Welcome everyone. My name is Alex Walley. I'm a General Internist and Addiction Specialist at Boston University School of Medicine, Boston Medical Center. I take care of patients in a primary care setting for HIV patients where I work in a multi-disciplinary team that treats addiction including with medications like buprenorphine or naltrexone. I also see patients in a methadone maintenance program. I spend some time every week at the health department focused on overdose prevention, and that's what I'm going to talk to you about today. The title of this talk is preventing opioid overdose with education and naloxone rescue kits. I have no financial relationships to disclose. I want to remind you that the overarching goal of the PCSS-MAT is to make available the most effective medication treatments to serve patients in a variety of settings including primary care, psychiatric care, and pain management setting. I'm hoping that you'll learn today an understanding of the epidemiology of opioid overdose. You should be able to describe the rationale for and the scope of overdose education and naloxone distribution programs. You should be able to implement overdose education and naloxone distribution in settings that offer medication for opioid use disorder. That includes educating your patients about overdose risk reduction and prescribing naloxone rescue kits. I'm going to frame today's presentation with a case. This case is a mosaic of many patients that I've had over the years and it's there to highlight the opportunities and the pitfalls for overdose education and naloxone. So this is a 29-year-old woman, presents to clinic for buprenorphine treatment. At age 18, she was an accomplished athlete with collegiate prospects when she tore her ACL and she was prescribed opioids after surgery. She develops an opioid use disorder within six months and at age 20, she had transitioned to injecting heroin daily and she had dropped out of college. Between the ages of 20 and 26, she had multiple detoxification and residential treatment program stays, but was not able to sustain greater than three months without a relapse. Then at age 26, she was pregnant and this was diagnosed at her last detoxification stay. Then at that point, she was transferred to methadone maintenance. On that methadone maintenance, she was able to stop using heroin, engage in a 12-step program, and she delivered a healthy baby which she breastfed and was able to retain custody. Then at age 28, she tapered herself off of methadone. She had wanted more time with the baby and to work. Her boyfriend had been incarcerated for selling drugs. She eventually, however, relapsed, lost custody, and was now seeking treatment with buprenorphine. She does not want to go to the methadone clinic every day. So she comes to you in the setting of a relapse. After been successfully treated with methadone, she now is interested in receiving buprenorphine treatment. Between the ages of 29 and 30, she had a good response to office-based buprenorphine treatment that included regular clinic visits with urine toxicology that was only positive for buprenorphine. She re-engaged in 12-step program and with her family, and she worked with the child protection to regain custody of her child. Then at age 30, she was hospitalized in intensive care for a overdose. What happened was that her boyfriend had been released from incarceration and returned to stay with her. He relapsed and overdosed on heroin on the third night after leaving incarceration. This overdose was likely a fentanyl sold as heroine. She packed his underwear with ice, tried to rescue breathe, but he did not respond. So she called 911 and they were unable to save him. Child protection was notified about the incident and they removed her son from the home. She stopped her buprenorphine at this point and started drinking alcohol and then relapsed to heroin and fentanyl, and overdosed. So the question I hope to answer during this session is, how could overdose prevention improve this case and the outcomes that we see here? So overdose continues to increase and it's the leading cause of accidental injury death. So here you see on the y-axis, the number of deaths from drug overdoses, car accidents, and gun violence between 2000 and 2014, the years on the x-axis. You can see that over this period of time, a transition occurred where the leading cause of accidental injuries switched from motor vehicle deaths to drug-related deaths. You can see that there's a rise in drug-related deaths. There was also somewhat of a rise from gun-related deaths, although not to the same degree that there were for drug-related deaths. The rates of a drug overdose deaths by state changing from 2010-2015 are represented on this image. You can see all 50 states here. In almost every state between 2010 and 2015, the rate of overdose deaths increased, particularly in states in Appalachian in New England like West Virginia, New Hampshire, Kentucky, Ohio, Rhode Island, etc. So the open circles are the overdose death rates in 2010 and the closed circles are those in 2015. The opioid death rates increased by 15.6 percent from 2014-2015 alone. This increase has been driven by synthetic opioids: we think illicitly manufactured fentanyl as well as heroin. Increases in these opioids subcategories occurred overall and across all demographics and regions. The overdose death since 2010 appear to be driven by heroin and fentanyl and not, as in the previous decade, by prescription opioids. So here you can see