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OVERDOSE SOLUTIONS 2013 ADDRESSING OPIOID OVERDOSE WITH COMMUNITY-BASED EDUCATION AND NALOXONE RESCUE KITS Alexander Walley, MD MS c Medical Director,

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Presentation on theme: "OVERDOSE SOLUTIONS 2013 ADDRESSING OPIOID OVERDOSE WITH COMMUNITY-BASED EDUCATION AND NALOXONE RESCUE KITS Alexander Walley, MD MS c Medical Director,"— Presentation transcript:

1 OVERDOSE SOLUTIONS 2013 ADDRESSING OPIOID OVERDOSE WITH COMMUNITY-BASED EDUCATION AND NALOXONE RESCUE KITS Alexander Walley, MD MS c Medical Director, Massachusetts Dept. of Public Health Opioid Overdose Prevention Pilot

2 Addressing opioid overdose with community-based education and naloxone rescue kits Alexander Y. Walley, MD, MSc Boston University School of Medicine Boston Medical Center Allegheny County Overdose Prevention Coalition Wednesday, July 24 th, :15am-10:45am

3 Disclosures – Alexander Y. Walley, MD, MSc The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: –Consultant for Social Sciences Research Inc. which is developing a training module for first responders My presentation will include discussion of “off-label” use of the following: –Naloxone is FDA approved as an opioid antagonist –Naloxone delivered as an intranasal spray with a mucosal atomizer device has not been FDA approved and is off label use Funding: CDC National Center for Injury Prevention and Control 1R21CE

4 Learning objectives At the end of this session, you will know: 1.Epidemiology of overdose, the rationale and history of the MA OEND program 2.The scope of the MA OEND program 3.Effectiveness of OEND: INPEDE OD Study 4.Venues and models 5.How to incorporate OEND into medical settings 6.To acknowledge and address overdose stigma

5 The source of the data is: Registry of Vital Records and Statistics, MA Department of Public Health Poisoning Deaths vs. Motor Vehicle-Related Injury Deaths, MA Residents ( ) More Opioid Overdose Deaths than MVA Deaths in Massachusetts

6 The source of the data is: Registry of Vital Records and Statistics, MA Department of Public Health Poisoning Deaths vs. Motor Vehicle-Related Injury Deaths, MA Residents ( ) More Opioid Overdose Deaths than MVA Deaths in Massachusetts Rate of opioid-related fatal overdoses in MA in 2006 was 9.9 per 100K

7 Motor vehicle traffic, poisoning, drug poisoning, and unintentional drug poisoning death rates: United States, NOTES: Drug poisoning deaths are a subset of poisoning deaths. Unintentional drug poisoning deaths are a subset of drug poisoning deaths. SOURCE: CDC/NCHS, National Vital Statistics System; and Warner M, Chen LH, Makuc DM, Anderson RN, Miniño AM. Drug poisoning deaths in the United States, 1980–2008. NCHS data brief, no 81. Hyattsville, MD: National Center for Health Statistics Intercensal populations

8 Allegheny County Trends in Accidental Drug Overdose Deaths * * 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.

9 Opioid overdose costs $20.4 billion per year in 2009 – $2.2 billion direct costs inpatient, ED, MDs, ambulance – $18.2 billion indirect costs lost productivity from absenteeism and mortality $37,274 cost per opioid overdose event Inocencio TJ et al. Pain Medicine 2013

10 What is Driving the Increase in Overdose? New Drug Use Patterns –New Initiates to prescription drugs –Vicodin/Percocet/oxycodone >>> heroin Heroin Availability/Purity/Lethal Mixture –Heroin is the leading drug threat in New England –From ‘93-’10 Heroin reported as primary drug increased from 20% - 40% of treatment admissions in MA Prescribing Patterns –Schedule II Opioid prescriptions more than doubled since the 1990s

11 Strategies to address overdose Prescription monitoring programs – Paulozzi et al. Pain Medicine 2011 Prescription drug take back events – Safe disposal Safe opioid prescribing education – Albert et al. Pain Medicine 2011; 12: S77-S85 Expansion of opioid agonist treatment – Clausen et al. Addiction 2009:104; Safe injection facilities – Marshall et al. Lancet 2011:377;

