Family members get involved in OD prevention

by Maya Doe-Simkins

Overdose education and naloxone distribution (OEND) has fundamentally changed the way that harm reduction service providers and friends and family of drug users interact -- it is a “game changer.”  

Syringe exchanges, for example, have often (though definitely not always) had a tenuous relationship with loved ones of drug users -- there is a very acute response to knowing that you are frantically doing everything you can think of to entice your child/partner/family member to stop injecting heroin and find “recovery,” while someone at an exchange is giving that person clean needles, cookers, tourniquets, filters. Public health practitioners acknowledge the two events can and should happen in tandem. Some loved ones find solace in knowing that needle exchange workers are taking care of their loved ones with supplies and seeing them for the wonderfully complex people they are -- but there is no denying that it is intense to know that there are people out there handing out injection equipment to a person whose potential abstinence consumes so much of your time and energy.

Enter take home naloxone. Families and friends of drug users are acutely aware of the lurking possibility of overdose -- I met one woman who went to three wakes in one week. Possessing naloxone gives loved ones a reprieve from the nagging fear and allows people to breathe a little more easily.  What parents and family members have done with the extra breath is talk -- to local health service organizations, local, state and federal elected officials, the police, the media, each other, the drug users they care about, pharmaceutical manufacturing companies, grant making organizations, and importantly organizations that provide harm reduction services. 

In Massachusetts, “non-users” (friends/family/service providers) approached syringe exchange and drop in programs that were providing OEND services to train them -- in church basements, around the kitchen table, etc. In recognizing that training this group of people is different than training drug users about overdose, a “Friends & Family” curriculum was developed. (Curriculum and accompanying power point can be downloaded here.)  

But that wasn’t enough -- fierce and vocal family members themselves wanted to be able to participate in spreading the training and materials to save lives.  A parent group, Learn To Cope, has been approved to be trainers & some members now provide overdose education and naloxone in addition to the practical, logistical and emotional support that they had been offering families.  

This graph, presented to the FDA in April 2012, shows the breakdown of “users” (self- identified current or ever) and “non-users” enrolled in four years at various sites -- about 1/3 of the people who get trained in Massachusetts to recognize overdose and administer naloxone are “non-users”.  Parents, other family, and friends of drug users are incredible advocates for better overdose prevention programs.

Normalization of naloxone

There has been a deluge of support for take-home naloxone lately. 

To name just a few (mostly U.S.) developments ...

•  The UK Advisory Council on the Misuse of Drugs endorsed take-home naloxone.
• The American Medical Association endorsed take-home naloxone, thanks to the efforts of a group of medical students.
• The US Food and Drug Administration convened a major meeting on take-home naloxone.
• The US Substance Abuse and Mental Health Services Administration is including take-home naloxone guidelines in their overdose prevention kit.
• The US National Institute on Drug Abuse funded the first R01 for naloxone distribution.
• Rhode Island passed a recent Good Samaritan law that included both naloxone and protection from prosecution components.
• Connecticut passed a law intended to expand availability of take-home naloxone.
• Gil Kerlikowske, Director of the US Office of National Drug Control Policy, spoke in favor of take-home naloxone on June 10th 2012 at the College on Problems of Drug Dependence conference in Palm Springs. In fact, 3 of his 14 recommended action items involved naloxone availability.

It seems that overdose death, like fatality from motor vehicle accidents, is finally being recognized as preventable, and naloxone as the seatbelt. 


This is not remotely a comprehensive list of what's happening. Please post other developments, by commenting here or by contacting an editor to publish a more detailed story.

American Medical Association Endorses Naloxone-Based Overdose Prevention as its Official Policy

By Leo Beletsky, Elena Moroz
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A Press Release from the American Medical Association on June 19th, 2012 stated the following on AMA’s new policy on community-based programs offering naloxone to prevent opioid overdoses:


PROMOTING PREVENTION OF FATAL OPIOID OVERDOSE: Opioid addiction and prescription drug abuse places a great burden on patients and society, and the number of fatal poisonings involving opioid analgesics more than tripled between 1999 and 2006. Naloxone is a drug that can be used to reverse the effects of opioid overdose. The AMA today adopted policy to support further implementation of community-based programs that offer naloxone and other opioid overdose prevention services. The policy also encourages education of health care workers and opioid users about the use of naloxone in preventing opioid overdose fatalities.

