To view an archived recording of this presentation please click the following link: http://pho.adobeconnect.com/p7e04yv04s3p/ Please scroll down this file to view a copy of slides from the session.

PublicHealthOntario.ca

Helpful tips when viewing the recording:

• The default presentation format includes showing the “event index”. To close the events index, please click on the following icon and hit “close”

• If you prefer to view the presentation in full screen mode, please click on the following icon in the top right hand corner of the share screen

PHO Grand Rounds:

Opioid Early Warning Systems

Dr. David Williams

Chief Medical Officer of Health

February 13, 2018

4

National opioid-related mortality data, 2016 (Health Canada)

Provincial Overdose

Coordinator

Opioid overdose early

warning systems

Opioid Tracker

5

Rate per 100,000 population of significant opioid poisoning

hospitalizations by census metropolitan area, Canada, 2016-2017 (CIHI)

Provincial Overdose

Coordinator

Opioid overdose early

warning systems

Opioid Tracker 30.5

24

32

21.1

25.8

20.6

16.3

11.6

21.8

37.9

16 15.1

29.7

24.3

13.8 13.3

28.4 28.2 26.3 26.1

18.3 15.7

27.4

7.9

20 20.1 18.2

10.2

0

10

20

30

40

Age-adjusted rate per 100,000 population

NOTE: To be considered a census metropolitan area, the area must have a total population of at least 100,000 of which 50,000 or more live in the urban core.

6

Cases of opioid-related ED visits and hospitalizations, Ontario, 2003-2016

Provincial Overdose

Coordinator

Opioid overdose early

warning systems

Opioid Tracker

1858 2043 2086 2150 2231

2411

2886 2841 2934 3154

3051

3347

3628

4427

1188 1275 1323 1232 1239 1316 1450 1435

1605 1775

1671 1706 1745 1906

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

ED visits Hospitalizations

7

Cases of opioid-related ED visits and hospitalizations, Ontario, Jan-Sept 2017

Provincial Overdose

Coordinator

Opioid overdose early

warning systems

Opioid Tracker

404 426

522

612 600

676

807

972

897

162 150 176 191 180

153 182

216 168

0

200

400

600

800

1000

1200

Jan Feb March April May June July Aug Sept

ED visits Hospitalizations

8

Cases of opioid-related deaths, Ontario, 2003-2016

Provincial Overdose

Coordinator

Opioid overdose early

warning systems

Opioid Tracker

336 340

444 436 468

491 529

571 556 585

639 676

728

865

0

100

200

300

400

500

600

700

800

900

1000

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Deaths

9

Type of opioid present at death, Ontario, 2003-2016

Provincial Overdose

Coordinator

Opioid overdose early

warning systems

Opioid Tracker

NOTE: Drug categories are not mutually exclusive; multiple drugs may have been present in a single death.

0

50

100

150

200

250

300

350

400

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Codeine Fentanyl Heroin Hydrocodone

Hydromorphone Methadone Morphine Oxycodone

10

The increasing presence of illicit synthetic opioids in Ontario

Provincial Overdose

Coordinator

Opioid overdose early

warning systems

Opioid Tracker

**Anonymized post- and ante-mortem drug detection data sent to Chief Coroner and Chief Medical Officer of Health by Centre of Forensic Sciences Toxicology Section

12

5

4

4

2

2

1

87

54

32

22

8

7

1

EARLY DRUG IDENTIFICATION NOTICES**, JUNE 2017 – JANUARY 2018

Notices Issued Number of Cases

11

Early Drug Identification Notices Cases April 1-December 31, 2017

Provincial Overdose

Coordinator

Opioid overdose early

warning systems

Opioid Tracker

Geographical Distribution U‐47700

Carfentanil

Furanylfentanyl

alpha‐PVP

para‐Fluorofentanyl

para‐Fluorobutyrylfentanyl

Cyclopropyl/Crotonylfentanyl

In 2017, the ministry announced new investments of

$222M over three years, which are focused on four key

areas:

12

The Strategy To Prevent Opioid Addiction And Overdose

• Appropriate Pain Management

• Treatment for Opioid Use Disorder

• Harm Reduction

• Surveillance and Reporting

13

Establishing an Early Warning System in Ontario

Examples of support for local opioid overdose early warning

systems:

• funding to boards of health for the development of systems to

identify and track risks posed by illicit synthetic opioids (ISO)

locally: • resulting in systems that will include a set of “real-time” qualitative and

quantitative indicators and complementary information on local ISO risk

• communication mechanisms and structures to allow timely sharing of

information among health system and community partners, including

people who use drugs, about changes in the acute, local risk level, to

inform action

• exploring enhanced toxicology laboratory capacity to screen

biological samples from people with overdose for ISOs.

