Morning report

5/27/2015
By Matt Evans

Case
3 year old female brought to PCMC for opioid overdose.
Pt. was initially brought by EMS to outside hospital, and
pt. was given Narcan with improvement in mentation and
respiratory status according to EMS.
Mother states that she herself had fallen asleep just after
filling her weekly medication dispensing box, then woke
up to find her 3 year old sleepy and surrounded by
scattered meds (including her Lortab) and her open pill
box.
In the PCMC ED, patient did not require additional doses of
Narcan and she was eventually admitted to the RTU for
further observation.

Case continued, questions

Patient did well, DCFS saw patient since EMS
providers called them due to concern about the
poorly cared for house and the situation
How would the clinical situation have been
different if med was methadone?
Are there any other additional questions youd
like to ask the mother or father of this child?
Are there any treatment/prevention options for
next time?
What education is indicated if any?
Was getting DCFS involved necessary? What
if the drug was
powdered heroin that the child got into

Case continued
DCFS recommended that patient could go home as she
was remorseful about situation and she would take
precautions so it would not happen again
This was the first time DCFS has been contacted about
this mother
Pharmacy educated the patients mother about the use of
rescue intranasal naloxone in case of future overdose
events, naloxone dispensed
The House of Hope (family drug court) in Utah provides a setting
where women can have their children with them in residential
treatment.
Research strongly indicates that women are much more likely to
succeed in treatment if they are able to keep their children with
them, and that they are less likely to become involved or remain
in treatment if their children must be placed with family, friends, or

Naloxone
Saving a life is childs play

Naloxone for home use

By Matt Evans

Background
Drugs are bad. Worse than guns, and even worse than
cars.
Number 1 cause of accidental death nationwide since 2007
Motor vehicle traffic deaths (2012)
All injury deaths (2012)
Number of deaths: 33,804
Number of deaths: 192,945
Deaths per 100,000 population: 60.2

All poisoning deaths (2012)

Deaths per 100,000 population: 10.7

All firearm deaths (2012)

Number of deaths: 33,636

Deaths per 100,000 population: 10.6

Number of deaths: 48,545

Deaths per 100,000 population: 15.4

2012

Opioid Overdose
Death
Rates in
the U.S. are
climbing

Note:*Per
100,000
population

The DOPE project

DRUG OVERDOSE PREVENTION EDUCATION
First successful overdose prevention programs were in Chicago & Santa Cruz
DOPE is a grassroots effort in San Francisco to distribute clean needles which
later turned into educating IDUs (injection drug users) on rescue naloxone
Grassroots initiative was eventually supported by local health departments
and this was translated to HIV patient care (since HIV patients were dying
from heroin overdoses faster than from AIDS)
Initial overdose education trainers taught their population about rescue
breathing, taught them about safely calling 9-1-1 with the protection of a
good Samaritan law, and dispelled overdose risks (no ice baths!), etc
In 2003, after a law allowing MDs/NPs to prescribe take home IM naloxone
rescue kits was passed, Dr. Josh Bamberger established a program to
distribute naloxone at multiple sites after a short visit with a nurse
practitioner
In 2010 a law allowing trainers to distribute naloxone based on a standing
order to promote even easier access was passed

Opioid Overdose
Death
Rates in
the U.S. are
climbing

Note:*Per
100,000
population

OEND (overdose education and

intranasal naloxone distribution) in
Massachusetts
OBJECTIVE: To evaluate the impact of state
supported overdose education and nasal naloxone
distribution (OEND) programs on rates of opioid
related death from overdose and acute care
utilization in Massachusetts.
INTERVENTION: OEND programs equipped people
at risk for overdose and bystanders with nasal
naloxone rescue kits and trained them how to
prevent, recognize, and respond to an overdose by
engaging emergency medical services, providing
rescue breathing, and delivering naloxone.
MAIN OUTCOME MEASURES: Adjusted rate
ratios for annual deaths related to opioid overdose
and utilization of acute care hospitals.
RESULTS: Among these communities, OEND
programs trained 2912 potential bystanders who
reported 327 rescues. Both community-year strata
with 1-100 enrollments per 100,000 population
(adjusted rate ratio 0.73, 95% confidence interval
0.57 to 0.91) and community-year strata with
greater than 100 enrollments per 100,000
population (0.54, 0.39 to 0.76) had significantly
reduced adjusted rate ratios compared with
communities with no implementation. Differences in
rates of acute care hospital utilization were not
significant.
CONCLUSIONS: Opioid overdose death rates were
reduced in communities where OEND was
implemented. This study provides observational
evidence that by training potential bystanders to
prevent, recognize, and respond to opioid overdoses,
OEND is an effective intervention.

Project Lazarus if it works for

heroin, will it work for all forms of
opioid abuse?
Background.In response to some of the highest drug overdose death rates in the
country, Project Lazarus developed a community-based overdose prevention program
in Western North Carolina. The Wilkes County unintentional poisoning mortality rate
was quadruple that of the state's in 2009 and due almost exclusively to prescription
opioid pain relievers, including fentanyl, hydrocodone, methadone, and oxycodone.
The program is ongoing.
Methods.The overdose prevention program involves five components: community
activation and coalition building; monitoring and surveillance data; prevention of
overdoses; use of rescue medication for reversing overdoses by community
members; and evaluating project components. Principal efforts include education of
primary care providers in managing chronic pain and safe opioid prescribing, largely
through the creation of a tool kit and face-to-face meetings.
Results.Preliminary unadjusted data for Wilkes County revealed that the overdose
death rate dropped from 46.6 per 100,000 in 2009 to 29.0 per 100,000 in 2010. There
was a decrease in the number of victims who received prescriptions for the substance
implicated in their fatal overdose from a Wilkes County physician; in 2008, 82% of
overdose decedents received a prescription for an opioid analgesic from a Wilkes
prescriber compared with 10% in 2010.
Conclusions.While the results from this community-based program are
preliminary, the number and nature of prescription opioid overdose deaths in Wilkes
County changed during the intervention. Further evaluation is required to understand
the localized effect of the intervention and its potential for replication in other areas.

