Opioid overdoses are a growing public health concern in Vermont and nationwide. Naloxone can save the life of someone who overdoses, if those around them know how to use it. This project investigates the feasibility of offering naloxone education as an element of routine primary care encounters with patients who do not use opioids themselves.https://scholarworks.uvm.edu/fmclerk/1472/thumbnail.jp

Goldberg, Eli

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University of VermontScholarWorks @ UVMFamily Medicine Clerkship Student Projects Larner College of Medicine2018Incorporating Naloxone Education Into RoutinePrimary CareEli GoldbergUVM Larner College of MedicineFollow this and additional works at: https://scholarworks.uvm.edu/fmclerkPart of the Medical Education Commons, and the Primary Care CommonsThis Book is brought to you for free and open access by the Larner College of Medicine at ScholarWorks @ UVM. It has been accepted for inclusion inFamily Medicine Clerkship Student Projects by an authorized administrator of ScholarWorks @ UVM. For more information, please contactdonna.omalley@uvm.edu.Recommended CitationGoldberg, Eli, "Incorporating Naloxone Education Into Routine Primary Care" (2018). Family Medicine Clerkship Student Projects.418.https://scholarworks.uvm.edu/fmclerk/418Incorporating Naloxone Education Into Routine Primary CareEli Goldberg ⁙ November 2018Northern Green Mountain Family Practice ⁙ Michael Corrigan, MDProblem IdentificationOpioid overdoses are a growing public health concern in Vermont. Between 2012 and 2017, the number of fatal opioid overdoses in Vermont nearly doubled, from 51 to 101.1 Of all Vermont counties, Franklin County has the 3rd highest rate of fatal opioid overdoses. 1 Nationally, up to 49% of adults personally know someone who has faced opioid addiction, and 10% know someone who has died because of it. 2Naloxone can save lives… if people know how to use it. Only 20% of American adults know what naloxone is; that it can be given by a layperson; and that it is available without a prescription. 3 When informed about naloxone, up to 68% would be willing to use it to help someone who had overdosed. 3 For every overdose fatality in Vermont, 5 other people are saved by community-administered naloxone. 42Public Health Cost“[P]revious estimates of the economic cost of the opioid crisis greatly understate it by undervaluing the most important component of the loss – fatalities resulting from overdoses.”--White House Council of Economic Advisors5 In 2015, opioid overdoses killed 41,033 people in the United States. The White House Council of Economic Advisors estimates the “cost” of these deaths at $431.7 billion. 5 The cost of two units of Narcan (naloxone nasal spray) is approximately $150. 6 A 2013 NIAID study found that naloxone distribution to heroin users was cost-effective, with an incremental cost effectiveness ratio of $14,000 in the most conservative scenario. 7 More recent data from Vermont indicate much greater cost effectiveness. In 2018, one Vermont social service agency that distributes naloxone kits estimated a cost per life saved of $325-$450.83Community PerspectiveInterview with Karen Heinlein-Grenier, Katie DeForge, and Maria Carlson, staff at Turning Point Center of Franklin County: Turning Point has distributed free Narcan for 4 years, and has noted steadily increasing interest during that time. Requests for Narcan come from a mixture of active users, people in treatment/recovery, and non-users. They do not always have follow-up with people who receive Narcan kits, so are not sure how often kits are used. Recently they have seen more requests from elderly people, and more people referred by healthcare providers. People may find it difficult to get Narcan from a pharmacy because: They are concerned about stigma from pharmacists and other customers, and lack of privacy at the pharmacy counter. They worry that asking for Narcan will broadcast that they have opioids and make them a target. They do not know that it is available without a prescription, how much it will cost, or whether insurance will cover it. 4Community Perspective, continuedInterview with Karen Heinlein-Grenier, Katie DeForge, and Maria Carlson, staff at Turning Point Center of Franklin County: It is beneficial for people to carry Narcan even if they don’t know of anyone who abuses opioids: If someone in their home has an opioid prescription, they may accidentally take an excess dose because of memory decline or polypharmacy; or a child may gain access to the medication. A friend, family member, or coworker may be a “closet user.” Opioids may be cut into other drugs, such as marijuana or cocaine. People may encounter someone who has overdosed in a public setting – for example, slumped over the steering wheel in a parking lot. Interviewees were enthusiastic about the idea of incorporating naloxone education into routine primary care encounters, noting that this could provide the opportunity to educate a “captive audience” and may have a positive normalizing effect.5Intervention & Methodology During the course of routine primary care visits, patients who were not being prescribed opioids or receiving treatment for opioid use disorder were asked:“Many of our patients have friends and family who are affected by the opioid epidemic. There is a medication called naloxone that you could use to save a life if someone around you