Wanted: Overdose Prevention Tailored to Women

By Leo Beletsky, Elena Moroz
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Over the past 20 years, the overall prevalence of fatal opioid overdose has tripled.  Historically, the risk of overdose among men had been significantly higher; over the last decade, however prevalence of opioid overdose deaths has been increasing faster among women than men. With the gender gap decreasing, women now face a greater risk for opioid drug overdose than ever before.

Women of all racial and socioeconomic backgrounds are facing greater risk of overdose from opioid drugs. Recent data sheds light on the role of pregnancy as one the possible channels for increasing opioid dependence, which is a precursor to overdose. In the past, neonatal abstinence syndrome had been documented primarily in underserved urban areas, it is increasingly observed in hospitals across geographical and socioeconomic strata.  However women who live in the South, Midwest and the East appear to be at an elevated risk than those in the West of the United States. Overdose is most common among middle aged women (45-55 years old).

Transcript from FDA Hearing on Naloxone Access Now Available

As previously discussed on OPA, the U.S. Food and Drug Administration (FDA) organized a workshop this past April to examine access to naloxone as a means to reduce opioid overdose fatalities in the Unites States. FDA has now published the complete transcript of the event, available here (PDF). 


We will post choice excerpts in coming weeks, but the entire transcript is worth reviewing and referencing, and includes testimony from leading advocates, researchers, and officials from CDC, FDA and SAMHSA among others. 


One immediate way that advocates may follow up on the workshop is to submit comments on the subject, which FDA is accepting until June 12. Doing so will support efforts to convince FDA to take action on expanding naloxone access, which has included discussion of rescheduling the medication to remove prescription requirements. For information on how to submit comments and suggestions for doing so, follow this link. 

Pubmed May 2012 Update

This is actually an interim update because my last PubMed pull came up dry. We have papers from New Mexico, Serbia, and Italy, as well as a case report, addressing sociodemographics, depression, naltrexone, methadone, buprenorphine, and heart failure.

1) The influence of living along the U.S.-Mexico border on unintentional drug overdose death, New Mexico (USA), 2005-2009.

Shah NG, Lathrop SL, Flores JE, Landen MG.

Drug Alcohol Depend. 2012 Apr 16.

Comment: An analysis of New Mexico overdose deaths (many of us have been waiting with bated breath for a deeper analysis of deaths there). Authors found that living in a border region was associated with less overdose death, particularly from heroin or methadone; among their hypotheses is that this is a paradoxical benefit of reduced access to medical care and opioid prescriptions. 

2) [Differences in depression severity and frequency of relapses in opiate addicts treated with methadone or opiate blocker after detoxification].

Jovanović T, Lazarević D, Nikolić G.

Vojnosanit Pregl. 2012 Apr;69(4):326-32. Serbian.

Comment: Does anyone read Serbian? I'd love to see some additional comment on this intriguing paper. The issues around depot naltrexone versus agonist maintenance are becoming a real issue. The concerns around overdose death in the setting of naltrexone have not been adequately addressed. This paper appears to compare depression scales for patients on those two therapies, but I can't tell from the abstract exactly what the populations are or what the analysis showed.

Naloxone has Rensselaer Country Sheriffs enthusiastic about preventing overdose deaths

By Leo Beletsky, Elena Moroz

In our last entry, we talked about the innovative police program in Massachusetts who have successfully implemented the use of naloxone to reverse opioid overdoses. This program is one of the first among a growing number of police departments that are responding to the overdose epidemic in their communities by undergoing training on overdose prevention.

One the newest of these initiatives is a collaboration between The New York Department of Health and law enforcement in the rural Rensselaer County in upstate New York.

