10:15 a.m. -11:15 a.m. - ASPMN Conference Documents-Images/H… · Heroin is hydrolyzed to 6-monoacetylmorphine (6MAM)which is associated with the rapid euphoria. Morphine and morphine-6-glucuronide(m-6-g)

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Naloxone Harm Reduction Strategies: Saving Lives and Providing Safe Care

Naloxone Harm Reduction Strategies: Saving Lives and Providing Safe Care

Paula Kobelt, MSN, RN-BC

Michelle Meyer, PharmD, BCPS, BSNSP

Dr. Krisanna Deppen

OhioHealth Grant Medical Center, Columbus Ohio

Friday, September 9, 2016

10:15 a.m. - 11:15 a.m.

Paula Kobelt, MSN, RN-BC

Michelle Meyer, PharmD, BCPS, BSNSP

Dr. Krisanna Deppen

OhioHealth Grant Medical Center, Columbus Ohio

Friday, September 9, 2016

10:15 a.m. - 11:15 a.m.

ObjectivesObjectives

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Explain the severity of the epidemic and the changing demographics of

the overdose population

Describe the utilization of naloxone nasal administration for preventing

overdose death

Discuss the programs and resources available to prevent overdose death

and encourage recovery

Summarize the steps involved in developing an Emergency Department

(ED) based naloxone harm reduction program

SituationSituation

� The opioid overdose death epidemic continues to escalate � In the US, “Since 1999, opiate overdose deaths have increased 265% among men and 400% among

women” and the epidemic “killed more than 28,000 people in 2014, more than any year on record”

� Patients identified as “high risk” are not provided with opioid antidote, naloxone, education, training, and resources at discharge from Emergency Departments, despite recommendations to improve access to naloxone

� The opioid overdose death epidemic continues to escalate � In the US, “Since 1999, opiate overdose deaths have increased 265% among men and 400% among

women” and the epidemic “killed more than 28,000 people in 2014, more than any year on record”

� Patients identified as “high risk” are not provided with opioid antidote, naloxone, education, training, and resources at discharge from Emergency Departments, despite recommendations to improve access to naloxone

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention [CDCIP], 2016, p. 1; Substance Abuse and Mental Health Services Administration [SAMSHA], 2015, p. 1; Centers for Disease Control and Prevention [CDC], 2016; Martins, Sampson, Cerda, & Galea, 2015.

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Background: National Epidemic WorseningBackground: National Epidemic Worsening

In 2014 U.S. 200% increase in opioid related overdose deaths (OROD):

� More people died from OROD than from MVA

� Heroin related deaths tripled, heroin use escalates

� Direct link to Rx opioid misuse and dependence

In 2014 Ohio lead nation in:

� Opioid overdose deaths (top 5 states)

� 514 fentanyl-related overdose deaths, compared to 92 in 2013

� More people died from opioid overdoses than from MVA

In 2014 U.S. 200% increase in opioid related overdose deaths (OROD):

� More people died from OROD than from MVA

� Heroin related deaths tripled, heroin use escalates

� Direct link to Rx opioid misuse and dependence

In 2014 Ohio lead nation in:

� Opioid overdose deaths (top 5 states)

� 514 fentanyl-related overdose deaths, compared to 92 in 2013

� More people died from opioid overdoses than from MVA

Centers for Disease Control and Prevention, National Center for

Injury Prevention and Control, Division of Unintentional Injury

Prevention. (2016). Injury prevention and control: Opioid overdose.

Retrieved May 30, 2016, from

http://www.cdc.gov/drugoverdose/index.html

Centers for Disease Control and Prevention. (2015). CDC vital signs: Today’s heroin epidemic: More people at risk, multiple drugs abused. Retrieved from www.cdc.gov/vitalsigns/heroin

Centers for Disease Control and Prevention. (2015). CDC vital signs: Today’s heroin epidemic: More people at risk, multiple drugs abused. Retrieved from www.cdc.gov/vitalsigns/heroin

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Changing Demographics Changing Demographics

http://www.ohioattorneygeneral.gov/Media/Videos/Marin-s-Story-The-Battle-Against-HeroinTylerslight.com

http://fox8.com/2014/02/10/heroin-hits-home-robbys-story/

Drug cartels targetDrug cartels target

�Safe neighborhoods

�Access to a car

�Money

�Cell phone

�Safe neighborhoods

�Access to a car

�Money

�Cell phone

Photo provided by CDC/Debora Cartagena

Health warnings for people who use heroin Boyce, Niall, Lancet, The, Volume 377, Issue 9761, 193-194Copyright © 2011 Julien Behal/PA Wire/Press Association Images

