Combating the Opioid Overdose Epidemic

Public Safety Naloxone

Michael W. Dailey, MD FACEP

Regional EMS Medical Director

Associate Professor

of Emergency Medicine

Disclosure

No academic conflict of interest

No financial conflict of interest

FDA Off-label use of a medication will be discussed

Slides are available on Slideshare

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Upon Completion of the Program, Participants Will Be Able to:

Describe the advancement of naloxone into the

out-of-hospital arena to treat opioid overdoses

Identify opportunities for increasing the distribution of

naloxone into high-risk opioid overdose environments

Specify the next steps in increasing the intranasal use

of naloxone for the urgent treatment of opioid

overdose in the community

Recall the results of the NYS pilot project to increase

public safety personnel access to naloxone

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Why Do We Have anOpioid Overdose Epidemic?

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What Are Opioids?

Drugs derived from, or similar to, opium

Morphine (named after Morpheus, Greek god of sleep)

Heroin

Oxycontin (long acting oral opioid)

Oxycodone (Percocet)

Hydrocodone (Lortab, Vicodin)

Fentanyl

Methadone

Many others

NOT Opioids:

• Cocaine

• Amphetamines

• Valium

• Xanax

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Why Are Opioids So Much Trouble?

Dependency

– Opioids fill receptors in the body

– If taken for a “long” time the body makes more receptors

– If a person does not get medication, receptors are not filled

and a person feels ill – this is withdrawal

Addiction

– People may need escalating doses of opioid to feel the

same way they did once – “chasing the dragon”

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Strategies to Address Overdose

Prescription monitoring programs

– Paulozzi et al. Pain Medicine 2011

Prescription drug take back events

Safe opioid prescribing education

– Albert et al. Pain Medicine 2011; 12: S77-S85

Expansion of opioid agonist treatment

– Clausen et al. Addiction 2009:104;1356-62

Safe injection facilities

– Marshall et al. Lancet 2011:377;1429-37

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Drug Treatment: Opioid Dependence

Methadone and buprenorphine (Suboxone, Zubsolv)

are medications used to treat opioid dependence

If taken daily these medications reduce the risk of

overdose death by as much as 80%

Both may be diverted and sold on the street for

recreational use and for self administration to avoid

withdrawal

Incorrect use of methadone has a much higher risk for

overdose than does buprenorphine

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Heroin User Experiences

About 2% of heroin users die each year,

many from heroin overdose

1/2 to 2/3 of heroin users experience at least one

nonfatal overdose

80% have observed an overdose

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Sporer BMJ 2003, Coffin Acad Emerg Med 2007

Who Overdoses?

Among heroin users it has generally been those who

have been using 5-10 years

– After rehab

– After incarceration

Less is known about prescription opioid users

Anecdotal reports of youth dying suggest that many of

those have been in drug treatment and relapse

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Sporer 2003, 2006

Risk Factors for Overdose

Using alone

Reduced tolerance

Mixing drugs

Major changes in opioid supply/ Variations in strength

of street drugs

– >1000 deaths USA 2006 with fentanyl

Depression

History of previous overdose

Injection drug use

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Sporer 2006, Wines 2007, Pollini 2006

http://www.whitehousedrugpolicy.gov/news/fentnyl%5Fheroin%5Fforum

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Context of Opioid Overdose

The majority of heroin overdoses are witnessed

(gives an opportunity for intervention)

Fear of police may prevent calling 911

Witnesses may try ineffectual things

– Myths and lack of proper training

– Abandonment is the worst response

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Tracy 2005

Signs and Symptoms of Opioid OD

Unresponsive or minimally responsive

Not breathing or respiratory arrest

Slow breathing (< 10 per minute)

Snoring with gurgling

Blue or ashen color (cyanosis)

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How Overdose Occurs

Opioids repress the urge to breathe

Carbon dioxide levels increase

Oxygen levels decrease

Process takes time

There is time to respond, but no time to waste

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How Overdose Occurs

Lack of oxygen may cause brain damage

Breathing stops

Slow breathing

Heart stops

Death

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Prevention Messages for Users

Use with others who know what to do if an overdose

happens – make a plan

Be aware of companions at all times when using

Be careful if using alone, especially if:

