1. 1 Get the SKOOP: Skills and Knowledge on Overdose Prevention Bill Matthews, RPA-C Harm Reduction Coalition November 2012

2. 2 Objectives Participants will be able to: Discuss the epidemiology and physiology of overdose; risk factors and response Offer a 10-20 minute overdose prevention training to other staff and clients

4. Number of drug poisoning deaths involving opioid analgesics by opioid analgesic category, heroin and cocaine: United States, 1999--2010 NOTES: Opioid analgesic categories are not mutually exclusive. Deaths involving more than one opioid analgesic category shown in this figure are counted multiple times. Natural and semi-synthetic opioid analgesics include morphine, oxycodone and hydrocodone; and synthetic opioid analgesics include fentanyl. 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. 2011. http://www.cdc.gov/nchs/data/databriefs/db81.htmhttp://www.cdc.gov/nchs/data/databriefs/db81.htm

5. 5 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.http://www.cdc.gov/nchs/deaths.htm

6. Motor vehicle traffic, poisoning, drug poisoning, and unintentional drug poisoning death rates: United States, 1999--2010 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. 2011. http://www.cdc.gov/nchs/data/databriefs/db81.htm. Intercensal populations http://www.cdc.gov/nchs/nvss/bridged_race/data_documentation.htm http://www.cdc.gov/nchs/data/databriefs/db81.htm http://www.cdc.gov/nchs/nvss/bridged_race/data_documentation.htm

7. 7 Opioid treatment admissions: 1999-2009 ages 12-24 NYS OASAS Data Warehouse

8. 8 Opioid treatment admissions: 1999-2009 ages 12-24 NYS OASAS Data Warehouse

9. Counties Reporting Increases in Heroin- Related Overdoses, 2008–2010 9 National Drug Threat Assessment 2011

10. Percentage of patients and prescription drug overdoses, by risk group MMWR / January 13, 2012 / Vol. 61 / No. 1

11. 11 Initial route of opioid abuse versus route of abuse at admission in a substance abuse treatment center. Katz, Am J of Drug and Alcohol Abuse, 2011

12. 12 What is the most dispensed prescription drug in the United States? (number of prescriptions filled; generic and branded products, 2004-06) 12

13. 13 Top 10 Drugs Dispensed in 2010 1. Hydrocodone/Acetaminophen (Vicodin) 2. Amoxicillin 3 Hydrocodone/Acetaminophen (Lortab) 4. Lipitor 5. Levothyroxine 6. Lisinopril 7. Simvastatin 8. Plavix 8. Nexium 10. Singulair Source: http://www.rxlist.com/script/main/hp.asp 13

14. 14 Opioid pain reliever (OPR) death rates, sales, and substance abuse treatment admission rates increased in parallel National Vital Statistics System (99-09); Automated Reports Consolidated Orders System (99-10); Treatment Admissions Data Set (99-09) Age-adjusted rates per 100,000 population for OPR deaths, crude rates per 10,000 population for OPR abuse treatment admissions, and crude rates per 10,000 population for kilograms of OPR sold.

15. 15 Heroin Overdose Epidemiology About 2% of heroin users die each year- many from heroin overdose 1990-98: 5,506 deaths in NYC Average of 1-2/day in NYC Up to 2/3 of heroin users experience at least one nonfatal overdose 2006: 979 OD deaths in NYC (70% due to opioids) = ~ 685 opioid deaths Sporer BMJ 2003, Galea 2003, Coffin Acad Emerg Med 2007

16. 16 What do we know about overdose?

17. 17 Who overdoses? Happens most often in dependent long term users with 5- 10 years of experience rather than new users Sporer 2003, 2006

18. Drug poisoning death rates by age: United States, 1999--2010 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. 2011. http://www.cdc.gov/nchs/data/databriefs/db81.htmhttp://www.cdc.gov/nchs/data/databriefs/db81.htm Intercensal populations http://www.cdc.gov/nchs/nvss/bridged_race/data_documentation.htmhttp://www.cdc.gov/nchs/nvss/bridged_race/data_documentation.htm 15-24 25-34 35-44 45-54 55-64 65 and over

20. 20 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

21. 21 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

22. 22 An Antidote exists Naloxone (Narcan), an injectable opioid antagonist will reverse the effects of opioids preventing a fatal overdose.

