan in my bag right now, because you never know,” Wen said in an interview, using one of the drug’s brand names….In 2001, New Mexico changed its laws to make naloxone easier to get, and since then, every state except for Kansas, Montana, and Wyoming has altered policies to improve access to naloxone…“It might not be a friend or family member, but it might just be a person passed out at the bus stop,” said Evan Hoessel of Albuquerque Health Care for the Homeless, who has done trainings for church groups….

Shirley Buntain, a mother of four in Louisville, Ky., got trained to use naloxone last summer because she has a son who uses illegal substances. But she said she may have to save others as well and carries naloxone in a backpack wherever she goes. “I trained for him, but I also trained for the people who didn’t want to admit that their child had a problem,” said Buntain, 54, an office manager at a machine shop. “I went from being a mom who carried an EpiPen for a bee allergy to being a mom who carries an antidote. It’s not a place I ever imagined being in.” “That shit works wonders,” 30-year-old Andrew Chamberlain said one day last month as he left the needle exchange van here with clean syringes. “By the time you put in the second [dose], they’re jumping up.”Chamberlain said he had used naloxone several times in the past year on fellow drug users and got refills of the drug at methadone clinics, among other places. “I’ve used it three times in the past week,” chimed in a woman standing on the sidewalk, which was littered with needle caps. “Once in that alley, once in that alley over there,” she said, pointing to alleys into which some people vanished after they stepped off the van. The woman, combing her soaking wet hair, added: “I’ve had it used on me.”

People who are trained to use naloxone receive a card so they can get refills at local pharmacies.

59

https://www.cdc.gov/drugoverdose/epidemic/

https://www.statnews.com/2016/08/22/heroin-huntington-west-virginia-overdoses/


.

A man leaves the needle exchange van after getting clean syringes and learning how to use naloxone {{54}

Kudos to Dr. Wen, Evan Hoessel training church groups, Ms. Buntain, Mr. Chamberlain saving 3 people in one

week, and the unidentified woman who actually saved herself, they get it, and yet we are not distributing Naloxone

in New Mexico near enough as this article might be inferred….

And from University of New Mexico, Health Services Division, Project Echo, presentation in 2016:

“Expanding access to naloxone has been supported by:

U.S. Conference of Mayors (2008 Resolution) – sponsored by Santa Fe Mayor David Coss American Society of Addiction Medicine (Policy Statement 2010) American Medical Association (2012 Resolution) American Public Health Association (2012 Resolution) National Alliance of State and Territorial AIDS Directors (Testimony to FDA, April 2012) {20}

The New Mexico Medical Board Support. Minutes of the New Mexico Medical Board in November 2015 indicate the

following:

“Mr. Frank apprised the Board of Department of Health’s Naloxone Regulations. DOH has been working on increasing access to Naloxone, one issue is the storage and distribution of Naloxone. It is still considered a dangerous drug, not over the counter, but it appears to be relatively safe. One of the barriers is that the Pharmacy Board controls the storage and distribution of the drug. One option is to allow third party entities to store and distribute Naloxone. This would directly affect Board of Pharmacy regulations. The DOH has proposed that they will allow the third party to distribute Naloxone by DOH regulation. After discussion, the Board decided that this is a Board of Pharmacy issue, however the Board generally supports the proposed regulation.” {55}

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It appears, first, that there needs to be some training of doctors from the Department of Health about the incorrect

perception that Naloxone is dangerous and cannot be given over the counter. Second, it appears that the Department of

Health allows third party entities to distribute Naloxone. Finally, the Medical Board supports this option.

And then we have a step backwards from politicians like the Governor of Maine, not looking at the data, and making a

“kneejerk reaction and a deadly decision, although thankfully his veto was overrode by the Maine Legislature:

“Naloxone does not truly save lives; it merely extends them until the next overdose,” Maine Governor Paul LePage, wrote in April, when he vetoed a bill that would have made it easier to get naloxone (the legislature overrode the veto).” {54}

I am afraid that Governor LePage is touching on what is the background of this issue, drug abuse stigma and the

resulting implication-they are not worth saving, they are going to die anyway. It’s real this perception, it can’t be

underestimated, and yet I hope I have shown that even if you believe this, it is more cost effective to keep them alive.

So, Governor LePage, educate thyself:

“Public health advocates say such views reflect the stigma against people struggling with addiction; they also note that overdoes are often caused when users inadvertently take heroin laced with more potent opioids like fentanyl or carfentanil. But even if naloxone did encourage riskier behavior, experts say that it saves far more people than it could ever endanger. Cities and states report hundreds of lives saved each year. A A recent survey of 140 organizations found that lay people had reversed more than 26,000 overdoses from 1996 to 2014; more than 80 percent of the people who saved someone with naloxone were fellow drug users.” {54}

And, while I am thinking of it, let’s dispel some wrong information about Naloxone:

Myth #1: If you give an overdose antidote to drug users, they will abuse more drugs.Fact: Studies report that naloxone does not encourage drug use, and in fact, has been shown to decrease it in some circumstances. By blocking the effects of opiates, naloxone can produce unpleasant withdrawal symptoms, which nobody wants, especially not an active drug user. Myth #2: We can’t trust a person who is high to respond appropriately in a life-threatening situation.Fact: Since 1996, over 10,000 overdose reversals have taken place using naloxone. The vast majority of these were done by active drug users. Many of them were probably high. Myth #3: Naloxone will keep drug users from seeking treatment.Fact: Death keeps people from seeking treatment. Naloxone gives people another chance to get help if they choose, and often, the near-death experience of drug overdose and being saved with naloxone acts as a catalyst to encourage people to get into treatment. Myth #4: Naloxone makes people violent.Fact: There is some truth to this - but not much. While naloxone can cause confusion and “fight or flight” response when administered at high doses, in smaller amounts, naloxone rarely causes overdose victims to become combative.

Myth #5: Naloxone Can Give People Heart Attacks61

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6423a2.htm

https://www.statnews.com/2016/07/28/overdoses-elephant-sedative-heroin/

https://www.statnews.com/2016/09/29/fentanyl-heroin-photo-fatal-doses/


Fact: According to research in the American Journal of Public Health, “Complications such as seizures and arrhythmia have been reported after naloxone administration on very rare occasions. However, their links to naloxone have been questioned in the medical literature, and, even if there is a connection, it constitutes a risk only for patients with pre-existing heart disease... Similarly, in a study of 1192 episodes in Norway in which paramedics administered naloxone out of hospital, just 3 adverse events— or 0.25% of cases—were considered serious enough to require hospitalization.” Pulmonary edema has also occurred in overdose patients, but that is a result of respiratory depression, not naloxone administration. Myth #6: Intramuscular naloxone isn’t safe.Fact: Many people avoid intramuscular naloxone because it involves the use of a syringe, however, it is just as safe and effective as naloxone administered through other measures, such as intranasally. With intranasal naloxone, less is absorbed into the body which means it can be slower to take effect and is also less likely to cause withdrawal symptoms or induce combativeness. However, intramuscular naloxone has been shown to have a slightly quicker effect, which means that life-saving breathing function is restored sooner. Myth #7: Naloxone Loses Effectiveness Under High TemperaturesFact: Even after exposure to extreme temperature change, naloxone still works. In clinical studies, naloxone maintained a concentration 89.62 +- 1.33% even when subjected to ~21 and ~129 degrees Fahrenheit temperatures every twelve hours for 28 days. Nevertheless, it is recommended that naloxone be kept at room temperature and/or stored in UV ray resistant materials. {72}

And back in New Mexico, people are standing up. From Rio Rancho, a school board member stands up and demands

Naloxone and she states that the Albuquerque High Schools have no Naloxone program, I wonder if they know they can

get it for free (to be explained below)?

“If EpiPens can be used by bee-sting victims and others, including non-professionals, to combat allergic reactions, maybe the next step in treating drug overdoses from opioids is the use of naloxone. It’s not that Cullen has heard any high school in Rio Rancho has a plethora of opiate abusers. But if one life can be saved, how can that be wrong? “Rio Rancho Public Schools should lead by example,” she said. Albuquerque Public Schools doesn’t have a naloxone program. Finding funds could be problematic. Gov. Susana Martinez signed House Bill 277 into law on Feb. 9. It provides for the “authorized possession, storage, distribution, prescribing and administration of opioid antagonists; providing for immunity from civil and criminal liability; declaring an emergency. “Those last three words are the key.” Rio Rancho Fire Rescue carries the drug and, according to RRFD Dep. Chief Paul Bearce, “Naloxone has been part of the scope of practice for EMTs and paramedics for at least two decades. … We have used naloxone 48 times in 2016.” {56}

Well done Ms. Cullen, standing up, and Chief Bearce, for using Naloxone for over 20 years, saving 48 people in 2016. And Ms. Cullen, we will get free units in your high schools, very soon. And in Santa Fe County:

“Today Santa Fe County announces a new partnership with the Santa Fe Public Schools and its Santa Fe Prevention Alliance for the purchase and distribution of Narcan to first responders, the Santa Fe Public schools and community laypersons in Santa Fe County. The contract also includes provisions for opioid overdose prevention training and Narcan administration for first responders, people who use opioids, and family members who may be in position to witness and respond quickly to a drug overdose. The total amount of the contract is $100,000.” {56}

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I am not sure how much of those resources are going to purchasing Naloxone for the high schools, but, again, they can get

it free and they will have it for free very soon.

From the New Mexico Department of Human Services Division minutes in 2016, I note a very important observation

by Mr. Tom Starke of Recovery Santa Fe.:

“They worked very hard this year on trauma:

Most of these individuals they are trying to get out of the criminal justice system carry trauma from past experience and when they get into interacting with your agencies they are frequently re-traumatized by interactions with people and also because the systems are unaware they are carrying trauma. These systems can re-traumatize them and greatly reduce their ability to function and take advantage of the resources you are trying to provide them because, without realizing it, they are pulling these people's abilities to function way down (through these interactions).

Furthermore, people working in your organizations can be traumatized by dealing with these clients, and not realize it. A big source of burnout, people exposed constantly to trauma can catch it, it's almost like a virus, the frontline staff. They tried to get a SAMSHA training for all Santa Fe front-line workers, to train twenty trainers and have them fan out and train more. He asks you to consider all of your staff, not just those in Santa Fe but all over NM, whether to train that staff would be helpful. Thank you.” {58} Kudos to Mr. Starke, he gets it…. This is very important when we consider the Naloxone distribution strategy to law

enforcement officers, probation departments, courts, etc. And most important, they mention the burnout rate having to

deal with citizens in trauma all the time. These overdose citizens, who have had any contact with these agencies

may be traumatized and not reach out to them for Naloxone. Once again, the need for the general public providing

access to Naloxone.

Naloxone Cost: As it is often with these difficult issues, the argument eventually comes down to resources. Naloxone, an

antagonist agent that has been around since 1971, and at least some type of Naloxone program has existed since 2001 in

New Mexico at the Department of Health, I cannot find anywhere a cost benefit analysis study of any kind (?). On January

4, 2017, I talked with Dominick Zurlo from the New Mexico Department of Health, who was kind enough to immediately

provide me additional data about the Naloxone program, (I note that he adroitly suggested that I go to the New Mexico

Sunshine portal for budgetary and spending histories, however The Department of Health and The Human Services

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Division are not participating agencies, I guess transparency is optional for New Mexico State government agencies), he

indicated:

“Naloxone itself is purchased through the Public Health Division Pharmacy (because it is a medication) and the Atomizers are purchased through the Hepatitis and Harm Reduction Program. The Pharmacy retains these purchase records for a longer period,” Of course, The Public Health Division, is a division of Mr. Zurlo’s agency. Surely you talk to each other, don’t you? Do you do effectiveness and efficiency studies together?

Naloxone Atomizers

FY09 $29,932.30 N/A

FY10 $74,882.50 N/A

FY11 $34,261.50 $5,040.00

FY12 $29,881.60 $5,300.00

FY13$139,467.6

8$16,166.72

FY14 $8,677.36 $27,318.09

FY15$262,513.4

9$8,132.00

FY16$126,775.7

4$23,431.50

TOTAL$706,392.1

7 $85,388.31

Narcan nasal FY17

$110,791.68

“All of these purchases were made with state general funds, or with revenue generated by Medicaid billing for naloxone distribution (in FY15 and FY16), except in FY15, $80,000 of the purchases were made with funding provided by BHSD (Behavioral Health Services

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Department). This was the first year federal SAPT (Substance Abuse Prevention and Treatment) Block Grant funding from SAMSHA (Substance Abuse and Mental Health Services Administration) could be used to help purchase naloxone. The years listed here are all using the naloxone device which requires assembly of the medication into a syringe barrel and the attachment of an atomizer for it to be administered nasally. The purchase in FY17 is a new device from Adapt Pharma which requires no assembly. I’ve also attached the education sheet which contains the curriculum for both devices. It is titled: “Overdose Prevention 20 Min 11-15-16.” (See Appendix) While the cost of naloxone has increased over the years, the cost of the current device through a Government Interest Price is $75.00 for two doses, although this price can vary some at times. So, for example, in FY17, the NMDOH has purchased 3,000 doses so far. The NMDOH does not currently have any federal funding to purchase naloxone itself; however, BHSD does have a grant to do so over the next 4 years (they are a separate Department, so I do not have access to their fiscal information directly regarding how much they are planning on spending in future years).

