1

Panel In Order of Appearance

• Peter Friedmann, MD, MPH, DFASAM, FACP, Chief Research Officer, Baystate Health; President-Elect MASAM

• Robert Roose, MD, MPH, FASAM, Vice President, Mercy Behavioral Health Care; Member, Governor Baker’s Working Group on Opioids

• Alexander Walley, MD, MSc, Medical Director, Opioid Overdose Prevention Pilot Program, Mass DPH; Associate Professor of Medicine, BUSM

Panel In Order of Appearance

• Liz Whynott, MPH, Director, HIV Health and Prevention, Tapestry

• Brandon Marshall, PhD, Associate Professor of Epidemiology, Brown School of Public Health; Expert advisor, RI Governor’s Overdose Task Force.

• Jess Tilley, MA, Director, New England Users Union; Coordinator, SIF-MA Now! Western Chapter

Disclosures

• Friedmann: Endo Pharmaceuticals – legal consultation.

• Marshall, Tilley: Off-label use of fentanyl test strips

Proximate Causes and Epidemiology of Opioid Overdose Mortality

Peter D. Friedmann, MD, MPH, DFASAM, FACP Associate Dean for Research UMass Medical School-Baystate

Chief Research Officer, Baystate Health President-Elect, Massachusetts Society of Addiction Medicine

Opioids = Opiates (natural) + Opioids (synthesized)

Activate the Mu Opiate Receptor

Mu Opiate receptor

Full agonist binds & fully activates

receptor

Mu Opiate receptor

Antagonist binds but does not

activate

Mu Opiate receptor

Partial agonist binds & activates to a ceiling

high dose

DRUG DOSE

low dose

% Mu Receptor Activity

0

10

20

30

40

50

60

70

80

90

100

Full Agonist

Antagonist

Partial Agonist

Chronic Changes to Brain Circuitry

• Addiction – 4 C’s : – compulsive use, – impaired control, – continued use despite

consequences – Craving

• Behavior change is difficult – recurrence is common

Conditioned learning, memory & emotion

Decision- making

Reward and motivation

Addiction ≠ Dependence

• Physiological dependence • Seen with appropriate use of medication

• Tolerance: –↓effect with chronic use

–↑dose to achieve same effect

• Tolerance lost: »↑effect at usual dose (e.g. overdose)

»↓ dose to achieve same effect • Withdrawal

Opioid Withdrawal Syndrome

• Excruciating symptoms on cessation

• Strong Negative Reinforcer

Overdose Deaths Involving Opioids 2000-2015

Fentanyl Drives Recent Trends

Graphs from NY Times Article , MMWR Report 2017

MMWR Oct 27, 2017 (early release)

2017: 81% in Mass.

Opioid-related deaths in Mass increased 5x, 2000 to 2016

MA-DPH. An Assessment of Opioid-Related Overdoses in Massachusetts 2011-2015. Aug 2017.

2017 Q3 1,470 (↓10%)

Fatal Opioid ODs per 100,000 by MA Zip Code, 2011-2015

MA-DPH. An Assessment of Opioid-Related Overdoses in Massachusetts 2011-2015. Aug 2017.

Before 1990, most started with

heroin

% H

eroi

n Tr

eatm

ent

Adm

issi

ons

that

Use

d H

eroi

n or

Rx

Opi

oid

Firs

t

Cicero et al. JAMA Psychiatry. 2014;71(7):821-826.

Decade of First Opioid Use (No. of Users)

Slide courtesy Wilson Compton

1990-2010, most start w/

prescription opioids

The Evolving Opioid Epidemic

Prescribers have responded: 23% decrease in opioid prescribing, 2010 to 2016

Slide courtesy Wilson Compton

Now most start with heroin…again

Cicero T et al. Addictive Behaviors 2017;74:63-66Slide courtesy Wilson Compton

Year Beginning Regular Use

Overdose Deaths Involving Opioids 2000-2015

Proximate CausesClamp down on opioid

prescribing since ~2010

Poor access to medication for addiction

treatment (MAT)

Abstinence-focus (jail/prison, detox & med-free tx.) ! loss of tolerance

Riskier illicit opioid supply ↑potency, ↑variability

Overdose Death

Wider distribution of illicit opioids

↑availability, ↓price ! more 1o heroin

initiates

Death Rate Rises After Tolerance Lost

Dea

th R

ate

Per

100,

000

0.0

500.0

1000.0

1500.0

2000.0

Incarceration History No Incarceration History

MA-DPH. An Assessment of Opioid-Related Overdoses in Massachusetts 2011-2015. Aug 2017.

