preventing overdose deaths through client … overdose deaths through client education and naloxone...

1Preventing Overdose Deaths Through Client Education and Naloxone Distribution: Toolkit for Substance Use Disorder Treatment Programs

Preventing Overdose Deaths Through Client Education and Naloxone Distribution:Toolkit for Substance Use Disorder Treatment Programs

Introduction...............................................................................................................................................3

Implementing an overdose education and naloxone program can prevent overdose deaths..............................................................................................................4

The facts about naloxone......................................................................................................................5

SUD treatment programs can help prevent overdose deaths..................................................6

Billing for naloxone.................................................................................................................................8

Prescribing naloxone..............................................................................................................................9

How to talk to clients about naloxone..............................................................................................10

Legal protections for overdose education programs..................................................................11

Contact list.................................................................................................................................................12

Other resources.......................................................................................................................................12

Appendices................................................................................................................................................13

Endnotes.....................................................................................................................................................13

References.................................................................................................................................................14

Table of Contents


In 2013 the rate of overdose deaths in Baltimore City was 39.5 per 100,000 people—more than three times that of New York City.2,3 With an estimated 19,000 active heroin users in Baltimore and far more who misuse prescription opioid medications, the city cannot be healthy without reducing opioid addiction and overdoses.

Opioid overdose deaths are preventable. When people know how to respond to an overdose and are equipped with naloxone—the lifesaving drug that reverses the effect of an opioid overdose—overdose deaths in the community decrease.4,5

Substance use disorder (SUD) treatment providers can be powerful agents of change in reducing overdose deaths.

Introduction

Approximately 80% of people who die of overdose in Baltimore City have received substance use disorder treatment.6 Moreover, people who relapse during or after SUD treatment are at a higher risk for overdose. Integrating overdose education and naloxone distribution (OEND) into SUD treatment programs provides a critical opportunity to make naloxone more readily available in high-risk communities and decrease overdose deaths.

This toolkit can help SUD treatment providers implement OEND by providing key information and resources. Behavioral Health System Baltimore (BHSB) is available to provide technical assistance and other resources to assist providers with starting OEND.

Drug overdose is the leading cause of accidental death in the United States.1 And Baltimore City is facing an opioid overdoseepidemic.


Research shows it works!

Overdose education and naloxone distribution programs:

Implementing an overdose education and naloxone program can prevent overdose deaths

Expansion of overdose education and naloxone distribution to reduce overdose deaths has been recommended by (partial list):

• The World Health Organization21

• Office of the National Drug Control Policy (ONDCP)22

• Substance Abuse and Mental Health Services Administration (SAMHSA)23

• American Society of Addiction Medicine24

• Maryland Department of Health and Mental Hygiene Behavioral Health Administration

• Governor Hogan’s Heroin and Opioid Emergency Taskforce25

• Mayor Stephanie Rawlings-Blake’s Heroin Taskforce26

Are feasible7,8,9,10,11,12

Are successful in increasing skills and knowledge to prevent overdose deaths13, 14, 15, 16

Reduce overdose deaths19, 20

Do not encourage drug use18

Increase admission into SUD treatment17

4


NARCAN

NARCAN

OPIOID RECEPTOR ON BRAIN

OPIOIDS

The facts about naloxone (also known as Narcan®)

Naloxone:

Narcan Reversing an Overdose

Narcan has a stronger affinity to opioid receptors than opioids like heroin or Percocet, so it knocks the opioids off the receptors for a short time. This allows the person to breathe again and reverses the overdose.

Reverses opioid overdose by restoring breathing

Has no effect on someone who has not taken opioids

Wears off in 30 to 90 minutes

Can be safely administered by laypersons via intramuscular or intranasal routes

May cause mild withdrawal symptoms27

Carries no potential for abuse or getting high

Has minimal and rare side effects

1

2

3

4

5

6

7


SUD treatment programs can help prevent overdose deaths

SUD treatment programs can play an important role in reducing overdose deaths. Based on experience in Baltimore and across the United States, BHSB recommends that all SUD treatment programs incorporate the following components into their programs:

Prescribe naloxone to all clients

• By prescribing to all clients, we reduce the stigma of identifying someone who has a “higher risk” for overdose.