I’ve also included our program Legislative Fact sheet which shows the overdose prevention work through the Harm Reduction Program. In addition, working with community partners the Epidemiology and response Division of NMDOH also began some programs to help increase distribution of naloxone through providers and other non-harm reduction type programs. So, the total amounts of naloxone dispensed/distributed from 2010-2015 breaks down like this for the two different divisions. You may notice a slight discrepancy in 2015 between this and the Legislative fact sheet graph. This is due to additional forms being submitted after the Legislative Fact sheet was produced (in October 2016). The following data is current as of today (however, may be changed based on additional submissions):2010: 13352011: 15802012: 30112013: 3813 (172 from ERD, which started that year)2014: 5879 (718 from ERD)2015: 7211 (414 from ERD)

Ok, lets take this this data, critically thinnk about it, crunch it, and see if it is effective and efficient. Please forgive me for the rudimentary spreadsheet below but I frankly do not have any more time to make it pretty (use your zoom function in MS Word to see more clearly), however it is critical that we understand what the data is telling us:

NALOXONE DISTRIBUTIONIN NEW MEXICO

An Analysis - Jan 2017

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NM NM NAX NM NAX NM NMNAX UNITS DISPENSED BY REPLACED BY NAX DEATH NAX UNITSDISPENSED: ENROLLEES: ENROLLEES: REVERSALS: PURCHASED:

? ? $29,932894 0.97 441 204 $74,8831179 1.17 401 128 $34,2621779 1.38 1232 455 $29,8821706 1.63 1935 709 $139,4682474 1.81 2687 844 $8,677

Data Received: 1/4/2017, NM Department of Health website, Various Divisions.Cost of Overdose death: The U.S. National Institute on Drug Abuse, Medical Care, News Release, Sept. 14, 2016

This data is for naloxone distribution to enrollees in the Department of Health program only. This means that the enrollee must sign up for the program which includes needle exchanges for opioid abusers. Therefore, Naloxone is distributed to an enrollee who is currently not overdosing, is an IV drug user, and perhaps, a higher risk for overdose and multiple overdose.

The costs of Naloxone distribution, staffing, travel costs, education, etc. is not included in this analysis, although negligible, when you consider the benefits and savings.

Reversals are only reported reversals by the enrollees themselves. Therefore, this number could be exactly accurate or even higher than what was reported by the enrollees. Given they are IV drug users, there is a higher chance that these users may have multiple reversals than opioid abusers only.

The calculations are based on this population and applied to this population only, IV drug users. The total cost of Naloxone, the number of units distributed, and the units replaced, and the resulting number of reversals may be higher or lower for the general opioid abuser population. We just simply do not know because we have no data on the total population of opioid abusers who use Naloxone for all prescription and illicit opioid abuse.

Some data I could not find after exhaustive research. General Data Analysis:

1. We can see the number of Enrollees in the program is expanding, almost doubling in CY 2016, that’s good. Why we are getting more enrollees I do not know? And if the Enrollees doubled, why didn’t the opioid overdose death rate only decrease by 7.5%? Because, while distributing to these users is important, Naloxone is not reaching the majority of opioid abusers and addicts.

2. The amount of Naloxone distributed is also growing in the last few years, that’s good as well. The average was 1.5 Naloxone kits per enrollee. About 66% of the distributions, were replacements, meaning that these Naloxone distributions were for a second kit or more. This means that, given by the number enrollees, many enrollees were getting more than one kit. Therefore, there were many who were taking more than one kit, and others who did not take any.

3. The amount of Reversals (those who were saved by Naloxone) also has increased, that’s great. However, in CY2016, when the amount of Naloxone distributed doubled, the number of Reversals went down, Why? This could mean that, in this population, there is point where the amount of Naloxone distributed has a diminishing return rate on Reversals in this population.

4. In CY 2014, one of the worst years ever for opioid overdose deaths, Naloxone funding fell 80% why?5. IN CY2011, CY2015, CY2016, the Reversals rate was substantially higher, what was the reason for this? This is

good. We need to know what was different in those years which saved many more overdose deaths.6. The Naloxone cost per enrollee was about $67.00. There was one reversal for every 5 Naloxone units

distributed. If New Mexico citizens paid themselves for the Naloxone (and they didn’t completely, but partially in their taxes), each New Mexico citizen would contribute $.00012 cents each. That’s right, that is a fraction of

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one cent per year. I’m willing to give one cent, how about you?7. The New Mexico economic savings was also $4B in eight years with a total of 13,058 enrollees. The savings

to each New Mexico citizen would be about $350 every year if the savings were distributed to them. Really, you mean distributing Naloxone would actually save me $350 per year, every year, if the savings were given to New Mexico citizens?

8. If we used this formula and sought to save all New Mexican overdose deaths, it would cost an additional $207,000, over eight years. If New Mexican citizens paid to save the overdoses themselves (and they don’t, except in their taxes), it would cost us each .02 cents each year. And if we saved all overdose deaths over the 8 years, it would have saved us $4B in economic costs. Ok, so your saying that if every New Mexican would have contributed $.02 a year during all this time, we could have purchased enough Naloxone if given to these opioid overdose abusers who died to (2961 deaths)? Yes, that is what I am saying.

9. If this model was expanded to include all deaths in the United States, would the results be similar? Yes, I am saying that, given the costs of an overdose death and the total population would be different, but it would still be a negligible cost to each American.

Why? Because there are relatively few deaths every year in comparison to the total population, Naloxone distribution is relatively cheap, if the Naloxone gets in the hands of the user and they use it in time-they live, every time. A high rate of return for a low cost.

By all accounts, Naloxone is a worthy, small investment….

Naloxone Distribution Partners. The providers for Naloxone, of which Mr. Zurlo directed me to the New Mexico

HIV/Hepatitis/STD online site, http://www.nmhivguide.org/ . (See Appendix) While I am not understanding why this

distributor information is not prominently available at the New Mexico Department of Health site, for those who need it

(opioid users and abusers) to find (and do, or do not have HIV/Hepatitis/STD), I am glad it is listed somewhere. At the

Harm Reduction site: https://nmhealth.org/about/, there are the various statutes and standing orders as it relates to

Naloxone as well as the three hour training required to be a Harm Reduction certified, https://nmhealth.org/publication/.

(See Appendix) While I applaud each and every distributor of Naloxone in New Mexico, and without them, certainly

the opioid overdose rate would be higher, it is still not enough to significantly change the opioid overdose death

rates in New Mexico.

Pharmaceutical Naloxone Providers. Certainly, the cost of Naloxone has skyrocketed in the last few years as it is

being used more and more to prevent overdose death in the United States . It is no different in New Mexico, and, at

least some pharmaceutical companies should have their feet held to the fire for doing this to the American people.

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https://nmhealth.org/publication/view/guide/2177/

https://nmhealth.org/about/phd/idb/hrp/

http://www.nmhivguide.org/search_results.php?city=&county=&regions=null&harm_naloxone=on&submit=go#results


Naloxone is cheap to produce and it could be provided as a public service to stop death from opioid overdose. And, of

course, a great deal of opioid abuse problem is overprescribing of prescriptions sold by the pharmaceutical

industry:

“Used to reverse the effect of opioid overdose, police and first responders have carried injectable versions of the drug for years. Demand has surged as the federal government and some states – including New Mexico – are adopting policies to combat the opioid addiction crisis through tactics such as dispensing naloxone with every opioid prescription. The 2014 development of a nasal spray form has further driven demand. However, the drug’s price has also risen steeply in the last couple of years: the most costly version, the auto-injector…The other side of rising drug costs: prices are rising faster than utilization... Increased demand and rising prices resulted in an over 250 percent increase in spending on naloxone from 2011 to 2015. Health Notes: Prescription Drug Costs Page 7 Evzio, was introduced in 2014 at $287, increased to $375 by late 2015, and has a current price of $2,250. Increased demand and rising prices resulted in an over 250 percent increase in spending on naloxone from 2011 to 2015.” {59}

Some pharmaceutical companies do have community grants and programs which can be used to help reduce the cost of

naloxone and educate the public. I have begun discussions already with several of them. Already, there is good news on

that front from one pharmaceutical company: They are willing to greatly reduce the price and provide free naloxone

kits to all high schools in New Mexico. I will be working very closely with this company. Kudos to this company,

they get it. They will make a profit for sure, but it’s a reasonable profit and at $37.50 a unit, well worth it. 24,000 deaths

a year (2013) divided by $25M = $1042.00 a life. And, of course. this $25M is for the whole industry with their high-

priced injectors for several hundred dollars. If we purchased them all from this company, I predict a price lower than

$37.50 from them with the increased volume, it could be much, much less. By making relationships with other state

programs distributing Naloxone, we could make regional or national purchase volumes. And maybe, just maybe, some of

the other companies might come down on their prices too. In Cleveland, injectable naloxone is at $12 a unit:

“Naloxone manufacturers have donated thousands of doses to communities and offer discounts to first responders, but the rising cost of the drug — combined with the rising need — has forced some programs to cut back on what they can buy. Emily Metz, who coordinates a naloxone training program in the Cleveland area, said the price of the nasal spray the program purchased has gone from $12 to $30 per dose in recent years. The program is switching to an injectable version it can buy for about $12.” {54}

Way to go Ms. Metz! I will be talking with her soon to find out who she is buying her Naloxone from! The Colorado

Consortium has a great program and they are currently raising funds to provide Naloxone to law enforcement and first

responders. Further research indicates they want to obtain $2,500 kits at the cost of $187,500 which equals $75 per unit

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http://www.healthy.ohio.gov/vipp/drug/ProjectDAWN.aspx

https://www.statnews.com/pharmalot/2016/06/07/naloxone-opioids-heroin-drug-prices/


(with perhaps two doses) which appears to be a common price. {39} And some companies have not gotten it – yet. Kaleo

Pharma and I will be in future discussions regarding their short-sighted response and the market they are actually missing:

“Whether naloxone manufacturers want to apply to make naloxone available over the counter is a different story. One of them, Kaleo Pharma, told STAT it has no plans to get its naloxone auto-injector approved for over-the-counter use.” {54}

What Should We Research and Study? I am suggesting we look at the following possible studies and see if they help

with our mission of reducing opioid overdose deaths (And forgive me if this has already been done, I no longer have

time for any more research, I have got to get funded and immediately to the streets of New Mexico.)

1. Why have Americans needed to take increasingly more pain medication without any real change in reported

pain? What is happening within the collective and individual psyches of Americans? {20}

2. What possible reasons would there be for different opioid prescribing levels by state, and specifically, in New

Mexico? {20}

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3. So, if we control the heroin addiction problem better we also address prescription opioids and cocaine addiction at

the same time? And our heroin overdose death rate continues to climb in New Mexico…. {20}

4. What are endemic factors that are causing this in America, and in New Mexico? Women, youth,

white, middle and higher incomes, those with private insurance are growing, why? {20}

17

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5. What are the psycho-social factors that are causing this specifically with Americans? We are creating the

market that is killing us. {20}

Americans use 80% of the global supply of opioids and 99% of

hydrocodone, but make up only 4.6% of the world’s population

Critical Thinking & Analysis. This is the hardest part of writing this paper for we as New Mexicans must take

responsibility for are actions, good decisions, inactions, and poor decisions in regards to the opioid overdose death

epidemic in New Mexico. We must all take our “lumps” for failed policy, strategy, and perhaps view when it comes

to opioid overdose deaths. I will start with an apology myself, as a New Mexico citizen and as an American, for

looking the other way for a long while (6 months) and not stepping up earlier to write this paper and to offer

solutions that could have been implemented earlier. New Mexico citizens died while I looked away and they

continue to die right now. As a former chief probation officer, and as a businessman, I have devoted most of my adult life

making a difference in addressing the ravages of substance abuse. This epidemic is unprecedented, and even in bringing

all of my experience with substance abuse to bear, while helpful, is still not enough for this is a new problem in America

never before seen. So, I am standing up now, having educated myself, and I’m saying, “no more will this epidemic

Institute of Addiction Medicine, Inc.

