Overdose Education and Naloxone Distribution in medical settings MO-HOPE Topics covered today: Opioid Overdose Background Delivering Overdose Education & Naloxone Distribution training
MO-HOPE evaluation 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 100 people die from drug overdose every day in the U.S. Presribetoprevent.org ASAM.org nhtsa.gov 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
Naloxone laws in MO RSMO 195.206 & RSMO 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 RSMO 195.206.2 enacted August 28, 2017 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 or imitation 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.
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. Federally funded Continuing Medical Education (CME)
courses are available at no charge at http://www.OpioidPrescribing.com Types of naloxone 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 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) Naloxone is effective American Medical Association endorsed distribution to anyone at risk of having or witnessing an overdose 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) 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 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
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 WHAT IS OEND? Overdose Education and Naloxone Distribution 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 DAST Drug Abuse Screen Test
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 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 Bottom line on opioid overdose (narcotic toxidrome): Depressed mental status or coma Ineffective or absent breathing Pinpoint pupils
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
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 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 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! What happens if I use my naloxone? If it gets used, tell your physician 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 Evaluation efforts led by the Missouri Institute of
Mental Health (MIMH) with the University of Missouri-St. Louis The rationale - Why project evaluation is important: 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: The date is 01-03-18. You are the spouse (PLEASE SELECT TEST/ DEMO OPTION) of a White, non-Hispanic, 52 year-old male who is prescribed high daily doses of opioids for chronic pain. You arrive to
your home in St. Charles, MO (zip code: 63304) around 2:00pm to find your spouse in what appeared to be a opioid overdose state so you administered one dose of Narcan nasal spray you received from St. Charles Family Pharmacy. He came out of the overdose and began vomiting. You call 911 and wait for EMS to arrive. No additional naloxone is administered and your spouse is then transported to the hospital. 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 Sandra Mayen 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
