Morning report5/27/2015By Matt Evans

Case• 3 year old female brought to PCMC for opioid overdose. • Pt. was initially brought by EMS to outside hospital, and pt. was given

Narcan with improvement in mentation and respiratory status according to EMS.

• Mother states that she herself had fallen asleep just after filling her weekly medication dispensing box, then woke up to find her 3 year old sleepy and surrounded by scattered meds (including her Lortab) and her open pill box.

• In the PCMC ED, patient did not require additional doses of Narcan and she was eventually admitted to the RTU for further observation.

Case continued, questions

• Patient did well, DCFS saw patient since EMS providers called them due to concern about the poorly cared for house and the situation

• How would the clinical situation have been different if med was methadone?

• Are there any other additional questions you’d like to ask the mother or father of this child?

• Are there any treatment/prevention options for next time?

• What education is indicated if any? • Was getting DCFS involved necessary? What if the drug

waspowdered heroin that the child got into instead of Lortab?

Case continued

• DCFS recommended that patient could go home as she was remorseful about situation and she would take precautions so it would not happen again

• This was the first time DCFS has been contacted about this mother• Pharmacy educated the patient’s mother about the use of rescue

intranasal naloxone in case of future overdose events, naloxone dispensed

• The House of Hope (family drug court) in Utah provides a setting where women can have their children with them in residential treatment.

• Research strongly indicates that women are much more likely to succeed in treatment if they are able to keep their children with them, and that they are less likely to become involved or remain in treatment if their children must be placed with family, friends, or in foster care. https://www.houseofhopeut.org/

NaloxoneSaving a life is child’s play

Naloxone for home useBy Matt Evans

Background• Drugs are bad. Worse than guns, and even worse than cars.

• Number 1 cause of accidental death nationwide since 2007• All injury deaths (2012)

• Number of deaths: 192,945• Deaths per 100,000 population: 60.2

• All poisoning deaths (2012)• Number of deaths: 48,545• Deaths per 100,000 population: 15.4

• Motor vehicle traffic deaths (2012)• Number of deaths: 33,804• Deaths per 100,000 population: 10.7

• All firearm deaths (2012)• Number of deaths: 33,636• Deaths per 100,000 population: 10.6

2012

Opioid OverdoseDeathRates inthe U.S. are climbing

Note: *Per 100,000 population

The DOPE projectDRUG OVERDOSE PREVENTION EDUCATION

• First successful overdose prevention programs were in Chicago & Santa Cruz• DOPE is a grassroots effort in San Francisco to distribute clean needles which

later turned into educating IDUs (injection drug users) on rescue naloxone• Grassroots initiative was eventually supported by local health departments and

this was translated to HIV patient care (since HIV patients were dying from heroin overdoses faster than from AIDS)

• Initial “overdose education trainers” taught their population about rescue breathing, taught them about safely calling 9-1-1 with the protection of a good Samaritan law, and dispelled overdose risks (no ice baths!), etc

• In 2003, after a law allowing MDs/NPs to prescribe take home IM naloxone rescue kits was passed, Dr. Josh Bamberger established a program to distribute naloxone at multiple sites after a short visit with a nurse practitioner

• In 2010 a law allowing trainers to distribute naloxone based on a standing order to promote even easier access was passed

Opioid OverdoseDeathRates inthe U.S. are climbing

Note: *Per 100,000 population

OEND (overdose education and intranasal naloxone distribution) in Massachusetts

• OBJECTIVE: To evaluate the impact of state supported overdose education and nasal naloxone distribution (OEND) programs on rates of opioid related death from overdose and acute care utilization in Massachusetts.

• INTERVENTION: OEND programs equipped people at risk for overdose and bystanders with nasal naloxone rescue kits and trained them how to prevent, recognize, and respond to an overdose by engaging emergency medical services, providing rescue breathing, and delivering naloxone.

• MAIN OUTCOME MEASURES: Adjusted rate ratios for annual deaths related to opioid overdose and utilization of acute care hospitals.

• RESULTS: Among these communities, OEND programs trained 2912 potential bystanders who reported 327 rescues. Both community-year strata with 1-100 enrollments per 100,000 population (adjusted rate ratio 0.73, 95% confidence interval 0.57 to 0.91) and community-year strata with greater than 100 enrollments per 100,000 population (0.54, 0.39 to 0.76) had significantly reduced adjusted rate ratios compared with communities with no implementation. Differences in rates of acute care hospital utilization were not significant.

• CONCLUSIONS: Opioid overdose death rates were reduced in communities where OEND was implemented. This study provides observational evidence that by training potential bystanders to prevent, recognize, and respond to opioid overdoses, OEND is an effective intervention.

Project Lazarus – if it works for heroin, will it work for all forms of opioid abuse?

• Background.  In response to some of the highest drug overdose death rates in the country, Project Lazarus developed a community-based overdose prevention program in Western North Carolina. The Wilkes County unintentional poisoning mortality rate was quadruple that of the state's in 2009 and due almost exclusively to prescription opioid pain relievers, including fentanyl, hydrocodone, methadone, and oxycodone. The program is ongoing.

• Methods.  The overdose prevention program involves five components: community activation and coalition building; monitoring and surveillance data; prevention of overdoses; use of rescue medication for reversing overdoses by community members; and evaluating project components. Principal efforts include education of primary care providers in managing chronic pain and safe opioid prescribing, largely through the creation of a tool kit and face-to-face meetings.

• Results.  Preliminary unadjusted data for Wilkes County revealed that the overdose death rate dropped from 46.6 per 100,000 in 2009 to 29.0 per 100,000 in 2010. There was a decrease in the number of victims who received prescriptions for the substance implicated in their fatal overdose from a Wilkes County physician; in 2008, 82% of overdose decedents received a prescription for an opioid analgesic from a Wilkes prescriber compared with 10% in 2010.