Institute of Addiction Medicine, Inc.

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continue to plague New Mexico.” But I need the help of many New Mexicans, many other Americans, it cannot be done

by me alone. Wait, maybe I am overreacting, maybe overdose deaths are not that concerning to New Mexicans?

{22}

1 in 5 New Mexicans know someone who has died of a drug overdose and 1 out of 2 New Mexicans know someone

struggling with a substance abuse problem and 80% are concerned about drug abuse? Nope we are informed and

concerned about substance abuse in New Mexico…

The Hard Truth: I am sorry to say it but we have been sold the proverbial “bill of goods” and we have paid for it

with our tax dollars when it comes to opioid overdose death prevention. For all New Mexico organizations and

individuals on the front lines of this epidemic, I am genuinely sorry, and thank you for the lives you have saved, and will

save, with your efforts. But unfortunately, you can only do so much with funds and staffing you have, the Naloxone you

have, or don’t have, and the myriad rules and regulations you are up against in trying to stem this epidemic overdose death

emergency tide.

1. We have not made opioid overdose deaths a real priority in this state and never have. We have had

millions of dollars thrown at it, duplicative research, poor strategies, no policy evaluation, innovative

legislation and laws, declared it a state emergency, and the death rate has remained essentially the same-

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with the solution in our back pocket since at least 2001. And again, until recently with the Obama

Administration, Representative Ben Lujan, Senators Martin Heinrich and Tom Udall’s efforts, it is the

same in America. If this is the real policy of the Martinez administration, then it is time to stand up, hold

a press conference, state the true policy, and accept the consequences. If these lives are expendable,

somehow worth less than any other deaths of our citizens in New Mexico, then we need to say it.

2. We have two state agencies, and subdivisions within, and the Governor’s office, who have been funded and

charged with addressing this issue. Yet I could not find one interagency joint press conference, with or without

the Governor, nor have I even seen one inter-agency press conference within the Department of Health where

there are at least 3 divisions involved in this issue, that shows me there is any joint effort to maximize the

pool of resources we have, focus it, and direct it to the problem strategically and efficiently. Dr. Landen is

right, there has been little to no study of the policies and responses to this issue. Our government doesn’t

know what to do, knows what we are doing is not working, and have not made a real effort to find out

why. And the answer is in their own data, they have control of the Naloxone, control of the funding, and

thus control of the death rate as it has stood and stands in New Mexico.

3. The federal government has poured millions and millions of dollars into New Mexico for this issue and I cannot

find where they did any accountability of how these funds were used and what effectiveness these funds have

produced. These are our tax dollars and, in the end, we have the say of how they are to be spent.

4. As far the Health Sciences Division at the University of New Mexico, ditto. Get out of your analytical

ivory tower, see the real issues, and use your multi-million-dollar annual grant funding to study what I

have suggested in this paper if you really want to address the overdose deaths. Redirect some of the

research funds you are using every year towards this issue specifically, purchase some Naloxone, find out

the barriers that are preventing them from using it, study the citizens who actually overdose and the

reasons behind the overdose, provide 2000 beds where they can be treated, and then study those results.

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Why do family members and friends pass along opioid prescriptions to those who do are then abusing it?

Why are Native Americans dying at a rate 2 or 3 times the rate of other New Mexico citizens? And the

big one: Why is Naloxone not effectively getting into the hands of the people who most need it, the

overdosing opioid abusing citizen? What is about Americans, and New Mexicans, where we are creating

the opioid market for prescription drugs that is killing our fellow citizens?

5. We have researched this issue to death studying demographics, locations, etc. and spent millions gathering it, in

triplicate, duplicating our efforts in government agencies, and with government funding. and then applying it to

no meaningful strategy or policy that will reduce these deaths. People are dying in New Mexico at an epidemic

rate and we are not responding to it well or, if, at all. The studies that really need to be done are not being done.

6. The strategy of providing Naloxone at pharmacies, where it is even actually there behind the counters,

has been a sham – we have no data that shows that it is even effective and I have shown many barriers

that make it ineffective. The fact that in the capitol of our State, not 15 miles from the seat of our

gubernatorial, legislative, and governmental agency power and funding, 3 out of 5 pharmacies have no

Naloxone, are uneducated about its ability to prevent deaths, and it is not promoted or marketed to the public

who needs it, is indicative of the true policy of this administration. You would think, at least in Santa Fe, for

appearance purposes at least, we would have Naloxone flowing into the community. And the Pharmacy

Prescription Management Program is important, in its current “optional participation” state, is also near

worthless. Until we order these pharmacies, all 300 of them, to participate fully in reporting opioid

prescriptions data, and providing Naloxone with every suspect or refill opioid prescription, we are

kidding ourselves. Until these pharmacies take an active role in educating the public about the problem,

telling them where they can have excess opioid prescriptions taken back and destroyed, and fully

reporting multiple opioid prescriptions by prescriptions physicians and by the customers receiving them,

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their effect is negligible. If this is truly a proclaimed emergency, then they need to be ordered to do this,

by law or executive order, Governor Martinez and/or the New Mexico Legislature.

7. You have got to ask yourself: “How did this Hallford guy get all this information, crunch the data, come

up with an action plan, and write this paper in 2 weeks? Why aren’t our agencies doing this already and

why haven’t they done this in the past?

So, we must look at our governmental agencies, the University of New Mexico, and what we can do with the federal

funding we have.

New Mexico Governor’s Office. I will begin by starting at the top, fellow New Mexico citizen and our Governor, the

Honorable Susana Martinez. And some of this also applies to our former Governor’s Richardson and Johnson, since

Naloxone existed, and we knew about it, and never used it meaningfully to address the continually rising opioid overdose

death rate in New Mexico. Governor Martinez stated, just a few days ago, the following:

“This is an issue that we’ve been focused on since day one of my administration. While we’ve made important strides, we still have a lot of work to do,” said Governor Susana Martinez. “One overdose death is one too many, which is why we’re going to continue doing everything in our power to end this epidemic.” {5}

I believe Governor Martinez when she says that this is an important issue and she recognizes it as an epidemic. She has

publicly declared is an emergency. As a former district attorney, she has also seen the ravages of substance abuse and

prosecuted drug dealers, and other substance abuse addicts, who were also criminals. And while there are certainly some

of these overdose deaths that are drug dealers and criminal/addicts, she knows that there is also a very significant

portion of these deaths who are not those people. Her administration’s own research, ad infinitum, has shown that.

There are many innocent victims who, had they not abused opioids or become addicted, had not, or would have not, ever

committed a crime. They are high school football players, a teenager on the swim team, college students, people

successful in their careers, people with chronic pain, the elderly, too many Native Americans, Hispanic, Black, and

White-they are just like us –they are us -New Mexican citizens.

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However, either she has been horribly misinformed by her staff and/or cabinet secretaries or perhaps she does not know

where significant, necessary, and just a part, of millions of dollars, that have not been directed strategically towards

stopping these deaths have been spent. Part of it has been spent on endless research, education and public service programs

which have not effectively produced significant results, and at least no visible analysis of what is, or is not, working. And

with our budget woes in New Mexico, every dollar counts. And I am sure she believes that she is ultimately responsible

in her position as Governor, the leader of all New Mexico citizens and our government, some who are no longer with us

due to this epidemic. But I am sorry to say, Governor Martinez, you were and are not “doing everything in your

power” to combat this epidemic.

We can look at Governor Martinez’s Executive Budget Recommendations:

Her 2015 EXECUTIVE BUDGET RECOMMENDATION Fiscal Year 2015 (July 1, 2014 - June 30, 2015) indicates:

Table 5 Performance Measures Summary and Evaluation

FY14 FY14 FY15 FY16 Target Actual Target

Output Number of naloxone prescriptions provided in conjunction with 1,000 154 500 opioid prescriptions.

Her 2016 EXECUTIVE BUDGET RECOMMENDATION Fiscal Year 2016 (July 1, 2015 - June 30, 2016) and in Fiscal Year 2017 (July 1, 2016, June 30, 2017) indicates: FY17 Target:Output Number of naloxone prescriptions provided in conjunction with 1000 opioid prescriptions. {60}

Apparently, the Governor reached only15% of her target for 2014 and then decided to not increase that target in

2015 (after the highest opioid overdose death rate in 2014) and then to increase its distribution to only 50% of her original

goal from 2014 in 2016 (?) She doubles it for 2017, 1000 Naloxone units to be provided with opioid prescriptions of

which there are almost 2 million opioid prescriptions in New Mexico every year? I’m sorry Governor Martinez,

1000 units is not going to do it, not even close…

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In my estimation, Governor Martinez needs to convene her cabinet secretaries in the Department of Health, Department of

Human Services, and the Department of Finance and Administration and their best analysts to gather the data that is

already there, strategically analyze it, and see what is possible, as I have done. This is not my data, it is our data, with

the answers right here from the citizens of New Mexico. She needs to find out why, in 2015, the death rate was the

worst after spending millions of dollars trying to address it. Next, she needs to convene bipartisan legislature leadership,

the University of New Mexico Health Sciences Division leadership, bipartisan state Senators and House Representatives,

federal agencies, public and community interest groups, and maybe even a few willing opioid-addicted New Mexico

citizens from Rio Arriba County, to learn one thing – why is Naloxone not getting in the hands of those overdosing

citizens who desperately need it and they, then die? That is, really, the only question. Or, save us all some time, and

maybe even some deaths and all the other cost savings that are possible, and implement the plan that I am proposing in this

paper immediately. We need the Governor, and the relevant state and federal agencies to work with us, providing us

funding and support, and working with the community level agencies also wanting to address this epidemic. We need to

join together, we can do this, now.

For some reason, there is a pervasive resistance, in the face of all the research that supports it, a refusal to get Naloxone,

en masse, out in the communities and tribal lands of New Mexico and most importantly, in the hands of the opioid

abuser themselves. She needs to use the power of her office to inform New Mexicans that this strategy is going to

save many lives, is very cost efficient, civilly responsible, and will “build community in the communities of New

Mexico”, New Mexicans taking care of New Mexicans.

The New Mexico Department of Health:

State Epidemiologist, Dr. Landen, has, while not, with perhaps epidemic haste in my judgment, been moving in the right

direction over the last 2 years. I believe he sees the issue with overdose deaths and has begun to call for changes. In May

2016, at the Prevention for States Awardee Meeting, he concludes and recommends:

Conclusions:

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Multiple overdose prevention bills may assure that something passes PMP bill probably would not have passed without naloxone bill Starting with strongest language might be best Compromising later helped PMP bill Overdose prevention community support essential Abuse deterrent opioid bill failed this session Policy evaluation has been an afterthought

Recommendations: If major issues with naloxone access exist, consider naloxone standing order legislation or equivalent. Any PMP mandate legislation may be helpful if subsequent board rules are required and a minimum standard

for checks is set. The overdose death epidemic is evolving and policy must constantly evolve too Begin planning for policy evaluation as early as possible. {61}

Kudos Dr. Landen, well said. We haven’t studied what works or doesn’t work, we need statewide and community

level support, and he is speaking specifically about overdose death prevention. But then we have this, in June 2016,

where we are, once again, promoting distributing Naloxone to only 10% of the pharmacies in New Mexico, and as if

increasing distribution here, will be effective as the “ideal setting for both patients and families to access Naloxone,” with

no data to prove it, and actually, plenty of data that disproves it:

“…There were only 59 naloxone claims provided via Medicaid from pharmacies in the first quarter of 2015. …Overdose death impacts every community in New Mexico and requires community-wide efforts and collaboration to combat this epidemic,” said Department of Health Secretary Designate Lynn Gallagher. “Pharmacies provide an ideal setting for both patients and families to access naloxone and overdose prevention education and this is a great example of how multiple community partners can participate in reducing overdose deaths.”

While this recent increase in pharmacy-based naloxone is encouraging, the naloxone Medicaid claims came from 35 pharmacies across the state. This represents only 10% of all pharmacies in the state. In order to continue to increase the availability of naloxone and increase the number of pharmacies dispensing naloxone, the Department of Health and the Human Services Department are working with pharmacies across the state to implement the statewide standing order for naloxone.” {62}

Sorry, Secretary Gallagher, you are very, very mistaken. If you are speaking about Southwest Care Center’s effort

through the Department of Human Services, I don’t think so. And really, that does not matter - It is not getting in the

hands of the end user… efficiently and effectively, NOW.

My Recommendations:

Convene a statewide overdose death prevention policy task force. Have it staffed with the people on the front

lines of this issue, Rio Arriba County, tribal authorities, legislators, emergency services personnel, ER

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doctors, UNM Project Echo physicians, opioid overdose citizens who are still alive. I’ll be happy to chair it

and lead it.

