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Ems world expo naloxone 11112014.handout

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Opioid overdose has emerged as one of the leading causes of preventable death in the United States. Paramedics and emergency department staff know that naloxone is the best treatment for opioid overdose and have been using this antidote for over 40 years. In the past few years, programs distributing naloxone are being implemented by EMT-Basics, firefighters, law enforcement first responders and members of the community. Dr. Dailey served as the medical director for a New York State pilot project for the implementation of BLS naloxone, has trained law enforcement providers in several states and routinely prescribes naloxone to members of the community.

Publicada em: Saúde e medicina
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Ems world expo naloxone 11112014.handout

  1. 1. Combating the Opioid Overdose Epidemic Public Safety Naloxone Michael W. Dailey, MD FACEP Regional EMS Medical Director Associate Professor of Emergency Medicine
  2. 2. Disclosure No academic conflict of interest No financial conflict of interest FDA Off-label use of a medication will be discussed Slides are available on Slideshare 2
  3. 3. Upon Completion of the Program, Participants Will Be Able to: Describe the advancement of naloxone into the out-of-hospital arena to treat opioid overdoses Identify opportunities for increasing the distribution of naloxone into high-risk opioid overdose environments Specify the next steps in increasing the intranasal use of naloxone for the urgent treatment of opioid overdose in the community Recall the results of the NYS pilot project to increase public safety personnel access to naloxone 3
  4. 4. Why Do We Have an Opioid Overdose Epidemic?
  5. 5. 5
  6. 6. What Are Opioids? Drugs derived from, or similar to, opium Morphine (named after Morpheus, Greek god of sleep) Heroin Oxycontin (long acting oral opioid) Oxycodone (Percocet) Hydrocodone (Lortab, Vicodin) Fentanyl Methadone Many others NOT Opioids: • Cocaine • Amphetamines • Valium • Xanax 6
  7. 7. Why Are Opioids So Much Trouble? Dependency – Opioids fill receptors in the body – If taken for a “long” time the body makes more receptors – If a person does not get medication, receptors are not filled and a person feels ill – this is withdrawal Addiction – People may need escalating doses of opioid to feel the same way they did once – “chasing the dragon” 7
  8. 8. Strategies to Address Overdose Prescription monitoring programs – Paulozzi et al. Pain Medicine 2011 Prescription drug take back events Safe opioid prescribing education – Albert et al. Pain Medicine 2011; 12: S77-S85 Expansion of opioid agonist treatment – Clausen et al. Addiction 2009:104;1356-62 Safe injection facilities – Marshall et al. Lancet 2011:377;1429-37 8
  9. 9. 9
  10. 10. Drug Treatment: Opioid Dependence Methadone and buprenorphine (Suboxone, Zubsolv) are medications used to treat opioid dependence If taken daily these medications reduce the risk of overdose death by as much as 80% Both may be diverted and sold on the street for recreational use and for self administration to avoid withdrawal Incorrect use of methadone has a much higher risk for overdose than does buprenorphine 10
  11. 11. Heroin User Experiences About 2% of heroin users die each year, many from heroin overdose 1/2 to 2/3 of heroin users experience at least one nonfatal overdose 80% have observed an overdose Sporer BMJ 2003, Coffin Acad Emerg Med 2007 11
  12. 12. Who Overdoses? Among heroin users it has generally been those who have been using 5-10 years – After rehab – After incarceration Less is known about prescription opioid users Anecdotal reports of youth dying suggest that many of those have been in drug treatment and relapse Sporer 2003, 2006 12
  13. 13. Risk Factors for Overdose Using alone Reduced tolerance Mixing drugs Major changes in opioid supply/ Variations in strength of street drugs – >1000 deaths USA 2006 with fentanyl Depression History of previous overdose Injection drug use Sporer 2006, Wines 2007, Pollini 2006 http://www.whitehousedrugpolicy.gov/news/fentnyl%5Fheroin%5Fforum 13
  14. 14. 14
  15. 15. Context of Opioid Overdose The majority of heroin overdoses are witnessed (gives an opportunity for intervention) Fear of police may prevent calling 911 Witnesses may try ineffectual things – Myths and lack of proper training – Abandonment is the worst response 15 Tracy 2005
  16. 16. Signs and Symptoms of Opioid OD Unresponsive or minimally responsive Not breathing or respiratory arrest Slow breathing (< 10 per minute) Snoring with gurgling Blue or ashen color (cyanosis) 16
  17. 17. How Overdose Occurs Opioids repress the urge to breathe Carbon dioxide levels increase Oxygen levels decrease Process takes time There is time to respond, but no time to waste 17
