Child Fatality Task Force Poisoning & Overdose Prevention Update

Updated Aug 2015

Alan Dellapenna, Jr.

Unintentional Death Committee Co-Chair Injury and Violence Prevention Branch

North Carolina Division of Public Health

Unintentional Death Committee’s Focus is on Acute Lethality from Poisonings

We recognize the highly addictive nature of controlled substances have downstream devastating impacts on families and society from child neglect, abuse, family destruction, foster care, criminal activity, etc. that has cascading effects on children immediately and long term.

Controlled Substance A drug which has been declared by federal or state law to be illegal for sale or use, but may be dispensed under a physician's prescription. The basis for control and regulation is the danger of addiction, abuse, physical and mental harm (including death), the trafficking by illegal means, and the dangers from actions of those who have used the substances.

http://legal-dictionary.thefreedictionary.com/controlled+substance

Poison A substance that can cause people or animals to die or to become very sick if it gets into their bodies especially by being swallowed.

http://www.merriam-webster.com/dictionary/poison

1955

NC and the Nation

faced an epidemic of

childhood Poisonings

deaths.

Injury Prevention History in North Carolina - Poisoning

"The adoption of such a closure could mean a saving

of many small children's lives from the accidental

ingestion of drugs . . . ." Dr. Arena, 1957, letter to

fellow physicians.

North Carolina was a national leader in

Solving the child poisoning epidemic of the 1950’s & 1960’s

• Duke University opened the 2nd Poison Control Center in the US

• The child-proof cap was developed by Dr. Arena at Duke.

Regulate the Sale of E- Liquid Containers Law

Signed into law - July 8, 2015

• Unlawful to sell e-liquid unless the in a child-resistant container • Class A1 misdemeanor • Liable for damages • Effective Dec 1, 2015

6

National Vital Statistics System, http://wonder.cdc.gov, multiple cause dataset

Source: Death files 1968-2012,CDC WONDER Analysis by Injury Epidemiology and Surveillance Unit

1989 Pain, 5th

Vital Sign

Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 1999-2014 (*2014 data is provisional) Analysis by Injury Epidemiology and Surveillance Unit Medication or drug overdose: X40-X44, X60-X64, Y10-Y14, X85

Medication or Drug Overdose Deaths by Intent North Carolina Residents, 1999-2014*

1,287

1,052

198

36

0

200

400

600

800

1,000

1,200

1,400

1999 2001 2003 2005 2007 2009 2011 2013

Num

ber

of death

s

All intents

Unintentional

Self-inflicted

Undetermined

Assault

2014

350% increase in deaths since 1999 1,000+ Deaths per year 20,000+ Emergency Dept. visits per year

Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 1999-2014 ( *2014 data is provisional and subject to change Analysis by Injury Epidemiology and Surveillance Unit

Substances Contributing to Medication or Drug Overdose Deaths North Carolina Residents, 1999-2014*

709

221

252

0

100

200

300

400

500

600

700

800

900

1999 2001 2003 2005 2007 2009 2011 2013

Num

ber

of death

s

Prescription Opioid

Cocaine

Heroin

20% decline in medication deaths

565% increase in Heroin deaths since 2010

2014

0

300

600

900

1,200

1,500

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Num

ber o

f Dea

ths

Unintentional

Suicide

Homicide

Undetermined

All Poisonings

1382

1101

248

320

North Carolina’s Response to the Drug Overdose Epidemic Capt. Alan Dellapenna Jr. (Ret.), Scott K. Proescholdbell

Injury and Violence Prevention Branch, N.C. Division of Public Health

Contact: Alan Dellapenna • Injury and Violence Prevention Branch • NC Division of Public Health • alan.dellapenna@dhhs.nc.gov • (919) 707-5441

The Division of Public Health collaborates with a broad network of partners to combat the epidemic of medication overdose deaths with policy, epidemiology, and community-based strategies.