Redirect and use your funding for massive Naloxone distribution, placed strategically in the hands of the

opioid abusers.

Redirect dollars into opioid addiction treatment, providing inpatient beds in areas like Rio Arriba County,

outpatient therapist, invoke the national guard to augment law enforcement interdiction efforts, and go after

the distribution level dealers of this poison

The New Mexico Department of Human Services:

This department is managing at least a $1.3M annual package to be utilized for Naloxone distribution and

marketing. Your efforts in this capacity have been less than acceptable. Naloxone is not in pharmacies, your

marketing efforts have had little to no effects, and your partner, Southwest Care is not doing what you contracted

them to do. You have done studies already done by the Department of Health and you have done no analysis

worthwhile to figure out what does work to stop this death epidemic. And I do not see you working with the

Department of Health in tandem on this issue. You need to do what is necessary to get Naloxone in the hands of as

many opioid users, and abusers, period. Marketing is about educating the public at the grass roots level on this

issue, pharmacies are not the ideal place for distribution or education, and you can educate the whole state quickly

through effective computer and cellular phone mediums. You, and others, must get your “hands a little dirty” and

get on the streets, in communities, in small towns, and the farms of New Mexico. If you will work with Stop OD,

Inc., we can get this done efficiently and effectively.

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FINDINGS:

Hopefully, I have shown the following with the data and research on opioid overdose deaths in New Mexico:

1. Almost all that we have done, and are doing, on this specific issue, have not effectively reduced the death from opioid overdoses. We are also up against an epidemic never before seen, and we must do our best to respond. We are losing over 50,000 lives each year.

2. All of our research and data generation has not been effectively analyzed and a comprehensive policy developed. We know who, what, when, where, and how of the opioid abuser who overdoses and dies. But we do not know what to do that is most effective.

3. While we have had multi-million-dollar funding to address the issue, we have not used it wisely or well. We have a university that is out of touch on this issue, and using millions of dollars that could be used to address the opioid abuse crises directly.

4. We have known about Naloxone since 2001, and, while the use of it is now finally increasing, we have not used it enough to reduce the deaths.

5. We have a belief that distribution on Naloxone is best done through pharmacies and through law enforcement agencies and first responders. This is not the best solution. It is to get it directly into the hands of the opioid abuser themselves and to those who are with them: fellow abusers, family members, friends, roommates, neighbors, strangers. It must be distributed for free, anonymous, and without barriers to finding it in the community.

6. We can maximize the benefit and use of Naloxone through strategic marketing, inventory control, distribution strategies, and reduce the cost per unit.

7. We must ask for the help of our fellow New Mexicans to address this issue at the community level. And studies are showing that those who save the life of another brings them optimism.

8. Saving each and every one of these deaths will not happen but, in saving as many as we can, we are actually saving money ourselves, in our economy, in America itself.

9. Until we address the special challenges of Native American opioid overdose deaths, we will not reduce the deaths near as quickly as we could. We need to provide resources directly to the Native American communities which address directly opioid abuse and overdose deaths.

10. After overdose reversals, if we do not have effective inpatient and outpatient treatment safety nets, we will be seeing these citizens again and again, and will lose some of them to overdose death.

11. If we do not actually declare war against the illicit opioid distributors, within and outside our borders, we will not stem the tide of illegal, and increasingly more dangerous, drugs flowing into our country. If we do not figure out, as Americans, why we are creating our own market of overflowing prescription drugs, misused and overused, we will not effectively stop the rampant overdose rates. We must track the prescriptions, the prescribers, and the users along with the pharmaceutical manufacturers to reduce the epidemic of unneeded prescriptions. And if we do not figure why one family member or friend would give unused and unneeded opioids to another family member or friend, or sell it on the street.

When I ran two public agencies, I believed they could be run like a business and I was right. We figured out, as a criminal

justice agency, who are customers were, what programs were needed, how to efficiently and effectively market our

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products with limited resources, and how to promote our agency in the community. So, I formed another one, a not for

profit, Stop OD, Inc. Stop OD, Inc. is poised and ready to address this problem-which is really, a problem of marketing,

placing financial resources where they most impact this issue, and distribution. Getting Naloxone into the hands of

those who need it, the overdosing citizens of New Mexico. They are our customers.

Conclusions. Let’s start with what we can all now, hopefully agree about:

We are, and have been in a long, painful, life-losing opioid drug war and overdose deaths that have reached

epidemic proportions.

Our enemies are in many countries, and all over, and within the borders of our own country. Until we realize that

we are dealing with a large group of some very dark souls, true terrorists, who have no problem with knowingly

killing over 50,000 Americans, addicting millions more, costing us over $50B annually in economic costs, and

breaking millions of American hearts in our communities, families, friends, and even in total strangers. And they

do it every year. These individuals make ISIS look like amateurs. Nothing short of declared war will

change this.

For those of us who have been battling this problem for years have not been able to meaningfully react with any

real results in the opioid overdose death rates. It is beyond any one of our governments, agencies, community

groups, religious communities, schools, neighborhoods, even often beyond preventing it in our own homes. We

are tired, overwhelmed, frustrated, and some of have given up hope, making those that die every year somehow

expendable. We are the wealthiest country in the history of the world and we cannot take care of our own.

And even with this wealth, we are the main abusers by far of opioids, we, by far, are the consumers driving

the opioid world market. There is something collectively endemic in our culture that we have to address for

it affecting all of us, everywhere, no matter where we live.

We must critically assess our meaningful, intentional, genuine, efforts that have not worked to address this issue.

We must, individually and collectively, “take our lumps” where we are wrong, point ourselves in another 81


direction, and respond together in a united front, non-partisan, non-racial, strategic way. Looking at the history

of this country, we have done this with far more ominous threats, often with much less resources than we

have for this issue.

And, here is the good news, we have the solution for this issue right in front of us and the means to initiate

it. And the solution will build community without judgement, those who help out are proven in studies to

become more optimistic and feel good about themselves, and they do not have to risk sacrificing their lives, or

even a particularly large amount of time, to save one life, or even, perhaps many, lives.

We can stand up individually and, in doing this, collectively save thousands of lives every year. And perhaps,

one day, like polio, stop these deaths.

Finally, I am not suggesting anything unachievable and I am also not saying this will magically save us from the

epidemic facing us that is the ravages of rampant substance abuse. To address this endemic cancer, completely,

we have a very hard battle in front of us. We have to look at ourselves, as Americans collectively and

individually, and ask our ourselves: What is driving us to put into our bodies these highly and increasingly

more addictive poisons that most of us know is either going to ruin our and other’s lives, and in some cases,

kill us? What pain are these fellow Americans, who abuse, are addicted, and in some cases, overdose, and

die from opioids and other substances, really, trying to medicate? There is a voice, collectively and

individually, in this country and in their heads, that is very painful that we, and they, don’t want to hear,

and we are trying to silence that voice by turning away and/or using these substances in epidemic

proportions. And until we allow, and truly hear these voices expressed, without judgment, these desperate voices

of pain that I submit come from loss of hope, poverty, hunger, racism, sexism, the raped, the abused, those

subjected to daily to violence and overwhelming fear, those with no economic hope or future, those who have lost

faith in our leaders, in our country in their God, the Native Americans, those in real physical and psychological

pain, those with chronic pain and incurable diseases, our veterans horribly wounded physically and

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psychologically, the abhorrently lonely and disconnected, and the many lost and disconnected youth who have no

idea what they are putting into their bodies, we will not overcome this huge and multi-faceted epidemic of

collective and individual substance abuse. But what I am saying is that one very important and significant

issue, opioid overdose deaths, can be reduced significantly, immediately, and in the future.

Naloxone needs to be in medicine cabinets, cars, buses, public parks, airports government agencies and private

businesses throughout New Mexico. Every location it is available should be also promoting and educating the free

cellular phone application. And the drug should be provided, without judgment, to anyone who requests it –

anonymously. Who better to get into the hands of those who need it – it is us, the citizens of New Mexico . It

won’t cost us anything, only educating ourselves for an hour or two in the privacy of our homes (who doesn’t have

a cellular phone these days?), and if it crosses our path, helping another New Mexican not die from an overdose. I

believe most New Mexicans are willing and able to do that. We just have to ask them and provide that

Naloxone.

What We Might Not Agree Upon:

1. Perhaps the biggest issue in the background, and sometimes the foreground, is the idea that opioid abusers

are all drug addicts, street-level, homeless, lifelong addicts that, through their bad choices, deserve their fate.

I hope first I have shown that the opioid overdose death citizens are not all that, not even the majority. They

are us. I also hope that I have shown that keeping these citizens alive is cost effective, a community building

effort, and can be reduced greatly in a short period of time.

2. We may not agree that we are at war in this epidemic. I hope I have shown you with this paper and the

Editorial I have written within it, below, that we are and our casualty rate is over 50,000 lives a year. We are

being attacked by real terrorists who also make billions of dollars and cost us billions of dollars, every year.

This plan is cost-effective, reasonable, ethical, fiscally, and civilly responsible, because no New Mexican or American

should not have the opportunity to save another citizen’s life, or their own. It must be done in the streets, backyards, 83


neighborhoods, rural farms, towns, cities, businesses, governments, and community organizations of New

Mexico and America, by the people who live there. And what could be a better community building effort than

one community member saving another community member? We are at war, we have part of the army, right

here in New Mexico, it is ourselves.

Let’s think of ourselves as “The Red Cross” on this drug war battlefield, saving as many as we can, no questions

asked. And we do not have to do “triage” because everyone we give Naloxone to in time, lives. There is little to no

danger to be on this battlefield, the enemy is not shooting at us. The Red Cross army is the citizens of New Mexico,

Good Samaritans, led by our Governor, backed by our government, fighting back, removing our wounded from the

battlefield-fully alive. That’s fighting back against these terrorists, with compassion, civic duty, empathy, and dare I

say it, unconditional Love. This is a power that cannot be denied, and once again we become a model state, as we

lead the rest of the country on another front of the substance abuse, needless overdose death-rate battlefield, with a

huge reduction in overdose deaths.

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STRATEGIC ACTION PLAN:

Like most research papers, this paper does the research, looks at the policies, has conclusions, and makes

recommendations. Unlike most research papers, this paper includes what we are going to do about it in New Mexico,

how, and immediately. Stop OD, Inc. is standing up now and we will address this issue, one way or the other.

Either stand with us, beside us, or behind us, but do not stand in front of us .

Stop OD, Inc. will enact the following plan for New Mexico as soon as it is funded by a combination of our own

federal grants, donations, agency grant funding, and support from governments, activists and community organizations,

businesses, and individuals. We will be applying for federal grants for funding our program., soliciting medical and

pharmacy organizations, universities, pharmaceutical companies, opioid overdose prevention organizations, churches,

companies and small businesses, local community groups, and private individuals to help us in any way they can. We also

will accept public and private donations through various channels. We also will be soliciting existing New Mexico state

government agencies, specifically managing the federal and state resources provided to our citizens. for this important

strategic, emergency epidemic response we are proposing in this paper, from their existing and future funding. With

government help, our even without it, we will reduce the deaths from opioid deaths significantly and very soon.

1. We will partner with the New Mexico Department of Health’s Naloxone distribution program as well as free and

discounted Naloxone sources for our supply of Naloxone. We will immediately request free Naloxone to all New

Mexico high schools from our pharmaceutical source and work with the New Mexico Public Education Department

for its immediate distribution.

2. We will distribute Naloxone kits first, to targeted areas where the opioid abuse is the highest. We already know this

information from the New Mexico Department of Health, emergency medical services (EMS) data

https://nmhealthEMSData, hospitals, community organizations, pharmacies, and law enforcement data. We will 85

https://nmhealthEMSData/


plot this information and make ‘heat maps” telling us where to go first. The Naloxone kits will include two

injections due to the increase of synthetic opioids which often can take two doses to revive the overdosed citizen.

We will strategically place Naloxone in radiuses within communities where it is available quickly and easily, no

questions asked. We will analyze data from rural counties, where Naloxone has never existed at all, determine

historic overdose death rates, and make sure there is enough Naloxone, strategically placed, to make sure it is

available in remote parts of New Mexico. And we will provide Naloxone to anyone who asks for it, free.

3. We will go into to targeted neighborhoods and provide Naloxone in strategically placed locations which could

cover a section of streets, a neighborhood, or small town. We will load this information into a cellular phone

application, one that we create ourselves or approve from existing cell phone applications for this purpose. In these

kits, will be the information necessary to administer the Naloxone safely, a copy of the Good Samaritan law,

treatment center information, and an online and by mailing reporting format to report the use of the Naloxone that

has saved a life. We will provide a weather-resistant sticker and/or placard which can be displayed in the windows

and/or on the mailboxes of agencies, community organizations, businesses, and homes were Naloxone kits are

available.