14

Opioid Overdose Early Warning System Framework

Developed in consultation with the Illicit Synthetic Opioid

Provincial Response Advisory Committee (ISOPRAC), the

Opioid Overdose Early Warning System Framework promotes

an integrated community response that includes a wide variety

of partners.

Data sources

Triggers Actions

15

Opioid Overdose Early Warning System Framework: Data Sources

Data sources are the people, institutions and services that can

provide useful and timely information on the state of drug use and

naloxone use in the community.

Qualitative Sources Quantitative Sources

People who use drugs self-

report

First Responders

Harm reduction programs Emergency Departments

Law enforcement Prisons

Coroners

Toxicology laboratory testing

16

Opioid Overdose Early Warning System Framework: Triggers

Triggers are the observed changes in the community that would

suggest a surge in opioid overdoses is occurring and will require a

response. Triggers may include:

Community outrage New or potent drug

Increased naloxone use Unusual overdose

symptom presentation

Increase in opioid overdoses

Increase in opioid overdose related deaths

17

Opioid Overdose Early Warning System Framework: Actions

If a surge in opioid overdoses has been identified, a number of

measures could be put into place to minimize further risk,

including:

Release of naloxone stockpiles

Redistribution of naloxone

Diversion of drugs from the street

Rapid rollout of opioid substitution therapies

Enhanced surveillance

18

Opioid Overdose Early Warning System Framework: Communication

Communication is a crucial component of the response to an

opioid overdose surge and messaging needs to be directed to a

variety of stakeholders:

People who use drugs

Harm reduction programs

Law enforcement

First responders

Health care providers

The public The media School boards

Others

19

Final Thoughts

Addressing the opioid crisis is a key priority for the Ministry of

Health and Long-Term Care and the government.

We will continue to work with key partners at the local, municipal,

provincial and federal levels to respond to this crisis in a

comprehensive way.

20

2016-17 SPRING/SUMMER 2017

APPENDICES

21

The current opioid library held by toxicology labs in Ontario

22

Opioid Overdose Early Warning System

Provincial Overdose Coordinator Opioid overdose early warning systems Natural

Codeine

Morphine

Thebaine

Ester of Morphine/Codeine

6 Acetyl codeine

6 Acetyl morphine

Heroin (Diacetylmorphine)

Semi-Synthetic

Buprenorphine

Hydrocodone

Hydromorphone

Oxycodone

Oxymorphone

Synthetic

3 - Methylfentanyl

Acetylfentanyl

Acrylfentanyl

AH-7921

Alfentanil

Betahydroxyfentanyl

Betahydroxythiofentanyl

Butyrfentanyl

Carfentanil

Cyclopropylfentanyl

Fentanyl

Furanylfentanyl

Levorphanol

Lofentanil

Meperidine

Methadone

Synthetic cont…

Mitragynine

MT-45

Norcarfentanil

Normeperidine

Ocfentanyl

Pentazocine

Parafluorobutyrlfentanyl

Parafluorofentanyl

Propoxyphene

Remifentanil

Sufentanil

Tapentadol

Tramadol

U47700

Varlerylfentanyl

W15

W18

Healthy People, Healthy Places

LOCAL EARLY WARNING

SYSTEMS AND

SURVEILLANCE FOR

OPIOIDS

Kieran

Moore MOH

KFLA Public

health

February 2018

Harm Reduction Program Enhancement

funding: Third Pillar

• PHUs will implement, maintain and/or expand local opioid‐related programming based on an assessment of local data and community needs.