Individuals at high risk for opioid overdose Individuals at high risk for opioid overdose

Individuals with:

� pain and using opioids for treatment of chronic pain

� using illicit drugs such as heroin

� alternating opioid regimens

� need of pain medication for a medical problem and also have a substance use disorder

� history of or currently misusing prescription opioids, or using someone else’s opioids

� lower opioid tolerance following some type of abstinence or opioid detoxification including recently being released from prison, treatment, hospitalization or rehabilitation

Individuals with:

� pain and using opioids for treatment of chronic pain

� using illicit drugs such as heroin

� alternating opioid regimens

� need of pain medication for a medical problem and also have a substance use disorder

� history of or currently misusing prescription opioids, or using someone else’s opioids

� lower opioid tolerance following some type of abstinence or opioid detoxification including recently being released from prison, treatment, hospitalization or rehabilitation

Substance Abuse and Mental Health Services Administration. (2016). SAMHSA opioid overdose prevention toolkit HHS Publication No. (SMA) 16-4742. Retrieved April 3, 2016, from store.samhsa.gov/shin/content//SMA16-4742/SMA16-4742.pdf

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Pathway to Heroin

• Abuse Rx opioids- crush pills to inject or snort • Number of prescription opioids quadrupled, yetthe incidence of pain reported has not changed, and opioid overdose deaths from prescription opioids quadrupled

• Heroin related overdose deaths have quadrupled in US since 2002, taking more than 8,200 lives in 2013

• Greater than 500,000 U.S. citizens, (age 12 or older) were treated for heroin use in 2013, the rate nearly doubling since 2002

• National Institute on Drug Abuse: National Institutes of Health; U.S. Department of Health and Human Services [NIHNIDA], 2014,, CDC, 2016, Substance Abuse and Mental Health Services Administration [SAMHSA], 2016, CDC, 2015; CDCHAN, October 26, 2015

Why Heroin?Why Heroin?

� Heroin is cheaper and easier to obtain

than RX

� Similar effects as long acting oxycodone hydrochloride (OxyContin), hydrocodone/acetaminophen (Vicodin), oxycodone hydrochloride/acetaminophen (Percocet), immediate release oxycodone hydrochloride

� Smoke, inject, snort or sniff (white or brown powder, sticky “black tar heroin”)

� All routes deliver drug to brain quickly

� Heroin is cheaper and easier to obtain

than RX

� Similar effects as long acting oxycodone hydrochloride (OxyContin), hydrocodone/acetaminophen (Vicodin), oxycodone hydrochloride/acetaminophen (Percocet), immediate release oxycodone hydrochloride

� Smoke, inject, snort or sniff (white or brown powder, sticky “black tar heroin”)

� All routes deliver drug to brain quickly

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National Institute on Drug Abuse: National Institues of Health; U.S. Department of Health and Human Services. (2014). Drug facts: Heroin. Retrieved July 13, 2016, from https://www.drugabuse.gov/publications/drugfacts/heroin; Rook, E. J., Huitema, A. D., Van den Brink, W., Van Ree, J. M., & Beijnen, J. H. (2006). Population pharmacokinetics of heroin an its major metabolites. Clinical Pharmacokinetics, 45, 401-417. http://dx.doi.org/10.2165/00003088-200645040-00005

Heroin PharmacokineticsHeroin Pharmacokinetics

� Heroin is rapidly absorbed and crosses the blood brain barrier, but has little affinity for the mu receptors.

� Heroin is hydrolyzed to 6-monoacetylmorphine (6MAM)which is associated with the rapid euphoria.

� Morphine and morphine-6-glucuronide(m-6-g) are both active long circulating metabolites.

� 5% of IV morphine will cross the blood brain barrier compared to 68% of heroin.

� Heroin is rapidly absorbed and crosses the blood brain barrier, but has little affinity for the mu receptors.

� Heroin is hydrolyzed to 6-monoacetylmorphine (6MAM)which is associated with the rapid euphoria.

� Morphine and morphine-6-glucuronide(m-6-g) are both active long circulating metabolites.