4. We will track the distributors of the Naloxone when possible and award and honor those who have saved lives with

their efforts. We will track the overdose citizens with an identifier that will allow them to remain anonymous and

yet provide us with data about location, age, race, sex, education, income level, and whether they have used

Naloxone before and how many times. We will promote any overdose citizens saved by Naloxone who are willing

to come forward and tell their story. We will provide Naloxone to those who ask for it, no questions asked. It is

not a controlled substance, cannot be used to get high, is safe, and the person is protected by the Good

Samaritan Law. If we are so worried about losing the antidote, what else can, or are they going to do with

it? We will never provide identifiable information about any opioid user without their permission, or in the case of

a minor, their parents and their parent’s permission.

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5. We will replenish Naloxone kits to agencies, organizations, and individuals when requested and have toll-free

number and online communications formats. We will safely and securely store the Naloxone inventory, track its

shelf life, and provide accounting of the use of the Naloxone and other expenses. We will collect Naloxone that is

months away from its expiration date, redistribute these units to the street, so that they can be used immediately and

before the expiration date.

6. We will design a strategic advertising campaign using the media, billboards, posters, other advertising

formats (shirts, mugs, etc.) and community presentations which will include the cellular phone application

information about Naloxone and where to get it, our telephone number, and recognize supporting partner

agencies, organizations, businesses, and pharmaceutical company(s) who provide us financial and other

support for our mission.

7. We will negotiate with the pharmaceutical industry, and pharmaceutical companies individually, to obtain very

discounted, or free, Naloxone for New Mexico. We will honor those companies who will step forward and help

stop this epidemic, it is their corporate responsibility, and a relatively small cost in comparison to the volume

and revenue they are receiving from the sale of opioids in New Mexico and in America. For those that do not

participate, we will pursue a class action suit, by the People of New Mexico, for the many and significant costs of

opioid overdose deaths as evidenced in this paper, and the ripple effect of harm that affects thousands of New

Mexicans every year in New Mexico.

8. We will work with individuals and communities to safely take back unused opioids, illicit drugs, and assure their

immediate destruction through proper law enforcement channels. We will also take back any used syringes safely

for their immediate and safe destruction. We will hand out clean syringes, if they are provided to us by any

community or governmental agency, to anybody who asks for them.

9. We will provide law enforcement officials with any information we may gain about illicit opioid manufacturers,

illicit doctors, or pharmacists prescribing opioids illicitly, street dealers, and what opioids and other drugs we may

find being distributed in all the areas of New Mexico, while protecting the information’s source. 87


EDITIORIAL:

I have designed this paper as a research paper but I cannot resist the need to editorialize now….

We are at a critical juncture of the opioid overdose abuse death epidemic in New Mexico. We have the resources, even

with shrinking governmental budgets, which are earmarked for this expressed purpose and we have even more available at

the federal level. We are asking federal agencies, New Mexico governments, tribal authorities, treatment agencies,

hospitals, businesses, pharmaceutical companies, community groups, law enforcement and emergency service personnel to

partner with us because we can reduce greatly opioid overdose very soon. When I came to New Mexico in 2003, we were

#1 in death and injury from Driving While Intoxicated (DWI) offenses. We moved to 25th in a few short years, we can do

the same with opioid overdose deaths, in a much shorter period.

We are in an epidemic here, opioid abuse, overdoses, and overdoses causing death. If this were asthma,

tuberculosis, malaria, or Ebola, we would, and do, respond in kind. We marshalled are available resources and we

went out in metropolitan and rural communities and provided inoculations. I guess the difference here is an unconscious

or, sometimes conscious, view that these citizens are “causalities of the drug war” and perhaps we should use our tax

dollars in other efforts. My mother taught me as a kid that “you have to stand for something or you will fall for

anything,” so I stand and declare we are at war, and we need to address this problem with a multi-faceted strategic

approach; find and eradicate the drug mills that are making these synthetic, highly addictive, killers of the innocent, in our

country and in foreign countries (Heroin-Afghanistan, Pakistan, Tajikistan, Albania, Turkey, The Netherlands, Iran, India,

Thailand, Kyrgyzstan) and (synthetic opioids – China, Mexico, Ukraine, The Netherlands) {63} Are any of these countries,

except perhaps China, Pakistan, and India, really, any kind of threat to the full force and weight of the United States of

America? And we know where the money is being laundered as well (see Central Intelligence Agency Report). {64}

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Go after those who are bringing the drugs into New Mexico at the distributor level (I’m not sure why those who are

convicted are not given life imprisonment-this is a war crime now and there is plenty of room now at Guantanamo

and other prisons filled with opioid addicts, for them), the illicit drug prescribing doctors and pharmacists who are

knowingly prescribing for monetary gain after swearing an oath to protect and care for their patients (ditto on the life

imprisonment), sweep up the dealers on the street (and remember that many of these are opioid addicts themselves

forced to deal drugs to support their own habit), reduce overprescribing of opioid prescriptions by doctors, and learn

other ways to deal with pain, limit refills of these prescriptions when they are not needed, provide treatment and social

services to opioid abusers and addicts, and of course, Naloxone distribution. These people are the real terrorists,

knowing, genocidal, killers making billions of dollars from us and causing billions of dollars in cost to us. And this is

every year… I am seriously suggesting that we use our armed forces and our state national guards to augment the

law enforcement efforts to address this drug war, after all we declared it a state emergency, and maybe we could start in

El Paso, just south of our border, a hub for the drug distribution from Mexico. {65}

We are obsessed with the “terrorist threat” within, and outside, our borders and if we added up all of the people

killed in the United States by terrorist’ s attacks in the last 13 years, including 9/11, (3412 deaths), they would be

less than just 40 days of opioid overdose deaths (3640 deaths), if we want to add the Pearl Harbor attack (2403

deaths), add one more month of opioid overdose death (2700 deaths). The current opioid overdose death rate in one

year is almost the same to all deaths from the Korean War or in two years, the death rates would be almost the same

as the combination of all deaths from the Korean War and Vietnam. At this annual death rate, for 10 years, these

deaths would exceed the total deaths from World War II by over 100,000 deaths. {66} Looking at the terrorism

innocent loss of lives from a strictly economic point of view (3412 deaths over 13 years) we spend $100B a year {67},

equating to over $1.2T in the last 13 years, to prevent the present and future risk of losing how many lives (don’t get me

wrong, these were horrible innocent lives lost)? Yes, I know that many of the opioid deaths are Americans who have drug

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dependency (a disease, proven, a chemical imbalance) but now these internal and external terrorists are making

increasingly more addictive synthetic opioids specifically designed to create a whole population of new addicts and more

and more American deaths that are not currently drug dependent. And they are laughing all the way to the bank. And now

overdose deaths are increasing around the world:

{71}

Wait, we are only 4.3% of the world population and we have almost 33% of all overdose deaths in the world?

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For a local example, in Taos:

“Wilma Romero, 66, pleaded guilty to trafficking heroin and conspiring to launder the proceeds and under her plea agreement will face no more than two years in prison followed by a term of supervised release. Elena Carabajal,26, pleaded guilty to one charge of possessing heroin with intent to distribute and will be sentenced to no more than 1 1/2 years in prison and supervised probation. Wilma Romero’s sons – Ivan Romero, 40, and Ricco Romero, 29 — were responsible for purchasing large quantities of heroin from suppliers in Albuquerque and Los Lunas. Other members of the organization, like Jason “Jurassic” Duran, would act as couriers and transport the drugs to Ivan and Ricco in Taos County. Upon getting the heroin, Ivan and Ricco prepared it for distribution by mixing it or “cutting” it with other substances and packaged it into smaller portion for sale either directly or through a network of dealers. Ivan and Ricco pleaded guilty to drug trafficking and money laundering in December and agreed to forfeit over $400,000 to the U.S. government. If those pleas are accepted, Ivan will received a sentence between 10 and 12 years in prison while Ricco will get a 10-year sentence. Melissa Romero also pleaded guilty to participating in a drug laundering scheme in December while Tyler “Zig-Zag” Baker pleaded guilty to his role in the organization in October. After Ivan was arrested in 2015, members of the ring made separate deposits of $90,000 and $150,000 at the same Taos bank in order to get bank or cashier’s checks to make his bail.” {68}

How many heroin overdoses and overdose deaths were there in Taos County during the Romero family’s terrorist reign

where they knowingly dealt heroin, and made great money at the profession? Sorry life imprisonment, they are serial

murderers, Wilma too, it’s the “cost of doing business.”

Why aren’t we after these real terrorists within our borders and in other countries? The distributors, those who

finance drug distributors, illicit prescribing doctors, and the clandestine laboratory’s making even more addictive

opioids to our citizens? We are at condition “red” on the real national terrorist meter right now in America. The

media brings into our living rooms daily, from every angle, terrorists attacks, shootings, and the like. Hollywood glorifies

drug dealers like Pablo Escobar, an absolutely genocidal maniac (who has at least 3 movies and series), Breaking Bad, and

countless others. And for those who think of what we have lost in the American culture (ironically in Hollywood) due to

opioid accidental overdose deaths, I remind us of the following:

George Michael – Singer, Heroin, age 53 Prince –Singer, Fentanyl, age 57 Phillip Seymour Hoffman – Actor, Heroin and drug cocktail, age 46 Michael Jackson = Demerol withdrawal, propofol to medicate withdrawal, age 50 Heath Ledger – Actor, several prescription opioids, age 29 Howie Epstein – Bassist, Tom Petty & Heartbreakers, Heroin, age 47 Dee Dee Ramone – Heroin, age 50 Chris Farley – Actor, age Heroin and other opioids, Age 33 Kurt Colbain – Singer, Heroin (possible suicide), age 27 River Phoenix - Actor, Heroin, Age 23 David Kennedy – Son of Robert Kennedy, Demerol, Age 28

91


John Belushi – Actor/Musician, Heroin, Age 33 Howard Arkley - Painter, Heroin, age 48 Jean-Michel Basquiat – Artist, Heroin, Age 28 Robert Bingham – Author, Heroin, Age 33 Derek Boogaard – Hockey Player, Oxycodone, Age 29 Tim Buckley – Musician, Heroin, Morphine, Age 28 Gram Parsons = Musician, Morphine, Age 27 Elvis Presley – Entertainer, Codeine, Age 47 Cory Monteith – Actor, Heroin, Age 31 Jim Morrison – Singer, Heroin, Age 28 Paula Courson – Jim Morrison’s partner, Heroin, age 33 Nick Drake – Musician, Heroin Age 28 Peter Fandom – Musician – The Pretenders, Heroin, age 31 Hillel Slovak – Musician, Red Hot Chili Peppers, Heroin, age 26 Brad Renfro – Actor, Heroin, age 26 Bradley Nowell – Musician, Band-Sublime, Heroin, age 28 Peaches Geldof – Daughter of Bob Geldof, Musician/Humanitarian, Heroin, Age 25 Paula Yates – British Television Presenter and mother of Peaches Geldof, Heroin, Age 41 Bridgette Anderson - Child Actress, Heroin, Age 21 Robbin Crosby – Musician, Band-RATT, Heroin, Age 43 Lucy Grealy – Irish Writer, survivor of cancer of the face in childhood, Codeine, Heroin, OxyContin, Age 39 Max Cantor – Journalist/Actor, Heroin, age 32 Jimmy McCulloch – Musician, Band-Paul McCartney & Wings, Morphine, age 26

(Source: Google Searches, “Famous Opioid Accidental Deaths”, accessed January 6, 2017)

And thousands and thousands more, less well known, but just as loved, Americans and New Mexicans, who should be

here today. All these who died accidentally, after Naloxone was introduced in 1971…

92

https://en.wikipedia.org/wiki/Derek_Boogaard

https://en.wikipedia.org/wiki/Jean-Michel_Basquiat


REFERENCES:

(Note: All the links listed below should be operational and take you directly to the report. I have shortened the address name for brevity. If I missed any, I’m sorry, contact me at [email protected] and I will get you the information.)

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93

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94


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46. “Substantial Improvement in National Ranking for Overdose Deaths, New Mexico Department of Health Press

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47. “New Mexico Department of Health, Harm Reduction Program,” https://nmhealth.org/about/phd/idb/hrp/ ,

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48. “Naloxone in New Mexico,” New Mexico Department of Health, March 2016, https://nmhealth.org/ .

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55. “RRPS considers having naloxone on hand to treat overdoses,” Gary Herron, Rio Rancho Observer, December 18,

2016, http://www.rrobserver.com/news/.

