Improve Links to Treatment for People who Experience Non-Lethal Overdoses or Naloxone Revivals

Introductory Paragraph

Of the 39 states that share overdose information with the CDC’s DOSE program, 32 have reported a significant increase in non-lethal drug overdoses, with the country as a whole having a 21% monthly increase. Drug overdose is one of the leading causes of death for those with a SUD, and those who experience at least one non-fatal overdose have a heavy increase of dying from a subsequent overdose. The National Survey on Drug Use and Health reports that 4 out 5 Americans with a SUD do not receive proper treatment, despite a decades-long epidemic.

The following recommended actions would support reversal of these negative statistics:

• Encourage providers, clinicians, and insurance agencies to learn about the impacts of overdose and the benefits of prevention, treatment, and access to resources.
• Expand access to and education about Naloxone, even if the patient doesn’t have a current opioid prescription
• Improve access to time-sensitive resources for at-risk populations.
• Increase access to test strips that can detect the presence of drugs laced with Fentanyl.

Key Information

'Social Impact of Overdose’ Non-lethal overdoses and substance use disorders come at a great social cost when left ineffectively treated. Community consequences include productivity losses and healthcare and treatment costs and incarceration costs. Approximately 65% of inmates qualify as having a substance use disorder.

The opioid epidemic is being made considerably more dangerous with the spike in fentanyl-related overdoses. It is a highly addictive pain medication, and it is commonly(illegally) added to other drugs to enhance potency and decrease costs. The addition of fentanyl is made even more deadly because it is often added to illicit drugs without the consumer being aware, and just a small amount can trigger an overdose. It is virtually undetectable to the unsuspecting user, as it can not be seen, tasted, or smelled.

Risk Factors for Overdose In order to provide comprehensive, effective treatment options, it is critical for clinicians and community leaders to be aware of risk factors surrounding non-lethal overdoses. The following have been linked to increasing the risk of a person experiencing a non-lethal overdose:

• Recent release from prison or hospital; heightened risk periods for non-lethal overdose include:
• the day of admission (to prison)
• weeks 1-4 after release from prison
• 1-2 weeks after hospital discharge
• being dispensed opioids or benzodiazepines for pain
• 3 or more weeks after discontinuation of antipsychotics
• Polysubstance use of benzodiazepine and opioids, decreasing the efficacy of Naloxone
• Anyone who uses opioids for long-term pain management
• Rotating opioid medication regimens (incomplete cross-tolerance)
• History of SUD or prescription misuse and need for pain relief medication
• Completion of detoxification or abstinence (reduced tolerance & high risk of return to use)

Personal Impact of Overdose Survival of an overdose has lasting physical, psychological, and personal health implications for the individual that increase in likelihood and severity of each overdose. These include:

• Opioid-Induced Respiratory Depression (OIRD) - most dangerous health consequence; acute respiratory compromise, dizziness, confusion, and ineptness.
• Brain injury - hypoxia-related brain injuries, complications caused by the OIRD
• Hypoxia injuries can contribute to:
• short-term memory loss,
• changes in cognitive and physical functioning,
• increased risk of stroke, mental disorientation,
• loss of bodily movement or lower-extremity paralysis,
• gait changes,
• incontinence,
• slow reaction time,
• reduced motor skills,
• kidney failure,
• cardiac complications,
• neurological consequences and seizures,
• nerve damage,
• fluid buildup in lungs and pneumonia, and
• temporary motor paralysis
• Increased risk of comorbid mental illness
• Interruptions in education or career goals
• Family and relationship conflicts

Types of Treatment for Overdose Recognizing the signs of an overdose is the first critical step to treatment and prevention of it becoming lethal. Signs of an overdose that everyone should be aware of include (but are not limited to) :

• unconsciousness
• very small pupils
• slow or shallow breathing
• vomiting
• inability to speak
• faint heartbeat
• limp arms and legs
• pale skin
• purple lips and fingernails

If an overdose is suspected, 911 needs to be called immediately; administer Naloxone if available; remain with the person, moving them to their side; and/or administering CPR is necessary until a first responder arrives.

• Naloxone: is an opioid antagonist which rapidly reverses the symptoms of an opioid overdose by quickly restoring normal breathing. It is important to note that Naloxone is a treatment for opioid overdose and NOT for OUD. It is available as an injection or a nasal spray and can be administered by first responders, family, and friends. Co-Prescription of Naloxone and opioids has been shown in some research to reduce the risk of overdose, even if the Naloxone prescription doesn’t get filled, indicating that its prescription serves as an effective educational strategy.

Once the emergency of the overdose has passed, the individual is at an increased risk of subsequent overdosing, making the discharge period a critical time for an intervention. Comprehensive treatment may look different for each individual.

• Medication-Assisted Treatment (MAT) is clinically effective in treating substance use. FDA-approved options for opioid addiction include Methadone, Buprenorphine, and Naltrexone. For alcohol use disorder, common medications include Disulfiram, Naltrexone, and Acamprosate. The use of MAT has been shown to decrease opioid cravings and “help to sever the ties between opioid use and established situational or emotional triggers.” MAT has been clinically found to be the safest option for treating OUD, therefore access is vital for those with an opioid use disorder.
• Behavioral Therapy in Conjunction with MAT targets the broad range of issues and problems that medication doesn’t address, and addresses the “limitations associated with each form of medication.” The combination of behavioral therapy and medication is appropriate for individuals whose drug use is the result of extenuating factors such as stress, trauma, resource insecurity, etc, and is seen as an effective addition for those with comorbidities.
• Individual and Group Substance Use Treatment Therapy: Targeted group therapy provides support, witness to recovery, education, resources, accountability, stability, and a model of appropriate behavior. Individual and family therapies have been shown to reduce use, promote prosocial behaviors, and improve family functioning.
• Harm reduction services - The CDC reports that providing access to evidence-based harm reduction services such as Naloxone, 911 Good Samaritan Laws, Syringe Services Programs, academic detailing, and MAT can greatly reduce future overdoses.