a representation of, again, on the y-axis, the rate of death per 100,000 and then the year on the x-axis. You can see that with prescription opioid deaths, which is the top graph, there's been this surge that went from 1999-2010, but then there was a leveling off in 2010. Then a concomitant surge in heroin-related deaths in 2010. So it looks to be like there was a transition here from prescription opioids to heroin being the primary drivers of overdose deaths. So that showed you data up through, I think, 2014. Here, we see changes from 2015 and you see this really dramatic surge in 2015 of fentanyl-related deaths, continuing increase in heroin deaths, and actually an uptake in prescription deaths, cocaine-related deaths, and methamphetamine-related deaths. So we're seeing on multiple fronts an ongoing and increasing surge in opioid-related, which is primarily driven by fentanyl. So this leaves us with the question of what strategies do we have to address overdose? I'm going to go through a number of the current public health strategies and then we'll focus on overdose education and naloxone distribution. So one of the tools that's been implemented have been prescription monitoring programs now, I believe, in all 50 states. These are systems that one can check prior to prescribing to see whether patients are getting prescription opioids or other controlled substances prescribed from another provider. There's also prescription drug safe storage and disposal efforts. So here you can see a prescription return box that allows patients to return their unused prescription opioids and have them safely disposed of. There's still sponsored by the DEA twice a year, drug take back programs that occur usually in the fall and spring. A number of states including the state I work in, Massachusetts, have mandated safe opioid prescriber education. You can see here the guidelines for prescribing opioids for chronic pain from the CDC, which are widely disseminated guidelines that are focused on trying to reduce the risks of overprescribing prescription opioids. What hopefully came through in the case was an important role for medication for opioid use disorders. Here, we see the photographs of Vincent Dole and Nyswander who were the partner scientists who really developed methadone as the treatment for opioid use disorder. I would like to mention supervised injection facilities, though not legal anywhere in the United States currently. These are evidence-based public health interventions that exist throughout Canada, and Europe, and Australia and have been demonstrated to have a benefit in reducing overdoses as well as other injection drug-related complications. There's a number of cities in the United States who are looking at implementing this, although at this point in time none have successfully done so. Finally, overdose education and naloxone distribution. I'd show you here a chart that shows the different formulations of naloxone that's available for free at prescribetoprevent.org, which is a great online resource for people interested in finding out more. So I want to say a little bit more about fentanyl and how that specifically changes our approach to or updates our approach to responding to overdoses. So here are some public health response recommendations that came out of a opioid investigation that was jointly conducted by the CDC and the Massachusetts Department of Public Health. It was a mixed methods approach which included qualitative interviews of people who survived or witnessed overdoses as well as the review of death records between 2014 and 2016. I'll read the quote here from one of the overdose bystanders that sums up the role of fentanyl. "So now what they are doing is they're cutting the heroine with the fentanyl to make it stronger, and the dope is so strong with the fentanyl in it, that you get the whole dose fentanyl at once rather than being time-released, and that's why people are dying, plain and simple. You know, they are doing the whole bag and they don't realize that they can't handle it, their body can't handle it." So the summary recommendations that came out of this project included the following. So the public health response to drugs overdose is related to illicitly made fentanyl included that fentanyl should be included on standard toxicology screens, that we should adapt existing harm reduction strategies such as incorporating direct observation of anyone using illicit opioids and ensuring that bystanders are equipped with naloxone. We should also enhance access and linkage to medication for opioid use disorders. So overdose education and naloxone distribution is a key tool in addressing the overdose crisis. You can see here that it's been endorsed by many of the major mainstream medical organizations including the American Medical Association, the American Pharmacists Association, the American Society of Addiction Medicine, the World Health Organization, and the Office of National Drug Control Policy. I'm going to give you some basics on naloxone. So the medication itself after administered takes effect in 2-3 minutes. If a patient isn't responding in this time, a second dose may need to be administered, although we counsel that you do wait the 2-3 minutes to allow it to work before giving a second dose. The naloxone wears off in 30-90 minutes. So the implications of that are that patients can go back into an overdose if they have long acting opioids onboard. Long acting opioids include fentanyl patch, methadone, extended-release morphine