– Mixing different classes of drugs

– Using after abstinence

– (And watch out for others in these situations)

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Naloxone (Narcan®)

Opioid antagonist which reverses opioid overdose

– Can be administered intravenous, injectable or intranasal

Blocks opioids from acting on the body

Works for about 30-90 minutes

Analogy: “Steals the parking place”

– Naloxone prevents opioids from going where

they want to go

– It steals the “parking place”

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Naloxone in Action

Causes sudden withdrawal in the opioid dependent

person – an unpleasant experience

Doesn’t get a person “high” and is not addictive

Has no effect if an opiate is not present

Routinely used by EMS for over 40 years

Available for use as first aid on another person in

many states, including New York

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Models of Overdose Treatment

Increasing Access to Naloxone

Community prescribing/distribution to drug user

and/or social networks

Prescribing in outpatient care

Increasing access among first responders

Pharmacy collaborative agreements

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Chicago

First in the country in 1992

Founder died of an OD in 1996

Program was illegal, but not prosecuted

SCARE ME

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Overdose Fatality Prevention Programs that Distribute Naloxone: USA, 2010

2010 survey of programs known to the Harm

Reduction Coalition

189 local programs in 16 states ranging from

state-funded to underground

1996 - 2010:

– 53,339 individuals received kits

– 10,194 overdose reversals reported

CDC MMWR February 17, 2012http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6106a1.htm

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States with 3rd Party Naloxone Laws

(Coffin, 2013)

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Does Naloxone Distribution Help?

Is Naloxone Distribution Decreasing Mortality?

Observational studies in places with overdose

prevention programs find an association with

reductions in overdose deaths:

– Massachusetts, New York City, San Francisco,

Baltimore, Pittsburgh, Chicago

More studies are in progress

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Incremental Cost Effectiveness Ratio

ICER = Added cost of intervention divided by increase

in Quality Adjusted Life Years

Generally accepted efficacy threshold is $50,000/year

Chlamydia screening < $14,000

Problem drinking screening and counseling

< $14,000

Naloxone provision $438 - $14,000 depending on

variables used

Coffin 2013

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Logistics of a CommunityAccess Program

Naloxone Preparations

Injectable

– Less expensive: $1-8 per dose

– Well-documented efficacy

– Requires injection, drawing from a medical vial into a

syringe

Intranasal

– More expensive: $21.00 per dose

– Less well-documented efficacy

– Requires assembly of spray device with nasal adaptor and

naloxone capsule

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Intranasal Administration

Disadvantages

– Vasoconstrictors

(cocaine) prevent

absorption

– Bloody nose, nasal

congestion, mucous

– > 0.5 ml per nostril

likely to run off

Advantages

– Nose is easy access

point for medication

and delivery

– Eliminates risk of a

contaminated needle

stick

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Implementation in NY State

Hundreds of sites registered including:

– Syringe exchange/syringe access sites

– Hospitals

– Drug Treatment Programs

– HIV programs

– Homeless shelters

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Review of NYS Law

Overdose Law in NYS (PHL 3309)

“Community Access Naloxone Law”

Protects the non-medical person who administers

naloxone in setting of overdose from liability

– “shall be considered first aid or emergency treatment”

– “shall not constitute the unlawful practice of a profession”

Allows the medical provider to provide naloxone for

use as first aid on another person

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Syringe Access Programs

Legal to possess syringes in NYS

Chance to enroll people in community access

naloxone programs

Chance to enroll people in treatment programs

Protects users from infections from sharing needles

Gets dirty syringes off the street

Protects public safety personnel and the public from

dirty needles

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Law Enforcement and First Response Naloxone

NYS Good Samaritan 911

Intent: To encourage those present at an overdose to

do the right thing and call for help

This law protects an overdose victim and those who

summon EMS:

– From arrest in the presence of misdemeanor drug

possession and/or underage drinking

– From prosecution in felony possession unless there are

aggravating circumstances, e.g. possession with intent to

sell or outstanding warrants

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Why Our Program in NYS?

