Lowe-2014

V i r g i n i a R u r a l H e a l t h A s s o c i a t i o n A n n u a l C o n f e r e n c e

D e c e m b e r 1 1 , 2 0 1 4

J a s o n L o w e , M S W

R E V I V E ! P r o j e c t M a n a g e r

B e h a v i o r a l H e a l t h P r o g r a m A n a l y s t

O f f i c e o f S u b s t a n c e A b u s e S e r v i c e s

V i r g i n i a D e p a r t m e n t o f B e h a v i o r a l H e a l t h

a n d D e v e l o p m e n t a l S e r v i c e s

REVIVE!Opioid Overdose Reversal for Virginia

What is REVIVE! all about?

Overview

Topics for this presentation:

Opioid Overdose Deaths in the United States and Virginia

Development of REVIVE!

Lay Rescuer Training for REVIVE!

REVIVE! Process and Outcome Data

REVIVE! Moving Forward – 2015 and Beyond

Opioid Overdose Deaths in the US

Opioid Overdose Deaths in Virginia

In 2011, for the first time ever in Virginia, drug-related deaths happened at a higher per capita rate than motor vehicle crashes (9.6 DRD, 9.4 MVC).

In 1999, 23 people died as the result of misuse of fentanyl, hydrocodone, methadone, and/or oxycodone (FHMO). By 2003, that figure increased to 137, an increase of 595%. By 2012, it was 354, an increase of more than 1,500% (1,539.1%).

Prescription drug-related deaths have dropped, but heroin deaths have increased dramatically. There were 115 deaths attributed to heroin use in 2012, but the preliminary figure for 2013 is 177, an increase of 53.9% in one year.

The trend continues in 2013; data from the OCME indicates that 648 individuals died in Virginia in 2013 as a result of opioid overdose up from 469 in 2012 (an increase of more than 38%).


23

137

354

0

50

100

150

200

250

300

350

400

1999 2003 2012

FHMO-Related Deaths, 1999-2013


384

424

507

549

595

498

545

669

717735

713692

818 805

0

100

200

300

400

500

600

700

800

900

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Total Drug/Poison Deaths by Year, 1999-2012


0

100

200

300

400

500

600

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800

900

20072008

20092010

20112012

388 450433 479 505

433

Deaths by Cause, 2007-12

Others

NOS

Ethylene Glycol

OTC

Inhalant

Mixed

Illegal

Prescription

Ethanol


0

500

1000

1500

2000

2500

3000

20062007

20082009

20102011

2012

706665 777

801745 918 1017

Classes of all Drugs Present in Drug Deaths, 2006-12

Cannabanoids

Medical

Anti-Convulsant

Anti-Psychotic

Other

Muscle Relaxant

Anaglesic

Sedative/Hypnotic

Stimulant

Anti-Histamine

Alcohol

Anti-Depressant

Anti-Anxiety

Narcotic


Drugs Detected in deaths in Virginia, 2012


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400

2006 2007 2008 2009 2010 2011 2012

FHMO Combination Deaths, 2006-12

Oxycodone/Fentanyl/Hydrocodone

Oxycodone/Methadone/Hydrocodone

Oxycodone/Methadone/Fentanyl

Fentanyl/Hydroconde

Methadone/Hydrocodone

Methadone/Fentanyl

Oxycodone/Hydrocodone

Oxycodone/Fentanyl

Oxycodone/Methadone

Hydrocodone

Fentanyl

Methadone

Oxycodone


721 735713

690

819800

912

489509 504

463

582541

661

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800

900

1000

2007 2008 2009 2010 2011 2012 2013

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Number of All Drug/Poison Deaths Compared to All Opioid Deaths by Year, 2007-2013

All Drug/Poison Deaths

All Opioid Deaths

1 All drug/poison deaths are those in which the primary cause of death was attributed to one or more drug/poisons2 Opioid deaths are drug/poison deaths in which one or more opioids caused or contributed to death3 No data for 2014 is included in this graph due to differences in report timing of toxicology results