Comprehensive Community Approach Chronic

Pain Initiative

Policy & Practice

Research

Policy

Monitoring

System

Drug Take Back

Prescription

Drug

Substanc

e Abuse

Public Health

Carolinas

Poison Center

Poisoning Death Study Opioid Death Task Force

Enforcement

SBI & Medical Board Divs. of Public Health, Medical

Assistance, Mental Health/DD/

Substance Abuse

2000 2002 2003 2004 2005 2007 2008 2009 2010 2011 2012 2013 2014

Surveillance identifies an increase in drug poisoning deaths

CDC EPI Aide investigation of increased poisoning deaths conducted. Findings lead to establishment of a Governor’s Task Force.

Governor’s Task Force to Prevent Deaths from Unintentional Drug Overdoses convened. Recommendations include establishment of a controlled substance reporting system.

The North Carolina Controlled Substances Reporting System Act (CSRS) enacted. CSRS is a statewide reporting system to improve the state’s ability to identify people who abuse and misuse prescription drugs.

Wilkes County has the 3rd highest drug overdose death rate in the nation.

Project Lazarus established in Wilkes County combat the overdose epidemic.

Drug overdose deaths in Wilkes County drops 69%.

Enhanced surveillance of drug overdose deaths initiated by the Division of Public Health.

Collaboration with the UNC Injury Prevention Research Center on the overdose epidemic begins.

UNC IPRC conducts a CSRS users evaluation.

The Sate Advisory Council (SAC) on Poisoning/Overdose established. The group advises and coordinates on overdose communications, research and policy

Community Care of North Carolina, supported by a $2.6 million grant from the Kate B. Reynolds Charitable Trust and matching funds from the Office of Rural Health expands Project Lazarus approach statewide

The Revise the Controlled Substances Reporting System Act enacted. Components include: automated reporting of questionable patient and provider behavior, steps to increase utilization of CSRS by providers, and enhanced public health surveillance of CSRS.

The Good Samaritan Law/Naloxone Access Act enacted; establishes limited immunity from prosecution for reporting drug and alcohol overdoes, and prescribing and administering the opioid antigen Naloxone.

•NC Harm Reduction Coalition documents 50 overdose reversals thru legal use of Naloxone.

•NC Pharmacy Board approves changes to Naloxone rule, establish standing orders for PHN distribution of Naloxone by local Health Departments.

•State EMS Medical Director revises Naloxone policy, establishes protocol for EMS and law enforcement distribution of Naloxone.

•Program Evaluation Division of the General Assembly conducts an evaluation of the CSRS, legislation introduced to further revise CSRS.

North Carolinians have safely disposed of approximately 61 million total doses of medication at Operation Medicine Drop events since the campaign’s establishment in 2009.

Since 1999, the number of medication related

overdose deaths have increase 300%.

Prescription medications are the leading cause of overdose deaths in North Carolina.

The Hub

Community Awareness – of the problem of overdose from prescription opioid analgesics

Coalition Action – to cooperate all sectors of the community in a response

Data and Evaluation – to ground community’s unique approach in their locally identified needs.

Project Lazarus Model

The Wheel

Community Education – improve the public’s capacity to recognize and avoid the dangers of misuse/abuse of prescription opioids.

Provider Education – improve effective treatment of chronic pain; support treatment addiction, mental health illness and pain.

Hospital ED Policies – help emergency departments avoid drug seeking behavior.

Diversion Control – reduce the presence of excess medications in society.

Pain Patient Support – help successfully and safely manage their pain.

Harm Reduction – help people who do abuse opioids prevent overdose death.

Drug Treatment – help those with addiction to recover.

Harm Reduction

Drug Treatment

Community Education

Provider Education

Hospital ED

Diversion Control

Pain Patient Support

Community Awareness

Coalition Action

Data & Evaluation

2000 – CDC Epi Aid of Overdose Deaths

in Wilks Co.

2010 – Operation Medicine Drop

initiated, largest drug take-back campaign in US

2007 – NC’s PDMP initiated.

2013 – CFTF CSRC &

Naloxone bills.

201 – CFTF CSRC,

Naloxone , Drug Take

back, Poison Center

Spectrum of Prevention to Treatment How Public Health looks at intervention Strategies.

