Contents
I Introduction
II A Critical Intervention Addressing the Opioid Crisis in Ontario
III Risk of Overdose
IV Accidental Overdose is Preventable
V Naloxone Can Save a Life
VI Opioid Overdose Prevention Kits Containing Naloxone
VII Raising Awareness: Prevention Education and Training
VIII Next Steps: Expanding Access
IX References
X Related Resources
–submitted by Meghan O’Leary, MSc, Kingston Community Health Centres, Ron Shore, B.A., M.P.A., Director, Clinical Services, Kingston Community Health Centres, and Nadia Zurba, MPA, Program Manager, Ontario Harm Reduction Distribution Program, Kingston Community Health Centres
I Introduction
Death from drug-related overdose is a leading cause of accidental death in Ontario. Opioid overdose is a major public health concern requiring attention through targeted intervention strategies (Walley et al., 2013; Fischer et al., 2008). Each year in Ontario between 300 and 400 people die from overdose involving prescription opioids, most commonly oxycodone (OPDP Notice, 2012).With the removal of OxyContin from the Canadian market and replacement by a new tamper-proof formulation of the oxycodone-based medication, OxyNeo in March 2012, thousands of people are at greater risk of accidental overdose as they transition to using other substances and opioids.
Removing OxyContin from the Canadian market, delisting OxyNeo from the Ontario Drug Benefit Program, in conjunction with implementing a narcotics monitoring database are intended to curb the number of people addicted to opiate painkillers but, these alone will not solve the crisis of widespread opioid dependence and misuse. Increased access to support services, treatment, harm reduction measures and prevention education initiatives are required as part of a coordinated response, as recognized by the Honourable Minister of Health, Deb Mathews (MOHLTC Health Bulletins, 2012).
The Ontario Minister of Health convened an Expert Working Group on Narcotic Addiction in early 2012 to provide guidance on Ontario’s opioid crisis. Stemming from their recommendations, “the government has devoted new resources to col¬lect real-time information on withdrawal, expand ac¬cess to addiction treatment and deploy emergency overdose kits across the province, including to First Nation communities” (Honourable Minister of Health, Deb Matthews, 2012).
As of 2011, only two programs in Canada were providing Naloxone kits to their clients in tandem with overdose prevention training. The first was Streetworks in Edmonton (Dong et al., 2012). The second was the Point Program at The Works, Toronto Public Health – the first program in Ontario to pilot this prevention strategy as part of a comprehensive plan to reduce overdose deaths in Toronto. Building on this model, and working in collaboration with its staff, the program has been developed for provincial application with the intention of making Naloxone – a life-saving medicine, accessible to all Ontarians at risk of opioid overdose. British Columbia followed suit, implementing a provincial Naloxone Program in 2012 (Buxton et al., 2012).
II A Critical Intervention Addressing the Opioid Crisis in Ontario
The Ontario Harm Reduction Distribution Program (OHRDP) is funded to distribute overdose prevention kits containing Naloxone throughout the province, as well as support the implementation of standardized overdose prevention training and education to staff and clients of harm reduction programs. This overdose prevention initiative expands on the support currently being provided through OHRDP to 36 core needle syringe programs (which further support approximately 200 additional needle syringe programs across Ontario). OHRDP, a program of Kingston Community Health Centres, is mandated to bulk purchase and distribute harm reduction supplies including sterile water, tourniquets, filters, alcohol swabs, cookers, and vitamin C, to complement the needles and syringes supplied by the Public Health Division of the Ministry of Health and Long-Term Care. This prevention program helps reduce the risks of transmission of infectious diseases, such as hepatitis C (HCV) and HIV and other blood borne pathogens (Leonard and Germain, 2009). Overdose prevention kits containing Naloxone are an additional harm reduction supply item that enhances the existing inventory of products currently distributed through OHRDP, promoting equal access province-wide.