or extended-release oxycodone. So patients should avoid taking more opioids after naloxone administration so they do not go back into overdose after naloxone wears off, and patients may want to take more opioids during this time because they may feel withdrawal symptoms. So this is a conundrum that patients are facing after they're rescued from an overdose. Note that the shelf life of naloxone products is 12-24 months, and that it should be stored at room temperature to minimize degradation. Here's examples of naloxone formulations. So there's an intranasal formulation with an atomizer attachment shown here. This is, by the way, not FDA-approved. So it's an off-label delivery system. There's an auto-injector represented on the upper right, which provides audio instructions to the administrator and it can be administered through clothing as demonstrated here in the picture. There's a intranasal spray which is FDA-approved called NARCAN nasal spray. Then, there is a intramuscular injection where they have single use vials or 10 milliliter vials that can be used with a needle and syringe where that's drawn up and injected intramuscularly. So what's the Rational for Overdose Education and Naloxone Rescue kits? Well, first of all, most people who use opioids, do not used alone. So there's someone else present at some point, that is available and able to intervene when an overdose occurs. We also know the risk factors for overdose, and so we can educate our patients and the community about these risk factors so that they can decrease their risk of overdosing in the first place. Those risk factors include mixing substances with opioids, that can make the risk of overdose higher such as benzodiazepines, alcohol, other sedating medications. There's also loss of opioid tolerance. So the irony is that people who stop using opioids are able to lower their tolerance, are then subject to a higher risk of overdose, if they relapse. There's particular populations that carry this risk, such as people getting out of incarceration or people completing inpatient medically managed withdrawal, or detoxification, patients coming out of the hospital, or people in recovery. So it's important that education include that understanding, that abstinence or lots of opioid tolerance, actually increases the risk of overdose in the setting of a relapse. Using alone is a big risk factor, especially in the age of fentanyl, and then not knowing where the opioid comes from, an unknown source that is a radically prepared, which again we see especially with the [inaudible] fentanyl. The opportunity window to intervene in during an overdose, traditionally takes minutes to hours. So there's minutes to hours of an opportunity window to intervene. During that time, if noloxone is administered, the person can be rescued. However, fentanyl has reduced that window to seconds to minutes. So it shrunk that response window time down, because of its potency and it's rapidity. Bystanders are trainable to recognize and respond to overdoses, and that's really a big reason why we're promoting overdose education in noloxone distribution today. There is also a fear of public safety. So no matter how good the relationship is between, say law enforcement and the community, there will be some people who are fearful of calling for help during an overdose, for fear that they might be arrested or something might happen to their loved ones. So there's always going to be cases where people don't call for help. In that case, it's better to have naloxone than have nothing. There's been a cascade of research and program evaluation on overdose education and naloxone rescue programs, and I've listed many of those citations here on this slide. They've shown that programs are feasible in multiple populations, that the education increases knowledge and skills. That there is no increase in use, but there is an increase in drug treatment among people trained. There is a reduction in overdosing communities that implement naloxone in overdose education, and needs are highly cost-effective public health interventions. So I'm going to summarize one study that we did in Massachusetts, that contributed to this literature. So the objective of the INPEDE OD study was to determine the impact of opioid overdose education, with intranasal naloxone distribution programs on fatal and non-fatal opioid overdose rates in Massachusetts. So here, you see a slide of Massachusetts, with each town color-coded based on the number of overdoses that occurred between 2004 and 2006. So that darker towns had more overdoses. In 2006 and 2007, the first two OEND programs were implemented in Boston, Cambridge, both towns with high numbers of overdoses. Then in 2007 and 2008, there was an expansion to other towns in the state, represented by the green diamonds, and then a further expansion in 2009, to two more towns. So that was good news, an expansion of this public health program. But at the same time, there were several towns that had substantial numbers of overdose, but did not have counts implemented or programs implemented. So that gave us the opportunity to do a natural experiment, where we could compare the overdose rates from the change and overdose rates in the towns with and without Noloxone Rescue Program. So I'll show you the results from that. So here you see that the adjusted rate ratio and account that had low implementation between one and 100 was 0.73, and the adjusted rate ratio in the towns that had high implementation, which means greater