Expanded Overdose Prevention Efforts in Michigan With Naloxone Rescue Kits

1. Expanded Overdose Prevention Efforts in Michigan With Naloxone Rescue Kits Steve Alsum The Grand Rapids Red Project steve@redproject.org (616) 456-9063

2. Outline • Introduction • Overdose Epi • Naloxone Distribution: Core Components • Distribution Models • Community Based • Law Enforcement • Pharmacy • Co-Prescription • Naloxone Distribution: Michigan • What’s Next?

3. Intro To Red Project

4. Red Project Basics • A 501c3 non-profit founded in 1998 • Mission: Improve Health, Reduce Risk, Prevent HIV • We utilize a Harm Reduction philosophy • The space in between prevention & treatment • Meeting people where they are at • Providing a range of options • Client centered • Low threshold approach • Pre-recovery supports • Health Issues: HIV, Hepatitis C, and Overdose

5. Red Project Programming • Overdose Prevention • Rapid HIV/Hepatitis C Testing • Risk Reduction Counseling • Syringe Access • HIV Linkage To Care & Case Management • Recovery Coaching/Access To Treatment • Support Groups • Red Project provides comprehensive programming along the continuum of care

6. Overdose Epidemiology

7. these deaths are preventable…

8. Mortality: Michigan

11. The Silver Lining

12. Core Components of Naloxone Distribution

13. Core Components- Physician • Naloxone can be prescribed like any other medication- the issue is physician awareness • PA 311 of 2014 allows prescription to: • Third parties, ie family members, friends, etc • An organization that: • Acts at the direction of a prescriber • Stores the naloxone properly • Dispenses the naloxone under a valid prescription to a patient • Performs requirements without charge or compensation • PA 462 of 2014- Law Enforcement • No matter what model: a physician must be involved at some point in the process

14. Core Components- Training • Why are we here? • To train community health responders • What is an overdose? • Why do people die of overdoses? • What do people overdose on? • Opioids, and the role of naloxone • Overdose risk/prevention • Mixing, tolerance, quality, using alone, etc… • Recognizing an overdose • The line… • Responding to an overdose • S.C.A.R.E. M.E. and the 3 A’s • Naloxone kit assembly/storage/legality

15. Core Components- Naloxone • Naloxone Rescue Kit Options • Intramuscular ($40-75) • Intranasal ($75-105) • Auto-injector ($650-3,000) • Stocking and assembling the kit • Will you do this yourself? • Or work with a pharmacy? • Paying for the kit… • Some options are more affordable than others • Work with your insurance companies- this is cost effective • no longer cost effective at a cost of $4,480/kit- Coffin et al. AIM 2013; 158: 1-9.

16. Naloxone

17. National Models

18. Community Based • Piloted by Chicago Recovery Alliance, Harm Reduction Coalition’s DOPE Project, Massachusetts programs • Typically provided in conjunction with other harm reduction/SUD services: • Syringe access • Methadone maintenance • Detox • Recovery housing • Family Groups • Reach very high risk individuals and their social networks

19. National Model Programming • CDC MMWR, June 18, 2015 • Nationally there were 136 local overdose prevention programs that distribute Naloxone • From 1996-2014 • Trained 152,283 people • 26,463 reported reversals • Multiple Models For Successful Programming • Syringe Access/Harm Reduction-Chicago Recovery Alliance, etc • Point of Prescription/Medical Model-Project Lazarus • State Health Department- Massachusetts, etc • The Take Away: • Finding ways to put tools in hands to save lives…

20. The Chicago Recovery Alliance

21. Law Enforcement Naloxone • Rationale • Law enforcement are first responders • Better serve the public/improve relations • Prevent unnecessary death/potential PTSD • Successfully Modeled In: • MA, IN, NC, NY, RI, VT, CT, etc… • http://www.nchrc.org/law-enforcement/us-law-enforcement-who-carry-naloxone/ • Most successful when people feel comfortable calling 911