1 year before delivery, prior to conception

First Trimester

Second Trimester

Third Trimester

0—42 days after delivery

43—180 days after delivery

181—365 days after delivery

Overdose Events / 1 million person-days

0 1.25 2.5 3.75 5

3.6

2.4

2.5

0.7

0.7

1.9

2.1

When MAT stopped after pregnancy

After Incarceration

Medication Treatment of Opioid Use Disorder

Effectiveness in Reducing Opioid-Related Deaths

Robert J. Roose, MD, MPH, FASAM VP, Behavioral Health

Mercy Medical Center and affiliates

NIDA. Principles of Drug Addiction Treatment. 2012: www.drugabuse.gov McLellanet al., JAMA, 284:1689-1695, 2000 .

Pharmacological Treatments

(Medications)

Behavioral & Cognitive

Interventions

Social Services

Medical & Psychiatric Care

HEALTH

HOME

COMMUNITY

PURPOSE & MEANING

Treatment

Recovery

www.pediatrics.org/cgi/doi/10.1542/peds.2013-3524

Medication Treatment of OUD: Timeline

1984: Oral NTX approved for OUD 2010: ER Injectable NTX approved

 Hser, Y-I.; Hoffman, V.; Grella, C.E.; and Anglin, M.D. A 33-year follow-up of narcotics addicts. Archives of General Psychiatry 58(5):503-508, 2001.

© 2016 The Pew Charitable Trust

MAINTAINS TOLERANCE NO TOLERANCE

Schwartz RP et al. Am J Public Health. 2013 May;103(5):917-22 Carrieri MP et al. Clin Infect Dis. 2006 Dec 15;43 Suppl 4:S197-215 Kimber J, et al. BMJ. 2010; 340:c3172.

Opioid Agonist Therapy Saves Lives

H H HH

H H HH

H H HH

H H HH

H

H H HH

H H HH

H H HH

H H HH

H

Methadone Regular Outpatient

Baseline

OAT (Methadone) Effectiveness

Gunne and Gronbladh, Soc Med Aspects Drug Use 1984.

P H HH

H

P HP

H H HH

H H HH

H H H

Methadone

After 2 Years

1

32

1- Sepsis & endocarditis 2- Leg amputation 3- Sepsis

Regular Outpatient

OAT (Methadone) Effectiveness

Gunne and Gronbladh, Soc Med Aspects Drug Use 1984.

P H H

H

P P

P

OAT (Methadone) Effectiveness

After 5 YearsMethadone Regular Outpatient

Gunne and Gronbladh, Soc Med Aspects Drug Use 1984.

OAT (Buprenorphine) Effectiveness

Treatment duration (days)

# R

emai

ning

in tr

eatm

ent

0

5

10

15

20

0 50 100 150 200 250 300 350

N=20 Control (6 day taper)N=20 Subutex® Maintained

NO DEATHS IN PATIENTS MAINTAINED

4 DEATHS (20% OF SAMPLE) IN DETOXED PATIENTS (P=.015)

All received weekly individual cognitive-behavioral counseling, and twice-per-week supervised urine toxicology 

Kakko, et al. Lancet, 2003.

Lee J, Friedmann PD, Kinlock T, et al. N Engl J Med 2016;374:1232-42.

Opioid Antagonist Therapy Reduces Relapse

Clinical Treatment Individual Counseling

Group Counseling Treatment Planning

Medication Treatment Daily, Observed Dosing

Reduces Opioid Withdrawal Reduces Opioid Cravings

Blocks Opioid Effect

Adjunctive Support Care Coordination Recovery Support

Transportation Assistance Financial Counseling

Nursing & Medical Care Daily Nursing Assessments

On-Site Medical Care Laboratory Testing

Comprehensive Opioid Agonist Treatment Program

Reduces Illicit Drug Use Reduces HIV, HCV Transmission

Improves Health Status Reduces Death Rates

Jones. AJPH. Aug2015;105. Volkow ND, Frieden TR, et al N Engl J Med 370;22 May 29, 2014

OAT Treatment Gap Is Missed Opportunity

914,000

~ 50% of treatment programs offer medication

< 38% of eligible patients are offered medications

< 5% of MDs waivered to prescribe buprenorphine

Increased risk of death while waiting for treatment or just after leaving treatment

Volkow ND, Frieden TR, et al N Engl J Med 370;22 May 29, 2014

A key driver of the overdose epidemic is Opioid Use Disorder.