12 Rationale for overdose education and naloxone distribution Most opioid users do not use alone Known risk factors: – Mixing substances, abstinence, using alone, unknown source Opportunity window: – opioid OD takes minutes to hours and is reversible with naloxone Bystanders are trainable to recognize OD Fear of public safety

13 2010 States w/ OENDs 15 Programs 188 People enrolled 53,032 OD rescues 10,171 Wheeler E et al. Morb Mortal Wkly Rep 2012;61: Overdose Education and Naloxone Rescue Kits

14 About Naloxone Naloxone reverses opioid-related sedation and respiratory depression = pure opioid antagonist – Not psychoactive, no abuse potential – May cause withdrawal symptoms May be administered IM, IV, SC, IN Acts within 2 to 8 minutes Lasts 30 to 90 minutes, overdose may return May be repeated Narcan® = naloxone naloxone ≠ Suboxone ≠ naltrexone

15 Evaluations of OEND programs Feasibility – Piper et al. Subst Use Misuse 2008: 43; – Doe-Simkins et al. Am J Public Health 2009: 99: – Enteen et al. J Urban Health 2010:87: – Bennett et al. J Urban Health. 2011: 88; – Walley et al. JSAT 2013; 44:241-7 (Methadone and detox programs) Increased knowledge and skills – Green et al. Addiction 2008: 103; – Tobin et al. Int J Drug Policy 2009: 20; – Wagner et al. Int J Drug Policy 2010: 21: No increase in use, increase in drug treatment – Seal et al. J Urban Health 2005:82: Reduction in overdose in communities – Maxwell et al. J Addict Dis 2006:25; – Evans et al. Am J Epidemiol 2012; 174: – Walley et al. BMJ 2013; 346: f174

16 MA Timeline: Key events & players : 1 CBO underground 2005: 2 CBO underground – Boston EMTs equipped with IN via special project waiver

17 MA Timeline: Key events & players : 1 CBO underground 2005: 2 CBO Boston underground – Boston EMTs equipped with IN via special project waiver 2006: underground suspended >> incorporated, 2 city governments 2007: city, state government, CBOs 2009: expansion to more CBOs and outreach 2010: first responders – police and fire 2011: parents organizations 2012: legislature passed good sam and limited liability protection

18 Implementing the Massachusetts public health pilot: December 2007 Pilot program conducted under DPH/Drug Control Program regulations (M.G.L. c.94C & 105 CMR ) Medical Director issues standing order for distribution Naloxone may be distributed by public health workers

19 Massachusetts DPH standing order Authorizes Registered Programs to maintain supplies of nasal naloxone kits Authorizes Approved Opioid Overdose Trainers to possess and distribute nasal naloxone to approved responders Authorizes Approved Opioid Overdose Responders who are trained by Approved Opioid Overdose Trainers to possess and administer naloxone to a person experiencing an overdose

20 Program Components Approved staff enroll people in the program and distribute naloxone Curriculum delivers education on OD prevention, recognition, and response Referral to treatment available Reports on overdose reversals are collected as enrollees return for refills Enrollment and refill forms submitted to MDPH Kits include instructions and 2 doses

21 Staff Training and Support Staff complete: 4 hour didactic training At least 2 supervised bystander training sessions Sites participate in: Quarterly all-site meetings Monthly adverse event phone conferences

22 Prefilled naloxone ampule Intranasal Administration Pro 1 st line for some local EMS RCTs: slower onset of action but milder withdrawal Acceptable to non-users No needle stick risk No disposal concerns Con Not FDA approved No large RCT Assembly required, subject to breakage High cost: –$ per kit Mucosal Atomization Device (MAD) Luer-lock syringe