� 5% of IV morphine will cross the blood brain barrier compared to 68% of heroin.

Heroin 6-monoacetylmorphine Morphine morphine-6-glucuronide

Rook, E. J., Huitema, A. D., Van den Brink, W., Van Ree, J. M., & Beijnen, J. H. (2006). Population pharmacokinetics of heroin an its major metabolites. Clinical Pharmacokinetics, 45, 401-417. http://dx.doi.org/10.2165/00003088-200645040-00005

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Heroin PharmacokineticsHeroin Pharmacokinetics

� Duration of heroin and metabolites

� Heroin = 2-5 min

� 6MAM = 10-30 min

� Morphine/m-6-g = 30-120min

� Co-administration

� Benzodiazepines competitively inhibit glucuronidation of morphine

� Alcohol delay the metabolism of heroin to 6MAM (in vitro studies)

� Cocaine inhibits the transition of 6MAM to morphine, prolonging the half-life of 6MAM

� Overall onset and duration with injection

� Onset 2-4 minutes

� Peak at 10-30 minutes

� Duration of 120-180 min

� Duration of heroin and metabolites

� Heroin = 2-5 min

� 6MAM = 10-30 min

� Morphine/m-6-g = 30-120min

� Co-administration

� Benzodiazepines competitively inhibit glucuronidation of morphine

� Alcohol delay the metabolism of heroin to 6MAM (in vitro studies)

� Cocaine inhibits the transition of 6MAM to morphine, prolonging the half-life of 6MAM

� Overall onset and duration with injection

� Onset 2-4 minutes

� Peak at 10-30 minutes

� Duration of 120-180 min


Defining Substance UseDefining Substance Use

� Substance Use disorder- “Substance use disorders occur when the recurrent use of alcohol and/or drugs causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home.”

� 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.”

Substance Abuse and Mental Health Services Administration. (2016). Mental and Substance Abuse Disorders. Retrieved July, 24 2016, from http://www.samhsa.gov/disorders/substance-usePrinciples of Harm Reduction. (n.d.). Retrieved July 24, 2016, from http://harmreduction.org/about-us/principles-of-harm-reduction/

� Substance Use disorder- “Substance use disorders occur when the recurrent use of alcohol and/or drugs causes clinically and functionally significant impairment, such as health problems, disability, and failure to meet major responsibilities at work, school, or home.”

� 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.”

Substance Abuse and Mental Health Services Administration. (2016). Mental and Substance Abuse Disorders. Retrieved July, 24 2016, from http://www.samhsa.gov/disorders/substance-usePrinciples of Harm Reduction. (n.d.). Retrieved July 24, 2016, from http://harmreduction.org/about-us/principles-of-harm-reduction/

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Pathways of AddictionCrisis-PleasurePathways of AddictionCrisis-Pleasure

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“Drug addiction is a chronically relapsing disorder that has been characterized by (1) compulsion to seek and take the drug, (2) loss of control in limiting intake, and (3) emergence of a negative emotional state (eg, dysphoria, anxiety, irritability) reflecting a motivational withdrawal syndrome when access to the drug is prevented. Drug addiction has been conceptualized as a disorder that involves elements of both impulsivity and compulsivity that yield a composite addiction cycle composed of three stages: ‘binge/intoxication’, ‘withdrawal/negative affect’, and ‘preoccupation/anticipation’ (craving)” (Koob, G.F., Volkow, N.D. 2010 p. 1)

Alterations in brain connectivity in three sub-regions of the anterior cingulate

cortex in heroin-dependent individuals: Evidence from resting state fMRI

Zhang, Y., Neuroscience, Volume 284, 998-1010

Copyright © 2014 IBRO

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Pathways of AddictionRecovery-RelapsePathways of AddictionRecovery-Relapse

Commitment to Recovery

Trigger or

Craving

Resume Previous Rituals

Relapse

Feel Guilty

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CDC, DEA recommendations include:

� Increase reporting by EDs

� Expand access and use of naloxone

� Provide naloxone toolkits to people misusing opioids, train how to administer intranasal naloxone, and call 911

Stigma and Consequences- ROLStigma and Consequences- ROL

� Education can improve the negative attitudes and knowledge gaps in health care professionals

� Stigmatization and negative attitudes towards patients with substance use disorders (SUD) by health care professionals are widely documented in the literature

