Overdose Crisis: A harm

reduction approach CAPA Conference, Ottawa

October 29, 2017

Stan Kupferschmidt Joanna Binch

Objectives

• Describe the current landscape of opioid use in Canada.

• Discuss the dangers of fentanyl use.

• Review effective responses to opioid overdose.

• Review the current use of safer consumption sites in Canada.

• Describe the evidence used to support the use of supervised injection sites in harm reduction.

Disclosures

• No pharmaceutical disclosures/ conflicts of interest

• Our NESI peer program/ volunteers with lived experience contributed to this presentation

• Although opioids are prescribed for many patients across this lifespan, the focus of this presentation is relating to IDU and/or those using opioids not as prescribed

Myth or Fact

Drug overdoses are a new problem for Canada.

Myth

• While statistics show a dramatic rise in overdose deaths in the last two years (2,458 for 2016 alone), overdoses among people who inject drugs is common

• As long as drugs are unregulated and produced in clandestine labs, there will always be overdoses.

SIS: Safe injection Service

Myth or Fact

There is no safe injection service. SIS: Supervised Injection Service. This is a Best Practices Harm Reduction Strategy.

Myth

911 is called in over 80% of overdoses.

Myth or Fact

9-1-1 is called in less than 50% of overdoses.

OPH 2016; PROUD 2016

Myth

Myth or fact?

Fentanyl is the issue

• The issue as it has always been is trauma, violence, poverty and stigma, mental illness

• For people who use, drugs are not the problem, they are the answer

• Moral panic around a particular drug is a common narrative

Mark Tyndall, 2017

Myth

Myth or Fact

People are aware they are taking Fentanyl.

Truth

• With the delisting of Oxycontin in 2012, the currency of diverted prescriptions change to a more toxic drug.

• Prohibition leads to more toxic drugs

• Most people know they are taking Fentanyl, the dose is just more difficult to manage.

Fentanyl is being cut into all kinds of drugs – nothing is safe

Myth or Fact

• Toxicology from overdose victims usually shows multiple drugs including fentanyl because many people use multiple drugs

• Confiscated drugs purchased as cocaine or crystal meth that contain fentanyl are mostly due to a processing mistake

• Fentanyl is being sold because it is profitable for the suppliers, cheaper for the users, and readily available

Myth

Myth or fact

The supply of Fentanyl can be stopped by tougher enforcement

• If we can’t stop massive bags of heroin, how do we stop tiny envelopes of fentanyl?

• The focus needs to be on the demand side, addressing the social drivers that lead to addiction and supporting those who are addicted.

Myth

Current Landscape

Trump declares opioid epidemic a national public health

emergency

Scope of the Problem • 2,458 overdose deaths in 2016 in all of Canada

• Approximately seven Canadians die of overdose each day.

• Highest rates of death in Western Canada opioid-related death rates of over 10 per 100,000 population

• Serious fear of police response if call 911

• 20% of people who use drugs OD’d in the previous 6 months

• Average lifetime number of OD’s: 5

• Opioid Crisis - Fentanyl / Carfentanil

• http://www.cbc.ca/1.3909658

An OVERDOSE is a medical

emergency. Anyone that suspects

or witnesses an overdose should

immediately CALL 9-1-1, even if

Naloxone has been given.

16 # of patients administered

naloxone by paramedics for

suspected opioid overdose

72 # of patients administered

naloxone by paramedics for suspected

opioid overdose

NALOXONE

Ottawa Paramedic Service Data: January 2017 to May 2017

1,122 visits

549 visits

127 visits

2016Total

2017year todate

2017year todate

May 2017

May 2017

Key points:

Emergency department

visits by week were stable in

December 2016

An increase started in January

2017, and returned to pre-2017

levels in late March 2017

An increase started in early

April 2017, and has continued

into May

Drug overdose-related emergency department visits with life-threatening or potential life-threatening circumstances

9-1-1

The diagram on the right

shows weekly counts of

drug overdose-related

emergency visits in

Ottawa for the past

6 months among those

aged 10 to 64. It only captures emergency

department visits with life-threatening or

potential life-threatening circumstances.

It does not include people who overdose and

do not access an emergency department.