10089

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389

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Number of Fatal Heroin and Prescription Opioid Overdoses by Year, 2007-2013

Heroin

Prescription Opioids

1 Heroin and prescription drug deaths are tallied separately, therefore decedents in which heroin and prescription opioids caused or contributed to death will be counted twice2 Prescription opioid deaths are drug/poison deaths in which one or more prescription opioids caused or contributed to death3 No data for 2014 is included in this graph due to differences in report timing of toxicology results


100

89

107

48

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2007 2008 2009 2010 2011 2012 2013 2014*

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Number of Fatal Heroin Overdoses by Year, 2007-2014*

1 Fatal heroin overdoses may have one or more drug/poisons contributing to death2 The number of fatal heroin overdoses in 2014 is estimated based upon the first six months of data for 2014 (January 1, 2014 to June 30, 2014); the predicted number for all of 2014 is indicated by a star

What happens in an opioid overdose?

Opioids in excessive quantities can inhibit the central nervous system (CNS), which controls our breathing and heart rate

Opioids bind to receptors in the brain, inhibiting communication between neurotransmitters

When this communication is interrupted, CNS stops effectively controlling breathing and heart rate

Overdose episodes are rarely instantaneous. Onset can take 1-3 hours as CNS slowly stops maintaining breathing and heart rate

What is naloxone?

Naloxone (Narcan®) is an opioid antagonist

Naloxone has a higher affinity for the receptors in the brain than opioids, thus kicking the opioid off the receptor and binding to the receptor

Once this has occurred, the individual experiences resuscitation and possibly withdrawal, which can be acute

How does naloxone work?

Naloxone has a strongeraffinity to the opioidreceptors than the opioid,so it knocks the heroin offthe receptors for a shorttime and lets the personbreathe again.

Opioid receptor

Naloxone

Opioid

What is naloxone?

Is naloxone safe?

Naloxone is a Schedule VI drug in Virginia, meaning it requires a prescription

Because naloxone is an opioid antagonist, it has no potential for abuse

Naloxone has little to no effect on a person unless they are experiencing an opioid overdose

Reports of adverse consequences such as seizures or hypersensitivity are extremely rare

Accidental administration poses no threat or danger, including to children or pregnant women

Is naloxone safe? (cont.)

Naloxone is included on the World Health Organization’s List of Essential Medicines

According to the Centers for Disease Control and Prevention, more than 50,000 people in the US have been trained to administer naloxone

More than 10,000 opioid overdoses have been reversed with naloxone from 1996 to 2010


Expansion of naloxone access is supported by:

American Association of Poison Control Centers

American Academy of Clinical Toxicology

American College of Medical Toxicology

American Medical Association

American Public Health Association

Office of National Drug Control Policy

Substance Abuse and Mental Health Services Administration

United Nations Office on Drugs and Crime

United States Attorney General


Intranasal administration is effective in reversing opioid overdoses, although two administrations may be necessary depending on half life of substance(s) being abused

Studies suggest that laypersons trained in the intranasal administration of naloxone can do so as effectively as emergency medical personnel

Studies also suggest that earlier administration of naloxone leads to less inpatient admissions for overdose survivors

Objections to Naloxone Access

Objections to Naloxone Access (cont.)

Objection One: Naloxone encourages drug use

Objection Two: Naloxone discourages accessing treatment

Objection Three: Naloxone should be administered by medical professionals

Objections to Naloxone Access (cont.)

What is REVIVE!?

In response to the severe impact of opioid use and overdose in Virginia, concerned citizens approached Delegate John O’Bannon, R-73, to patron a bill allowing for Good Samaritan protection for the use of naloxone.

Delegate O’Bannon is a neurologist representing portions of Henrico county.

What is REVIVE!?