23. 23 Many opioid overdoses are preventable! Get the SKOOP!

24. 24 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

25. 25 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

26. 26 What is Naloxone? Naloxone (Narcan) is an injectable opioid antagonist which reverses the effects of opioids preventing fatal overdose What else will it do?

27. 27 Naloxone (Narcan) Opioid antagonist which reverses opioid overdose Pushes most other opioids off the receptors, then sits on the receptor preventing it from being activated for 30- 90 minutes Analogy- getting the wrong key stuck in a lock

29. NOP Opioid Receptor binding pocket http://www.nature.com/nature/journal/v485/n7398/fig_tab/485314a_F1.html

30. 30 Naloxone preparations Injectable –Inexpensive: $4.50 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

31. 31 Intramuscular naloxone A face mask for rescue breathing Two safety syringes 2 pre-filled vials of Naloxone 2 alcohol swabs 2 latex gloves 1 brochure reviewing OD and rescue steps. Contact information for program

33. 33 Papaver Somniferum “Poppy Plant”. WHAT ARE OPIOIDS?

34. Most commonly used opioids Heroin Codeine Demerol Morphine Darvocet Fentanyl Dilaudid Methadone Opium Hydrocodone Oxycodone Levorphanol Vicodin OxyContin Tylenol 3 Tylox Percocet Percodan 34 Boston Public Health Commission

35. 35 Naloxone does not work for substances that are not opioids Alcohol Benzodiazepines –Xanax, Valium, Klonopin Tricyclics –Elavil (amitriptylene) GBH Ketamine Cocaine Amphetamines Methamphetamine Ecstasy

36. 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

37. 37 What are the Risk Factors for Opioid Overdose?

38. 38 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

39. 39 Mixing Drugs: Major Risk for Overdose Using an opioid with other depressants such as alcohol or benzodiazepines Cocaine is a stimulant but: –High doses can reduce the respiratory drive –Wears off sooner than heroin in a speedball –Involved in about 53% of opioid overdose deaths in NYC

40. 40 Major risk factor: Lowered tolerance 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

41. 41 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

42. 42 Illness and overdose Overdose is more likely in the presence of significant illness Liver disease: notably cirrhosis Advanced AIDS Coronary disease Pulmonary disease: notably pneumonia Wang 2005, Darke 2006

43. 43 Other risk factors 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%5Ff orum,

44. 44 Prevention Messages 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) Use a trusted source – one that you know “Taste” (test) your shot Control your own shot

45. 45 What does an Opioid Overdose Look Like?

46. 46 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

47. 47 Recognizing a Stimulant Overdose (Naloxone won’t be effective unless an opioid is also present) Fever Profuse sweating Rapid, (maybe irregular) heart beat Chest pain Seizures Heart attack, Stroke

48. 48 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)

49. 49 What NOT to do if a person is overdosing Leave without calling 911 Salt shots Milk shots Cocaine shots Ice on genitals/ Shower Hitting or burning feet or fingertips

50. 50 RESPONDING TO AN OPIOID OVERDOSE

51. 51 Step One: Get Help Call 911- “My friend is overdosing and not breathing” This phrase is more likely to bring paramedics with naloxone than EMT, who don’t carry it Give location Police may come New 911 law

52. 52 Check for breathing Chest rising and falling Nostrils moving in and out Mirror or glass by nose or mouth will fog up Touch moistened finger next to nostrils, feel for cool draft of inward breathing

53. 53 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)

54. 54 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.

55. 55 Intramuscular naloxone A face mask for rescue breathing Two safety syringes 2 pre-filled vials of Naloxone 2 alcohol swabs 2 latex gloves 1 brochure reviewing OD and rescue steps. Contact information for program

56. 56 Administration: Naloxone Injection Inject into a muscle (subcutaneous and intravenous are also effective) Acts within 2-8 minutes If no response in 2-5 minutes, give 2 nd naloxone injection Lasts for 30 – 90 minutes (reminder that if 911 has not been called do it now!!)

