In the summer of 2011, I met Sheila, a client living at POWER’s residential treatment facility, POWER House. Sheila had a larger-than-life, bubbly personality. She frequently talked of her young daughter – one of her primary motivators to “get it right”. After six months, Sheila was discharged. Two days later we learned from her roommate that Sheila was dead of an opiate overdose. Sadly, Sheila’s daughter will never again feel her mother’s loving

embrace. We were devastated and wondered what we could have done that would have led to a

much happier outcome.

As the Associate & Clinical Director at POWER I am responsible for ensuring that our treatment and services exemplify our mission of helping women reclaim their lives from the disease of addiction, reducing the incidence of addiction in future generations. Through my participation in the Allegheny County Overdose Prevention Coalition (ACOPC), I realized that the more traditional approaches to

drug and alcohol treatment are not always conducive with effective overdose prevention strategies.

I wondered how treatment providers were handling overdose prevention and discovered the same answer across the board: abstinence. Though abstinence may be ideal, it may be unrealistic. Relapse is common. And people like Sheila are at higher risk for overdose after they’ve been abstinent for a while. They relapse, use at the same level they did before, and their bodies are overwhelmed. Like Sheila, they will never have another opportunity to “get it right”. While we know that abstinence is the best way to prevent overdose, we also know that, even with quality treatment and support, relapse still happens. Numerous studies have shown individuals on methadone or buprenorphine maintenance are much less likely to die from an overdose. We also know that Naloxone

works to reverse an opiate overdose.

How do we implement what works and get buy-in from the stakeholders? While there are no easy answers, I envision a day when any person suffering from addiction will have easy access to treatment providers that can truly provide individualized treatment that helps to identify and support them on their recovery path. Some may need Medication-Assisted Treatment (MAT). Some may need

the support of 12-step meetings. All should have access to Naloxone.

Steadily, POWER has been implementing practices that can reduce death from overdose. We have established the processes to accept women on methadone at POWER House. We also instituted overdose prevention education groups for all of our clients at POWER House. We used educational materials from Prevention Point Pittsburgh with information about how to access and use

Naloxone and the importance of rescue breathing. I recently received this email from our clinical supervisor:

“[W]e had a client leave treatment against medical advice. I called to follow up and she let me know that she’s willing to take numbers for detox because last night, while she was using with two other people, one of them overdosed. She shared that it was the overdose prevention group that she attended at POWER that taught her to do rescue breathing while waiting for help. She says her using friend will live. The group made enough of an impact that she remembered that to “press hard and fast on the chest” would not be enough. She knew she had to do rescue breathing.”

There are many paths to recovery. We’re in the business of lighting the way and helping our clients explore what works best for them. I remember climbing a mountain with a friend and feeling anxious as we had to cross a narrow ridge that had sheer cliffs on either side. We came to an area with a small tree in the middle of the path; my friend, who was much more sure-footed than I, simply skirted around the tree, stepping onto the edge of the cliff. I knew there was no way I could do that, so I used the tree as my anchor and looked like a fool – but with the encouragement of my friend, I made it across. The point is that we both made it to the top of

the mountain, each in our own way.

I am proud to be part of the ACOPC which shows tremendous leadership through its relentless advocacy and innovative efforts to

prevent overdose deaths, giving individuals like Sheila another chance to “get it right”.

FALL Issue November, 2014

Diane’s Perspective

Diane Johnson, RN

OVERDOSE PREVENTION FORUM

ACOPC Conference 2

TheSupportGroupProject OverdoseFreePA.org

3

Legislative Update Naloxone Delivery

4

The Governor’s Workgroup Report

5

Allegheny County—Glance at the Data

6

Inside this issue:

Each issue will highlight a different member’s perspective

Page 2

All Presentations Are Available on the ACOPC Website: www.acopc.pitt.edu

This year’s ACOPC Summer Conference 2014 was hosted in a new, venue on July 24. The much larger and comfortable accommodations in Scaife Hall on the University of Pittsburgh Oakland campus was much appreciated by conference attendees. Attendance exceeded previous year’s participation with 136 registrants signing in the day of the conference. Attendees represented physical and behavioral healthcare providers, pharmacists, students, addiction specialists, recovery and rehabilitation organizations, county drug and alcohol

personnel, criminal and justice services, harm reduction, media representatives and a variety of community support and services groups and parents/mentors. For the first time, we were pleased to offer continuing education hours this year with the aid of University of Pittsburgh School of Social Worker, through the Western Psychiatric Institute and Clinic for NBCC-approved clock hours , and Professional Certification Board (PCB) credits with sponsorship by Pyramid Healthcare, Inc.. Approximately 50

attendees requested credit.

