SAMHSA Initiatives to Prevent Opioid Overdoses ...

SAMHSA Initiatives to Prevent Opioid Overdoses & Deaths Brandon T. Johnson, Ph.D.(c), M.B.A. LCDR, U.S. Public Health Service Center for Substance Abuse Treatment Substance Abuse Mental Health Services Administration U.S. Department of Health & Human Services

Preventing Opioid Overdoses & Deaths You’ve already heard the grim statistics:

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Preventing Opioid Overdoses & Deaths Many of us are at risk:  Anyone who uses opioids for the treatment of pain

is at some risk for overdose.  Those who use illicit opioids such as heroin are

at even greater risk. Beletsky LB, Rich JD, Walley AY. Prevention of fatal opioid overdose. JAMA. 2013;308(180): 1863‐1864.

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Call to Action  President’s Plan to Address Rx Abuse and Heroin Use

• Prescriber Training • Improving Access to Treatment  Secretary’s Opioid Initiative • Provider Training and Educational Resources • Increasing the use of Naloxone • Expanding the use of Medication‐Assisted Treatment (MAT). 7

Preventing Opioid Overdoses & Deaths However, there is good news!  We now have scientifically proven strategies for

preventing opioid overdose.  And we have the drug naloxone to prevent death

when an overdose occurs. BMJ Evidence Centre. Treatment of opioid overdose with naloxone. British Medical Journal. Updated October 23, 2012.

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Preventing Opioid Overdoses & Deaths So prevention is possible, but only if:  Prescribers, patients and others are aware of and

know how to use proven strategies for preventing opioid overdose.  Paramedics and other first responders have ready

access to naloxone and know how to use it to reverse overdose.

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Preventing Opioid Overdoses & Deaths To share the requisite knowledge, SAMHSA has developed an Opioid Overdose Toolkit to outline each of the critical steps. • The toolkit consists of five separate booklets, each designed for a specific audience. – – – – –

Community members First responders Prescribers Patients Survivors and their families.

Substance Abuse and Mental Health Services Administration (SAMHSA). SAMHSA Opioid Overdose Toolkit: Preventing, Treating, and Surviving Overdose. HHS Publication No. (SMA) 13‐4742. Rockville, MD: SAMHSA, 2013.

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Preventing Opioid Overdoses & Deaths  Booklet 1, Facts for Community Members:

• Educates local governments, community organizations, and private citizens about the risks of opioid overdose. • Helps them develop sound policies and practices to prevent opioid overdoses and deaths. Substance Abuse and Mental Health Services Administration (SAMHSA). SAMHSA Opioid Overdose Toolkit: Facts for Community Members. HHS Publication No. (SMA) 13‐4742. Rockville, MD: SAMHSA, 2013.

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Preventing Opioid Overdoses & Deaths  Booklet 2, Five Essential Steps for First Responders,

describes: • Five steps that should be taken by paramedics, EMS personnel, police, and other helpers when they respond to an opioid overdose. • How to use naloxone and provide other life‐saving assistance. Substance Abuse and Mental Health Services Administration (SAMHSA). SAMHSA Opioid Overdose Toolkit: Five Essential Steps for First Responders. HHS Publication No. (SMA) 13‐4742. Rockville, MD: SAMHSA, 2013.

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Preventing Opioid Overdoses & Deaths  Booklet 3, Information for Prescribers, provides

physicians and other health care professionals with: • Reliable information on how to assess each patient’s risk of opioid overdose. • Clinically sound strategies for educating and monitoring patients to reduce the risk of overdose. Substance Abuse and Mental Health Services Administration (SAMHSA). SAMHSA Opioid Overdose Toolkit: Information for Prescribers. HHS Publication No. (SMA) 13‐4742. Rockville, MD: SAMHSA, 2013.

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Preventing Opioid Overdoses & Deaths  Booklet 4, Safety Advice for Patients, empowers

patients who are prescribed opioids by: • Helping them learn how to use their opioid medications safely so as to minimize the risk of overdose.

Substance Abuse and Mental Health Services Administration (SAMHSA). SAMHSA Opioid Overdose Toolkit: Safety Advice for Patients. HHS Publication No. (SMA) 13‐4742. Rockville, MD: SAMHSA, 2013.

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Preventing Opioid Overdoses & Deaths  Booklet 5, Recovering from Opioid Overdose, assists

overdose survivors and their family members by: • Offering resources to help them recover from the trauma of overdose, provide support to the survivor, and become advocates for prevention.

Substance Abuse and Mental Health Services Administration (SAMHSA). SAMHSA Opioid Overdose Toolkit: Recovering from Opioid Overdose. HHS Publication No. (SMA) 13‐4742. Rockville, MD: SAMHSA, 2013.

