<v ->Hello everyone, welcome.</v> I want to thank the Providers Clinical Support System for giving me the opportunity to present to you on the topic of Preventing Opioid-Involved Overdose with Education and Naloxone. My name is Alex Walley, I'm a addiction specialist and a general internist at Boston University School of Medicine, Boston Medical Center. I also play a role with the Massachusetts Department of Public Health where I am the Medical Director for the Bureau of Substance Addiction Services. And I'm offering this presentation today representing the Association of Multidisciplinary Education and Research in Substance Use and Addiction, which is a multidisciplinary organization that I am a member of. So, I'm very excited to be here today to give this presentation on an important topic. I have no disclosures or relevant financial relationships. The overreaching goal of PCSS is to train healthcare professionals in evidence-based practices for the prevention and treatment of opioid use disorders, particularly in prescribing medications as well as for the prevention and treatment of substance use disorders. My objectives are that at the conclusion of this activity, you should be able to, one, describe the epidemiology of opioid involved overdose. Two, explain the rationale for and scope of overdose education and naloxone distribution, which is abbreviated as OEND, and implement OEND in medical and community settings through educating people about overdose risk reduction and through prescribing or dispensing naloxone. I want to point out that here you see an advertisement from the Healing Community Study, which I'm involved in in Massachusetts. It's also occurring in New York, Kentucky, and Ohio. And here's one of the communication campaign advertisements. It says, "Help save lives, carry naloxone. I saved my best friend's life." I'm going to start with a case of a 29-year-old woman who presented to clinic for buprenorphine treatment. Here's some of her history. At age 18, as an athlete she tore her ACL and was prescribed opioids after surgery. She developed an opioid use disorder within six months, and then at age 20 she was injecting heroin daily. Between the ages of 20 and 26, she had multiple medically managed withdrawal and residential treatment program encounters. She was not offered or not willing to start medication for opioid use disorder during these encounters, and she was not able to sustain more than three months of off treatment without return to opioid use. At age 26, she was pregnant at her last treatment episode and she initiated methadone treatment at that time. So, started medication for opioid use disorder for the first time. She was able to stop using heroin and engage in a 12-step program, and she delivered a healthy, baby, breast fed and retained custody through that treatment course. Then two years later, at age 28, she tapered off of methadone. She wanted more flexibility and time with the baby and to work. Her boyfriend at that time became incarcerated and so triggered by that, she returned to use, she lost custody, and now she's coming 29-years-old seeking treatment with buprenorphine. She does not want to go to the methadone clinic every day and so she's stating a preference for office-based treatment with buprenorphine. So, from age 29 to 30, she had a good response to office-based buprenorphine treatment. She had regular clinic visits with urine toxicology testing that was only positive for buprenorphine. She reengaged in 12-step program and with her family, and she works with child protection to regain custody after losing custody during her return to use episode. Then at age 30, she was hospitalized in intensive care for a fentanyl overdose at a period where she returned to use. What happened was her boyfriend was released from incarceration and returned to stay with her. He returned to use and overdosed on heroin on the third night home from being incarcerated, and it was likely fentanyl. 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. At this point, she stopped buprenorphine, started drinking alcohol, and then returned to using fentanyl and overdosed. How could overdose prevention improve this case? So, hopefully we'll get some answers to that during my talk today. So, now I'm going to review some of the epidemiology. And important for everyone to know is that overdose is now the leading cause of accidental injury death by far. So, you can see here from 2020 deaths from drug overdose, car accidents, and gun violence from the CDC. And there were about 40,000 deaths from motor vehicle accidents, about 45,000 from firearms, and over 90,000 from overdoses, here indicated as poisonings. So, almost twice as many overdose-related deaths as there were motor vehicle or firearm deaths. And what's driving this is fentanyl. So, fentanyl is driving the surge in overdose deaths in the United States. This graph here shows January 2015 through 2021 data with the cumulative overdoses over the previous 12 months ending in each individual month. And so, you can see here they top out here, we're talking about opioid overdoses in the black and fentanyl overdoses in the brown. The opioid overdoses exceed or approach 80,000 in the previous 12 months. And the fentanyl overdoses surge past 60 to almost 70,000 in the previous 12 months. And this is data that's freely available at this provisional drug overdose death counts site at the National Vital Statistics System. So, the drug supply is become increasingly toxic due to the presence of fentanyl. So, here's a study that we did in collaboration with the CDC that looked at overdose deaths in southeastern Massachusetts between 2014 and 2016. And in this study we looked specifically at fentanyl-related overdose deaths. There were three main take home messages, public health responses that we