Preventing Opioid Overdose: A new role for prevention August 27, 2019 (1:15-2:30 PMCST) Chuck Klevgaard , CSPS, Prevention Manager (PTTC) Erin Ficker , CSPS, Prevention Manager (PTTC) 1
Welcome & Introductions
At the conclusion of this workshop, you will be able to : Understand a public health approach for addressing opioid misuse and overdose Describe factors associated with misuse and opioid overdose, including demographic risk factors Describe strategies that have shown promise in reducing opioid misuse and/or overdose Describe the roles for prevention practitioners as catalysts for ensuring a culturally relevant comprehensive prevention approach
Waves of f th the Crisis 7 Natural and semi- Synthetic Opioids Heroin synthetic opioids like fentanyl 6 like oxycodone or Deaths Per 100,000 population hydrocodone 5 4 3 2 1 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Wave 3: Rise in Synthetic Wave 1: Rise in Prescription Wave 2: Rise in Heroin Opioid Overdose Deaths Opioid Overdose Deaths Overdose Deaths Source: National Vital Statistics Systems Mortality File.
Waves of f th the Crisis Natural and semi- Synthetic Opioids Heroin synthetic opioids like fentanyl Focus like oxycodone or hydrocodone “Iatrogenic” Supply Policy Demand: Surveillance Aging Population Harm Reduction 1999 2000 2001 2002 2003 2004 2005 2006 2007 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Wave 3: Rise in Synthetic Wave 1: Rise in Prescription Wave 2: Rise in Heroin Opioid Overdose Deaths Opioid Overdose Deaths Overdose Deaths Source: National Vital Statistics Systems Mortality File.
Waves of f th the Crisis Focus Natural and semi- Synthetic Opioids Heroin synthetic opioids like fentanyl like oxycodone or SUPPLY: hydrocodone Mexican TCO Surveillance Demand: “Intertwined” New, Young Heroin Users, HARM: Active Users, 1999 2000 2001 2002 2003 2004 2005 2006 2007 Bystanders 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Policy Wave 3: Rise in Synthetic Wave 1: Rise in Prescription Wave 2: Rise in Heroin Opioid Overdose Deaths Opioid Overdose Deaths Overdose Deaths Source: National Vital Statistics Systems Mortality File.
Waves of f th the Crisis Focus Natural and semi- Synthetic Opioids Heroin synthetic opioids like fentanyl Supply like oxycodone or hydrocodone Traffickers Mail Demand: All Demographics Determinants HARM : SIF, Point of Use Testing Policy: naloxone Good Samaritan 1999 2000 2001 2002 2003 2004 2005 2006 2007 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Pain Management Wave 3: Rise in Synthetic Wave 1: Rise in Prescription Wave 2: Rise in Heroin Opioid Overdose Deaths Opioid Overdose Deaths Overdose Deaths Source: National Vital Statistics Systems Mortality File.
Waves of f th the Crisis Natural and semi- Synthetic Opioids Heroin synthetic opioids like fentanyl like oxycodone or hydrocodone Mexican TCOs Pharma China Emphasis on BLAME 1999 2000 2001 2002 2003 2004 2005 2006 2007 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Wave 3: Rise in Synthetic Wave 1: Rise in Prescription Wave 2: Rise in Heroin Opioid Overdose Deaths Opioid Overdose Deaths Overdose Deaths Source: National Vital Statistics Systems Mortality File.