These two components – Naloxone kits and education – are the keystones of prevention initiatives widely known as “community-based Naloxone distribution programs.” This targeted intervention intends to directly reduce the number of opioid overdoses in Ontario.
III Risk of Overdose
The extensive proliferation of non-medical use of prescription opioids throughout Ontario, in both the general population and street-drug-use populations, is alarming, particularly because it has been accompanied by a steep increase in opioid related mortality (Fischer and Rehm, 2009; Martin et al., 2006). In areas with high prescription rates, street access to prescription opioids and their misuse may also be greater. Ontario research highlights “a strong association between regions with high opioid prescription utilization and those with high opioid-related death rates” (Gomes et al., 2011). Between 1991 and 2007, prescriptions for oxycodone increased by 850% while opioid-related deaths doubled between 1991 and 2004 to approximately 340 Ontarians in 2004 (Dhalla et al., 2009).
Among injection drug users, prescription opioids has grown to be the drug of choice for many; with morphine being the most commonly used, far exceeding cocaine or heroin (Fischer et al., 2008). Studies of drug use trends show that illicit prescription opioid use has become more prevalent than heroin use (Davis and Johnson, 2008; Fischer et al., 2006). But, recent media reports indicate that heroin is making a resurgence as a cheap, available alternative to OxyContin (Ogilvie, 2012; Richmond, 2012), while Fentanyl is gaining attention for overdose deaths in other communities in Ontario (CBC News, 2012; Hurley, 2012). There is concern expressed by harm reduction service providers across the province that the number of fentanyl-related overdoses could continue to rise as more people experiment with fentanyl as they find a replacement drug of choice in lieu of OxyContin. This mimics the evidence reported by U.S researchers studying the shifting drug-use patterns since the abuse-deterrent formulation of OxyContin was released back in August 2010, in the U.S. The findings concluded that there was no evidence that OxyContin abusers ceased their drug abuse as a result of the reformulation. Instead, the unexpected outcome was people shifting to other opioids, with heroin most commonly reported, which may pose a much greater health risk. As well, high-potency fentanyl and hydromorphone as a drug of choice rose noticeably from 20% to 32% (Cicero et al., 2012).
Switching opioids is a major risk factor for overdose as the strength and potency varies between each type of opioid and a person’s own tolerance also varies between drugs. Turning to increasingly harmful drug use, such as injecting heroin or Fentanyl, is associated with further negative health effects including an increased risk of transmitting hepatitis C and HIV by sharing drug preparation equipment (Firestone et al., 2009; Strike et al., 2006).
Overdose risk factors Include:
Mixing drugs and alcohol (licit and illicit): There is no ex¬act formula for determining how much of a certain drug or combination of drugs, will lead to an overdose.
Using alone.
Using in an unfamiliar environment.
Using after a period of abstinence (including treatment programs and prison); statistically, there is an increased risk of overdose during the first two weeks after release from prison.
Switching opioids: from one to another, as the strength and potency varies between each type of opioid. As well, a person’s tolerance also varies among different drugs.
Using without testing first.
Using from an unknown source or new dealer, as a person does not know exactly what they are getting.
An individual’s physical characteristics play a role: weight, health, tolerance for a drug at that particular time, drug potency, route of administration, or frequency/amount used.
The statistics surrounding Ontario’s opioid crisis vindicate the immediate need for targeted public health interventions and educational resources focused on overdose prevention education, including the availability of overdose prevention kits containing Naloxone as a primary initiative to reduce the number of opioid overdoses in Ontario.
IV Accidental Overdose is Preventable
According to the Report of the To¬ronto and Ottawa Supervised Consumption Assess¬ment Study, about one in five people who use drugs in Toronto and Ottawa reported that they had overdosed in the last six months (Bayoumi and Strike et al., 2012).