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Preventing Opioid Overdoses & Deaths  All five booklets feature clear explanations and

simple strategies that are based on current scientific evidence and clinical experience.  They answer questions such as the following.

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Preventing Opioid Overdoses & Deaths What are opioids? • Opioids are drugs that minimize the body's perception of pain. They do this by binding to specific receptors in the brain, spinal cord and gastrointestinal tract. • As a class, opioids include legal drugs such as morphine, codeine, methadone, oxycodone (Oxycontin, Percodan, Percocet), hydrocodone (Vicodin, Lortab, Norco), fentanyl (Duragesic, Fentora), hydromorphone (Dilaudid, Exalgo), and buprenorphine (Subutex, Suboxone), as well as illegal drugs such as heroin. 17

Preventing Opioid Overdoses & Deaths Why do opioids cause overdose? • Depresses Autonomic Body Systems • Dose Increases • Polysubstance Use

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Preventing Opioid Overdoses & Deaths Who is at risk? • Anyone who uses opioids long‐term for cancer or non‐ cancer pain is at some risk for opioid overdose, as are persons who use heroin. • Persons at elevated risk are those who: – Are being transferred from one opioid medication to another. – Have a history of substance abuse, dependence, or non‐medical use of prescription or illicit opioids. – Recently completed withdrawal from opioids or have not engaged in regular opioid use for a period of time. – Use multiple opioids in combination, or combine their prescribed opioid with use of benzodiazepine tranquilizers, alcohol, or illicit drugs such as heroin. 19

Preventing Opioid Overdoses & Deaths What are the signs of opioid overdose? • Signs of overdose include the following: – The person's face is extremely pale and/or clammy to the touch – The body is limp – Fingernails or lips have a blue or purple cast – The patient is vomiting or making gurgling noises – He or she cannot be awakened from sleep or is unable to speak – Breathing and heartbeat are very slow or stopped. 20

Preventing Opioid Overdoses & Deaths • Signs of overmedication, which can progress to overdose, include: – Unusual sleepiness or drowsiness – Mental confusion, slurred speech, intoxicated behavior – Slow or shallow breathing – Pinpoint pupils – Slow heartbeat and low blood pressure – Difficulty waking the person from sleep.

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Preventing Opioid Overdoses & Deaths • A telltale sign that a person is in a critical state is the “death rattle.” – If a person emits a death rattle — an exhaled breath with a very distinct, labored sound coming from the throat — emergency resuscitation should be performed immediately, as it almost always is a sign that the person is near death.

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Preventing Opioid Overdoses & Deaths How can overdose be prevented? • In the Opioid Overdose Toolkit, SAMHSA describes five broad strategies for preventing opioid overdoses and resulting deaths.

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Preventing Opioid Overdoses & Deaths  STRATEGY 1: Encourage health care professionals,

persons at high risk, family members and others to learn how to prevent and respond to opioid overdose. • Practitioners should be encouraged to update their knowledge of evidence‐based practices for the use of opioid analgesics to manage pain, as well as specific strategies to prevent and manage opioid overdose.

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Preventing Opioid Overdoses & Deaths  STRATEGY 1 (continued):

• To help health care professionals stay up‐to‐date, federally funded CME courses on opioid prescribing are available at no charge at www.OpioidPrescribing.com (five courses funded by SAMHSA) and on MedScape (two courses funded by the National Institute on Drug Abuse).

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• Family members and other laypersons can learn how to prevent and manage overdose from Project Lazarus (http://projectlazarus.org/) or from the Massachusetts Health Promotion Clearinghouse (www.maclearinghouse.org).

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Preventing Opioid Overdoses & Deaths  STRATEGY 2: Ensure access to treatment for

individuals who are misusing or addicted to opioids or who have other substance use disorders. • Effective treatment of substance use disorders can reduce the risk of overdose and help overdose survivors attain a healthier life.

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• Medication‐assisted treatment, as well as counseling and other support services, are provided at SAMHSA‐certified and DEA‐registered opioid treatment programs (OTPs), as well as from physicians who are trained to provide care in office‐based settings with medications such as buprenorphine/naloxone and oral and injectable naltrexone. 28

Preventing Opioid Overdoses & Deaths STRATEGY 2 (continued): • Information on treatment services available in local communities can be obtained from state health departments, state alcohol and drug agencies, or from SAMHSA's website at www.samha.gov.

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Preventing Opioid Overdoses & Deaths  STRATEGY 3: Ensure ready access to naloxone:

• Opioid overdose deaths can be prevented when naloxone is administered in a timely manner. • As an opioid antagonist, naloxone blocks the effects of opioids on the brain and reverses respiratory depression, which usually is the cause of overdose deaths.

