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Side Event: Preventing Overdose

Preventing Overdose Side Event.
Dr. Gerra.  UNODC. Introduces Michael Boticelli.  Speaking of principles who take care of people in all stages of disease.  Cannot recover if you can’t survive.  Change mentality of society in general.  When you die there is someone else to take care of you.  Cannot imagine that you can die without someone taking care of you.

Michael Boticelli.  Pleasure to be a participant on this matter.  Issue of utmost importance and public health.  Human rights issue.  What is the role of government, and persons. For protecting most vulnerable.  Very intuitive issue.  Think about conclusions from Scientific committee. Addition a disease.  Think of health issue. Treat like life threatening situation from other chronic diseases.  Ie heart attack.  Revive.  Train in interventions.  Interventions we are putting in place must support that line of work.

G. Gerra’s slides.  Standing for the right to life: overdose prevention.  Information from WDR 2013. 102,000 to 247K overdoses 2011.  Underestimated.  In all countries this is mixed with heart attack, stroke, etc. .  In many cases an overdose.  Harm Reduction Conference in UNODC presented this data.  Now collaborating.  Put together initial thought and documents since Vilnius.  More literature scientific etc.  Implementing a package of education and naloxone distribution, good results in communities where methodologies applied.  Concrete results.
1992.  Italy.  Experience as a practitioner.    Acute overdose training.  Ambulances and ER rooms not prepared to manage fatal overdoses.  People who might be present can reduce mortality if they know how to use naloxone.

Growing level of complexity.  Not enough just to distribute medication.  Treatment of drug dependency in general.  People who are not alone, but in an institution can be helped.  More retention in treatment, less overdose.  Direct relationship.  Risk when you stop treatment, so need to have package of education and naloxone when treatment being ended.  Who is more at risk?  Those with no knowledge.  28% not aware how to prevent.  Migrants and people from other countries, low level of education.  Poorest of the poor always more at risk.  Consider people affected by psychiatric disorder concomitant with SAD.  At risk of suicide.  Reciprocal influence.   Overdoes is a common method of suicide.  Addiction 2014.  Family matters – importance of take home naloxone.  Parents and partners.  Simple and cheap tool.  Moving from social exclusion and loneliness perspective to condition of acceptance, treatment, recovery and rehabilitation.  Priorities rather than last thing on budget.  In framework for intervention.

Dr. Poznyak.  WHO. Chief of Substance Abuse.  For WHO, one key objective is to prevent premature death and disability.  Happy to cosponsor with UNODC and focus on overdose.  Slides.  Latest estimate of disease burden clearly shows that opioids clearly responsible for most disease burden in the world.  Unique characteristic of suppressing respiratory function. Easily preventable for different opiates by administrat.  65% are witnessed, 20% of fatal are witnessed.  Deaths result usually within 1-3 hours, not immediately after administration of opioid, IDU, but there is some period of time that allows for life saving intervention if people around are properly trained and have effective measures.  Estimated 100K people per year die of opioid overdose.  How to make this effective medicine available for non-professionals.  First responders to emergency.

WHO has one of the key functions to provide normative guidance on technical issues.  Recently started process of developing WHO guidelines on mgmt. of suspected opioid overdose.  Conditions that occur in the communities when suspected overdose can be identified and effective interventions can be urgently delivered, saving lives.  Pleased to convey this information.  Specific guidelines.  Proper representations of different regions and different healthcare systems.  Manage properly conflict of interest.  Formulate questions.  Target pop, interventions, outcomes we are looking at.  Systematic review of available evidence.  Survey values and preferences regarding target populations.

In process of finalizing.
1) people likely to witness should have access to naloxone and should be instructed in its use.  Addresses question by Dr. Gerra and Boticelli.  Who should be in first line of respondents and what should be in the armory?
2) Way of administration.  Apart from injectable form, new formulations for internasal. What formulation should be recommended for first line respondents?  No particular method of administration.  Naloxone is effective when administered through…nasal, etc.. based on availability, skills, etc.  Gives sufficient availability.
3) Focus on airwave maintenance. Clear airwaves essential.
4) Px should have level of consciousness and breathing closely observed until they have recovered.  Does not mean ambulance should not be called.

Chenil Garakne?? National rehab center in Abu Dhabi.  Senior advisor to Ambassador.  UAR – 7 states in Persian Gulf.  Small country.  National Rehabilitation Center has broad remit for treatment.  May 2002 to serve country at large.
Soft data – based on people who have been treated for overdose.  Anecdotal.  13 deaths in 2013.  Report from UAE, 40 deaths.  Would be an underestimate.  Indirect.  No automatic referral to coroner, so most families would want body for burial.  Implication for country that has relatively small population becomes national security issue.  Legal framework poses challenges.  33 people have arrived at NRC in advance state of overdose. Sent to accident and emergency department.  Age of px.  20-24, 30-34 peak years.  Residency – all states of UAR.  Poly drug use as well as opioids.  Tramadol a growing problem. Primary intervention is acceptance and sympathetic treatment.  Illegal to use a substance that carries minimum 4 year sentence.  Consultant physician and team.  Treat mild overdose within NRC.  Rehabilitation is a key response mode.  Avoid legal prosecution and are shifted to rehab.  Health education is our biggest weapon.  Educate px about overdose and families to give them impression they are not condoning drug use.  Families don’t want to know.