56. “Santa Fe County Releases Funds to Reduce Drug Overdose, Santa Fe County Government, Rachel O’Connor,

10/3/2016, https://www.santafecountynm .

57. “Human Services Division Meeting,” July 24, 2016, http://www.newmexico.networkofcare.

58. “Prescription Drug Costs: Maximizing State Agency Purchasing Power,” Health Notes, Program Education Unit,

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About Timothy L. Hallford

Timothy Hallford is President & CEO of Stop OD, Inc. and President and CEO of Road Safety Technologies, LLC, a

company using technology to reduce needless death and injuries on our highways. He is working associate of the Joseph

Campbell Foundation and participant and presenter at the Parliament of World Religions. He has a Master’s Degree in

Public Affairs form Indiana University and has studied psychology at the PhD level at Pacifica Graduate Institute. He

completed the Academy for the Love of Learning, “Leading by Being” program in Santa Fe, NM in 2013. He is the proud

father of Ashley Seidner, D.O. and Devin Hallford. He resides with his rescue dogs, Puck and Cormac, in Santa Fe, New

Mexico. He can be reached at 505-469-5319 or [email protected].

100

mailto:[email protected]


APPENDIX

101


CURRENT NALOXONE PROVIDERS IN

NEW MEXICO

102


103

Albuquerque Healthcare for the Homeless

1217 1st St. NW, Albuquerque, NM 87102

505-266-4188

3 - Albuquerque Metro

▪ HIV Testing & Prevention▪ STD Testing & Services▪ Hepatitis Services▪ Harm reduction/syringe

services▪ Overdose

prevention/Naloxone

Anthony Public Health Office

865 N. Main, Anthony, NM 88021

575-882-5858

5 - Southwest



prevention/Naloxone

Artesia Public Health Office

1001 Memorial Drive, Artesia, NM 88210

575-746-9819

4 - Southeast



prevention/Naloxone

Carlsbad Public Health Office

1306 W. Stevens, Carlsbad, NM 88220

575-885-4191

4 - Southeast



prevention/Naloxone

Casa De Salud (Just Healthcare)

1608 Isleta Blvd NW, Albuquerque, NM 87501

505-907-8311

3 - Albuquerque Metro

▪ Harm reduction/syringe services

▪ Overdose prevention/Naloxone

Chaparral Public Health Office

317 McCombs, Chaparral, NM 88081

575-824-4734

5 - Southwest



prevention/Naloxone

Cibola Public Health Office

700 E. Roosevelt Ave., Suite 100, Grants, NM 87020

505-285-4601

1 - Northwest



prevention/Naloxone


NEW MEXICO STATUTES/ STANDING ORDERS

TITLE 7 HEALTHCHAPTER 32 ALCOHOL AND DRUG ABUSEPART 7 OVERDOSE PREVENTION AND EDUCATION PROGRAM AUTHORIZATION FOR OPIOID ANTAGONISTS 7.32.7.1 ISSUING AGENCY: Department of Health; Public Health Division; Infectious Disease Prevention and Control Bureau.[7.32.7.1 NMAC - Rp, 7.32.7.1 NMAC, 7/15/2016] 7.32.7.2 SCOPE: This rule applies to all New Mexico department of health registered overdose prevention and education programs that obtain, prescribe, dispense, distribute, or administer an opioid antagonist.[7.32.7.2 NMAC - Rp 7.32.7.2 NMAC, 7/15/2016] 7.32.7.3 STATUTORY AUTHORITY: The statutory authority for adopting these rules is found in Subsection E of Section 9-7-6 NMSA 1978 (Department of Health Act) and Subsection J of Section 24-23-1 NMSA 1978 which requires the secretary of health to “promulgate rules relating to overdose prevention and education programs.”[7.32.7.3 NMAC - Rp 7.32.7.3 NMAC, 7/15/2016] 7.32.7.4 DURATION: Permanent.[7.32.7.4 NMAC - Rp, 7.32.7.4 NMAC, 7/15/2016] 7.32.7.5 EFFECTIVE DATE: July 15, 2016, unless a later date is cited at the end of a section.[7.32.7.5 NMAC - Rp, 7.32.7.5 NMAC, 7/15/2016] 7.32.7.6 OBJECTIVE: The objective of these regulations is to reduce mortality due to opioid overdose by increasing the administration, distribution, prescription and dispensation of opioid antagonists to individuals who are at risk of opioid overdose and to individuals, such as family members, friends or other persons, who may be in a position to assist individuals who are experiencing an overdose. These regulations shall set standards for the establishment of standing orders to obtain, store, distribute and administer an opioid antagonist; the establishment of overdose prevention and education programs and standards for them to register, obtain, store, and distribute naloxone; the establishment of standards for overdose prevention curricula, training and the certification of individuals to store and distribute opioid antagonists for the overdose prevention and education programs.[7.32.7.6 NMAC - Rp, 7.32.7.6 NMAC, 7/15/2016] 7.32.7.7 DEFINITIONS: A. “Administration of opioid antagonist” means the direct application of an opioid antagonist to the body of an individual by injection, inhalation, ingestion or any other means. B. “Department” means the New Mexico department of health. C. “Dispense” means to evaluate and implement a prescription for an opioid antagonist, including the preparation and the delivery of a drug or device to a patient or patient’s agent; D. “Distribute” means to deliver an opioid antagonist drug or opioid antagonist device by means other than by administering or dispensing;

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E. “Enrollment form” means the form approved by the department to register an individual as a trained targeted responder. F. “Licensed prescriber” means any individual who is authorized by law to prescribe an opioid antagonist in the state. G. “Medication log” means the form used to track the storage and distribution of the opioid antagonist. H. “Opioid” means any substance containing or derived from opium including, but not limited to morphine and heroin, and any morphine-like synthetic narcotic that produces the same effects as substances derived from the opium poppy. I. “Opioid antagonist” means a drug approved by the federal food and drug administration that, when administered, negates or neutralizes in whole or in part the pharmacological effects of an opioid in the body. "Opioid antagonist" shall be limited to naloxone or other like medications that are indicated for use in reversing an opioid overdose and are approved by the department for such purpose. J. “Overdose prevention and education program (OPE)” means any community-based organization, law enforcement agency, detention facility or school that has registered with the department in accordance with department rules and uses an approved department curriculum to teach overdose prevention and opioid antagonist administration. K. “Overdose response educator” means any staff or volunteer who is registered with an overdose prevention and education program who are trained and certified by the department in the overdose response education curriculum. L. “Overdose response educator curriculum” means a department approved curriculum to train and certify overdose response educators, which must be repeated every two years. M. “Possess” means to have physical control or custody of an opioid antagonist. N. “Record of use form” means the department designated report for the use or loss of an opioid antagonist, the response to a suspected opioid overdose or the re-issuance of an opioid antagonist to a trained targeted responder. O. “Standing order” means a licensed prescriber’s instruction or prescribed procedure that is either patient specific or non-patient specific that can be exercised by other persons until changed or canceled by a licensed prescriber. P. “Storage” means possession of an opioid antagonist with the intent to dispense or distribute it. Q. “Trained targeted responder” means a person who is trained by overdose response educators to possess and administer an opioid antagonist to a person who is experiencing an opioid overdose, and has completed the trained targeted responder curriculum. R. “Trained targeted responder curriculum” means a department approved curriculum for trained targeted responders.[7.32.7.7 NMAC - Rp, 7.32.7.7 NMAC, 7/15/2016]

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7.32.7.7 REQUIREMENTS FOR OVERDOSE PREVENTION AND EDUCATION PROGRAMS, 7.32.7.8 OVERDOSE RESPONSE EDUCATORS AND TRAINED TARGETED RESPONDERS:

A. Overdose prevention and education program requirements: An overdose prevention and education program is a program which facilitates the distribution of opioid antagonists and provides education related to overdoses, overdose prevention and the administration of opioid antagonists. An overdose prevention and education program shall:

(1) register with the department using the form approved by the department which shall include at a minimum:

(a) date of registration; (b) overdose prevention and education program name; and

(c) name, address, e-mail and telephone number of overdose prevention and education program contact;

(2) identify who will be overdose response educator (3) train or verify overdose response educators have successfully completed and maintained a current certification in the overdose response educator curriculum; (4) enroll trained targeted responders using the enrollment form; (5) train or verify trained targeted responders have completed the trained targeted responder curriculum; (6) identify and maintain a secure location for the storage of the opioid antagonists designated for distribution in accordance with these regulations; (7) label the opioid antagonist in accordance with these regulations; (8) utilize the record of use form to report all known uses or losses of an opioid antagonist, responses to a suspected opioid overdose, or the re-issuance of an opioid antagonist to a trained targeted responder; (9) maintain personal protective equipment and response equipment at training locations; (10) provide trained targeted responders with necessary response equipment; and (11) be prepared for scheduled and unscheduled site visits by the department where the department may review the maintenance of enrollment forms, record of use forms, medication logs and any other information required to be maintained pursuant to these rules. B. Overdoes response educators shall: (1) successfully complete the overdose response educator curriculum and maintain this certification; (2) comply with the terms of a standing order issued by a licensed prescriber, which may include possession of opioid antagonists and distribution of the opioid antagonist to trained targeted responders; (3) teach trained targeted responders the trained targeted responder curriculum; and (4) complete medication log, enrollment forms and record of use forms for trained targeted

responders. C. Trained targeted responders: (1) are trained in the trained targeted responder curriculum; and

(2) shall report all known responses to suspected opioid overdoses to an overdose prevention and education program using the record of use form.

[7.32.7.8 NMAC - Rp, 7.32.7.9 & 10 NMAC, 7/15/2016]

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7.32.7.8 REQUIREMENTS FOR DISTRIBUTION OF OPIOID ANTAGONIST:A. The New Mexico department of health public health division pharmacy warehouse can distribute the opioid antagonist to any registered overdose prevention and education program.B. Standing orders from a department licensed prescriber for the distribution of an opioid antagonist shall include at a minimum:

(1) authorization to maintain supplies of opioid antagonists for the purposes of distributing the as part of the department’s overdose prevention efforts;

(2) authorization for overdose response educators to possess and distribute the opioid antagonist to trained targeted responders; (3) instructions for overdose response educators to educate and advise clients of overdose prevention methods, recognizing an overdose, and potential contraindications and precautions. C. Medication log, enrollment forms and record of use forms shall be utilized by an overdose prevention and education program in order to document the distribution and administration of opioid antagonists.[7.32.7.9 NMAC - Rp, 7.32.7.10 NMAC, 7/15/2016] 7.32.7.10 REQUIREMENTS FOR STORAGE OF THE OPIOID ANTAGONIST: A. Any opioid antagonist designated for distribution by an overdose prevention and education program must be stored in a secure designated location. (1) The location must be locked with entry limited to overdose response educators and other individuals as designated by the overdose prevention and education program. (2) A medication log of the opioid antagonist must be maintained, and include the following information, at minimum: (a) lot numbers of the opioid antagonist; (b) expiration dates of the opioid antagonist; (c) date, quantity of opioid antagonist doses and the name of the individual who is removing the opioid antagonist from the secured location for distribution; (d) date, quantity of opioid antagonist doses and the name of the individual who is returning doses of the opioid antagonist to the secured location if they have not been distributed; and (e) for doses of the opioid antagonist distributed, the medication log must also include the name and date of birth of the trained targeted responder, the date of distribution, lot number of each opioid antagonist dose and the expiration date of each opioid antagonist dose. B. Any registered overdose prevention and education program, may make an opioid antagonist available for use in response to a possible overdose incident. The opioid antagonist designated for use at an overdose prevention and education program for a possible overdose response shall be stored in a secure but accessible location.[7.32.7.10 NMAC - Rp, 7.32.7.10 NMAC, 7/15/2016]

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7.32.7.11 LABELING OF THE OPIOID ANTAGONIST:

A. The overdose prevention and education program shall label the opioid antagonist prior to it leaving the designated secure storage location which shall include: (1) the name and address of the overdose prevention and education program distributing the opioid antagonist; and (2) the text “use as directed.” B. At the time of distribution of an opioid antagonist to a trained targeted responder, the overdose response educator shall complete the following information on the label: (1) name of the trained targeted responder; (2) date of distribution of the opioid antagonist; and C. At the time of distribution of an opioid antagonist to a trained targeted responder, the overdose response educator will provide directions for use of the opioid antagonist.[7.32.7.11 NMAC - N, 7/15/2016] 7.32.7.12 MINIMUM REQUIREMENTS FOR ENROLLMENT AND RECORD OF USE FORMS:

A. The enrollment form shall include at a minimum: (1) name of the overdose prevention and education program; (2) department designated code of the trained targeted responder; and (3) the quantity of the opioid antagonist distributed. B. The record of use form shall contain at a minimum: (1) the name of the overdose prevention and education program recording the report; (2) the department designated code of the reporting trained targeted responder; (3) the quantity of the opioid antagonist administered, lost, or expired; (4) the date or approximate date of the overdose incident, if there is one being reported; (5) the disposition of the person who was administered the opioid antagonist; and (6) the quantity of the opioid antagonist distributed.[7.32.7.12 NMAC-N, 7/15/2016] 7.32.7.13 APPLICABILITY OF REGULATIONS: In the event an approved opioid antagonist is classified as an “over the counter” (OTC) medication the following portions of these regulations shall no longer be applicable: 7.32.7.9, 7.32.7.10, 7.32.7.11 NMAC. Department protocols will remain in effect.[7.32.7.13 NMAC-N, 7/15/2016] History of 7.32.7 NMAC:Pre - NMAC History: None. History of Repealed Material:7.32.7 NMAC, Authorization to Administer Opioid Antagonists, filed 6/1/2001.7.32.7 NMAC, Authorization to Administer Opioid Antagonists, filed 8/30/2001 - Repealed effective 7/15/2016. Part name changed to Overdose Prevention and Education Program Authorization for Opioid Antagonists.