23 Program data

24 Enrollments and Rescues: Enrollments – 16,379 individuals – >10 per day Rescues –1,741 reported –>1 per day AIDS Action Committee AIDS Project Worcester AIDS Support Group of Cape Cod Brockton Area Multi-Services Inc. (BAMSI) Bay State Community Services Boston Public Health Commission Greater Lawrence Family Health Center Holyoke Health Center Learn to Cope Lowell House/ Lowell Community Health Center Manet Community Health Center Northeast Behavioral Health Seven Hills Behavioral Health Tapestry Health SPHERE

25 Enrollee characteristics: User n=11,002 Non-User n=5,377 Witnessed overdose ever75%42% Lifetime history of overdose49% Received naloxone ever41% Inpatient detox, past year64% Incarcerated, past year28% Reported at least one overdose rescue7.5%2.0% Program data

26 Data only from people with current use or in treatment n = 10,589 Enrollee past 30 day use:

27 OEND program rescues: Active use, in treatment, in recovery N=1,132 Non-User (family, friend, staff) N= called or public safety present30%59% Rescue breathing performed32%31% Stayed until alert or help arrived90%94% Program data

28 Adverse Events: Sept 2006-Dec 2012 N=1,741 Deaths 7 / % OD requiring 3 or more doses 72 / % Recurrent overdose 3/ % Withdrawal symptoms after naloxone 107/219 49% Difficulty with device 11/ % Negative interactions with public safety 114/ % Confiscations 205 / % Program data

29 Withdrawal symptoms after naloxone Program data Symptoms N=219 None51% Irritable or angry21% Dope sick20% Physically combative4% Vomiting3% Other13% Confused, Disoriented, Headache, Aches and chills, cold, crying, diarrhea, happy, miserable

30 Do trained rescuers perform differently than untrained rescuers? Doe-Simkins et al. Under review Rescues after training (N=508)Rescues before training (N=91) Friend of OD victim67% (341/508)69% (63/91) OD setting: Public20% (100/498)29% (26/89) > 1 naloxone dose used48% (23/468)39% (33/85) 911 called or EMS present23% (119/508)27% (25/91) Rescue breathing47% (166/350)52% (34/66) Stayed with victim89% (445/498)89% (78/88) Sternal rub63% (222/350)62% (41/66)

31 INPEDE OD (Intranasal Naloxone and Prevention EDucation’s Effect on OverDose) Study Objective: Determine the impact of opioid overdose education with intranasal naloxone distribution (OEND) programs on fatal and non-fatal opioid overdose rates in Massachusetts Co-authors: Ziming Xuan H Holly Hackman Emily Quinn Maya Doe-Simkins Amy Sorensen-Alawad Sarah Ruiz Al Ozonoff

32 Opioid Overdose Related Deaths: Massachusetts No Deaths Number of Deaths OEND programs Towns without

33 Design, population and setting Design: – Quasi-experimental interrupted time series Population: – 19 Massachusetts cities and towns with 5 or more opioid-related unintentional or undetermined poison deaths in each year from Setting: – MA OEND programs were implemented by 8 community-based programs starting in 2006

34 OEND program data collection Enrollment form: –program staff collect potential bystander demographics and OD risk factors Refill form: –Upon return to program for more naloxone, staff collect data on use of naloxone, including overdose rescues

35 Analyses Poisson regression to compare opioid-related overdose rates among cities/towns with no vs. low and high implementation between 2002 and 2009 – Natural interpretations as rate ratios (RRs) calculated by exponentiating the beta coefficents

36 Fatal opioid OD rates by OEND implementation Cumulative enrollments per 100kRRARR*95% CI Absolute model: No enrollmentRef Low implementation: High implementation: > * Adjusted Rate Ratios (ARR) All rate ratios adjusted for the city/town population rates of age under 18, male, race/ ethnicity (hispanic, white, black, other), below poverty level, medically supervised inpatient withdrawal treatment, methadone treatment, BSAS-funded buprenorphine treatment, prescriptions to doctor shoppers, and year Walley et al. BMJ 2013; 346: f174.

37 Naloxone coverage per 100KOpioid overdose death rate 27% reduction 46% reduction Fatal opioid OD rates by OEND implementation Walley et al. BMJ 2013; 346: f174.