� Stigmatization and negative attitudes perpetuate suboptimal care :

Misdiagnosing ►Lack of trust ►Unwilling to share important information

� Education can improve the negative attitudes and knowledge gaps in health care professionals

� Stigmatization and negative attitudes towards patients with substance use disorders (SUD) by health care professionals are widely documented in the literature

� Stigmatization and negative attitudes perpetuate suboptimal care :

Misdiagnosing ►Lack of trust ►Unwilling to share important information

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Primary Prevention and Harm ReductionPrimary Prevention and Harm Reduction

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Primary Prevention

Harm Reduction

Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention, March 23, 2016

Harm Reduction and LegislationHarm Reduction and Legislation

IndividualNaloxone and

opioid overdose prevention education

Family and FriendsIncreased access to naloxone and opioid

overdose prevention education, Good Samaritan Laws, Liability Laws

CommunityNaloxone- first responders EMS, Law Enforcement, FirefightersOpioid overdose educationDistribution of naloxoneHarm Reduction agencies/organizations

Prescribers(PMP)Prescription Monitoring ProgramsEvidence-based prescribingNaloxone Risk Assessment

State GovernmentOptimization of PMPsGood Samaritan, Third Party Prescribing- LawsCivil and Criminal Liability

Federal GovernmentFDA- naloxone pricing, supplyCDC- ResearchNIH- Fund Research for Harm ReductionSAMHSA- initiatives to educate public

Hawk, K. F., Vaca, F. E., & D’Onofrio, G. (2015, September). Reducing fatal opioid overdose: Prevention, treatment and harm reduction strategies. Yale Journal of Biology and Medicine, 88(3), 1-19. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4553643/

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22https://www.whitehouse.gov/sites/default/files/ondcp/Blog/nalo

xonecirclechart_january2016.pdf

Ohio continues to address the epidemicOhio continues to address the epidemic

Significance to HealthcareSignificance to Healthcare

� Many hospitals and emergency departments do not provide naloxone, opioid overdose prevention and harm reduction education.

� Intranasal naloxone is available to the public, individuals at risk for overdose, and first responders

� Opioid overdose admissions to Emergency Departments are increasing

� ED RN and providers can screen and identify high risk patients (seek care for other reasons)

� Most overdoses occur at home, providing naloxone for home use will save lives

� Many hospitals and emergency departments do not provide naloxone, opioid overdose prevention and harm reduction education.

� Intranasal naloxone is available to the public, individuals at risk for overdose, and first responders

� Opioid overdose admissions to Emergency Departments are increasing

� ED RN and providers can screen and identify high risk patients (seek care for other reasons)

� Most overdoses occur at home, providing naloxone for home use will save lives

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Nasal naloxone spray saves livesNasal naloxone spray saves lives

� 4.6 minutes to arrive at scene

� 18 minutes spent at scene

� 12.2 minutes for transport to hospital

� Average EMS response time in Ohio is 34.8 minutes

Most overdoses occur at home

� 4.6 minutes to arrive at scene

� 18 minutes spent at scene

� 12.2 minutes for transport to hospital

� Average EMS response time in Ohio is 34.8 minutes

Most overdoses occur at home

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193 people died from opioid overdose in 2014

Majority of deaths

occurred at home

Naloxone Nasal PharmacokineticsNaloxone Nasal Pharmacokinetics

� Each spray of 4mg is approximately equal to 0.4mg parenteral naloxone

� Onset of action is within 2 minutes, doses may be repeated every 2-3 min until response

� Slightly longer half-life when administered nasally

� Injected = 1.24hrs

� Inhaled = 2.08hrs

� Duration of action is usually 30-60 minutes

� Each spray of 4mg is approximately equal to 0.4mg parenteral naloxone

� Onset of action is within 2 minutes, doses may be repeated every 2-3 min until response

� Slightly longer half-life when administered nasally

� Injected = 1.24hrs

� Inhaled = 2.08hrs

� Duration of action is usually 30-60 minutes

Lexicomp version 2.4.0 2016 Wolters Kluwer Clinical Drug Information Inc.