advocated after doing this review of overdose deaths. First of all, that fentanyl should be included in standard toxicology screening, so you can know when fentanyl is present. Two, adapt existing harm reduction strategies such as direct observation of anyone using illicit opioids and ensuring bystanders are equipped with naloxone. And three, enhanced access and linkage to medication for opioid use disorder. This is a quote that we got from one of the qualitative interviews we did with one of the overdose bystanders. So, now what they are doing is they're cutting the heroin with fentanyl to make it stronger. And the dope is so strong with fentanyl in it that you get the whole dose of fentanyl at once rather than being timed released. And that's why people are dying plain and simple. You know, they're doing the whole bag and they don't realize that they can't handle it, their body can't handle it. So, in addition to this surge in fentanyl in the drug supply, there's also been a surge in cocaine involved overdose deaths. And so, here you can see on the left side another graph that goes from 2009 to 2019, and it shows the deaths per 100,000 where different substances were involved. And all overdose deaths involving cocaine surged to five per 100,000. Cocaine and opioids was responsible for most of that surge, whereas cocaine without opioids was up, but mostly flat through 2019. And you can see that the percent of cocaine-involved deaths with opioid present is greater than 60% in almost every region of the United States, although there is some variability. Let's look at the same data with methamphetamine-involved overdose deaths. And you see a somewhat similar picture where overdose deaths involving methamphetamine are surging, those where it's methamphetamine and opioids are especially surging, but you're also seeing an increase in psycho stimulants or methamphetamine where there are no opioids present. In 2019, looking at multiple regions in the United States, the percent of stimulant or methamphetamine-involved deaths varied from as high as 70 or almost 80% in the northeast to as low as 44% in the west. So, a newer phenomenon that it's important that everybody understands with overdose epidemiology is that an increasing, but unknown number of people who do not have opioid use disorder are overdosing due to fentanyl contamination of cocaine, methamphetamine, and counterfeit prescription pills. People without opioid tolerance are unwittingly being exposed to fentanyl via non-op opioids and overdosing. Fentanyl-related overdose is on the rise in people who use methamphetamine and cocaine, as I just showed you in the previous two slides. And the implication here is that overdose prevention efforts need to expand and innovate to focus on engaging people who use stimulants and counterfeit non-prescription opioids. So, overdose has continued surging during COVID-19. And so, here you can see January through July 2020, the increases in multiple states, substantial increases in multiple states where the red circles indicate the overdose deaths per million where they were in 2020 compared to where they were in previous years. And in almost every state's case, they had more overdoses in 2020 than previous years. This was also demonstrated in Philadelphia during the pandemic, but particularly among Black residents of Philadelphia, so non-Hispanic Black individuals. You can see in February of 2020, the next month March, which was when the pandemic started, there was a surge in overdose deaths among Black non-Hispanic residents in Philadelphia. And then in Massachusetts, you can see that as White opioid deaths decreased, that's you know from about 2016 through 2020 there was a surge among Black and Hispanic deaths where the highest rates of overdose deaths in both of those population groups was in 2020. Other studies nationwide have showed Black Americans outpace White Americans and opioid-involved overdose deaths from 1999 to 2018. You can see the slope of the curves here for African Americans compared to White Americans, much steeper and looks like as it has in Massachusetts, the overall rates will likely overtake those of White Americans in the coming years. There's been a recognition in the Biden-Harris 2021 drug policy priorities that have aligned with this concern around racial equity that we're seeing in overdose, as well as enhancing evidence-based harm reduction efforts. So, this is the first ever of the National Drug Control Policy documents that specifically focused on advancing racial equity and on enhancing harm reduction. So, those are very good news in the world of overdose prevention because these are both important elements to our response. Here are the harm reduction strategies that were specifically mentioned in these 2021 drug policy priority documents. So, multiple of them include syringe service programs or SSPs, specifically mention naloxone in multiple places as well as fentanyl test strips and supporting research. So, this all started the movement to distribute naloxone in the United States with Dan Bigg, who was a force behind the Chicago Recovery Alliance, and first really innovated the idea of distributing naloxone directly to people who used drugs and their social networks in the 1990s and early 2000s. And here you can see him on his van there in Chicago with a colleague distributing naloxone. So, that was before it was mainstream, and now it is mainstream. The American Medical Association, American Pharmacist Association, the National Drug Control Strategy since 2013, American Society of Addiction Medicine, and the World Health Organization all endorse community distribution of naloxone to people who use drugs and their social networks. That has also endorsed since 2018 by the Surgeon General who issued in an advisory on naloxone and opioid overdose