Overdose commonly occurs in the user’s home and in the company of others. Of those who inject with other people, 65% reported that they most commonly injected with a close friend and about 30% reported that they most commonly injected with a regular sex partner (Bayoumi and Strike et al., 2012). Although emergency medi¬cal staff are trained to administer Naloxone in the case of opioid overdose, 911 is not always called to respond due to fear of repercussions (Waterloo Region Crime Prevention Council, 2012). There is a critical period of time when an intervention can take place to reverse overdose and save a life, if the people present have access to Naloxone and are trained on how to administer it. There is an important role for health care service providers to play in collaborating with first responders to promote the necessity of calling 911 as well as educating people about reducing the risk of overdose, dispelling myths, and how to respond appropriately in an overdose situation.
V Naloxone Can Save a Life
Naloxone is an opioid antagonist that can immediately reverse the effects of an opioid and help restore breathing and consciousness, allowing time to access emergency medical services. It is to be used as a crisis intervention, injected into a muscle and working within minutes to help save a life. There are little or no risks when given as described in the overdose prevention kits and it has not been shown to produce tolerance or cause physical or psychological dependence (Product Monograph, 2005). Naloxone produces withdrawal symptoms when administered in an opioid-dependent person, thereby discouraging misuse.
By increasing access to Naloxone and delivering key prevention messaging and training, this initiative has proven effective in other countries and cities at mitigating the risks associated with drug use, and in particular, reducing the number of accidental, opioid-related deaths.
Harm reduction programs in the United States started distributing Naloxone in 1996 and as of 2010, 150 programs in 19 states operate a take‐home Naloxone program. One ex¬ample, the Chicago Recovery Alliance, has con¬ducted more than 4600 trainings and Naloxone prescriptions resulting in 416 overdose reversals reported between 1999 and 2006 (CDC, 2012).
A recent report by the US Centre for Disease Control on community-based Naloxone programs in the United States found that take-home Naloxone programs help to reduce overdose deaths by giving members of the community the right information, training, and tools. Since the first opioid overdose prevention program began distributing Naloxone in 1996, programs reported training and distributing Naloxone to 53,032 people and re¬ceiving reports of 10,171 overdose reversals. Pro¬viding opioid overdose education and Naloxone to people who use drugs and to people who might be present at an opioid overdose can help reduce opioid overdose mortality. The report con¬cludes that Naloxone could save thousands of lives if public health agencies distributed it more broadly (CDC, 2012).
In addition, a recent study revealed that those who witnessed an overdose and administered Naloxone are less likely to share syringes than those who didn’t administer Naloxone. This data contributes to the larger question as to the potential wider, positive effects or behavioural modifications that Naloxone distribution may have beyond its ability to reduce overdose risk behaviours or reverse an overdose (Coffin et al., 2012), such as potentially helping reduce transmission of hepatitis C and HIV.
VI Opioid Overdose Prevention Kits Containing Naloxone
Opiod Overdose Prevention Kit
It is recommended that each kit contain:
2 ampoules of Naloxone
2 retractable syringes: 1cc ‐ 25G x1”
2 alcohol swabs
Non‐latex gloves
Rescue breathing barrier (for agencies that recommend rescue breathing)
Client identifier card
Overdose response pamphlet.
The components of the overdose prevention kits, including Naloxone, are available for order through OHRDP. Each agency has the ability to customize the kit beyond what is supplied through OHRDP to en¬sure that the kit reflects agency and community need. The kit contents are also dependent on an agency’s own policies and procedures – namely, its related medical directive.
Agencies interested in making overdose prevention kits containing Naloxone available to their clients can contact OHRDP for assistance with next steps and accountability measures.
VII Raising Awareness: Components of the Overdose Prevention Initiative
To support the implementation of community-based Naloxone distribution programs, the Ontario Harm Reduction Distribution Program developed supporting resources and educational material for program staff and clients.
In March 2012, OHRDP coordinated a webinar series on overdose prevention and Naloxone distribution, based on the training currently being offered at The Works, Toronto Public Health and through The Waterloo Region Crime Prevention Council and Preventing Overdose Waterloo Wellington (POWW). Training consisted of three sessions:
Opioid overdose prevention and identification
How to develop and operate a community-based Naloxone distribution program
Discussion on the legal, liability, and practice issues related to the operation of a Naloxone program.
