Opioid Overdose Prevention No One Has to Die Trying

Opioid Overdose Prevention
No One Has to Die Trying
Emil Affsa III, LPC, LCADC
Jayne S. Cavanaugh, MA, LCADC, LCS
NADCP Conference 2016
Course Abstract & Learning Objectives
Course Abstract
• The opiate epidemic that is shocking the nation has come of no surprise to New Jersey Drug
Courts, where opiate use has persisted across all sociocultural lines for some twenty years. In the
midst of trying to help themselves, offenders are dying of overdose at an alarming rate of nearly
16 per day in New Jersey, a fate that awaits the rest of the country. Drug Court Teams invest time,
energy, and passion in helping addicted offenders, such that the news of an overdose death is
paralyzing.
• In August 2015, the New Jersey Drug Court Unit launched statewide training to raise the
awareness of overdose prevalence and prevention, and potential life saving measures among
participants, family and teams.
• This overdose prevention stratagem we offer to all NADCP attendees through one, easy-toreplicate power point here presented, inclusive of adaptation tips.
Learning Objectives
1. Increased awareness of overdose prevalence and participant risk factors
2. Take home methods that your teams, participants, and family members can use to
decrease the risk of overdose
3. Learn of potential life-saving measures available to non-medical laypersons
National Prevalence of Overdose Deaths
• Approximately 120 people die of overdose each day in the USA
• Between 2002 and 2013, the rate of heroin-related overdose deaths
nearly quadrupled
• Heroin-involved overdose deaths nearly doubled between 2011 and
2013; more than 8,200 people died in 2013 alone
• Heroin overdose rate nearly tripled in the US from 2010 to 2015
• 1 in 50 heroin users will die this year
per Center for Disease Control
State Prevalence of Overdose Deaths
New Jersey
• Drug-related deaths increased 30% from 2011 (1,031) to 2013 (1,336)
• Of the 1,336 total drug-related deaths in 2013, toxicology results
identified 1,300 incidents of opiate derived drug(s) = 97%
• Heroin accounted for 82% of the drug-related deaths
• 741 heroin-related deaths 2013, 781 in 2014
• 8.3 heroin deaths per 100k = 3x the national average of 2.6 per 100k
• Fentanyl-related deaths increased 189% from 2013 to 2014
Center for Disease Control
Total New Jersey Drug-Related Use Deaths
(Insert Your State Chart)
Chart Title
1600
1400
1200
1000
800
600
400
200
0
2011: 1031
2012: 1221
2013: 1336
New Jersey State Police DMI 2014 Annual Report
2014: 1157
preliminary
New Jersey State Police DMI 2014 Annual Report
Opiate Painkillers
National Perspective
State Prevalence of Fentanyl
New Jersey
• Fentanyl is approximately 15 to 20 times more potent than heroin
• Significant factor in the increasing number of overdoses in New Jersey
• According to preliminary State Medical Examiner data, fentanyl-related
deaths increased 189% between 2013 (46) and 2014 (133)
• Historically, fentanyl was utilized as an adulterant to increase heroin’s
potency & appeal. More recently, dealers have been selling glassines
containing fentanyl without heroin
• Law enforcement intelligence indicates Mexican cartels are exploiting &
supplying this new market by importing non-pharmaceutical grade
fentanyl. Acetyl-fentanyl (fentanyl analog) may be as much as 5 to 15 times
stronger than heroin & is increasingly being seen in New Jersey
New Jersey State Police DMI 2014 Annual Report
New Jersey Fentanyl Deaths
140
120
100
80
60
40
20
0
2011: 31 total
2012: 42 total
2013: 45 total
New Jersey State Police DMI 2014 Annual Report
2014: 133 preliminary
New Hampshire Sample
(It’s all on the ‘net)
New Mexico Sample
http://www.bhc.state.nm.us/pdf/4.%20EPI%20Drug%20Overd
ose%20in%20NM%20(Jim%20Davis-Karen%20C).pdf
Overdoses per 100k All U.S. States
Removing the “NIMBY” Stigma (Graph by Counties)
New Jersey State Police DMI 2014 Annual Report
New Jersey Judiciary Clients
Heroin & Opiate Prevalence 2007-2015