38 Opioid-related ED visits and hospitalization rates by OEND implementation Cumulative enrollments per 100kRRARR*95% CI Absolute model: No enrollmentRef Low implementation: High implementation: > * Adjusted Rate Ratios (ARR) All rate ratios adjusted for the city/town population rates of age under 18, male, race/ ethnicity (hispanic, white, black, other), below poverty level, medically supervised inpatient withdrawal treatment, methadone treatment, BSAS-funded buprenorphine treatment, prescriptions to doctor shoppers, and year Walley et al. BMJ 2013; 346: f174.

39 INPEDE OD Study Summary 1.Fatal OD rates were decreased in MA cities-towns where OEND was implemented and the more enrollment the lower the reduction 2.No clear impact on acute care utilization

40 Cost-effectiveness of distributing naloxone to heroin users for overdose reversal In a simulation model: One heroin overdose death prevented for every 164 kits distributed Cost for naloxone distribution would range between: – $438-$14,000 (best-worst case scenario) for every quality-adjusted life year gained Generally accepted threshold is $50,000/year – For dialysis: recently calculated as $129,000 Lee et al. Value Health 2009;12(1): – For primary care-based SBIRT: recently calculated as $6960 Tariq et al. PLoS One 2009;4(5) Coffin and Sullivan. Ann Intern Med. 2013; 158: 1-9.

41 Venues and Models

42 Enrollment locations: Data from people with location reported: Users: 9,824 Non-Users: 4,818 Program data

43 Implementing OEND in MMT and detox ModelAdvantagesDisadvantages 1. Staff provide OEND on-site Good access to OEND OD prevention integrated Patients may not disclose risk 2. Outside staff provide OEND on- site OD prevention integrated Interagency cooperation Low burden on staff Community OEND program needed 3. OE provided onsite, naloxone received off-site OD prevention integrated Interagency cooperation Increased patient burden to get naloxone 4. Outside staff recruit near MMT or detox Confidential access to OD prevention OD prevention not re-enforced in treatment Not all patients reached Walley et al. JSAT 2013; 44: Among 29 MMT and 93 detox staff who received OEND, 38% and 45% respectively reported witnessing and overdose in their lifetime. Among 1553 OEND participants who reported taking methadone, 47% were trained in detox, 25% at HIV prevention programs, and 17% in MMT. Previous overdose, recent inpatient detox or incarceration, and polysubstance use were OD risks common among all groups.

44 Other venues and models First responder OEND – Quincy, Revere, Gloucester Emergency Department (ED) SBIRT Post-incarceration Prescription naloxone – Prescribetoprevent.org

45 Quincy P.D. Statistics May 2009 – October 2010 (17 months) –47 Fatal Overdoses October 2010 – December 2012 (26 months) –206 Non-Fatal Overdoses –19 Fatal Overdoses –134 Naloxone Administrations 131 Successful Reversals (98%) 2 Deceased (1.5%) 1 No Effect (probably not an opioid O.D.)

46

47 Incorporating overdose education and naloxone rescue kits into medical and addiction practice 1.Prescribe naloxone rescue kits PrescribeToPrevent.org 2.Work with your OEND program

48 Challenges for community programs Prescription and prescriber typically required Naloxone cost is increasing, funding is minimal Missing people who don’t identify as drug users, but have high risk CBOs target IDU, people w/ substance use disorders, HIV prevention Opportunities for prescription naloxone Co-prescribe naloxone with opioids for pain Co-prescribe with methadone/ buprenorphine for addiction Insurance should fund this Increase patient, provider & pharmacist awareness Universalize overdose risk

49 Practical Barriers to Prescribing Naloxone 1.Prescriber knowledge and comfort 2.How to write the prescription? 3.Does the pharmacy stock rescue kits? Rescue IN kit with MAD? Rescue IM kit with needle? 4.Who pays for it? Insurance in Massachusetts covers naloxone, but not the atomizer yet The MAD costs $3 each>> $6-7 per kit Work with your pharmacy to see if they will cover it