Have shifted  to prescribing suboxone.  All px are followed up in outpatient clinic.  Keeping people in continuous treatment best way to reduce risk.  Considering giving people naloxone spray.  Legal issues with doing that.  Look at co-occurring medical symptom.  Biggest issue is legal framework and potential prosecution.  Have been working to change it.  Ongoing process.  Will be changed soon in AbuDhabi.  Sensitive area.  Educating physicians one of the main things.  Many prescribe drugs that have the risk of overdose.  Management a high priority for NRC and UAE.  Day to day mgmt. as well as prevention.  Legal framework needs to be changed to align with evidence.  Work with neighboring countries to synchronize policy in area.

Dr. Sharon Stancliffe.  Director of Harm Reduction Coalition in NY.  An honor to be on this panel.  What kinds of results do we see?  First responders.  Only in 12 states do ambulances carry naloxone.  Police interested, also residential supervisors at treatment programs.  Residential and outpx treatment, people at risk when they leave.  Models that people can take home with them.

Relapse is common in drug treatment.  People have to try several times.  Might be at risk for dying when they leave.  We care about you even if you relapse.  Why give them naloxone.  In communities of other drug users.  We are telling them that you, as part of changing your relationship to drugs are a good enough person that you can actually save lives.  Very positive resonse.  Fosters response as a community member – key part of treatment.  Of 327 rescues, neither 90% found at NSP centers with active drug users.  Therapeutic community in NY with abstinence based treatment now distributing naloxone because it saves lives.  People in treatment do this and then come back for more treatment.  One of religious based centers has been going out to community with help of paramedics and making sure naloxone gets into the hands of parents.  You can’t recover, or go to prison if you are not alive.

EMTs not carrying naloxone and they may arrive 20 minutes before anyone else in rural areas.  Trained to use internasal.  About 2000 in 1.5 years.  200 had used their kits.  One reversal for every 10-11 kits.  No adverse events at all and no hazards to EMTs.  Some EMTs were police officers.  Suddenly in a relatively rural part of NY state police officers carrying naloxone.  Has shifted their role from law enforcement to public safety a little bit.  In Abu Dhabi arrests, but this was in conjunction with law saying no arrest and prosecution for people who have called for help.  Very key to getting kits into the hands of law enforcement.  Not just in the US, but with WHO recommendations this is coming quickly.

People are not going to call official emergency services in China.  Have to train community.  Have to improve understanding and acceptance.  Thanks OSF.

Dr. Massimo Barra.  International Federation of Red Cross.  Primum vivere…First survive, then theorize.  If you want to treat a drug user, he has to be alive.  At that time, naloxone was not available in Italy.  Naloxone not as negative as predecessor.  Can be used by specifically trained, non-medical staff.  Free from contraindications.  Pure antagonist of opioid molecule.  Can provoke temporary withdrawal if person has physical dependence on heroin.  Consider including in Red Cross kit.  Train volunteers in use.  Intense advocacy action— now considered lifesaving medicine.  Should be available in any pharmacy in the country without prescription.  Should be able to reach as many drug users as possible if a credible strategy.  Never understand why it is so difficult for a drug user to be treated.  Should do outreach to drug users in the street where they live their daily tragedy.  Emergency service and 2 mobile units set up in areas highly exposed to drug use and users.  Hospital intervention not enough.  Person could show up dead.  Shooting rooms not legal in Italy.  Many of our staff trained to use naloxone.  Those considered more exposed equipped with two naloxone files.  Also sent to drug users parents, relatives, friends, and other interested parties.  Risk increases after prolonged abstinence.  Doses have to be adapted given reduction in tolerance levels.  Also increases with use of alcohol or use of drugs at home, alone, new dealers – too pure or bad quality heroin.  Long lasting drug users more exposed than younger ones.  In certain areas, overdose cases usually occur 3 or four times in short period – a few grams of heroin – too pure can result in OD situation.  Sept. 1999, six people in Palermo.  Represented a striking case.  Local government representative asked for immediate intervention.

Dr. Jim Cleary (question)   Italy process started when opioid availability very low. In US now our problem even though opioid availability very high. Italy still very low, but never a problem to find good heroin.  In 30 years all kinds of drugs at a good price.  No based on diversion on licit market, but illicit market.

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