Naloxone laws to reduce overdose - update

Back by popular demand is the map of U.S. states with legislation improving lay naloxone access. This post was delayed by a very active legislative season which I think has slowed down for the moment. As usual, this may have errors so please comment and I'll correct. 

This time I've only included states on the map (in black) with existing legislation improving lay naloxone access (e.g. not Oklahoma and Ohio as those bills target first responder access to naloxone, and not pending legislation that improves access in states - like California - that already have it). There are now lay naloxone access laws in CA, CO, CT, IL, KY, MA, MD, NJ, NC, NM, NY, OR, RI, VA, VT, WA, and the District of Columbia.

Unsuccessful bills this season included Maine and West Virginia.


Here's a summary from the Network for Public Health Law of naloxone (and Good Samaritan) laws that is kept regularly updated.

PubMed Update June 2013

13 new papers this month, from drug development to naloxone programming, epidemiology to practice management, toxicology to supply side drug control.

1) Illicit drug overdose - Prevalence and acute management.

Li W, Gunja N.

Aust Fam Physician. 2013 Jul;42(7):481-5.

Comment: Unable to access.  Appears to be a general review of managing illicit drug toxicities.

2) Development and implementation of an opioid overdose prevention and response program in Toronto, Ontario.

Leece PN, Hopkins S, Marshall C, Orkin A, Gassanov MA, Shahin RM.

Can J Public Health. 2013 Apr 18;104(3):e200-4.

Comment: Unable to access. There have been several papers describing the initial experience of naloxone programs and this is a welcome addition to that literature.

3) Vital signs: overdoses of prescription opioid pain relievers and other drugs among women - United States, 1999-2010.

Centers for Disease Control and Prevention (CDC).

MMWR Morb Mortal Wkly Rep. 2013 Jul 5;62(26):537-42.

Comment: A review of drug overdose mortality data among women, demonstrating that women have been particularly affected by the recent epidemic.

4) Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal in Russian cities.

Coffin PO, Sullivan SD.

J Med Econ. 2013 Jun 19. [Epub ahead of print]

Comments: An adaptation of the model developed for the United States, taking into account structural differences, epidemiologic data, and costs in Russia. Because of limitations in emergency medical services in Russia, the high rate at which overdoses are witnessed, and the very low costs of naloxone, this intervention is likely to be even more cost-effective in Russia than it appears to be in the United States.

New site NaloxoneInfo.org is chockablock with overdose prevention resources

Interested in learning more about opioid overdose and how to build prevention projects? The recently launched NaloxoneInfo.org site is worth a look. Made live during the International Harm Reduction Conference in June 2013, the site was developed by the Open Society Foundations in collaboration with Population Services International, Harm Reduction International, the Eurasian Harm Reduction Network, the Scottish Drugs Forum, Harm Reduction Coalition, and the Asian Network of People Who Use Drugs. 

The site is currently available in English and Russian and includes background information on overdose by region, a number of useful case studies, and tons of freely downloadable program, training, and advocacy materials that should help anyone starting a project. 

New Film: "Reach for Me: Fighting to End America's Drug Overdose Epidemic"

I posted on OPA recently with a preview cut, and I'm very happy to say that we've now launched the final version of our film Reach for Me: Fighting to End America's Drug Overdose Epidemic and our accompanying website. The film  looks at how naloxone pricing, production shortages, and the lack of government support are affecting overdose prevention efforts around the United States. 

We interviewed 30 people, including a number of regular OPA contributors, representing California, Colorado, Connecticut, DC, Louisiana, Michican, Minnesota, New York, North Carolina, Oregon, Wisconsin and more. In addition to the full length (but still just 15 min!) film, we're posting everyone's complete interviews, as well as, soon, a 3 minute version.  

The goal is to use the film as a platform for education and advocacy in order to push for universal access to opioid overdose prevention education and take-home naloxone for those who need it. To that end, over coming weeks on the website we'll be rolling out more advocacy tools and a petition aimed at U.S. federal funding. 

The film was produced by Sawbuck Productions, a Chicago-based nonprofit documentary film company that works on issues related to harm reduction, and which is headed up by Greg Scott & Erin Scott. Eliza Wheeler of HRC and the DOPE Project also contributed magnificently, and Nigel Brunsdon of the UK-based Injecting Advice and HIT did the website. The Open Society Foundations generously contributed to production and distribution costs.  

