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

OVERDOSE SOLUTIONS 2013

ADDRESSING OPIOID OVERDOSE

WITH COMMUNITY-BASED EDUCATION AND

NALOXONE RESCUE KITS

Alexander Walley, MD MScMedical Director, Massachusetts Dept. of Public Health Opioid

Overdose Prevention Pilot

Addressing opioid overdose with community-based education and naloxone rescue kits

Alexander Y. Walley, MD, MScBoston University School of Medicine

Boston Medical Center

Allegheny County Overdose Prevention CoalitionWednesday, July 24th, 2013

9:15am-10:45am

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 1R21CE001602-01

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

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100

200

400

600

800

1000

1200

All Poisoning Deaths Motor Vehicle-Related Injury Deaths

Dea

ths

per

year

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 (1997-2008)

More Opioid Overdose Deaths than MVA Deaths in Massachusetts

1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100

200

400

600

800

1000

1200

All Poisoning Deaths Opioid-related Poisoning Deaths Motor Vehicle-Related Injury Deaths

Dea

ths

per

year

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 (1997-2008)

More Opioid Overdose Deaths than MVA Deaths in Massachusetts

Rate of opioid-related fatal overdoses in MA in 2006 was 9.9 per 100K

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100

2

4

6

8

10

12

14

16

18Motor vehicle traf-fic

Poisoning

Drug poisoning

Unintentional drug poisoning

Deat

hs p

er 1

00,0

00 p

opul

ation

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

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 20120

50

100

150

200

250

300

350

Heroin

Cocaine

Prescription Opioids

Total Overdose Deaths

Allegheny County Trends in Accidental Drug Overdose Deaths

2000-2012*

*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.

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

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

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;1356-62

• Safe injection facilities– Marshall et al. Lancet 2011:377;1429-37

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

2010

States w/ OENDs 15

Programs 188

People enrolled 53,032

OD rescues 10,171

Wheeler E et al. Morb Mortal Wkly Rep 2012;61:101-5.

Overdose Education and Naloxone Rescue Kits

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

Evaluations of OEND programs• Feasibility

– Piper et al. Subst Use Misuse 2008: 43; 858-70– Doe-Simkins et al. Am J Public Health 2009: 99: 788-791– Enteen et al. J Urban Health 2010:87: 931-41– Bennett et al. J Urban Health. 2011: 88; 1020-30– Walley et al. JSAT 2013; 44:241-7 (Methadone and detox programs)

• Increased knowledge and skills– Green et al. Addiction 2008: 103;979-89– Tobin et al. Int J Drug Policy 2009: 20; 131-6– Wagner et al. Int J Drug Policy 2010: 21: 186-93

• No increase in use, increase in drug treatment– Seal et al. J Urban Health 2005:82:303-11

• Reduction in overdose in communities– Maxwell et al. J Addict Dis 2006:25; 89-96– Evans et al. Am J Epidemiol 2012; 174: 302-8– Walley et al. BMJ 2013; 346: f174

MA Timeline: Key events & players

• 2000-2004: 1 CBO underground• 2005: 2 CBO underground

– Boston EMTs equipped with IN via special project waiver

MA Timeline: Key events & players

• 2000-2004: 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

Implementing the Massachusetts public health pilot: December 2007

• Pilot program conducted under DPH/Drug Control Program regulations

(M.G.L. c.94C & 105 CMR 700.000)

• Medical Director issues standing order for distribution

• Naloxone may be distributed by public health workers

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 administernaloxone to a person experiencingan overdose

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

Staff Training and Support

Staff complete:• 4 hour didactic training• At least 2 supervised bystander

training sessionsSites participate in:• Quarterly all-site meetings• Monthly adverse event phone

conferences

Prefilled naloxone ampule

Intranasal Administration

Pro• 1st 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:

– $40-50+ per kit

Mucosal Atomization Device (MAD)

Luer-lock syringe

Program data

Enrollments and Rescues: 2006-2012

• 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

Enrollee characteristics: 2006-2012

User n=11,002 Non-User n=5,377

Witnessed overdose ever 75% 42%

Lifetime history of overdose 49%

Received naloxone ever 41%

Inpatient detox, past year 64%

Incarcerated, past year 28%

Reported at least one overdose rescue 7.5% 2.0%

Program data

Data only from people with current use or in treatment n = 10,589

Enrollee past 30 day use: 2006-2012

OEND program rescues: 2006-2012

Active use, in treatment, in

recovery N=1,132

Non-User (family, friend, staff)