OHRDP has developed a Community-Based Naloxone Distribution Guidance Document to assist programs with implementation of overdose prevention training and community-based Naloxone distribution in an accountable, sustainable way. Additionally, OHRDP has produced three client education posters; Drug Categories, Prevent Overdose and Opioid Overdose Signs and Symptoms, to help begin discussions with clients about overdose prevention.
VIII Next Steps: Expanding Access
Wider dissemination of staff training is needed as organizations work to build capacity and knowledge around the importance of overdose prevention education and the public health benefit of instituting a community-based Naloxone distribution program in communities throughout Ontario. There is widespread interest from harm reduction service providers but without adequate staff training, program uptake is slow.
OHRDP will continue to disseminate prevention resources, including the overdose prevention kits containing Naloxone, and supporting agencies in their programming efforts.
A major reduction in opioid related death will continue to be a challenging public health priority requiring various intervention strategies and robust prevention education. Access to overdose prevention education and Naloxone kits through harm reduction programs is one critical initiative that will help to save lives in Ontario.
IX References
Bayoumi AM, Strike C, et al. (2012) Report of the To¬ronto and Ottawa Supervised Consumption Assessment Study, 2012. Toronto, Ontario. St. Michael’s Hospital and the Dalla Lana School of Public Health, University of Toronto.
Buxton, J, Purssell, R, Gibson, E, &Tzemiz, D (2012) Increasing access to Naloxone in BC to reduce opioid overdose deaths. BC Medical Journal, Vol 54, No5.
CBC News (July 10, 2012) Fentanyl kills ‘perfect wife’ and other addicts in Ontario city. CBC News.
Center for Disease Control and Prevention (November 4, 2011) MMWR- vital signs: overdose of prescription opioid pain relievers—United States, 1999-2008. 60(43); 1487-1492. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm
Cicero, Theodore, Ellis, Matthew & Surratt, Hilary (2012) Effect of abuse-deterrent formulation of OxyContin. The New England Journal of Medicine, 367; 2 P. 187-189.
Coffin, P, Coffin, L, Fitzpatrick, T & Murphy, S. (2012) Drug overdose, lay Naloxone and HIV risk behaviours among persons who inject drugs. Presented at AIDS Conference 2012, Washington, D.C., USA.http://pag.aids2012.org/Abstracts.aspx?AID=7909
Davis, W & Johnson, B. (2008) Prescription opioid use, misuse, and diversion among street drug users in New York City. Drug and Alcohol Dependence, 92, 267–276.
Dhalla, Irfan A. et al. (2009) Prescribing of opioid analgesics and related mortality before and after the introduction of long‐acting oxycodone. Canadian Medical Association Journal, vol. 181 no. 12. http://www.cmaj.ca/con¬tent/181/12/891
Dong, Katheryn, Taylor, Marliss, Wild, Cameron, et al. (2012) Community-based Naloxone: A Canadian pilot project. The Canadian Journal of Addiction Medicine, Vol. 3, no. 2 p.4-9.
Firestone, M, Goldman, B, &Fischer B. (2009) Fentanyl use among street drug users in Toronto, Canada: behavioural dynamics and public health implications. Int J Drug Policy, 20( 1):90-2.
Fischer, B, Rehm, J, Patra, J, & Firestone Cruz, M. (2006) Changes in illicit opioid use profiles across Canada. Canadian Medical Association Journal, 175, 1–3.
Fischer, Benedikt, Goldman, Brian, Rehm, Jürgen & Popova, Svetlana (2008) Non-medical use of prescription opioids and public health in Canada: An urgent call for research and interventions development. Canadian Journal of Public Health, vol 99, no. 3.
