The Role of Prevention in Addressing Opioid Overdose · 2017-10-20 · harm that occurs when a...

CAPT TRAINING

The Role of Prevention in Addressing

Opioid Overdose

Trainers:

Erin Haas, MPH, CAPT Associate

Erin Ficker, MPAff, CSPS, Associate Coordinator for the Central Resource Team,

SAMHSA’s CAPT

October 19, 2017

2

Technical Information

This training was developed under the Substance Abuse and

Mental Health Services Administration’s Center for the

Application of Prevention Technologies task order. Reference

#HHSS283201200024I/HHSS28342002T.

The views expressed in this training do not necessarily

represent the views, policies, and positions of the Substance

Abuse and Mental Health Services Administration or the U.S.

Department of Health and Human Services.

3

Trainers

Erin FickerAssociate Coordinator,

Central Resource Team

SAMHSA’s CAPT

Erin HaasCAPT Associate

SAMHSA’s CAPT

4

Welcome and Introductions

Please share:

• Your name

• Your role

• One thing you

hope to get out

of today’s

training

5

Group Guidelines

• Take turns speaking

• Participate fully

• Be open and respectful

• ELMO (enough, let’s move on)

• Save email, etc., for breaks

• Return promptly from breaks

6

Roadmap for Today’s Training

Defining the Problem

Focus Populations

Factors that Place

Individuals at Risk

Prevention Strategies

Common Challenges

7

Defining the ProblemTerminology and National Data on

the Opioid Crisis

8

How is

preventing

opioid misuse

and overdose

different from

other prevention

work you’ve

done in the

past?

9

Definitions

Non-medical Use

MisusePrescription

Opioids

Opioids

Used Illicitly

Non-Medical

Use

Handout: Glossary of Commonly-Used

Terms Associated with Preventing Opioid

Misuse and Overdose

10

How Opioids Work1

Opioids attach to receptors found in the brain (and

other organs) and reduce pain.

Source: http://www.copeaustralia.com.au/home-mobile/naloxone/

11

Health Effects of Opioids1

• Health effects include

drowsiness, confusion,

slowed breath, and

euphoria.

• Individuals who use

opioids for extended

periods will develop a

tolerance over time.

12

Opioid Overdose2,3

An overdose is bodily

harm that occurs when a

person takes more of a

substance than his/her

body can process or a

dangerous combination

of substances.

Overdoses can be fatal

or nonfatal.

13

What does

the opioid

crisis look

like in your

community?

14

Overdose Rates on the Rise4,5

1999

CDC/NCHS National Vital Statistics System

2015

>15.2 Age-Adjusted Death Rate from Drug Poisoning per 100,000

15

Overdose Deaths Involving Opioids,

by Type of Opioid (1999-2015)6,7

National Center for Health Statistics (NCHS), Multiple Cause of Death (2016)

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Heroin

Natural and

Semi-synthetic

Opioids

Synthetic

opioids (e.g.,

fentanyl)

Methadone

16

Prescriptions Filled8

2015 IMS Health, National Prescription Audit

17

Sources of Misused Prescription Drugs9

2015 National Survey on Drug Use and Health

From a

relative or

friend: 53.7%

From a Health

Care Provider:

36.4%

Some other way: 4.9%

From a drug dealer or stranger: 4.9%

Given free: 40.5% Taken: 3.8%

Rx from 1

doctor: 34%

Rx from 2+ doctors:

1.7%

Rx stolen: .7%

Source of Rx

Drugs Among

People Aged

12 or Older

Bought: 9.4%

18

Opioid Crisis: Related Trends10,11,12,13,14

Opioid Crisis

Widespread prescribing of

opioids

Lack of education about opioid use

disorders

Increased availability of

heroin

Increased hopelessness and

depression associated with

economic decline

19

Roadmap for Today’s Training


Focus Populations

Factors that Place

Individuals at Risk


Common Challenges

20

Focus PopulationsWho Is the Target of Your Opioid

Overdose Prevention Efforts?