In the Keynote Address, Melinda Campopiano, MD (Medical Officer at the Center for Substance Abuse Treatment) outlined the new Opioid Overdose Prevention Toolkit published by the Substance Abuse and Mental Health Services Administration. The toolkit consists of five booklets, each intended for a different audience: community members (including local governments), first responders (such as EMT personnel and police), prescribers, patients prescribed opioids, and overdose survivors. Taken together, the information contained in these booklets accords with the five broad strategies that SAMHSA has selected as the focus of its overdose prevention efforts: encourage the populations listed above to learn how to prevent and respond to overdose; ensure access to treatment, including medication-assisted treatment; ensure access to naloxone; encourage the public to call 911 in response to overdose; and encourage prescribers to use Prescription Drug Monitoring Programs. Dr. Campopiano detailed the process through which organizations and individuals can obtain naloxone and stressed the importance of physician education

about opioid overdose.

Neil Cappretto DO, FASAM (Medical Director of Gateway Rehabilitation) spoke about the effort at Gateway to integrate “Abstinence-based” treatment and “Harm Reduction” strategies. First, he noted that opposing these two terms creates a false dichotomy, since there are many different definitions of “abstinence” – and of “recovery” itself. Gateway Rehabilitation offers both Medication-Assisted Treatment (MAT, also called OAT) and more traditional Twelve-Step Facilitation (TSF) therapy in the hope of promoting abstinence if possible and reducing harm if not. Their Naloxone Pilot Project will “reduce harm” by distributing intranasal naloxone to patients and families and training them in its use while promoting “abstinence” through

education and monitoring.

Adam Gordon, MD MPH FACP FASAM CMRO (Associate Professor of Medicine and of Clinical and Translational Sciences at the University of Pittsburgh School of Medicine, and Director of the VA Pittsburgh Healthcare Systems’ Interdisciplinary Addiction Program for Education and Research) gave a talk about the role of physical health providers in overdose prevention focused on Opioid Agonist Therapy (OAT; e.g. methadone, buprenorphine, or naltrexone). He encouraged PCPs to acknowledge their partial responsibility, through the inappropriate prescription of painkillers, for the overdose epidemic, and traced PCPs’ adoption of OAT since the Drug Abuse Treatment Act of 2000 allowed them to direct OAT outside specialized clinics. While citing evidence that uptake of office-based OAT has increased to meet the growing demand, Gordon lamented that use of this

evidence-based treatment is not more widespread.

Kevin McCarthy (Assistant District Attorney of Allegheny County) discussed the state’s drug-related crime prevention strategies. He first outlined two bills in the Pennsylvania legislature, one of which (SB 1164) is now law and is described in this newsletter. The other, SB 1180, was passed by the Senate and the House and presented to the PA Governor on October 20. The bill would expand the types of officials with access to, and the categories of substances controlled by, Pennsylvania’s Prescription Drug Monitoring Program. McCarthy stressed that the bill achieves a balance between privacy interests and the interests of law enforcement. He then described Drug Court, a special court that handles cases of individuals with SUDs in the criminal justice system accused of certain non-violent crimes through an extensive treatment program. These individuals are placed under

probation and supervised closely, “graduating” only after completing treatment and maintaining employment for some time.

Karl Williams, MD MPH (Chief Medical Examiner of Allegheny County) reported on how the national overdose epidemic has affected our region. According to the Allegheny County Medical Examiner’s Office, there have been approximately 2,847 overdose deaths between January 1, 2002 and December 31, 2012. In 2012, of the 446 accidental deaths investigated by the office, 64.5% have been unintentional drug deaths. The high proportion of the decedents in the 45-54 age range (29.5%) accords with previous years, but the proportion in the 25-34 age range (32.6%) has been increasing for the last decade. While

most deaths involved multiple drugs (61%), heroin was by far the most commonly found (identified in 47.9% of cases).

The Lunch Extra! Naloxone Administration Technical Assistance led by Alice Bell, LSW, Overdose Prevention Project, Prevention Point Pittsburgh provided practical knowledge on Naloxone education, administration and prescribing. This program was

enthusiastically received, with approximately 80% of attendees chose to attend during their lunch break!

Conference goers described the day’s content as ‘interesting’, ‘informative’, ‘inspiring’…’a nice mixture of local issues and results, plus national trends and issues.’ Upon exit, commenters expressed a desire to return again next year, a willingness to stay longer

for expanded content and an interest encouraging more of their peers to participate.

Overdose Prevention

Page 3 Overdose Prevention

The Support Group Project

Have you heard about THESupportGroupPROJECT

It is crucial that those facing a loved one’s addiction counter the associated stigma with social support; yet at the same time, this stigma can make it difficult to find the needed support. For this reason, the Treatment Research Institute and Hope for Addiction have collaborated to create The Support Group Project, a national searchable directory of in person or online

support groups for families of individuals struggling with substance use and its consequences.