• Prescribing can be done at initial intake or after orientation. Many programs have made this part of a client’s treatment plan and periodically check in to ensure clients still have their naloxone kit.

Directly dispense naloxone to all clients

• A naloxone prescription alone cannot save a life! An assessment of several Baltimore programs has shown that less than 10% of people who are prescribed naloxone actually get their prescription filled. By working with your local pharmacy, you can ensure that clients are not only prescribed naloxone but receive the kit.

• Some housing programs prohibit residents from having any medication in their possession, including naloxone. If this is a barrier for your clients, consider addressing these policies, both in-house and with partner agencies. BHSB can assist your program with making these changes.

Create an on-site overdose prevention plan

• There is always the chance that a client experiences an overdose in or around a treatment facility. Programs should have an operating procedure for overdose prevention, recognition, and response. Please see the appendix for a sample policy.

• All treatment staff should be trained to recognize the signs of an overdose and how to administer naloxone to save a life. This includes doctors, nurses, counselors, maintenance staff, peer educators, and volunteers.

BHSB can provide the following support:

• Training staff to respond to overdose

• Training staff to educate clients about overdose prevention

• Training staff to integrate training into routine clinical care

• Working with pharmacies to negotiate on-site deliveries

>


Other opportunities to discuss overdose with your clients:

• Waitlists

• Intake assessment

• Trauma screening

• Induction or orientation phase

• Individual or group counseling

• Group counseling

• Routinely upon positive drug screen results

• At discharge

• When client overdoses

• International Overdose Awareness Day (August 31– the day before Recovery Month)

Case study: Opportunities to Discuss Overdose

At the Center for Addiction Medicine (CAM) at the University of Maryland, Midtown Campus, every new admission to either long-term maintenance or short-term medically supervised withdrawal is offered naloxone training and a prescription. In addition, every patient is annually offered training and a refill prescription. Documentation of the prescription is entered into the electronic record.

For maintenance patients, a counselor gives the training along with pre- and post-test education (sample available in appendix). Detox patients are trained by the medication nurse.

Once the patient is trained in using naloxone, the front office staff faxes a prescription to the Mt. Vernon Pharmacy. The pharmacy delivers the medication to CAM the following business day. The medication is then given to the patient by the nurse, with the front office tracking the process. The pharmacy bills the patient’s insurance.


Billing for naloxone

Maryland Medicaid• Maryland Medicaid will reimburse for intramuscular and

intranasal kits without pre-authorization.

• There is a $1 copay for generic naloxone, however pharmacies may not deny the medication to patients who cannot afford the copay (COMAR 10.09.03.03 (M)).

• Intranasal naloxone kits require atomizers, which may cost extra.

• The EVZIO Auto Injector, which is significantly more expensive, requires pre-authorization. This type may be appropriate for people with limited motor skills or other disabilities. See the appendix for the pre-authorization sample form.

Medicare• Medicare Advantage and Medicare Part D plans in

Baltimore City all cover naloxone. A few also cover EVZIO.

• Costs for copays range between $2 and $47 depending on the plan’s prescription deductible and whether a Medicare preferred pharmacy is used.

Private Insurance• Naloxone is covered by some private insurance, but cost

may vary depending on the insurance plan.

The cost of take-home naloxone should not be a prohibitive factor. If you can’t afford your copay, BHSB may be able to help your program access naloxone in other ways.

>


Prescribing naloxone

Naloxone can be dispensed in four ways. The information below identifies the type of naloxone and kit components. Please see the appendix for a comprehensive naloxone product chart.

Other information about providing naloxone• To directly dispense naloxone to clients, many providers use pharmacy delivery. Work with

your local pharmacy to establish this.

• Not all community pharmacies stock naloxone routinely but they can order it.

• If you are caring for a large population of patients who are likely to benefit from naloxone, you may wish to notify the pharmacy when you implement naloxone prescribing as a routine practice.

• If you are interested in purchasing canvas bags, atomizers, safety masks, or other materials, go to 1800safety2.com.