Disaster opioid overdoses in areas of New York with

little coverage by advanced EMS providers

Medical providers from rural areas recognized

problem with BLS response and overdose morbidity

Rochester, Mountain Lakes and Suffolk County EMS

were invited to participate in initial development

Career fire department BLS-FR in Rochester

Law enforcement in REMO and Suffolk County

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Skills Addition Matrix

High Reward

Low Frequency

Low Reward

Low Frequency

High Reward

High Frequency

Low Reward

High Frequency

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Law Enforcement Naloxone Success

New Mexico

– Discussed, 2004

– Implemented, 2013

Quincy Massachusetts

– Implemented 2010

– Lt. Pat Glynn

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Law Enforcement Training

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Why Law Enforcement Naloxone?

Why watch someone die?

Early treatment improves outcomes for victim

– Reduced cost in medical care

– Increased potential for seeking rehab

Improves community relations

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Why Police Officers?

Often the first on the scene at an overdose

To be better prepared to assist the public

To assure we are prepared to deal with opioid users in crisis

To improve interactions with the public

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Questions From Officers:

What if we want to get blood for DWAI drugs? Will naloxone effect the forensic testing?

– No. Naloxone may appear on drug screen though.

– You can testify to the person’s presentation, their reaction, and that you reversed their opioid overdose

What if we give it to someone who hasn’t taken opioids?

– Nothing. They get a wet nose.

What about accidental spraying in the air near others?

– Won’t hurt anyone else or you.

So what do we teach the police?

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Intranasal Naloxone

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When to Use Naloxone

Overdose suspected

Not responsive to painful stimuli

Breathing status

Normal or FastSlow

(<10x minute) No or Gasping

Turn on side NaloxoneNaloxoneand CPR

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Administration

Wipe the nose if it is messy

Hold the patient’s head with one hand

Keep the head tilted backward (this prevents the medication from running out of the nostril)

Place the atomizer within one nostril

Gently, but firmly, spray half the vial (about 1 ml) into that nostril

Spray the rest of the medication into the other nostril

Steps to Assemble

Open box; remove yellow and purple caps

Open and attach atomizer

Screw medication into holder

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Hands-On Training

Post-Administration Considerations

Use CAUTION when administering naloxone to

narcotic dependent patients!

Rapid opiate withdrawal may cause nausea and

vomiting and may cause combativeness

Roll patient to their side after administration to keep

airway clear

If patient does not respond within 3-5 minutes,

administer second dose

– Must wait 3-5 minutes or second dose will not be effective

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New York’s pilot for BLS providers

1,978 EMTs trained

Over 200 opioid overdose reversals (40% Suffolk PD)

– 1 reversal for every 10 EMTs trained

No adverse events

No significant hazards to EMS personnel

Case of reduced hazard for EMS personnel

One interesting unplanned complication with law

enforcement…

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Law Enforcement and Naloxone

Law enforcement will frequently be the first on the

scene

Suffolk County Police Department was very proactive

to address problem when it was discovered

Law enforcement policy development to assist with

scope of the NYS 911 Good Samaritan Law

– Patrol directives now in place

– No arrest in cases of simple overdose notification

– No further issues

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What About the Rest of the Country?

All 53 jurisdictions permit Paramedics to administer naloxone

Of the 48 jurisdictions with mid-level EMS personnel, all but

one authorize those personnel to administer naloxone

Only twelve jurisdictions explicitly permit EMTs to administer

naloxone

Five additional states permit some or all EMTs to administer

the drug through pilot programs or agency medical director

authority

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Davis, Walley, Dailey, Southwell, Neihaus, “EMS Naloxone Access:

A National Systematic Legal Review”, Academic EM, August 2014

Naloxone for Basic EMT - 2013

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Results

Additional states may allow BLS personnel or other

first responders to administer naloxone as part of a

separately regulated community access program.

At least four jurisdictions modified law or policy to

expand EMS access to naloxone in 2013.

Many others have changed since this review

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What Did We Learn?

Naloxone for first responders can be a phenomenal success

Must have physician oversight to assure safety to patients and

training of providers

Training and equipping providers should be expanded where

useful

– Law enforcement

– Fire first response

– Others…

Scope of practice expansion for ALL EMS providers

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Thank you.

daileym@mail.amc.edu