Calendar Year
% of Evals Heroin Primary
% of Evals Heroin Plus Pills
Primary
Total Opiate Primary
2007
20%
24%
44%
2008
17%
21%
38%
2009
19%
24%
43%
2010
18%
24%
42%
2011
17%
25%
42%
2012
19%
27%
46%
2013
24%
32%
56%
2014
26%
33%
59%
2015
26%
33%
59%
Let’s Talk Overdose Risk
Persons Are at Risk for Overdose Who…
• Use opioids or heroin
• Receive rotating opioid pain medication regimens (at risk for incomplete crosstolerance)
• Discharged from emergency medical care following opioid intoxication or
“poisoning” (overdose)
• Take legitimate-need opiates for analgesia coupled with history of substance use
disorder or non-medical use of medications
• Complete opioid detoxification or are abstinent for a period of time (and
presumably with reduced opioid tolerance and high risk of relapse to opioid use)
• Recently released from incarceration and a past user of opioids (and presumably
with reduced opioid tolerance and high risk of relapse to opioid use)
• 2-6x overdose risk post jail (NADCP workshop 2015)
• 5 days in jail = 2x overdose risk (NADCP workshop 2015)
"Overdose Toolkit", SAMHSA
Additional Overdose Risk Factors
• Extended abstinence followed by use
• The brain has begun to recover from the alterations that lead to
increased tolerance; tolerance is lowered with abstinence, so it takes
less opiates to shut down respiratory and cardiac functions
• Overdose history
• Users who previously overdosed are higher risk, since overdose
sensitizes the brain to repeat
• Mixing opiates with other substances
• Use of licit or illicit opiates (heroin, narcotic pills) in conjunction with
alcohol, benzodiazepines (i.e.: Xanax), Methadone, barbiturates, and/or
other sedating substances elevates chances of overdose
Still More Overdose Risk Factors
• Medication Assisted Treatment or MAT (Methadone, Suboxone, Vivitrol)
• Often used to decrease craving for illicit opiates paradoxically results in
decreased tolerance during abstinence, and thus increases overdose risk
• Vivitrol blocks opiate receptors, preventing opiate users from getting high; it
is possible to use enough opiates to over-ride the block– but the amount
needed to over-ride can lead to overdose
• Synergistic effects of Methadone with continued use of heroin/opiates,
sedatives, or alcohol heighten overdose risk
• Adulterants added to heroin by drug “manufacturers”
• Fentanyl, Cocaine, Acetyl-Fentanyl, Methamphetamine, Tramadol are more
commonly being cut into heroin, rendering higher overdose risk and
potentially diminished life-saving effects of Naloxone
Tolerance Defined
• Tolerance develops when someone uses an opioid drug regularly, so
that their body becomes accustomed to the drug and needs a larger
or more frequent dose to continue to experience the same effect.
• Loss of tolerance occurs when someone stops taking an opioid after
long-term use. When someone loses tolerance and then takes the
opioid drug again, they can experience serious adverse effects,
including overdose, even if they take an amount that caused them no
problem in the past.
"Overdose Toolkit", SAMHSA
State Prevalence of Overdose Calls
Worchester, Massachusetts Sample
Symptoms of an Overdose
1. Slow and shallow breathing
2. Very sleepy and unable to talk, or unconscious
3. Skin color is blue or grayish, with dark lips and fingernails
4. Snoring or gurgling sounds
Because opioids depress respiratory function and breathing, one telltale sign
of an individual in a critical medical state is the “death rattle.” Often mistaken
for snoring, the “death rattle” is an exhaled breath with a very distinct,
labored sound coming from the throat. It indicates that emergency
resuscitation is needed immediately. (“Overdose Toolkit”, SAMHSA)
“Opioid Overdose Resuscitation”, American Society of Anesthesiologists
Opioid Overdose Resuscitation
If There Are Symptoms of an Overdose
1. Lightly tap, shake, and shout at the person to get a response.
If still no response, rub knuckles on the breast bone.
