Overview of opioid overdose, development of the epidemic in the US, and a focus on efforts in Rhode Island to address this public health concern.

1. OPIOID OVERDOSE: A RHODE
ISLAND INJURY PREVENTION
PRIORITY AREA
Valerie Strezsak
valerie_m_strezsak@brown.edu
Capstone Project, December 2013
Injury as a Public Health Problem

2. Rhode Island ranks seventh
in the nation for overdose
deaths (17.2 deaths per
100,000 persons according to
the Centers for Disease
Control and Prevention)...
2

3. and is one of 20 states where
unintentional drug overdose
is the leading cause of
unintentional injury-related
death.
3

4. How did this happen, and what
is being done to address it?
4

5. OBJECTIVES OF THIS PRESENTATION

Overview of the problem
What are opioids?
 What is an opioid overdose?


Opioid overdose at the national level
Scope of the problem
 Risk factors
 Development of the epidemic


Opioid overdose in Rhode Island
Why opioid overdose is now a priority area
 Planned approaches to reduce opioid overdose


Future directions
5

6. WHAT ARE OPIOIDS? WHAT DO THEY DO?
Opioids are narcotic pain relievers
 They bind to specific receptors in the brain, spinal
cord, and gastrointestinal tract

Minimize perception of pain
 Can also trigger other systems such as those that
regulate mood, breathing, and blood pressure

6

7. TYPES OF PRESCRIPTION OPIOIDS
Morphine
 Codeine
 Methadone
 Oxycodone
 Hydrocodone
 Fentanyl
 Hydromorphone
 Buprenorphine

7

8. HEROIN: A NON-PRESCRIPTION OPIOID

Unlike prescription
opioids, there is no
legal use for heroin
8

9. HOW DOES OPIOID OVERDOSE OCCUR?

Dosing error
By prescriber, pharmacist, patient, caregiver
 Unintentional in the commonly understood sense, an
“accident”


Deliberate misuse
Of own prescription (taking larger and/or more frequent
doses than prescribed)
 Of opioids obtained illicitly
 Typically considered unintentional, in that the individual
did not intend to overdose, even though he/she did
intentionally use the drug

9

10. WHAT HAPPENED WHEN PERSON
OVERDOSES?
10

11. SCOPE OF THE PROBLEM
Overdoses killed nearly 15,000
people in the US in 2008, more
than 3 times the 4,000 people
killed by overdose in 1999
 Nonmedical use of prescription
painkillers costs health insurers
up to $72.5 billion annually in
direct health care costs.

11

12. INJURY PYRAMID: DEATH IS THE PROVERBIAL TIP
OF THE ICEBERG
12

13. THE VICTIMS MAY NOT BE WHO YOU EXPECT
THEM TO BE…
13

14. INDIVIDUAL RISK OF OVERDOSE
Anyone using opioids is at risk of overdose
 Increased risk associated with:







Misuse of prescription, including combining opioids with
other substances such as alcohol
History of substance abuse, dependence
Gender: men are much more likely to overdose, but the
rate of overdose among women is increasing
Age: middle-aged adults are at increased risk
Living in a rural locale increases risk
Race: whites and American Indians/Alaskan Natives are
at the greatest risk
14

15. THERE HAS BEEN A MARKED INCREASE IN
OPIOID OVERDOSE IN PAST DECADE+
15

16. IS THE EPIDEMIC AN UNINTENDED
CONSEQUENCE OF PAIN MANAGEMENT?

2001 Joint
Commission Pain
Management
Standards called for
more attention to and
treatment of pain

Increase in opioid overdose deaths coincided with
a nearly fourfold increase in use of prescriptions for
pain medication
16

17. INCREASE IN OPIOID USE IS
CLEAR, ALTHOUGH PREDATES 2001
STANDARDS
17

18. OPIOIDS ARE INHERENTLY RISKY; WHEN MORE
PEOPLE RECEIVE PRESCRIPTIONS, MORE PEOPLE
WILL OVERDOSE
18

19. OVERLAP OF PRESCRIPTIONS AND OVERDOSE:
NOT PERFECT, BUT TRENDS ARE EVIDENT
19

20. OPIOID OVERDOSE IN RHODE ISLAND
20

21. RHODE ISLAND VIOLENCE AND INJURY
PREVENTION PROGRAM (VIPP)
Identifies injury prevention
priorities
 Supports implementation and
evaluation of statewide
interventions based on
population-based
recommendations