  18. 18. How Overdose Occurs Slow breathing Breathing stops Lack of oxygen may cause brain damage Heart stops Death 18
  19. 19. Prevention Messages for Users Use with others who know what to do if an overdose happens – make a plan Be aware of companions at all times when using Be careful if using alone, especially if: – Mixing different classes of drugs – Using after abstinence – (And watch out for others in these situations) 19
  20. 20. Naloxone (Narcan®) Opioid antagonist which reverses opioid overdose – Can be administered intravenous, injectable or intranasal Blocks opioids from acting on the body Works for about 30-90 minutes Analogy: “Steals the parking place” – Naloxone prevents opioids from going where they want to go – It steals the “parking place” 20
  21. 21. 21
  22. 22. Naloxone in Action Causes sudden withdrawal in the opioid dependent person – an unpleasant experience Doesn’t get a person “high” and is not addictive Has no effect if an opiate is not present Routinely used by EMS for over 40 years Available for use as first aid on another person in many states, including New York 22
  23. 23. Models of Overdose Treatment
  24. 24. Increasing Access to Naloxone Community prescribing/distribution to drug user and/or social networks Prescribing in outpatient care Increasing access among first responders Pharmacy collaborative agreements 24
  25. 25. Chicago First in the country in 1992 Founder died of an OD in 1996 Program was illegal, but not prosecuted SCARE ME 25
  26. 26. Overdose Fatality Prevention Programs that Distribute Naloxone: USA, 2010 2010 survey of programs known to the Harm Reduction Coalition 189 local programs in 16 states ranging from state-funded to underground 1996 - 2010: – 53,339 individuals received kits – 10,194 overdose reversals reported CDC MMWR February 17, 2012 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6106a1.htm 26
  27. 27. States with 3rd Party Naloxone Laws (Coffin, 2013) 27
  28. 28. Does Naloxone Distribution Help?
  29. 29. Is Naloxone Distribution Decreasing Mortality? Observational studies in places with overdose prevention programs find an association with reductions in overdose deaths: – Massachusetts, New York City, San Francisco, Baltimore, Pittsburgh, Chicago More studies are in progress 29
  30. 30. Incremental Cost Effectiveness Ratio ICER = Added cost of intervention divided by increase in Quality Adjusted Life Years Generally accepted efficacy threshold is $50,000/year Chlamydia screening < $14,000 Problem drinking screening and counseling < $14,000 Naloxone provision $438 - $14,000 depending on variables used Coffin 2013 30
  31. 31. Logistics of a Community Access Program
  32. 32. Naloxone Preparations Injectable – Less expensive: $1-8 per dose – Well-documented efficacy – Requires injection, drawing from a medical vial into a syringe Intranasal – More expensive: $21.00 per dose – Less well-documented efficacy – Requires assembly of spray device with nasal adaptor and naloxone capsule 32
  33. 33. Intranasal Administration Disadvantages – Vasoconstrictors (cocaine) prevent absorption – Bloody nose, nasal congestion, mucous – > 0.5 ml per nostril likely to run off Advantages – Nose is easy access point for medication and delivery – Eliminates risk of a contaminated needle stick 33
  34. 34. Implementation in NY State Hundreds of sites registered including: – Syringe exchange/syringe access sites – Hospitals – Drug Treatment Programs – HIV programs – Homeless shelters 34
  35. 35. Review of NYS Law
  36. 36. Overdose Law in NYS (PHL 3309) “Community Access Naloxone Law” Protects the non-medical person who administers naloxone in setting of overdose from liability – “shall be considered first aid or emergency treatment” – “shall not constitute the unlawful practice of a profession” Allows the medical provider to provide naloxone for use as first aid on another person 36
  37. 37. Syringe Access Programs Legal to possess syringes in NYS Chance to enroll people in community access naloxone programs Chance to enroll people in treatment programs Protects users from infections from sharing needles Gets dirty syringes off the street Protects public safety personnel and the public from dirty needles 37
  38. 38. 38
  39. 39. Law Enforcement and First Response Naloxone
  40. 40. NYS Good Samaritan 911 Intent: To encourage those present at an overdose to do the right thing and call for help This law protects an overdose victim and those who summon EMS: – From arrest in the presence of misdemeanor drug possession and/or underage drinking – From prosecution in felony possession unless there are aggravating circumstances, e.g. possession with intent to sell or outstanding warrants 40