2. If the person responds, keep them awake.
3. Call 911.
Opioid overdose is a medical emergency. Overdose can cause coma or death within
minutes. When calling 911, state that it’s an overdose so responders can bring Narcan
(Naloxone). Stay with the person– Good Samaritan Law provides protection from arrest
& prosecution for drug possession crimes. (“Overdose Tool Kit” SAMHSA)
“Opioid Overdose Resuscitation”, American Society of Anesthesiologists
Opioid Overdose Resuscitation
If You Get Little or No Response
1. Call 911.
2. If their breathing is shallow or non-existent, or if the skin color is blue or
grayish, with dark lips and fingernails, perform mouth-to-mouth rescue
breathing by tilting head back and lifting up chin until mouth opens, clearing
airway. Give two quick breaths to start and then a strong breath every 5
seconds.
3. If the person no longer has a heartbeat (pulse), continue rescue breathing.
Perform CPR by pushing hard on the chest bone at a rate of 100 times per
minute.
4. Stay with the person. If you have to leave the person alone or vomiting occurs,
place the person on their side.
5. If you have access to Naloxone, administer it according to the package
instructions, in addition to calling 911.
“Opioid Overdose Resuscitation”, American Society of Anesthesiologists
Is Naloxone Administration permitted by Laypersons?
New Jersey
• A person, other than a health care professional, may in an emergency
administer, without fee, an opioid antidote, if the person has received
patient overdose information pursuant to section 5 of this act and
believes in good faith that another person is experiencing an opioid
overdose. C.24:6J-4b
• Nasal Narcan use by first responders began in Ocean County in April
2014 & is now approved for use statewide
• Naloxone was administered more than 3,000 times by first
responders in the first year 2014. (State Police DMI Annual Report)
Narcan Use by County
New Jersey
New Jersey State Police DMI 2014 Annual Report
Naloxone Administrations 2014 to Mid-2015
New Jersey State Police DMI 2015 August 2015 Report
New Jersey January-June 2015 Narcan Update
• In this 6 months alone, Narcan was administered by EMS and law
enforcement over 2,900 times– an average of 16 times per day,
• There is a 20% increase in Narcan administrations on Fridays and
Saturdays.
New Jersey State Police DMI August 31, 2015
Naloxone Administrations
Ohio Sample
http://www.publicsafety.ohio.gov/links/2013%20Naloxone%20
epidemiological%20report.pdf
Naloxone (Narcan®) Administration
Ohio Sample
• Approximately 74,000 naloxone administrations occurred from 2003
to 2012.
• The number of naloxone administrations per year grew every year
from 4,010 in 2003 to 10,589 in 2012 (164%).
• Average was 11 administrations per day (or 334 per month) in 2003
and 29 per day (or 882 per month) in 2012.
• Annual rate of naloxone administration more than doubled from 3.51
in 2003 to 9.17 in 2012. The administration rate grew from 2003 to
2006 and then leveled off until 2012.
• Between 2011 and 2012, the rate of naloxone administration grew 21
percent, representing the second highest increase in 10 years.
Naloxone Administrations by Age
Ohio Sample
Naloxone Administrations
Ohio Sample
http://www.publicsafety.ohio.gov/links/2013%20Naloxone%20
epidemiological%20report.pdf
Naloxone (Narcan®) Administration
Ohio Sample
• Approximately 74,000 naloxone administrations occurred from 2003
to 2012.
• The number of naloxone administrations per year grew every year
from 4,010 in 2003 to 10,589 in 2012 (164%).
• Average was 11 administrations per day (or 334 per month) in 2003
and 29 per day (or 882 per month) in 2012.
• Annual rate of naloxone administration more than doubled from 3.51
in 2003 to 9.17 in 2012. The administration rate grew from 2003 to
2006 and then leveled off until 2012.
• Between 2011 and 2012, the rate of naloxone administration grew 21
percent, representing the second highest increase in 10 years.