N=123

911 called or public safety present 30% 59%

Rescue breathing performed 32% 31%

Stayed until alert or help arrived 90% 94%

Program data

Adverse Events: Sept 2006-Dec 2012

N=1,741

Deaths 7 / 1729 0.4%

OD requiring 3 or more doses 72 / 1604 4%

Recurrent overdose 3/1741 0.2%

Withdrawal symptoms after naloxone 107/219 49%

Difficulty with device 11/1741 0.6%

Negative interactions with public safety 114/ 466 24%

Confiscations 205 / 5271 4%

Program data

Withdrawal symptoms after naloxone

Program data

Symptoms N=219None 51%Irritable or angry 21%Dope sick 20%Physically combative 4%Vomiting 3%Other 13%

Confused, Disoriented, Headache, Aches and chills, cold, crying, diarrhea, happy, miserable

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 victim 67% (341/508) 69% (63/91)

OD setting: Public 20% (100/498) 29% (26/89)

> 1 naloxone dose used 48% (23/468) 39% (33/85)

911 called or EMS present 23% (119/508) 27% (25/91)

Rescue breathing 47% (166/350) 52% (34/66)

Stayed with victim 89% (445/498) 89% (78/88)

Sternal rub 63% (222/350) 62% (41/66)

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 XuanH Holly HackmanEmily QuinnMaya Doe-SimkinsAmy Sorensen-AlawadSarah RuizAl Ozonoff

Opioid Overdose Related Deaths: Massachusetts 2004 - 2006

No Deaths

1 - 5

6 - 15

16 - 30

30+

Number of Deaths

OEND programs2006-072007-08

2009Towns without

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 2004-2006

• Setting: – MA OEND programs were implemented by 8 community-based programs starting

in 2006

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

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

Fatal opioid OD rates by OEND implementation

Cumulative enrollments per 100k RR ARR* 95% CI

Absolute model:

No enrollment Ref Ref Ref

Low implementation: 1-100 0.93 0.73 0.57-0.91

High implementation: > 100 0.82 0.54 0.39-0.76

* 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.

Naloxone coverage per 100K

0

50

100

150

200

250

Opioid overdose death rate

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

No coverage

1-100 ppl

100+ ppl

27% reduction46% reduction

Fatal opioid OD rates by OEND implementation

Walley et al. BMJ 2013; 346: f174.

Opioid-related ED visits and hospitalization rates by OEND implementation

Cumulative enrollments per 100k RR ARR* 95% CI

Absolute model:

No enrollment Ref Ref Ref

Low implementation: 1-100 1.00 0.93 0.80-1.08

High implementation: > 100 1.06 0.92 0.75-1.13

* 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.

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

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): 80-7.

– 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.

Venues and Models

Enrollment locations: 2008-2012

Data from people with location reported: Users: 9,824 Non-Users: 4,818

Program data

Implementing OEND in MMT and detox

Model Advantages Disadvantages

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; 44:241-7.

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.

Other venues and models

• First responder OEND– Quincy, Revere, Gloucester

• Emergency Department (ED) SBIRT• Post-incarceration• Prescription naloxone

– Prescribetoprevent.org

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.)

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

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

Practical Barriers to Prescribing Naloxone

1. Prescriber knowledge and comfort2. 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

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; 237-248.

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.

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?

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

Prescribetoprevent.org

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 overdoseA 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.

William SmithJones, 44Worked for AcmeWilliam SmithJones died unexpectedly at the Whidden Memorial Hospital in Everett on March 5, after being stricken at his Oak Island home in Revere. He was 44 years old.Born in Lynn, he was a lifelong resident of Oak Island, attended Revere schools and was employed by Acme Company of Revere until his untimely death.He was the father of Brendan SmithJones and Krysti SmithJones, both of Salem, NH; son of Cheryl SmithJones of Malden and the late Harold SmithJones; brother of Lori SmithJones of Tewksbury, Harold SmithJones of Fremont, NH, Annie SmithJones of Medford and Robert SmithJones of Somerville. He is also survived by the mother of his children, Heidi SmithJones of Salem, NH, Mildred SmithJones, his maternal grandmother, Ruth Smith of Revere; a cousin, Jonathan A. SmithJones of Revere; and several nieces, nephews and other cousins. He was also the grandson of the late Robert SmithJones and Oswell and Anna SmithJones.Funeral arrangements were entrust ed to the Vertuccio Home for Funerals of Revere.

