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Trauma & Injury Prevention

Opioid Overdose Prevention and Response

Elizabeth A. Samuels, MD, MPH
Department of Emergency Medicine
Alpert Medical School of Brown University

Elizabeth SamuelsSince 1990, unintentional drug overdose deaths have more than tripled nationwide1,2 and since 2004, drug related emergency department (ED) visits increased by over 80%. Half of the 5.1 million drug related ED visits in 2011 were associated with drug misuse or abuse, evenly distributed between nonmedical pharmaceutical and illicit drug use.3 Prescription opioid overdose now results in more overdose deaths than heroin, cocaine, and psychostimulants combined, but heroin use is increasing.1,2 One in fifteen people who use prescription opioids will try heroin in their lifetime and more people with histories of opioid prescription misuse or abuse are starting to try heroin (5% in 2004 vs 13% in 2010).4

On the front line of overdose response, the ED offers a tremendous opportunity not only for prevention of opioid overdose and overdose deaths, but also to increase access and referral to addiction treatment. Over 60% of ED visits for substance misuse result in discharge to home, but only 4-11% of patients are referred to a detox or treatment program. Infrequent referral to treatment is due to multiple factors, including poor service availability or decreased treatment access, especially in institutions that do not have or are not connected to specialized addiction treatment services.

RiskFactorsAddiction researchers have demonstrated that overdose events are an important indicator not only of future overdoses, but also represent a critical opportunity for overdose prevention and engagement in treatment; those who have overdosed on heroin are four to five times more likely to suffer a subsequent overdose event, and are at higher risk for death from opioid overdose.5,6 The time period immediately after an overdose also provides a unique window of opportunity, with some population studies showing that 20% of intravenous drug users enroll in a treatment program within 30 days after an overdose,7 far exceeding the rate of treatment enrollment compared to people who have not overdosed.

Increasingly, public health experts have recognized that opioid overdose is not an urban phenomenon limited to nonmedical prescription or illicit opioid use among young people. Opioid overdose is also seen among older patients living in non-urban environments.8 Risk factors of opioid overdose are listed in Table 1.9-11

After an overdose, many, but not all, people are brought to the ED for evaluation and treatment. Naloxone, an opioid antagonist, is the antidote to opioid drug overdose and an effective tool to prevent opioid overdose deaths that has been in use for over forty years. There are more than 50 Overdose Education & Naloxone Distribution (OEND) programs in the United States that provide training to community members in opioid overdose prevention, recognition, and response, combined with community-distributed naloxone.12 OEND programs have been shown to decrease opioid overdose mortality in Massachusetts, New York City, Chicago, and North Carolina and have proven that laypeople, including intravenous drug users, can reliably administer naloxone.13-18 Cost modeling research has demonstrated that these programs are cost effective and safe.19 Researchers studying the effects of OENDs have observed a decline20 or no change in opioid use and other risk behaviors21, 22 as well as a trend toward increased enrollment in treatment.23

Many emergency physicians have worked with first responders to expand naloxone access and EDs in Massachusetts, Rhode Island, Ohio, Colorado, California, and Washington have started providing take-home naloxone rescue kits to patients identified as at risk for opioid overdose.24, 25 Recognizing the lifesaving potential of increased naloxone access, ACEP approved two related resolutions in 2014: to train and equip first responders with naloxone and to expand pharmacy-based naloxone provision and education. The known barriers to ED naloxone distribution include pharmacy regulations, limited insurance reimbursement, provider attitudes, provision of patient education, and limited financial support. This year, ACEP will develop a clinical policy on emergency physician naloxone prescribing26 and this summer, TIPS will host a webinar to help members start naloxone distribution programs in their ED.

For more information about overdose prevention and naloxone overdose rescue education, you can see Prescribe to Prevent www.prescribetoprevent.org. Check out the Provider Resources tab for resources specific to ED naloxone distribution.