Injury Event

Poison Center

(First Aid) Drug Take Back

(hazard reduction, Public Awareness)

Naloxone (Lifesaving First Aid)

CSRS (Manage &

Reduce Hazard)

E-Cig Packaging (hazard reduction, Public Awareness)

Prevent Treatment

Rehab Pre-Hosp Policy Community Hosp Addiction

Svcs

Suboxone (Addiction

treatment )

Clean Syringe (Disease Prev)

Project Lazarus (Community-

based)

Law Enforcement (Criminal Justice System) Family Services

(Protecting Children)

■ Replace 2 Specialist in Poison Information positions (RN, RPh) – Had lost 3 positions and 1 technician (Poison Info Provider) – Had lost 1 MD/manager position ■ Exploring upgrading telephonic platform hardware and software – Hasn’t been updated since 2004 – Are we communicating with the public in an optimal manner?

Carolinas Poison Center

As of Oct 31, 2015, 67,465 Calls answered by the Carolinas Poison Center

• 27% from Healthcare Providers treating a patient • 45% for children under 6 years old • 59% for ages 0-19 years old

75% of calls avert an emergency department visit

Every $1 spent on the Poison Center saves $22 health care costs

Impact of restored CPC funding for FY 2015-16 and 2016-17

Controlled Substances Reporting System

2015 Enhancements

• Delegate Online Registration

• Auto Deactivation/Renewal for Delegate Accounts

• Quarterly Data Transfer

• Unsolicited Reporting to prescribers

• 90 patients identified

• 896 prescribers notified (50% currently not registered)

• 729 pharmacies

• Practitioner Online Registration

• Threshold Reports to NC Medical Board

• 84 prescribers with 2 or more deaths over past year

• 14 prescribers in top 1% prescribing 100 morphine milligram

equivalent per patients per day

Drug Take Back in North Carolina March 15-17, 2015

• 220 events across the state • 15.4 million doses turned

NC Medical Journal Article Jan 2016

150+ Permanent Take-Back Locations across North Carolina

https://apps.ncdoi.net/f?p=102:4:13074836663687::NO:::

Since August 1, 2013 • 18,081 overdose rescue kits distributed

• 12,366 in 2015 alone • 1,288 confirmed overdose reversals 2015 • 1,064 confirmed overdose reversals

Impact of North Carolina’s 2013 Good Samaritan/ Naloxone Access Law

Reched a Tipping Point in 2015:

More overdose reversals than overdose deaths.

County Opioid Overdose Reversals with Naloxone Reported to the North Carolina Harm Reduction Coalition

8/1/2013 - 7/21/2015

Rocky Mount (1)

High Point (78)

Elkin (1)

4 reversals in an unknown location in North Carolina and 11 reversals in other states reported to NCHRC.

Asheville (178)

Greensboro (142)

Maiden (1)

NC Harm Reduction Coalition targets high overdose areas for naloxone distribution.

31 Law Enforcement Agencies in NC Carry Naloxone

App State University Police Watauga Co. Sheriff

Ayden Police Dept

Greenville Police Dept East Carolina Univ Police Dept Pitt Co. Sheriff

Canton Police Dept

Clyde Police Dept

Maggie Valley Police Dept

Waynesville Police Dept Haywood Co. Sheriff

Orange Co. Sheriff

Carrboro Police Dept

Cramerton Police Dept

Fayetteville Police Dept

Guilford Co. Sheriff Halifax Co. Sheriff

Roanoke Rapids Police Dept

Kinston Police Dept Lenoir Co. Sheriff

Pink Hill Police Dept

N.C. State Bureau of Investigation and Alcohol Law Enforcement also carry Naloxone.

Agencies that have reported opioid overdose reversals with Naloxone

Henderson Co. Sheriff

Brevard Police Dept Transylvania Co. Sheriff

Rutherfordton Police Dept

19 overdose reversals by law enforcement agencies

Next Steps

• Identifying more pharmacies willing to dispense naloxone

under a standing order

• Increasing volunteer network, particularly in rural and

remote counties

• Working with EMS to pass out naloxone to bystanders at

the scene of an overdose

• Expanding number of law enforcement departments

carrying naloxone