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• Naloxone injection has been approved by the U.S. Food and Drug Administration for more than 40 years by emergency medical services (EMS) personnel to reverse opioid overdose and resuscitate persons who otherwise might have died. • Prescribers and first responders should be familiar with the manufacturer's recommendations and local regulations regarding naloxone dosage (especially dosage for children, adolescents, and older adults), as well as naloxone storage and disposal. 31


• Naloxone has no psychoactive effects and thus no potential for abuse. • It also is relatively inexpensive. • Naloxone is supplied in a kit with two syringes.

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• It is important that local EMS personnel and other first responders be trained to care for overdose, and that they are allowed to stock naloxone in their drug kits. • As a safety measure, physicians should consider prescribing naloxone to their patients who are receiving long‐term pain treatment with opioids.

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Preventing Opioid Overdoses & Deaths  STRATEGY 4: Encourage the public to call 911:

• A person who is experiencing opioid overdose needs immediate medical attention. • An essential first step is to get help from someone with medical expertise as quickly as possible. • Therefore, members of the public should be educated to call 911. • All they need to say is, “Someone is not breathing” and give a clear address or description of the location. 34

Preventing Opioid Overdoses & Deaths  STRATEGY 5: Encourage prescribers to use state

Prescription Drug Monitoring Programs (PDMPs): • State Prescription Drug Monitoring Programs (PDMPs) are a key strategy for addressing the misuse and abuse of prescription opioids and thus preventing opioid overdoses and deaths. • Through the PDMP, a prescriber can access a state database to determine whether a patient is filling the prescriptions provided and/or obtaining prescriptions for the same or similar drugs from multiple physicians.

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• While a majority of states now have operational PDMPs, the programs differ from state to state in terms of the exact information collected, how quickly that information is available to physicians, and who may access the data. • Information about the program in a particular state is best obtained directly from the state PDMP or from the board of medicine or pharmacy. 36


• SAMHSA has sponsored a new educational course for prescribers on how to use state PDMPs, which can be accessed at no cost at www.opioidprescribing.com.

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Preventing Opioid Overdoses & Deaths Where is SAMHSA’s Opioid Overdose Toolkit available? • The information outlined here and more can be viewed at or downloaded from SAMHSA's website at www.samhsa.gov. • The toolkit also refers readers to other reliable sources of information, including those offered by the CDC, ONDCP, and private sector organizations. 38

Preventing Opioid Overdoses & Deaths What else is SAMHSA doing to help prevent opioid overdoses and deaths? • Educating prescribers: – SAMHSA has supported 65 in‐person CME courses on safe and effective opioid prescribing, which have reached almost 10,250 practitioners in 38 states. – SAMHSA has supported development of online CME courses at www.OpioidPrescribing.com. To date, the online courses have been completed by more than 64,063 health care professionals since 2011. – The courses are provided at no cost because of SAMHSA’s support. 39

Prescription Opioid Overdose & Deaths

Feedback from CME live training attendees

(continued on next page)

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Preventing Opioid Overdoses & Deaths What else is SAMHSA doing (continued)? • Providing health care professionals with Practice Guidelines: – A Treatment Improvement Protocol (TIP)on Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders (published November 2013). – A guidance document entitled Clinical Use of Extended‐ Release Naltrexone in the Treatment of Opioid Use Disorder: A Brief Guide (published 2014). – A curriculum focusing on Naloxone Education Best Practices (to be released 2016)

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Preventing Opioid Overdoses & Deaths What else is SAMHSA doing (continued)? • SAMHSA assisted with development and distribution of the third edition of a handbook on Responsible Opioid Prescribing, published in 2014 and endorsed by the Federation of State Medical Boards. • SAMHSA is updating the Opioid Overdose Toolkit to include new formulations of Naloxone • SAMHSA is developing a Spanish language version of the Toolkit and a new module for pharmacists. 42

Preventing Opioid Overdoses & Deaths What else is SAMHSA doing (continued)? • Physician Clinical Support System for Opioids: Through this system for mentoring and education, opioid prescribers can: – Connect by email or phone with experts on opioid prescribing. – Obtaining mentoring at no cost.

• In 2012, the program was expanded to include dentists and oral surgeons. • The program can be accessed at www.pcss‐o.com. 43

Preventing Opioid Overdoses & Deaths How can physicians and other interested parties access these SAMHSA resources? • Simply go to www.samhsa.gov to access available resources, and for announcements as new resources become available.

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Questions?  Contact Information:

Brandon Johnson, Ph.D.(c),M.B.A. Phone: (240) 276‐2889 Email: [email protected]

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