than 100 rescue kits distributed per 100,000 people, had a distinctly ratio of 0.54. I may show you that same data represented in another way here. So in the towns that had no coverage, we consider there overdose rate at 100 percent of the baseline. You can see that the towns that had between one and 100 people per 100,000 enrolled had a 27 percent reduction in the rate of overdose deaths during that time. Then a further reduction of 46 percent reduction in the opioid overdose rate in towns that had more implementation. So greater than 100 people per 100,000 who had been enrolled in the Naloxone Overdose Education Program. So that was strong observational evidence that implementing overdose education and naloxone distribution can have a community level impact improvement on the overdose death rates. Now these naloxone rescue kit programs have disseminated across the country, and here's a map that comes from a survey that was done in 2014 of the United States, with each of the programs marked on the map with a white dot. So you can see that there have been a substantial growth in the number of programs, but there are still many places in the United States where there are no programs. Even in states that have substantially high overdose rates, those would be the darkest blue states. So at that time, West Virginia, which by the way now has multiple naloxone program since 2014. But at the time they did not. Nevada, and Arizona, and Kentucky, and Florida are examples. Those are the community-based programs, and now I'm going to talk to you about many of the venues where naloxone can be implemented. So here's a study that we did, focusing on the Massachusetts Naloxone Program, and specifically looking at what addiction treatment settings naloxone had been implemented. Here we specifically we're looking at medically managed withdrawal or in-patient detox programs, and methadone programs. So we came up with this schematic of implementation strategies at these locations. So the first one is where the staff provide OEND on-site. The advantages to that are good access to OEND or Overdose Education and Naloxone Distribution. Opioid overdose prevention is actually integrated into treatment. The downside to that is that patients may not be comfortable in a treatment setting, disclosing their own ongoing use or their risk, because in many treatment programs there are penalties if you're not completely abstinent. So that's something to be aware of. Another model, is that outside stack from a community overdose education program come in to provide the treatment on-site, or not treatment, to provide the prevention education on-site. The advantage of this is that opioid overdose prevention is integrated. There's inter-agency cooperation between treatment programs and community-based prevention or outreach programs, and there's a low burden on the staff at the treatment programs. The disadvantage is of you need a community program that offers this service. Another model is that overdose education is provided on-site and naloxone is received off-site. So the advantage here is that opioid overdose prevention has integrated, there's inter-agency cooperation, but it requires that the person who's being trained has to actually go and get the naloxone elsewhere, which is a barrier. Then the last model is that outside staff recruit near a methadone maintenance treatment program or detoxification program. So this is what's been necessary for those programs that have not permitted overdose education or naloxone distribution to be done on-site. Of course, in contrast to what the American Society of Addiction Medicine recommends to treatment programs, the advantage to that there's confidential accessed overdose prevention. The downside is that opioid overdose prevention has not reinforced in treatment, and not all patients are reached. I want to just make sure we don't forget about the staff of these program. So in part of this project, we interviewed staff and found that among the 29 methadone providers and 93 providers who worked in in-patient detox, 38 percent and 45 percent of them respectively reported witnessing an overdose in their lifetime. There are other venues and models in addition to methadone treatment programs and in-patient detox programs may include buprenorphine and Naltrexone treatments. So office-based addiction treatment. First responders, including police and fire, as well as EMS. Then emergency department efforts to do screening, brief intervention, and referral to treatment. Post-incarceration programs are good venues to integrate overdose education and naloxone distribution, as well as community corrections like parole and probation. Then those of us who were prescribers, who are working in the clinic, we should be prescribing naloxone to our patients that are high risk. For prescribers, you can get more support and more information at prescribetoprevent.org. When I'm talking to my patients about overdose education, here are the things that I think about, and I start doing this for a lot of patients of mine because I'm in Massachusetts where there's a really high public health burden. So the first thing is that I review their medications and ensure that I communicate with other prescribers about the overdose risk when there are multiple sedating medications or multiple opioid medications, for example. I also take a substance use history. So substance use is very common, and it's important health risks that we need to ask about and understand as providers. I check