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NMSA 24-23-1 Authority to possess, store, distribute, dispense, prescribe and administer opioid antagonists; release from liability; rulemaking.

A. person may possess an opioid antagonist, regardless of whether the person holds a prescription for the opioid antagonist.

B. Any person acting under a standing order issued by a licensed prescriber may store or distribute an opioid antagonist.

C. Pursuant to a valid prescription, a pharmacist may dispense an opioid antagonist to a person: (1) at risk of experiencing an opioid-related drug overdose; or (2) in a position to assist another person at risk of experiencing an opioid-related drug overdose.

D. A pharmacist may distribute an opioid antagonist to a registered overdose prevention and education program.

E. A person may administer an opioid antagonist to another person if the person: (1) in good faith, believes the other person is experiencing a drug overdose; and (2) acts with reasonable care in administering the drug to the other person.

F. A licensed prescriber may directly or by standing order prescribe, dispense or distribute an opioid antagonist to: (1) a person at risk of experiencing an opioid-related drug overdose; (2) a family member, friend or other person in a position to assist a person at risk of experiencing an opioid-related drug overdose; (3) an employee, volunteer or representative of a community-based entity providing overdose prevention and education services that is registered with the department; or (4) a first responder.

G. A registered overdose prevention and education program that possesses, stores, distributes or administers an opioid antagonist in accordance with department rules and on standing orders from a licensed prescriber pursuant to this section shall not be subject to civil liability, criminal prosecution or professional disciplinary action arising from the possession, storage, distribution or administration of the opioid antagonist; provided that actions are taken with reasonable care and without willful, wanton or reckless behavior.

H. A person who possesses or who administers, dispenses or distributes an opioid antagonist to another person pursuant to this section shall not be subject to civil liability, criminal prosecution or professional disciplinary action as a result of the possession, administration, distribution or dispensing of the opioid antagonist; provided that actions are taken with reasonable care and without willful, wanton or reckless behavior.

I. The department shall create, collect and maintain any individually identifiable information pursuant to this section in a manner consistent with state and federal privacy laws.

J. The secretary shall promulgate rules relating to overdose prevention and education programs: (1) establishing requirements and protocols for the registration of overdose prevention and education programs that are not licensed pharmacies; (2) monitoring registered overdose prevention and education programs' storage and distribution of opioid antagonists; (3) gathering data from overdose prevention and education programs to inform public health efforts to address overdose prevention efforts; and (4) authorizing standards for overdose prevention education curricula, training and the certification of individuals to store and distribute opioid antagonists for the overdose prevention and education program.

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K. As used in this section: (1) "administer" means the direct application of a drug to the body of an individual by injection, inhalation, ingestion or any other means; (2) "department" means the department of health; (3) "dispense" means to evaluate and implement a prescription for an opioid antagonist, including the preparation and delivery of a drug or device to a patient or patient's agent; (4) "distribute" means to deliver an opioid antagonist drug or opioid antagonist device by means other than by administering or dispensing; (5) "first responder" means any public safety employee or volunteer whose duties include responding rapidly to an emergency, including:

(a) a law enforcement officer; (b) a firefighter or certified volunteer firefighter; or (c) emergency medical services personnel;

(6) "licensed prescriber" means any individual who is authorized by law to prescribe an opioid antagonist in the state; (7) "opioid antagonist" means a drug approved by the federal food and drug administration that, when administered, negates or neutralizes in whole or in part the pharmacological effects of an opioid in the body. "Opioid antagonist" shall be limited to naloxone or other like medications that are indicated for use in reversing an opioid overdose and are approved by the department for such purpose; (8) "possess" means to have physical control or custody of an opioid antagonist; (9) "registered overdose prevention and education program" means any community-based organization, law enforcement agency, detention facility or school that has registered with the department in accordance with department rules and uses an approved department curriculum to teach overdose prevention and opioid antagonist administration; (10) "standing order" means a licensed prescriber's instruction or prescribed procedure that is either patient specific or non-patient specific that can be exercised by other persons until changed or canceled by a licensed prescriber; and (11) "storage" means possession of an opioid antagonist with the intent to dispense or distribute it. History: Laws 2001, ch. 228, § 1; 2016, ch. 45, § 1; 2016, ch. 47, § 1.

New Mexico Department of Health Public Health Division Registered Overdose Prevention and Education Programs NALOXONE STANDING ORDER

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Authority: NMSA 1978, 24-23-1.B: Any person acting under a standing order issued by a licensed prescriber may store or distribute an opioid antagonist; and NMSA 1978, 24- 23-1.F A licensed prescriber may directly or by standing order prescribe, dispense or distribute an opioid antagonist to:

1) a person at risk of experiencing an opioid-related drug overdose; (2) a family member, friend or other person in a position to assist a person at risk of experiencing an opioid-related drug overdose; 3) an employee, volunteer or representative of a community-based entity providing overdose prevention and education services that is registered with the department; or 4) a first responder.

Purpose: To contribute to decreasing morbidity and mortality related to opioid overdose, this standing order permits: • Clinical staff of registered overdose prevention and education programs (OPE) to obtain, store, and dispense/distribute naloxone to eligible clients; and • Non-clinical staff and volunteers of OPE’s who have completed the NMDOH Hepatitis and Harm Reduction Certification training to obtain, store and distribute naloxone to eligible clients. Naloxone storage for OPE’s: naloxone may be stored at any OPE so long as the storage location is kept secure, with entry limited to Hepatitis and Harm Reduction Certified staff and individuals designated by the OPE to have access.

Assessment: 1. Clients presenting for opioid overdose prevention services are eligible for management under this standing order. Clients are eligible if they have received training through an approved overdose prevention and education curriculum. Eligible clients include: - A person at risk of experiencing an opioid-related drug overdose; - A family member, friend or other person in a position to assist a person at risk of experiencing an opioid-related drug overdose; - An employee, volunteer or representative of a community-based entity providing overdose prevention and education services that is registered with the department; and, - A first responder. 2. If any of the above conditions are not met, contact a licensed healthcare provider for an order. 3. If a client has insurance or other means to access or obtain naloxone through their primary health care provider or through a pharmacy, they should be encouraged to obtain naloxone through those sources. However, this should not Rev: JS/DVZ/CN 9-26-16 be a barrier to providing them with the education or medication if they are unable to reasonably access naloxone through other means. 4. Assess the client who presents for contraindications and precautions, including: - Contraindications: hypersensitivity or allergy to naloxone. - Precautions: o Anaphylactic shock may occur in those allergic to naloxone or any component of the medication. o Acute withdrawal symptoms may occur in individuals currently using opioids including: body aches, fever, sweating, runny nose, sneezing, yawning, weakness, shivering or trembling, nervousness, restlessness or irritability, diarrhea, nausea, abdominal cramps, increased blood pressure and tachycardia. o Respiratory depression may occur due to other substances - naloxone is not effective against respiratory depression due to non-opioid substances. o Reversal of respiratory depression by partial agonists or mixed agonist/antagonists, such as buprenorphine, may be incomplete or require higher doses of naloxone.

Order 1. At initial enrollment: - Document as an Initial Enrollment using the Naloxone Enrollment and Record of Use Form. - Dispense as available: Two (2) Naloxone 2 mg/2 ml in prefilled syringe for intranasal use AND Two (2) Mucosal Atomization Devices (MAD) OR Two (2) Naloxone 4 mg/0.1 ml in FDA-approved intranasal administration devices More

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than two prefilled-syringes of naloxone and MADs, or FDA-approved intranasal naloxone devices, may be provided if the client indicates one of the following: a) Lengthy travel to reach the program location;b) Limited hours of the program location; or c) Potential to use multiple doses prior to ability to return to the program location.

2. For clients presenting for a refill: - Document as a Record of Use using the Naloxone Enrollment and Record of Use Form. - Dispense as available: Two (2) Naloxone 2 mg/2 ml in prefilled syringe for intranasal use Rev: JS/DVZ/CN 9-26-16 AND Two (2) Mucosal Atomization Devices (MAD) OR Two (2) Naloxone 4 mg/0.1 ml in FDA-approved intranasal administration devices More than two prefilled-syringes of naloxone and MADs, or FDA-approved intranasal naloxone devices, may be provided if the client indicates one of the following:a) Lengthy travel to reach the program location; b) Limited hours of the program location; or c) Potential to use multiple doses prior to ability to return to the program location.3. Advise clients that the use of naloxone in individuals with contraindications or precautions may cause adverse effects. 4. Offer all clients a copy of the drug information sheet located at http://nmhealth.org/about/phd/idb/hrp/ 5. Offer all clients a copy of the Overdose Prevention and Rescue Breathing in 20 Minutes or Less educational handout, located at http://nmhealth.org/about/phd/idb/hrp/

Administration For any individual who presents with a possible overdose:

1. Activate EMS/call 911. 2. Administer intranasal naloxone by inserting the atomizer end into the nostril and pushing the plunger at the base of the device. Either of these devices may be utilized: a. Naloxone 2 mg/2 ml in prefilled syringe for intranasal use using a Mucosal Atomization Device (MAD). Administer ½ of the medication in each nostril. OR b. Naloxone 4 mg/0.1 ml in FDA-approved intranasal administration devices. Administer all of the medication in one nostril. Warning: Naloxone reversal of an opioid overdose can be rapid – following administration, the patient may regain consciousness quickly, but may be confused, agitated, irritable, and/or combative (due to precipitated withdrawal and possibly due to hypoxia). Safely restrain the patient and find a quiet place for the client to rest. 3. Provide rescue breathing as needed. If rescue breathing is not necessary, place the patient on their side (to prevent aspiration). Rev: JS/DVZ/CN 9-26-16 4. If a comatose patient with suspected overdose fails to awaken with naloxone within 5 minutes, administer a second dose of naloxone (prefilled syringe or spray) via one of the two intranasal forms as above. Consider alternate causes for the condition (e.g., MI, hypoglycemia). 5. Stay with the individual until EMS or other medical services arrive. Naloxone may rarely cause adverse effects in individuals with contraindications, so the person must be observed during this time, either by the person who administered naloxone, another trained individual, EMS personnel, or a clinically licensed individual. 6. Naloxone wears off after 30-90 minutes - respiratory depression may re-occur with long-acting opioids. Additional doses of naloxone may be required until emergency medical assistance becomes available. 7. Report the incident to the Hepatitis and Harm Reduction Program utilizing the Naloxone Enrollment and Record of Use Form located at: http://nmhealth.org/about/phd/idb/hrp/ This standing order shall remain in effect until rescinded. Licensed Prescriber NPI Signature Date Christopher Novak PHD Medical Director 1508834110 10/4/2016

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http://nmhealth.org/about/phd/idb/hrp/


A. What causes an overdose (OD) Toxic amount: too much of the substance; reduce amount and do tester shot Mixing: effects are amplified; reduce amounts, inject first if mixing with alcohol Tolerance: lowers during periods of non-use (i.e.: detox/jail/no money); reduce and do tester shot Quality: varies in strength and purity; try to use known source and do tester shot Using Alone: if something goes wrong – nobody to help; fix w/friend, unlocked door, and call someone trusted

B. How to recognize an OD Over-amp: Stimulants (cocaine/speed) make the body speed up Overdose: Heroin and other downers (alcohol/benzos) make the body slow o Signs of OD: Unresponsive, unconscious, breathing slow/shallow (<12 breaths/min); pale, clammy, loss of color, blue/gray (esp. lips/nails); loud/uneven snoring/gurgling; not breathing; faint/no pulse o High vs OD: “the line”= UNRESPONSIVE

