Local Service Bulletin 2020-02
DATE ISSUED: NOVEMBER 25, 2020
RECIPIENTS
- All certified, funded, otherwise authorized providers
- Local Governmental Units (LGUs)
APPLICABILITY
This Local Services Bulletin (LSB) is applicable to all certified, funded, or otherwise authorized providers of prevention, treatment, and/or recovery services.
PURPOSE
This LSB outlines the obligation of all providers referenced herein to provide, maintain, and/or administer naloxone to clients, patients, and/or family members and significant others.
SCOPE OF THE PROBLEM
The United States (US) is in the midst of an opioid crisis, with dramatic increases in opioid use, opioid use disorder (OUD), and opioid-related overdose deaths.[1, 2, 3] According to preliminary data from the Centers for Disease Control and Prevention (CDC), after a decrease in drug overdose deaths between 2017 and 2018 in the United States, drug overdose deaths rose between 2018 and 2019 (from approximately 68,000 to approximately 71,000), and opioid-related overdose deaths increased from approximately 47,000 to 50,000. Between 2018 and 2019, preliminary data for New York State (NYS), as a whole, showed a 5% decrease in all drug overdose deaths and a 4% decrease in opioid-related overdose deaths, due to large decreases outside of New York City (NYC), but NYC saw a 4% increase in overdose deaths (from 1,482 to 1,535) and an 8% increase in opioid-related overdose deaths (from 1,155 to 1,243). Counties outside of NYC saw a 10% decrease in all drug overdose deaths (from 2,235 to 2,010) and a 12% decrease in opioid-related overdose deaths (from 1,856 to 1,633) between 2018 and 2019. Statewide, both in NYC and outside of NYC, 81% of all overdose deaths involved opioids.[4] According to the NYC Department of Health and Mental Hygiene (DOHMH), NYC had seen a 3% decrease in opioid overdoses in 2018, after 7 years of increases, though fentanyl-related overdoses continued to increase, with 60% of drug overdoses having evidence of fentanyl in 2018.[5]
Opioid overdose induces respiratory depression that can lead to a low oxygen level and an elevated carbon dioxide level in the blood, and death. In an attempt to expedite treatment and improve outcomes following overdose, naloxone is increasingly being utilized in the community by both emergency personnel and laypersons.[6] Research has shown that providing naloxone kits and minimal amounts of training to laypersons is effective at reducing deaths caused by overdose.[7] NYS agencies have distributed 330,099 naloxone kits from 2016-2018 and there were 11,619 reports of naloxone administration from fire fighters, law enforcement, and community programs for those three years.[8] These kits are cost-effective[9] and safe[10], and naloxone has been shown to have no potential for misuse.[11] A NYC overdose prevention and naloxone administration training program reported an 83% success rate of people who survived when naloxone was administered during a suspected overdose.[12] Since naloxone may be administered by other people using drugs in as many as 83% of cases, many success stories go unheard and unreported.[13]
STAFF TRAINING ON OVERDOSE PREVENTION
All staff working in OASAS certified or otherwise authorized programs shall be trained in opioid overdose prevention and naloxone administration. Training is conducted by Opioid Overdose Prevention Programs (OOPPs). Programs may also utilize the overdose prevention training recorded and posted on the OASAS website here.
PREVENTION AND RECOVERY PROGRAMS
All staff of prevention and recovery services must be trained in the administration of naloxone. Training is conducted by Opioid Overdose Prevention Programs (OOPPs). Service providers may also utilize the overdose prevention training recorded and posted on the OASAS website here.
Prevention providers and recovery-oriented programs, such as Clubhouses and Recovery Centers, must have naloxone available onsite and for any staff working with members of the public in the community. All staff working with members of the public in the community should be provided with a naloxone kit which can be carried on their person during all working hours.
Prevention and recovery settings must have available at least one naloxone kit onsite but should gauge the quantity of naloxone needed onsite based on the individual needs of the program and the clients served. Naloxone kits should be readily and quickly accessible in all areas of program settings where members of the public may be present. For example, staff should not have to change floors or go through any extensive process to access naloxone in an emergency. Programs may have staff carry naloxone on their person while on program premises.
TREATMENT SERVICES
Patient Access to Naloxone:
All providers of treatment services shall make naloxone training and medication available to patients and their family members and/or significant others. Such access can be by providing a prescription or by distributing a kit. However, naloxone kits should be made available onsite for any patients, as well as their family members and/or significant other(s), who are leaving and/or being discharged from the program, who are at increased risk of experiencing or witnessing an overdose, and/or who are unlikely to access naloxone at a pharmacy, even when prescribed to them.