that it's important for widespread knowledge about the use of it and keeping it within reach as an opportunity to save people's lives. And then further recommendations for when to prescribe and co-prescribe naloxone came out here in December of 2018, which really involves prescribing naloxone to patients who are also prescribed opioids, particularly those who have higher doses of 50 milligram morphine equivalents or more, people with respiratory conditions, people who are prescribed benzodiazepines or have some non-opioid substance use disorder, as well as people at high risk for experiencing or responding to an overdose like those who are using illicit opioids, people using methamphetamine and cocaine, which are potentially contaminated with fentanyl, those receiving treatment for opioid use disorder, and those with a history of misuse and being in recent controlled settings where tolerance to opioids has been lost, like incarcerated settings or like medically managed withdrawal detox programs. So, what's the case for overdose education and naloxone distribution? What's the rationale? Well, most people who use opioids do not use alone. We know there are known risk factors which include mixing substances, using alone, and then having an unknown source. Abstinence is also a risk factor, so that's a little bit ironic because many people are trying to recover from their opioid use by stopping using, but when you stop using, you lower your opioid tolerance and that makes people who then return to use more vulnerable to an overdose. There's an opportunity to respond to opioid overdose, so they typically take minutes to hours and they're reversible with naloxone. However, for fentanyl, the response window is narrower. Naloxone still works, but the window is narrower and it's seconds to minutes. Bystanders are trainable to recognize and respond to overdoses. And there is a fear of public safety, which we're not going to be able to eliminate 100%. And so, for those people who are not willing to call for help, it's very important that we equip them with naloxone so they can respond and rescue someone on their own. Prescribed to Prevent, there are some helpful materials for people who are trying to prescribe or distribute naloxone. Some of the basics, naloxone takes two to three minutes to take effect. So, if the patient is not responding this time, after this time, a second dose may need to be administered. Although, I do recommend waiting the three minutes because it does take that much time for the naloxone to start working. It wears off in 30 to 90 minutes so patients can go back into an overdose if they took long-acting opioids such as a fentanyl patch, methadone, or extended-release morphine or oxycodone. Patients should avoid taking more opioids after naloxone administration, so they do not go back into an overdose after naloxone wears off. And patients may want to take more opioids during this time because they may feel withdrawal symptoms. So, just be aware of that. The shelf life of naloxone is 12 to 24 hours. It should be stored at room temperature to minimize degradation. Here are some of the naloxone formulations. There's older formulation of intranasal with an atomizer attachment, which we see less often. There are intranasal sprays on the left, and then on the right there's intramuscular injections. Here's one prefilled syringe. And then you can also have your needle and vail where you drop your own naloxone and that way your dose can be customized. It's important for the clinical providers out there to make an overdose risk reduction plan with patients. What does this entail? Well, it includes reviewing medications and communicating with other prescribers about the risk profile of people, taking a substance use history. I ask my patients, "How do you protect yourself against overdose?" And many times patients are saying to me, "Well doc, I'm not planning on overdosing, so my plan is to not to not use." And so I say, "Well, that's a fantastic plan, but I really need to know about your plan B, your backup plan." And so, sometimes I'll hear the backup plan as well, "If I feel like using, I'll call somebody who I know will keep me safe." And I say, "That's a fantastic plan B, a fantastic backup plan. What's your plan C? What if that person isn't home? Or for whatever reason you end up using, how are you going to keep yourself safe?" And so, then hopefully they're going to tell me something about their own plan to keep themselves safe when they're using, which should include equipping themselves with naloxone. We also talk about safety when it comes to their medications, how do you keep your medication safe at home? Do you have a lockbox? Are they only accessible to you, et cetera? And what about loved ones? What is your plan if you witness an overdose in the future? Have you received training to prevent, recognize, or respond to an overdose? These questions I have found to be very helpful in being conversation starters and getting people interested in the basics of overdose prevention and response. I kind of went through these things about what people need to know. There's mixing substances, abstinence that generates low tolerance, using alone, an unknown source, chronic medical disease, and remembering that long-acting opioids last longer. Recognizing an overdose means that somebody's unresponsive to painful stimuli, they have slow or absent breathing, they may have blue lips and pinpoint pupils. And then knowing what to do. We're going to call for help, we're going to rescue breath or do chest compressions, we're going to administer naloxone and wait three minutes, and we're going to stay until help arrives. Especially important for people who are using fentanyl, we want to make sure they use with other people present. That gets back to that project we did