Overdose Education and Naloxone Distribution for medical providers

Overdose Education and Naloxone Distribution for medical providers

Overdose Education and Naloxone Distribution for medical providers and social service agencies MO-HOPE Project The Missouri Opioid-Heroin Overdose Prevention and Education (MO-HOPE) Project Mission: to reduce opioid overdose deaths in Missouri through expanded access to naloxone, overdose education, prevention, public awareness, assessment, and referral to treatment, for those at risk of experiencing or witnessing an overdose event MO-HOPE

Topics covered today: Opioid Overdose Background Delivering Overdose Education & Naloxone Distribution training MO-HOPE Evaluation Overview 100 people die from drug overdose every day in the U.S. Death by leading cause of injury (per 100,000)

70,000 64,070 60,000 52,404 51,930 50,000 42,331 41,502 40,000

36,415 35,092 37,461 30,000 20,000 12,779 10,000 6,094

0 1980 Motor1995 Vehicle 2012 Drug Poisoning 2015 2016

Presribetoprevent.org ASAM.org nhtsa.gov Drugs Involved in U.S. Overdose Deaths, 1999 to 2017 30,000 29,406 25,000 20,000 15,000

15,958 14,958 14,556 10,721 10,000 5,000 3,295 0 99 000 001 002 003 004 005 006 007 008 009 010 011 012 013 014 015 016 017 9 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

Source: CDC WONDER 2016 Eastern Region Overdose Rate Adjusted by Population (Per 100,000) Warren County St. Louis County St. Louis City St. Charles County Lincoln County Jefferson County Franklin County 0

10 20 30 40 50 60 70

P e r c e n t o f O p io id -in v o lv e d D e a t h s A Focus on Heroin and Fentanyl in St. Louis City and County In 2017, St. Louis accounted for 47% of statewide opioid-involved deaths In 2017, 84% of opioidinvolved deaths in St. Louis involved fentanyl St. Louis Opioid-Involved Deaths 2015-2017 90 80 70

60 50 40 30 20 10 0 2015 Heroin-Involved Deaths 2016

2017 Fentanyl-Involved Deaths *Percentages do not sum to 100 due to both heroin and fentanyl were present in a subset of decedents. Fentanyl Myths and Facts MYTHS Coming in contact with even a small amount

of fentanyl can cause an overdose. FACTS Most commonplace contact, such as touching or being in a room with an open bag, is not enough to harm you

Powdered fentanyl does not penetrate the skin easily There are some forms of fentanyl that are resistant to naloxone. Naloxone counteracts the effects of all opioids, including all analogues of fentanyl. Since fentanyl is more potent than heroin, more doses of naloxone may be required

Theres no problem with first responders being overly cautious around fentanyl. Being overly cautious can cause unnecessary delays in delivery of care to people who need immediate assistance, which can lead to death Fentanyl Safety Tips If you touch fentanyl, it can be removed from skin with soap and water

Alcohol-based products, such as hand sanitizer or wipes, may increase fentanyl absorption Wash your hands soon, but not necessarily immediately Powdered fentanyl does not penetrate the skin very easily but avoid touching lips or eyes What's being done to address the epidemic Prevention Primary prevention Prescription Drug Monitoring Program (PDMP) Mental Health parity laws

Alternative pain treatments What's being done to address the epidemic Treatment Expanded access to medications for Opioid Use Disorder Missouri's State Targeted Response (Opioid STR) Prevention, treatment, impact Recovery support

Visit: www.missouriopioidstr.org to learn more including a list of state-funded treatment facilities What's being done to address the epidemic Harm reduction Syringe access Safe consumption sites Good Samaritan laws Increased access to overdose education and naloxone Whats naloxone?

