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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
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
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
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
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
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
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.
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