As we have previously discussed, police officers are often the first on the scene of an overdose and can provide critical response to avert death or brain injury resulting from these events. The pilot program in the rural Rensselaer County is particularly well placed because overdose victims here will often find themselves far from any ambulance or hospital. To date, this pilot is the first in New York State where police are trained to use naloxone. Other rural counties should follow suit and implement naloxone programs among first-responders.

The Harm Reduction Coalition has a round-up of recent online overdose resources, including a video on overdose and naloxone for prisoners (which I had the opportunity to review while it was being made - it's really good), a guide about naloxone for prescribers and pharmacists, and the new Prescribe to Prevent site. Check them out here. 

UK Government Committee Endorsed Naloxone Distribution

Harm reductionists in the United Kingdom were among the first to take up leadership on overdose prevention, and now in more good news the UK Advisory Council on the Misuse of Drugs (ACMD) has issued a new report (PDF) which concludes that:

"naloxone provision is an evidence-based intervention, which can save lives. Naloxone provision fits with other measures to promote recovery by encouraging drug users to engage with treatment services, and ultimately, keep them alive until they are in recovery."

Established in 1971 under the Home Office, the ACMD is Britain's chief independent advisory body on drug related issues. 

The report is worth reading and citing. Aside from being politically useful it provides a review of overdose prevention programs in the UK as well as summaries of British and international evidence for naloxone provision.

Important! FDA Accepting Public Comments on Naloxone Availability

Last month OPA reported on a U.S. Food and Drug Administration hearing on strategies for improving access to naloxone. FDA is now accepting public comments until noon EST June 12, 2012. The more comments that FDA receives, the more likely our allies in the U.S. federal government will be able to push the issue.


You may submit comments individually or on behalf of an organization through this link, or by going to www.regulations.gov, searching for "naloxone" and clicking the link for "Role of Naloxone in Opioid Overdose Fatality Prevention."


Here are some suggestions sent out today by Harm Reduction Coalition's Whitney Englander:

(1) We need to generate VOLUME to FDA for the docket on the public workshop - numbers matter (2) The messages in the comments should be - as much as possible - to include references to the science, evidence, data, etc. - especially anything in the MMWR, or other data produced or published by government (e.g., NIDA, SAMHSA, FDA, CDC, etc.) (3) Any additional references to information or statements by other groups about the problem of overdose (e.g., data from American Hospital Association) and how naloxone will be a good remedy (4) We should extrapolate the data to illustrate what the "market" could be for naloxone -number of households with prescription opioids, number of American households with children/teenagers, etc.  anything to show that the potential market is bigger than what the industry rep suggested it is (5) Anything regarding economic impact - the cost of overdose - cost of emergency services/emergency department cost of someone who doesn't get emergency services right away and experiences brain damage from lack of oxygen, etc. - show the impact on society and economy (6) Be sure to make clear there is no adverse impact on people who do not have opioids in their system - science to illustrate this and anything regarding lack of side effects or nominal adverse effects - that the benefits FAR outweigh any possible problems with naloxone's use/expanded access.

And a few more guidelines from Maya Doe-Simkins:

On the comment page, fill in the fields and paste your comment of 2000 characters or less. 

All submitted comments are public record, which means that they are publically available, but comments from individuals will not be displayed on the website, unless you specifically request it.

Unless you are representing an organization, select "Individual Consumer" under the "Category" choice. 

You can use 2000 characters for an overview and submit a much lengthier statement as a PDF attachment, including letter on letterhead if available, graphs, figures, published papers, pictures, photos, etc. So, no need to feel constrained to 2000 characters if you have more to say!

Tips for crafting comments that may be helpful in expanding naloxone access:Comments should focus less on IF naloxone works, and more about the pros and cons of giving it to lay overdose bystanders and how simple (or not) that process is/should be. 