Injectable (intramuscular or IM) Autoinjectable EVZIO is a prefilled to inject naloxone quickly into the outer thigh. Once activated, the device provides verbal instruction to the user describing how to deliver the medication like defibrillators Prepackaged Nasal Spray NARCAN Nasal Spray is a prefilled, needle-free device that requires no assembly and is sprayed into one nostril

Naloxone laws in MO RSMO 190.255, enacted August 28, 2014 Distribution to first responders First responder administration immunity RSMO 195.206 and 338.205, enacted August 28, 2016 Pharmacy availability (without an outside prescription) Pharmacist criminal and civil immunity Third party access/right to possess Any person administering naloxone in good faith and with reasonable care has criminal and civil immunity and is immune from any disciplinary action from his/her professional licensing board if 911 is called Any person or organization acting under a standing order issued by someone who is

authorized to prescribe naloxone may store and dispense naloxone if the person does not collect a fee Amended in 2017 with statewide standing order Missouris Good Samaritan Law (RSMO 195.205) A person who, in good faith, seeks or obtains medical assistance for someone who is experiencing a drug or alcohol overdose or other medical emergency or a person experiencing a drug or alcohol overdose or other medical emergency who seeks medical assistance for himself or herself or is the subject of a good faith request shall not be Arrested Charged Prosecuted

Convicted Have property subject to civil asset forfeiture If the evidence was gained as a result of seeking or obtaining medical assistance. What does immunity cover? RSMO 579.015, 579.074, 579.078, 579.105 Possession of a controlled substance Possession of paraphernalia Keeping or maintaining a public nuisance RSMO 311.310, 311.320, 311.325

Alcohol sale to minor Possession of an altered ID Purchase or possession of alcohol by a minor Violating a restraining order Violating probation or parole What is NOT covered? Outstanding warrants an offense other than an offense under subsection 2 of this section, whether the offense arises from the same circumstances as the seeking of medical assistance.

Opioid use disorder & the brain Addiction & substance use disorder Preventable Treatable Recovery Brain disease Prognosis

Progression Symptoms Risk factors for SUD Victims of abuse Easy availability Poor self concept Difficulties coping with stress Weak family relationships Early experimentation Behavior problems Genetics

United States 5% of Worlds Population The influence of prescription monitoring programs on chronic pain management, Pain Physician, 2009 80% of Worlds Opioid

Painkillers 99% of Worlds Vicodin International Narcotics Control Board Report, 2008 Cicero et al 2017 Thats why it feels good! Dopamine Release 2500

2000 1500 Dopamine Level 1000 500 0 Food

Nicotine Cocaine Heroin Why do people use opioids? Alexander Walley,MD Medications for Opioid Use Disorder (OUD) Methadone

Dolophine, Methadose Methadone activates opioid receptors in the brain, fully replacing the effect of whichever opioid the person is addicted to. Naltrexone Vivitrol Naltrexone binds to opioid receptors in the brain, blocking the effects of opioids. Buprenorphine Suboxone, Subutex, Probuphine Buprenorphine activates opioid receptors in the brain, partially replacing the effect of whichever opioid the person is addicted to.

Source: National Institute on Drug Abuse, Pew Charitable Trusts Credit: Rebecca Hersher and Alyson Hurt/NPR Medications for OUD Alexander Walley,MD OEND Overdose Education and Naloxone Distribution Prescribers Role SAMHSA Physicians and other health care providers can make a major

contribution toward reducing the toll of opioid overdose through the care they take in prescribing opioid analgesics and monitoring patients response, as well as through their acuity in identifying and effectively addressing opioid overdose. According to NIDA: Roughly 21-29% of patients rx opioids for chronic pain misuse them 8-12% develop an OUD Federally funded Continuing Medical Education (CME) courses are available at no charge at http://www.OpioidPrescribing.com Naloxone is effective

American Medical Association endorsed distribution to anyone at risk of having or witnessing an overdose Surgeon General advisory April 2018 From 1996 to 2014, at least 26,500 opioid overdoses in the U.S. were reversed by laypersons using naloxone NIDA In CA, counties with naloxone programs had an overall slower rate of growth in opioid overdose deaths than counties without a naloxone program Davidson PJ et al (prescribetoprevent.org)