21

22. IN 2011, DRUG OVERDOSE PREVENTION &
RESCUE BECAME A VIPP PRIORITY AREA
22

23. INCREASE IN OPIOID OVERDOSE DEATHS DRIVE
THE INCREASE IN POISONING DEATHS IN RI
23

24. INCREASE IN RI OVERDOSE DEATHS
MIRRORS INCREASE IN US
24

25. GENDER DIFFERENCE IS CLEAR: MORE MEN HAVE
DIED OF OPIOID OVERDOSE IN RI
25

26. MOST DEATHS HAVE OCCURRED IN MIDDLEAGED ADULTS IN RI
26

27. DEATHS ONLY REPRESENT A FRACTION OF THE
TOTAL IMPACT OF OPIOID OVERDOSE INJURIES IN
RI, AS IN THE US
27

28. VIPP DRUG PREVENTION OVERDOSE AND
RESCUE SUBCOMMITTEE
Goal: Prevent death from unintentional drug
overdose
 Current objective: decrease or maintain rate of
death due to unintentional poisonings at 2009 level
of 13 per 100,000

28

29. HOW TO ACCOMPLISH GOAL?

Drug Overdose Prevention and Rescue
Subcommittee recommends 10 strategies:
29

30. Establish statewide overdose
surveillance mechanisms.
30

31. Increase usage and
effectiveness of the
Prescription Monitoring
Program (PMP).
31

32. Increase access to naloxone
training and distribution
programs.
32

33. Increase licensed healthcare
worker and institutional
responsibility.
33

34. Implement and expand
disposal units throughout the
state.
34

35. Support prevention policies
that work.
35

36. Increase general public
awareness of drug overdose
as a preventable public
health problem.
36

37. Support and affirm people at
risk for drug overdose.
37

38. Increase access to
substance abuse treatment.
38

39. Build state capacity to
implement drug overdose
prevention and rescue
programs.
39

40. Future
Directions: How
to Choose
Interventions?
40

41. Lack of
evidence at this
point; epidemic
is still fairly
new!
41

42. FEDERAL GOVERNMENT EFFORTS
CDC released several
promising
recommendations, including
establishment and use of
Prescription Monitoring
Program
 Substance Abuse Mental
Health Services Administration
released the first federal
resource promoting safety and
prevention information in
October 2013

42

43. RHODE ISLAND-SPECIFIC EFFORTS
Rhode Island initiative: pilot study Preventing
Overdose and Naloxone Intervention (PONI)
 From Discussion of publication:

43

44. Continued and improved
surveillance and
evidence-based methods
are underway to reverse
the opioid epidemic in RI
and the US as a whole
44

45. CITATIONS, BY SLIDE NUMBER

2: http://www.123rf.com/photo_11850338_drug-overdose-concept--passive-hand-on-floor-pills-andinjection.html; http://www.health.ri.gov/publications/plans/2013InjuryPrevention.pdf

3: http://prescription-drug.addictionblog.org/oxycontin-overdose-how-much-amount-of-oxycontin-to-od/;
http://www.health.ri.gov/publications/plans/2013InjuryPrevention.pdf

4: http://imagebing.portrait-photo.net/ocean-drive-newport-rhode/

7: http://atforum.com/news-updates/201104.php

8: http://www.neurosoup.com/heroin/

10: http://harmreduction.org/issues/overdose-prevention/overview/overdose-basics/what-is-anoverdose/

11: http://atforum.com/news/2013/06/the-soaring-cost-of-the-opioid-economy/

12: http://www.cdc.gov/homeandrecreationalsafety/rxbrief/

13: http://www.cdc.gov/vitalsigns/PainkillerOverdoses/index.html

15:
http://www.ripha.org/content/ripha/Data_Briefs/Data_Brief_Prescription_Drug_Deaths_12192011_FIN.p
df

16: http://www.va.gov/painmanagement/docs/toolkit.pdf
45

46. CITATIONS, CONTINUED

17: http://dartmed.dartmouth.edu/summer09/html/vs_opioid.php

18: http://jama.jamanetwork.com/article.aspx?articleid=1686609

19: http://www.cdc.gov/vitalsigns/painkilleroverdoses/infographic.html

20: http://www.maripoisoncenter.com/prescription.html

21: http://vaccinenewsdaily.com/medical_countermeasures/326126-health-warns-rhode-islanders-tobeware-of-risk-of-shigella-infection/; http://www.health.ri.gov/publications/plans/2013InjuryPrevention.pdf

22-39: http://www.health.ri.gov/publications/plans/2013InjuryPrevention.pdf

28: http://www.heretohelp.bc.ca/factsheet/dealing-with-alcohol-or-other-drug-overdose-situations

41: http://www.flprobatelitigation.com/2010/11/articles/new-probate-cases/will-and-trust-contests/trusteeguardianship-litigation-no-evidence-reversal-on-all-grounds/

42: http://store.samhsa.gov/product/opioid-overdose-prevention-toolkit/all-new-products/sma13-4742

43: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3177423/

44: http://www.bryandunlop.com/what-we-do/consultative-selling/
46