Help us spread the word further by liking our Facebook page (www.facebook.com/reach4me) and following us on Twitter (@reach4us). We especially want to build awareness outside the harm reduction community.  

For those of you in the U.S., if you'd like a copy on DVD, please follow this link. We'd also be happy to arrange local screenings and discussion -- please be in touch through the contact link on the reach4me.org site if you'd like to do so.

Preview Cut Now Available: "Reach for Me: Fighting to End the American Drug Overdose Epidemic"

Late last year we posted about seeking people to interview for a short documentary film about access to naloxone in the United States. The results are now available in a preview (aka not-quite-final-but-almost) cut of Reach for Me: Fighting to End the American Drug Overdose Epidemic.  Please have a look and tell us what you think! 

The film explores the interconnected issues of naloxone pricing and production shortages, public funding support (or more often lack thereof), and other factors affecting access to overdose prevention tools. It features interviews with leading experts and advocates from around the country, including California, Minnesota, New York, North Carolina, Oregon, Washington, DC, and Wisconsin. 


The point, for us, is to use Reach for Me as a platform for building awareness, understanding, and support for overdose prevention programs. To that end, over the next couple weeks we'll be rolling out the final version of the film, a short (c. 3 minute) version, along with a website and Facebook and Twitter pages. The film will be freely available on DVD (follow this link to request up to 20 copies) and online for streaming or download. We'll also be making available the full interviews with the nearly 30 people who participated. Stay tuned!

Elizabeth Owens of VOCAL New York
in a scene from Reach for Me

The film was directed by Greg Scott, and produced by Matt Curtis and Erin Scott, with an assist from Eliza Wheeler, and was produced under the aegis of Sawbuck Productions. We'd like to thank everyone involved, and especially the Open Society Foundations for their financial support and the Harm Reduction Coalition for allowing us to film during their excellent biennial conference. 

Chicago Recovery Alliance and Gateway Foundation 

Begin Opioid OD Prevention in Cook County Jail

On Tuesday June 11, 2013, Ashley Tsang (a UChicago Medical Student and Schweitzer Fellow) and Dan Bigg, CRA's Director met with Mike Colombatto, PsyD Program Administrator at Gateway Foundation's Treatment System at Cook County Jail regarding integrating opioid overdose at the Jail.  Ashley concluded from research that non-dependent opioid users leaving corrections had over 100 times the risk of death through overdose as ordinary citizens.

A quick meeting of the minds was had and Ashley and Dan began trainings at Cook County Jail's Gateway Treatment System's two programs (Day Treatment and Pre-Release residential settings).

The OD trainings on June 13 and 14, 2013 were very well received showing the majority of individuals there had been around opioid overdose and nearly a third had been around a fatal such OD.

Plans are to continue these trainings and improve the process of making OD preventative options readily available to all tolerance-lessened individuals and those around opioid users under IL's OD Program law (20 ILCS 301/5-23) which allows lay persons to become OD Responders and carry and use naloxone via injection.

We are delighted with this life affirming progress in Chicago and thank our colleagues in Pittsburgh, Rhode Island, and San Francisco among others for their guidance and other assistance with this effort.

PubMed Update May 2013

Here is the May 2013 roundup with 7 papers and some extra kudos to the authors for important steps forward in data or practice.

1) Ethanol Reversal of Cellular Tolerance to Morphine in Rat Locus Coeruleus Neurons.

Llorente J, Withey S, Rivero G, Cunningham M, Cooke A, Saxena K, McPherson J, Oldfield S, Dewey W, Bailey C, Kelly E, Henderson G.

Mol Pharmacol. 2013 May 28. [Epub ahead of print]

Comments: Intriguing analysis of ethanol and morphine, suggesting that alcohol may enhance the effects of morphine. Could this account for some of the risk of combining opioids with alcohol?

2) Hypoglycemia during rapid methadone dose escalation.

Moryl N, Pope J, Obbens E.

J Opioid Manag. 2013 Jan-Feb;9(1):29-34. doi: 10.5055/jom.2013.0144.

Comments: One of a handful of issues with methadone dosing that may have factored into the challenges encountered by providers and patients with this drug when used for pain.

3) Benzodiazepine use during buprenorphine treatment for opioid dependence: Clinical and safety outcomes.

Schuman-Olivier Z, Hoeppner BB, Weiss RD, Borodovsky J, Shaffer HJ, Albanese MJ.