Remembrances may be made to the American Heart Association, 20 Speen St., Framingham, MA 01701.

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

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

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

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

Thank you! [email protected]

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 BernsteinProgram sites, staff and participantsNOPE group

Helpful Websites:Prescribetoprevent.orgOverdosepreventionalliance.orgNaloxoneinfo.org

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

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

How does drug use change after OEND?

Doe-Simkins et al. Under review

N=325 Increased Decreased No change

Heroin 115 (35%) 122 (38%) 88 (27%)

Methadone 84 (26%) 70 (22%) 171 (52%)

Buprenorphine 73 (22%) 66 (20%) 186 (58%)

Other Opioids 59 (18%) 62 (19%) 205 (63%)

Cocaine 83 (26%) 96 (30%) 146 (44%)

Alcohol 69 (21%) 70 (22%) 186 (57%)

Benzo/Barbiturate 99 (30%) 74 (23%) 152 (47%)*

Number of substances** used 131 (40%) 125 (38%) 69 (21%)

*p < 0.05 - 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

2002 2003 2004 2005 2006 2007 2008 20090

5

10

15

20

No enrollmentLow enrollment (1-100 per 100,000)High enrollment (>100 per 100,000)

Year

Opi

oid-

rela

ted

over

dose

dea

ths

per 1

00,0

00 p

opul

ation

Unadjusted unintentional opioid-related overdose death rates in 19 communities with no, low and high OEND enrollment

in Massachusetts, 2002-2009

Walley et al. BMJ 2013; 346: f174.

Unadjusted unintentional opioid-related acute care hospitalization rates in 19 communities with no, low and high OEND enrollment

in Massachusetts, 2002-2009

2002 2003 2004 2005 2006 2007 2008 20090

20

40

60

80

100

120

No enrollment Low enrollment (1-100 per 100,000)

High enrollment (>100 per 100,000)

Year

Opi

oid-

rela

ted

acut

e ca

re ra

tes

per 1

00,0

00 p

opul

ation

Walley et al. BMJ 2013; 346: f174.

Control models of OEND implementation and ratio of opioid related overdose deaths to cancer deaths

Cumulative enrollments per 100k Adjusted β estimate* P-value

Absolute model:

No enrollment Ref

Low implementation: 1-100 -0.0222 0.01

High implementation: > 100 -0.0326 0.01

Relative model:

No enrollment Ref

Low implementation: 1-100 -0.0238 <0.01

High implementation: > 100 -0.0183 0.07

* 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.

Control models of OEND implementation and ratio of opioid related to MV crash related acute care hospitalizations

Cumulative enrollments per 100k Adjusted β estimate* P-value

Absolute model:

No enrollment Ref

Low implementation: 1-100 -0.022 0.6

High implementation: > 100 0.0001 0.98

Relative model:

No enrollment Ref

Low implementation: 1-100 -0.0044 0.3

High implementation: > 100 0.0027 0.5

* 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.

Learn2cope.org Meeting Schedule

• Every Monday evening 7 - 9 PM– Good Samaritan Medical Center, 235 North Pearl Street, Brockton, MA. 02301

• 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 01610

• Email 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, email [email protected] for dates.

US and MA Age-Adjusted All Poisoning and MA Opioid-related Death Rates, 2000-2010

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 2000-2006; 18% decrease in rate from 2006 to 2010. Overall APC 2000-2010: 4.05 (p <.05)

73% increase in opioid-related poison death rate in MA from 2000-2006; 13% decrease in rate from 2006 to 2010. Overall APC 2000-2010: 4.06 (p<.05)

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 20100.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0

U.S. All Poisoning MA All Poisoning MA Opioid-related Poisoning

Year

Ag

e A

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Acts of 2012, Chapter 192, Sections 11 & 32

(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)

(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.

(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. 91-513, 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.

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

Patient instructionsEducation Videos:• Overdose Prevention Video for chronic pain

patients

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

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