PERMEATING BORDERS OVERDOSE PREVENTION Summer Conference 2014 July 24, 2014 ACOPC Allegheny County Overdose Prevention Coalition Presents

Overdose Prevention: National Perspectives Melinda Campopiano von Klimo, MD Medical Officer Center for Substance Abuse Treatment (CSAT)

Overdose Prevention: National Perspectives Allegheny County Overdose Prevention Coalition Pittsburgh, PA July 24 th 2014 Melinda Campopiano, MD Substance Abuse & Mental Health Services Administration

Objectives Be able to integrate the SAMHSA Opioid Overdose Prevention Toolkit into local prevention efforts. Be familiar with community overdose prevention implementation strategies. Understand the role of medication assisted treatment in overdose prevention.

Opioid pain reliever-related overdose deaths increasing at a faster rate than deaths from any major cause WISQARS, 2000 and 2010; CDC/NCHS, National Vital Statistics System

Opioid Overdose Toolkit Community Members First Responders Patients and family Prescribers Overdose survivors

7 Preventing Opioid Overdoses & Deaths  All five booklets feature clear explanations and simple strategies that are based on current scientific evidence and clinical experience.  They answer questions such as the following: What are opioids? Why do opioids cause overdose? Who is at risk? What are the signs of overdose? How can overdose be prevented?

Booklet 1, Facts for Community Members: Educates local governments, community organizations, and private citizens about the risks of opioid overdose. Helps them develop sound policies and practices to prevent opioid overdoses and deaths. Substance Abuse and Mental Health Services Administration (SAMHSA). SAMHSA Opioid Overdose Toolkit: Facts for Community Members. HHS Publication No. (SMA) Rockville, MD: SAMHSA, 2013.

Booklet 2, Five Essential Steps for First Responders, describes: Five steps that should be taken by paramedics, EMS personnel, police, and other helpers when they respond to an opioid overdose. How to use naloxone and provide other life- saving assistance. Substance Abuse and Mental Health Services Administration (SAMHSA). SAMHSA Opioid Overdose Toolkit: Five Essential Steps for First Responders. HHS Publication No. (SMA) Rockville, MD: SAMHSA, 2013.

Booklet 3, Information for Prescribers, provides physicians and other health care professionals with: Reliable information on how to assess each patient’s risk of opioid overdose. Clinically sound strategies for educating and monitoring patients to reduce the risk of overdose. Substance Abuse and Mental Health Services Administration (SAMHSA). SAMHSA Opioid Overdose Toolkit: Information for Prescribers. HHS Publication No. (SMA) Rockville, MD: SAMHSA, 2013.

Booklet 4, Safety Advice for Patients, empowers patients who are prescribed opioids by: Helping them learn how to use opioids safely so as to minimize the risk of overdose. Substance Abuse and Mental Health Services Administration (SAMHSA). SAMHSA Opioid Overdose Toolkit: Safety Advice for Patients. HHS Publication No. (SMA) Rockville, MD: SAMHSA, 2013.

Booklet 5, Recovering from Opioid Overdose, assists overdose survivors and their family members by: Offering resources to help them recover from the trauma of overdose, provide support to the survivor, and become advocates for prevention. Substance Abuse and Mental Health Services Administration (SAMHSA). SAMHSA Opioid Overdose Toolkit: Recovering from Opioid Overdose. HHS Publication No. (SMA) Rockville, MD: SAMHSA, 2013.

13 Preventing Opioid Overdoses & Deaths  STRATEGY 1: Encourage health care professionals, persons at high risk, family members and others to learn how to prevent and respond to opioid overdose. Practitioners should be encouraged to update their knowledge of evidence- based practices for the use of opioid analgesics to manage pain, as well as specific steps to prevent and manage opioid overdose.

14 Preventing Opioid Overdoses & Deaths  STRATEGY 2: Ensure access to treatment for individuals who are misusing or addicted to opioids or who have other substance use disorders. Effective medication-assisted treatment of substance use disorders reduces the risk of overdose and helps overdose survivors attain a healthier life.

15 Preventing Opioid Overdoses & Deaths  STRATEGY 3: Ensure ready access to naloxone: Opioid overdose deaths can be prevented when naloxone is administered in a timely manner. As an opioid antagonist, naloxone blocks the effects of opioids on the brain and reverses respiratory depression, which usually is the cause of overdose deaths. Naloxone has no psychoactive effects and thus no potential for abuse.