Local opioid response

• PHUs, or their designated organization, will act as naloxone distribution leads for community organizations in order to increase dissemination of naloxone kits to priority populations by agencies where individuals are already receiving services.

Naloxone distribution and

training

• Opioid Overdose Early Warning and Surveillance

Opioid Overdose Early Warning

and Surveillance

Provide a coordinated response to mass opioid

overdose event (contaminated product :

beware opioid naive)

Provide a coordinated response to mass opioid

overdose event (contaminated product :

beware opioid naive)

Minimize opioid overdose morbidity and mortality

(IVDU/Addicted population)

Minimize opioid overdose morbidity and mortality

(IVDU/Addicted population)

Need to Prepare-Two exposures

Suggested Steps of an Opioid Overdose Outbreak

Investigation

1. Identify investigation team and resources

2. Establish existence of an outbreak-SURVEILLANCE

3. Construct a case definition

4. Verify the diagnosis

5. Find cases systematically and develop line listing

6. Perform descriptive epidemiology/develop hypotheses

7. Evaluate hypotheses/conduct additional studies as necessary

8. Implement control measures

9. Communicate findings

10. Maintain surveillance

• SELHIN-wide:3 LPHA

• 100+ first responders, first receivers, public health, community health, provincial and federal government representatives

• 3 table top outbreak scenarios

• roles/responsibilities, priority actions and required resources

February 27, 2017

Responding to

and

Recovering

from a M ass

Casualty Event

Secondary to

Opioid

Overdose.

Exercise objectives:

• Determine roles and responsibilit ies

including the lead agency

• Identify priority actions to respond to a

surge event

• Identify the necessary resources,

communicati on structures, and training

required for response

KFL&A Public Health

Top 5 Recommendations

01 Establish local task force to address Opioid use and drugs, Share information

02 Develop mass opioid overdose response plan in anticipation of surge event

03 Local partners collaborate with F/P/T partners to share post‐event debrief

04 Increase public awareness on harms related to Opioids

05 Increase needle exchange, safe disposal and naloxone kits , Overdose prevention sites

2. Develop a mass opioid overdose response plan in anticipation of surge event

Define planning partners Define planning partners

Triggers for activation Triggers for activation

Key actions

Key actions

Key response partners Key response partners

Communication Pathway Communication Pathway

EYES and EARS: Nothing about you without

you: Timely, Accurate, Actionable

Opioid Injury Pyramid: DATA SOURCES

Adapted from: http://apps.who.int/iris/bitstream/10665/149798/1/9789241508018_eng.pdf?ua=1&ua=1&ua=1 http://www.cdc.gov/drugoverdose/pdf/policyimpact‐prescriptionpainkillerod‐a.pdf

Fatal

Fatal

Hospitalizations

Not treated/ Not reported/Social

Hospitalizations

Emergency department visits

Primary care

Not treated/ Not reported/Social

Emergency department visits

Primary care

Know sources in your community

Prescribing ‐ Often unsafe ‐ Diversion

Uncontrolled -Illegal manufacturing - Counterfeit pills

Photo sources: 1) http://www.detoxrehab.org/prescription‐drug‐use‐and‐college‐campuses/ 2) http://www.lumitradeglobal.com/show_prod_detail/buy‐furanyl‐fentanyl‐fuf‐powder‐x3g/7.html 3) CBC.ca 4) http://www.ontario‐travel‐secrets.com/kingston‐ontario.html

Situational

Awareness...

• Police

• EMS

• Street health clinic and pts.

• Primary Care

• Acute Care

• Regional Coroner

• 3 LPHAs

• SE LHIN

• Corrections Canada

• Fentanyl/Carfentanyl detection

Figure 3. Communication patJ1way for n o t if r in g tJ1e health system dur ing an o p ioid overdose surge.