These are issues that have the potential to impede expanded naloxone access.  Consider addressing one or more in your comments if you are able:

• Is the training simple?/ Do people feel well prepared to use it?/ If you did use it, could you/the person who used it easily remember instructions?
• Does having naloxone increase drug use or decrease treatment?
• Does having naloxone during an overdose mean that people won’t call 911?
• Any bad outcomes after using naloxone?  Naloxone has a shorter half-life than opioid drugs- has anyone ever re-overdosed after the Narcan wore off?  If yes, what happened?
• Anyone who used naloxone or had it used on them by a lay person may want to mention if it was nasally administered or injected.
• If you are a provider/prevention/public health organization, Has it changed your service delivery?  How much training is necessary? 
• If the price or availability of naloxone has been a concern, please mention this!

Personal experience is powerful if you are comfortable sharing

If you submit comments, please advise Eliza Wheeler (wheeler [at] harmreduction.org) and Alice Bell (abell [at] pppgh.org) of your submission.

The Quincy Police Department: Pioneering Naloxone Among First Responders.

By Leo Beletsky, Elena Moroz

In Massachusetts, opioid overdose is the leading cause of accidental fatality; it ranks third overall behind heart disease and cancer. In this state, 60% of all poisoning deaths are due to opioid overdoses. Communities just outside of Boston, including Quincy and Lynn have been particularly hard-hit. These areas have three times more heroin-related ER visits than the rest of the country. Heroin, not alcohol, is the most common substance of abuse in Abington, Quincy and Weymouth. Other opioids besides heroin are also abused more frequently in New England than any other region of the United States.

In response to the rising number of opiate overdoses in the area over the past 10 years, the Massachusetts Department of Public Health (MDPH) launched a program to facilitate bystander intervention. The Overdose Education and Naloxone Distribution (OEND) program has reached out to thousands of drug users, their caregivers and other members of the community, distributing naloxone and authorizing bystander administration. The program has also expanded to training non-medical first responders, including fire fighters and police, after a group of drug users’ parents, advocated for increased police involvement in the program.

Nancy is the mother of Brendan, who was a college-bound honor student and an athlete at Boston College High School. It was a shock to everyone when Brendan developed an addiction to his father’s pain medication – OxyContin. The addiction lead Brendan to heroin, homelessness, problems with the law and finally a near-fatal overdose event. Kathy’s son Michael also found his way to opioid addiction through painkillers. When Michael suffered a motorcycle accident, he became addicted to Vicodin and later transitioned to heroin, also surviving an overdose.

Who cares about overdose prosecutions?

by Matt Curtis

We’ve had a lot of good news around overdose lately. The U.S. Centers for Disease Control and Prevention recently released a report on community-based overdose prevention programs, and the Food and Drug Administration just held a hearing on making naloxone more available. The Commission on Narcotic Drugs – the annual social mixer for lifer international drug war bureaucrats – endorsed giving more attention and resources to overdose prevention. It seems like every week there’s more great work being done on the front lines.

One other thing you’ll notice if you keep track of overdose-related news in the United States is the number of criminal prosecutions following overdose deaths.

These prosecutions have their origins in the Narcotics Penalties and Enforcement Act of 1986, also known as the “Len Bias Law” after the star University of Maryland forward who died of cocaine poisoning two days after being drafted by the Boston Celtics. This was the first major federal legislation of the ‘war on drugs’ era, which amended the Controlled Substances Act to introduce mandatory minimum sentences and a number of other enhanced criminal drug penalties.  One novel feature of the law was that it significantly increased prison time for anyone convicted of supplying drugs “if death or serious bodily injury results from the use of such substance.” Though federal prosecutions are still common, many states subsequently adopted similar legislation.

So, fine you say, isn’t this just drug dealers and corrupt pill mill doctors getting what they deserve for poisoning people?  A scan of news articles from the past couple years does show the occasional major dealer going down with a second-degree murder charge tacked on for an overdose. More common is a case like that of April Lynn Baker and Ryan Hartley in Maryland.

