OPIOID OVERDOSE: A RHODE
ISLAND INJURY PREVENTION
PRIORITY AREA

Valerie Strezsak
valerie_m_strezsak@brown.edu
Capstone Pr...
Rhode Island ranks seventh
in the nation for overdose
deaths (17.2 deaths per
100,000 persons according to
the Centers for...
and is one of 20 states where
unintentional drug overdose
is the leading cause of
unintentional injury-related
death.

3
How did this happen, and what
is being done to address it?

4
OBJECTIVES OF THIS PRESENTATION


Overview of the problem
What are opioids?
 What is an opioid overdose?




Opioid ov...
WHAT ARE OPIOIDS? WHAT DO THEY DO?
Opioids are narcotic pain relievers
 They bind to specific receptors in the brain, spi...
TYPES OF PRESCRIPTION OPIOIDS
Morphine
 Codeine
 Methadone
 Oxycodone
 Hydrocodone
 Fentanyl
 Hydromorphone
 Bupren...
HEROIN: A NON-PRESCRIPTION OPIOID


Unlike prescription
opioids, there is no
legal use for heroin

8
HOW DOES OPIOID OVERDOSE OCCUR?


Dosing error
By prescriber, pharmacist, patient, caregiver
 Unintentional in the commo...
WHAT HAPPENED WHEN PERSON
OVERDOSES?

10
SCOPE OF THE PROBLEM
Overdoses killed nearly 15,000
people in the US in 2008, more
than 3 times the 4,000 people
killed by...
INJURY PYRAMID: DEATH IS THE PROVERBIAL TIP
OF THE ICEBERG

12
THE VICTIMS MAY NOT BE WHO YOU EXPECT
THEM TO BE…

13
INDIVIDUAL RISK OF OVERDOSE
Anyone using opioids is at risk of overdose
 Increased risk associated with:









...
THERE HAS BEEN A MARKED INCREASE IN
OPIOID OVERDOSE IN PAST DECADE+

15
IS THE EPIDEMIC AN UNINTENDED
CONSEQUENCE OF PAIN MANAGEMENT?


2001 Joint
Commission Pain
Management
Standards called fo...
INCREASE IN OPIOID USE IS
CLEAR, ALTHOUGH PREDATES 2001
STANDARDS

17
OPIOIDS ARE INHERENTLY RISKY; WHEN MORE
PEOPLE RECEIVE PRESCRIPTIONS, MORE PEOPLE
WILL OVERDOSE

18
OVERLAP OF PRESCRIPTIONS AND OVERDOSE:
NOT PERFECT, BUT TRENDS ARE EVIDENT

19
OPIOID OVERDOSE IN RHODE ISLAND

20
RHODE ISLAND VIOLENCE AND INJURY
PREVENTION PROGRAM (VIPP)
Identifies injury prevention
priorities
 Supports implementati...
IN 2011, DRUG OVERDOSE PREVENTION &
RESCUE BECAME A VIPP PRIORITY AREA

22
INCREASE IN OPIOID OVERDOSE DEATHS DRIVE
THE INCREASE IN POISONING DEATHS IN RI

23
INCREASE IN RI OVERDOSE DEATHS
MIRRORS INCREASE IN US

24
GENDER DIFFERENCE IS CLEAR: MORE MEN HAVE
DIED OF OPIOID OVERDOSE IN RI

25
MOST DEATHS HAVE OCCURRED IN MIDDLEAGED ADULTS IN RI

26
DEATHS ONLY REPRESENT A FRACTION OF THE
TOTAL IMPACT OF OPIOID OVERDOSE INJURIES IN
RI, AS IN THE US

27
VIPP DRUG PREVENTION OVERDOSE AND
RESCUE SUBCOMMITTEE
Goal: Prevent death from unintentional drug
overdose
 Current objec...
HOW TO ACCOMPLISH GOAL?


Drug Overdose Prevention and Rescue
Subcommittee recommends 10 strategies:

29
Establish statewide overdose
surveillance mechanisms.

30
Increase usage and
effectiveness of the
Prescription Monitoring
Program (PMP).

31
Increase access to naloxone
training and distribution
programs.

32
Increase licensed healthcare
worker and institutional
responsibility.

33
Implement and expand
disposal units throughout the
state.

34
Support prevention policies
that work.

35
Increase general public
awareness of drug overdose
as a preventable public
health problem.

36
Support and affirm people at
risk for drug overdose.

37
Increase access to
substance abuse treatment.

38
Build state capacity to
implement drug overdose
prevention and rescue
programs.

39
Future
Directions: How
to Choose
Interventions?

40
Lack of
evidence at this
point; epidemic
is still fairly
new!

41
FEDERAL GOVERNMENT EFFORTS
CDC released several
promising
recommendations, including
establishment and use of
Prescription...
RHODE ISLAND-SPECIFIC EFFORTS
Rhode Island initiative: pilot study Preventing
Overdose and Naloxone Intervention (PONI)
 ...
Continued and improved
surveillance and
evidence-based methods
are underway to reverse
the opioid epidemic in RI
and the U...
CITATIONS, BY SLIDE NUMBER


2: http://www.123rf.com/photo_11850338_drug-overdose-concept--passive-hand-on-floor-pills-an...
CITATIONS, CONTINUED


17: http://dartmed.dartmouth.edu/summer09/html/vs_opioid.php



18: http://jama.jamanetwork.com/a...
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Opioid Overdose in Rhode Island, December 2013

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Overview of opioid overdose, development of the epidemic in the US, and a focus on efforts in Rhode Island to address this public health concern.

