Prevention Education and Naloxone Rescue Kits in Massachusetts - - PowerPoint PPT Presentation

Evaluating the Impact of Overdose Prevention Education and Naloxone Rescue Kits in Massachusetts

Alexander Y. Walley, MD, MSc Boston University School of Medicine Exploring Naloxone Uptake and Use: Measuring Progress and Impact July 2, 2015 FDA White Oak Campus

Community level impact

• Naloxone kits and overdose prevention education help save lives
• The harms are few
• Training should not be a barrier
• Populations and venues

1. Active users

• Syringe access programs
• Emergency Department*
• Detox programs
• Criminal justice-involved*
• Methadone maintenance
• Pharmacy and primary care*

2. Caregivers and social networks

• Community meetings and support groups
• Primary care providers
• Pharmacy – Behind the counter, over the counter

3. First responders

• Public health-public safety partnership

* Innovation and research needed

Opioid Overdose Related Deaths: Massachusetts 2004 - 2006

No Deaths 1 - 5 6 - 15 16 - 30 30+ Number of Deaths

OEND programs 2006-07 2007-08 2009 Towns without

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% No coverage 1-100 ppl 100+ ppl

27% reduction

Fatal opioid overdose rates reduced where OEND implemented

Naloxone coverage per 100K

250 200 150 100 50

Opioid overdose death rate

46% reduction

Walley et al. BMJ 2013; 346: f174.

Fatal opioid OD rates by OEND implementation

Cumulative enrollments per 100k RR ARR* 95% CI Absolute model: No enrollment Ref Ref Ref Low implementation: 1-100 0.93 0.73 0.57-0.91 High implementation: > 100 0.82 0.54 0.39-0.76 * Adjusted Rate Ratios (ARR) All rate ratios adjusted for the city/town population rates of age under 18, male, race/ ethnicity (hispanic, white, black, other), below poverty level, medically supervised inpatient withdrawal treatment, methadone treatment, BSAS-funded buprenorphine treatment, prescriptions to doctor shoppers, and year

Walley et al. BMJ 2013; 346: f174.

Opioid-related ED visits and hospitalization rates by OEND implementation

Cumulative enrollments per 100k RR ARR* 95% CI Absolute model: No enrollment Ref Ref Ref Low implementation: 1-100 1.00 0.93 0.80-1.08 High implementation: > 100 1.06 0.92 0.75-1.13 * Adjusted Rate Ratios (ARR) All rate ratios adjusted for the city/town population rates of age under 18, male, race/ ethnicity (hispanic, white, black, other), below poverty level, medically supervised inpatient withdrawal treatment, methadone treatment, BSAS-funded buprenorphine treatment, prescriptions to doctor shoppers, and year

Walley et al. BMJ 2013; 346: f174.

INPEDE OD Study Summary

• 1. Fatal OD rates were decreased in MA cities-towns

where OEND was implemented - The more enrollment the more benefit

• 2. No clear impact on acute care utilization

Adverse Events: 2006 - 2014

N=4,227 Deaths

45/4177

1% Overdose requiring 3 or more doses

244/3981

6% Recurrent overdose

9/2655

0.3% Difficulty with device

17/2655

0.6% Withdrawal symptoms after naloxone

1022/2141

48% Negative interactions with public safety

268/1385

19% Confiscations

405/11462

4%

Program data

Withdrawal symptoms after naloxone rescue 2010-2014

Community naloxone (n=2141) Police/fire naloxone (n=645) 52% 48% 26% 24% 23% 21% 11% 9% 7% 5% 5% 3% None Irritable/angry "Dope Sick" Vomiting Combative Other Program data – 2008-2014

Other = confused, disoriented, headache, aches and chills, cold, crying, diarrhea, happy, miserable

Do trained rescuers perform differently than untrained rescuers?

Naloxone rescue after training (n=508) Naloxone rescue before training (n=91)

89% 89% 63% 62% 52% 48% 47% 39% 27% 23%

Sternal rub >1 dose given 911 called or Rescue Breathing Stayed with the EMS present victim Doe-Simkins et al. BMC Public Health 2014

Help-seeking (calling 911 or EMS present) by people reporting rescues with MDPH naloxone

46% 42% 37% 37% 34% 32% 26% 2007/8 2009 2010 2011 2012 2013 2014

Program data

Training family members at support group meetings

Bagley et al. Overdose Education and Naloxone Rescue Kits for Family Members of Individuals Who Use Opioids: Characteristics, Motivations, and Naloxone Use. Substance Abuse 2015.

Police and Fire naloxone rescues in MA 2010-2014

Massachusetts DPH First Responder Pilot

8 67 111 160 318

50 100 150 200 250 300 350 2010 2011 2012 2013 2014

Signs

• f

life, but died Dead

• n

arrival Rescue

Rescues and deaths, 2010-2014

Community level impact

• Naloxone kits and overdose prevention education help save lives
• The harms are few
• Training should not be a barrier
• Populations and venues

1. Active users

• Emergency Department*
• Syringe access programs
• Detox programs
• Criminal justice-involved*
• Methadone maintenance
• Pharmacy and primary care*

2. Caregivers and social networks

• Community meetings and support groups
• Primary care providers
• Pharmacy – Behind the counter, over the counter

3. First responders

• Public health-public safety partnership

• Evaluations of Overdose Education and

Naloxone Distribution Programs

Feasibility

• Piper et al. Subst Use Misuse 2008: 43; 858-70.
• Doe-Simkins et al. Am J Public Health 2009: 99: 788-791.
• Enteen et al. J Urban Health 2010:87: 931-41.
• Bennett et al. J Urban Health. 2011: 88; 1020-30.
• Walley et al. JSAT 2013; 44:241-7. (Methadone and detox programs)

Increased knowledge and skills

• Green et al. Addiction 2008: 103;979-89.
• Tobin et al. Int J Drug Policy 2009: 20; 131-6.
• Wagner et al. Int J Drug Policy 2010: 21: 186-93.

No increase in use, increase in drug treatment

• Seal et al. J Urban Health 2005:82:303-11.
• Doe-Simkins et al. BMC Public Health 2014 14:297.

Reduction in

• verdose in

communities

• Maxwell et al. J Addict Dis 2006:25; 89-96.
• Evans et al. Am J Epidemiol 2012; 174: 302-8.
• Walley et al. BMJ 2013; 346: f174.

Cost-effective

$438 (best) $14,000 (worst ) per quality adjusted life year gained

Coffin and Sullivan. Ann Intern

• Med. 2013 Jan 1;158(1):1-9.

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Evaluation Questions Study Design and Data Sources What is the secondary gain from naloxone rescue kits?

• Responder empowerment, social network

dissemination, mitigating law enforcement actions Qualitative studies Social network cohort studies What happens after rescue?

• Connection to treatment, harm reduction services,

re-overdose Observational cohort studies What should happen after rescue?

• Connect to harm reduction and treatment services,

community outreach, “incentivized” treatment Qualitative studies Controlled trials How best to match training to venues and populations?

• Automated, online, in-person, hands on demo

Implementation trials Simulation lab trials Monitoring for adverse events? Surveillance Cohort studies Is naloxone naloxone co-prescribing happening?

• Primary care, addiction treatment, pharmacy

Surveillance Include in PMP?

Thank you – awalley@bu.edu