Providing education about the naloxone pharmacy program is encouraged. The NYS Department of Health Naloxone Co-Payment Assistance Program (N-CAP) provides co-payment assistance for individuals with commercial insurance, up to $40.00, at most pharmacies around the state. Naloxone is now available in more than 2,600 pharmacies throughout NYS. Individuals who are themselves at risk for an overdose or their family members or friends may acquire naloxone in these participating pharmacies without a prescription. Additional information about the N-CAP program, including a list of participating pharmacies, can be found here.
Program Access to Naloxone:
All certified, funded and otherwise authorized programs must maintain naloxone onsite in sufficient quantity to administer to patients in the event of suspected overdose. Programs should gauge the quantity of naloxone needed onsite based on the individual needs of their program and clients. ALL program staff must be trained to administer naloxone. The location of the naloxone kits should be readily accessible, such as by visibly posting such information on each floor and/or by other means of educating staff and patients. Kits should be readily and quickly accessible in all patient care areas of programs. Staff should not have to change floors or go through any extensive process to access naloxone in an emergency. Programs may have staff carry naloxone on their person.
Programs with Registered Nurses (RN) and Licensed Practical Nurses (LPN) staff must have a non-patient specific order and protocol, ordered by a physician, nurse practitioner, or physician assistant, for administering opioid-related overdose treatment. LPNs can administer opioid-related overdose treatment as directed by the RN. Direction may be verbal or by written policy and protocol.
Additional information on non-patient-specific orders and protocols can be found on the New York State Education Department Website.
NYS GOOD SAMARITAN LAW
NYS has enacted a “Good Samaritan Law” which provides protections for individuals from certain drug-and-alcohol-possession-related charges and prosecution in the event they seek help for someone during an overdose event. This protection extends to both the individual that is experiencing an overdose and the individual that seeks healthcare (i.e., calls 911) but does not apply to other bystanders. The Good Samaritan Law applies to minors as well as adults and protects against criminal charges related to possession of marijuana (any amount), drug paraphernalia, up to eight ounces of any controlled substance, as well as alcohol possession in the case of individuals under age 21. Individuals should always be encouraged to contact 911 if they think someone is overdosing.[14]
SOURCES OF ADDITIONAL INFORMATION
- OASAS Guidance on Prescribing Naloxone in Addiction Treatment Settings, from the OASAS Chief Medical Officer
- More information about NYS Opioid Overdose Prevention Programs, from the NYS DOH
- Good Samaritan Law: NYS PEN § 220.78
REFERENCES
1 Rose A. Rudd, Puja Seth, Felicita David and Lawrence Scholl. Morbidity and Mortality Weekly Report, Vol. 65, No. 50 & 51 (December 30, 2016), pp. 1445-1452 2 https://www.samhsa.gov/data/report/2017-nsduh-annual-national-report
3 Scholl L, Seth P, Kariisa M, Wilson N, Baldwin G. Drug and Opioid-Involved Overdose Deaths — United States, 2013–2017. MMWR Morb Mortal Wkly Rep 2019;67:1419–1427. 4 https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm 5 https://www1.nyc.gov/assets/doh/downloads/pdf/epi/databrief116.pdf
6 Opioid Overdose Prevention Programs Providing Naloxone to Laypersons - United States, 2014, Wheeler E, Jones TS, Gilbert MK, Davidson PJ, Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep. 2015 Jun 19; 64(23):631-5.
7 Walley A, 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;346:1–12.
8 NYS Heroin and Opioid Task Force Progress Report, November 2019
9 Coffin PO, Sullivan SD. Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal. Ann Intern Med 2013;158:1–9.
10 Doyon S, Aks SE, Schaeffer S. Expanding access to naloxone in the United States. Clin Toxicol (Phila) 2014;52:989–92.
11 Bureau of Justice Assistance Law Enforcement Naloxone Toolkit
12 Evaluation of a Naloxone Distribution and Administration Program in New York City. Tinka Markham Piper, Sharon Stancliff, Sasha Rudenstine, Susan Sherman, Vijay Nandi, Allan Clear, and Sandro Galea. Substance Use & Misuse Vol. 43, Iss. 7,2008.
13 NEW YORK TIMES: Naloxone Saves Lives, but Is No Cure in Heroin Epidemic