Drug Alcohol Depend. 2013 May 17. doi:pii: S0376-8716(13)00133-6. 10.1016/j.drugalcdep.2013.04.006. [Epub ahead of print]

Comments: For patients on any opioid medications, benzodiazepines are associated with an increased risk of overdose. This study of 328 buprenorphine maintenance patients didn’t find an association with benzodiazepine prescriptions and overdose, but did find an association with more frequent emergency department visits and injury-related ED visits. We may never learn if benzodiazepines are causal in this pathway or merely a marker, but these data do contribute to the overall concern.

4) The relationship between age and risky injecting behaviours among a sample of Australian people who inject drugs.

Horyniak D, Dietze P, Degenhardt L, Higgs P, McIlwraith F, Alati R, Bruno R, Lenton S, Burns L.

Drug Alcohol Depend. 2013 May 9. doi:pii: S0376-8716(13)00116-6. 10.1016/j.drugalcdep.2013.03.021. [Epub ahead of print]

Comments: More excellent work from this team. I particularly appreciate the estimate of the reduction in overdose risk with age. In a mathematical model of overdose, we estimated a 50% reduction in the risk of overdose over 10 years of use, whereas this paper suggests the figure is closer to 20% - data that will be very helpful in future iterations.

5) Reducing the Health Consequences of Opioid Addiction in Primary Care.

Bowman S, Eiserman J, Beletsky L, Stancliff S, Bruce RD.

Am J Med. 2013 May 8. doi:pii: S0002-9343(13)00138-1. 10.1016/j.amjmed.2012.11.031. [Epub ahead of print]

Comments: Congratulations to this team on producing what I think are the first primary care guidelines in the scientific literature recommending overdose prevention and naloxone for at-risk patients.

6) Acute Pain Control Challenges with Buprenorphine/Naloxone Therapy in a Patient with Compartment Syndrome Secondary to McArdle's Disease: A Case Report and Review.

McCormick Z, Chu SK, Chang-Chien GC, Joseph P.

Pain Med. 2013 May 3. doi: 10.1111/pme.12135. [Epub ahead of print]

Comments: Less an overdose article per se, but a paper that pays attention to the overdose issue when titrating opioids.

7) Barriers to medical provider support for prescription naloxone as overdose antidote for lay responders.

Green TC, Bowman SE, Zaller ND, Ray M, Case P, Heimer R.

Subst Use Misuse. 2013 May;48(7):558-67. doi: 10.3109/10826084.2013.787099.

Comments: A qualitative look at providers feelings about providing naloxone to “drug users” and, separately, to “pain patients.” This is a great and useful analysis – and honestly surprisingly positive across the board. The major concern raised seemed to be that naloxone not be the only thing done to try to reduce overdose. This is a pretty dramatic shift in attitudes since earlier evaluations of provider opinion on lay naloxone (Beletsky et al 2007, Coffin et al 2003).

PubMed Update April 2013

10 papers this time. Good stuff.

1. Take-Home Emergency Naloxone to Prevent Heroin Overdose Deaths after Prison Release: Rationale and Practicalities for the N-ALIVE Randomized Trial.

Strang J, Bird SM, Parmar MK.

J Urban Health. 2013 May 1. [Epub ahead of print]

Comment: Really interesting article on the design of the N-ALIVE trial of naloxone provision to prisoners pre-release.

2. Determination of dextromethorphan and levomethorphan in seized heroin samples by enantioselective HPLC and electronic CD.

Tedesco D, Di Pietra AM, Rossi F, Garagnani M, Del Borrello E, Bertucci C, Andrisano V.

J Pharm Biomed Anal. 2013 Apr 6;81-82C:76-79. doi: 10.1016/j.jpba.2013.03.024. [Epub ahead of print]

Comment: Methods paper demonstrating methorphan in some heroin samples involved in overdose death.

3. All-cause mortality in criminal justice clients with substance use problems-A prospective follow-up study.

Hakansson A, Berglund M.

Drug Alcohol Depend. 2013 Apr 24. doi:pii: S0376-8716(13)00109-9. 10.1016/j.drugalcdep.2013.03.014. [Epub ahead of print]

Comments: Another analysis of post-release mortality among prisoners, in which the largest group (39%) of deaths were due to accidental or undetermined intent poisoning.

4. Changing law from barrier to facilitator of opioid overdose prevention.

Davis C, Webb D, Burris S.

