Overdose Prevention, Recognition, and Response MISSION Centering Harm Reduction in Arizona Through Participant-Driven Advocacy, Education, and Outreach

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Overdose Prevention, Recognition, and Response MISSION Centering harm reduction in Arizona through participant-driven advocacy, education, and outreach

HOW WE DO IT ● Statewide Overdose Prevention and Naloxone Distribution Program ● Comprehensive Harm Reduction Education and Outreach Program ● In-depth Trainings on HIV/HCV, Stimulants, Needlestick Prevention, Stigma, & more ● Local and Legislative Advocacy OVERVIEW • Harm Reduction & Stigma • National and State Overdose Trends • The Drugs • Overdose Prevention, Recognition & Response • Next Steps HARM REDUCTION HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE 19.3 Million

did not receive substance use treatment at a specialty facility 18.3 Million did not perceive a need for treatment HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE

WHAT IS HARM REDUCTION?

A set of practical strategies and ideas aimed at reducing negative consequences associated with drug use.

Harm Reduction is also a movement for social justice built on a belief in, and respect for, the rights of people who use drugs.

https://harmreduction.org/about-us/principles-of-harm-reduction/ HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE

WHAT DOES HARM REDUCTION DO? Centers people who use drugs as more than their drug use and as experts on their own care.

Recognizes that drug use and recovery is complex and exists along a continuum. For some, drugs meet important needs so drug-related harm cannot be assumed and abstinence can be just one of many possible goals.

Aims to meet people “where they’re at” by supporting ANY positive change.

Harm reduction does not aim to minimize real harm related to substance use. HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE

HARM REDUCTION IN ACTION

DRUG USE SEX WORK HIV/HCV

● Needle ● Screening clients ● Access to testing exchanges ● Peer-education ● Not sharing ● Wound care ● Safe sex supplies equipment ● Take-home ● Condom ● Or only sharing with others who Naloxone negotiating skills have the same ● Fentanyl testing ● The buddy system status strips ● Knowing ● Reducing alcohol ● MAT boundaries consumption for ● Supervised HCV consumption sites ● PEP, PrEP, Antiretrovirals ● Bleach kits STIGMA HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE

WHAT IS STIGMA Stereotype: a negative belief about a group (dangerousness, laziness, moral weakness)

Prejudice: Agreement with belief + negative emotional reaction (fear, anger)

Discrimination: Behavior response to prejudice (avoidance, withhold access to basic needs/help)

Stigma permeates every aspect of a marginalized person’s life – relationships, health care, housing, employment, and education. HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE

WHAT IS STIGMA • Stigma from individuals – “Junkies”

• Institutional stigma – HCV tx excluding current users

• Self-stigma (internalized) – “I don’t deserve anything good”

• Stigma by association – Married to a person who uses drugs HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE

HEALTH DISPARITIES Hepatitis C – 33% of young PWID, 70-90% of older & former PWID (CDC) HIV – Global prevalence among PWID 28x higher • 50-90% of PWUD living with HIV also have HCV Trauma - In surveys of adolescents receiving treatment for substance abuse, more than 70% of patients had a history of trauma exposure Nutrition - Lower average weight than controls Arrest - 1,488,707 drug arrests in 2015 (84% possession) Incarceration - 2,224,400 in 2014 Education – Financial aid denied for students w/ drug convictions http://www.drugpolicy.org/press-release/2017/09/new-fbi-report- shows-drug-arrests-increased-2016-drug-war-rages TRENDS HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE

NATIONAL TRENDS • Overdose > motor vehicle accidents • 70,000+ deaths in 2017 • Rural, veterans • Death most likely in ﬁrst 28 days after leaving inpatient

https://www.dea.gov/press-releases/2018/11/02/dea-releases-2018-national-drug-threat-assessment-0 https://www.cdc.gov/drugoverdose/data/statedeaths.html https://www.mdedge.com/emergencymedicine/article/132735/toxicology/who-overdoses-opioids-va-emergency-departm ent https://www.ncbi.nlm.nih.gov/pmc/articles/PMC153851/ HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE

ARIZONA TRENDS • 2017 – 949 opioid related deaths • Age group – 42% 25-44 y.o. • Over 51,000 opioid-related encounters costing $431 million • 4 Arizonans a day die of OD • Mohave, Pima, Graham, Gila

https://www.azdhs.gov/documents/prevention/womens-childrens-health/injury-prevention/opioid-prevention/2017-o pioid-emergency-response-report.pdf https://www.azdhs.gov/prevention/womens-childrens-health/injury-prevention/opioid-prevention/opioids/index.php# dashboard HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE DRUGS HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE

WHAT IS SUBSTANCE USE DISORDER? • A DSM V recognized mental health disorder

• Can be mild, moderate, or severe

• Does not occur in every person who uses drugs, or even every person who becomes physically dependent

• Often related to social determinants of health, past or current abuse and trauma

• Can be a coping mechanism for some people

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5525418/ HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE

OPIOIDS Types • Heroin • Prescription opioids (licit and illicit use) – Hydrocodone (Vicodin), Oxycodone (Oxycontin, Percocet), Hydromorphone (Dilaudid), Morphine, Methadone, Fentanyl, Codeine • Methadone used in opioid replacement therapy Eﬀects • Chronic and acute pain relief; cancer and non-cancer pain • Cough suppression (often codeine) • Sleep • Euphoric feelings • Relaxation HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE

FENTANYL Facts • Most fentanyl found in street drugs is produced illegally • Fentanyl is usually added to the drug supply before it enters the US • The CDC reports a 200% increase (between 2000 and 2014) in the rate of overdose deaths involving opioids, including an 80% increase in fatal overdoses involving fentanyl and other synthetic opioids in only one year • It is often impossible to tell if a drug is laced with fentanyl unless you test it

http://www.drugpolicy.org/sites/default/ﬁles/Synthetic-Opioids-Fact-Sheet.pdf HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE

FENTANYL Myths • You can overdose and die from touching fentanyl • People who know there is fentanyl in their drugs do not care and will not change their behavior • Naloxone can’t save you from a fentanyl overdose • Fentanyl overdoses are diﬀerent from other opioid overdoses

http://www.drugpolicy.org/sites/default/ﬁles/Synthetic-Opioids-Fact-Sheet.pdf HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE

FENTANYL HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE

NON-OPIOID DEPRESSANTS Types • Benzodiazepines – Klonopin, Xanax, Valium, Ativan • Sleep Aids – Ambien, Lunesta • Muscle Relaxers – Somas, Flexeril

Eﬀects • Sedative, sleep-inducing, anti-anxiety, anticonvulsant, muscle relaxing properties. • Useful in treating anxiety, insomnia, agitation, seizures, muscle spasms, alcohol & opioid withdrawal • Enhance the eﬀects of heroin, alcohol, and marijuana HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE

STIMULANTS Types • Cocaine – powdered and crack • Meth/Speed • Prescription stimulants – Ritalin, Adderall Eﬀects • Historically used to treat asthma & other respiratory problems, obesity, neurological disorders • Prescribed for the treatment of narcolepsy, ADHD, and depression that has not responded to other treatments • Increased alertness, attention, & energy, elevate blood pressure, increase heart rate and respiration, constrict blood vessels, increase blood glucose OVERDOSE HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE

WHAT IS A STIMULANT OVERDOSE? • Also known as “overamping” • Not as cut and dry as an opioid overdose, more unpredictable & harder to deﬁne • Can be physical, psychological, or both • Likelihood of stimulant OD often tied to a person’s physical health – pre-existing high blood pressure or heart disease, lack of sleep, nutrition, hydration

https://harmreduction.org/issues/overdose-prevention/overview/stimulant-overamping-basics/ HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE

HOW TO RESPOND TO A STIMULANT OVERDOSE • First, ﬁgure out what is needed, medical assistance, or support and rest? • There is no “antidote” to a stimulant OD, like Naloxone. • A stimulant OD can result in serious medical emergencies like seizure, stroke, overheating or heart attack. HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE

WHAT IS AN OPIOID OVERDOSE? HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE

LOCATION OF SUSPECTED OVERDOSE

http://azdhs.gov/documents/prevention/womens-childrens-health/injury-prevention/opioid-prevention/opioid-re port.pdf HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE

High Overdosed

Muscles become relaxed Pale or gray, clammy skin

Speech is slowed or slurred Breathing is infrequent or has stopped Sleepy looking Deep snoring, gurgling, or rattling Responsive to shouting, sternal Unresponsive to any stimuli rub, or earlobe pinch

Normal heart rate and/or pulse Slow or no heart rate and/or pulse Normal skin tone Blue or gray lips and/or ﬁngertips HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE

RISK FACTORS FOR OVERDOSE

• Mixing drugs

• Variation in purity

• Tolerance changes

• Using alone

• Physical health NALOXONE/ NARCAN HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE

RESPONDING: NARCAN/NALOXONE HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE

ARIZONA NALOXONE LAWS • HB 2489 (2015), HB 2355 (2016), HB 2493 (2017)

A.R.S. 36-2266 & 36-2267 • Protects prescribers from certain liabilities • Allows for standing order • Allows for 3rd party prescription • Protects person who administers medication

A.R.S. 32-1979 • OTC pharmacy sale • Pharmacy board must create rule HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE

NALOXONE MYTHS • “Naloxone encourages drug use.”

• “It sends the wrong message!”

• “It could hurt somebody not overdosing.”

• “Reversal requires medical professional.”

• “But in Pulp Fiction…”

https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6423a2.htm https://prescribetoprevent.org/wp2015/wp-content/uploads/PHLRKnowledgeAsset_Naloxone_FINALfull_8J une15.pdf HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE

RESPONDING TO AN OPIOID OVERDOSE • 1. Sternum rub • 2. Call 911 • 3. Administer naloxone, if on hand • 4. Rescue breathe HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE

RESPONDING: NARCAN • Administer one dose • Return to rescue breathing • Should work within 2 minutes; if it doesn’t, give 2nd dose • Narcan can wear oﬀ within 45-90 minutes – overdose could reoccur • Transfer care to EMS, otherwise stay with person and observe 3 hours • 911 should always be called ﬁrst!! HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE

RESPONDING: RESCUE BREATHING • One hand tilting forehead back and plugging nose • Other hand on chin opening mouth • Create a seal with your mouth around their mouth HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE

RECOVERY POSITION HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE

INTRAMUSCULAR NARCAN INTRANASAL NARCAN HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE

WHO SHOULD HAVE NALOXONE? • CDC: 83% of people who administered naloxone were people who use drugs (2015) • Friends and family • Law enforcement • Jails, prisons, probation • Treatment centers, sober living • Homeless shelters & services

https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6423a2.htm HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE

AFTER THE OVERDOSE • “Ungrateful that I saved their life” • ONE person communicating, explain what happened • Prevention messages – what happened this time and how can we keep it from happening again? • Get OD survivor and their family Naloxone • Could be a good time to talk treatment and support options WHERE? WHERE TO INCORPORATE? • Street-based outreach • Peer distribution • Co-prescribing • Treatment centers, jails distribute upon release • Probation/Parole Oﬃcers distribute to clients • EMS and hospital distribution/prescription • Pharmacist-initiated distribution HARM REDUCTION STIGMA TRENDS DRUGS OVERDOSE NALOXONE

SPW NUMBERS

Sep 2016-May 2019 233,192 Doses of Naloxone 7,251 Overdose Reversals RESOURCES ● Harm Reduction Coalition - http://harmreduction.org/issues/overdose-pre vention/ ● Drug Policy Alliance - http://www.drugpolicy.org/drug-overdose ● Overdose Prevention Alliance - http://overdoseprevention.blogspot.com/ ● Prescribe to Prevent - http://prescribetoprevent.org/ Thank you

STAFF NAME Overdose Prevention Coordinator

STAFF CONTACT INFO www.spwaz.org