The project launched its website, www.supportgroupproject.org, on October 1, 2014. This new site is asking that local support groups register a group administrator and add information about their group so those in the community may more easily find support that fits their needs. Although a small number of groups in Pennsylvania have signed up, there are only four in Western PA, so far. If you are allied with a local addictions-related support group, please encourage your group to join the above website and help families and friends not feel so all alone. You may register your group right away by going to the

project’s website and clicking on, “Register a Group.” Let’s let our local families know that we are there for them!

Program Evaluation and Research Unit (PERU) at the University of Pittsburgh School of Pharmacy, the Department of Drug

and Alcohol Programs (DDAP), the Allegheny County Medical Examiner’s Office, U.S. Attorney Hickton’s Office, and the

Single County Authorities of Allegheny, Blair, Bucks, Butler, Dauphin, Delaware and Westmoreland counties have

collaborated to launch www.OverdoseFreePA.org. This website, in the words of PERU director Janice Pringle, PhD, was

designed to “help show Pennsylvanians the true effect of overdoses within their community and provide resources for

increasing public awareness of the overdose risk and strategies for reducing this risk.”

Healthcare professionals, professionals in criminal justice, community leaders in education, faith-based programs and other

mentoring roles, and friends and family of individuals at risk of overdose will find important information and educational

materials on the site that are tailored to their area of interest.

One of the most popular features is the reporting of close-to-real-time overdose death data from the Allegheny County

Medical Examiner’s Office. What makes this feature especially informative are the interactive graphs showing overdose

deaths by year, age, race, gender, neighborhood, and drug(s) involved. The site also hosts a database of potential speakers

willing to share their expertise on a variety of overdose-related topics such as overdose prevention, recovery from substance

use disorders and administration of naloxone. This Speaker’s Bureau is searchable by geographic location and topic of

interest. An Active Communities section is evolving with announcements and resources specific to each county participating

in the project. The most recent addition to the site is a “Recommended Reading” section on the home page, highlighting

some of our Advisory Group members’ latest suggested dispatches.

The website launched on August 27, and has since been featured on several news sources including USA Today, WHIRL

Magazine, and the IRETA blog. With 1,100 unique visitors, and counting, we hope you will visit, and return soon!

OverdoseFreePA.org

Page 4 Overdose Prevention

Legislative Update—A New Law

Last spring, this newsletter

reported that the FDA had

approved a hand-held

naloxone auto-injector for

release in April. The device is

now on the market as Evzio, a

pocket-sized injector that is

easy for non-professionals to

use. In anticipation of the stress that may impede

overdose witnesses’ ability to act, each Evzio contains

voice instructions that are activated as soon as the

safety guard tab is removed. Each prescription of Evzio

also comes with a dummy practice model that can be

used for training purposes.

Another intranasal naloxone delivery device received

Fast-Track designation from the FDA (meaning that its

review process will be expedited) on July 15. Daniel

Wermeling, Assistant Professor of Pharmacy at the

University of Kentucky and expert on intranasal

naloxone delivery, founded specialty drug company

AntiOp Inc. and has partnered with Reckitt Benckiser

Pharmaceuticals to market a simple ready-to-use, no-

assembly-required intranasal device. Wermeling’s

device entered a final round of clinical testing in

August.

Naloxone Delivery Devices

On Sept. 30, SB 1164 was signed into law as Act 139 of 2014. The new law will go into effect on November 29.

The act will increase access to Naloxone, a rescue drug that can reverse the effects of a

drug overdose, and allow its administration by medical service providers, law

enforcement, and friends or family of someone experiencing an overdose. The law allows

physicians and other licensed prescribers to prescribe naloxone by standing order and

provides broad immunity from liability for prescribers as well as those who administer

naloxone to someone who is experiencing an overdose. This will make it much easier for

medical centers, substance use disorder (SUD) treatment programs and community-

based organizations to work with prescribers to make sure naloxone is readily available in

an emergency. Act 139 not only authorizes law enforcement agencies, fire departments,

and ambulances to obtain and administer Naloxone, but requires governmental

departments to “develop or approve training and instructional materials about

recognizing opioid-related overdoses, administering naloxone and promptly seeking

medical attention,” and further that “the training and instruction materials shall be

provided free of charge on the Internet.”

In addition, Act 139 provides some protection from prosecution for possession of small amounts of drugs to individuals who

transport a person experiencing a drug overdose or call 911 to get medical attention for someone who has overdosed. The law

requires the person making the call to provide their name and stay with the person until help arrives. Because deaths due to

opioid overdose are estimated to occur between 1-3 hours after ingestion, and because concern about police involvement is

the most common reason cited by users for failing to summon emergency help during that window, good Samaritan laws are

significant in preventing overdose deaths.