50 Legal Barriers to Prescription Model “ Prescribing naloxone in the USA is fully consistent with state and federal laws regulating drug prescribing. The risks of malpractice liability are consistent with those generally associated with providing healthcare, and can be further minimized by following simple guidelines presented.” 1.Only prescribe to a person who is at risk for overdose 2.Ensure that the patient is properly instructed in the administration and risks of naloxone Burris S at al. “Legal aspects of providing naloxone to heroin users in the United States. Int J of Drug Policy 2001: 12;

51 Massachusetts - Passed in August 2012: An Act Relative to Sentencing and Improving Law Enforcement Tools Good Samaritan provision: Protects people who overdose or seek help for someone overdosing from being charged or prosecuted for drug possession –Protection does not extend to trafficking or distribution charges Patient protection: A person acting in good faith may receive a naloxone prescription, possess naloxone and administer naloxone to an individual appearing to experience an opiate-related overdose. Prescriber protection: Naloxone or other opioid antagonist may lawfully be prescribed and dispensed to a person at risk of experiencing an opiate-related overdose or a family member, friend or other person in a position to assist a person at risk of experiencing an opiate-related overdose. For purposes of this chapter and chapter 112, any such prescription shall be regarded as being issued for a legitimate medical purpose in the usual course of professional practice.

52 Overdose Education in Medical Settings Where is the patient at as far as overdose? –Ask your patients whether they have overdosed, witnessed an overdose or received training to prevent, recognize, or respond to an overdose Overdose history: 1.Have you ever overdosed? 1.What were you taking? 2.How did you survive? 2.What strategies do you use to protect yourself from overdose? 3.How many overdoses have you witnessed? 1.Were any fatal? 2.What did you do? 4.What is your plan if you witness an overdose in the future? 1.Have you received a narcan rescue kit? 2.Do you feel comfortable using it?

53 Overdose Education in Medical Settings What they need to know: 1.Prevention - the risks: –Mixing substances –Abstinence- low tolerance –Using alone –Unknown source –Chronic medical disease –Long acting opioids last longer 2.Recognition –Unresponsive to sternal rub with slowed breathing –Blue lips, pinpoint pupils 3.Response - What to do Call for help Rescue breathe Deliver naloxone and wait 3-5 minutes Stay until help arrives

54 Prescribetoprevent.org

55 Stigma Related to Overdose These articles appeared in the same paper, one in police reports the other in the obituary Woodland Avenue resident dies of an apparent overdose A 44-year-old Woodland Avenue man is believed to have overdosed on heroin and died as a result last Thursday morning at a Cooledge Avenue home. The man, William SmithJones, of Woodland Avenue, was found by a friend in the bathroom after he went in to shower and shave around 8 a.m. After spending more time than usual in the bathroom, the friend pushed her way inside and found him on the floor, purple colored. EMTs from Cataldo Ambulance administered Narcan to Anderson and rushed him to Whidden Hospital, where he died later.

56 Reduce the Stigma Talk about it!!! Information DOES NOT = “enabling” Denying access increases risk Open up the issue like any other Chance for intervention Discuss overdose information along with use/recovery/treatment etc., Listen and talk with users/non- users/politicians/community

57 Next steps Sustain existing programs Expand sites and venues Target incarcerated and ED patients Facilitate wider prescribing of naloxone – Chronic pain and addiction practices – Family members of opioid users

58 Lessons Learned Standing order facilitates expansion Nasal naloxone helps acceptability Use existing networks to reach high risk people and build out from there Both grass roots and top down leadership are useful Prescription naloxone takes patience and perseverance Parents and public safety can be powerful advocates Overdose can bring people together on common ground

59 Learning objectives At the end of this session, you will know: 1.Epidemiology of overdose, the rationale and history of the MA OEND program 2.The scope of the MA OEND program 3.Effectiveness of OEND: INPEDE OD Study 4.Venues and models 5.How to incorporate OEND into medical settings 6.To acknowledge and address overdose stigma

