New Allegheny County data, a Massachusetts model, and a local public health response

This model of overdose shows risks and many intervention opportunities

This model of overdose shows risks and many intervention opportunities
*OEND: Overdose Education and Naloxone Distribution

There were more registrants than seats at the second annual Allegheny County Overdose Prevention Coalition (ACOPC) conference held July 24 at the University of Pittsburgh.  Addiction treatment providers, other healthcare professionals, community members, and harm reduction experts packed an auditorium to learn about and support the ACOPC’s vision: “to reduce overdose and eliminate overdose deaths in Allegheny County.”

The diversity of the audience reflected the sort of widespread buy-in required to effectively address any public health issue.  More than once, speakers remarked, “This is truly a coalition.”

Although (see below) 2012 data in Allegheny County is not encouraging, the conference focused on solutions, including the introduction of two local efforts just getting off the ground.  These initiatives, coupled with the audience’s size and energy, suggest that Allegheny County is mobilizing to prevent overdose.

Perhaps, of the many social issues related to substance use, preventing deaths caused by overdose is one of the most straightforward and can act as a rallying point for disparate groups to come together with the simple goal of saving lives.

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2012 Allegheny County Data

Jennifer Janssen, toxicology laboratory manager at the Allegheny County Office of the Medical Examiner (ACOME), summarized last year’s fatal overdose data.  The statistics show that in Allegheny County, overdose is:

Becoming a bigger problem

In 2012, drug deaths accounted for over a quarter of morgue cases, a distinctly upward trend.  In 2007, drug deaths were just 18.7% of morgue cases.  In 2012, drug deaths were almost 65% of all accidental deaths, up from 49% in 2007.

Jennifer Janssen's graph shows the proportion of deaths caused by drugs, 2007-2012

The proportion of deaths caused by drugs, 2007-2012

Becoming a younger problem

Although the highest rate of drug overdose is still (as it has been in recent memory) in the 45-55 year old age group, 2012 saw a significant upsurge in overdose deaths for individuals aged 20-34 (40.9% of drug deaths in 2012 as compared to 27.2% in 2007).

Jennifer Janssen's graph shows drug deaths in various age groups

2012 drug deaths in various age groups

Still mostly a white male problem

Data from past years consistently show that white males make up by far the highest proportion of drug deaths and this remained true in 2012 (52.4%).  But fatal overdose among white females rose this year to 32.2%, a higher percentage than in previous years and consistent with national trends.

drug deaths race sex

2012 drug deaths broken down by race and sex

Becoming, it seems, a more complicated problem

Janssen’s presentation showed a striking increase in the number of overdose deaths caused by heroin in 2012.  But a closer look at local (and national) data points to a complex overlap between prescription opioids and heroin that results in fatal overdose.

2012 was the first year that oxymorphone (brand name Opana) was listed as a top 8 drug found in overdose deaths in Allegheny County.  Oxycodone (brand names like OxyContin and Percocet) also made the list.  Like the rest of the nation, prescription drug abuse is rising locally and users often develop an opioid dependence abusing pills, eventually moving to heroin, which is then ultimately the cause of death.

Our high rate of heroin overdose fits into a “traditional pattern of drug deaths,” as Janssen characterized it, and is typical of other cities like Detroit and Cleveland, where heroin has long been available to those interested in finding it.  The upward trend in overdose deaths, then, has to do with both heroin and prescription drug abuse; not one or the other.

The top eight drugs involved in OD include two types of prescription opioids and heroinn

The top eight drugs involved in OD include two types of prescription opioids and heroin

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Strategies to prevent overdose

Dr. Alex Walley

Dr. Alex Walley

Janssen’s presentation set a somber context for the rest of the conference.  She was followed by Dr. Alex Walley, who offered examples of solutions in his talk entitled “Addressing Opioid Overdose with Community-based Education and Naloxone Rescue Kits.”

Walley is an Assistant Professor of Medicine at Boston University, a researcher and clinician who has approached substance use and addiction from an impressive number of angles, including the implementation of effective harm reduction strategies.

He shared five strategies for addressing overdose

  • Prescription monitoring program
  • Prescription drug takeback events
  • Expansion of opioid agonist treatment
  • Safe injection facilities
  • Naloxone distribution

These strategies, as Walley emphasized, all have a place in a public health response to overdose.  They also have limitations.  For example, prescription monitoring programs don’t track illicit drugs like heroin and safe injection facilities are not currently politically feasible in the United States.

The Massachusetts Department of Public Health has particularly focused on the fifth strategy, naloxone distribution.  Since 2007, Walley has served as the Medical Director for a statewide pilot project to prevent overdose by getting naloxone into the hands of a much wider population than ever before.

Under the pilot project, the Department of Public Health offered Overdose Education and Naloxone Distribution (OEND) to community-based organizations that provide opioid users, social services agency staff, police and firefighters, and parent organizations concerned about opioid use and overdose.  It was made possible by a standing order issued by the Massachusetts Department of Health authorizing non-medical personnel to distribute naloxone.

Because naloxone is not available over-the-counter and generally requires a prescription from a medical provider, a standing order is one of the most effective ways of expanding its use and distribution.  Standing orders have been used in states like New Mexico and Illinois and cities like San Francisco and Santa Cruz.

Also notable about the Massachusetts project is its use of a relatively new vehicle for administering naloxone, an intranasal device.

intranasal naloxone

Intranasal administration of naloxone avoids needle sticks, but is not currently FDA-approved.

Walley and his colleagues published an article this year demonstrating that the program has significantly reduced overdose deaths in areas where OEND took place.

Here in Pennsylvania, the state Department of Health has not issued a standing order; naloxone is available locally through Prevention Point Pittsburgh, which distributes it to opioid users by prescription from local healthcare providers.

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Two Coalition Initiatives, Safe Landing and Project Life Line

ACOPC_banner

At the conference, the ACOPC unveiled two local initiatives designed to reduce overdose deaths in Pittsburgh and surrounding areas.

Safe Landing embeds Screening, Brief Intervention and Referral to Treatment (SBIRT) into the Allegheny General Hospital Emergency Room.  Nurses and representatives from POWER and Pyramid link patients who screen positive to community resources, emphasizing a warm hand-off under the premise that “recovering from addiction is hard enough–paperwork and navigating the system should not be barriers to recovery.”  Soon, ER staff will also provide overdose prevention education and prescribe naloxone.  Safe Landing was launched earlier this year.

Project Life Line is an ongoing partnership between local physicians and pharmacists.  Participating physicians (family doctors, pain specialists, internal medicine practices) agree to co-prescribe opioids and naloxone.   Participating pharmacists (at select Walgreen’s, Giant Eagle, and Medicine Shoppe pharmacies) receive training on opioid safety and overdose prevention and educate patients on these topics as they dispense their prescriptions.  The project is planned to launch by the end of 2013.

ACOPC was spearheaded by concerned community members and its members donate their time to these projects.  The projects themselves, as ACOPC member Dr. Jan Pringle pointed out at the conference, are not funded by grants.

“This is a true coalition of people contributing their services,” she said.

Related Articles

When Numbers Get Serious: Drugs cause a third of all accidental deaths in Allegheny County

Recommended Resources

2013 ACOPC Conference presentations are posted online and are highly recommended

Guide to Developing and Managing Overdose Prevention and Take-Home Naloxone Projects by the Harm Reduction Coalition outlines several different models for naloxone distribution

Prevention Point Pittsburgh is a nonprofit organization dedicated to providing health empowerment services to injection drug users