in southeastern Massachusetts. How do you do that? Well, they're using in the presence of a partner. In places like New York City now and in Vancouver, Canada and other places in Canada, they have overdose prevention sites. As of this current time, there are no other sanctioned overdose prevention sites where people can go and use drugs they obtained on the street and use them in the presence of somebody who will keep them safe. We want to instruct people to take turns so that people don't use at the same time and risk overdosing at the same time. We want to have naloxone ready and an immediate way to call for help. There's also this concept of virtual spotting, which means connecting with someone by phone or video when they can't be there in-person to monitor somebody while or immediately after they're using. So, some of these services include the website neverusealone.com. In Massachusetts, New York, and Vermont, we have our own line that people can call and get somebody on the phone to make sure they're safe while they're using. And then, there's the Canary overdose prevention app as well as the Be Safe app from Brave.coop. We want people to be reminded to start low and go slow and use a small amount and give slowly to gauge the potency. So, when an overdose happens, we want somebody to recognize the overdose, call for help, administer naloxone as soon as it is available and do rescue breathing and/or chest compressions compared depending on how you were trained. Okay, and so if you're comfortable doing chest compressions, do those. If you're comfortable rescue breathing, you should do those. You want to stay until help arrives and place the person in the recovery position if they are breathing. So, what's the evidence behind naloxone distribution and rescue? Well, there's been multiple evaluations of overdose education and naloxone distribution programs. They show feasibility, they show increased knowledge and skills, there's no increase in use, but an increase in drug treatment. In some of the studies there's a reduction in overdose in communities and then they're cost effective, highly cost effective. And there's now been endorsed and incorporated into the American Heart Association's scientific guidance around opioid associated out of cardiac arrest, out-of-hospital cardiac arrest. They go into detail explaining the role that naloxone plays in this emergency response. And so, here's some of the algorithms. This one is designed for lay responders that walks people through a very similar algorithm as I just showed you, recognizing that there's an overdose, calling for help, if the person's not breathing and unresponsive administering naloxone or doing chest compressions if you're trained. Here's this similar algorithm, but this time for healthcare providers, which provides a little bit more guidance and detail. So, these are materials good to be familiar with and good to update yourself on. And when you get trained for CPR or basic life support or ACLS, be sure you ask people about the role of naloxone. So, now I'm going to talk about one of the studies that really provides some of the observational evidence. So, here's a map of Massachusetts from 2004 to 2006 that shows the shaded the community based on the number of overdose deaths that occurred during this time. And the darker shades are the communities that had more overdoses. There's now two purple diamonds marking Cambridge in Boston, which were the first OEND programs were started. And then, in subsequent years there were more programs started. 2009 there were nine programs. And then, at that time there were many towns that didn't have any programs that had multiple overdoses. So, this provided us the opportunity to run a natural experiment to see what the likelihood of an opioid overdose was in communities that had implemented compared to communities that had not. And what we see is, if you consider the baseline rate where there was no implementation to be 100% in the communities where between one and 100 people per 100,000 received a naloxone kit, there was a 27% reduction in the opioid overdose death rate. And similarly, in communities where we had even more implementation, there was a greater reduction in the opioid overdose rate, almost a 46% reduction in the opioid overdose death rate. So, not only does naloxone impact overdose death, also non-fatal overdose or trips to the emergency department at least. So, this is a study that was done in San Francisco at a federally qualified health center to evaluate the feasibility and effect of implementing naloxone prescriptions to patients prescribed opioids for chronic pain at six safety net primary care clinics. So, 38% of the almost 2,000 patients received long-term opioids co-prescribed naloxone rescue kit. Patients with higher opioid doses and previous opioid-related emergency department visits were more likely to be prescribed naloxone. Opioid-related ED visits were reduced by 47% at six months and 63% at 12 months among those who were co-prescribed naloxone compared with those who were not. In the net prescribed opioid doses for patients who were co prescribed naloxone, no change was was detected. I also need to bring up this concept of risk compensation and moral hazard. So, one place you hear about this is the urban myth of a narcan party where people intentionally use more than they can handle, so then they get rescued by naloxone. So, this has been sensationalized in the press. There is research to show that naloxone distribution does not increase drug use and, in fact, instead of sensationalizing it, I should put into context with other harm reduction efforts such as seat belts, which don't result in more motor vehicle accidents, but fewer. Syringe distribution does not result in HIV transmission and it protects from it. Vaccinations and