22. Pharmacy Access: Collaborative Practice Agreements • Almost over the counter • Through a CPA, pharmacists can issue a naloxone rescue kit, without a preexisting prescription for a patient • CVS and Walgreens have taken the lead, nationally • Plans to expand to most states • Is new legislation necessary in Michigan- we already do this with other medications? • Think flu shots and vaccinations • Benefits…

23. Co-Prescription With Opioids • www.prescribetoprevent.org • A comprehensive online resource to encourage naloxone prescribing • Inclusion Criteria for a Naloxone Rescue Kit • Received emergency medical care involving opioid intoxication or poisoning • Suspected history of substance abuse or nonmedical opioid use • Prescribed methadone or buprenorphine • Higher-dose (>50 mg morphine equivalent/day) opioid prescription

24. Inclusion Criteria, continued • Receiving any opioid prescription for pain plus: • Rotated from one opioid to another because of possible incomplete cross tolerance • Smoking, COPD, emphysema, asthma, sleep apnea, respiratory infection, or other respiratory illness or potential obstruction. • Renal dysfunction, hepatic disease, cardiac illness, HIV/AIDS • Known or suspected concurrent alcohol use • Concurrent benzodiazepine or other sedative prescription • Concurrent antidepressant prescription • Patients who may have difficulty accessing emergency medical services (distance, remoteness) • Voluntary request from patient or caregiver

25. Project Lazarus and Chronic Pain Initiative • Community Engagement • 2008: Wilkes County, NC has 6th highest OD mortality rate in nation • Fatality is caused primarily by prescription opioids • Work with doctors to train individuals receiving opioid prescriptions in how to respond to overdose with Naloxone • OD deaths down 69% between 2009 and 2011 • Less than 1% change in how many residents had a prescription for an opioid pain reliever in Wilkes County • In 2008 82% of OD fatality victims had a prescription from a Wilkes County prescriber, in 2011 this decreased to 0%

26. Project Lazarus

27. North Carolina Medical Board Statement • “The prevention of drug overdoses is consistent with the Board's statutory mission to protect the people of North Carolina.  The Board therefore encourages its licensees to cooperate with programs like Project Lazarus in their efforts to make naloxone available to persons at risk of suffering opioid drug overdose.” 

28. Naloxone Distribution: Michigan

29. GR Area Programming • Clean Works Program- October 2008 • Cherry St Health Methadone Clinic- 2012 • Network 180 and SUD Treatment- 2013 • SA Turning Point, Arbor Circle IOP, Our Hope, Jellema House, Freedom House, Cherry St Health Methadone Clinic, Degage Open Door Women’s Shelter, Network 180 Access Center, etc • Results (as of 6/30/2016) • 3,150 individuals trained which has led to 345+ reported reversals • The Future • Increased collaboration/partnerships • Multiple points of distribution

30. 2016 Expansions • Direct Client Service Delivery • Allegan, Ottawa, Muskegon, lake, Mason, and Oceana counties • Technical Assistance/Program Start-Up • Region 10 PIHP- 4 County Region Flint to Port Huron • SWMBH- Kalamazoo and 8 Counties in SW MI • Lansing and Montcalm Counties • Law Enforcement Training

31. 2016/17 Expansions • Local Task Force Creation • This epidemic is bigger than what the capacity of a few scattered not-for-profits can handle- it requires a community response • Local Law Enforcement Training • Integration into the medical community- co-prescription along with opioids

32. Legal Status In Michigan • Naloxone is an unscheduled prescription medication both nationally and in Michigan • PA 311 – 314 signed into law October 2014 • Allow prescription to anyone • Allows prescription to an organization • Allow administration to anyone • Eliminates potential criminal and civil liability, and professional disciplinary action, for prescribers and end-users • Naloxone is one of the easiest/safest medications to prescribe, we need to make it easier to obtain • Still no Good Samaritan legislation