Expanding access to evidence-based medication treatment is an essential

component of a comprehensive response.

Medication Treatment Saves Lives!

Overdose Education and Naloxone Distribution

Alexander Y. Walley, MD, MSc Associate Professor of Medicine

Boston University School of Medicine Medical Director, Opioid Overdose Prevention Pilot Program

Massachusetts Department of Public Health

Rescue breathe/ chest compressions per rescuer’s level of training

3 4

How to Respond in an OverdoseSteps to teach patients, family, friends, caregivers

Recognize overdose

Call 911 for help

Administer naloxone as soon as it is available

Stay until help arrives

Place in recovery position if

breathing

5

1

2

Multi-step nasal spray

Single-step nasal spray (NARCAN®)

Intramuscular injection

Auto-injector (EVZIO®)

How do opioids affect breathing?

39

Opioid Receptors

How do opioids affect breathing?

40

Opioid

Opioid Receptors

Causes: • Euphoria • Pain relief • Sedation

Too Many Opioids

41

Opioid Receptors

Causes: • An overdose • Slowing and

stopping breathing

OVERDOSE

How does Naloxone affect overdose?

42

How does Naloxone affect overdose?

43

How does Naloxone affect overdose?

44

Restores Breathing

Opioid Overdose Related Deaths: Massachusetts 2004 - 2006

No Deaths1 - 56 - 1516 - 3030+

Number of Deaths

OEND programs 2006-072007-08

2009Towns

without

Naloxone coverage per 100K

0

63

125

188

250

Opioid overdose death rate

0%

25%

50%

75%

100%

No coverage1-100 ppl100+ ppl

27% reduction46% reduction

The more overdose education & naloxone distribution, the lower the opioid overdose death rate

Walley et al. BMJ 2013; 346: f174.

45-minute enhanced counseling session reduces overdose events among people with previous overdose, already

equipped with naloxone from a naloxone program

Proportion of REBOOT and control participants with any overdose in preceding 4

months, San Francisco 2014-2016

Coffin PO et al. (2017) PLoS ONE 12(10): e0183354.

Patients co-prescribed naloxone with chronic opioids for pain have fewer

opioid-related ED visits

Coffin PO, et al. Nonrandomized intervention study of naloxone coprescription for primary care patient receiving long-term opioid therapy for pain. Ann Intern Med 2016; 1-8.

Risk Compensation and Moral Hazard->> Narcan Party Urban Legend = Fake News

Naloxone distribution does not increase drug use – Maxwell et al.,Journal of Addictive Diseases, 2006; – Seal et al., Journal of Urban Health, 2005; – Wagner et al., 2010 International Journal of Drug Policy;  – Doe-Simkins et al, BMC Public Health, 2014 – Jones et al. Addictive Behaviors 2017:71:104-6

?

Role of Syringe Service Programs (SSPs) in

Implementing Effective Interventions to Reduce Mortality 

Liz Whynott, MPH Director of HIV Health and Prevention

Tapestry

Numerous Public Health, Policy & Faith-Based Organizations Support

SSPsPublic Health & Policy Organizations :

1. American Medical Association 2. American Public Health Association 3. American College of Physicians 4. American Academy of Family Physicians 5. American Academy of Pediatrics 6. American Society of Addiction Medicine 7. American Medical Student Association 8. American Bar Association 9. International Red Cross-Red Crescent

Society 10. Latino Commission on AIDS 11. NAACP 12. National Academy of Sciences 13. National Black Leadership Commission on

AIDS 14. National Black Police Association 15. National Institute on Drug Abuse 16. Office of National Drug Control Policy 17. Presidential Advisory Committee on AIDS 18. US Conference of Mayors 19. World Bank 20. World Health Organization

Faith -based organizations: 1. Catholic Charities of the Albany

Diocese (operates SEP in Albany) 2. Central Conference of American

Rabbis 3. Episcopal Church 4. National Council of Jewish Women 5. Presbyterian Church of the United

States 6. Society of Christian Ethics 7. Union for Reform Judaism 8. Unitarian Universalist Association 9. United Church of Christ 10. United Methodist Church, General