condoms do not cause sexually transmitted infections, they actually prevent them. And fire extinguishers don't cause forest fires, they treat them. So, I have the "Flatliners" video here because that was a movie in the '80s, which showed medical students who were on purpose stopping each other's hearts after they learned how to do advanced cardiac life support. So, after they learned to bring people back from cardiac arrests, they thought it would be fun to try it themselves. And that's just not a realistic thing that people are doing, certainly not with drug use and overdose and it wasn't really what they were doing in "Flatliners" either. There's multiple distribution streams for naloxone. And so, top of the list should be partnering with harm reduction providers to get naloxone to those at highest risk for overdose. Many communities have a community pharmacy standing order, and then there's also the facilitation of pharmacy distribution through this type of standing order and ensuring insurance coverage. Engaging addiction treatment providers, federally qualified health centers and emergency departments is important. And then there's this distribution through administering naloxone at the scene of an overdose, but then giving extra naloxone to family members or friends who were there at the time of the overdose. Naloxone is primarily distributed through community harm reduction programs. Here's a figure from a paper that we did in Massachusetts called Broadening Access to Naloxone Community Predictors of Standing Order Naloxone Distribution, and you can see the great majority in all of those quarters of naloxone distributed is community, OEND, naloxone. Syringe service program-based overdose education naloxone distribution programs by Census division. So, you can see here that there are syringe service programs in all regions or almost all regions of the United States. They're often underground and not officially sanctioned, but here's a paper that did a survey of them to provide us with a little more detail. State laws nationwide have drastically increased patient's ease of access to naloxone through pharmacies. Most states permit pharmacies. Naloxone distributed without a prescription via standing order, collaborative practice agreement, or pharmacists prescribing authority. Then there's people not at risk themselves, overdose may receive naloxone via third party. Yes, that's true, a lot of distribution through family groups and they may distribute the naloxone on further. Pharmacist's immunity from liability for furnishing naloxone. And then mandated insurance coverage. What are some practical barriers to prescribing naloxone? Well, the prescriber has to be knowledgeable and comfortable. How to write the prescription? That's pretty simple, how to write the prescription. So, now most pharmacy stock it so you can simply write a prescription and I usually write for refills so people can come back to the pharmacy and get naloxone at their own pace. Does the pharmacy stock naloxone? Well, if they don't, you should work with them to get it stocked. Who pays for it? You can work with the pharmacy in many states, Mass Health is going to pay for it as a health necessity. Okay, I just want to delve in a little bit more depth to the pharmacy naloxone purchase. So, there's tale of two pharmacy naloxone purchase trials. The lesson here is it really depends on where you live to see your likelihood of getting naloxone out of pharmacy and having a good experience. So, in Massachusetts from 2018 to 2019, statewide pharmacy standing order mandated stocking and counseling. So, in this project we selected 200 pharmacies at random, 83% purchase success with no difference between people who use drugs versus bystanders. The reasons for failure to purchase was most commonly it was not stocked, a quarter of the time it costs more than $150, and 50% of the time they required a prescription even though there was a statewide standing order. In West Virginia 2020 to 2021, so during the pandemic, the statewide pharmacy standing order mandated counseling and reporting to PMP. Again, 200 randomly selected pharmacies, just like in Massachusetts. And instead of 83%, they only saw 29% purchase success with no difference again in people who use drugs or bystanders. Reasons for failure, 41% non-stock, 35% prescription required, 23% an ID was required. ID problems are super common. Mandating co-prescribing. It's a quick, but limited fix. So, here's the study that spanned from 2011 to 2018, it shows the two states that had a co-prescribing mandate when they were effective March 15 and July 1st in 2017. And then the the surgeon pharmacy distributed naloxone that occurred in those communities quite substantially. And then you see a regression in the near term, that's still something people can do, but are not necessarily aware of. What about prescribing naloxone during COVID? Well, naloxone prescribing is even more important since the COVID-19 pandemic. There are more take home doses of methadone. So, people maybe at more risk, although we're not seeing it revealed in any of the numbers of methadone. There's greater social isolation, stress, and anxiety that may lead to worsening of mental health and addiction symptoms. EMS services may be overwhelmed and slower to respond. Community naloxone may be more limited during the crisis. Pharmacies may not stock naloxone. Consider working with a local pharmacy or local naloxone distribution programs to ensure that their patients have the ability to fill the prescriptions they are given or obtain naloxone. What about in implementing overdose prevention in addiction treatment settings? Well, we did a paper where we looked specifically at patients who were receiving methadone. We identified multiple models which include both internal and external staff engaging with folks. And there were advantages and disadvantages to those around privacy, around disclosure. I would say either way, you want to make sure that if you're distributing naloxone within a traditional residential treatment program should really consider involving the local harm reduction agency who can help partner with you and ensure that you're providing person-centered care. So, some more data, looking back at known and unknown touchpoints, this is cohort was designed to find the 1,300 opioid-related overdose deaths in data from 2014. And one way to do that is to look at the conditions where we know there's elevated risk, and those include opioid prescription touchpoints, which occur in 19% of the people who eventually die from overdose. 