Nasal Narcan:NARCAN Nasal Spray (4mg of naloxone hydrochloride in 0.1mL)

Directions: spray into one nostril. May repeat x1, if no response after 3 minutes.

Intranasal: Naloxone (2 mg/2mL) single dose Luer-Lock prefilled syringe. Qty = 2 syringesDispense with intranasal mucosal atomizer device.

Directions: spray one-half of syringe (1ml) into each nostril upon signs of opioid overdose. May repeat ×1, if no response after 3 minutes.

Intramuscular:Naloxone 0.4mg/ml single dose vial and 3cc, 23g, 1 inch syringes. Qty = 2 vials

Directions: Inject 1mL in shoulder or thigh. May repeat x1, if no response after 3 minutes.

Auto-injector:EVZIO auto-injectors (Naloxone 0.4 mg)

Directions: Use as instructed by device. May repeat x1, if no response after 3 minutes.

1

2

3

4

Please see the appendix for:

Sample release formSample prescribing and dispensing protocol

>


While the discussion can be difficult, overdose education can be a powerful tool to engage clients in conversation about drug use and behavior change.

Here are a few tips for talking to your client about overdose:

Focus on safety and reducing the risk of overdose • This sends the message that your priority is the client’s

survival, even during a relapse

• Use words such as avoidable, preventable, survivable

• Emphasize that you talk to everyone about overdose prevention

Acknowledge trauma of experiencing and witnessing overdose

• Discussing overdose can play a powerful role in therapeutic engagement

Emphasize clients’ ability to contribute to their community

• They are a potential life saver in an overdose situation

• They can be responders, not just victims

How to talk to clients about naloxone

Photo Credit: Martindale Pharma


Naloxone is not a controlled substance, and state laws encourage naloxone prescribing. Licensed health care providers, including physicians and advance practice nurses (APNs) with prescribing authority may prescribe naloxone to their patients as well as their caregivers, family members, and friends (third party prescriptions).

Provider Protections and Liability

In 2015, the Maryland General Assembly passed legislation to strengthen legal protections for health care providers who prescribe and dispense naloxone.28

• Physicians, APNs, and pharmacists are protected from civil suits when prescribing or dispensing naloxone and paraphernalia in good faith to their patients.

• Although third party prescriptions are not typically covered by malpractice insurance, providers now have independent legal protection against lawsuits when they prescribe or dispense naloxone.

Good Samaritan Law

The 2015 Maryland General Assembly also amended the “Good Samaritan” law to provide immunity for people who call 911 to report an overdose. Under the new law, a person who reports an overdose cannot be arrested, charged, or prosecuted for possession of a controlled dangerous substance, possession or use of drug paraphernalia, or providing alcohol to minors. Calling 911 will also not affect a person’s parole or probation status.29

Legal protections for overdose education programs


Behavioral Health System BaltimoreNatanya Robinowitz, MSPH, Harm Reduction [email protected] 410-637-1900

The following programs successfully implemented OEND. They can be a resource for you.

Institute for Behavior Resources (IBR)-REACHContact Molly Greenberg, Health Home Director, Nurse Care [email protected] Center for Addiction MedicineContact Marian Currens, nurse [email protected]

Health Care for the Homeless Contact Katie League, Director of Community [email protected]

Other Resources

Crisis information and referral line: Baltimore City’s 24/7 hotline offering crisis assistance, information about substance use or mental health issues, treatment referrals, and other assistance. 410-433-5175

Dontdie.org: Access the electronic version of this toolkit. Download all forms from the appendix. Learn about other overdose prevention work being done in Baltimore City.

Maryland Crisis Hotline: Links to a network of crisis hotlines throughout the state: 1-800-422-0009

Prescribetoprevent.org: This is a comprehensive resource on integrating naloxone prescribing into your program. Includes patient education videos, fact sheets, prescribing information, and other materials.