In 2008, Ms. Baker acquired methadone and morphine from a nursing home staff, which she traded to Mr. Hartley for marijuana. Hartley then sold a single 40 mg methadone wafer and 20 ml of liquid morphine to Brandon Sgaggero, who was found dead from an apparent overdose five days later. In describing Baker and Hartley as drug dealers, prosecutors note that both used drugs themselves, which is what led Sgaggero to seek out Hartley, and that Hartley sold to Sgaggero on only one occasion. In the event, Baker was sentenced to three years in prison and Hartley six.

Other examples abound, in Tennessee, Wisconsin, Washington and elsewhere. We’ve even seen prosecution of people for not adequately responding to a witnessed overdose, as in this case in Virginia.

The way in which criminal liability for overdose deaths is currently handled is very difficult to square with our rhetoric about harm reduction and drug policy. Yet I have rarely have heard colleagues in harm reduction or the broader public health and medical fields even mention the issue. This may be because the issue presents itself infrequently in the context of harm reduction services, and it’s even less often brought to the attention of people working in policy or academia. For those cognizant of overdose prosecutions, I suspect there’s a degree of ambivalence related to the getting-what-they-deserve issue. Among the many people working in harm reduction now who come from a professional rather than activist background, many may feel that the issue lies outside the scope of public health or social work.

So I think it’s time to take a deeper look at this issue, and it’s time for harm reduction and drug policy reform advocates to take it on. What is the best way to do so is a little more complicated, and something I will address in future posts around some of these questions:

• What is the scope of the problem? Where and how are overdose-related prosecutions happening?
• Should sellers be responsible for outcomes, and if so then under what circumstances? Should the expectation of potential harm from illegal drug use be a legitimate defense?
• How or why should we approach this differently than sellers of other (potentially) adulterated products, like produce contaminated with E. coli or counterfeit medication?
• People who use drugs tend not to keep a log of who they buy from, and medical examiners can’t determine the provenance of a morphine or cocaine metabolite. So is it appropriate to prosecute someone for an act that cannot be forensically linked to the outcome?
• People in drug policy reform often say something akin to ‘No one should be incarcerated for a petty, nonviolent drug crime.’ Where is the line drawn? Who is a drug dealer? Are there any circumstances under which supplying drugs that lead to “death or serious bodily injury" should result in criminal liability, and if so, in the current system is there any way to fairly determine guilt?

I admit some of these questions are a bit loaded. I don’t have the answers figured out though, and welcome comments, counterarguments, data, and anything else you would like to contribute.

Pubmed April 2012 Update

Here we go with April 2012 ...

Mortality and causes of death among users of methadone maintenance treatment in Israel, 1999-2008.

Rosca P, Haklai Z, Goldberger N, Zohar P, Margolis A, Ponizovsky AM.

Drug Alcohol Depend. 2012 Apr 6. [Epub ahead of print]

Comment: Rate of overdose mortality was 0.22/100 person-years (i.e. 0.22%), one-quarter to one-fifth the expected rate in most studies of other cohorts

Intravenous use of illicit buprenorphine/naloxone to reverse an acute heroin overdose.

Yokell MA, Zaller ND, Green TC, McKenzie M, Rich JD.

J Opioid Manag. 2012 Jan-Feb;8(1):63-6.

Comment: Buprenorphine is a partial agonist with a ceiling effect that limits the capacity for overdose among those with a tolerance to opioids. Like naloxone, buprenorphine really likes binding to opioid receptors and kicks most other opioids out. Since buprenorphine out-competes other opioids for receptors and has a ceiling effect, administration in the setting of overdose may result in reversal of opioid overdose. That said, this wouldn't be the approach I would advocate for dissemination since (1) buprenorphine could cause overdose in an opioid user with minimal tolerance and (2) buprenorphine could cause prolonged withdrawal (for over a day) in those with a very high tolerance.

Understanding drug-related mortality in released prisoners: A review of national coronial records.

Andrews JY, Kinner SA.

BMC Public Health. 2012 Apr 4;12(1):270. [Epub ahead of print]

Comment: An interesting exploration of circumstances surrounding prisoner death post-release.