37% is the proportion of people who had one of these critical encounters prior to their overdose death. And so, those critical encounters include opioid detox or medically-managed withdrawal, non-fatal opioid overdose, injection-related infection. So, you can see that the proportion of overdoses explained by each of these touchpoints ranges between 6% and 19%. And so, these touchpoints are important for us to keep in mind as venues and populations that we want to focus on. On the other hand, you could see the community providers who had no touchpoint, they were in some ways harder to find. They were 50% of the folks didn't have any touchpoint. And so, that's an important area for new research and thinking is how to get engaged with the people who don't have any engagement in the health system. So, how do you respond to fentanyl contamination of cocaine, methamphetamine, or counterfeit pills? Well, first of all, we need to educate the public, to tailor our outreach for cocaine, methamphetamine, and counterfeit pills so that it includes these concrete materials, naloxone, fentanyl, test strips, and smoking supplies. Coordinating surveillance and response for outbreaks and developing and promoting accessible and evidence-based treatment for people who use other substances. Okay, so we're going to go back to the case and see what happens when this time we have naloxone available. So, again, our 29-year-old woman presents to treatment for buprenorphine. And remember, at 18 she was an athlete, she tore ACL, she was exposed to opioids, developed opioid use disorder. At age 20, she started injecting heroin daily. In the world where we have naloxone readily available, she would've been counseled about the risks of overdose addiction and safe storage. She would've been prescribed a naloxone rescue kit when prescribed opioids for pain. She would've received a new naloxone kit from the syringe service program. From ages 20 to 26 when she was having multiple medically-managed withdrawal and residential program encounters where she was not offered medication or were able to sustain greater than three months off treatment. She would've been counseled at this time around starting low and going slow, respecting her tolerance at each of these turn to use episode. And she would've potentially rescued her boyfriend. At age 26 when she's pregnant at her last treatment episode and initiated methadone treatment where she was able to stop using heroin, engage in 12-step program and delivered a healthy baby and retained custody. This is when she could have gotten more overdose prevention education during orientation into her methadone program. Then when she tapered off of methadone at age 28, wanted more flexibility, her boyfriend was incarcerated, which triggered her to return to use, she could have gotten more overdose prevention education during orientation and incorporated that whenever she was using or around people who were using. So, age 29 to 30 when she had a good response to office-based buprenorphine treatment, regular visits with urine tox only positive for bup, re-engaging in 12-step and with her family and works in child protection to regain custody, works with child protection. More overdose prevention education and naloxone kit. At age 30, she continues her buprenorphine despite her boyfriend's return to use this time and overdosed. Her boyfriend is now released from jail and returns to stay with her. He returned to use and overdosed on fentanyl the third night. This time she called 911, started rescue breathing and administered one dose of nasal naloxone. He was transported, observed, and transferred to residential program for formerly incarcerated people with drug problems. Police and EMS praised her for her response saying, "It saved his life." She called her buprenorphine program counselor and went to group counseling that week where she received support. And so, here she was in remission from her opioid use disorder, no overdose, her boyfriend survived, she retained custody, she was engaged in treatment. Okay, so I hope that's a happy ending. This is a harm reduction intervention and it's specifically, well, it's really for anybody who's at risk of an opioid overdose, but it's particularly important for those people who are going to continue to use, who are not ready or interested in continuing all of their opioid use. I hope at the conclusion of this activity, you are able to describe the epidemiology of opioid-involved overdose, explain the rationale for and scope of overdose education and naloxone distribution, and be empowered to implement OEND in your medical and community settings through educating people about overdose risk reduction and prescribing or dispensing naloxone. Thank you very much. Here's some helpful website, resources, and our references. It's really been a pleasure, I appreciate the opportunity, and thank the PCSS and AMERSA for working together to make all of this possible.

Dr. Alex Walley

addiction specialist

opioid-involved overdose

education

naloxone

harm reduction

overdose prevention