Contact list


Visit the BHSB website for the following materials:

• Pharmacy delivery form

• Educational materials

• How to respond

• How to assemble naloxone (intransal, intramuscular, auto-injector)

• Preventing overdose

• Sample agency policies for on-site overdose response

• Form for critical incidents

• Opioid overdose prevention and related trauma: incorporating overdose prevention, response, and experience into substance use disorder treatment

• Naloxone product chart

Appendices

(1) Warner, Chen, Makuc, Anderson, & Miniño, 2011 (2) “Drug- and Alcohol-Related Intoxication Deaths in Maryland, 2014,” 2014 (3) New York City Department of Health and Mental Hygiene, 2014 (4) Walley, Xuan, et al., 2013 (5) “Drug- and Alcohol-Related Intoxication Deaths in Maryland, 2014,” 2014 (6) Baltimore City Health Department SMART data (7) Behar, Santos, Wheeler, Rowe, & Coffin, 2015 (8) (Bennett, Bell, Tomedi, Hulsey, & Kral, 2011 (9) Doe-Simkins, Walley, Epstein, & Moyer, 2009 (10) Enteen et al., 2010 (11) Walley, Doe-Simkins, et al., 2013 (12) Walley, Xuan, et al., 2013 (13) Green, Heimer, & Grau, 2008 (14) Mueller, Walley, Calcaterra, Glanz, & Binswanger, 2015 (15) Tobin, Sherman, Beilenson, Welsh, & Latkin, 2009 (16) Wagner et al., 2010 (17) Doe-Simkins et al., 2014 (18) Seal et al., 2005 (19) Maxwell, Bigg, Stanczykiewicz, & Carlberg-Racich, 2006 (20) Maxwell et al., 2006 (21) WHO, 2014 (22) https://www.whitehouse.gov/ondcp/national-drug-control-strategy (23) SAMHSA, 2015 (24) http://www.asam.org/docs/default-source/publicy-policy-statements/1naloxone-rev-8-14.pdf?sfvrsn=0 (25) “Heroin and Opioid Emergency Taskforce,” 2015 (26) “Baltimore Mayor’s Heroin Treatment & Prevention Task Force Report,” 2015 (27) Enteen et al., 2010 (28) Chapter 356 (SB516, 2015) –“Public Health –Overdose Response Program” Effective October 1, 2015 (29) Chater 375 (SB654, 2015)—Criminal Procedure –Immunity – Alcohol – or Drug-Related Medical Emergencies, Effective October 1, 2015

Endnotes

http://www.bhsbaltimore.org/policy-advocacy/overdose-prevention/overdose-prevention-toolkit-sud-treatment-programs/


Baltimore Mayor’s Heroin Treatment & Prevention Task Force Report. (2015). Retrieved December 14, 2015, from http://health.baltimorecity.gov/sites/default/files/Task force report_071015_Full.pdf

Barton, E. D., Colwell, C. B., Wolfe, T., Fosnocht, D., Gravitz, C., Bryan, T., … Bailey, J. (2005). Efficacy of intranasal naloxone as a needleless alternative for treatment of opioid overdose in the prehospital setting. The Journal of Emergency Medicine, 29(3), 265–271. doi:10.1016/j.jemermed.2005.03.007

Behar, E., Santos, G.-M., Wheeler, E., Rowe, C., & Coffin, P. O. (2015). Brief overdose education is sufficient for naloxone distribution to opioid users. Drug and Alcohol Dependence, 148, 209–12. doi:10.1016/j.drugalcdep.2014.12.009

Bennett, A. S., Bell, A., Tomedi, L., Hulsey, E. G., & Kral, A. H. (2011). Characteristics of an overdose prevention, response, and naloxone distribution program in Pittsburgh and Allegheny County, Pennsylvania. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 88(6), 1020–30. doi:10.1007/s11524-011-9600-7

Doe-Simkins, M., Quinn, E., Xuan, Z., Sorensen-Alawad, A., Hackman, H., Ozonoff, A., & Walley, A. Y. (2014). Overdose rescues by trained and untrained participants and change in opioid use among substance-using participants in overdose education and naloxone distribution programs: a retrospective cohort study. BMC Public Health, 14, 297. doi:10.1186/1471-2458-14-297

Doe-Simkins, M., Walley, A. Y., Epstein, A., & Moyer, P. (2009). Saved by the nose: bystander-administered intranasal naloxone hydrochloride for opioid overdose. American Journal of Public Health, 99(5), 788–91. doi:10.2105/AJPH.2008.146647