Effects of concurrent intravenous morphine sulfate and naltrexone hydrochloride on end-tidal carbon dioxide.

Goli V, Webster LR, Lamson MJ, Cleveland JM, Sommerville KW, Carter E.

Harm Reduct J. 2012 Mar 15;9(1):13. [Epub ahead of print]

Comment: An intriguing analysis of whether or not injecting the pre-formulated morphine + naltrexone actually blocks the effects of morphine. It appears to partially, but not completely, block the effect.

Incidence and risk factors for non-fatal overdose among a cohort of recently incarcerated illicit drug users.

Kinner SA, Milloy MJ, Wood E, Qi J, Zhang R, Kerr T.

Addict Behav. 2012 Feb 7. [Epub ahead of print]

Comment: Prior overdose, daily or binge drug use, and public injecting are associated with nonfatal overdose among recently released drug users.

Dexmedetomidine infusion to facilitate opioid detoxification and withdrawal in a patient with chronic opioid abuse.

Upadhyay SP, Mallick PN, Elmatite WM, Jagia M, Taqi S.

Indian J Palliat Care. 2011 Sep;17(3):251-4.

Comment: An interesting use of a particular sedative to assist with opioid withdrawal in an intensive care unit.

Drug-related deaths with evidence of intracorporeal drug concealment at autopsy: five case reports.

Wilcher G.

Am J Forensic Med Pathol. 2011 Dec;32(4):314-8.

Comment: Intriguing review of 5 cases of drug-induced death among "body packers" or "body stuffers", including a review of that language. Interestingly, most of the deaths were due to overdose on consumed drugs rather than toxicity from rupture of drug packets.

FDA Hears Testimony on Naloxone Access and Potential for Over-the-Counter Status

This past Thursday, April 12, the U.S. Food and Drug Administration (FDA) held its first ever workshop on naloxone availability and use in emergency first aid in the United States. The event marks an important first step in the federal government taking greater responsibility for overdose prevention efforts, and by all accounts FDA was looking for ways to be a constructive partner with local peer distribution efforts.  More information on the goals of the meeting, the agenda, and a speakers list may be found on the FDA website. 

While the goal of rescheduling naloxone to remove prescription requirements faces significant bureaucratic hurdles, FDA may be able to take other measures in the near term, such as approving emergency importation of naloxone from manufacturers in Europe or elsewhere in order to address the stock-outs and price hikes plaguing overdose projects in recent years.

We'll soon have more analysis about the meeting and next steps from several participants. In the meantime, Time magazine's Maia Szalavits continues her quest to make completely OPA redundant with an excellent first-take on the meeting. 

News: FDA will discuss making naloxone over-the-counter

By Maia Szalavitz, The Fix Posted on March 31, 2012, Printed on April 3, 2012 http://www.alternet.org/story/154786/the_drug_that_saves_addicts%3A_fda_will_discuss_making_naloxone_over-the-counter When I was injecting drugs back in the mid-1980s, several sneaky killers were haunting addicts. We didn’t know it at the time, but half of all New Yorkers who shot drugs were already infected with HIV and many more were carrying the hepatitis C virus. There was no effective treatment for either disease. Thousands died. And unfortunately, many in the recovery community stayed silent. The risk we knew about—overdose—seemed just as implacable. You could reduce the danger by limiting your doses and not mixing similar drugs, such as heroin, Valium and alcohol, say, or cocaine and amphetamines, and that remains good advice. Back then, we fatalistically assumed that this menace pretty much came with the territory. In 2012, however, both HIV and hepatitis C are not only treatable but amenable to prevention campaigns. New HIV infections among drug users have been cut in half in the last decade, largely by clean-needle programs, which can also fight hepatitis C (though not as effectively). But some 15,000 people still die annually from opioid overdoses—even though there’s a cheap, effective and safe remedy that could save most of these lives if it were more widely available. With prescription opioid misuse now the main cause of rising overdose fatalities and with the overwhelming failure of ongoing efforts to cut supply, it’s long past time to focus on the most direct way to prevent death by OD.