the prescription monitoring program when I'm prescribing a controlled substance. Then I ask specifically about overdose and hear the questions that I ask and I encourage you to ask your patients these questions. So first of all, how do you protect yourself against overdose? I typically ask this of patients who had disclosed a substance use history. I find that they're very open to answering this question, and I want to know what their plan is to keep themselves safe. For my patients who say don't have a substance use history but are taking a controlled substance like an opioid, I may start with how you keep your medication safe at home. If they asked me why? Which they usually do, then I'll explain to them about the overdose risk of their medications. I find that's a good approach to get them engaged and to start a practical discussion about safety planning. Now in the addiction treatment setting, many of my patients answer the question, how do you protect yourself against overdose by saying, "Well, I never planned to use opioids again. That's why I'm here." My response to that is to say, well, that's a fantastic plan A, and I applaud you for taking that on, but I want to know about your plan B. What happens if you use? Even if you're not planning to relapse, what's going to happen if you do and how are you going to keep yourself safe? So then we walk through the overdose prevention strategies that they should take, which include not using by themselves, making sure somebody is right there with them equipped with naloxone, trying not to mix sedating substances. If an overdose occurs, make sure somebody in the bystander calls 911. So then I also ask them about their loved ones or the people that they may have observed who had a risk for overdose. By saying, what is your plan if you witnessed an overdose in the future? Then specifically, have you received training to prevent, recognized, or respond to an overdose? So here are the things that people need to know that you want to review with your patients who have an overdose risk. First of all, prevention. They should know the risks about mixing substances, about low tolerance from abstinent, about using alone and the substances coming from an unknown source. If they have chronic medical disease like liver or lung disease, they're at higher risk for an overdose. Then they also need to know that long acting opioids last longer. Next, they need to know how to recognize an overdose. So we encourage them to check whether somebody who's unresponsive to a sternal rub or has slow or absent breathing, then in those cases, you need to think about overdose. Other signs would include gray or blue lips and pinpoint pupils. Then what do you do? The first thing we want people to do is call for help, rescue breathe and administer naloxone as soon as it's available. They can wait three minutes before administering a second dose and then stay until help arrives. While they're waiting for that dose, the second dose to be administered, they should be doing rescue breathing. So here's that response in a repeated in a graphic here, and these are the steps to teach patients, family, friends, and caregivers. So Number 1, recognize the overdose. Number 2, call for help. Number 3 and 4, administer naloxone as soon as it's available and initiate the rescue breathing. If you're trained in CPR and the patient's heart has stopped, then you should start chest compressions. Then stay until help arrives and you can place the person in the recovery position on their side if they start breathing while you're waiting for help. Here's a reminder of the four different formulations of naloxone. To reiterate this the third time, I'm showing you that this has been incorporated into the training for algorithms for the American Heart Association in responding to community overdose. So these are the same steps that we just showed on the other slide. But in the AHA algorithm that it encouraged administration of naloxone as soon as it's available, and after of course you've determined that it is an opioid-related overdose. Here's a study that talks about the implementation of naloxone into community health centers. So non-randomized intervention study of naloxone co-prescription for primary care patients receiving long-term opioid therapy for pain. The objective of this study was to evaluate the feasibility and effect of implementing naloxone prescription to patients prescribing opioids for chronic pain at six safety-net primary care clinics in San Francisco. What they found was that after training all the staff and the prescribers in these clinics, that 30 percent of the 1,985 patients on long-term opioids were also co-prescribed naloxone rescue kits. The patients with higher opioids doses and previous opioid-related emergency department visits were more likely to be prescribed naloxone kits. The good news was the opioid-related emergency department visits were reduced by 47 percent at six months and 63 percent at 12 months. Among those who were co-prescribed naloxone compared with those who were not. There was no change detected in the net prescribed opioid doses for patients who were co-prescribed naloxone. So this study, I think is encouraging for people in primary care settings that they really can and should prescribe naloxone to their patients who are on chronic opioid therapy. The likely result is there'll be fewer opioid related emergency department visits. In order to prescribe naloxone, you need to have a pharmacy that's willing to fill it. So