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

Finding a site

http://towardtheheart.com/site-finder

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