Bill Matthews from the Harm Reduction Coalition presents an overview of opiate overdose prevention. Presented at the Harm Reduction Coalition's 8th National Conference, November 18-21, 2010 in Austin, Texas.
7. 7
Death Rates for the Three Leading Causes of
Injury Death 1979--2007
CDC Morbidity and Mortality Weekly Report, August 6, 2010
8. 8
Motor-Vehicle & Poisoning Death Rates,
2005- 2006
• Among adults aged 34-56 years, poisoning death rates were higher than
motor –vehicle traffic death rates.
• 92% of poisoning deaths involved drugs.
National Vital Statistics System, mortality data, http://www.cdc.gov/nchs/deaths.htm.
9. 9
Injection drug and heroin use: 2006
New York City
Estimates
150- 200,000 heroin users, at least 50%
of whom inject regularly
• 108,500 injection drug users
• Unknown number of prescription opioid
users
Frank MSJM 2000, Friedman 2005, Des Jarlais – personal communication
10. 10
Heroin Overdose
Epidemiology
About 2% of heroin users die each year- many
from heroin overdose
New York City, 2006: 979 OD deaths (70% due to
opioids) = ~ 685 opioid deaths
Up to 2/3 of heroin users experience at least one
nonfatal overdose
Sporer BMJ 2002, Galea 2003, Coffin Acad Emerg Med 2007
12. 12
Who overdoses?
• Happens most often in dependent long
term users with 5- 10 years of experience
rather than new users
Sporer 2003, 2006
14. 14
Physiology
• Generally happens over course of 1-3 hours-
the stereotype “needle in the arm” death is
only about 15%
• Opioids repress the urge to breath –
decrease response to carbon dioxide -leading
to respiratory depression and death
Slow breathing>Breathing stops>Heart
stops>Circulation of blood to the brain stops
15. 15
Context of Opioid Overdose
• The majority of overdoses are witnessed
(gives an opportunity for intervention)
• Fear of police may prevent calling 911
• Witnesses may try ineffectual things
– Myths and lack of proper training
– Abandonment is the worst response
Tracy 2005
16. 16
An Antidote exists
• Naloxone (Narcan) is an opioid antagonist
which reverses the effects of opioids
preventing fatal overdose
• Pushes most other opioids off the opioid
receptors and continues to blocks them for
30-90 minutes
17. 17
Legal Status- New Overdose Law in
New York State (Effective April 1,
2006)
• Protects the non-medical person who administers
naloxone in setting of overdose from liability.
– “shall be considered first aid or emergency
treatment”.
– “shall not constitute the unlawful practice of a
profession”.
• Allows the medical provider to provide naloxone for
secondary administration.
• NYSDOH created regulations for implementation of
opioid overdose prevention programs.
• Naloxone must be dispensed by MD, PA, NP by
federal regulation
18. 18
Components of Opioid Overdose
Prevention Training
• What is naloxone?
• What are opioids?
• Prevention and understanding risk factors:
• Overdose recognition
• Action Call 911
– Rescue breathing- using dummy
– Naloxone administration and how it works
– Recovery position
• Report and get refill
• Legality
21. 21
Risk Factors for Opioid
Overdose
• Reduced
Tolerance
• Illness
• Depression
• Unstable housing
• Mixing Drugs
• Changes in the Drug
Supply
• History of previous
overdose
• Using in a new
environment
22. Overdose deaths in New York
City involve multiple drugs
(2008)
Nearly all unintentional drug overdose deaths (98%)
involve more than one substance, including alcohol.
Opioids were the most commonly noted drug type
(74%). Types of opioids included heroin,
methadone, and prescription pain relievers.
Other drugs commonly found were: cocaine (53%),
benzodiazepines (35%), antidepressants (26%),
and alcohol (43%).
NYC VITAL SIGNS Volume 9, No. 1, NYCDOHMH
23. 23
Lowered tolerance: Major risk
• Tolerance- repeated use of a substance may
lead to the need for increased amounts to
product the same effect
• Abstinence decreases tolerance increasing
overdose risk
– Incarceration
– Hospitalization
– Drug treatment/ Detox/ Therapeutic communities
– Sporatic patterns of drug use
– Sporer 2007, Binswanger 2007
24. 24
Risk factor: Overdose Death
following Incarceration
Cause of Death in the 2 weeks post-
incarceration
Washington State Corrections – studied 30,237 inmates
released (7/99-12/03)
Former Inmates were:
– 12.7 times more likely to die vs. WS residents of same
age, race, and sex
– 129 times more likely to die of overdose vs WS residents
• Opioids: 60%
• Cocaine and other stimulants: 74%
• Binswanger et al., 2007
25. 25
Other risk factors
• Significant illness
• 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
• Using alone increases risk of death
Sporer 2006, Wines 2007, Pollini 2006
http://www.whitehousedrugpolicy.gov/news/fentnyl%5Fheroin%5Ff
orum,
27. 27
Continuum of Overdose
• Overdose is rarely immediate – can happen
over 1-3 hours
• Heavy/ Uncontrollable Nodding
– Still arousable
– Snoring or loud breathing
– May have excess drooling
• Overdose
– Not responsive
– Very shallow breathing, gurgling
– Skin changes, blue lips and nails
• Fatal Overdose
28. 28
Recognition
• Opioid overdose happens over time
• Blue lips and nail beds
• Slow or no breathing, gurgling, snorting
sound
• Not responsive*
29. 29
Stimulate the person overdosing
• Shake, call name loudly
• Sternal rub: rub knuckles hard up and
down breast bone (it hurts!)