KFL&A Public Health

Opioid

Presentation

Relevant Task Force partner and

their responsibilities

Contribution to Task Force

Drug

confiscated Regional p9lioe

• Initiate investigation to

determine source

• Arrange expedJted toxicological

testin11:

Inform task force of potentially

contaminated drugs preent in the

community

Surge in opioid

overdose

syndrome

patients

presenting to

health system

Eme rgenc::i:: medical services

• Communicate increased

naloxone usage

• Collect and share data with. other

emergency first response partners,

public health, and task force

Patient demographics, amount of

naloxone used (ifprovided),and the

drug used (if known)

Emeraenc::t dcj!&rtmcnt

• Patient data sent to public health

whi le acute care sends specimen for

tcstinit

Patient demographics, amount of

nalox.onc used (if provided), and the

drug used (if known)

Surge indeaths Coroner

• Initiate: investigation

• Request expedited toxicological

testing

• Report the death to public health

and task force

With confirmed opioid toxicology the

cause of death is reported to the

Regional Coroner who in tum could

share the

information with the regional task

force (so they can limit further

banns)

Data sharing

and

Surveillance

Public health

• Surveillance (health system and

drugusing community)

• DeliYer risk communiwition to

public

• Coordinate response

• Provide enhanced naloxone

canacitv

Share information among task

force partners

v.1111 i l l cit opl0ilf)1 D

- -

I n ..-..,tin c1..·... 1 1. - - - -

•lp u r g r nl ri·r;.k r.on1n1u 111ca.t 1o n ,, nrl h.1r n 1 r<:"duc: t Jon

"1'1t lo kn o;, U 1• c 1u ..-..-1c 1v l!' H "l l l l

IF "it:! "denlh.U>tt i1WQ5tigrumg c a _ . •lmul:! silnrm 1114 m il l n l ! t l o C1$1;115S ·O l o$1ing 11$111g 1111) llleil;bn lrl'Q,

I f cw1111nS •beto1confi§C>Mell b'I'pOtc&. • >l)ltd11e11 W"lll lhroilgh Hft l l ' ICl l N<lil

mar bit • rangtd . IF 111 $C!Mf;41$ 110. - ' K t 11;1 IOiPlrtg b l n n l,lll1lf.IQh Ho;Jltll CnB;MS.

IF Ille SflOCl'tteib arc frOtn a pllliel ' l l ' IA CJncal IC0Li11111 -HP·tr.e IOlowiltg

IOI: mhantt t l d nlclll 1 '11ng:

•·Unne

• fOl'ln - dinlc:al inlamMion • sent la JC l l l t c.nll•

KFL&A Public Health

SUf

Q,

e 111 ovordoff• Ii\ an oplQld nalv• popurAilQn(Ngntut.pli::lon .o:r eONamlnUl(lft

OplGfd o...ei-.do11t yndromt :11r 1entMlon l\nd (thac:k .Allt1111t .AAiJI;,>):

HIQhINWll rosulon llilli:.ll ra(lWGll (•Jmo.11

Pliikitioed MIClll> ..., uht<l?

ll'llll:ecJ fflPOl\SC rrom llmo nnrcan 'Mill overdose l')tKlrcrne or ltllpas...i-7

D 0 D

D

othnr (please d11cllbt):

D

()pool OY01il!lM · ·ii!kin.tiu

LPt*

IMll-homa-ptdMo

AMO

p ....... (ln ..., ol Jftdr-

• l!lill'l1 • O.C.uliiutl oe1w.o:i.1rillll' • DtaolUCd-of C!01151:iouv!I!.. • <:yllllCllll

AMO

J>o-••>fO'.,. 'O "llo•Oi'll (!Ip)

II.. ConAIJll*d

M GI Illa li*I•YllanWJ<y car6maDan ol °""la • n th r• .i ho\1e 1 1

n

iy h(

r.11cu1e•i

Messaging

GAPS : Prescribed Opioid Load MME

Ontario Opioid Atlas, 2016, TIMELINESS

Chain of Survival-OPIATES: Persistent and

Consistent

Deflating the Addiction Balloon-SLOWLY To

AVOID Unintended Negative Consequences

Common Challenges -Surveillance

• Need to identify triggers for urgent community response-threshold

• Communication and coordination of efforts between partners

• Plan rural emergency response

• Review resource limitations

• Personal health information and privacy implications during criminal

investigations

• After-action evaluation for quality improvement and lessons learned

Suspected OD Surge: Communication Pathway

Case Definition:

