Post on 26-Feb-2021
Drugs Research Network Scotland &
Glasgow Caledonian University
June 18, 2018
Naloxone perspectives
from BC, Canada
Jane Buxton MBBS, MHSc, FRCPC
Harm reduction lead BC CDC
In recognition of staff at BCCDC and health authorities,
first responders and people with lived experience who
are dedicated to saving the lives of others
Overview• Background OD crisis
Illicit drug deaths and the role of fentanyl
• Take home naloxone THN sites, kits distributed & used
Training – videos and apps
Facility Overdose Response Box (FORB) program
Research: Evaluations: program, youth, corrections, ED (A&E)
Data from administration forms
o Withdraw symptoms; # amps used;
o Giving breaths; Calling 911
Lives saved (modeling)
Summary policy changes
Make opioid use3
Source BCCS: Illicit Drug Overdose Deaths in BC, Posted May 10, 2018
http://www2.gov.bc.ca/assets/gov/public-safety-and-emergency-services/death-investigation/statistical/illicit-drug.pdf
*
Illicit drug overdose deaths (IDD) and death
rate/100,000 population BC
250
BC Drug Overdose & Alert Partnership
5
DOAP
Law Enforcement
Testing Labs
Coroners
Emergency Health
Services
Health &
Emergency Depts.
BC Drug & Poison Info
Centre
Researchers (CISUR, BCCSU)
People with Lived
Experience
• Opioids depress breathing;
become unconscious, breathing
stops, brain damage and death
• Naloxone - opioid antidote
temporarily reverses opioid OD
• No pharmacologic action in
absence of opioids
How does NALOXONE work?
LASTS
20 TO 90
MIN
WORKS IN
2-5 MIN
(1) Naloxone binds to opioid receptors in the
brain
(2) opioids are
forced off
(3) Breathing
is restored
6
Naloxone
7
8
9
10
11
12
13
14
15
Public health interventions
Provisional data to Mar 31, 2018 will change as cases closed; Source BCCS, May 10, 2018http://www2.gov.bc.ca/assets/gov/public-safety-and-emergency-services/death-investigation/statistical/illicit-drug.pdf
Illicit drug overdose deaths (IDD) and death
rate/100,000 population BC (4.7m)
250
DOAP
THN
Public Health
emergency
declared
Vancouver 4-
pillars approach
adopted
Insite
opens
Powdered fentanyl mixed with or
sold as heroin
Oct 2014: 31 ODs at InSite (2days)
Fentanyl Urine Screen Study (FUSS) Feb 2015 - 242 participants across BC
Fentanyl in all regions (29% +ve)
73% those +ve unaware took fentanyl
Fake oxy; green monsters CDN one side 80 other
Aug 2015: Deaths in young adults
Pills seized and tested by police variable
fentanyl little to lethal dose
Fentanyl analogues appear Late 2016: Carfentanil
Fentanyl
17
Percentage of illicit drug deaths in which
fentanyl detected in BC
*Provisional data to Mar 31, 2018, may change as cases closed; Source BCCS, May 10, 2018http://www2.gov.bc.ca/assets/gov/public-safety-and-emergency-services/death-investigation/statistical/illicit-drug.pdf
*
BC overdose response program
19
20
BC Take Home Naloxone kit
Case - changes with input
Proud to carry naloxone
White zip - easy find in bag
Belt hook – easy to carry
Silver cross
Contents
Amp snappers
3 amps naloxone 0.4mg/ml
3 safety needles
Breathing barrier
• Program evaluation qual and quant, youth
• Input from Community Advisory Board
22
BC Take Home Naloxone Sites
23
Aug 31, 2012 – Apr 15, 2018
BC THN kits distributed ODs reported
24
BC Take home naloxone program
http://towardtheheart.com/naloxone/
* Data extracted May 15, 2018; kit distribution data entry fairly complete until Mar 31st, 2018
** includes 579 community pharmacies enrolled since Dec 2017, excludes inactive sites
*** based on client kits refilled reported due to naloxone use on self/others to reverse an OD
2012 2013 2014 2015 2016 2017 2018*
Active THN Sites cumulative total
6 33 61 106 454 992 1,389 **
Kits Distributedcumulative total
(2017 only)106 724 1,922 5,075 26, 302 86, 504 98,071
Overdose Reversals
Reported using
THN Kits***
(2017 only)
5 41 168 565 4,504 19,407 22,051
(>60,000)
(14,903)
25
PH emergency
declared
Media
CarfentanilMonthly data
26
0
500
1000
1500
2000
2500
3000
3500
4000
4500
5000
Nu
mb
er
of
Kit
s O
rdere
d
Week
Rush Order Kits Standing Order Kits Kits Ordered (Not Standing or Rush)
# of Kits Ordered by Week (Nov 2016 - Apr 2017)
27
R
E
S
P
O
N
S
E
Call 911
28
29
30
Dec 1, 2016; Boxes with 5-20 doses of naloxone and OD supplies
given to approved community based organizations
http://towardtheheart.com/naloxone/forb/program-modules
Facility Overdose Response Box program
Registered sites commit to • Develop OD response policy
• Staff training, debriefing &
support
• Plan drills to maintain staff
competencies & train new staff
• Documentation to BCCDC: re
naloxone use - restocks
31
Dec 1, 2016 to April 30, 2018
490+ sites registered:
Non-profit organizations where people may OD, offer various services
- 12% shelters
- 43% supportive housing
- 26% drop-in & Friendship Centres
- 25% HR supply distribution
- 24% counselling
- 15% OD training and THN distribution
540+ OD reversals (>90 off site)
http://towardtheheart.com/naloxone/forb/program-modules
Facility Overdose Response Box program
32
The Rt. Rev. Melissa Skelton
(centre) bishop of the Anglican
Diocese of New Westminster,
performs a blessing and prayer
over an overdose-reversing
naloxone kit on Sunday, May 6 at
St. Barnabas Anglican Church in
the city of New Westminster
Overview• Background OD crisis
Illicit drug deaths and the role of fentanyl
• Take home naloxone THN sites, kits distributed & used
Training – videos and apps
Facility Overdose Response Box (FORB) program
Research: Evaluations: program, youth, corrections, ED (A&E)
Data from administration forms
o Withdraw symptoms; # amps used;
o Giving breaths; Calling 911
Lives saved (modeling)
Summary policy changes
Make opioid use33
34
http://www.cmajopen.ca/content/2/3/E153.full.pdf+html 2014
Sep 2015
BMJ Open (Jun 2016)
Aug 2016
35
• Adults: Empowerment
Challenges
Peer led training
Engagement opp.