60 Thank you! MA DPH Sarah Ruiz John Auerbach Andy Epstein Holly Hackman Michael Botticelli Kevin Cranston Dawn Fakuda Barry Callis Grant Carrow Len Young Kyle Marshall Office of HIV/AIDS Bureau of Substance Abuse Services BU/BMC Gregory Patts Chris Chaisson Jeffrey Samet Ed Bernstein Program sites, staff and participants NOPE group Helpful Websites: Prescribetoprevent.org Overdosepreventionalliance.org Naloxoneinfo.org

61 Considerations Intranasal works and is popular – It could be improved with a one-step, affordable FDA-approved intranasal delivery device – Intramuscular may be more affordable and implementable Nonmedical community health workers provide effective OEND – Broad dissemination to high risk groups and their families – Facilitated by state-supported standing order Prescription status is a barrier

62 Limitations True population at risk for overdose is not known –Adjusted for demographics, treatment, PMP, and year Cause of death subject to misclassification –One medical examiner for all of MA Non-fatal overdose measure >> Diagnostic codes are subject to misclassification –No reason bias should be in one direction Overdoses may occur in clusters –Study conducted over wide area and several years Measures of OEND implementation have not been validated

63 How does drug use change after OEND? Doe-Simkins et al. Under review N=325IncreasedDecreasedNo change Heroin115 (35%)122 (38%)88 (27%) Methadone84 (26%)70 (22%)171 (52%) Buprenorphine73 (22%)66 (20%)186 (58%) Other Opioids59 (18%)62 (19%)205 (63%) Cocaine83 (26%)96 (30%)146 (44%) Alcohol69 (21%)70 (22%)186 (57%) Benzo/Barbiturate99 (30%)74 (23%)152 (47%)* Number of substances** used131 (40%)125 (38%)69 (21%) *p < Wilcoxon signed rank test which compares the median difference between two repeated measures among the repeat enrollers **Participants were asked about use of heroin, methadone, buprenorphine, other opioids, cocaine, alcohol, benzodiazepine/barbiturate, methamphetamine, clonidine, and other substances

64 Unadjusted unintentional opioid-related overdose death rates in 19 communities with no, low and high OEND enrollment in Massachusetts, Walley et al. BMJ 2013; 346: f174.

65 Unadjusted unintentional opioid-related acute care hospitalization rates in 19 communities with no, low and high OEND enrollment in Massachusetts, Walley et al. BMJ 2013; 346: f174.

66 Control models of OEND implementation and ratio of opioid related overdose deaths to cancer deaths Cumulative enrollments per 100kAdjusted β estimate*P-value Absolute model: No enrollmentRef Low implementation: High implementation: > Relative model: No enrollmentRef Low implementation: <0.01 High implementation: > * Adjusted Rate Ratios (ARR) All rate ratios adjusted for the city/town population rates of age under 18, male, race/ ethnicity (hispanic, white, black, other), below poverty level, medically supervised inpatient withdrawal treatment, methadone treatment, BSAS-funded buprenorphine treatment, prescriptions to doctor shoppers, and year Walley et al. BMJ 2013; 346: f174.

67 Control models of OEND implementation and ratio of opioid related to MV crash related acute care hospitalizations Cumulative enrollments per 100kAdjusted β estimate*P-value Absolute model: No enrollmentRef Low implementation: High implementation: > Relative model: No enrollmentRef Low implementation: High implementation: > * Adjusted Rate Ratios (ARR) All rate ratios adjusted for the city/town population rates of age under 18, male, race/ ethnicity (hispanic, white, black, other), below poverty level, medically supervised inpatient withdrawal treatment, methadone treatment, BSAS-funded buprenorphine treatment, prescriptions to doctor shoppers, and year Walley et al. BMJ 2013; 346: f174.

