This document discusses strategies to address the opioid overdose epidemic, including increasing access to the opioid overdose reversal drug naloxone. It summarizes models of overdose prevention programs that distribute naloxone, studies showing these programs are associated with reductions in overdose deaths, and the cost-effectiveness of naloxone distribution. The document then reviews New York state's law allowing community distribution of naloxone and a pilot program that trained EMTs, law enforcement officers, and other first responders to administer naloxone, resulting in over 200 overdose reversals.

1. Combating the Opioid
Overdose Epidemic
Public Safety Naloxone
Michael W. Dailey, MD FACEP
Regional EMS Medical Director
Associate Professor
of Emergency Medicine

2. 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
2

3. 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
3

4. Why Do We Have an
Opioid Overdose Epidemic?

5. 5

6. 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
6

7. 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”
7

8. 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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9. 9

10. 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
10

11. 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
Sporer BMJ 2003, Coffin Acad Emerg Med 2007
11

12. 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
Sporer 2003, 2006
12

13. 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
Sporer 2006, Wines 2007, Pollini 2006
http://www.whitehousedrugpolicy.gov/news/fentnyl%5Fheroin%5Fforum
13

14. 14

15. 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
15
Tracy 2005

16. 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)
16

17. 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
17

18. How Overdose Occurs
Slow breathing
Breathing stops
Lack of oxygen may cause brain damage
Heart stops
Death
18

19. 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)
19

20. 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”
20

21. 21

22. 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
22

23. Models of Overdose Treatment

24. 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
24

25. Chicago
First in the country in 1992
Founder died of an OD in 1996
Program was illegal, but not prosecuted
SCARE ME
25

26. 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, 2012
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6106a1.htm
26

27. States with 3rd Party Naloxone Laws
(Coffin, 2013)
27

28. Does Naloxone Distribution Help?

29. 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
29

30. 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
30

31. Logistics of a Community
Access Program

32. 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
32

33. 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
33

34. Implementation in NY State
Hundreds of sites registered including:
– Syringe exchange/syringe access sites
– Hospitals
– Drug Treatment Programs
– HIV programs
– Homeless shelters
34

35. Review of NYS Law

36. 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
36

37. 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
37

38. 38

39. Law Enforcement and
First Response Naloxone

40. 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
40

41. 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
41

42. Skills Addition Matrix
High Reward
Low Frequency
Low Reward
Low Frequency
High Reward
High Frequency
Low Reward
High Frequency
42

43. Law Enforcement Naloxone Success
New Mexico
– Discussed, 2004
– Implemented, 2013
Quincy Massachusetts
– Implemented 2010
– Lt. Pat Glynn
43

44. Law Enforcement Training

45. 45
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

46. 46
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

47. 47
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.

48. So what do we teach the police?

49. 49
Intranasal Naloxone

50. 50
When to Use Naloxone
Overdose suspected
Not responsive to painful stimuli
Breathing status
Normal or Fast
Slow
(<10x minute) No or Gasping
Turn on side Naloxone
Naloxone
and CPR

51. 51
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

52. Steps to Assemble
Open box; remove
yellow and purple caps
Open and attach
atomizer
Screw medication
into holder
52

53. Hands-On Training

54. 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
54

55. 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…
55

56. 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
56

57. 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
57
Davis, Walley, Dailey, Southwell, Neihaus, “EMS Naloxone Access:
A National Systematic Legal Review”, Academic EM, August 2014

58. Naloxone for Basic EMT - 2013
58

59. 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
59

60. 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
60

61. Thank you.
daileym@mail.amc.edu