J Law Med Ethics. 2013 Mar;41 Suppl 1:33-6. doi: 10.1111/jlme.12035.

Comments: Excellent analysis of naloxone and Good Samaritan legislation.

Naloxone: Keep it with your lipstick

Excellent "Here and Now" radio story on naloxone in Massachusetts and administration by parents!

 

Mother Saves Her Son From Overdose Thanks To Pilot Program

PubMed Update February/March 2013

Another 8 papers on opioid overdose issues.

1) 'It's more about the heroin': injection drug users' response to an overdose warning campaign in a Canadian setting.

Kerr T, Small W, Hyshka E, Maher L, Shannon K.

Addiction. 2013 Mar 28. doi: 10.1111/add.12151. [Epub ahead of print]

Comment: Interesting qualitative analysis of warnings issued regarding high-potency heroin. Respondents instead sought out the suspect drug.

2) Opioid Agonist Treatments and Heroin Overdose Deaths in Baltimore, Maryland, 1995-2009.

Schwartz RP, Gryczynski J, O'Grady KE, Sharfstein JM, Warren G, Olsen Y, Mitchell SG, Jaffe JH.

Am J Public Health. 2013 Mar 14. [Epub ahead of print]

Comment: This analysis failed to consider heroin overdose prevention programming – i.e. naloxone distribution – that was scaled up over the exact same period that buprenorphine treatment expanded and heroin overdoses declined. While not all variables can be considered in the interrupted time series approach, not considering the impact of a naloxone-based “overdose prevention program” seems to be a major flaw in the presentation. Disappointing that this was not rigorously addressed.

3) Determination of substance overdose in two Iranian centers: Comparison between opioids and non-opioids.

Taghaddosinejad F, Arefi M, Fayaz AF, Tanhaeivash R.

J Forensic Leg Med. 2013 Apr;20(3):155-7.

Comment: Interesting exploration of overdose in Iran – opioids still predominate (1782) compared to other drugs (94).

4) Opioid overdose fatality prevention.

Leece P, Orkin A.

JAMA. 2013 Mar 6;309(9):873-4.

Comment: This reply to Beletsky, et al’s, November 2012 commentary Prevention of fatal opioid overdose is followed by the authors’ response.

5) Development of Opioid Overdose Knowledge (OOKS) and Attitudes (OOAS) Scales for take-home naloxone training evaluation.

Williams AV, Strang J, Marsden J.

Drug Alcohol Depend. 2013 Feb 28.

Comment: We are in desperate need of standardized and validated measures for overdose and naloxone distribution. These scales may be useful, although as a word of caution several elements are specific to UK programming.

News: Police host naloxone training for community

In response to a run of opioid overdoses, the Yarmouth police are co-sponsoring a training of lay persons in the community, so that there will be more naloxone in the community should future overdoses occur. 

This rapid response is made possible by the naloxone program supported by and run through the State health department, and raises the very intriguing concept that naloxone may have stark benefit in settings of overdose "outbreaks."

The Scottish Highland Overdose Prevention Programme Goes to Prison

Lisa Ross

NHS Highland Clinical Harm Reduction Nurse Specialist / Naloxone Lead

In July 2009, I started the Highland programme in Inverness, in the north of Scotland, to deliver overdose prevention services to those at risk of opiate overdose, their friends and family members, and staff working with those at risk. The program is part of the Scottish National Health Service, our universal public health care system. 

Trainees were given a supply of naloxone for intramuscular administration to take home and use in the event of witnessing an opiate overdose. The programme also included Inverness prison; those who were identified as at risk were trained whilst in prison and given a naloxone pack on their liberation date.

The Programme was rolled out after the first year throughout the Highland area. To date over 900 kits have been supplied and there have been over 200 recorded uses of naloxone with successful reversal of the overdose state. In 2012, the programme was developed to include supply of naloxone for intranasal administration.

Last year I also started to develop a network of peer trainers; one of the aims of this was to increase uptake to those at risk, particularly those who had not previously engaged with the programme. Peer trainers are ideally placed to deliver this training; after all they hold the most experience and are far more likely to engage with the identified target group.

This again included Inverness Prison; I trained a peer trainer as a trainer and he now delivers the training in prison to those at risk. The results of this have been hugely positive so far. In a short space of time he has managed to engage with more individuals and deliver the training to them than the health and addictions staff have managed throughout the year. This is even more impressive when we consider the prison is in its fourth year of delivering this intervention and supplies of naloxone were starting to decrease given that the majority of people had already been trained. Or so we thought!