Winning! Or are we?

Fast forward to 2013

Unfortunately, a side effect of physicians being more

stringent with prescription opioids has resulted in a
resurgence of heroin use/death
Nationwide heroin overdose deaths are only increasing,
and opioid analgesic deaths are not slowing down

But Utah doesnt have a drug

problem, right?

Age-adjusted drug-poisoning death rates, by state: United States, 2012

The states with the highest rates per 100,000 population in 2012
were #1 West Virginia (32.0), #2 Kentucky (25.0), #3 New
Mexico (24.7), #4 Utah (23.1), and #5 Nevada (21.0).

FIGURE 2. Number (N = 188) and location* of local drug overdose prevention

programs providing naloxone in 2010 and age-adjusted rates of drug
overdose deaths in 2008 United States

* Not shown in states with fewer than three local programs.

Per 100,000 population. Source: National Vital Statistics System. Available at
http://www.cdc.gov/nchs/nvss.htm. Includes intentional, unintentional, and undetermined

Emergency department utilization and subsequent

prescription drug overdose death
Pulished in Annals of Epidemiology in March of 2015 by Joanne E. Brady PhD, Charles J. DiMaggio PhD, Katherine M. Keyes PhD, John J. Doyle
DrPH, Lynne D. Richardson MD, Guohua Li MD, DrPH

Purpose: Prescription drug overdose (PDO) deaths are a

critical public health problem in the United States. This study
aims to assess the association between emergency department
(ED) utilization patterns in a cohort of ED patients and the risk
of subsequent unintentional PDO mortality.
Methods: Using data from the New York Statewide Planning
and Research Cooperative System for 2006-2010, a nested
case-control design was used to examine the relationship
between ED utilization patterns in New York State residents of
age 18-64 years and subsequent PDO death.
Results: The study sample consisted of 2732 case patients
who died of PDO and 2732 control ED patients who were
selected through incidence density sampling. With adjustment
for demographic characteristics, and diagnoses of pain,
substance abuse, and psychiatric disorders, the estimated odds
ratios of PDO death relative to one ED visit or less in the
previous year were 4.90 (95% confidence interval [CI]: 4.505.34) for those with two ED visits, 16.61 (95% CI: 14.72-18.75)
for those with three ED visits, and 48.24 (95% CI: 43.23-53.83)
for those with four ED visits or more.

Conclusions: Frequency of ED visits is strongly associated with

the risk of subsequent PDO death. Intervention programs
targeting frequent ED users are warranted to reduce PDO
mortality.

FREQUENT FLYERS:
ANY CONCERN FOR
OPIOID USE, GIVE
THEM NALOXONE

If we care about saving lives without

discriminating, we should be
prescribing naloxone to the following
vulnerable people:

Recommendati
ons

Opioid IDUs (e.g. heroin)

Those who combine opioids with

other CNS depressants (benzos)

Those who use opioid doses

greater than 100 mg/day of
morphine equivalent

Those who lose opioid tolerance

after detoxification or incarceration
and are at risk to resume opioid use
(every opioid user who leaves
rehab, prison)

Comorbid mental health, CNS,

renal, hepatic or pulmonary
diseases

Young people experimenting with

opioids

if you went into medicine to save lives,

naloxone really is the easiest way to
do so.

preferably dont do drugs either

Projects

Matt Evans Giving out 50 naloxone kits

to Uni outpatient addiction patients
Pre-video survey of naloxone
knowledge
Post-video survey of naloxone
knowledge
Video created by Boston Public Health
Commission is publicly accessible for
use
Participants encouraged to fill out
use form describing situation in
which their kit was used to empower
the importance of naloxone when
future presentations are given. If they
do, then they get a free naloxone kit
refill
Jennifer Plumb Obtained grant that is
going to be used to distribute naloxone in
EDs (PCMC, U of U, etc), HIV clinics, other
hi risk locations
Creating Salt Lakes own naloxone
education video with the help of some
incredible young talent
Collaborating with pharmacists who

References
Centers for Disease Control and Prevention (CDC). CDC grand rounds:
prescription drug overdoses a US epidemic.MMWR Morb Mortal Wkly
Rep. 2012;61(1):1013.7
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3838403/#b20-sar-4-065
https://www.networkforphl.org/_asset/lhscnj/October-Webinar.pdf
(http://harmreduction.org/overdose-prevention/overdose-news/take-homenaloxone-for-opioid-overdose-exploring-the-legal-policy-and-practice-landscapes/)

http://harmreduction.org/issues/overdose-prevention/tools-best-practices
/naloxone-program-case-studies/project-lazarus/
http://www.cdc.gov/nchs/data/hestat/drug_poisoning/drug_poisoning.htm
Opioid overdose rates and implementation of overdose
education and nasal naloxone distribution in Massachusetts:
interrupted time series analysis. By Walley AY, Xuan Z,
Hackman HH, Quinn E, Doe-Simkins M, Sorensen-Alawad A, Ruiz S,
Ozonoff A. BMJ. 2013 Jan 30;346:f174.
Project Lazarus: Community-Based Overdose Prevention in Rural
North Carolina. By Su Albert MD, MPH,Fred W. Brason II
Chaplain,Catherine K. Sanford MSPH,Nabarun Dasgupta MPH,Jim
Graham and Beth Lovette MPH. Pain Medicine. Published 13 JUN 2011.