House Bill 1672 of the 2013 General Assembly changed the Code of Virginia to: Allows doctors to prescribe naloxone for non-patient-specific use

Provide Good Samaritan protection for individuals administering naloxone to an individual experiencing an opioid overdose

HB 1672 named DBHDS as the lead agency to conduct pilot programs on the administration of naloxone and report back results to the General Assembly in December 2014

Naloxone in Virginia

Virginia’s law allows for non-patient-specific prescribing, i.e. a doctor prescribing naloxone to someone other than the person who will receive it

Virginia’s laws provide Good Samaritan protection for the person administering the naloxone

Virginia’s laws DO NOT provide criminal amnesty protection for individuals calling 911

Implementation of REVIVE!

DBHDS convened an interagency workgroup with staff from the Departments of Health and the Department of Health Professions to discuss obstacles, challenges, and opportunities for implementing pilot programs

DBHDS held stakeholder meetings with community members in both pilot areas to discuss issues specific to their communities to collaboratively determine the best way to implement REVIVE!


After numerous conversations, it was determined that intranasal administration of naloxone would be the most efficient, effective method for Virginia:

Safer to carry and store in any location(no needles)

Dose is premeasured, full syringe is administered

Similar effectiveness to intramuscular administration

No issues with needles and drug paraphernalia laws

REVIVE! Training

While not mandated in legislation, DBHDS determined that a vital part of implementation for REVIVE! would be training individuals in understand opioid overdoses, how they work, how to identify them, understanding who may be at higher risk, and what to do in an opioid overdose emergency

DBHDS prepared specific curricula for trainers and Lay Rescuers to use as part of REVIVE!

REVIVE! Kits

Kits include:

Mucosal atomizer

Latex-free gloves

Rescue breathing shield

Information card (includes naloxone and rescue position graphics)

Return cards

Stickers

REVIVE! – Responding to an Opioid Overdose Emergency

How to respond to a suspected opioid overdose emergency:

1. Check for responsiveness and administer rescue breaths if person is not breathing.

2. Call 911.

3. Continue rescue breathing if not breathing.

4. Administer naloxone.

5. Resume rescue breathing if the person has not yet started breathing.

6. Conduct follow-up and administer a second dose of naloxone if no response after three minutes.


1. Check for responsiveness and breathing Yell their name and touch their shoulder. You can also pinch

their ear lobe.

Give a sternal rub. Make a fist and rake your knuckles hard up and down the front of the person’s sternum (breast bone). This is sometimes enough to wake the person up.

Check for breathing. Place your ear over the person’s nose and mouth so that you can also watch their chest. Feel for breath and watch to see if the chest rises and falls.

If the person does not respond or is not breathing, administer three rescue breaths.


Put on latex gloves from naloxone kit.

Check the person’s airway for obstructions and remove any

obstructions that can be seen. Clear any obstructions with a

sweeping (not poking or stabbing) motion.

Tilt the person’s forehead back and lift chin

Place breathing mask on persons face, covering their nose

(you can still do mouth-to-mouth rescue breathing if a mask is not available).

Pinch the person’s nose and give normal breaths – not quick or overly powerful breaths.

Give one breath every five seconds.

Continue rescue breathing for approximately 30 seconds.

PLEASE NOTE - Brain damage can occur after three to five minutes without oxygen. Rescue breathing gets oxygen to the lungs quickly. Once you give naloxone, the person may not start breathing on their own right away. You may have to keep breathing for the person until the naloxone takes effect or until emergency medical services arrive.


2. Call 911 - [If you have to leave the person, put the person in the recovery position – see details below].

Quiet down the scene, and speak calmly and clearly. State that

someone is unconscious and indicate if the person is not breathing.

You DO NOT have to mention drugs or overdose when calling 911.

Give the exact address and location. If you’re outside, use an intersection or landmark.

When first responders arrive, tell them it is an overdose and what drugs the person may have used.