What are the emergency department (ED) overdose trends in the last 6 months?

www.StopOverdoseOttawa.caThis product was developed in partnership with the Ottawa Overdose

Prevention and Response Task Force. For more information visit:

This report provides available monthly trend data on drug overdose-

related emergency department visits. It provides information on

the overdose-related emergency department visit trends relating to

overdoses in the last 6 months.

The data used in this report is from:

Drug overdose-related emergency department data

Ottawa Paramedic Service naloxone administration data

This data is updated monthly with additional data and indicators added as they become available. Data may change slightly between monthly reports based on updates to historical data. The reporting periods for the

data sources used in this report may not align exactly with calendar months, as it is based on weekly data.

Emergency Department Visit s for Drug Overdoses in Ot tawaJune 2017 Report

Context-How did this happen?

• War on drugs

• Stigma & discrimination

• Delisting of oxycotin in 2012

• Recent provincial response to overdose crisis makes prescribers fear prescribing

• Fentanyl patches no longer covered by drug programs for people with social assistance

• Ease of supply of fentanyl from overseas

• What is an opioid? • What is fentanyl? • Discuss the dangers of fentanyl use • What is carfentanil?

Objectives

What is an opioid?

What is Fentanyl?

• Developed in 1959, in 1990’s developed as transdermal patch for palliative care

• Around 50 to 100 times more potent than morphine. • Available in both pharmaceutical and illicit forms. • Illicit fentanyl is often made as a powder and mixed with other

drugs • Street names: fake oxy, greenies, green beans, green apple, shady

eighties, etc. or for fentanyl-laced heroin include Apache, China Girl, China White, Dance Fever, Friend, Goodfella, Jackpot, Murder 8, TNT, and Tango and Cash.

P.E.I. Police Photo Shows Just How Little Fentanyl and Carfentanil It Takes To

cause a fatality

Carfentanil • Used by vets for very large animals like elephants. • 100 x more potent than fentanyl. • 10,000 times more potent than morphine. • Cut into some drugs like heroin & counterfeit pills made to look

like prescription opioids • There is no easy way to know if carfentanil is in drugs, you can’t

see it, smell it or taste it. It is extremely toxic and a very small amount can cause an overdose.

Opioid Overdose

1. What are the risks for overdose? 2. Message for your patients 3. How to recognize an overdose 4. What you should have in the clinic to manage 5. What harm reduction approach you could be a part of

Overdose risk factors

DECREASED TOLERANCE

You are at increased risk if you have not used in a few days because you were incarcerated, you just returned from

treatment….

MIXING DRUGS

Danger = Use one drug at a time

USING ALONE

Have a plan and know your limit

Overdose risk factors

DRUG QUALITY & POTENCY

Drugs can have added ingredients

HEALTH STATUS Use less if you are sick.

ROUTE

Fentanyl Overdose Prevention Message

• Store medications safely • Don’t use alone • Leave door unlocked • Tell someone to check on you • Start with a small amount • Try to procure your drug from a familiar source, but alert if anything looks “different” • Do testers to check strength • Mixing drugs, including alcohol, increases risk of overdose • If you do mix, choose to use drugs before alcohol (you can puke out the alcohol, but not the drug you shot up) • Pace yourself • Choose a safer route of taking drugs • Be aware: using drugs while on prescribed medications can increase overdose risk • Call 911 right away if someone overdoses [e.g. has difficulty breathing or loses consciousness] • Use less if you are sick • Use where help is easily available (e.g. most importantly around people you trust) • Make a plan/know how to respond in case of OD. • Be prepared to give breaths and/ or administer naloxone (Narcan) until help arrives • Overdose response training and naloxone kits are available for free!

Signs of opioid overdose

X

• Can’t be woken up (“no response to shake and shout”)

• Slow breathing or no breathing (<12 breaths/minute)

• Blue lips and nails

• Snoring or gurgling sounds

• Skin feels cold

• Very small pupils

Signs of opioid overdose

Office Supplies • Naloxone (multiple doses)

• Intranasal

• Intramuscular

• Oxygen

• Ambu-bag attached to the oxygen tank

• BP Cuff

• O2 Sat monitor

• Air ways

• Nasal

• Oral

• Snacks

What is Naloxone

A “Competitive Antagonist” at Opioid Receptor Sites

• Naloxone is a medication that can temporarily reverse the effects of an overdose

• The goal of naloxone is to restore adequate breathing (required for life)

Image: Harm Reduction Coalition / Graphics by Maya Doe-Simkins

The drug is still in the body.