21

The Institute of Medicine (IOM)

Continuum of Care Model

22

Opportunities for Prevention

Interventions

Universal Prevention

Selective Prevention

Indicated Prevention

23

Target Populations for Opioid

Overdose Prevention

Selective

Universal

Indicated

24

Is It Universal, Selective, or Indicated?

Example:

Providing information to

all people who use

opioids on strategies for

reducing overdose risk

(for example, to avoid

alcohol while using

prescriptions)

25

Example:

Educating people who

have previously

overdosed on

strategies to reduce

their overdose risks

(for example, by using

naloxone)

Is it Universal, Selective, or Indicated?

26

Example:

Reaching out to

people who currently

misuse opioids to

reinforce safe-use

messages

Is it Universal, Selective, or Indicated?

27

Road Map for Today’s Training


Focus Populations

Factors that Place

Individuals at Risk


Common Challenges

28

Factors that Place Individuals

at Risk

29

Components of Prevention Planning

Risk and Protective Factors

Interventions

Problems and Related Behaviors

30

What are

some risk or

protective

factors that

you have

addressed in

previous

prevention

work?

31

Areas of Overlap15,16

Non-medical use of

prescription drugs

Heroin useOpioid

overdose

32

Factors Associated with Opioid

Overdose

Ability to Process Opioids

Chronic Pain and Mental

Health

Opioid Access and Supply

Opioid Knowledge and

Perceptions

Opioid Use and Misuse

Non-Fatal

Overdose

33

• Illicit use of any opioids

o Non-medical use of prescription opioids

o Use of heroin and other non-prescription opioids

o Illicit use of opioids in combination with other

controlled substances (similar to medical use)

• Using opioids alone (increases risk of fatal

overdose)

Opioid Use and Misuse: Related

Factors20,21,22

34

Opioid Use and Misuse: Related

Factors17,18,19

• Medical use of prescription

opioids

o Nature of the prescription

(e.g., high dosage, long-

acting, long-term)

o Concurrent prescriptions

(e.g., multiple opioids or

opioids and

benzodiazepines)

35

Ability to Process Opioids:

Related Factors23,24,25

• Opioid dependence and opioid use

disorder

• Change in tolerance

o Increase in tolerance with opioid use

o Decrease in tolerance with time

away from use (due to

hospitalization, treatment,

incarceration)

• Compromised physical health

36

Chronic Pain and Mental Health:

Related Factors20,23,26,27

• Chronic pain

• Mental health

disorders

37

Chronic Pain and Mental

Health: Related Factors20,28

• Adverse life experiences/

periods of severe stress

o Witnessed a family member

overdose

o Financial struggles,

including unemployment

o Homelessness

38

Opioid Access and Supply:

Related Factors17,19

• Opioid prescribing

practices

o Increases in number of

opioid prescriptions

o Increases in dosage

and/or duration (includes

days supply/number of

pills prescribed)

39

Opioid Access and Supply:

Related Factors19,29

• Diversion of prescription opioids

o Friends or relatives

o Healthcare providers (doctor shopping,

pharmacy hopping, pill mills)

o Drug dealers

• Availability of other/non-prescription

opioids

40

Opioid Knowledge and

Perceptions: Related Factors30,31

• Lack of awareness/understanding of

overdose risks

• Low perception of harm associated with

opioids (specifically prescription

opioids)

41

Non-fatal Overdose: Related

Factors32

• Experiencing a non-

fatal overdose in the

past increases an

individual’s risk of fatal

overdose in the future.

42

How are these

factors similar

to or different

from those

you’ve

addressed in

the past?

