OPIOID OVERDOSE: A RHODE ISLAND INJURY PREVENTION PRIORITY AREA

Valerie Strezsak

valerie_m_strezsak@brown.edu

Capstone Project, December 2013

Injury as a Public Health Problem

Rhode Island ranks seventh in the nation for overdose deaths (17.2 deaths per 100,000 persons according to the Centers for Disease Control and Prevention)...

and is one of 20 states where unintentional drug overdose is the leading cause of unintentional injury-related death.

How did this happen, and what is being done to address it?

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OBJECTIVES OF THIS PRESENTATION

Overview of the problem What are opioids? What is an opioid overdose?

Opioid overdose at the national level Scope of the problem Risk factors Development of the epidemic

Opioid overdose in Rhode Island Why opioid overdose is now a priority area Planned approaches to reduce opioid overdose

Future directions

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WHAT ARE OPIOIDS? WHAT DO THEY DO?

Opioids are narcotic pain relievers They bind to specific receptors in the brain,

spinal cord, and gastrointestinal tract Minimize perception of pain Can also trigger other systems such as those that

regulate mood, breathing, and blood pressure

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TYPES OF PRESCRIPTION OPIOIDS

Morphine Codeine Methadone Oxycodone Hydrocodone Fentanyl Hydromorphone Buprenorphine

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HEROIN: A NON-PRESCRIPTION OPIOID

Unlike prescription opioids, there is no legal use for heroin

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HOW DOES OPIOID OVERDOSE OCCUR?

Dosing error By prescriber, pharmacist, patient, caregiver Unintentional in the commonly understood

sense, an “accident” Deliberate misuse

Of own prescription (taking larger and/or more frequent doses than prescribed)

Of opioids obtained illicitly Typically considered unintentional, in that the

individual did not intend to overdose, even though he/she did intentionally use the drug

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WHAT HAPPENED WHEN PERSON OVERDOSES?

SCOPE OF THE PROBLEM

Overdoses killed nearly 15,000 people in the US in 2008, more than 3 times the 4,000 people killed by overdose in 1999

Nonmedical use of prescription painkillers costs health insurers up to $72.5 billion annually in direct health care costs.

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INJURY PYRAMID: DEATH IS THE PROVERBIAL TIP OF THE ICEBERG

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THE VICTIMS MAY NOT BE WHO YOU EXPECT THEM TO BE…

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INDIVIDUAL RISK OF OVERDOSE

Anyone using opioids is at risk of overdose

Increased risk associated with: Misuse of prescription, including combining

opioids with other substances such as alcohol History of substance abuse, dependence Gender: men are much more likely to overdose,

but the rate of overdose among women is increasing

Age: middle-aged adults are at increased risk Living in a rural locale increases risk Race: whites and American Indians/Alaskan

Natives are at the greatest risk

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THERE HAS BEEN A MARKED INCREASE IN OPIOID OVERDOSE IN PAST DECADE+

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IS THE EPIDEMIC AN UNINTENDED CONSEQUENCE OF PAIN MANAGEMENT?

2001 Joint Commission Pain Management Standards called for more attention to and treatment of pain

Increase in opioid overdose deaths coincided with a nearly fourfold increase in use of prescriptions for pain medication

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INCREASE IN OPIOID USE IS CLEAR, ALTHOUGH PREDATES 2001 STANDARDS

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OPIOIDS ARE INHERENTLY RISKY; WHEN MORE PEOPLE RECEIVE PRESCRIPTIONS, MORE PEOPLE WILL OVERDOSE

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OVERLAP OF PRESCRIPTIONS AND OVERDOSE: NOT PERFECT, BUT TRENDS ARE EVIDENT

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OPIOID OVERDOSE IN RHODE ISLAND

Identifies injury prevention priorities

Supports implementation and evaluation of statewide interventions based on population-based recommendations

RHODE ISLAND VIOLENCE AND INJURY PREVENTION PROGRAM (VIPP)

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IN 2011, DRUG OVERDOSE PREVENTION & RESCUE BECAME A VIPP PRIORITY AREA

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INCREASE IN OPIOID OVERDOSE DEATHS DRIVE THE INCREASE IN POISONING DEATHS IN RI

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INCREASE IN RI OVERDOSE DEATHS MIRRORS INCREASE IN US

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GENDER DIFFERENCE IS CLEAR: MORE MEN HAVE DIED OF OPIOID OVERDOSE IN RI

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MOST DEATHS HAVE OCCURRED IN MIDDLE-AGED ADULTS IN RI

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DEATHS ONLY REPRESENT A FRACTION OF THE TOTAL IMPACT OF OPIOID OVERDOSE INJURIES IN RI, AS IN THE US

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VIPP DRUG PREVENTION OVERDOSE AND RESCUE SUBCOMMITTEE

Goal: Prevent death from unintentional drug overdose

Current objective: decrease or maintain rate of death due to unintentional poisonings at 2009 level of 13 per 100,000

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HOW TO ACCOMPLISH GOAL?