Naloxone Administrations by Age
Ohio Sample
Naloxone (Narcan)
• FDA approved opioid antagonist used to reverse opioid overdose and resuscitate individuals
who have overdosed on opioids
• Has been used for decades by emergency room and EMS personnel
• Reverses overdose symptoms in seconds: person will awaken suddenly; withdrawal triggered
by Naloxone can feel “unpleasant”. Some persons become agitated or combative… and need
help to remain calm
• Should be administered to any person who shows signs of opioid overdose, or when
overdose is suspected
• Narcan can be re-administered if person does not revive or falls back into overdose before
help is obtained; longer-acting opioids may require multiple (i.e.: Fentanyl)
• Naloxone may cause dizziness, drowsiness, or fainting. These effects may be worse if it is
taken with alcohol or certain medicines
• No risk if opioids were not the cause of the medical emergency
• No reversal in non-opioid overdoses (i.e.: alcohol, benzodiazepines, etc.)
• Heroin adulterants (i.e.: acetyl fentanyl) can impair/inhibit Narcan efficacy
• Once Narcan is administered, person must go to emergency room. Narcan lasts only 15-20
minutes, but the window of overdose lasts longer
"Overdose Toolkit", SAMHSA
Naloxone Myths
• Myth #1: Naloxone makes it safe for addicts to continue using & thus
promotes relapse.
Truth: Naloxone does not promote relapse– the experience of
withdrawal is miserable and instant withdrawal is worse.
• Myth #2: Naloxone impacts drug test results, leading to a clean test.
Truth: Naloxone will not impact drug testing– the result will show
positive for heroin or the opiate or other substance(s) used.
CVS Makes Narcan Available
National Perspective
• Friends and family members of people suffering from opiate addiction
will now be able to get the overdose reversal drug naloxone without a
prescription
• Massachusetts and Rhode Island were first, followed in September
2015 by New Jersey, Arkansas, California, Minnesota, Mississippi,
Montana, New Jersey, North Dakota, Pennsylvania, South Carolina,
Tennessee, Utah and Wisconsin.
Narcan Intranasal Administration Technique
http://www.pdcbank.state.nj.us/health/ems/documents/narca
n/narcan_administration_edu_material.pdf
Dosage for Intranasal Narcan Administration
• Vial has 2mg of naloxone in 2mL
• Give 1mg (1ml) in each nostril, quickly
• Medication is atomized & absorbed through vessels in the nasal cavity
http://www.pdcbank.state.nj.us/health/ems/documents/narca
n/narcan_administration_edu_material.pdf
Intramuscular Narcan Administration Technique
1. Remove
auto injector from outer
case.
2. Pull off the safety guard.
3. Place the auto injector firmly against
the outer thigh, through clothing, if
needed.
4: Continue to press firmly and hold in
place for 5 seconds.
http://www.pdcbank.state.nj.us/health/ems/documents/narca
n/narcan_administration_edu_material.pdf
Dosage for Intramuscular Narcan Administration
• The auto injector administers 0.4 mg (0.4 mL) dose of naloxone into
the muscle.
• •The auto injector will have a retractable needle that the user will not
see before, during, or after an injection.
• •The auto injector may include voice prompts to assist with
administration.
• •The auto injector should be disposed of immediately after use in a
sharps container.
http://www.pdcbank.state.nj.us/health/ems/documents/narca
n/narcan_administration_edu_material.pdf
New Jersey’s “Overdose Prevention Act”
Includes Good Samaritan Clause
The Legislature finds and declares that encouraging witnesses and
victims of drug overdoses to seek medical assistance saves lives and is
in the best interests of the citizens of this State and, in instances where
evidence was obtained as a result of seeking of medical assistance,
these witnesses and victims should be protected from arrest, charge,
prosecution, conviction, and revocation of parole or probation for
possession or use of illegal drugs. C.24:6J-1
Enacted May 2, 2013
Good Samaritan Laws
National Perspective
• Good Samaritan Laws exist in many states. In the event of an
overdose, these policies protect the victim and the person seeking
medical help for the victim from drug possession charges.1
http://www.cdc.gov/drugoverdose/opioids/odprevention.html
Good Samaritan Law
Tennessee Sample
July 2014, Tennessee became the 18th state to pass a "Good Samaritan"
