This Health Advisory highlights the issue of opioid overdose, provides guidance and identifies resources available for helping prevent future overdose among patients who have experienced opioid overdoses. Thus, involvement in opioid overdose prevention helps save lives.
Background:
Drug overdose is a serious public health concern and opioid-related overdose has increased as a health threat. Opioid overdose is characterized by a decrease in breathing rate which can lead to death. Death usually occurs one to three hours after injection, rather than suddenly. Overdose is frequently witnessed by someone who does not recognize the danger or does not want to act on it. In many cases of overdose, opioids are mixed with alcohol or benzodiazepines. Overdose is most common among those who have been using for five to 10 years, rather than in the new user. Other risks include:
- resumption of use after a period of abstinence from opioid use, such as recent release from detoxification, drug treatment or correctional facility;
- use of opioids without others present raises the risk of death if an overdose occurs;
- mixing opioids with other drugs, particularly alcohol or the sedatives;
- injection; and
- serious medical problems such as AIDS and impaired liver function.
Nationally, the rates of unintentional poisoning deaths increased 64 percent from 1999 to 2004 with nearly all attributed to drugs*1. There is growing concern about deaths associated with opioid analgesics (e.g., fentanyl, oxycodone, hydrocodone, morphine and methadone). The Centers for Disease Control and Prevention (CDC) found a 91.2 percent increase of poisonings listed on death certificates from opioid analgesics from 1999 to 2002. During the same period, deaths related to heroin and cocaine increased 12.4 percent and 22.8 percent, respectively*2.
In New York state, in 2007 there were 8,756 opioid-related ED visits that did not result in a hospital admission and 22,001 opioid-related hospital admissions (NYSDOH Bureau of Biometrics and Health Statistics).
What You Can Do:
Educate all patients regarding safe practices associated with the use and home storage of prescription opioids. For patients who have experienced an opioid overdose:
- Recognize opioid overdose as a risk factor for and predictor of future opioid overdose and assess history of overdose on admission.
- Inquire about current and past substance use, including use of heroin and prescription opioids.
- Recommend disposal of any remaining prescription opioids if they were not obtained by a medical prescription;
- Counsel patients about the risk of overdose and how it may be prevented, highlighting the risk of using alone and the risk of using after a period of abstinence (including recent detoxification and/or incarceration). Also be sure to mention that calling 911 when someone is unconscious or not breathing could save their life.
- Recommend substance abuse treatment options (e.g., methadone and buprenorphine maintenance) and provide referrals and assistance to obtain treatment through clinics and physicians who prescribe buprenorphine.
- Recommend substance abuse treatment options, including methadone and buprenorphine maintenance, and provide referrals and assistance to obtain this through clinics and physicians who prescribe Buprenorphine.
- Provide referrals for patients not willing or ready to abstain from substance use, as appropriate, to NYSDOH-approved Harm Reduction/Syringe Exchange Programs; Expanded Syringe Access Program (ESAP) sites; or Syringe Collection and Safe Disposal sites.
- Provide referrals to NYS Department of Health (NYSDOH) approved Opioid Overdose Prevention Programs.
Overview of Available Referral Resources, Programs and Services:
- NYS OASAS oversees the state’s system of chemical dependence services. Services available for patients who have experienced an opioid overdose include counseling, methadone maintenance, buprenorphine treatment and naltrexone treatment.
Opioid Overdose Prevention Programs
In NYS, Opioid Overdose Prevention Programs registered with the NYSDOH train non-medical individuals to reverse potentially fatal overdoses. These trained overdose responders may legally obtain and administer naloxone, an FDA-approved medication that can reverse an overdose (opioid antagonist).
If there are no Opioid Overdose Prevention Programs in your area and you see many high risk patients, consider becoming an Opioid Overdose Prevention Program. A provider that wishes to operate an Opioid Overdose Prevention Program needs to register with the NYSDOH.
Treating Patients with HIV/AIDS - "Substance Use in Patients with HIV/AIDS: HIV Clinical Guidelines for the Primary Care Practitioner," produced by the NYSDOH AIDS Institute Committee for the Care of Substance Users with HIV Infection contains specific guidance for clinicians on overdose prevention. "Substance Use in Patients with HIV/AIDS" (NYSDOH publication #9600).
- Harm Reduction/Syringe Exchange In NYS - Syringe exchange services are provided within a comprehensive harm reduction model. Clients learn about risk reduction measures for themselves and their partners. In addition to provision of clean injection equipment, services include:
- outreach and education on risk reduction practices related to sexual and drug-using behaviors;
- distribution and demonstration of male and female condoms and dental dams;
- distribution and demonstration of bleach kits and safer injection techniques;
- distribution of other harm reduction supplies and literature; and
- provision of supportive services, HIV counseling and testing, partner notification assistance, case management, health care, legal, and housing services.
Programs provide referrals for services if they are unable to provide them directly. Over 158,800 referrals have been made to detoxification and substance use treatment programs, health care services, HIV counseling and testing and social services.
There are currently 17 approved harm reduction/syringe exchange programs in New York state: Twelve in New York City, and one each in Buffalo, Rochester, Ithaca/Binghamton, Mount Vernon and Albany. The AIDS Institute’s Harm Reduction Unit can be reached at (212) 417-4661.
- Syringe Access and Safe Disposal The Expanded Syringe Access Program (ESAP) provides enhanced access to new syringes. Up to 10 syringes may be sold or furnished to persons 18 years of age or older without a prescription by pharmacists, health care facilities, and health care practitioners who have registered with the NYSDOH. As a public health program, ESAP reduces the transmission of blood borne diseases, including HIV and hepatitis B and C.
Questions:
- Questions about Opioid Overdose Prevention Programs may be directed to the NYSDOH AIDS Institute at (212) 417-4770 or by sending an e-mail to [email protected]
- Questions about addiction medicine may be directed to the Addiction Medicine Unit at OASAS. The Addiction Medicine Unit may be reached as follows: E-mail: [email protected]
References
- “Unintentional Poisoning Deaths - United States, 1999-2004,” MMWR, February 9, 2007;56(05);93-96.
- Paulozzi LJ, Budnitz DS, Yongli Xi. “Increasing deaths from opioid analgesics in the United States,” Pharmacoepidemiol Drug Saf. 2006;15:618-627.