Barriers to Treatment Although MAT has been recognized as a safe and effective treatment option, it remains unavailable to most people who need it due to a variety of factors including:

• delivery and financing issues
• administrative and legal barriers to medical provider prescription of FDA-approved medications
• moratoriums on mobile van clinic
• state funding for clinics (mobile and brick-and-mortar)
• insurance coverage (public and private)
• social stigma and misunderstanding surrounding MAT
• varying state and hospital policies on administering MAT
• inadequate professional education and training
• concerns about diverting MAT medications

Impact of Treatment Treatment for overdose is comprehensive, including many factors that address the physical and mental health implications of nonlethal overdose. Communities that employ various harm reduction services, such as access to Naloxone, Fentanyl testing strips, syringe service programs (SSP), mental health services, and MAT see improvements that impact the individual and the community as a whole. Benefits of access to treatment for nonlethal overdose include:

• Health seeking behaviors - access to a SSP has shown a five-fold increase in the number of people seeking treatment for their SUD.
• Cost benefit - SUD treatment is cheaper than incarceration, with every $1 spent on treatment saving $4 in health care costs.
• Improvement in job performance - Ohio programs saw 91% decrease in absenteeism).

Relevant Research

• This article examines the unintended effects of drug-reducing policies designed to tackle the opioid epidemic ny inhibiting the practice of over-prescribing. Research revealed a reduction in misuse of prescription drugs, but it also found an increase in opioid deaths related to the illicit drug market, suggesting that those who had their prescriptions restricted sought out drugs from an illegal third party.
• This article documents the efficacy of the OdRi Questionnaire that assesses risk factors for an overdose to be used in the medical and mental health fields. The tool shows promise in identifying those at risk for an overdose based upon key components addressing personal, situational, and organizational factors. Results showed mental health, specifically depression, to be a positive predictor of overdoses, along with early-life trauma and stress. Lack of treatment for illicit drug use was a positive predictor for overdoses. .
• This study found a demographic shift in overdose populations. Nonlethal overdose had primarily been seen in the non-Hispanic white community. However, the epidemic has broadened, and non-Hispanic Black men have seen the highest increase in opioid overdoses. At the time of the study, there was no difference in the likelihood of nonlethal overdose between non-Hispanic White or Black men. This suggests a marked need to address the causes of this change and treatment implementation.
• This multi-agency report titled “Medications for Opioid Use Disorder Save Lives,” covers the efficacy of MAT in different populations.

Impactful Federal, State, and Local Policies

Policy progress is being made at the federal level. An ACA Medicaid expansion now allows those leaving incarceration to have Medicaid coverage, expanding their access to MAT and other treatment options upon release from jail or prison. The Centers for Medicare & Medicaid Services has been working toward federal implementation of PDMPs for prescriptions under Medicare’s Part D plan. However, outpatient Methadone treatment can only be used when the patient is enrolled in a state or federally certified opioid treatment program which usually requires a daily visit.

Most states have also made considerable progress in the policy doamain. However, there is substantial variability in state policies. For example, every state provides ‘’criminal liability’’ protections for first responders & laypersons who administer Naloxon, but 46 states & D.C. provide ‘’civil liability’’ protections and 37 states offer’’ criminal liability’’ protections and 41 offer ‘’civil liability’’ protections for prescribing or distributing Naloxone. , Likewise, 47 states plus D.C. have some form of Good Samaritan Overdose Immunity and & Naloxone access law, but Wyoming, Kansas & Texas do not. Finally, requirements for reporting of non-fatal overdoses vary from state-to-state.

Available Tools and Resources

• SAMHSA has developed the “Opioid Overdose Prevention Toolkit” which provides steps for first responders, information for prescribers, safety advice for patients and family, and information on recovering from an opioid overdose. It also provides a state-by-state directory of opioid treatment programs. SAMHSA also has a resource for drug-free workplace on policies, testing, employee help and education, supervisor training, and program implementation. Its goal is to assist employers and employees in working towards treating/preventing drug misuse and improve testing that will help with gainful employment rather than punitive termination.

• The CDC has published “Evidence-Based Strategies for Preventing Opioid Overdose: What’s Working in the United States.”

• The Rhode Island Department of Health has put out a “Master List of Evidence-Based and Innovative Interventions for Drug Overdose Prevention,” covering the pillars of prevention, rescue, treatment, and recovery.

• Warm Handoffs offers a wide range of resources for the overdose survivor to help prevent future overdoses and negative health outcomes. This is a cross-disciplinary effort involving medical and health care professionals, law enforcement, and social workers. Successful warm handoff interventions have included provision of Naloxone, post-overdose outreach and follow-up, emergency department-based screening and referral.

• CHESS Health provides E-Recovery and mobile health connections to support people with opioid use disorder and to promotes positive behavioral change.

Promising Practices

• Drug Free Communities (DFC). There are hundreds of local substance use prevention coalitions that have participated in the DFC Program. Funding by the White House Office of National Drug Control Policy (ONDCP) provides up to $125,000 per year for five years to local community coalitions to apply evidence-informed strategies.
• The CDC has highlighted several states with promising PDMP programs. Oregon was recognized for its successful PDMP implementation, its use of the Core State Violence and Injury Prevention Program, and training collaborative for physicians and allied health care professionals on safe and effective pain care. .
• Florida’s PDMP is coupled with the implementation of regulated pain clinics and a ban on providers from giving prescription opioids in their offices. A 2012 review saw a 50% decrease in overdose deaths. .