Enteen, L., Bauer, J., McLean, R., Wheeler, E., Huriaux, E., Kral, A. H., & Bamberger, J. D. (2010). Overdose prevention and naloxone prescription for opioid users in San Francisco. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 87(6), 931–41. doi:10.1007/s11524-010-9495-8

Green, T. C., Heimer, R., & Grau, L. E. (2008). Distinguishing signs of opioid overdose and indication for naloxone: an evaluation of six overdose training and naloxone distribution programs in the United States. Addiction (Abingdon, England), 103(6), 979–89. doi:10.1111/j.1360-0443.2008.02182.x

Heroin and Opioid Emergency Taskforce. (2015). Retrieved December 14, 2015, from https://governor.maryland.gov/ltgovernor/wp-content/uploads/sites/2/2015/12/Heroin-Opioid-Emergency-Task-Force-Final-Report.pdf

Kerr, D., Kelly, A.-M., Dietze, P., Jolley, D., & Barger, B. (2009). Randomized controlled trial comparing the effectiveness and safety of intranasal and intramuscular naloxone for the treatment of suspected heroin overdose. Addiction (Abingdon, England), 104(12), 2067–74. doi:10.1111/j.1360-0443.2009.02724.x

Maxwell, S., Bigg, D., Stanczykiewicz, K., & Carlberg-Racich, S. (2006). Prescribing naloxone to actively injecting heroin users: a program to reduce heroin overdose deaths. Journal of Addictive Diseases, 25(3), 89–96. doi:10.1300/J069v25n03_11

Mueller, S. R., Walley, A. Y., Calcaterra, S. L., Glanz, J. M., & Binswanger, I. A. (2015). A Review of Opioid Overdose Prevention and Naloxone Prescribing: Implications for Translating Community Programming Into Clinical Practice. Substance Abuse, 36(2), 240–53. doi:10.1080/08897077.2015.1010032

SAMHSA. (2015). Federal Guidelines for Opioid Treatment Programs|SAMHSA. Retrieved from http://store.samhsa.gov/product/Federal-Guidelines-for-Opioid-Treatment-Programs/PEP15-FEDGUIDEOTP

Seal, K. H., Thawley, R., Gee, L., Bamberger, J., Kral, A. H., Ciccarone, D., … Edlin, B. R. (2005). Naloxone distribution and cardiopulmonary resuscitation training for injection drug users to prevent heroin overdose death: a pilot intervention study. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 82(2), 303–11. doi:10.1093/jurban/jti053

Tobin, K. E., Sherman, S. G., Beilenson, P., Welsh, C., & Latkin, C. A. (2009). Evaluation of the Staying Alive programme: training injection drug users to properly administer naloxone and save lives. The International Journal on Drug Policy, 20(2), 131–6. doi:10.1016/j.drugpo.2008.03.002

Wagner, K. D., Valente, T. W., Casanova, M., Partovi, S. M., Mendenhall, B. M., Hundley, J. H., … Unger, J. B. (2010). Evaluation of an overdose prevention and response training programme for injection drug users in the Skid Row area of Los Angeles, CA. The International Journal on Drug Policy, 21(3), 186–93. doi:10.1016/j.drugpo.2009.01.003

Walley, A. Y., Doe-Simkins, M., Quinn, E., Pierce, C., Xuan, Z., & Ozonoff, A. (2013). Opioid overdose prevention with intranasal naloxone among people who take methadone. Journal of Substance Abuse Treatment, 44(2), 241–7. doi:10.1016/j.jsat.2012.07.004

Walley, A. Y., Xuan, Z., Hackman, H. H., Quinn, E., Doe-Simkins, M., Sorensen-Alawad, A., … Ozonoff, A. (2013b). Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ (Clinical Research Ed.), 346(jan30_5), f174. doi:10.1136/bmj.f174

WHO. (2014). Community management of opioid overdose. doi:10.1007/SpringerReference_44514

References

preventing overdose deaths through client … overdose deaths through client education and naloxone...

Documents