Board of Church and Society 11. Regional AIDS Interfaith Network

Syringe Service Initiatives Western MA

1993 State Legislature approves pilot program 1994 Boston/Cambridge SAP Program opened 1995 Legislature approved expansion to 10 sites 1995 Northampton SAP opened 1996 Provincetown SAP opened, Holyoke & Springfield SAP debates 1998 Springfield SAP debate 2001 Needle exchange planning initiative, Holyoke SAP debate 2005 Springfield SAP debate 2006 Legislation passes legalizing pharmacy sales 2009 12/2009 Federal ban lifted 2012 1/5/2012 Federal Ban reinstated 8/15/2012 Holyoke SAP Opened 10/2012 Lawsuit filed by members of Holyoke City Council

2016- 3/2016 Court rules Holyoke SAP improperly established, ordered to close in absence of City Council vote

2016. 7/2016- new law eliminates 10-clinic cap on MADPH-sponsored needle-exchange programs, clarifies need for “local approval” before opening, approval put in the hands of local health officials.

2016-17 Greenfield, North Adams and Pittsfield vote to allow SSP

2017 6/2017 State High Court rules private SAP’s are legal

Syringe Service Initiatives Western MA

Syringe Service(SSPs) Public Health Impact

• Decrease prevalence of HIV and HCV, incidence of HIV.1-3 • Decrease costs associated with HIV and HCV4-5

– Lifetime cost of HIV treatment ~$380,000, HCV treatment $40,000.

– Tapestry pays 19c per syringe • Increase entry into addiction treatment. 6-8 • Do not increase discarded syringes in the community. 9-11 • Do not increase crime where they are located.12-13 • Reduce needlestick injuries to first responders.14

Total Reported Tapestry Pilot Reversals 2014-2016Tapestry Reports That Narcan Was Used to Reverse an

Overdose**

0

55

110

165

220

2012 2013 2014 2015 2016

203

178

112

86

60

Tapestry Reports That Narcan Was Used to Reverse an Overdose**

**Reported Reversals are self-reported data from Tapestry Clients

Holyoke Opioid Overdose Deaths & Reported Tapestry

Pilot Reversals 2014-2016

0

20

40

60

80

2012 2013 2014 2015 2016

71

50

31

171511

71085

Overdose Deaths*Tapestry Reported Overdose Reversals**

*https://www.mass.gov/files/documents/2017/11/13/sec3-od%20deaths%20by%20city-town%20Nov-17.pdf **Reported Reversals are self-reported data from Tapestry Clients

Springfield Opioid Overdose Deaths & Reported Tapestry

Pilot Reversals 2014-2016

0

13

25

38

50

2012 2013 2014 2015 2016

91012118

4141

212226

Overdose Deaths*Tapestry Reported Overdose Reversals**

*https://www.mass.gov/files/documents/2017/11/13/sec3-od%20deaths%20by%20city-town%20Nov-17.pdf **Reported Reversals are self-reported data from Tapestry Clients

Summary• SSPs essential to comprehensive

community strategy to reduce opioid-related mortality: – Increase addiction treatment entry – Allow lifesaving interventions (e.g.

naloxone) to reach affected population – Reduce HIV, HCV

• No effect on drug use, crime, unsafe disposal

Thank you!