Expansion of Pennsylvania’s Prescription Drug Monitoring Program, another legislative step toward overdose prevention, still

awaits passage in the House of Senate Bill 1180, which passed unanimously in the Senate on May 6. However, with the signing

LAWS LAWS LAWS LAWS LAWS LAWS LAWS

Overdose Prevention Page 5

On May 9, 2014, Governor Corbett held a press conference about the opioid overdose crisis. He called for the creation of a

Governor’s Heroin and Other Opioids Workgroup, led by the Department of Drug and Alcohol Programs (DDAP), to provide

recommendations on how to address the escalating heroin and opioid crisis in Pennsylvania. Five subcommittees were formed,

each addressing a key area of concern, and met beginning in June. On September 30 they published the following

recommendations and suggested implementation strategies.

Subcommittee A. Safe and Effective Use of Prescription Opioids Subcommittee Recommendations

Recommendation A1. Promote safe prescribing practices by increasing adoption of the Pennsylvania Guidelines on the Use of Opioids to Treat Chronic Non-Cancer Pain, the Pennsylvania Emergency Department Pain Treatment Guidelines, and similar

guidelines. This will require disseminating the guidelines among prescribers and insurers.

Recommendation A.2. Promote safe dispensing practices by establishing communication between state agencies and public/private insurers regarding protocols, such as those developed by the Pharmaceutical Assistance Contract for the Elderly

(PACE) for safe dispensing, and regarding the impact of cost-sharing mechanisms on prescription drug misuse.

Recommendation A.3. Promote safe prescribing and dispensing practices in the context of the Pennsylvania Workers’ Compensation (WC) program by increasing awareness among legislators of the prevalence of unsafe practices in this context

and by initiating a discussion between WC insurers and the appropriate state agencies.

Recommendation A.4. Encourage the passage of legislation establishing an extensive Prescription Drug Monitoring Program (PDMP) and prepare for its enactment. This will require gathering evidence that supports the effectiveness of PDMPs in other

states, informing legislators of this evidence, and specifying the most effective mechanism for a PDMP in Pennsylvania.

Subcommittee B. Access to Treatment Subcommittee Recommendations

Recommendation B.1. Increase provider education about substance use disorders (SUDs), screening and appropriate referrals

to treatment.

Recommendation B.2. Educate state employees about how to access care for SUDs via the State Employee Assistance Program

and the Pennsylvania Employees Benefit Trust Fund.

Recommendation B.3. Establish partnerships between state agencies and public/private insurers to address SUDs by cross-

agency training to increase awareness of SUDs and opioid misuse, and by establishing collaborative partnerships with insurers.

Recommendation B.4. In collaboration with the Pennsylvania District Attorneys Association, expand availability of Restrictive Intermediate Punishment treatment diversion sentences for offenders with SUDs who are currently being sentenced to county

jail or to low-level state prison.

Subcommittee C. Professional Licensing Subcommittee Recommendations

Recommendation C.1. Develop and implement an education program for the health-related boards administered by the

Department of State’s Bureau of Professional and Occupational Affairs.

Recommendation C.2. Develop and implement an education and engagement program designed to appeal to business-related boards and associations that focuses on the effects of SUDs on work performance, employee absenteeism, health

insurance costs, professional misconduct and customer/client safety.

Subcommittee D. Prevention, Intervention, and Outreach Subcommittee Recommendations

Recommendation D.1. Establish an informal internal Executive Prevention Council, from the Pennsylvania Commission on Crime and Delinquency and the Departments of Drug and Alcohol Programs, Education, and Public Welfare, to identify and

review evidence-based and cost-effective SUD prevention programs on an ongoing basis.

Recommendation D.2. Collaborate with the Department of Drug and Alcohol Programs to educate state employees and the general public about the prevalence, identification, and impact of SUDs through brochures, websites, social media, and other

resources.

Subcommittee E. Overdose Response Committee Recommendations

Recommendation E.1. Support legislative efforts that would expand access to naloxone through third-party prescription and

Good Samaritan laws (see p. *).

Sept. 30 Report by Governor Corbett’s Heroin and Other Opioids Workgroup: Summary

P A G E 6

THE NEWSLETTER IS PUBLISHED AS ACOMMUNITY SERVICE BY: PROGRAM EVALUATION RESEARCH UNIT (PERU)

University of Pittsburgh School of Pharmacy The Offices at Baum, 5607 Baum Blvd. Pittsburgh, PA 15206 shr35@pitt.edu

Website: www.acopc.pitt.edu

From the OverdoseFreePA.org Overdose Data Set—Allegheny County