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Naloxone NasalSprayNaloxone NasalSpray

2. Screw atomizer onto syringe

1. Remove Caps

Screw in cartridge

Education InterventionNaloxone Nasal SprayEducation InterventionNaloxone Nasal Spray

Content:• Scope and seriousness of problem• Substance use disorder disease • Changes in the brain with addiction• Pathway from prescription opioids

to heroin• Treatment and recovery• Harm reduction: Intra nasal

naloxone• Patient education and training

Assessment:Assessment:

�First Responders carry and administer naloxone

(EMS, Law Enforcement, Fire Department)

�Simple training – proven safe and effective

�Limited Project DAWN (Deaths Avoided With Naloxone) sites in Franklin and Marion County

�Most overdoses occur at home

�First Responders carry and administer naloxone

(EMS, Law Enforcement, Fire Department)

�Simple training – proven safe and effective

�Limited Project DAWN (Deaths Avoided With Naloxone) sites in Franklin and Marion County

�Most overdoses occur at home

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Naloxone storyNaloxone story

http://www.ohioattorneygeneral.gov/Media/Videos/Ideas-That-Work-Naloxonehttp://www.ohioattorneygeneral.gov/Media/Videos/Ideas-That-Work-Naloxone

Process- PDSAProcess- PDSA

ScreenEducate

Train• ED RN• Pharmacy Intern• Social Services

Document• Physician• RN• Social Services• Other

Evaluate Audit

Screen for high risk ED patientsDischarged from ED following overdosePer ED physician discretion

Provide Naloxone ToolkitEducation and training using teach backEducational hand-out and DVDInformation for the family or others

EPICPhysician orders

Discharge InstructionsStaff documentation

• Identified High risk ED patients

• Naloxone and harm reduction discharge instructions given

• Documentation

Emergency Department Intervention

A. Stakeholders1. Multi-disciplinary

B. RegulationsC. Naloxone productD. FinanceE. Staff Education and trainingF. EvaluationG. Documentation, order setH. Patient Education

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1) Collaborate with ED staff2) Process: Provide naloxone, harm reduction education and training

to high risk patients A) Screen for high risk ED patients

Use of illicit opioids and/or misuse of prescription opioidsTaking high opioid doses for tx of chronic pain; extended-release

or long acting opioids Discharged from ED following overdoseCompleted detoxification, incarceration or abstinence programs

B) Provide Naloxone Toolkit per protocolEducation and training using teach back per Ohio State Board of

Pharmacy ProtocolInformation, recovery resources for patient, family/others

C) EPICPhysician ordersDocumentationDischarge Instructions

Cost SavingsCost Savings

Cost to Ohio

“Drug overdoses are associated with high direct and indirect costs. Unintentional fatal drug overdoses cost Ohioans $2.0 billion in 2012 in medical and work loss costs; while non-fatal, hospital-admitted drug poisonings cost an additional $39.1 million. The total cost equaled an average of $5.4 million each day in medical and work loss costs in Ohio.”

Ohio Department of Health, Healthy Ohio (2016) Drug overdose in Ohio: What’s new, p. 1

Cost to Ohio

“Drug overdoses are associated with high direct and indirect costs. Unintentional fatal drug overdoses cost Ohioans $2.0 billion in 2012 in medical and work loss costs; while non-fatal, hospital-admitted drug poisonings cost an additional $39.1 million. The total cost equaled an average of $5.4 million each day in medical and work loss costs in Ohio.”

Ohio Department of Health, Healthy Ohio (2016) Drug overdose in Ohio: What’s new, p. 1

Conflict of Interest DisclosureConflict of Interest Disclosure

Authors Conflicts of Interest:

�Paula Kobelt, MSN, RN-BC, No Conflict of Interest

�Michelle Meyer, PharmD. BCPS, BSNSP, No Conflict of Interest

Authors Conflicts of Interest:

�Paula Kobelt, MSN, RN-BC, No Conflict of Interest

�Michelle Meyer, PharmD. BCPS, BSNSP, No Conflict of Interest

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ReferencesReferencesBahar, E., Santos, G.-M., Wheeler, E., Rowe, C., & Coffin, P. (2015). Brief overdose education is sufficient for naloxone distribution to opioid users. Drug and Alcohol Dependence, 148, 209-212.

http://dx.doi.org/org/10.1016/j.drugalcdep.2014.12.009

Califf, R.M., Woodcock, J., & Ostroff, S. (2016, February 4). Special report: A proactive response to prescription opioid abuse. The New England Journal of Medicine, 1-6. http://dx.doi.org/10:1056/NEJMsr16013107

Coffin PO, Sullivan SD. (2013) Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal. Ann Intern Med; 158:1–9.