  41. 41. Why Our Program in NYS? Disaster opioid overdoses in areas of New York with little coverage by advanced EMS providers Medical providers from rural areas recognized problem with BLS response and overdose morbidity Rochester, Mountain Lakes and Suffolk County EMS were invited to participate in initial development Career fire department BLS-FR in Rochester Law enforcement in REMO and Suffolk County 41
  42. 42. Skills Addition Matrix High Reward Low Frequency Low Reward Low Frequency High Reward High Frequency Low Reward High Frequency 42
  43. 43. Law Enforcement Naloxone Success New Mexico – Discussed, 2004 – Implemented, 2013 Quincy Massachusetts – Implemented 2010 – Lt. Pat Glynn 43
  44. 44. Law Enforcement Training
  45. 45. 45 Why Law Enforcement Naloxone? Why watch someone die? Early treatment improves outcomes for victim – Reduced cost in medical care – Increased potential for seeking rehab Improves community relations
  46. 46. 46 Why Police Officers? Often the first on the scene at an overdose To be better prepared to assist the public To assure we are prepared to deal with opioid users in crisis To improve interactions with the public
  47. 47. 47 Questions From Officers: What if we want to get blood for DWAI drugs? Will naloxone effect the forensic testing? – No. Naloxone may appear on drug screen though. – You can testify to the person’s presentation, their reaction, and that you reversed their opioid overdose What if we give it to someone who hasn’t taken opioids? – Nothing. They get a wet nose. What about accidental spraying in the air near others? – Won’t hurt anyone else or you.
  48. 48. So what do we teach the police?
  49. 49. 49 Intranasal Naloxone
  50. 50. 50 When to Use Naloxone Overdose suspected Not responsive to painful stimuli Breathing status Normal or Fast Slow (<10x minute) No or Gasping Turn on side Naloxone Naloxone and CPR
  51. 51. 51 Administration Wipe the nose if it is messy Hold the patient’s head with one hand Keep the head tilted backward (this prevents the medication from running out of the nostril) Place the atomizer within one nostril Gently, but firmly, spray half the vial (about 1 ml) into that nostril Spray the rest of the medication into the other nostril
  52. 52. Steps to Assemble Open box; remove yellow and purple caps Open and attach atomizer Screw medication into holder 52
  53. 53. Hands-On Training
  54. 54. Post-Administration Considerations Use CAUTION when administering naloxone to narcotic dependent patients! Rapid opiate withdrawal may cause nausea and vomiting and may cause combativeness Roll patient to their side after administration to keep airway clear If patient does not respond within 3-5 minutes, administer second dose – Must wait 3-5 minutes or second dose will not be effective 54
  55. 55. New York’s pilot for BLS providers 1,978 EMTs trained Over 200 opioid overdose reversals (40% Suffolk PD) – 1 reversal for every 10 EMTs trained No adverse events No significant hazards to EMS personnel Case of reduced hazard for EMS personnel One interesting unplanned complication with law enforcement… 55
  56. 56. Law Enforcement and Naloxone Law enforcement will frequently be the first on the scene Suffolk County Police Department was very proactive to address problem when it was discovered Law enforcement policy development to assist with scope of the NYS 911 Good Samaritan Law – Patrol directives now in place – No arrest in cases of simple overdose notification – No further issues 56
  57. 57. What About the Rest of the Country? All 53 jurisdictions permit Paramedics to administer naloxone Of the 48 jurisdictions with mid-level EMS personnel, all but one authorize those personnel to administer naloxone Only twelve jurisdictions explicitly permit EMTs to administer naloxone Five additional states permit some or all EMTs to administer the drug through pilot programs or agency medical director authority 57 Davis, Walley, Dailey, Southwell, Neihaus, “EMS Naloxone Access: A National Systematic Legal Review”, Academic EM, August 2014
  58. 58. Naloxone for Basic EMT - 2013 58
  59. 59. Results Additional states may allow BLS personnel or other first responders to administer naloxone as part of a separately regulated community access program. At least four jurisdictions modified law or policy to expand EMS access to naloxone in 2013. Many others have changed since this review 59
  60. 60. What Did We Learn? Naloxone for first responders can be a phenomenal success Must have physician oversight to assure safety to patients and training of providers Training and equipping providers should be expanded where useful – Law enforcement – Fire first response – Others… Scope of practice expansion for ALL EMS providers 60
  61. 61. Thank you. daileym@mail.amc.edu

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