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Opioid Overdose in Rhode Island, December 2013

  1. 1. OPIOID OVERDOSE: A RHODE ISLAND INJURY PREVENTION PRIORITY AREA Valerie Strezsak valerie_m_strezsak@brown.edu Capstone Project, December 2013 Injury as a Public Health Problem
  2. 2. Rhode Island ranks seventh in the nation for overdose deaths (17.2 deaths per 100,000 persons according to the Centers for Disease Control and Prevention)... 2
  3. 3. and is one of 20 states where unintentional drug overdose is the leading cause of unintentional injury-related death. 3
  4. 4. How did this happen, and what is being done to address it? 4
  5. 5. OBJECTIVES OF THIS PRESENTATION  Overview of the problem What are opioids?  What is an opioid overdose?   Opioid overdose at the national level Scope of the problem  Risk factors  Development of the epidemic   Opioid overdose in Rhode Island Why opioid overdose is now a priority area  Planned approaches to reduce opioid overdose   Future directions 5
  6. 6. WHAT ARE OPIOIDS? WHAT DO THEY DO? Opioids are narcotic pain relievers  They bind to specific receptors in the brain, spinal cord, and gastrointestinal tract  Minimize perception of pain  Can also trigger other systems such as those that regulate mood, breathing, and blood pressure  6
  7. 7. TYPES OF PRESCRIPTION OPIOIDS Morphine  Codeine  Methadone  Oxycodone  Hydrocodone  Fentanyl  Hydromorphone  Buprenorphine  7
  8. 8. HEROIN: A NON-PRESCRIPTION OPIOID  Unlike prescription opioids, there is no legal use for heroin 8
  9. 9. HOW DOES OPIOID OVERDOSE OCCUR?  Dosing error By prescriber, pharmacist, patient, caregiver  Unintentional in the commonly understood sense, an “accident”   Deliberate misuse Of own prescription (taking larger and/or more frequent doses than prescribed)  Of opioids obtained illicitly  Typically considered unintentional, in that the individual did not intend to overdose, even though he/she did intentionally use the drug  9
  10. 10. WHAT HAPPENED WHEN PERSON OVERDOSES? 10
  11. 11. SCOPE OF THE PROBLEM Overdoses killed nearly 15,000 people in the US in 2008, more than 3 times the 4,000 people killed by overdose in 1999  Nonmedical use of prescription painkillers costs health insurers up to $72.5 billion annually in direct health care costs.  11
  12. 12. INJURY PYRAMID: DEATH IS THE PROVERBIAL TIP OF THE ICEBERG 12
  13. 13. THE VICTIMS MAY NOT BE WHO YOU EXPECT THEM TO BE… 13
  14. 14. INDIVIDUAL RISK OF OVERDOSE Anyone using opioids is at risk of overdose  Increased risk associated with:        Misuse of prescription, including combining opioids with other substances such as alcohol History of substance abuse, dependence Gender: men are much more likely to overdose, but the rate of overdose among women is increasing Age: middle-aged adults are at increased risk Living in a rural locale increases risk Race: whites and American Indians/Alaskan Natives are at the greatest risk 14
  15. 15. THERE HAS BEEN A MARKED INCREASE IN OPIOID OVERDOSE IN PAST DECADE+ 15
  16. 16. IS THE EPIDEMIC AN UNINTENDED CONSEQUENCE OF PAIN MANAGEMENT?  2001 Joint Commission Pain Management Standards called for more attention to and treatment of pain  Increase in opioid overdose deaths coincided with a nearly fourfold increase in use of prescriptions for pain medication 16
  17. 17. INCREASE IN OPIOID USE IS CLEAR, ALTHOUGH PREDATES 2001 STANDARDS 17
  18. 18. OPIOIDS ARE INHERENTLY RISKY; WHEN MORE PEOPLE RECEIVE PRESCRIPTIONS, MORE PEOPLE WILL OVERDOSE 18
  19. 19. OVERLAP OF PRESCRIPTIONS AND OVERDOSE: NOT PERFECT, BUT TRENDS ARE EVIDENT 19
  20. 20. OPIOID OVERDOSE IN RHODE ISLAND 20
  21. 21. RHODE ISLAND VIOLENCE AND INJURY PREVENTION PROGRAM (VIPP) Identifies injury prevention priorities  Supports implementation and evaluation of statewide interventions based on population-based recommendations  21
  22. 22. IN 2011, DRUG OVERDOSE PREVENTION & RESCUE BECAME A VIPP PRIORITY AREA 22
  23. 23. INCREASE IN OPIOID OVERDOSE DEATHS DRIVE THE INCREASE IN POISONING DEATHS IN RI 23
  24. 24. INCREASE IN RI OVERDOSE DEATHS MIRRORS INCREASE IN US 24
  25. 25. GENDER DIFFERENCE IS CLEAR: MORE MEN HAVE DIED OF OPIOID OVERDOSE IN RI 25