1. Hall, H.I., Song, R., Rhodes, P., Prejean, J., An, Q., Lee, L., Karon, J., Brookmeyer, R., Kaplan, E.H., Mckenna, M.T., & Janssen, R.S. (2008). Estimation of HIV incidence. Journal of the American Medical Association, 300(5), 520-529. 2. Centers for 2. Schackman, B.R., et al., The lifetime cost of current human immunodeficiency virus care in the United States. Medical care, 2006. 44(11): p. 990-997. Disease Control and Prevention, HIV Cost-effectiveness. HIV/ AIDS 2015 September 23, 2015 [cited 2016 June 14]; Available from: HIV Cost-effectiveness. 3. Martin N.K., et al. , Hepatitis C virus treatment for prevention among people who inject drugs: modeling treatment scale-up in the age of direct-acting antivirals. Hepatology, 2013. 58(5): p. 12. 4. Schackman, B.R., et al., The lifetime cost of current human immunodeficiency virus care in the United States. Medical care, 2006. 44(11): p. 990-997. 5. Centers for Disease Control and Prevention, HIV Cost-effectiveness. HIV/ AIDS 2015 September 23, 2015 [cited 2016 June 14]; Available from: HIV Cost-effectiveness. 6. Kidorf M, King VL, Peirce J, Kolodner K, Brooner RK. Benefits of concurrent syringe exchange and substance abuse treatment participation. J Subst Abuse Treat 2011;40(3):265-71. 7. Strathdee SA, Celentano DD, Shah N, et al. Needle-exchange attendance and health care utilization promote entry into detoxification. J Urban Health 1999;76(4):448-60. 8. Hagan H, McGough JP, Thiede H, Hopkins S, Duchin J, Alexander ER. Reduced injection frequency and increased entry and retention in drug treatment associated with needle-exchange participation in Seattle drug injectors. J Subst Abuse Treat 2000;19(3):247-52 9. Doherty MC, Garfein RS, Vlahov D, et al. Discarded needles do not increase soon after the opening of a needle exchange program. Am J Epidemiol. 1997;145:730–737. 10. Toronto Dept of Public Works. Needle/syringes collected through the GTNOTS campaign. In: Lurie P, Reingold AL, Bowser B, eds. The Public Health Impact of Needle Exchange Programs in the United States and Abroad. Vol. 1. San Francisco: Institute for Public Health Studies,University of California at San Francisco; 1993:39. 11. Oliver KJ, Friedman SR, Maynard H, Magnuson L, Des Jarlais DC. Impact of a needle exchange program on potentially infectious syringe sin public places [letter]. J Acquir Immune Defic Syndr. 1992;5:534–535 12. Galea S, Ahern J, Fuller C, Freudenberg N, Vlahov D. Needle exchange programs and experience of violence in an inner city neighborhood. J Acquir Immune Defic Syndr 2001;28(3):282-8. 13.Marx, M., Crape, B, et. Al. Trends in crime and the introduction of a needle exchange program, Am J Public Health. 2000: 90(12): 1933–1936. 14. Lorentz J, Hill L, Samimi B. Occupational needle stick injuries in a metropolitan police force. Am J Prev Med 2000;18(2):146-50.

Liz Whynott, MPH Director of HIV Health and Prevention

413-588-4421 lwhynott@tapestryhealth.org

Safe Injection Facilities:

What Are They & How Do They Reduce Overdose Deaths?

 

Brandon D.L. Marshall, PhD. Associate Professor of Epidemiology

Brown School of Public Health

• 2016: over 3.6 million visits • Over 18,000 individuals registered • Over 700 visits/day (full capacity) • ~60% of visits include use of injection room • In 2016:

o 1,781 overdose incidents o 4,503 clinical treatment interventions o 5,321 referrals to social and health services o 464 referrals to Onsite detox

Vancouver SIF Stats

http://www.vch.ca/public-health/harm-reduction/supervised-injection-sites/insite-user-statistics

Wood et al., CMAJ, 2004

Supervised injection facilities reduce public injection and injection-related litter

DeBeck et al., Drug Alcohol Dependence, 2011

Post-SIF: Sep 21, 2003 – Dec 31, 2005

Fatal OD rates (per 100,000 py’s) before and after the opening of the SIFPre-SIF: Jan 1, 2001 – Sep 20, 2003

701 – 900; 901 – 1,100;0; 0.01 – 100; 101 – 300; 301 – 500; 501 – 700; 1,101 – 1,300; >1,300

Results

Acknowledgements• SEOSI & VIDUS participants; clientele and staff of Insite • SEOSI/VIDUS PIs Thomas Kerr & Evan Wood • CfE staff for their research and administrative assistance,

including Deborah Graham, Peter Vann, Tricia Collingham, Carmen Rock, Caitlin Johnston, Steve Cain, and Calvin Lai

• SIF evaluation originally made possible with a financial contribution from Health Canada; although the views herein do not reflect their official policies.

• The SIF evaluation currently supported by the Canadian Institutes of Health Research (HPR-85526 and RAA-79918) and VCH

• Photos by M-J Milloy

Thank You! brandon_marshall@brown.edu

Street Outreach & Safe Consumption Services for Users Who Will Not Access “Brick And Mortar” Sites

Jess Tilley, MA Director, New England Users Union

Coordinator, SIF-MA Now! Western Chapter

Western Chapter

Fentanyl Test Strips

One line POSITIVE

Two lines NEGATIVE

What the Results Mean