Get the SKOOP: overdose prevention - Bill Matthews - HRC 2010

3,644 views

Published on

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.

Published in: Health & Medicine
0 Comments
1 Like
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
3,644
On SlideShare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
23
Comments
0
Likes
1
Embeds 0
No embeds

No notes for slide
  • 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.
  • Get the SKOOP: overdose prevention - Bill Matthews - HRC 2010

    1. 1. 1 Get the SKOOP: Skills and Knowledge on Overdose Prevention William Matthews, RPA-C Sharon Stancliff, MD Harm Reduction Coalition November 2010
    2. 2. 4 What is the most dispensed prescription drug in the United States? (number of prescriptions filled; generic and branded products, 2004-06) 4
    3. 3. 5 Top 10 Drugs Dispensed in 2006 1. Hydrocodone/Acetaminophen(Vicodin) 2. Lipitor® 3. Amoxicillin 4. Lisinopril 5. Hydrochlorothiazide 6. Atenolol 7. Zithromax® 8. Furosemide 9. Alprazolam(Xanax) 10. Toprol-XL® Source: http://www.rxlist.com/script/main/hp.asp 5
    4. 4. 6 Opioid treatment admissions: 1999-2009 ages 12-24 0 2000 4000 6000 8000 10000 12000 14000 16000 NYC NYS 1999 2004 2009 NYS OASAS Data Warehouse
    5. 5. 7 Death Rates for the Three Leading Causes of Injury Death 1979--2007 CDC Morbidity and Mortality Weekly Report, August 6, 2010
    6. 6. 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.
    7. 7. 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
    8. 8. 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
    9. 9. 11 What do we know about overdose?
    10. 10. 12 Who overdoses? • Happens most often in dependent long term users with 5- 10 years of experience rather than new users Sporer 2003, 2006
    11. 11. 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
    12. 12. 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
    13. 13. 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
    14. 14. 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
    15. 15. 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
    16. 16. 19 What are opioids? • heroin • morphine • codeine • methadone • oxycodone – OxyContin – Percodan – Percocet • hydrocodone – Vicodin • fentanyl • hydromorphone – Dilaudid Papaver Somniferum “Poppy Plant”
    17. 17. 20 What are the Risk Factors for Opioid Overdose?
    18. 18. 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
    19. 19. 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
    20. 20. 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
    21. 21. 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
    22. 22. 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 %5Fforum,
    23. 23. 26 What does an Opioid Overdose Look Like?
    24. 24. 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
    25. 25. 28 Recognition • Opioid overdose happens over time • Blue lips and nail beds • Slow or no breathing, gurgling, snorting sound • Not responsive*
    26. 26. 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)
    27. 27. 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
    28. 28. 31 Check for breathing • Chest rising and falling • Nostrils moving in and out • Mirror or glass by nose or mouth will fog up
    29. 29. 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)
    30. 30. 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.
    31. 31. 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
    32. 32. 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
    33. 33. 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!!)
    34. 34. 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
    35. 35. 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
    36. 36. 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
    37. 37. 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
    38. 38. 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
    39. 39. 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
    40. 40. 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)
    41. 41. 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
    42. 42. 45 Number and rate per 100,000 New Yorkers of unintentional drug overdose deaths 1999-2008 663 675 666749874812778827766799 9.7 11.1 13.2 12.4 12 12.7 11.9 12.5 10.610.5 0 100 200 300 400 500 600 700 800 900 1000 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 Numberofunintentioanldrugoverdosedeaths 0 2 4 6 8 10 12 14 Age-adjustedmortalityrateper100,000population 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
    43. 43. Effect of naloxone on overdose death: Chicago, US
    44. 44. 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
    45. 45. 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.
    46. 46. Heroin Use in Allegheny County by Fiscal Year *Data from Pennsylvania Department Of Health
    47. 47. 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.
    48. 48. 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
    49. 49. 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
    50. 50. 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
    51. 51. 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
    52. 52. 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
    53. 53. 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
    54. 54. Harm Reduction Coalition stancliff@harmreduction.org 212-213-6376 ext 39 matthews@harmreduction.org ext 38 57

    ×