C. What to do if OD occurs Stimulation: Call name, sternum rub Call 911 - Good Samaritan 911 Law: protects against citation or arrest, except if another law is being broken o Quiet the scene (or go to a quiet area), be calm and speak clearly, and do not argue o Give exact address/location, person not breathing or turning blue o There is no need to say: it is an overdose, give a name, or if drugs were involved o Tell the paramedics everything known about the situation when they arrive Use Naloxone Perform Rescue Breathing = If they do not start breathing in 3 minutes, use a second dose of naloxone

D. Naloxone Administration (using device with separate atomizer) 1. Remove the colored caps on medicine vial and syringe barrel 2. Insert vial into barrel & gently turn until it stops 3. Twist nasal atomizer onto tip of barrel. It is ready to use‡ 4. Place assembled naloxone atomizer into one nostril 5. Press firmly on base of vial, spraying half into nostril 6. Repeat in other nostril ‡If an atomizer is not available (lost, missing, etc.…), slowly drip the naloxone under the tongue (using “all-in-one” intranasal device) * * 1. Remove device from blister pack 2. Place nozzle end into nostril 3. Press firmly on base of device, spraying medication into nostril *Stay with the person as naloxone loses effect 30-90 minutes after administration. E. Rescue Breathing Stimulation and Airway 1. Check responsiveness. Ask, ”Are you okay?”, shake foot, use sternum rub 2. Are they breathing? Look, listen and feel 3. If no response, call 911 4. Check for clear airway. If blocked, roll on side and use finger sweep to clear 1. Roll onto back, tilt head back and pinch nose 2. Give 2 regular breaths 3. Look, listen and feel

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4. If still not breathing give 1 breath every 5 seconds 5. Continue until person revives or help arrives 6. Once they start breathing, put them in the recovery position Rescue Breathing *Remember to keep breathing for them. Brain damage starts occurring 4 minutes after loss of oxygen. Recovery Position F. OD Myths – These do not work: Slap or punch: may bruise or break nose/jaw Put in cold water or use ice: makes the body cold, slow even more, and can lead to hypothermia Use a lamp cord like a home-made defibrillator: can cause electric burns, irregular heartbeat, or death Inject with milk/saline/other substances: can cause the body to go into shock ***How to demonstrate assembling the Naloxone if a training device is not available to Dispense Naloxone to participant o Have participant attach atomizer themselves o Show participant how the vial is assembled but do not actually remove the plastic caps or twist the vial into the barrel as this will cause the Naloxone to spoil before use.

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HARM REDUCTION COALTION INTERNATIONAL CONFERENCE 2016 APPLICABLE SESSIONS:

PANEL: Expanding Naloxone Moderator: Mark Kinzly, TX Opioid Narcan Initiative, Austin, TX

Issues in Initiating or Expanding Effective Opioid Overdose Prevention Work Dan Bigg, Chicago Recovery Alliance, Chicago, IL Maya Doe-Simkins, MDSC/Harm Reduction Michigan, Maple City, MI Eliza Wheeler, Harm Reduction Coalition, Oakland, CA

Naloxone at the Crossroads of North and South: Advocating for Access and Piloting Programs in North Carolina, Washington, D.C., Rural Maryland, and D.C.’s Maryland Suburbs Andrew Bell, HIPS, Washington D.C

New Mexico Naloxone Access: New Statutes to Increase Distribution by Non-Clinicians Dominick Zurlo, New Mexico Department of Health, Santa Fe, NM

Enhanced Naloxone Distribution in Six New York City Target Neighborhoods Monique Wright, NYC Department of Health and Mental Hygiene, New York, NY

The Naloxone Buffet Phillip Fiuty, Santa Fe Mountain Center, Tesuque, New MexicoDave Koppa, Santa Fe Mountain Center, Tesuque, New Mexico

How Overdose Prevention Training Media Can Save Lives AND Create Change

Gretchen Hildebran, Independent Acxel Barboza, New York Harm Reduction Educators, New York, NY Narelle Ellendon, NYSDOH/AIDS Institute, New York, NY

WORKSHOP: Opioid Overdose Prevention Initiatives on the College Campus: Partnerships with Academics and Community Experts

Mark Kinzly, TX Opioid Narcan Initiative & Austin Harm Reduction Coalition, Austin, TX Lori Holleran Steiker, The University of Texas at Austin School of Social Work, Austin, TX Mitchell Hinrichs, Student at University of Texas at Austin, Austin, TX Lucas Hill, University of Texas at Austin, School of Pharmacy, Austin, TXStephanie Danielle Hamborsky, University of Texas at Austin Students for Sensible Drug Policy, Austin, TX Chris Brownson, University of Texas at Austin Office of Student Affairs and Health Services, Austin, TX

WORKSHOP: Practicing Harm Reduction with Ourselves: The Beautiful Grit of Cultivating a Culture of Community Wellness in the Grip of Chronic Collective Grief/Trauma Kristin Doneski, AAC/Cambridge Needle Exchange and Overdose Prevention Program, Cambridge, MAHilary Eslinger, Preble Street, Portland, ME

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WORKSHOP: Community Engaged Research to Advance Naloxone Distribution in Treatment Settings Mary Hawk, University of Pittsburgh, Pittsburgh, PA James Egan, University of Pittsburgh, Pittsburgh, PA Sarah Danforth, Prevention Point Pittsburgh, Pittsburgh, PA

PANEL: Overdose in the Criminal Justice System Moderator: Demetrius McCord, Deputy Director, Harm Reduction Coalition, New York, NY

Overdose Education and Naloxone Delivery in Local Detention Centers in Maryland Kirsten Forseth, Maryland Department of Health and Mental Hygiene, Baltimore, MD Erin Haas, Maryland Department of Health and Mental Hygiene, Baltimore, MD Training Incarcerated Individuals Prior to Release and Equipping them with Naloxone Upon Release Valerie White, AIDS Institute, New York, NY Sharon Stancliff, Harm Reduction Coalition, New York, NYOverdose Prevention and Naloxone Distribution in Criminal Justice Settings: The NEXT Study Lynn Wenger, RTI International, San Francisco, CA Witnessed Overdoses and Naloxone Use Among Visitors to Rikers Island Trained in Overdose Prevention Lara Maldjian, NYC Department of Health and Mental Hygiene, New York, NY Overdose Prevention within Law Enforcement and Incarceration Systems Emilie Junge, Chicago Recovery Alliance, Chicago, IL Geoff Bathje, Adler University, Chicago, IL

PANEL: First Responder Moderator: Adam Butler, Harm Reduction Coalition The Nevada Rural Opioid Overdose Reversal (NROOR) Project: Successes and Challenges in Implementing a HRSA-funded Naloxone Program Karla Wagner, University of Nevada, Reno, NV Christopher Marchand, University of Nevada, Reno, NV Widespread Distribution of Intranasal Naloxone: Findings from a Multi-Site Overdose Prevention Project in Norway Desiree Madah-Amiri, Norwegian Centre for Addiction Research, Oslo, Norway “O.D. Be Gone!” a.k.a. Naloxone and the Inner City Youth Experience in Vancouver, BC Keren Mitchell, Inner City Youth Program, Providence Health Care, Vancouver, Canada Elise Durante, Inner City Youth Program, Providence Health Care, Vancouver, Canada Katrina Pellatt, Inner City Youth Program, Providence Health Care, Vancouver, Canada Jane Buxton, Inner City Youth Program, Providence Health Care, Vancouver, Canada

ROUNDTABLE: Red State Harm Reduction: Naloxone, Medical Amnesty, and Drug Policy in the Bible Belt Jeremy Galloway, Families for Sensible Drug Policy and Southeast Harm Reduction Project, Dahlonega, GA Mona Bennett, Atlanta Harm Reduction Coalition, Atlanta, GA Jeremy Sharp, Students for Sensible Drug Policy, Washington D.C. PANEL: Ask Mom How to Save a Life: Parents Taking a Lead Position to Prevent Overdose Deaths Gretchen Burns Bergman, Moms United to End War on Drugs/A New PATH, Spring Valley, CA Denise Cullen, Broken No More, Orange, CA April Ella, A New PATH, Spring Valley, CA Elon Burns, San Diego Coastal Sober Living, San Diego, CA Caroline Stewart, Caroline Stewart and Associates, San Diego, CA Peter Davidson, University of California at San Diego, San Diego, CA

PANEL: Fentanyl: A More Dangerous “Heroin”: Emerging Patterns in the Heroin Overdose Epidemic 116


Dan Ciccarone, University of San Francisco, San Francisco, CA Jeff Ondocsin, University of California at San Francisco, San Francisco, CA Sarah Mars, University of California at San Francisco, San Francisco, CA

PANEL: The Participant Experience Moderator: T Steve Jones

Peer Delivery Model for Naloxone Distribution and Increasing Opioid Safety Knowledge among Veterans: Preliminary Results of a Longitudinal Cohort Study in New York City Alex Bennett, National Development and Research Institutes (NDRI), New York, NY Take Home Naloxone Program Participants’ Perspectives and Program Evaluation Regarding Contacting Emergency Services During an Overdose Event Jane Buxton, British Columbia Centre for Disease Control, Vancouver, Canada Experiences of Opiate Overdose in Puerto Rico: PWIDs Readiness to Intervene and the Need for Overdose Prevention Training and Naloxone Distribution Debora Upegui-Hernandez, Intercambios Puerto Rico, Fajardo, Puerto RicoHarnessing the Expertise of Peer Educators in Health Promotion and Disease Prevention Megan Stapleton, New South Wales Users and AIDS Association, Sydney, Australia

PANEL: Curbing Overdose Moderator: William Matthews, Harm Reduction Coalition, New York, NY

Curbing Opioid Overdose using Programmatic and Geo-spatial Data Kate Lena, AHOPE Needle Exchange Program Boston Public Health Commission, Boston, MA Expanded Overdose Prevention Services with Naloxone in Michigan as an Instigator for Improved Access to Harm Reduction Services Steve Alsum, The Grand Rapids Red Project, Grand Rapids, MI Overdose Fatality Review Program Development and Results Erin Haas, Maryland Department of Health and Mental Hygiene, Baltimore, MD

PANEL: Overdose Moderator: Allan Clear, NYSDOH/AIDS Institute, New York, NY

Overdose and Naloxone Use Among Opioid Overdose Prevention Trainees in New York City: Results from a Longitudinal Cohort Study of Community-based Overdose Prevention Laura Maldjian, NYC Department of Health and Mental Hygiene, New York, NY

Opioid Overdose and Naloxone Distribution in San Francisco: From Epidemiology to Intervention Development to Implementation Alex Kral, RTI International, San Francisco, CA Perceptions and Behaviors Related to Overdose and Naloxone Among Opioid Users at Risk for Overdose Janelle Silvis, San Francisco Department of Public Health, San Francisco, CA

PANEL: Working with Young People Moderator: Demetrius McCord, Harm Reduction Coalition Access to Substance Use Treatment Among Young Adults Who Use Prescription Opioids Non-Medically Elliot Liebling, Brown University, Providence, RI

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Brandon Marshall, Brown University School of Public Health, Providence, RI Above/Below:Trauma, Transience, and Survival Kacey Byczek, Lower East Side Harm Reduction Center, New York, NY Harm Reduction and Mental Health: Approaches to Working with Transition Age Youth Joseph Bonnell, Outside In, Portland, OR

PANEL: Syringe Exchanges and the “New Heroin Epidemic” Kiefer Paterson, AIDS United, Washington, D.C. Magalie Lerman, NASTAD, Washington, D.C.

Empowering the People. Empowering The People shows how drug users are often marginalized from formal health care delivery institutions and from making their own health decisions. But, with community-based organizations at the forefront of providing naloxone, drug users can access it; a miracle drug, that does more than save people's lives. This video features Carl Hart, Louise Vincent, Robert Childs and Helen, a mother whose son is addicted to heroin.

LENGTH: 4 MINUTES LANGUAGE: ENGLISH DIRECTOR: HYUN NAMKOONG WEB PAGE: nchrc.org

LEADing a new direction This video features the work of Santa Fe, New Mexico's Law Enforcement Assisted Diversion program. Santa Fe's LEAD program has improved relationships between law enforcement and drug users. LEAD programs challenge police to consider multidisciplinary and comprehensive approaches to providing assistance and stability rather than incarceration to communities of people who use drugs. LENGTH: 5 MINUTES LANGUAGE: ENGLISH DIRECTOR: HYUN NAMKOONG WEB PAGE: nchrc.org

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