  26. 26. MOST DEATHS HAVE OCCURRED IN MIDDLEAGED ADULTS IN RI 26
  27. 27. DEATHS ONLY REPRESENT A FRACTION OF THE TOTAL IMPACT OF OPIOID OVERDOSE INJURIES IN RI, AS IN THE US 27
  28. 28. VIPP DRUG PREVENTION OVERDOSE AND RESCUE SUBCOMMITTEE Goal: Prevent death from unintentional drug overdose  Current objective: decrease or maintain rate of death due to unintentional poisonings at 2009 level of 13 per 100,000  28
  29. 29. HOW TO ACCOMPLISH GOAL?  Drug Overdose Prevention and Rescue Subcommittee recommends 10 strategies: 29
  30. 30. Establish statewide overdose surveillance mechanisms. 30
  31. 31. Increase usage and effectiveness of the Prescription Monitoring Program (PMP). 31
  32. 32. Increase access to naloxone training and distribution programs. 32
  33. 33. Increase licensed healthcare worker and institutional responsibility. 33
  34. 34. Implement and expand disposal units throughout the state. 34
  35. 35. Support prevention policies that work. 35
  36. 36. Increase general public awareness of drug overdose as a preventable public health problem. 36
  37. 37. Support and affirm people at risk for drug overdose. 37
  38. 38. Increase access to substance abuse treatment. 38
  39. 39. Build state capacity to implement drug overdose prevention and rescue programs. 39
  40. 40. Future Directions: How to Choose Interventions? 40
  41. 41. Lack of evidence at this point; epidemic is still fairly new! 41
  42. 42. FEDERAL GOVERNMENT EFFORTS CDC released several promising recommendations, including establishment and use of Prescription Monitoring Program  Substance Abuse Mental Health Services Administration released the first federal resource promoting safety and prevention information in October 2013  42
  43. 43. RHODE ISLAND-SPECIFIC EFFORTS Rhode Island initiative: pilot study Preventing Overdose and Naloxone Intervention (PONI)  From Discussion of publication:  43
  44. 44. Continued and improved surveillance and evidence-based methods are underway to reverse the opioid epidemic in RI and the US as a whole 44
  45. 45. CITATIONS, BY SLIDE NUMBER  2: http://www.123rf.com/photo_11850338_drug-overdose-concept--passive-hand-on-floor-pills-andinjection.html; http://www.health.ri.gov/publications/plans/2013InjuryPrevention.pdf  3: http://prescription-drug.addictionblog.org/oxycontin-overdose-how-much-amount-of-oxycontin-to-od/; http://www.health.ri.gov/publications/plans/2013InjuryPrevention.pdf  4: http://imagebing.portrait-photo.net/ocean-drive-newport-rhode/  7: http://atforum.com/news-updates/201104.php  8: http://www.neurosoup.com/heroin/  10: http://harmreduction.org/issues/overdose-prevention/overview/overdose-basics/what-is-anoverdose/  11: http://atforum.com/news/2013/06/the-soaring-cost-of-the-opioid-economy/  12: http://www.cdc.gov/homeandrecreationalsafety/rxbrief/  13: http://www.cdc.gov/vitalsigns/PainkillerOverdoses/index.html  15: http://www.ripha.org/content/ripha/Data_Briefs/Data_Brief_Prescription_Drug_Deaths_12192011_FIN.p df  16: http://www.va.gov/painmanagement/docs/toolkit.pdf 45
  46. 46. CITATIONS, CONTINUED  17: http://dartmed.dartmouth.edu/summer09/html/vs_opioid.php  18: http://jama.jamanetwork.com/article.aspx?articleid=1686609  19: http://www.cdc.gov/vitalsigns/painkilleroverdoses/infographic.html  20: http://www.maripoisoncenter.com/prescription.html  21: http://vaccinenewsdaily.com/medical_countermeasures/326126-health-warns-rhode-islanders-tobeware-of-risk-of-shigella-infection/; http://www.health.ri.gov/publications/plans/2013InjuryPrevention.pdf  22-39: http://www.health.ri.gov/publications/plans/2013InjuryPrevention.pdf  28: http://www.heretohelp.bc.ca/factsheet/dealing-with-alcohol-or-other-drug-overdose-situations  41: http://www.flprobatelitigation.com/2010/11/articles/new-probate-cases/will-and-trust-contests/trusteeguardianship-litigation-no-evidence-reversal-on-all-grounds/  42: http://store.samhsa.gov/product/opioid-overdose-prevention-toolkit/all-new-products/sma13-4742  43: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3177423/  44: http://www.bryandunlop.com/what-we-do/consultative-selling/ 46

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