Note: Complications may arise in overdose cases. Also, naloxone only works on opioids, and the person may have overdosed on something else, e.g., alcohol or benzodiazepines. Emergency medical services are critical.


2a. Recovery PositionIf you have to leave the person while they are still unresponsive, put the person in

the recovery position. Roll the person over slightly on the person’s side.

Bend their top knee.

Put the person’s top hand under the person’s head for support.

This position should keep the person from rolling onto their stomach or back and prevent them from asphyxiating in case of vomiting.

Make sure the person is accessible and visible to first responders (don’t close or lock doors that would keep first responders from being able to find the person).


3. Continue rescue breathing if person is not breathing

Tilt the person’s forehead back and lift chin

Place breathing mask on persons face, covering their nose (you can

still do mouth-to-mouth rescue breathing if a mask is not available).

Pinch the person’s nose and give normal breaths – not quick or overly powerful breaths.

Give one breath every five seconds.

Continue rescue breathing for approximately 30 seconds.

PLEASE NOTE - Brain damage can occur after three to five minutes without oxygen. Rescue breathing gets oxygen to the lungs quickly. Once you give naloxone, the person may not start breathing on their own right away. You may have to keep breathing for the person until the naloxone takes effect or until emergency medical services arrive.


4. Administer naloxone Pull the yellow caps off the syringe.

Pull the red/grey cap off the naloxone vial.

Screw the atomizer device, which looks like a white cone, onto the syringe.

Gently screw the naloxone capsule into the bottom of the syringe.

Put the tip of the spray device into one nostril and push on the capsule to spray half of the naloxone into the nostril; immediately switch to the other nostril and spray the other half of the naloxone into the nostril (see diagram below).

Please Note: If someone is dependent on opioids, giving them naloxone may result in temporary withdrawal. This response can include abrupt waking up, vomiting, diarrhea, sweating, and agitated behavior. While withdrawal can be dramatic and unpleasant, it is not life threatening and will only last until the naloxone has worn off.


4. Administer naloxone


5. Resume rescue breathing if the person has not yet started breathing

Please Note: Brain damage can occur after three to five minutes without oxygen. The naloxone may not kick in that quickly. You may have to breathe for the person until the naloxone takes effect or until emergency medical services arrive.


6. Conduct follow-up and next stepsIf an overdose victim revives, they may be in withdrawal. Withdrawal may include abrupt

waking up, vomiting, diarrhea, sweating, and agitated or violent behavior. They may not remember overdosing.

While dramatic and unpleasant, withdrawal is not life-threatening and will only last until the naloxone has worn off.

Keep the person calm. Tell the person that drugs are still in his/her system and that the naloxone wears off in 30-45 minutes.

Recommend that the person seek medical attention and assist him/her if necessary.

DO NOT let the person use more opiates. The naloxone will block them and the person could overdose again after the naloxone wears off.

DO NOT provide person with any food or water until they are fully alert.


6. Conduct follow-up and next steps (Cont.)Naloxone takes several minutes to kick in and wears off in 30-45 minutes. The person may go back into

overdose after the naloxone wears off.

Check to see if person starts to breathe and becomes responsive.

Resume rescue breathing if the person has not started breathing on their own.

Naloxone wears off in 30-45 minutes. An additional administration may be necessary. Therefore, it is STRONGLY RECOMMENDED that you watch the person for at least an hour or until emergency medical services arrive in case the person goes back into overdose.

The administration of naloxone to an individual is not the last step in responding to an opioid overdose emergency. Further attention and action are necessary. After administering naloxone, take the following steps to ensure that the person has been revived.

Apply “I’ve Received Naloxone” sticker somewhere visible on the person which can let first responders know that the person has experienced an overdose and received naloxone. If the person is in withdrawal, their skin may be sweaty or clammy. To ensure it stays, apply the sticker to the person's clothing or hair.

You may need to give the person more naloxone. Give a second dose if the person does not respond after three (3) minutes or if the person loses consciousness again. If the second does is applied, affix the second sticker from your kit to the person.