Handout: Factors Associated

with Opioid-Related Fatal and

Non-fatal Overdose

43



Focus Populations

Factors that Place

Individuals at Risk


Common Challenges

44

Strategies for Preventing Opioid

Overdose and Death

45

Components of Prevention Planning

Risk and Protective Factors

Interventions

Problems and Related Behaviors

46

Categorization of Strategies

Strategies to Prevent

Overdose


Overdose Death

47

• Education

• Prescription drug disposal

programs

• Prescription Drug

Monitoring Programs

• Prescribing and dispensing

regulations

• Law enforcement actions

• Treatment and follow-up

services

• Naloxone access and

promotion strategies

• Help-seeking promotion

strategies

• Supervised injection

facilities



Overdose


Overdose Death

48

A Note About Evidence

• Compared to other strategies, there is less evidence

for opioid overdose prevention strategies.

• However, less evidence does not mean ineffective.

• Practitioners should rely on their experience working

with other substances to inform opioid overdose

prevention efforts.

• Evaluation is key to building the evidence base.

49

Education Strategies

People Who Use

Prescription

Opioids Medically


Overdose

Community

Members

Healthcare

Professionals

People Who Use

Opioids Illicitly

Target

Audiences for

Education

Strategies

50

For People Who Use

Opioids Illicitly

Education topics include:

• Personal characteristics or

behaviors that increase overdose

risk

• Changes in the local drug supply

that increase overdose risk (e.g.,

types, purity, or negative effects of

available drugs)

• Available risk reduction, treatment,

and support services


Overdose

51

For Healthcare Providers


• Benefits and risks of

prescription opioids

• Best practices for

prescribing/dispensing

• Alternatives to opioids

• How to talk to patients about risks

• How to recognize an individual who is at risk

• Referrals to treatment and support services


Overdose

52

For People Who Use Rx

Opioids Medically


• Risks of prescription opioids and

non-opioid alternatives

• How to safely use prescriptions

• Proper medication storage and

disposal

• How to recognize the signs of an

opioid use disorder

• Available treatment and support

Strategies to Reduce

Opioid Misuse or

Overdose


Overdose

53

For Community Members

• Universal prevention programs

• Communication campaigns, including:

o Information dissemination campaigns

o Social marketing campaigns

http://pastop.org/


Overdose

54

Prescription Drug

Disposal Programs

• Encourage community members

to voluntarily and safely dispose

of their unwanted, expired,

and/or unused medications.

• Strategies include:

o Dropbox programs

o Take-back programs

o Mail-back programs


Overdose

55

Prescription Drug

Monitoring Programs

• Statewide electronic data systems

that collect, analyze, and make

available data on controlled

prescription medications,

including opioids.

• Can be used to:

o Target prevention efforts (e.g.,

identify “hot spots”)

o Change prescriber behavior

(e.g., through prescriber

report cards)


Overdose

56

Prescribing and

Dispensing Regulations

Designed to:

• Limit the number, quantity,

and duration of prescriptions

• Restrict the circumstances

under which prescriptions

can be issued or refilled

• Establish requirements for

monitoring patients who are

using prescription

medications


Overdose

57

Law Enforcement

Actions

• Use PDMP data to identify providers

and patients engaged in

troublesome behavior

• Implement “tip and reward”

programs

• Take criminal action against those

who possess, sell, or use illicit

substances

• Connect people with treatment and

support services


Overdose

58

Door Knock Program

Law enforcement and

outreach workers in several

Massachusetts

communities follow up with

individuals who have

experienced an opioid

overdose and their families

to provide education and

connect them to support

systems.

59

Treatment and Follow-

Up Services

• Medication-assisted

treatment, particularly

buprenorphine, can

prevent opioid overdose

• Follow-up services or

“after-care” keep

individuals engaged in the

recovery process


Overdose

60

Participant

Questions

61

• Education

• Prescription drug disposal

programs

• Prescription Drug

Monitoring Programs

• Prescribing and dispensing

regulations

• Law enforcement actions

• Treatment and follow-up

services

• Naloxone access and

promotion strategies

• Help-seeking promotion

strategies

• Supervised injection

facilities



Overdose


Overdose Death

62

What Is Naloxone?

