Monday, December 31, 2012

Press release: Naloxone cost-effective

City and County of San Francisco
Edwin M. Lee

San Francisco Department of Public Health
Barbara A. Garcia, MPA
Director of Health

Embargoed until 5p.m. Eastern Time

Eileen Shields, Public Information Officer
 December 31, 2012
415/554-2507 (o) 415/370-3377 (cell)

Study Shows Naloxone Cost-Effective in Preventing Overdose Deaths

San Francisco, CA, January 1, 2013 - The Annals of Internal Medicine released a study this week demonstrating that giving heroin users the overdose antidote naloxone is a cost-effective way to prevent overdose death and save lives. Phillip Coffin, MD, Director of Substance Use Research at the San Francisco Department of Public Health and Assistant Clinical Professor at the University of California San Francisco, and Sean Sullivan, PhD, Professor and Director of the Pharmaceutical Outcomes Research and Policy Program at the University of Washington, co-authored the study.

Drug overdose is now the leading cause of injury death in the United States with opioids, such as heroin, accounting for about 80% of those deaths. Naloxone is a safe and effective antidote that works by temporarily blocking opioid receptors. As of 2010, 183 public health programs around the country, including those supported by the San Francisco Department of Public Health, had trained over 53,000 individuals in how to use naloxone. These programs had documented more than 10,000 cases of successful overdose reversals.

The authors of this study developed a mathematical model to estimate the impact of distributing naloxone in this way. Their model was based on conservative estimates of the number of overdoses that occur each year. It accounted for people who overdose repeatedly, and it acknowledged that most people who overdose will survive whether or not they get naloxone.

In their basic model, Coffin and Sullivan estimated that reaching 20% of a million heroin users with naloxone would prevent about 9,000 overdose deaths over their lifetime. One life would be saved for every 164 naloxone kits given out. Based on optimistic assumptions, naloxone could prevent as many as 43,000 deaths – one life for every 36 kits given out.

Naloxone distribution would cost about $400 for every quality-adjusted year of life gained. This value is well below the customary $50,000 cutoff for medical interventions. It is also cheaper than most well-accepted prevention programs in medicine – most similar to the cost-effectiveness of smoking cessation or checking blood pressure. All reasonable assumptions produced costs that were well within traditional guidelines for cost-effectiveness.

“Naloxone is a highly cost-effective way to prevent overdose deaths,” said Dr Coffin. “And, as a researcher at the Department of Public Health, my priority is maximizing our resources to help improve the health of the community.”

Naloxone distribution has existed in San Francisco since the late 1990s, with SFDPH support since 2004. During that time, heroin overdose fatalities slowly decreased from a peak of 155 in 1995 to 10 in 2010. Opioid analgesic deaths (e.g., oxycodone, methadone, or hydrocodone) remain elevated, with 121 deaths in 2010. Efforts are currently underway to expand access to this lifesaving medication for patients receiving prescription opioids as well.

Contact Information and Follow-up
To obtain a copy of this study, see Annals of Internal Medicine

To discuss the paper, contact Dr. Coffin,


Tuesday, December 11, 2012

More OD videos - Cops, reentry, and Spanish OD training!

It seems like there are a bunch of good overdose advocacy and training videos coming out these days. 

Here's a new video from the San Francisco Police Department and Department of Public Health instructing police not to interfere with syringe access sites or naloxone distribution. (Nice narration Emalie Huriaux!)

And here's a new Spanish-language video from Boston about how to recognize overdose and respond properly. The video highlights the fact that those just released from prison or other lock-up facilities are at higher risk of OD, especially in those first two weeks.

And while we're at it, we realized that OPA didn't mention the great video, "Staying Alive on the Outside" from our friends in Rhode Island that came out a few months back. It's and English-language video that focuses on OD risk and response after prison release. 

We hope you find these useful in your work!

Monday, December 10, 2012

Quote of the Day

"The naloxone shortage is going to hurt us. It is hurting us. People are dying now because of the shortage. More people are going to die because of it. Whatever your story is, you shouldn't have to die for how you choose to navigate your life and what's happened to you. We need naloxone everywhere. Opioid users didn't just appear out of nowhere -- everybody has someone that loves them, a father, a mother, a grandparent, a friend, niece, nephew, brother sister ... and you're important to that person. Naloxone can keep them from dying. It's harm reduction on a really intimate, yet grand scale because every OD death that is prevented means hundreds if not thousands of people prevented from losing and grieving."
                ---------- Lee Hertel, Minneapolis USA

Sunday, December 2, 2012

PubMed Update October/November 2012

My apologies for tardiness. I'll try to be on time next month. 13 papers described below.

Beletsky L, Rich JD, Walley AY.
JAMA. 2012 Nov 14;308(18):1863-4. doi: 10.1001/jama.2012.14205.
Comment: An excellent summary of key issues in overdose prevention and increasing naloxone availability for lay overdose reversal. Read it.

Picetti E, Rossi I, Caspani ML.
N Engl J Med. 2012 Oct 4;367(14):1371-3
Comment: Multiple letters in response to the recent review article.

Krupitsky E, Zvartau E, Blokhina E, Verbitskaya E, Wahlgren V, Tsoy-Podosenin M, Bushara N, Burakov A, Masalov D, Romanova T, Tyurina A, Palatkin V, Slavina T, Pecoraro A, Woody GE.
Arch Gen Psychiatry. 2012 Sep;69(9):973-81.
Comment: This was a randomized, placebo-controlled trial comparing naltrexone implant to oral naltrexone to nothing for preventing relapse to opioid dependence among detoxified patients in Russia. Participants were followed for six months and then followed up a year later to see if there was more death from overdose. The implant was more effective in retaining participants through the six months although by 3 months off therapy there was no difference between the groups. Authors only report “no evidence of increased risk of death due to overdose after  naltrexone treatment” and cite the initial paper showing injectable naltrexone as effective for opioid dependence in Russia (I’m unclear as to why this citation was present). I find this radically insufficient. Naltrexone has lab evidence (animal evidence shows that exposing opioid receptors to naltrexone makes them more sensitive to opioids than mere abstinence) and clinical evidence (high death rates after oral naltrexone treatment) suggesting that it increases risk of overdose and overdose death. The authors of this paper provide no details as to how they showed no evidence of increased overdose. How many people were they able to follow-up with at 18 months (their numbers were really small to begin with)? Did they inquire as to non-fatal overdose? How did they collect information about overdose death (coroners in Russia rarely identify overdose as a cause of death due to stigma and payment issues)? While extended-release naltrexone formulations *might* have less of an association with overdose, the concerns about oral naltrexone are well-established - how did the investigators get approval for oral naltrexone for opioid users from a U.S. government funded study? This is a vulnerable population for whom greater attention to toxicities should be demanded. A high level of attention to overdose outcomes might put to rest these concerns, but I have not seen that as of yet.