57. 57 Injection Technique Inject into muscle of upper arm or front of thigh Inject straight in, not at an angle Rapidly push needle through skin into muscle and then push syringe to inject the medication Depth of whole needle is fine (maybe less deep if person is skinny) DON’T INJECT INTO THE CHEST, even if you saw Pulp Fiction…

58. 58

59. 59 Disposing of the Used Syringe If safety syringe, engage sheath Ask EMS to dispose of the needle or: Take to any SEP, hospital or nursing home for disposal, call first! Sharps accepted by some pharmacies and health care facilities Call DOH for disposal site near you (800-522-5006) Contact local Dept. of Public Works

60. 60 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

61. 61 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

62. 62 Next Steps Report use of Naloxone to the program Anonymous report of date, place, drugs used and outcome Get a refill of the Naloxone Even if just one dose was used If kit is lost If kit is confiscated If naloxone is nearing expiration date

63. TIME FOR HANDS ON SKILLS PRACTICE Practice these skills: 1. Rescue Breathing 2. Injection/intranasal Technique 3. Training a Partner

64. 64 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 since 1988

65. 65 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

66. 66 More about Naloxone cont. Emergency Medical Services give 1.2 to 1.6 milligrams of Naloxone which precipitates severe withdrawal in the dependent person Overdose prevention services recommend starting with 0.4 with an additional dose readily available – found to be effective in most instances

67. Role of EMS Patients receiving naloxone, not being transported to ER: deaths known to medical examiner 998 patients refused transport: none within 12 hours 552 patients refused transport: none within 48 hours 2241 patients discharged by EMS over 10 yrs: 14 within 48 hours; 3 (0.13%) of potential rebound overdose Limitations: some medical evaluation, varying doses of naloxone; all SKOOP responders instructed to call EMS San Diego: Vilke Acad Emerg Med 2003; San Antonio: Wampler Prehosp Emerg Care 2011; Copenhagen: Rudolph Rescusitation 2011

68. 68 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

69. 2010 survey of programs known to the Harm Reduction Coalition 189 local programs in 16 states 1996 - 2010: –53,339 individuals have received kits –10,194 overdose reversals reported Personal communication Eliza Wheeler, Harm Reduction Coalition Overdose fatality prevention programs that distribute naloxone: USA, 2010

70. 70 Cocaine and heroin rates decreased while opioid analgesic rate increased * P-Value less than.05; (2005 vs. 2009) Opioid Analgesics* Benzodiazepines * Methadone Cocaine*Heroin Anti-Psychotics Sedatives

71. Heroin-related Deaths, San Francisco, 1993-2010 *Data compiled from San Francisco Medical Examiner’s Reports, www.sfgsa.orgwww.sfgsa.org **no data available for FY 2000-2001 Naloxone distribution begins, 2003

72. Effect of naloxone on overdose death: Chicago, US

73. 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.

74. Heroin Use in Allegheny County by Fiscal Year * Data from Pennsylvania Department Of Health

75. Opioid maintenance and mortality Prospective study of opioid dependent patients applying for methadone treatment in Norway 3,789 subjects followed for up to 7 years Clausen Drug Alc Dep 2008

76. Results Pre-treatmentIn treatmentPost-treatment Total mortality Odds ratio 10.51.43 Total overdose Odds ratio 10.201.40 Percent of deaths due to overdose 79%27%61% Clausen 2008

77. 77 Maintenance therapy prevents overdose French population in 1999 = 60,000,000 196919711973197519771979198119831985198719891991199319951997 1999 Year No. of deaths 600 500 400 300 200 100 0 Patients receiving methadone (1998): N= 5,360 Patients receiving buprenorphine (1998): N= 55,000 Auriacombe et al., 2001 Since the institution of buprenorphine and methadone maintenance in 1996 in France heroin overdose has dropped by 79%

78. 78

79. "I did SOMETHING, you know, that made a difference. The whole world can’t see it but I know it made a difference. And that’s important... to me." --quote collected by Suzanne Carlberg-Racich, Chicago “You get nervous, you know – someone’s blue, someone’s dying. But you do it because we are all out here together and people are going out right and left.” --Boston man, age 29 "If you ever get in a meeting with some professional type people, tell ‘em that, you know, people like us– no, we’re not professionals, but if we have it at hand we can save somebody’s life with this stuff [naloxone]... it’s a lifesaver, there’s no question." --Program participant in Chicago; Maxwell S, et al. J Addict Dis. 2006;25(3):8996. 79

80. 80 RESOURCES Harm Reduction Coalition (harmreduction.org) NYSDOH(www.health.state.ny.us - search for overdose)www.health.state.ny.us On-line CASAC training and credit –www.oasas.state.ny.us