33. Naloxone In MI: 2016

34. Southwest Michigan

35. Central Michigan

36. Southeast Michigan

37. By The Bay and Thumb

38. Up North

39. Michigan: Law Enforcement • Governor Snyder’s office has endorsed this, and it will be the standard for LE agencies to be equipped • Currently carrying kits (and trained through Red Project): • Hastings PD, Barry Sheriff, Nashville PD, Barrein Sheriff, Berrein Springs-Oronoko PD, Buchanan PD, Coloma PD, Bridgmen PD, Pokagon Tribal PD, Three Oaks PD, Grand beach PD, New Buffalo PD, Niles PD, Michiana PD, Coldwater PD, Branch Sheriff, Bronson PD, Union City PD, Albion PD, Calhoun Sheriff, Battle Creek PD, Marshall PD, Dowgiac PD, Ontwa Township PD, Cass Sheriff, Cassopolis PD, Kalamazoo Sheriff, MSP- Specialty Teams, MSP-Wayland, MSP Post 54, MSP 5th District HQ, MSp-Niles, MSP-Paw Paw, St Joe Sheriff, Three Rivers PD, Centreville PD, Decatur PD, Van Buren Sheriff, Bangor PD, Hartford PD, Covert PD, Oceana Sheriff, Lake Sheriff, Mason Sheriff, Baldwin PD, Hart PD, Ludington PD, Benzie County Sheriff*, Macomb County Sheriff*, etc… • *not trained through Red Project

40. Law Enforcement- Legality • PA 462 makes it legal for law enforcement officers and agencies to purchase, possess, dispense, and administer naloxone • Removes potential civil and criminal liability • To carry, and administer, officers must: • Receive training • Believe someone is experiencing an opioid related overdose

41. The Medical Community • Pharmacy Access • Spartan/Nash Stores (Duthler’s, D&W, Family Fare)- have a CPA operating at three stores in the GR area • Results: • Medical Community/Co-Prescription • The epidemic is primarily among prescription opioid users in Michigan • We need statewide leadership in this area • To be addressed: • Physician awareness/education • Billing • Stocking Naloxone Rescue Kits

42. What’s Next?

43. A statewide epidemic… • Clear and direct leadership from the state • We are at least 10 years into this epidemic… • Legislative change • Broad Good Samaritan protections • Clear Standing Orders • Other access points • Full Integration Into Various System Points • Law Enforcement/Criminal Justice • Medical community, co-prescription and pharmacy access • Substance use, and addressing the trauma

44. What is the point? • Massachusetts provides overdose education and naloxone distribution on a statewide level, supported through their health department • Walley et al. BMJ 2013; 346: f174. found that: • 0 kits per 100,000 people resulted in a 0% change • 1-100 kits/100,000 people resulted in a 27% reduction in community overdose mortality rates • >100 kits/100,000 resulted in a 46% reduction • Decreasing overdose mortality is dependent on increasing naloxone kit distribution

45. Inclusion Criteria: Simplified • Anyone currently using opioids • Individuals using opioids as prescribed • Individuals abusing prescription opioids • Individuals using or abusing other opioids • Anyone with a history of opioid abuse • Relapse can be a part of recovery, and in relapse there is extreme danger of overdose • If an individual is allergic to bee-stings they have an epi-pen: We need to look at naloxone rescue kits in the same way…

46. A common concern addressed… Just because you own one of these… Does not mean you will start one of these…

47. A Special Thanks… • The Chicago Recovery Alliance and Dan Bigg • Network 180/CMH of Ottawa County/Health West/SWMBH/Region 10 PIHP • Our Physicians • Dr Vernon Proctor • Dr Sandra Dettmann • Dr Cara Poland • Our Staff • Our Clients • They do the real work

48. Sources • CDC: Injury Prevention and Control • MDHHS • Kent County Medical Examiner • MAPS • Physicians Desk Reference • CDC MMWR, June 18, 2015-Community-Based Opioid Overdose Prevention Programs Providing Naloxone – United States, 2010 • The Grand Rapids Red Project • Walleyet al. BMJ 2013; 346: f174. • North Carolina Harm Reduction Coalition • Coffin et al. AIM 2013; 158: 1-9.