No Need to Fear Naloxone!

• Listed on WHO’s list of essential It is a life-saving measure

• It works if someone has ingested opioids.

• It has no effect if someone has not ingested opioids

• The only reason not to give it is if someone has ever had an allergic reaction to naloxone previously

• Naloxone starts to work within 2-5 minutes, wears off as quickly as 30-90 minutes

• Can be administered into a muscle via injection,

or intranasal preparation.

• Used in Canada for over 40 years

• Do not need a prescription to use or obtain

What’s in a Naloxone Kit?

• 2 vials of Naloxone and 2 syringes

• OR two intranasal sprays

• 1 breathing mask

• Gloves

• Step-by-step instructions

In case of an overdose 1. Shake at the shoulders & Shout their name

(sternum rub)

2. Call 911 if unresponsive

3. Chest compressions

4. Naloxone

In case of an overdose 5. Better? If the person is not doing better after

3-5 minutes (not breathing, not waking up), give a second dose of Naloxone and continue CPR until paramedics arrive.

6. If you have to leave the person alone at any time, put them in the recovery position.

https://youtu.be/jym7F9PQHy0

Supervised Injection Service

1. Harm reduction philosophy 2. Approaches to harm reduction (opioids) 3. Test your knowledge 4. SIS https://yu.tube/ro3ZYHLG-po

Harm Reduction • Drug use as a human behaviour and complex social

issue that should be approached from a health perspective, not a criminal perspective

• A set of practical strategies and ideas aimed at reducing negative consequences with drug use

“The more doors you have open for people to come in to get help, the greater the chance we have to save decades of their lives.”

- Ray Harrison, NESI peer

Continuum of Substance Use

Non Use

Abstinence

Situational

Use Regular/Man

aged Use

Problematic

Use/ Addiction

Complex

Addiction

SMI

Chronic

We need to move towards social justice built on a belief in, and respect for the rights of people who use drugs.

Harm Reduction Approaches

• Peer involvement • Talk to your patients and ask the “right” questions • Naloxone & overdose prevention training • Offer drug testing & checking • Recognition consumption (include injection drug use and smoking) • Opioid substitution therapy • Managed opioid programs • Drug Testing • Overdose prevention sites https://www.youtube.com/watch?v=xInZreDLRis

Supervised Injection Services have been proven effective.

MYTH or FACT

There are 90 locations throughout Western Europe and Australia. SIS has proven to reduce overdoses, reduce the risk of HIV and Hep C transmission, and help drug users into addiction treatment services. www.communityinsite.ca

MYTH

Abstinence based addiction treatment and short term detox is the priority

MYTH or FACT

• While addiction treatment in the form of inpatient beds has a role, the staggering numbers of people currently at risk will require a much broader response

• Short term rapid taper detox with no follow up can actually contribute to overdose deaths.

MYTH

• An agency/organization requires a federal exemption from the controlled drug & substances act in order to serve people who use drugs.

MYTH or FACT

• Needle exchange – no exemption

• Administering naloxone – no exemption

• Alley patrols/outreach – no exemption

• Telling people to use with others – no exemption

• Opening a supervised consumption site – exemption required

Mark Tydall, 2017

MYTH

Supervised Consumption Sites

SIS

• The number one overdose intervention names by community groups and current drug users is supervised injection

• There has never been an overdose death at a supervised injection site.

• Currently, these services are quickly opening across Canada (Edmonton, Montreal, Ottawa, Vancouver, Kelowna, etc.)

• The local government and community groups play a critical role

Documented successes…

• Reduced overdose deaths

• Reduced sharing of needles (reduced risks of HIV & Hep C)

• Reduced public injecting

• Increased use of detox & treatment services

• Decreased number of publicly discarded needles

• Health Care costs

• Increased safety & decreased stigma

Questions!

The Science!

Published Science, Reports and Evaluations Insite for Community Safety