6. Conduct follow-up and next steps –Summary

Withdrawal is awful but not life-threatening. Try to keep them calm, let them know what happened, and explain that help is coming and they need to wait for emergency medical personnel to respond.

Monitor the individual to see that they start to breathe and becomes responsive.

Resume rescue breathing if the person has not started breathing on their own.

Naloxone takes several minutes to kick in and wears off in 30-45 minutes. The person may relapse into an opioid overdose emergency after the naloxone wears off. Therefore, it is STRONGLY RECOMMENDED that you watch the person for at least an hour or until emergency medical services arrive in case the person goes back into an opioid overdose emergency.

Do not let them ingest food, drinks, or more drugs.


Initial Training of Trainer events took place in late June 2014 in the far Southwest Virginia and Richmond pilot areas

Training figures to date:o Statewide

Training of Trainers – 14

Lay Rescuer Trainings - 24

o SWVA

Trainers - 150

Lay Rescuers - 213

o Richmond

Trainers - 21

Lay Rescuers – 126


● To date, there have been no confirmed overdose reversals as a result of REVIVE!


In November, DBHDS surveyed Trainers and Lay Rescuers to measure how many of them were having issues obtaining either a prescription or the medication


Reasons most cited for “No” included price of medication and perceived lack of need

November 2014


Reasons most cited for “No” included price of medication and perceived lack of need

December 2014


Lack of access to naloxone was cited as an issue by 20% of respondents


● Those who had obtained prescriptions but not had them filled were asked why not. Most frequent responses:

o Too expensive

o Pharmacy is too far away

o No insurance

o Pharmacy does not have naloxone available

o Do not have time

o Would rather spend money elsewhere

o Concerned about what pharmacist will think of them

REVIVE! Successes

● Number of Trainers and Lay Rescuers

● Collaborationo Appalachian Substance Abuse Coalition Voucher Program

o Prescribing Doctors

Public awareness about the inherent risks of prescription opioids

Naloxone is for risky DRUGS,

not risky PEOPLE!

REVIVE! Successes – Public Awareness

● National Safety Council

o Evidence that prescription opioids are not best treatment for acute pain, with the exception of end stage treatment

o Over the counter ibuprofen is more effective with far fewer side effects


• American Academy of Neurologyo Position paper issued in September 2014

o Found no substantial evidence for maintaining pain relief or improved function over long periods of time without serious risk of overdose, dependence or addiction


Franklin G M Neurology 2014;

83:1277-1284


● American College of Emergency Physicians

REVIVE! Challenges

● Funding

● Stigma

● Community Involvement

● Diversity of Pilot Locations

● Naloxone Access – Pharmacy Stocking and Cost

o Amphistar/IMS announced a price increase in November 2014

o Retail prices have effectively doubled

o Criticism from New York State Attorney General and others

REVIVE! Moving Forward in 2015

● Increased Outreacho Colleges and Universities

o Support Groups

o Harm Reduction Organizations

● More Trainings

● Potential Program Growth – 2015 General Assembly Session

Acknowledgments

REVIVE! has been made possible by the generous assistance of the following:o Boston Public Health Commissiono Chicago Recovery Allianceo Delegate John O’Bannon, R-73o Joanna Ellero Harm Reduction Coalitiono The McShin Foundationo Massachusetts Department of Public Healtho Multnomah County (OR) Health Departmento New York City Department of Mental Health and Hygieneo Ed Ohlingero One Care of Southwest Virginia o Project Lazaruso SAARA Recovery Center of Virginia o San Francisco Department of Health/DOPE Projecto University of Washington Alcohol and Drug Abuse Instituteo Virginia Department of Healtho Virginia Department of Health Professions

Questions and Answers

Thank you for your attention!

Contact Information:

Jason Lowe

[email protected]

804-786-0464

mailto:[email protected]

Lowe-2014

Health & Medicine

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