were to overdose. Would you like to learn more about naloxone while you’re here today?” Patients who consented were instructed in how to use Narcan and given: A quick reference sheet summarizing when and how to use Narcan nasal spray, and what to do afterward A list of local organizations that distribute free Narcan kits, and local pharmacies with prices The reference sheet was developed based on similar resources from the CDC, Vermont Department of Health, and the Narcan package insert, and has a Flesch-Kincaid grade level of 3.4 (i.e., a 3rd grade reading level).67Results Over the course of 7 days in clinic, naloxone education was offered to all patients who were not receiving opioid prescriptions – a total of 7 patients; 2 said yes (28%). After naloxone education: 100% said that they plan to obtain naloxone. 100% said that they would not be surprised if they witnessed an overdose in the next 12 months. 100% said that they would feel confident about administering naloxone if necessary. Patient feedback: “Honestly, you really never know when you might need this” – recently passed a driver who was pulled over unconscious with a child in the car, and called 911, but would have used naloxone if she’d had it Had heard of Narcan but “I had no idea that anyone can get it, or that it’s so simple to use – this is definitely life-changing information”8Evaluation & LimitationsAlthough naloxone education was well-received by those patients who received it, the number of patients participating in this project was very small, for three reasons:1.    The duration of the project was very short.2.    The vast majority of patients encountered were not part of the target group for this project, because they were receiving opioids (either as a component of medication-assisted treatment or for chronic pain).3.    Almost three-quarters of eligible patients declined naloxone education, largely because they did not perceive it as personally relevant. Most declined because to their knowledge, none of their friends or family members used opioids. One patient has a household member who is prescribed opioids, but did not perceive him to be at risk of overdose. One patient stated that he did not believe that people who overdose should be revived.9Future RecommendationsPotential directions for future work in this area include: Conducting a longer trial of this project, possibly in a different population in which fewer patients are being prescribed opioids. Develop materials that convey to patients that even if they do not know of friends or family who abuse opioids, they may still be in a position to save someone’s life. Determine demographic characteristics of patients who are more likely to consent to naloxone education, and develop recommendations regarding who should be offered naloxone education, when, and how often. Initiate collaboration with the Vermont Department of Health or other community agencies in order to distribute free Narcan kits from the office. Hold focus groups with community members to identify other needs and strategies for supporting family and friends of opioid users in a primary care setting.10References(1) “Opioid-Related Fatalities Among Vermonters.” Vermont Department of Health, 2018. http://www.healthvermont.gov/sites/default/files/documents/pdf/ADAP_Data_Brief_Opioid_Related_Fatalities.pdf(2) Blendon RJ, Benson JM. “The Public and the Opioid-Abuse Epidemic.” N Engl J Med 2018; 378:407-411. DOI: 10.1056/NEJMp1714529(3) Hensley S. “Poll: Most Americans Know About Opioid Antidote And Are Willing To Use It.” National Public Radio, August 21, 2018. https://www.npr.org/sections/health-shots/2018/08/21/640195328/poll-most-american-know-about-opioid-antidote-and-are-willing-to-use-it(4) VanDonsel A, Livingston S, Searles J. “Opioids in Vermont: Prevalence, Risk, and Impact.” Vermont Department of Health, October 27, 2018. http://www.healthvermont.gov/sites/default/files/documents/2016/12/ADAP_Opioids_Prevalence_Risk_Impact.pdf(5) “The Underestimated Cost of the Opioid Crisis.” White House Council of Economic Advisors, November 2017. https://www.whitehouse.gov/sites/whitehouse.gov/files/images/The%20Underestimated%20Cost%20of%20the%20Opioid%20Crisis.pdf(6) Gupta R, Shah ND, Ross JS. “The Rising Price of Naloxone – Risks to Efforts to Stem Overdose Deaths.” N Engl J Med 2016; 375:2213-2215. DOI: 10.1056/NEJMp1609578(7) Coffin PO, Sullivan SD. “Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal.” Ann Intern Med 2013 Jan 1; 158(1):1-9. DOI: 10.7326/0003-4819-158-1-201301010-00003(8) Boccia J. “Naloxone Administration: An Educational Video.” Family Medicine Clerkship Student Projects 2018: 370. https://scholarworks.uvm.edu/fmclerk/37011Interview ConsentThank you for agreeing to be interviewed. This project is a requirement for the Family Medicine clerkship. It will be stored on the Dana Library ScholarWorkswebsite. Your name will be attached to your interview and you may be cited directly or indirectly in subsequent unpublished or published work. The interviewer affirms that he/she has explained the nature and purpose of this project. The interviewee affirms that he/she has consented to this interview. Yes _X__ / No _____12

Incorporating Naloxone Education Into Routine Primary Care

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Incorporating Naloxone Education Into Routine Primary Care

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