here on this slide you can see examples of how to access pharmacy naloxone. So the first is there standard prescriber writes a prescription and then patient fills it at the pharmacy. Works for clinics that have insured patients. Ideally, you're going to alert a pharmacist to your prescribing plans, so they're prepared to fill a prescription. Most retail pharmacies in the US are now equipped with naloxone. Many of them actually have standing orders, which we'll go over in a second. But it's still good to communicate with the pharmacist. If you're prescribing naloxone, and you have to label naloxone, this pharmacy may not stock the atomizer. So you may have to provide them through your clinic. It's good to have informational brochures about how to fill it. A second model is where the pharmacy provides naloxone directly to a customer. This is without prescriber contact under a standing order as I mentioned. Typically, the pharmacists in order to implement a standing order have to do extra training. There are passive or active training models. They're also could have standing orders that are set up as a co-prescription where they're automatically dispense with any opioid prescription. Some pharmacies are moving towards a universal offer where they offer to all of their patients. But this can be clarified with a pharmacy policy. Then there's pharmacies that provide naloxone to patients while they're in a treatment center or clinic. This may happen without prescriber or pharmacy contact understanding order, and the training can be done onsite at the clinic facility level compliance and sustainability. So really bringing naloxone to the treatment environments. I think it's safe to basically offer naloxone to everyone, here the categories you can think of. So anyone with an opioid prescription, anybody with the opioid or Benzo prescription combination, anybody who has a disease plus an opioid combination, anyone who's been treated with methadone or buprenorphine or naltrexone. People who are going through transitions of care between say an addiction treatment and medical facility or vice versa. Friends and family of those who are at risk. When somebody has to buy syringes at a pharmacy, there potentially have access to people who are injecting and they can be offered naloxone. People who are going to addiction treatment, people are coming out of correctional institutions, and those who have concomitant mental illness too are involved in behavioral health care. There are practical barriers to prescribing naloxone. The first is prescribe a knowledge in comfort. How do I write the prescription? Does the pharmacy stock rescue kids? Way to address this is to work with your pharmacy to get it stock. Who pays for it? The best way to find out whether insurance pays for it is to have a good open dialogue with the pharmacist to see who will cover it and what co-pays are required, and then advocating with insurance to get naloxone on the formula area. This is the case in many states on the Medicaid formula. So there are no real legal barriers to prescribing naloxone. Here's a quote from a paper in the International Journal Drug Penalty that addressed this issue back in 2001. Prescribing naloxone in the USA is fully consistent with state and federal laws regulating drug prescribing. The risks to malpractice liability are consistent with those generally associated with providing healthcare, and can be further minimized by falling simple guidelines presented. These guidelines are what you see for any prescription. So only prescribed to a person who is at risk for overdose. Ensure that the patient is properly instructed in the administration and risks of naloxone. Now, a caveat to this is that many states have what are called third-party prescribing permission. So you can actually prescribe not only to a person who is at risk for an overdose, but a person who is likely to be present in an overdose, who may not have risk themselves. So a question you want to ask yourself is, does your state permit prescribing to people not at risk of overdose? Does your state Have a Good Samaritan Law? There's a great resource to find that out at pdaps.org. Here's an example of a naloxone overdose law that shows limited liability for both patients and prescribers and allows for third party prescribing. So first, the Good Samaritan Provision protects people who overdose or seek help for someone overdosing from being charged or prosecuted for drug possession. Note that the protection does not extend to trafficking or distribution charges. There's patient protections from liability. A person acting in good faith may receive a naloxone prescription, possess naloxone, administer naloxone to an individual appearing to experience an opioid-related overdose. There's prescriber protection. Naloxone or other opioid antagonist may lawfully be prescribed into spans, to a person at risk of experiencing an opioid-related overdose, or family member, friend, or other person in a position to assist the person at risk of experiencing opioid-related overdose. For purposes of this chapter and Chapter 112, any such prescription shall be regarded as being issued for legitimate medical purpose and the usual course of professional practice. So that provides prescriber liability protection, and allows for the prescribing to a third party. So now I want to get back to our case and go back through it and think about how overdose education and naloxone distribution could have been employed in this person's course and how it