Promising Overdose Prevention Practices

When it comes to opioid overdose death, some of the upstream actions or promising practices include:

• A balanced approach to addressing the opioid epidemic. Prescription opioids still account for the greatest number of deaths in Minnesota, and heroin deaths are still prevalent, and fentanyl and fentanyl analogs are a real and emerging concern in Minnesota. Our efforts must address prescription opioids, heroin, and fentanyl and fentanyl analogs.
• More timely, accurate, and consistent reporting of cause of death (e.g. more consistency between medical examiners and coroners across the nation to enable more accurate comparisons and trends nation-wide).
• Additional toxicology reports to ensure that the type of drug(s) involved in the death are accurately captured (e.g. standard toxicology reports show if opioids, including fentanyl are present, but further testing is needed to test for the presence of fentanyl analogs).
• More inquiry into deaths categorized as natural when only prescription pain pills are present at the scene or on the prescription history as they may be intentional/suicide or unintentional/accidental.

When it comes to nonfatal overdose, some upstream actions and promising prevention practices include:

• Standardizing notification from the hospital to the primary care clinic, and additional discharge planning procedures following a nonfatal overdose
• Creating a health information exchange (HIE) in Minnesota to connect hospital, clinic, treatment, claims and other social services data
• Notifying prescribers when a prescription they wrote was involved in a law enforcement encounter via the Prescription Monitoring Program (PMP) from the Board of Pharmacy (BoP) or the Drug Monitoring Initiative (DMI) from the Department of Public Safety (DPS)
• Creating one state-wide strategy for collection of naloxone administration data
• Increasing skills and knowledge about naloxone administration by health care professionals, EMS, law enforcement, and lay people
• Increasing participation in the Naloxone Protocol so pharmacies can dispense naloxone to anyone who is at risk for, or knows someone who is at risk for, an opioid overdose
• Expanding co-prescribing of opioids and naloxone
• Expanding Screening, Brief Intervention, and Referral to Treatment (SBIRT) services in primary care
• Deploying care coordinators, peer support specialists, or other wrap-around services during a nonfatal overdose to coordinate the transition of care out of the hospital, treatment, incarceration, or detox and into follow-up care

When it comes to use, misuse, and substance use disorder, some upstream actions and promising practices include:

• Non-opioid treatments: The National Institute of Health (NIH) is researching many solutions including a fentanyl vaccine, non-addictive opioids, targeting pain receptors for specific kinds of pain, and more.
• Integrated care: There is a movement toward integrated care; with the increased understanding about how medical, mental, dental, chemical and sexual health are interrelated. A clinical decision in one area or discipline is impacted by another clinical decision. In order to achieve a comprehensive health care system, health information privacy acts and data sharing agreements need further exploration.   
• Effective treatment to prevent self-medicating: Opioids are used to alleviate suffering. The suffering may be from physical pain, trauma, mental health, and/or chemical health. The root causes of suffering need to be addressed to prevent self-medicating with licit and illicit substances. 
• Genetic testing research: Expand the research on genetic testing to identify medications for mental and chemical health conditions that are more likely to be effective based on patient’s specific genotype. One of the root causes for prescription opioid misuse and substance use disorder is a lack of access to or efficacy of interventions. Patients are looking for effective solutions to alleviate suffering from physical pain and/or mental health conditions. Opioids are, unfortunately, very effective at numbing or escaping. Genetic testing is one tool for providers to identify effective interventions, without having to test out multiple ineffective solutions first. 
• Transition from prescription opioids to heroin: Develop deeper understanding, from a user’s perspective, of the transition from prescription opioids to heroin or other illicit substances. Professionals within the chemical health arena, the harm reduction community, and active users have a lot of knowledge and/or lived experience with the progression of a substance use disorder; further understanding may reveal opportunities for early intervention or treatment modalities that are not currently used.
• Culturally responsive interventions: Inquire about culturally and spiritually based meaning with regard to the use of prescription and/or illicit substances. Tailor interventions towards specific cultural groups or faith-based communities. It is important to understand cultural norms and traditions when developing effective interventions. Without community participation or acceptance, an intervention model will not be successful.
• Understanding the central nervous system’s response to pain: A patient’s pain sensitivity increases with long-term opioid use; the central nervous system’s alarm system is no longer sending accurate signals. Part of recovery from long-term opioid use includes addressing the central nervous system’s response and teaching the body that life can be safe again. Health systems that are skilled in trauma-informed practices are beginning to explore holistic healing from long-term chronic pain and/or long-term opioid use.
• Integration of chemical health treatment records: In order to protect the privacy of individuals within chemical health treatment, admissions data is kept separate from other claims data. However, the lack of integration of chemical health data has also posed many challenges to coordinating care, transitions of care, and monitoring. For example, primary care clinics are often unaware of whether a patient is engaged in methadone treatment, unless the patient voluntarily discloses this information. At this time, it is still possible for a patient to be engaged in methadone treatment at more than one clinic; methadone clinic treatment is not tracked in the Prescription Monitoring Program (PMP). In addition, a patient’s involvement in a methadone clinic shapes their daily experience, such as options for employment or how far a patient can travel away from home each day. 