Prevention – Speaking A Common Language Demand Reduction Supply Reduction Harm Reduction Preventing the uptake Preventing, stopping, Reducing the adverse and/or delaying the onset disrupting or otherwise health, social and of use of alcohol, tobacco reducing the production economic consequences and other drugs, reducing and supply of illegal drugs; of the use of drugs, the misuse of alcohol, and controlling, for the user, their tobacco and other drugs in managing and/or families and the wider the community; and regulating the availability community supporting people to of legal drugs. recover from dependence through evidence-informed treatment 9
Early Response to the Crisis Law Enforcement Medication-assisted Treatment Prescription Monitoring TREATMENT Interdiction SUPPLY Treatment for Prisoners Opioid Treatment Pre-trial Diversion Prescription Reducing Disposal Diversion Naloxone Distribution HARM REDUCTION Community Development Training First Supervised Injection DEMAND Responders, Mobile Crisis Units Consumption Volunteers, & Facility (SIF) Education Media / Marketing Bystanders 10
The Public Health Approach • Comprehensive Approach • Population Focused • Risk Factors • Evidence-based Strategies
Upstream and and Downstream Preventing Opioid Misuse or Overdose Preventing Overdose Death
Promoting a Comprehensive Approach A comprehensive approach to preventing substance use-related problems: Comprises multiple prevention strategies Operates at different levels of risk and influence How ha Ho have you u Involves diverse work rked in your r cu curr rrent stakeholders from ro role as co commu munit nity y across the community org rganizer? r? Marlatt GA, Witkiewitz K., 2002
Comprehensive Public Health Approach 14
IOM Continuum – NMUPD and Overdose The age group with the greatest past-year nonmedical use ( Misuse ) of opioids is young adults aged 18 to 25, yet the greatest ( Use) (i.e., exposure) of prescription opioids is among adults aged 26 and older. Misuse Use No Use 15
Impact on All Sectors Caseloads, Interactions Covering People with Treatment, Foster Struggling with OUD, Care, Staff Capacity and Access to Early Child Training Interventions and Tx. Medicaid Welfare Public Economic Health Development Criminal Education Justice Prevention: Raising community knowledge and awareness, improving communication and coordination across agencies, Workers Treatment disseminating surveillance information, and policy and infrastructure Compensation Centers development that supports harm reduction. (Brandeis University Heller School for Social Policy and Management, 2013) Chou et al. 1998
Socio-ecologic Model Laws; Prescribing, Pain Care, Integrated Care, Practitioner Education, Determinants of mental health and illness include Public Policy & PDMPs individual, social and societal factors, and their Community interaction with each other (Sturgeon 2007). Thus, mental health needs to be understood from Organizational biological, psychological as well as sociocultural perspectives (Kendler 2008), and in order to prevent Interpersonal mental illness and promote mental health, there is a need to simultaneously target several Positive and Negative multilayered factors (WHO 2012). + Parent Disapproval, Individual Strong Bonds, - Peer Attitudes, Witnessing an Overdose O’Connell, Boat, & Warner, 2009 18
Developmental Perspective Poor Outcomes from NAS Risk for Sedation, and Exposure to Opioids, Respiratory Depression, Separation and/or Confusion, Falls, Toxicity, Removal From Home, Overdose. Trauma, and (ACEs). People who report prescription opioid misuse in current cohorts initiated use in their early to late 20s, which may explain why prescription Across the Lifespan opioid mortality disproportionately affects adults aged 25 to 54 Botvin et al. 1995; Dishion et al. 2002
Comprehensive Public Health Approach 20
Factors Associated with Use / Misuse Alcohol, Illicit Drug History of Mental Use, Dependence Illness Use Misuse Perception of Relationships Harm Personality Characteristics
Use / Misuse to Overdose 22
Factors Associated with Opioid Overdose Ability to Opioid Process Opioids Use and Misuse Non-Fatal Overdose Opioid Chronic Pain Knowledge and and Mental Perceptions Health Opioid Access and Supply
Strategies
Upstream vs Downstream Preventing Opioid Misuse or Overdose Preventing Overdose Death
Two Roles for Prevention Prevent Use/Misuse Prevent Overdose Death and Overdose • Naloxone access and • Education promotion strategies • • 911 Good Samaritan laws Limiting Prescription Drug Access Strategies: and policies • Prescription drug disposal programs PREVENTING • Prescription drug PRESCRIPTION DRUG monitoring programs MISUSE: Overview of Factors • Prescribing and and Strategies dispensing regulations • Law enforcement actions • Treatment and follow-up services
Next Steps for Prevention Providers • Rationale For Prevention • A Comprehensive Approach • Strategies for Getting Prevention to the table
Rationale for Prevention Implementer Convener Organizer Process Designer Coordinator Facilitator Leader Provocateur 40
Focus Without Prevention at the Table Medication-assisted Treatment Prescription Local Monitoring Police TREATMENT SUPPLY Treatment for Prisoners Opioid Treatment Pre-trial Diversion Prescription Reducing Disposal Diversion Naloxone Distribution HARM REDUCTION Community Development Training Staff, Supervised Injection DEMAND Volunteers, & Mobile Crisis Units Consumption Bystanders Facility (SIF) Education Media / Marketing 41
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