would've made a difference. So again, we had a case of a 29-year-old woman presented to clinic for buprenorphine treatment. Going back of overheard history at age 18, she was an accomplished athlete with collegiate prospects when she tore her ACL and she was prescribed opioids after surgery. Then she developed an opioid use disorder within six months. So at this time when she was prescribed the opioids for her torn ACL, she could've been counseled about the risks about overdosed, addiction, and safe storage while being on prescription opioids, and she could have been co-prescribed in naloxone rescue kit when she was prescribed opioids for pain, even though it was before the time that she developed any addiction. When she initiated injection at age 20, hopefully she had access to the syringe service program where she could get regular sterile syringes to use while she was injecting. If she had been able to do that and most of the syringe service programs in the United States, she would've been able to access a new naloxone rescue kit from the needle exchange or the syringe service programs. From 22-26, she had multiple detoxification and residential treatment program episodes although she was not able to sustain more than three months without relapse. In these settings, she could have been counseled about starting low and going slow while she was using so that's an overdose prevention recommendation, respecting her tolerant that each relapse and she would have been able to rescue her boyfriend. At age 26 when she became pregnant at her last detoxification episode and transferred to methadone, she was able to stop using heroin and engaged in 12-Step and delivered a healthy baby, breastfed and retain custody. When she initiated methadone, she could have received overdose prevention education during orientation at the methadone program. Then at age 28 when she tapered off of methadone because you wanted more time with the baby and to work, and then her boyfriend had been incarcerated and she relapsed, lost custody and then came back to us looking for buprenorphine treatment because she didn't want to go to the methadone clinic every day. She could have gone an overdose education and naloxone rescue kit as part of the taper and discharge plan from the methadone clinic. So when the tapering people offer methadone, they should know the overdose risk goes up and that's an opportunity to educate people and equip them with a naloxone rescue kit. At age 29 and 30 when she had a good response to the office space, buprenorphine treatment with regular clinic visits and with a negative urine toxicology except for buprenorphine and when she reengaged in 12-step and with her family and worked with child protection to regain custody, she could have gotten overdose prevention education and naloxone kit as part of her orientation in the buprenorphine program. Then at age 30 which was when she relapse because of her boyfriend's overdose death. Well, if she had been equipped with naloxone and her boyfriend had been released from jail and she returned to stay with her and then he relapsed and overdosed on heroin on the third night, she would quit the naloxone, she could call 911, started rescue breathing and then administered one dose of nasal naloxone, then he would have been transported, observed, and transferred to a residential program, ideally from the emergency department for formerly incarcerated people with drug problems. She rescued him and saved his life and in response, police and EMS praised her for her response saying that, it saved his life. At that point, she call on buprenorphine program counselor and went to group counseling that week where she received the support around the stress and trauma of having her boyfriend return from incarceration and relapsed and then overdose, but also the strength to know that she was able to rescue him and maintain her own sobriety. From there, she lived happily ever after. So that concludes our case. I want to provide the opportunity to show you these several helpful websites that hit on many of the topics that I addressed today. That mean you could use this resources to build your knowledge and your practice around overdose education in naloxone distribution. Here are the references that were referred to during the presentation. Then I want to remind you about the PCSS Mentor Program, which is a fantastic program. I encourage people to take advantage of it. It's designed to offer general information to clinicians about evidence-based clinical practice in prescribing medications for opioid use disorders. PCSS mentors are a national network of providers with expertise in addictions, pain, evidence-based treatment including medications. There's a three-tiered approach that allows every mentor and mentee relationship to be unique and catered to the specific needs of the mentee. There's no cost for participation. Here's the website pcssNOW.org/clinical-coaching. I also want to remind you about the PCSS discussion forum, where if you have a clinical question, you can submit it and ask a colleague and expect responses from experts as well as people active in the field. Then here is just a reminder that this has all been sponsored and made possible by the PCSS-MAT Program, which is a collaborative effort of the American Academy of Addiction Psychiatry in partnership with the Addiction Technology Transfer Center and several other professional organizations which I will spare you from reading, but [inaudible] here on this drive. Thank you.