There will be the opportunity for the peer trainer to continue delivering the programme upon his own liberation, working in the community with the Harm Reduction Service and the community peer trainers.

My ongoing intention for the programme is to increase the number of peer trainers throughout Highland; there is no doubt that when it comes to overdose prevention and Naloxone training; peer trainers can have the maximum impact.

Naloxone laws to prevent overdose

There have been a slew of recent bills introduced or passed to improve naloxone access around the United States. Most of these are similar to previous U.S. models, although some are quite innovative. 

First, here's a summary from the Network for Public Health Law of naloxone (and Good Samaritan) laws as of October 2012, when 8 U.S. states had naloxone access laws (CA, CT, MA, NM, NY, IL, WA, RI).

Now, below are some links to recently approved or newly considered bill/law text. Please let us know if there are others and offer comments on any of these. It's getting hard to keep track, so I've added a simple map - black areas have naloxone laws and orange areas have pending laws (black states with an orange mark have existing laws with pending modifications).

New laws:

Virginia

Washington DC

Bills:

California (builds on existing law that is to sunset)
Colorado

Kentucky

Maryland

Massachusetts (not sure in what ways this expands on existing law Act 192)

New Jersey

New Mexico (appropriations to support naloxone distribution)

North Carolina

Oregon (SB 384, passage appears likely, bill with amendments here)

Vermont (bill appears to require only consideration of a law change to encourage naloxone prescription)

West Virginia (requires naloxone be offered to all patients receiving chronic opioid therapy)

News: FDA denies Reckitt's request to block generic buprenorphine/naloxone tablets

The U.S. Food and Drug Administration has roundly denied all requests from Reckitt-Benckiser to block approval of generic buprenorphine/naloxone tablets. This request was made at the time when the monopoly on the product was ending and was based on risks of pediatric exposures that the company claimed were higher with the tablet than their new film product. The FDA provided an excellent review of the issues and rejected all components of the request.

This is an enormous relief for public health agencies providing buprenorphine services, many of which would have dropped buprenorphine services altogether or would have ceased to provide the buprenorphine/naloxone formulation due to cost.

PubMed Update December 2012 - January 2013

This is a really exciting time for research into overdose in general and naloxone in particular. 15 papers this time.

1. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis.

Walley AY, Xuan Z, Hackman HH, Quinn E, Doe-Simkins M, Sorensen-Alawad A, Ruiz S, Ozonoff A.

BMJ. 2013 Jan 30;346:f174. doi: 10.1136/bmj.f174.

Comments: A long-awaited paper for which the authors deserve high praise, as they have produced the first real evidence of naloxone effectiveness and arguably the most important contribution to naloxone literature to-date. Although not randomized, the interrupted time series analysis is respectable and the results are impressive.

2. Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal.

Coffin PO, Sullivan SD.

Ann Intern Med. 2013 Jan 1;158(1):1-9. doi: 10.7326/0003-4819-158-1-201301010-00003.

Comments: I’ve wanted to write this paper for about a decade, when I thought about cost-effectiveness as three to four calculations on the back of a napkin, rather than years of work and RAM-straining matrices. There’s a long way to go with overdose research that will certainly contribute to future iterations of the model. In the meantime, this is probably a fair, if quite conservative, initial estimate. There is one sensitivity analysis – in which naloxone results in behavior change such that overdose risk is lower – which I suspect may be closer to the actual truth.

3. Naloxone for heroin overdose reversal.

Ann Intern Med. 2013 Jan 1;158(1):I-30. doi: 10.7326/0003-4819-158-1-201301010-00001. No abstract available.

Comments: An excellent editorial from our colleagues at NIDA and the FDA.

4. Prescription opioid use among addictions treatment patients: Nonmedical use for pain relief vs. other forms of nonmedical use.

Bohnert AS, Eisenberg A, Whiteside L, Price A, McCabe SE, Ilgen MA.

Addict Behav. 2012 Nov 23;38(3):1776-1781. doi: 10.1016/j.addbeh.2012.11.005. [Epub ahead of print]

Comments: Survey of prescription opioid use among treatment program patients. Use for reasons other than pain relief was associated with overdose as well as use of several other agents that increase the risk of overdose.