Risk Compensation A theory which suggests that people typically adjust their behavior in response to the perceived level of risk, becoming more careful where they sense greater risk and less careful if they feel more protected A familiar concern safe sex ed HIV prophylaxis needle exchanges seatbelts helmets

Societal public health Cost vs. Benefit Overdose Education and Naloxone Distribution (OEND) Effectiveness Those who received naloxone rescue kits as part of OEND had higher rates of calling 911, administering naloxone, and staying with the victim until help arrived (Dwyer et al., 2015) Providers/staff has a generally positive reception of program (Samuels, 2014) Reduces overdose at a population level, increases preparedness to respond effectively (Walley et al., 2013), levels of use do not change (e.g., Dwyer et al., 2015)

Reduces opioid-related ER and hospital visits, overdose events among chronic pain patients, prescribed dosage does not change (Coffin et al., 2016) Potential impact May lead to safer opioid use Ft. Bragg in NC averaged 8 overdoses per month. After initiating naloxone distribution, the rate dropped to ZERO with no naloxone use reported Can increase communication, trust, openness By being able to offer something concrete to protect patients from the danger of overdose, I am given an

opening to discuss the potential harms of opioids in a non-judgmental way. San Francisco PCP Overdose risk PrescribetoPrevent.org How to assess for risk In the past 6 months, have you taken any medications to help you calm down, keep from getting nervous or upset, raise your spirits, make you feel better, and the like? Have you been taking any medications to help you sleep? Have you been

using alcohol for this purpose? Have you ever taken a medication to help you with a drug or alcohol problem? Have you ever taken a medication for a nervous stomach? Have you taken a medication to give you more energy or to cut down on your appetite? Have you ever been treated for a possible or suspected opioid overdose? SAMHSA Toolkit for Prescribers Indications for naloxone prescription

All patients prescribed long-term opioids Many patients do not feel at risk Wilder CM, et al Patients prescribed opioids INCLUDING high-risk persons with a hx of overdose, report their risk of overdose was 2 out of 10 Prescribing to all makes naloxone prescription about risky drugs,

not risky people Most dangerous risk Long days supply Long acting/extended release

High dose Example OEND screening tool How can I incorporate OEND in my practice? SBIRT Screening, Brief Intervention & Referral to Treatment Billable Commercial Insurance: CPT 99408 (15 to 30 minutes)

Medicare: G0396 (15 to 30 minutes) Medicaid: H0050 (per 15 minutes) DAST, AUDIT or other brief screening tool Counsel on how to recognize overdose and administer Pharmacy access Many do not stock naloxone but it can be easily ordered

The conversation Use the time with your patient as an opportunity to: Talk about risk factors Discuss how to identify an overdose Demonstrate how to administer naloxone Emphasize this as standard practice; not a personal judgment **Educate families & friends when possible people cant administer naloxone to themselves!**

Opioid safety language Patients may not identify with the term overdose. Try: Overmedication Accidental overdose Opioid poisoning Bad reaction Opioid safety Naloxone is the antidote to opioids and can be used if there is a bad reaction and you cant be woken up

Opioids can sometimes slow or stop your breathing Naloxone is for opioid medications like an epi pen is for someone with an allergy What are risk factors for an overdose? Chronic: Previous overdose

History of substance use or misuse Previous suicide attempt Acute:

Period of abstinence= Decreased tolerance (Incarceration, detox, rehab, etc.) A change in amount or purity (e.g., fentanyl) Injecting

Mixing opioids with other substances Access to prescription drugs Witnessed a family member overdose High Rx opioid dose and/or sustained action (CNS depressants)

Using alone Being physically ill/respiratory disease Homeless in the past 90 days Bottom line on opioid overdose (narcotic toxidrome): Depressed mental status or coma

Ineffective or absent breathing Pinpoint pupils What is Narcan? Narcan (naloxone) is a medication that reverses the effects of an opioid overdose Onset of action: 2-3 minutes Narcans effects start to wear off after ~30 minutes and are gone by ~90 minutes. Average = 60 min Its possible that someone can slip back in to an overdose state which is why its important to

get immediate medical attention Heres what to do if someone overdoses 1.Call 911 2.Give 1 dose of Narcan nasal spray 3.Administer rescue breaths/put in recovery position 4.Stay with the person 5.Give 2nd Narcan dose after 2-3 minutes if 1st dose is not successful Airway tips Head-tilt/Chinlift maneuver

often lifts the tongue out of the way How to use Narcan How to use Narcan How to use Narcan What happens after an overdose is reversed? About 50% of administrations result in no negative side effects.