Opioid

Overdose

Syndrome

• BEWARE NEED FOR

HIGHER DOSE NALOXONE-over 2mg

Naloxone per patient is key signal of synthetic

Surge Response Pathway

Incident Management System

Municipal Emergency Response: Activation Guidance

VI " ' tJr Reid Par

- Needle and Syringe Program

- Opioid Substitution Therapy (Methadone)

- Opioid Overdose Prevention (Naloxone

Kits)

- Community Addictions Treatment Residential Addictions Treatment

Chtnge H. .Hll C•rt

Belle P111k flllrWa)'

. - Detoxification

rryfkl ·.., t 1.Jrv'1

emetery 'O ct

• i

Glen.Ydl!f\ Pillk

l f

0J k

Jottn1on .St

•>

<• i

,•. : l

11dtn St

Yi • .. .

v•

•> <

Bell tP11k Dr

·®· 25 0.5

'O ct •

•..

Thud Me Porl!

1

Kilometers Addiction Treatment and H:irm R11rh1r.tinn SP.rvir.P.i;

DrawnBy. Knowledge Man1gemen1D1"1stlon· l<FLAA Public HAAltti

Figure 20. Map of the Street Health Centre Outreach Van Calls/Visits, 2015 (Source:Personal communication with Justine Mcisaac, HCV Outreach Worker,

2016)

Outreach Van

Visits

0 · I 2 - 5

6 . 14

15 . 27

28 - 69 -

l:lglnburg / llvet Comct1 / hannol\'• Comers

Cararoqul W • tbtoak

C&tmqul North 0

- = -- = = = - 0 0 5 t

- • Kiometera 3 Outreach Van

Drawn By Knowledge Management

D1v1slon • KFL&A Public Health

0

0

( )

0

0

0 0

0 0

0

ntenac 'paramedic Services

Naloxone Administration

014 - 201 A Ith

0

0

()

0

0

ntenac 'paramedic Services

0

0

0

0

0

Naloxone Administration

014 - 201

4. Increase public awareness on harms related

to Opioids across the life course, proportionate

3. Local partners collaborate with F/P/T partners to share information & post-event debrief

• MEOC activation Oct.

2017

• Weekly operational

cycle

• Provincial use of EMCT

for situational

awareness and

information sharing

• Platform to share local

situation reports &

notable practices

5. Facilitate and increase availability of treatment & counselling for substance use disorders; needle exchange, safe disposal and naloxone kits for those at risk.

• Harm Reduction Program Enhancement

– Distribution of naloxone to community service providers ( schools, AED )

• Direct distribution to people, family or friends of those at risk for opioid OD

– Monday-Friday 0900h-1200h & 1300h- 1600h

• Safe inhalation/injection kits on-site

• Needle drop-box(s)

– 221 Portsmouth & HARS

– City of Kingston – Street Health partnership: 10 locations

More information…..

References

Moore K, Boulet M, Lew J, Papadomanolakis-Pakis N. A public health outbreak management framework applied to surges in

opioid overdoses. Journal of Opioid Management. 2017; 13(5).

World Health Organization. International Health Regulations (2005) 2nd ed. Geneva: WHO, 2008. Available at:

http://apps.who.int/iris/bitstream/10665/43883/1/9789241580410_eng.pdf. Accessed June 23, 2017.

Tomassoni AJ, Hawk KF, Jubanyik K, et al.: Multiple Fentanyl overdoses - New Haven, Connecticut, June 23, 2016. MMWR.

2016; 66(4):107-111. Available at https://www.cdc.gov/mmwr/volumes/66/wr/mm6604a4.htm. Accessed June 21, 2017.

Ontario Opioid Surveillance Monitor: Kingston Frontenac Lennox & Addington Public Health Informatics: Ontario Opioid

Surveillance Monitor. Available at

https://public.tableau.com/profile/kflaphi#!/vizhome/OntarioOpioidSurveillanceMonitor/ACESEDVisits. Accessed June 22, 2017.

PHO Interactive Opioid Tool: Public Health Ontario: Opioid-related morbidity and mortality in Ontario. Available at

http://www.publichealthontario.ca/en/DataAndAnalytics/Pages/Opioid.aspx. Accessed June 22, 2017.

Thank you.

This Photo by Unknown Author is licensed under CC

BY‐NC‐ND