16 Preventing Opioid Overdoses & Deaths  STRATEGY 3 (continued): It is important that local EMS personnel and other first responders be trained to care for overdose, and that they are allowed to stock naloxone in their drug kits. Physicians should consider prescribing naloxone to their patients who are receiving long-term pain treatment with opioids.

17 Preventing Opioid Overdoses & Deaths  STRATEGY 4: Encourage the public to call 911: A person who is experiencing opioid overdose needs immediate medical attention. An essential first step is to get help from someone with medical expertise as quickly as possible. Therefore, members of the public should be educated to call 911. All they need to say is, “Someone is not breathing” and give a clear address or description of the location.

18 Preventing Opioid Overdoses & Deaths  STRATEGY 5: Encourage prescribers to use state Prescription Drug Monitoring Programs (PDMPs): State Prescription Drug Monitoring Programs (PDMPs) are a key strategy for addressing the misuse and abuse of prescription opioids and thus preventing opioid overdoses and deaths. Through the PDMP, a prescriber can access a state database to determine whether a patient is filling the prescriptions provided and/or obtaining prescriptions for the same or similar drugs from multiple physicians.

19 Preventing Opioid Overdoses & Deaths Where is SAMHSA’s Opioid Overdose Toolkit available? The information outlined here and more can be viewed at or downloaded from SAMHSA's website at The toolkit also refers readers to other reliable sources of information, including those offered by the CDC, ONDCP, and private sector organizations.

20 HOW TO GET NALOXONE TO THOSE WHO NEED IT.

21 Block Grant Funds  Primary prevention set-aside funds may be used to support overdose prevention education and training  Other SABG funds may be utilized to purchase naloxone and the necessary materials to assemble overdose kits and cover the cost of dissemination of these kits

22 Discretionary Grant Recipients  May repurpose portions of current grants to purchase naloxone and the necessary materials to assemble overdose kits.  Must revise and resubmit a proposed budget

23 Individual Providers and Programs  For prescribers to routinely prescribe naloxone: Naloxone must be covered by public and private OUTPATIENT pharmacy benefits. Pharmacists need to be aware of plans to routinely prescribe naloxone to stock an adequate supply Pharmacists need to know how the patient will be trained.

24 Standing Orders  Order issued by health department physician  Overdose prevention training and naloxone may be provided in pharmacy in existing community sites (treatment, medical and behavioral health clinics)

25 Cooperative Practice Agreement  Formal agreement to cooperatively manage a patient  Specific to diseases and/or medications  Specific to physician(s) and pharmacist(s)

26 MEDICATION ASSISTED TREATMENT

27 A key driver of the overdose epidemic is underlying substance use disorder… Expanding access to MATs is a crucial component of the effort to help patients recover.

28 Increased access to opioid agonist therapy was associated with a reduction in heroin overdose rates.

29 Benefits of MAT  Reduces all cause mortality  Reduces HIV seroconversion  Improves adherence to medical treatment  Improves social function  Decreases criminal behaviors  Decreases drug use

30 Opioids were involved in 14.8% of all deaths. Overdose was the leading cause of death… and overdose deaths in former prisoners accounted for 8.3% of the overdose deaths among persons aged 15 to 84 years.

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32 Pretreatment and After Care Interventions to Reduce Mortality  Naloxone and ER injectable naltrexone  Detainees  Detox  Discharge

33 PRESCRIBER EDUCATION

34 JAMA 2011;305:

35 Opioid pain reliever prescribing rates vary by state CDC Vital Signs, July Rates per 100 people in 2012

36 Opioid prescribing rates correlate with drug overdose death rates Kg of opioid pain relievers used per 10,000 Age-adjusted rate per 100,000 Death rate, 2008, National Vital Statistics System. O pioid pain reliever sales rate, 2010, DEA’s Automation of Reports and Consolidated Orders System

37 Patients receiving high doses of opioid pain relievers account for disproportionate share of overdoses Percent CDC Grand Rounds: Prescription Drug Overdoses — a U.S. Epidemic. MMWR Weekly. January 13, 2012 / 61(01); multiple doctors, high doses one doctor, high dose one doctor, lower dose

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39 Where next?  Widen availability of training and naloxone New formulations/delivery systems  Expand access to medication assisted treatment  Prepare for community crisis response to closure of “pill mills.”