law, granting immunity from civil suit to providers who prescribe
naloxone to a patient, family member, friend or other person in a
position to assist giving the medicine naloxone; requiring individuals to
receive basic instruction, including taking a quiz and printing the
certificate, on how to give naloxone
Comparison causes of death in Tennessee in 2014:
Diabetes Mellitus
1,724
Pneumonia and Influenza
1,599
Drug Overdoses
1,263
Discharge of firearms
1,016
http://www.tn.gov/health/news/17419#sthash.BXZgUPMK.dpf
Good Samaritan Overdose Prevention Laws
Website Contains Interactive Map as to Your State’s Status
http://lawatlas.org/query?dataset=good-samaritan-overdose-laws
Bureau of Justice
http://www.bing.com/images/search?q=bureau+of+justice+opiate+overdose+stats+by+state+map&view=detailv2&adlt=strict&id=F79324F4C276E4727F0894837F
0C82297A76FDA5&selectedIndex=0&ccid=IRTdxc9x&simid=608037863906870087&thid=OIP.M2114ddc5cf714545c58af2980f96b138o0&ajaxhist=0
Overdose Awareness Online Video
http://www.stopoverdose.org
Overdose Prevention Measures for Teams
• SAMHSA requires MAT providers to educate patients about overdose prevention (SAMHSA MAT
Pocket Guide)
• Re-assess level of treatment for participants testing positive for multiple opiates (including
methadone or Buprenorphine) or opiates plus alcohol or sedatives
• When diversion is suspected the court may communicate with methadone clinics to restrict the
number of take-home bottles allotted and with buprenorphine prescribers to restrict the amount
of Suboxone per refill
• Safety of participants’ children—Methadone “take-home” dosages must be safely stored
• Providers must advise the team in advance when a participant is being recommended to use any
medication including medical, psychiatric, and MAT
• The use of benzodiazepines and other sedative hypnotics may be reason to suspend methadone
or buprenorphine (ASAM National Practice Guideline)
• Counseling is recommended with all forms of MAT
• Increase supervision and reassess treatment level when participants discontinue use of
methadone, buprenorphine, or naltrexone then resume opioid use
Additional Overdose Prevention Measures for Teams
• Be mindful which day of the week that you release participants from jail –
911 overdose calls double on Friday and Saturday nights
• Increase probation supervision of persons newly released from sanctions and newly
released from residential treatment stays
• Disposal of Unused Medicines – Participants, family members, & others in participant
homes should dispose of old medications
• Resource for how to dispose of medications “What You Should Know” (link on resource
slide)
• Prescription Drug Monitoring Programs (PDMPs) –
Physicians working with clients and prescribers have
access to PDMPs and can look to see if clients are
being prescribed medications from multiple prescribers.
New Jersey Overdose Prevention Methods
Implemented by Teams August 2015
Judiciary Substance Abuse Evaluators
Presented This Presentation
to Their Respective Drug Court Participants
Overall Response—
Participants were “stunned”
& took every last handout offered
Presented Overdose Awareness to Drug Court
Participants at the Holidays
The Team coupled Overdose Awareness with
Relapse Prevention at this time of year when
participants struggle most, seeking to reduce
the risk of relapse and sanctions but
more importantly to save lives
Highlighted Overdose Losses in Their County
through the Wearing or Displaying of Silver
Ribbons– the Symbol of a Life Lost Too Soon
• Ocean County presented Overdose Awareness to all 5 drug court sessions
• They created & displayed a poster bearing a ribbon for each of the 114
persons who died of overdose that year
• The Coordinator shared at a meeting a month later that a participant’s life
was saved because the family member learned of Narcan
• A Probation Officer wrote and shared a poem of what it’s like to lose a
participant to overdose
• The team placed a follow-up article in the local newsletter
• The team is also working with the county prosecutor on prevention
strategies for new arrestees
Counties Presented Overdose Awareness to
Drug Court Judges & Teams
Response–
Judges and teams were highly receptive.
One judge even asked for a private
tutoring so that he could be skilled to
present on Overdose Awareness
himself.