Centers for Disease Control and Prevention. (2015). Opioid overdose prevention programs providing naloxone to layperson- United States, 2014, Morbidity and Mortality Weekly Report (MMWR), www.cdc.gov/mmwr/preview/mmwrhtml/mm6423a2.htm

Centers for Disease Control and Prevention. (2015). Today’s heroin epidemic, Vital Signs, U.S. Department of Health & Human Services, Retrieved from http://www.cdc.gov/vitalsigns/heroin/index.html

Centers for Disease Control and Prevention. (2015). Understanding the Epidemic, Injury Prevention & Control: Prescription Drug Overdose, U.S. Department of Health & Human Services, http://www.cdc.gov/drugoverdose/epidemic/index.html

Centers for Disease Control and Prevention: CDC 24/7: Saving Lives. Protecting People. (2015). Leading cause of death reports, national and regional, 1999 – 2014. Retrieved from http://webappa.cdc.gov/sasweb/ncipc/leadcaus10_us.html

Center for Disease Control and Prevention Morbidity and Mortality Weekly Report. (2012). Community-based opioid overdose prevention programs providing naloxone- United States 2010. Retrieved from http://www.cdc.gov

DeWine, M. (2015). Naloxone rebate instructions. Retrieved from www.OhioAttorneyGeneral.gov/AmphastarRebateAgreement

Dwyer, K., Walley, A. Y., Langlois, B. K., Mitchell, P. M., Nelson, K. P., Cromwell, J., & Bernstein, E. (2015). Opioid education and nasal naloxone rescue kits in the Emergency Department. Western Journal of Emergency Medicine, 16, 381-384.

http://dx.doi.org/10.5811/westjem.2015.2.24909

Ford, R., Bammer, G., & Becker, N. (2008). The determinants of nurses’ therapeutic attitude to patients who use illicit drugs and implications for workforce development. Journal of Clinical Nursing, 17, 2452–2462. http://dx.doi.org/10.1111/j.1365-

2702.2007.02266.x

Koob, G.F., Volkow, N.D. (2010) Neurocircuitry of addiction. Neuropsychopharmacology Reviews, 35, 217–238. doi:10.1038/npp.2009.110

Ohio Emergency Medical Services. (2016). Administration of naloxone by emergency medical services in Ohio- 2014. Retrieved from ems.ohio.gov

Ohio Department of Health. (2015). 2014 Ohio drug overdose preliminary data: General findings. Retrieved from http://www.healthy.ohio.gov/~/media/HealthyOhio/ASSETS/Files/injury%20prevention/2014%20Ohio%20Preliminary%20Overdose%20Report.pdf


Siegler, A., Tuazon, E., O’Brien, D. B., & Paone, D. (2014). Unintentional opioid overdose deaths in New York City, 2005-2010: A place-based approach to reduce risk. International Journal of Drug Policy, 25, 569-574. Retrieved from

www.elsevier.com/locate/drugpo

Sporer, K. (1999) Acute Heroin Overdose. Ann Intern Med. 1999;130:584-590.

State of Ohio Board of Pharmacy. (2016). Dispensing of naloxone by pharmacists and pharmacy interns without a prescription. Retrieved from https://pharmacy.ohio.gov

Thornicroft, G., Rose, D., & Kassam, A. (2007, April). Discrimination in health care against people with mental illness. International Review of Psychiatry, 19, 113-122. http://dx.doi.org/10.1080/09540260701278937

U.S. Food and Drug Administration. (2016). Fact sheet- FDA opioids action plan. Retrieved from www.fda.gov/NewsEvents/Newsroom/FactSheets/ucm484714.htm

Wheeler, E., Jones, S., Gilbert, M. K., & Davidson, P. J. (2015, June 19). Opioid overdose prevention programs providing naloxone to laypersons- United States 2014. Centers for Disease Control and Prevention: Morbidity and Mortality Weekly Report (MMWR),

64(23), 631-635. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6423a.htm Ohio Department of Health. (2015). Fentanyl significantly contributes to rise in Ohio drug overdose deaths, www.healthy.ohio.gov/.../News%20Release%20--

%202014%20Prelim%20Drug%20Overdose%20Data%20FINAL.pd.