Drug Overdose Prevention and Rescue Subcommittee recommends 10 strategies:

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1Establish statewide overdose surveillance

mechanisms.

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2Increase usage and effectiveness of the

Prescription Monitoring Program (PMP).

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3Increase access to naloxone training and distribution programs.

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4Increase licensed healthcare worker and

institutional responsibility.

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5Implement and expand disposal units throughout

the state.

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6Support prevention policies that work.

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7Increase general public awareness of drug

overdose as a preventable public health

problem.

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8Support and affirm people at risk for drug overdose.

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9Increase access to substance abuse

treatment.

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Build state capacity to implement drug overdose

prevention and rescue programs.

Future Directions: How to Choose Interventions?

Lack of evidence at this point; epidemic is still fairly new!

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FEDERAL GOVERNMENT EFFORTS

CDC released several promising recommendations, including establishment and use of Prescription Monitoring Program

Substance Abuse Mental Health Services Administration released the first federal resource promoting safety and prevention information in October 2013

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RHODE ISLAND-SPECIFIC EFFORTS

Rhode Island initiative: pilot study Preventing Overdose and Naloxone Intervention (PONI)

From Discussion of publication:

Continued and improved surveillance and evidence-based methods are underway to reverse the opioid epidemic in RI and the US as a whole

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CITATIONS, BY SLIDE NUMBER 2: http://www.123rf.com/photo_11850338_drug-overdose-concept--

passive-hand-on-floor-pills-and-injection.html; http://www.health.ri.gov/publications/plans/2013InjuryPrevention.pdf

3: http://prescription-drug.addictionblog.org/oxycontin-overdose-how-much-amount-of-oxycontin-to-od/; http://www.health.ri.gov/publications/plans/2013InjuryPrevention.pdf

4: http://imagebing.portrait-photo.net/ocean-drive-newport-rhode/

7: http://atforum.com/news-updates/201104.php

8: http://www.neurosoup.com/heroin/

10: http://harmreduction.org/issues/overdose-prevention/overview/overdose-basics/what-is-an-overdose/

11: http://atforum.com/news/2013/06/the-soaring-cost-of-the-opioid-economy/

12: http://www.cdc.gov/homeandrecreationalsafety/rxbrief/

13: http://www.cdc.gov/vitalsigns/PainkillerOverdoses/index.html

15: http://www.ripha.org/content/ripha/Data_Briefs/Data_Brief_Prescription_Drug_Deaths_12192011_FIN.pdf

16: http://www.va.gov/painmanagement/docs/toolkit.pdf

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CITATIONS, CONTINUED 17: http://dartmed.dartmouth.edu/summer09/html/vs_opioid.php

18: http://jama.jamanetwork.com/article.aspx?articleid=1686609

19: http://www.cdc.gov/vitalsigns/painkilleroverdoses/infographic.html

20: http://www.maripoisoncenter.com/prescription.html

21: http://vaccinenewsdaily.com/medical_countermeasures/326126-health-warns-rhode-islanders-to-beware-of-risk-of-shigella-infection/; http://www.health.ri.gov/publications/plans/2013InjuryPrevention.pdf

22-39: http://www.health.ri.gov/publications/plans/2013InjuryPrevention.pdf

28: http://www.heretohelp.bc.ca/factsheet/dealing-with-alcohol-or-other-drug-overdose-situations

41: http://www.flprobatelitigation.com/2010/11/articles/new-probate-cases/will-and-trust-contests/trustee-guardianship-litigation-no-evidence-reversal-on-all-grounds/

42: http://store.samhsa.gov/product/opioid-overdose-prevention-toolkit/all-new-products/sma13-4742

43: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3177423/

44: http://www.bryandunlop.com/what-we-do/consultative-selling/