Source: http://www.copeaustralia.com.au/home-mobile/naloxone/

63

Characteristics of Early Naloxone

Distribution Programs33

• Subsisted on little or nonexistent

funding

• Sometimes operated without

local approval

• Community- and social network-

based

• Designed and delivered by

active drug users

• New programs supported by

informal resource-sharing and

technical assistance from

existing programs

Photo source: http://nationswell.com/life-saving-drug-prevent-100-deaths-day/

64

Naloxone Access and

Promotion Strategies

• Expand naloxone access to

those most likely to be on

the scene of an overdose

emergency

• Promote the use of

naloxone among people

who use drugs,

professional groups, social

service agencies, and the

broader public


Overdose Death

65

Who Needs Access?

Professional First Responders Lay First Responders


Overdose Death

66

Types of Naloxone Access

• Traditional prescriptions

• Third-party prescriptions

• Collaborative practice

agreements

• Standing orders

• Protocol orders


Overdose Death

67

Naloxone Education

Prescribers and

Dispensers

Potential First

Responders

Broader Community


Overdose Death

68

For Potential First Responders

In 2016, the New York City

Health Department led a

citywide overdose

prevention campaign

focused on educating

potential lay first

responders about naloxone.

https://www1.nyc.gov

69

For Prescribers34

In 2015, the San

Francisco Department

of Public Health

reached out to

prescribers, in one-on-

one meetings, to

promote the co-

prescribing of naloxone

and opioids for

individuals at risk for

opioid overdose. http://prescribetoprevent.org/wp2015/wp-

content/uploads/CA.Detailing_Provider_final.pdf

70

For the Community

International Overdose

Day (held every year

on August 31) creates

materials geared

towards the general

public to increase

awareness of the

overdose problem (and

naloxone’s role) and

reduce stigma.

https://www.overdoseday.com

71

Help-Seeking Promotion

Strategies

Strategies to encourage help-

seeking in the event of an

opioid overdose include:

• 911 Good Samaritan Laws

and Policies

• 911 Good Samaritan

Education


Overdose Death

72

911 Good Samaritan

Education

At the county needle

exchange in Seattle, the

Center for Opioid Safety

Education (COSE)

distributes wallet cards that

describe the state’s 911

Good Samaritan law (what

it does and does not

cover).

http://stopoverdose.org/docs/GoodSamcard

2017.pdf

73

Supervised Injection

Sites35

Legally sanctioned

settings where people

can obtain and use

sterile equipment to

inject opioids (obtained

elsewhere) under the

supervision of trained

medical staff.


Overdose Death

74

Implementing a Comprehensive

Approach


Opioid Misuse or

Overdose


Overdose Death

75

Case Study:

Sometown,

USA &

Anyville, USA

Handout: Case Study: Opioid

Overdose Prevention Strategies

76



Focus Populations

Factors that Place

Individuals at Risk


Common Challenges

77

Common Challenges to Preventing

Opioid Overdose and Death

78

What are some

challenges

you’ve

experienced

(or anticipate)

doing this

work?

79

Challenge #1: Engaging New Partners

Opioid overdose prevention requires collaboration with a

diverse range of sectors—for example, primary care,

professional first responders). Many of these may be

new partners for prevention practitioners and not easy to

engage.

80

Challenge #2: Stigma

Stigma experienced by people who use drugs may prevent

them from seeking help for a substance use disorder. It may

also prevent potential partners from supporting overdose

prevention efforts.

81

Challenge #3: Limitations of Naloxone

Naloxone can prevent death from opioid overdose, but it

will not reduce underlying substance use problems.

82

How might

your group

overcome this

challenge?

Challenge #1:

Engaging new partners

Challenge #2:

Stigma

Challenge #3:

Limitations of naloxone

83

Reflecting on the Day

84

Evaluation

Please take the time

to fill out the

evaluation form.

Your feedback is

very important to us!

86

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