68 Learn2cope.org Meeting Schedule Every Monday evening PM – Good Samaritan Medical Center, 235 North Pearl Street, Brockton, MA Every Tuesday at 7:00 pm – Gloucester Family Health Center, 302 Washington Street, Gloucester, MA. Every Tuesday at 7:00 - 8:30 pm – Eastern Nazarene College, 180 Old Colony Avenue Quincy Mass. Every Wednesday evening 7 - 9pm – Saints Medical Center, One Hospital Drive, Lowell. Every Thursday evening 7 PM – Salem Massachusetts at North Shore Childrens Hospital, 57 Highland Ave. – UMASS Community Healthlink Campus, 26 Queen Street, 5th Floor, Room 515, Worcester, MA for Dates – Mass General Hospital Boston in the Thier Research building first floor conference room. This meeting is new and room is subject to change, for

69 US and MA Age-Adjusted All Poisoning and MA Opioid-related Death Rates, Sources: All- poisoning rates from CDC, WISQARS web-based query (Accessed 2/19/2013) Opioid-related poisoning from Registry of Vital Records, MDPH. 99% increase in all poisoning death rate in MA from ; 18% decrease in rate from 2006 to Overall APC : 4.05 (p <.05) 73% increase in opioid-related poison death rate in MA from ; 13% decrease in rate from 2006 to Overall APC : 4.06 (p<.05)

70 Acts of 2012, Chapter 192, Sections 11 & 32

71 (d) Naloxone or other opioid antagonist may lawfully be prescribed and dispensed to a person at risk of experiencing an opiate-related overdose or a family member, friend or other person in a position to assist a person at risk of experiencing an opiate-related overdose. (emphasis added)

72 (a) A person who, in good faith, seeks medical assistance for someone experiencing a drug-related overdose shall not be charged or prosecuted for possession of a controlled substance under sections 34 or 35 if the evidence for the charge of possession of a controlled substance was gained as a result of the seeking of medical assistance. (b) A person who experiences a drug-related overdose and is in need of medical assistance and, in good faith, seeks such medical assistance, or is the subject of such a good faith request for medical assistance, shall not be charged or prosecuted for possession of a controlled substance under said sections 34 or 35 if the evidence for the charge of possession of a controlled substance was gained as a result of the overdose and the need for medical assistance.

73 (c) The act of seeking medical assistance for someone who is experiencing a drug-related overdose may be used as a mitigating factor in a criminal prosecution under the Controlled Substance Act,1970 P.L , 21 U.S.C. section 801, et seq. (d) Nothing contained in this section shall prevent anyone from being charged with trafficking, distribution or possession of a controlled substance with intent to distribute. (e) A person acting in good faith may receive a naloxone prescription, possess naloxone and administer naloxone to an individual appearing to experience an opiate-related overdose.

74 Prescription Directions Dispense: One naloxone rescue kit –2 prefilled syringes with 2mg/2ml naloxone –2 mucosal atomizer devices –Risk factor info and assembly directions Directions: For suspected opioid overdose, spray 1ml in each nostril. Repeat after 3 minutes if no or minimal response- include infosheet

75 Patient instructions Education Videos: Overdose Prevention Video for chronic pain patients Overdose Prevention Video

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78 Patient Selection After emergency medical care involving opioid intoxication or poisoning Suspected hx of substance abuse or nonmedical opioid use Patients taking methadone or buprenorphine Any patient receiving an opioid prescription for pain and: – higher-dose (>50 mg morphine equivalent/day) opioid – rotated from one opioid to another= poss incomplete cross tolerance – Smoking, COPD, emphysema, asthma, sleep apnea, respiratory infection, or other respiratory illness or potential obstruction. – Renal dysfunction, hepatic disease, cardiac illness, HIV/AIDS – Known or suspected concurrent heavy alcohol use – Concurrent benzodiazepine or other sedative prescription – Concurrent antidepressant prescription Patients who may have difficulty accessing emergency medical services (distance, remoteness) Voluntary request from patient or caregiver

79 Opioid OD conceptual model Fatal Opioid ODNon-fatal Opioid OD Heroin use Rx Opioid misuse OD prevention education OD management (naloxone, 911) Opioid addiction prevention and treatment Rx diversion bystander OEND OD risk factors polydrug use abstinence using alone unknown source PMP, Prescriber Education, Take Back Days


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