(Ice can work but this is easier)
30. 30
Step One: Get Help
• Call 911- “My friend is unconscious/not
breathing”
• This phrase is more likely to bring
paramedics with naloxone than EMT, who
don’t carry it
• Give location
• No need to say “overdose”
• Police may come
31. 31
Check for breathing
• Chest rising and falling
• Nostrils moving in and out
• Mirror or glass by nose or mouth will fog
up
32. 32
Step Two: Rescue breathing
Rescue breathing alone can sustain
someone until EMS arrives
Mouth to mouth is
using a dummy for
practice (if available)
Chest compressions not
included (unless
Responder is trained
in CPR)
33. 33
Rescue Breathing
• Tilt back head to open airway
• Hold nose, lift chin
• Make a seal over the mouth with your
mouth
• Start with 2 quick breaths then one breath
about every 5 seconds until EMS arrives
or person breathes on their own.
34. 34
Naloxone preparations
• Injectable
– Inexpensive: $2 - 3.00 per dose
– Well-documented efficacy
– Requires injection, drawing from a medical
vial into a syringe
• Intranasal
– More expensive: $19.25 per dose
– Less well-documented efficacy
– Requires assembly of spay device with nasal
adaptor and naloxone capsule
35. 35
The injectable kit contains:
• A face mask for rescue breathing
• Two safety syringes
• 2 vials of Naloxone
• 2 alcohol swabs
• 2 latex gloves
• 1 brochure reviewing OD and rescue
steps.
• Contact information for program
36. 36
Administration of Naloxone
• Inject into a muscle
or
spray up nose
• Acts within 2-8 minutes
• If no response in 2-5 minutes, give 2nd
dose
• Lasts for 30 – 90 minutes
• (reminder that if 911 has not been called
do it now!!)
37. 37
Recovery Position
• If you must leave the overdoser even for
a few minutes put them into the
recovery position so they won’t
choke on vomit
38. 38
Naloxone in Action
• Reverses opiate effect of sedation and
respiratory depression
• Causes sudden withdrawal in the opioid
dependent person – an unpleasant
experience
• No psychoactive effects – low potential for
diversion, is not addictive
• Routinely used by EMS (but in larger
doses)
• Has no effect if an opiate is not present
• Sold over the counter in Italy
39. 39
More about Naloxone
• It is regulated but not a controlled
substance
• Need to obtain from a licensed prescriber
• Should be stored at room temperature and
away from direct light (in kit is OK)
• Has a limited shelf life. Note expiration
date and obtain replacement
40. 40
Results: awake and breathing
Narcan wears off in 30-90 minutes
• Don’t leave the overdoser alone as
sedation may return
• Reassure the overdoser if s/he is drug
sick- the naloxone will wear off- don’t use
more heroin to feel better!!
• Encourage survivor to go to the hospital
41. 41
Safety in the field
Over 3,500 kits distributed
319 overdose reversals reported
• 1 unsuccessful revival
• 1 seizure
• 1 vomited
• Only 5 cases with more than 1 injection
• No cases of re-treatment after naloxone wore off
• Maxwell 2006
42. 42
Trained Overdose Responder
Responsibilities
• Complete initial opioid overdose
prevention training
• Complete refresher training at least every
2 years
• Contact EMS if suspected drug overdose
and advise if naloxone was used
• Report all opioid overdose responses/
naloxone administration to program
director and get a refill
43. 43
HRC initiative
• 2004 Tides grant: Trained over 90 participants at
one SEP
• 2005 – 2010 NYCDOHMH grant
– > 5,000 participants trained as overdose
responders and provided with overdose rescue kits
– Primarily at 14 syringe exchange programs, now
expanding to CBOs
About 350 overdose reversals reported to date
(10/10)
44. 2010 NOPE Survey of naloxone
distribution in US since 1996
• 53,339 kits dispensed
• 10, 194 overdose reversals reported
• 2010: Distribution from 155 sites in 16
states
• 38,860 units of naloxone dispensed
7/09 – 6/10
• Types of naloxone: 42% 1 mL vials, 67%
10 mL vials, 17% 2 mL Intranasal
Naloxone Overdose Prevention, Education (NOPE)
Eliza Wheeler <wheeler@harmreduction.org>
44
45. 45
Number and rate per 100,000 New Yorkers of
unintentional drug overdose deaths 1999-2008
663 675
666
749
874
812
778
827
766
799
9.7
11.1
13.2
12.4
12
12.7
11.9
12.5
10.6
10.5
0
100
200
300
400
500
600
700
800
900
1000
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Number
of
unintentioanl
drug
overdose
deaths
0
2
4
6
8
10
12
14
Age-adjusted
mortality
rate
per
100,000
population
Number of unintentional drug overdose deaths
Age-adjusted unintentional drug overdose death rates per 100,000 New Yorkers
Source: Bureau of Vital Statistics NYC DOHMH, 1999-2008; 2008 data are preliminary
47. 47
Experience in other US cities
• Population-level changes in mortality already
observable in some cities:
• 34% reduction in countywide fatal overdoses in
Cook County, IL, (Chicago) from 1999 – 2003
• 19% reduction in city-wide overdose fatalities in
Baltimore after the program’s first year of
operation
• San Francisco: 2,235 kits dispensed, 501
reversals, from 2003 – August, 2010.