When it comes to prescribing practices, some upstream actions and promising practices include:

• Opioid Prescribing Guidelines: The Opioid Prescribing Work group (OPWG) developed acute, post-acute, and chronic pain prescribing guidelines – Opioid Prescribing Guidelines.
• Provider Messaging Campaign: The Opioid Prescribing Improvement Program (OPIP) developed a peer-to-peer prescriber educational campaign called, "Flip the Script," This program addresses how to talk about the long-term risks of opioids. The program also rcplores how to introduce the idea of a taper and/or chemical health treatment for a patient on chronic opioids, and other clinical practices related to pain management and opioid prescribing.
• Co-Prescribing Naloxone: Some states have passed legislation that mandates co-prescribing of naloxone with all opioid prescriptions. Other states have set certain circumstances (e.g. MME over 50, benzo/opioid prescriptions) when a naloxone prescription would be required with an opioid prescription.
• Informed Decision Making: A JAMA study from December 2017 noted that 40% of people are sent home with opioids “just in case”, even when the patient was not using opioids upon release from the hospital. Patients can play an active role in decision-making about their care, including how to address pain management. A simple tool that patients can use is called the BRAIN acronym. When being offered a particular interventions, ask yourself what are the Benefits, Risks, Alternatives, What is my Intuition telling me?, and What if I say “No, not now?”. The BRAIN acronym can be helpful to think through options for pain management or selecting a treatment approach.

The PEW Charitable Trust published an extensive report on evidence-based practices to optimize prescriber use of the Prescription Monitoring Program (PMP), including:

• Prescriber use mandates
• Delegation
• Unsolicited reports
• Data timeliness
• Streamlined enrollment
• Educational and promotional initiatives
• Health information technology (IT) integration
• Enhanced user interfaces

Read more about the PMP recommendations at The PEW Charitable Trusts Prescription Drug Monitoring Programs Report.

When it comes to harm reduction, some of the upstream actions and promising practices include:

• Safe Disposal: Eighty percent of people who use heroin, started by using, and then misusing, prescription medications. When first starting to use prescription opioids, research shows that about 50% of people obtain the prescriptions from a family member or friend who is helping them out; only 15% of people obtained the prescriptions by buying them off the street with the intent to get high. Sources of prescription medications come from (1) medications prescribed to a patient, (2) unused medications prescribed to family members or friends, (3) legally prescribed medications now sold on the street, and (4) illegally manufactured prescription medications from pill mills. Ninety percent of people who were prescribed a prescription medication for an acute injury do not use the entire bottle. This results in millions of unused pills that now have become a viable source for diversion. Unused pills in a home are an overdose risk for children and pets. Some of the upstream interventions related to preventing diversion include: (1) providing pouches that are activated by carbon with all controlled substance prescription medications for safe at-home disposal and (2) providing incentives for safe disposal of unused medications.
• Real-time alerts for fentanyl-laced products: Communities are exploring the idea of using real-time alerts for fentanyl-laced products. In cities throughout the United States, there have been large number of overdoses within short periods of time, most likely caused from a single source of fentanyl-laced heroin or counterfeit prescription medications. The idea is to create an amber-alert-style of message that could go out to and from law enforcement, EMS, medical professionals, and people who use heroin or buy prescription opioids outside of a health system.
• Supervised Injection Sites: There are over 100 supervised injection sites in the world. There has not been one opioid overdose death associated with use at any of the injection sites. When law enforcement encounter a person on the street, in a park, or other public venue, now they have a place to refer people; this has reduced public injecting. Inside the supervised injection site, people can get help with vein access from a medical professional; this has reduced the harms associated with collapsed veins and scar tissue formation. The injection sites have supplies available such as sterile water, cotton, syringes, and scales for measuring; this has helped to regulate dosage and decrease harms associated with sharing needles and supplies. At the supervised injection sites, drug sharing or drug splitting is not allowed. There are rooms for people to stay in where they are observed for overdose by a medical professional.
• Fentanyl testing strips: At Insite, a supervised injection site in Vancouver, they offer fentanyl testing strips so people who inject drugs (PWID) can test for the presence of fentanyl in their heroin stash. Many users think that their dope is pure or raw, and have been surprised by the testing results. Fentanyl testing strips have allowed users to warn other people who use heroin about the presence of fentanyl. The principle is simple: fentanyl testing strips provide knowledge and information about what is being put in their body. However, fentanyl testing strips have not been found to reduce use. Most of the people who attend Insite are people who inject drugs daily; their main concern is running on empty, when the physical symptoms of opioid withdrawal kick in. When surveys have been returned, they have provided information about which brands might be more dangerous and what a tainted batch looks like or smells like during use.
• Needle Vending Machines: At the height of use, people may use upwards of 15 needles a day. Even within communities that have needle exchanges, the availability of needles does not meet the need. Las Vegas launched the first clean needle vending machine to measure the effectiveness of automated dispensing of clean needles for IV drug users. Clean needles are known to promote public health, by reducing the exposure to infectious diseases such as HIV and Hepatitis C (HCV). The vending machines also carry wound cleaning kits and safe sex kits. Users register, receive a swipe card and unique identification number, and can receive up to two kits per week. The vending machines are located in the HIV-prevention office and available 24/7. Staff are available during the day to answer questions and/or to provide referrals to detox, treatment, and support groups. In the first month of implementation, the needle vending machines were mostly used during the night, when no other needle exchange is open.
• Seeing Track Marks: The ability of family and friends to identify track marks is one way to detect use, and provide an opportunity for early intervention. Most people are using IV drugs for long periods of time in isolation, before family and friends become aware of the person’s use. Heroin, cocaine, methamphetamines, prescription stimulants, and prescription opioids can be injected into the bloodstream through a vein. Users prefer discrete injection sites. Most users start by shooting up in their forearms. When there is scarring, inflammation at the injection site, damaged or collapsed veins, lesions, or bruising, access to those veins becomes extremely painful or impossible. Users will move to other areas of the body such as neck, groin, hands, feet, or face. The more visible the injection site, the more likely a user is going to try to cover it up with clothing, make-up, or tattoos.

When it comes to co-occurring disorders, some upstream actions and promising practices include:

• Establishing partner notification services for infectious disease including syphilis
• Educating small sexual networks about containing the spread of sexually transmitted infections
• Monitoring infectious disease treatment retention, and providing services until completion
• Early detection of serious and persistent mental illness to prevent self-medication with illicit substances
• Streamlining Health Care Home (HCH) and Behavioral Health Home (BHH) services
• Aligning SAMHSA and CDC funded projects within clinical settings
• Integrating medical, mental, dental, sexual, and chemical health care
• Implementing comprehensive and routine opt-out HIV, hepatitis B, hepatitis C, syphilis, and TB testing, along with hepatitis A/hepatitis B immunizations for all people entering chemical health treatment centers

Neonatal abstinence syndrome (NAS)/neonatal opioid withdrawal syndrome (NOWS) occurs when infants experience withdrawal symptoms after being exposed to prescription and/or illicit opioids in the womb. Prevention strategies for NAS/NOWS include:

• Access to and use of preconception health that includes education around prescription and illicit drug use during pregnancy
• Increased substance use screening for women (e.g. SBIRT services) who are or wish to become pregnant
• Providing pregnant women with Medication for Addiction Treatment (MAT) when needed to minimize NAS/NOWS symptoms in the infant after birth. Suboxone, in particular, has been associated with shorter hospital stays for infants, higher rates of breast-feeding upon leaving the hospital, and higher rates of sustained long-term recovery for moms

When it comes to prescribing practices, some upstream actions and promising practices include:

• Health in All Policies (HiAP): integrate and articulate health considerations in policy making across sectors, at all levels, and for all communities and people
• Provide leadership for advancing health equity: engage state, tribal, and local government and encourage the adoption of a health in all policies (HiAP) approach
• Make health equity an emphasis: advancing health equity is the work of every person within an organization who has any impact on people, programs, communities, or policies
• Strengthen the collection and analysis of data to advance health equity: collect and analyze health data by population groups, including diversity within population groups, LGBTQ data, and data on the social and economic factors that create health