• Conclusions.  While the results from this community-based program are preliminary, the number and nature of prescription opioid overdose deaths in Wilkes County changed during the intervention. Further evaluation is required to understand the localized effect of the intervention and its potential for replication in other areas.

Winning! Or are we?Fast forward to 2013…

• Unfortunately, a side effect of physicians being more stringent with prescription opioids has resulted in a resurgence of heroin use/death

• Nationwide heroin overdose deaths are only increasing, and opioid analgesic deaths are not slowing down either

But Utah doesn’t have a drug problem, right?

The states with the highest rates per 100,000 population in 2012 were #1 West Virginia (32.0), #2 Kentucky (25.0), #3 New Mexico (24.7), #4 Utah (23.1), and #5 Nevada (21.0).

Age-adjusted drug-poisoning death rates, by state: United States, 2012

FIGURE 2. Number (N = 188) and location* of local drug overdose prevention programs providing naloxone in 2010 and age-adjusted rates† of drug overdose deaths§ in 2008 — United States

* Not shown in states with fewer than three local programs.† Per 100,000 population. § Source: National Vital Statistics System. Available at http://www.cdc.gov/nchs/nvss.htm. Includes intentional, unintentional, and undetermined

Purpose: Prescription drug overdose (PDO) deaths are a critical public health problem in the United States. This study aims to assess the association between emergency department (ED) utilization patterns in a cohort of ED patients and the risk of subsequent unintentional PDO mortality.

Methods: Using data from the New York Statewide Planning and Research Cooperative System for 2006-2010, a nested case-control design was used to examine the relationship between ED utilization patterns in New York State residents of age 18-64 years and subsequent PDO death.

Results: The study sample consisted of 2732 case patients who died of PDO and 2732 control ED patients who were selected through incidence density sampling. With adjustment for demographic characteristics, and diagnoses of pain, substance abuse, and psychiatric disorders, the estimated odds ratios of PDO death relative to one ED visit or less in the previous year were 4.90 (95% confidence interval [CI]: 4.50-5.34) for those with two ED visits, 16.61 (95% CI: 14.72-18.75) for those with three ED visits, and 48.24 (95% CI: 43.23-53.83) for those with four ED visits or more.

Conclusions: Frequency of ED visits is strongly associated with the risk of subsequent PDO death. Intervention programs targeting frequent ED users are warranted to reduce PDO mortality.

Emergency department utilization and subsequent prescription drug overdose deathPulished in Annals of Epidemiology in March of 2015 by Joanne E. Brady PhD, Charles J. DiMaggio PhD, Katherine M. Keyes PhD, John J. Doyle DrPH, Lynne D. Richardson MD, Guohua Li MD, DrPH

FREQUENT FLYERS:ANY CONCERN FOROPIOID USE, GIVETHEM NALOXONE

RecommendationsIf we care about saving lives without discriminating, we should be prescribing naloxone to the following vulnerable people: • Opioid IDUs (e.g. heroin)• Those who combine opioids with other

CNS depressants (benzos)• Those who use opioid doses greater

than 100 mg/day of morphine equivalent

• Those who lose opioid tolerance after detoxification or incarceration and are at risk to resume opioid use (every opioid user who leaves rehab, prison)

• Comorbid mental health, CNS, renal, hepatic or pulmonary diseases

• Young people experimenting with opioids

if you went into medicine to save lives, naloxone really is the easiest way to do so. preferably don’t do drugs either

Projects • Matt Evans – Giving out 50 naloxone kitsto Uni outpatient addiction patients

• Pre-video survey of naloxone knowledge• Post-video survey of naloxone knowledge• Video created by Boston Public Health

Commission is publicly accessible for use• Participants encouraged to fill out “use form”

describing situation in which their kit was used to empower the importance of naloxone when future presentations are given. If they do, then they get a free naloxone kit refill

• Jennifer Plumb – Obtained grant that is going to be used to distribute naloxone in EDs (PCMC, U of U, etc), HIV clinics, other hi risk locations

• Creating Salt Lake’s own naloxone education video with the help of some incredible young talent

• Collaborating with pharmacists who are also leading the movement to make naloxone more accessible to those are at risk of opioid overdose

• Your name here

References• Centers for Disease Control and Prevention (CDC). CDC grand rounds:

prescription drug overdoses – a US epidemic. MMWR Morb Mortal Wkly Rep. 2012;61(1):10–13.7

• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3838403/#b20-sar-4-065• https://www.networkforphl.org/_asset/lhscnj/October-Webinar.pdf

• (http://harmreduction.org/overdose-prevention/overdose-news/take-home-naloxone-for-opioid-overdose-exploring-the-legal-policy-and-practice-landscapes/)

• http://harmreduction.org/issues/overdose-prevention/tools-best-practices/naloxone-program-case-studies/project-lazarus/

• http://www.cdc.gov/nchs/data/hestat/drug_poisoning/drug_poisoning.htm• Opioid overdose rates and implementation of overdose education and nasal

naloxone distribution in Massachusetts: interrupted time series analysis. By Walley AY, Xuan Z, Hackman HH, Quinn E, Doe-Simkins M, Sorensen-Alawad A, Ruiz S, Ozonoff A. BMJ. 2013 Jan 30;346:f174.

• Project Lazarus: Community-Based Overdose Prevention in Rural North Carolina. By Su Albert MD, MPH, Fred W. Brason II Chaplain, Catherine K. Sanford MSPH, Nabarun Dasgupta MPH, Jim Graham and Beth Lovette MPH. Pain Medicine. Published 13 JUN 2011.