Naloxone can precipitate withdrawals among those with physical dependence. These may manifest as: Anger/Irritability (about 20%) Withdrawal (about 19%) Vomiting (about 7%) Combative (about 4%) Why have it? If you overdose, people around you will be able to save your life

If someone else overdoses, youll be able to save their life It is not dangerous and people cant get high from it No harm will be done if its used on someone who isnt overdosing How to get and store naloxone Take prescription to the pharmacy and pick up your naloxone Keep the naloxone with you or your medication Do not store it in the car

Try to keep it at room temperature Make sure others know where it is and how to use it! Preventing a future overdose Co-prescription is the gold standard it doesnt mean we dont trust you You can still overdose when on MAT If you choose to use Be around others Always have Narcan nearby (and someone who knows how

to use it) Test a small amount of a new product (e.g., taste your shot) Be extra cautious after a period of abstinence/non-use tolerance is depleted after 3-5 days Keep yourself safe Take only opioids prescribed to you, and as directed Make sure all prescribers know all your medications Dont mix opioids with alcohol or other sedatives Keep all medications in a safe and secure location What happens if I use my naloxone? If it gets used, tell your prescriber

No punishment Get a new dose of naloxone Naloxone is available at the pharmacy without an outside prescription if you or your family want additional doses Fill out the MO-HOPE overdose Field Report Your (very important) role in MO-HOPE project evaluation: Currently no centralized figures in Missouri on overdose

events and reversals who, what, where, etc. These figures = CRITICAL for better understanding overdose patterns and continuing to receive federal funding to provide more training and naloxone More knowledge in these areas = More effective training & intervention The basics - what were asking from you: Teach patients how to complete a brief report each time they witness or experience an OD (on their phone through a web link)

If/when they request additional dose, may do it together if not yet completed The field report what to expect: 1) Add this web link to your desktop: mohopeproject.org/ODreport 2) After responding to an overdose, click on the link and complete the form Zip, Sex, Age, Drugs involved, Use of Naloxone, etc. 3) Click submit and data will be sent to a secure database monitored by MIMH

Lets practice Set up the web link on your phone: mohopeproject.org/ODreport Complete the Field Report for the following scenario: It is 01-03-18 around 2:00pm. You arrive to your home in St. Charles, MO (zip code: 63304) to find your White, non-Hispanic, 22 year-old son (PLEASE SELECT TEST/DEMO OPTION) in what appeared to be a heroin overdose state so you administered one dose of Narcan nasal spray that you received from Mission Recovery Community Center. He came out of the overdose and began vomiting. You call 911 and wait for EMS to arrive (they do

not administer additional naloxone). Your son is then transported to a treatment facility. The specifics data protection and informed consent: Your personal information and responses will not be shared with anyone outside of Evaluation project personnel Aggregated data will be reported and shared to inform project direction and scope If you have any concerns about completing the Field Report or asking patients to do so, please contact Claire Ward with MIMH

immediately, as timely completion is a critical piece of our partnership agreement. Questions? Visit: www.MOHOPEproject.org For questions about scheduling trainings, Narcan supply, or treatment resources, contact NCADA: Brandon Costerison (trainings, supplies) [email protected] (314) 962-3456 xt 315 Nicole Browning, MA, LPC (treatment questions) [email protected]

314-962-3456 xt 366 For questions about evaluation (OD Field Reports), contact MIMH: Sandra Mayen [email protected] (314) 516-8414 Link to Training Materials www.mohopeproject.org/tx-fil es

Please note, training materials are updated frequently so please ensure you are using the most up-to-date materials when providing trainings.

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