Essex presented to All 5 modules of Drug Court
Participants & Handed Out the “Save-a-Life Card
in English & Spanish
Participant Response—
Participants took every last Save-a-Life
card, taking them for their friends
on the streets who were
still using
http://massclearinghouse.ehs.state.ma.us/ALCH/SA1067kit.html
National Priority Strategies and Activities
• Through 2019, CDC plans to give selected states annual awards between
$750,000 and $1 million to advance prevention in four key areas. Awarded
states are collaborating with key partners to maximize efforts and address
issues that impact prescribing and drug overdoses. Examples of states’
activities include:
• Maximizing PDMPs
• Community or Insurer/Health Systems Interventions
• Policy Evaluations--Evaluating interventions to better understand what
works to prevent prescription drug overdoses
• Rapid Response Project--Implementing a project to advance an innovative
prevention approach and respond to new and emerging crises and
opportunities
Overdose Prevention Measures
Learn of New Initiatives
Ohio Sample
Deaths Avoided with Naloxone
2016 initiative to increase availability of NARCAN
SUMMARY “Do’s and Don’ts”
in Responding to Opioid Overdose
•
•
•
•
DO support the person’s breathing by administering oxygen or performing rescue breathing.
DO administer naloxone.
DO put the person in the “recovery position” on the side, if he or she is breathing independently.
DO stay with the person and keep him/ her warm.
• DON'T slap or try to forcefully stimulate the person — it will only cause further injury. If you are unable
to wake the person by shouting, rubbing your knuckles on the sternum (center of the chest or rib cage),
or light pinching, he or she may be unconscious.
• DON'T put the person into a cold bath or shower. This increases the risk of falling, drowning or going
into shock.
• DON'T inject the person with any substance (salt water, milk, “speed,” heroin, etc.). The only safe and
appropriate treatment is naloxone.
• DON'T try to make the person vomit drugs that he or she may have swallowed. Choking or inhaling
vomit into the lungs can cause a fatal injury.
• NOTE: All naloxone products have an expiration date, so it is important to check the expiration date and
obtain replacement naloxone as needed.
"Overdose Toolkit", SAMHSA
Summary Points
How Opiate Users Can Help Prevent Overdose
• No use of opiates, alcohol, or any mind altering substances
• Commit no new offenses– recovering persons who live contrary to their values
cannot remain clean and sober
• Develop your recovery equally in all realms– physical, mental, and spiritual;
addressing all three will give you something to hold onto in tough times
• Educate significant others on overdose symptoms
• Educate significant others on availability of Narcan training & Narcan kits
• Give a “Opioid Overdose Resuscitation” or “Save A Life” card to someone close
• Reach out for help at the first thought or trigger; if you or someone you know is
struggling, confer immediately with a sponsor, court staff, counselor, or other
trained professional
• Know that you are innately valuable as a human being– and you matter to us!
Summary Points
What Drug Court and Judiciary Teams Can Do to Help
Prevent Overdose
• Create a forum for showing the preceding power point presentation to judiciary staff,
drug court teams, drug court participants, and/or other judiciary clients
• Wear a silver ribbon on August 31, 2015, the official color of International Overdose
Awareness Day
• Show one of the University of Washington’s stop overdose videos to judiciary staff, drug
court teams, drug court participants and/or family members, other judiciary clients
and/or family members http://stopoverdose.org/
• Display an overdose awareness poster prominently
• Hold a brief memorial in honor of a participant who overdosed, such as a moment of
silence or having a friend or family member speak
• Ask a probation officer or other team member to tell what it’s like to lose a participant
• Give “Save a Life” or “Overdose Resuscitation” cards two to each participant
• Ask an overdose survivor to speak on gratitude
• Download free resources and distribute to staff, clients, and/or family members of clients
from http://www.overdoseday.com/resources/downloadable-resources/
Resources
•
•
•
•
•
•
•
•
•
•
http://www.stopoverdose.org
www.samhsa.gov
http://www.overdoseday.com/resources/downloadable-resources/
http://massclearinghouse.ehs.state.ma.us/ALCH/SA1067kit.html
2014 New Jersey Drug Environment Report, New Jersey State Police Drug
Monitoring Initiative
Overdose Toolkit, SAMHSA
http://www.state.nj.us/humanservices/dmhas/initiatives/naloxone.html
Medication-Assisted Treatment of Opioid Use Disorder Pocket Guide, SAMHSA
http://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicine
Safely/EnsuringSafeUseofMedicine/SafeDisposalofMedicines/ucm186187.html
http://lawatlas.org/query?dataset=good-samaritan-overdose-laws
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Thank you for your commitment to
saving lives–
No one has to die trying
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