• Youth: Feel empowered: Skill to intervene; felt valued and respected
Relationships with staff: being genuinely cared for
QI – need new video
Effects of THN participation:
Banjo O, Tzemis D et al Implementing a provincial take home naloxone program CMAJ open (2014) 2(3) E153-161
http://www.cmajopen.ca/content/2/3/E153.full.pdf+html
Mitchell K, Durante E, Pellatt K, et al. Naloxone and the Inner City Youth Experience Harm Reduction Journal
(2017) 14:34 http://rdcu.be/tiN6
THN at BC Correctional Facilities
36
•THN Pilot starts at AlouetteCorrectional Centre for Women (ACCW) & Fraser Regional Correctional Centre (FRCC)
July 2015
•THN begins at Kamloops Regional Correctional Centre (KRCC)
July 2016•THN begins in
Federal Correctional Facilities
Sept 2016
•THN available at all 9 BC Corrections facilities
Dec 2016
Jun-Oct 2016Pilot Program Evaluation
May 2018 THN on release at:• 10 of 10 provincial corrections • 1 of 2 youth custody facility• 7 of 7 forensic psychiatry • 6 of 9 federal corrections in BC
37
Annals of Emergency Medicine (2016) 69 (3) 340-346
38
Naloxone administration forms results
• N = 2,350, July 1, 2015- Dec 31, 2017
• 15% all reported ODs
Address concerns we frequently hear:What about withdrawal?
Are 3 amps enough?
Will people administer rescue breathing?
Will people call 9-1-1 at an overdose?
39
Concerns about withdrawal symptoms
Source: Administration Forms Jul 2015 - Dec 2017
None64%
Mild19%
Moderate12%
Severe5%
Reported
withdrawal
symptoms:
40
# Naloxone amps administeredSource: Administration Forms, Jul 2015 - Dec 2017
Mar 20163 amps%
THN interventions - breaths reported
In 2017 – 20% reporting no breaths given as were breathing
39%62%
42
43
70%
Report
calling
Proportion report calling 9-1-1 Jan 2015-Jun 2017
Improving calling 9-1-1
• Police policy; VPD not attended ODs since 90s
• BC Emergency Health Services policy to not
routinely call police when OD occurs (Jun 2016)
• Federal Good Samaritan Drug Overdose Act
(May 2017) exemption for simple possession
44
45
Reason for not calling 911 Jul 2015-Dec 2017
THN administration forms%
http://www.thelancet.com/pdfs/journals/lanpub/PIIS2468-2667(18)30044-6.pdf
Irvine et al. Lancet Public Health (2018)
47
Lives saved by take home naloxone
Sep 2012- Oct 2016
300 deaths averted
Kit use increased after Oct
2016 but other confounders
48
Recent innovations THN access
• Coroners provide training and THN kits
• Ambulance provide replacement THN kits (pilot)
49
50
Date Policy changes in BC regarding naloxone
Aug 2012 BCCDC began THN; Dr./NP script; pharmacy storage - clinic; risk OD
Apr 2015 DST - RNs can dispense without a script (CRNBC)
Jan 2016 BCEHS - all ambulance crew can administer Nlx (ministerial order)
- firefighters administer Nlx if agreement & trained
Mar 2016 Nlx removed from federal prescription drug list (BC - behind counter)
Apr 2016 Public Health Emergency declared by Provincial Health Officer
Jun 2016 All EDs & health units directed to provide THN (BC MoH)
BCEHS – police no longer routinely informed of OD
CPSBC – physicians advised to offer THN at risk pts. Rx opioids
Sep 2016 Nlx unscheduled in BC – no script/names; F&F - witnessing OD
Dec 2016 FORB introduced; Overdose Prevention Sites ordered by BC MoH
May 2017 Good Samaritan Drug Overdose Act – simple possession
Dec 2017 Free kits in BC community pharmacies (no dispensing/training fee)51
Overview• Background OD crisis
Illicit drug deaths and the role of fentanyl
• Take home naloxone THN sites, kits distributed & used
Training – videos and apps
Facility Overdose Response Box (FORB) program
Research: Evaluations: program, youth, corrections, ED (A&E)
Data from administration forms
o Withdraw symptoms; # amps used;
o Giving breaths; Calling 911
Lives saved (modeling)
Summary policy changes
Make opioid use52