_____________________________________
References

  1. Calcaterra S, Glanz J, and Binswanger IA. National Trends in Pharmaceutical Opioid Related Overdose Deaths Compared to other Substance Related Overdose Deaths: 1999-2009. Drug Alcohol Depend. 2013;131(3):263-270.
  2. CDC. Unintentional Drug Poisoning in the United States. July 2010.
  3. Substance Abuse and Mental Health Services Administration, Drug Abuse Warning Network, 2011: National Estimates of Drug-Related Emergency Department Visits. HHS Publication No. (SMA) 13-4760, DAWN Series D-39. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013.
  4. Busch S, Zhang H, McLaughlin S, and Smith R. Abuse of Prescription Pain Medications Risks Heroin Use. Accessed September, 2014 at: http://www.drugabuse.gov/related-topics/trends-statistics/infographics/abuse-prescription-pain-medications-risks-heroin-use. Data from: National Survey on Drug Use and Health (NSDUH), 2010. The data and materials can be found here: http://www.icpsr.umich.edu/icpsrweb/SAMHDA/series/64
  5. Stoove MA, Dietze PM, Jolley D. Overdose deaths following previous nonfatal heroin overdose: record linkage of ambulance attendance and death registry data. Drug Alcohol Rev. 2009;28:347-52.
  6. Darke S, Mills KL, Ross J, Teesson M. Rates and correlates of mortality amongst heroin users: findings from the Australian Treatment Outcome Study (ATOS), 2001-2009. Drug Alcohol Depend. 2011;115:190-5.
  7. Pollini RA, McCall L, Mehta SH, Vlahov D, Strathdee SA. Non-fatal overdose and subsequent drug treatment among injection drug users. Drug Alcohol Depend. 2006;83:104-10.
  8. Green TC, Grau LE, Carver HW, Kinzly M, and Heimer R. 2011. Epidemiologic trends and geopgraphic patterns of fatal opioid intoxications in Connecticut, USA: 1997-2007. Drug Alcohol Depend. June 1; 115(3): 221-228. 
  9. Dunn KM, Saunders KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, et al. Opioid Prescriptions for Chronic Pain and Overdose: A Cohort Study. Ann Intern Med. 2010;152:85-92.
  10. Zedler B, Xie L, Wange L, Joyce A, Vick C, Kariburyo F, Rajan P, Baser O, Murrelle L. Risk Factors for Serious Prescription Opioid-Related Toxicity or Overdose among Vetrans Health Administration Patients. Pain Med 2014; Jun 14. doi: 10.1111/pme.12480. [Epub ahead of print]
  11. Seal KH, Shi Y, Cohen G, Cohen BE, Maguen S, Krebs EE, Neylan TC. Association of mental health disorders with prescription opioids and high-risk opioid use in US veterans of Iraq and Afghanistan. JAMA 2012 Mar 7;307(9):940-7. 
  12. CDC. Community-based opioid overdose prevention programs providing naloxone—United States, 2010. MMWR. 2012;61(06);101-105.
  13. Walley AY, Xuan Z, Hackman HH, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ. 2013;346:f174.
  14. Piper TM, Stancliff S, Rudenstine S, et al. Evaluation of a naloxone distribution and administration program in New York City. Subst Use Misuse. 2008;43:858-870.
  15. Maxwell S, Bigg D, Stanczykiewicz K, et al. Prescribing naloxone to actively injecting heroin users: a program to reduce heroin overdose deaths. J Addict Dis. 2006;25:89-96.
  16. Albert S, Brason FW, Sanford CK, et al. Project Lazarus: community-based overdose prevention in rural North Carolina. Pain Med. 2011;12(Suppl 2):S77-85.
  17. Strang J, Manning V, Mayet S, et al. Overdose training and take-home naloxone for opiate users: prospective cohort study of impact on knowledge and attitudes and subsequent management of overdoses. Addiction. 2008;103:1648-1657.
  18. Green TC, Grau LE, Heimer R. Distinguishing signs of opioid overdose and indication for naloxone: an evaluation of six overdose training and naloxone distribution programs in the United States. Addiction. 2008;103(6):979-989.
  19. Coffin P and Sullivan S. Cost-Effectiveness of Distributing Naloxone to Heroin Users for Lay Overdose Reversal. Ann Intern Med. 2013;158:1-9.
  20. Yokell MA, Green TC, Bowman S, McKenzie M, Rich J. Opioid Overdose Prevention and Naloxone Distribution in Rhode Island. Med Health R I. 2011 August ; 94(8): 240–242.
  21. Maxwell S, Bigg D, Stanczykiewicz K, Carlberg-Racich S. Prescribing naloxone to actively injecting heroin users: a program to reduce heroin overdose deaths. J Addict Dis 2006;25:89-96.
  22. Galea S, Worthington N, Piper TM, Nandi VV, Curtis M, Rosenthal DM. Provision of naloxone to injection drug users as an overdose prevention strategy: early evidence from a pilot study in New York City. Addict Behav 2006;31:907-12.
  23. Galea S, Worthington N, Piper TM, Nandi VV, Curtis M, Rosenthal DM. Provision of naloxone to injection drug users as an overdose prevention strategy: early evidence from a pilot study in New York City. Addict Behav 2006;31:907-12.
  24. Dwyer KH, Walley AY, Sorensen-Alawad A, et al. Opioid education and nasal naloxone rescue kit distribution in the emergency department. Abstract presented at ACEP Scientific Assembly 2013; Sept. 18, 2013; Seattle.
  25. Samuels E. Emergency department naloxone distribution: a Rhode Island Department of Health, recovery community, and emergency department partnership to reduce opioid overdose deaths. RI Med J. 2014;97(10):38-39.
  26. Bedard L, Bukata R, Hoffman J, et al. Naloxone prescriptions by emergency physicians. ACEP Resolution 39(14), 2014.

 

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