Bahar, E., Santos, G.-M., Wheeler, E., Rowe, C., & Coffin, P. (2015). Brief overdose education is sufficient for naloxone distribution to opioid users. Drug and Alcohol Dependence, 148, 209-212.

http://dx.doi.org/org/10.1016/j.drugalcdep.2014.12.009

Califf, R.M., Woodcock, J., & Ostroff, S. (2016, February 4). Special report: A proactive response to prescription opioid abuse. The New England Journal of Medicine, 1-6. http://dx.doi.org/10:1056/NEJMsr16013107

Coffin PO, Sullivan SD. (2013) Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal. Ann Intern Med; 158:1–9.

Centers for Disease Control and Prevention. (2015). Opioid overdose prevention programs providing naloxone to layperson- United States, 2014, Morbidity and Mortality Weekly Report (MMWR), www.cdc.gov/mmwr/preview/mmwrhtml/mm6423a2.htm

Centers for Disease Control and Prevention. (2015). Today’s heroin epidemic, Vital Signs, U.S. Department of Health & Human Services, Retrieved from http://www.cdc.gov/vitalsigns/heroin/index.html

Centers for Disease Control and Prevention. (2015). Understanding the Epidemic, Injury Prevention & Control: Prescription Drug Overdose, U.S. Department of Health & Human Services, http://www.cdc.gov/drugoverdose/epidemic/index.html

Centers for Disease Control and Prevention: CDC 24/7: Saving Lives. Protecting People. (2015). Leading cause of death reports, national and regional, 1999 – 2014. Retrieved from http://webappa.cdc.gov/sasweb/ncipc/leadcaus10_us.html

Center for Disease Control and Prevention Morbidity and Mortality Weekly Report. (2012). Community-based opioid overdose prevention programs providing naloxone- United States 2010. Retrieved from http://www.cdc.gov

DeWine, M. (2015). Naloxone rebate instructions. Retrieved from www.OhioAttorneyGeneral.gov/AmphastarRebateAgreement

Dwyer, K., Walley, A. Y., Langlois, B. K., Mitchell, P. M., Nelson, K. P., Cromwell, J., & Bernstein, E. (2015). Opioid education and nasal naloxone rescue kits in the Emergency Department. Western Journal of Emergency Medicine, 16, 381-384.

http://dx.doi.org/10.5811/westjem.2015.2.24909

Ford, R., Bammer, G., & Becker, N. (2008). The determinants of nurses’ therapeutic attitude to patients who use illicit drugs and implications for workforce development. Journal of Clinical Nursing, 17, 2452–2462. http://dx.doi.org/10.1111/j.1365-

2702.2007.02266.x

Koob, G.F., Volkow, N.D. (2010) Neurocircuitry of addiction. Neuropsychopharmacology Reviews, 35, 217–238. doi:10.1038/npp.2009.110

Ohio Emergency Medical Services. (2016). Administration of naloxone by emergency medical services in Ohio- 2014. Retrieved from ems.ohio.gov

Ohio Department of Health. (2015). 2014 Ohio drug overdose preliminary data: General findings. Retrieved from http://www.healthy.ohio.gov/~/media/HealthyOhio/ASSETS/Files/injury%20prevention/2014%20Ohio%20Preliminary%20Overdose%20Report.pdf


Siegler, A., Tuazon, E., O’Brien, D. B., & Paone, D. (2014). Unintentional opioid overdose deaths in New York City, 2005-2010: A place-based approach to reduce risk. International Journal of Drug Policy, 25, 569-574. Retrieved from

www.elsevier.com/locate/drugpo

Sporer, K. (1999) Acute Heroin Overdose. Ann Intern Med. 1999;130:584-590.

State of Ohio Board of Pharmacy. (2016). Dispensing of naloxone by pharmacists and pharmacy interns without a prescription. Retrieved from https://pharmacy.ohio.gov

Thornicroft, G., Rose, D., & Kassam, A. (2007, April). Discrimination in health care against people with mental illness. International Review of Psychiatry, 19, 113-122. http://dx.doi.org/10.1080/09540260701278937

U.S. Food and Drug Administration. (2016). Fact sheet- FDA opioids action plan. Retrieved from www.fda.gov/NewsEvents/Newsroom/FactSheets/ucm484714.htm

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