• Scott, 2007; 3/28/05 Baltimore Sun; DOPE Project, reported by Eliza Wheeler, 9/10
48. Heroin overdoses dropping
Allegheny County Trends in Accidental Drug Overdose Deaths
2000-2006*
*Data is from Allegheny County Medical Examiners Annual Reports and includes all
overdose deaths where these drugs were present at time of death, not necessarily cause of
death.
49. Heroin Use in Allegheny County by Fiscal
Year
*Data from Pennsylvania Department Of Health
50. 50
To receive a kit
• A medical professional must dispense the
naloxone kits. (Naloxone is regulated like
any other medication but is not a
controlled substance.)
• This requires a very brief medical history.
• Prescribers will usually give a prescription
saying naloxone and syringes“dispensed”
to keep in the kit.
51. 51
Who may offer an Opioid
Overdose Prevention Program?
• Licensed health care
facilities :
– Hospitals
– Diagnostic & Treatment
Centers
• Drug treatment programs
• Health care practitioners:
– Physicians
– Physician assistants
– Nurse practitioners
• CBOs with the services of
a clinical director
• Local health departments
52. 52
Overdose Program
Requirements
• Register with NYSDOH, update info
• Have P&P and training curriculum
• Keep log of trained OD responders,and
dates of trainings
• Have list of staff doing OD trainings
• Medical provider when naloxone given
• Send OD reversal reports to NYSDOH
and keep copy
53. 53
Overdose Program Staff
• Overdose Program Director- required
• Overdose Clinical Director- required
• Physician
• Physician assistant
• Nurse practitioner
• Affiliated prescribers, who must be physicians,
physician assistants or nurse practitioners
• Overdose Prevention Trainers
54. 54
Available resources
• Naloxone kits (free from NYSDOH)
• Sample policies and procedures
• Approved curriculum
• Fact sheets
• Sample medical history
• Certificates of completion
• OD reporting form
55. 55
Conclusions
• Many overdoses can be prevented
• Ask about risk factors and educate patients
• Overdose training consists of a few basic
components
• Integrate into intake, medical visits and patient care
• Drug users, friends, and family can learn to
prevent and safely treat overdose
• Goals:
• Overdose training as standard of care
• Naloxone available over the counter
56. 56
RESOURCES
• Harm Reduction Coalition
(harmreduction.org)
NYSDOH(www.health.state.ny.us -
search for overdose)
• On-line CASAC training and credit
– www.oasas.state.ny.us
The transition from sniffing to injection is significant because injection is an important risk factor for HIV.
In March 2003, the NEW YORK TIMES reported increases in heroin use among whites and Hispanics, with less of an increase among blacks.
Frank, B. An overview of heroin trends in New York City: Past, present and future. Mt. Sinai Journal of Medicine. 2000 Oct-Nov; 67(5-6):340-6.
Neaigus A, Miller M, Friedman SR., Hagen DL., Sifaneck SJ., Ildefonso G & Des Jarlais DC. Potential risk factors for the transition to injecting among non-injecting heroin users: A comparison of former injectors and never injectors. Addiction 1996; (6): 847-860, 2001.
Unfortunately, the reduction in overdose deaths involving heroin, has been overshadowed by a dramatic increase in overdose death from prescription opioids and the total number of overdose deaths has continued to climb.
In 2006, the Allegheny County Medical Examiner reported a total of 252 overdose deaths. Pittsburgh City EMS responded to 735 overdose calls, a 51% increase over the previous year.
(County wide, there were 2,608 overdose calls to 911 in 2006. )
While we initially thought this drop in heroin overdose might be explained by a reduction of heroin USE, anecdotal reports and data from the Pennsylvania Department of Health, actually indicate an INCREASE in heroin use in Allegheny County over the past 6 years.