Fischer, Benedikt & Rehm, Jürgen (2009) Deaths related to the use of prescription opioids. Canadian Medical Association Journal, vol. 181 no. 12. http://www.cmaj.ca/content/181/12/881.full
Gomes T, Juurlink DN, Moineddin R, Gozdyra P, Dhalla I, Paterson JM &Mamdani MM. (2011) Geographical variation in opioid prescribing and opioid-related mortality in Ontario. Healthcare Quarterly, 14 (1); 22-24.
Hurley, Meghan (November 14, 2012) Manotick struggles with explosion in Fentanyl abuse. The Ottawa Citizen.
Leonard, Lynne, & Germain, Andrée (2009) Ontario Harm Reduction Distribution Program: Final Outcome Evaluation. University of Ottawa, Ottawa, Ontario. Available online: http://www.ohrdp.ca.
Martin TL, Woodall KL &McLellan BA. (2006) Fentanyl-related deaths in Ontario, Canada: toxicological findings and circumstances of death in 112 cases (2002–2004). Journal of Analytical Toxicology, 30: 603–10.
Matthews, Deb. Minister of Health and Long-Term Care (April 6, 2012) Ministry moving on drug crisis. The Star.
Ministry of Health and Long-Term Care – Health Bulletins (April 4, 2012) Update on OxyContin Partnership Strategy. http://www.health.gov.on.ca/en/news/bulletin/2012/hb_20120404_1.aspx
Ogilvie, Megan (August 17, 2012) OxyContin replaced by explosion of small-town heroin use. The Star.
Ontario Public Drug Programs Division (February 17, 2012) Notice from the Executive Officer. Ministry of Health and Long‐Term Care.
Richmond, Randy (July 4, 2012) Heroin scourge lands in London. The London Free Press.
Strike, C. et al. (2006) Ontario Needle Exchange Programs: Best Practice Recommendations 2006. http://www.ohrdp.ca/wp-content/uploads/pdf/Best_Practices_Report.pdf
Walley, Alexander Y, Xuan, Ziming, et al. (2013) Opioid overdose rates and implementation of overdose education and nasal Naloxone distribution in Massachusetts: Interrupted time series analysis. BMJ.
Waterloo Region Crime Prevention Council (2012) Between Life and Death: The Barriers to Calling 911 During an Overdose Emergency. http://www.preventingcrime.ca/main.cfm?id=51A4A87F-B6A7-8AA0-652D134862F…
X Related Resources
The Ontario Harm Reduction Distribution Program resources related to opioid overdose prevention and community-based Naloxone distribution can be found at http://www.ohrdp.ca including:
Webinar training presentations and staff training resources
Community-Based Naloxone Distribution: Guidance Document
Client education posters
One-page Naloxone information sheet
Sample templates/documentation forms
An Agency Checklist of key issues/items to be addressed by agencies in preparation to offer overdose training to clients and distribute Naloxone.
Contact info@ohrdp.ca or 1-866-316-2217 for hard copies of the Guidance Document and posters.
Waterloo Region Crime Prevention Council has valuable background data and information on OxyContin and Overdose Prevention: http://preventingcrime.net/main.cfm?id=51A4A87F-B6A7-8AA0-652D134862FD5C… The Reports page includes:
Between Life and Death: The Barriers to Calling 911 During an Overdose Emergency
Oxy to Oxy: Impacts and Recommendations Infor¬mal Summary Report, March 14, 2012
A First Portrait of Drug Related Overdoses in Water¬loo Region, September 2008
Saving Lives: Overdose Prevention & Intervention Projects in Select North American Cities, September 2008.
Preventing Overdose Waterloo Wellington (POWW) delivers OD Prevention and Inter¬vention Training to service providers, people ac¬tive in their substance use and others who may be in a position to witness an OD. Training has been delivered across Ontario: http://preventingoverdose.ca.
The Opioid Advice series was developed by the Centre for Addiction and Mental Health (CAMH) and the Ministry of Health and Long-Term Care (MOHLTC) and is available on the CAMH website, along with other resources: https://knowledgex.camh.net/opioid_alert.x