The Arizona Department of Health Services launched an important public health campaign this week. In my opinion, the campaign aims to make naloxone available every where to save lives. When administered in time, naloxone has the ability to reverse an opioid overdose and allow individuals a chance to live. A theme of the campaign is opioid overdose does not need to be fatal. Arizona has seen a decrease in the number of overdose rates. Yet, we must continue to promote harm reduction strategies to save lives. Even one person who dies of an overdose is too many. Nationally, overdose rates continue to climb primarily driven synthetic fentanyl and polysubstance use. People may unknowingly take fentanyl because it has been pressed into pills that may look like another pharmaceutical but are actually fake. 

Naloxone is available over-the-counter, by prescription, from county public health departments and numerous other community locations (Sonoran Prevention Works, public libraries). 

• To learn more check out these resources:

  • Arizona Center for Rural Health, naloxone: https://crh.arizona.edu/programs/naloxone

  • Arizona Center for Rural Health, video on administering naloxone: https://crh.arizona.edu/ahead-training-videos-and-webinars 

Caring about people who knowingly or unknowingly take drugs is one of the most noble forms of compassion. People can't engage in change processes if they are no longer with us. 

Be safe!

Overdose continues to series public health concern. While nalmefene hydrochloride has been around for decades, in May 2023, the FDA approved it is part of the FDAs overdose prevention framework. It was approved for emergency treatment of a known or suspected overdose. 

Learn more from UArizona clinical assistant professor, Christopher Edwards, PharmD. here: https://www.kgun9.com/news/community-inspired-journalism/midtown-news/opvee-nasal-spray-a-newer-approach-to-help-opioid-overdoses

UPDATE: 2/23/2024.

As Dr. Edwards mentions, nalmefene has a longer duration of action which has the potential for exposing patients to a longer period of precipitated withdrawal. This can be incredibly painful and uncomfortable for patients. Which brings me to the reason for the update. 

On September 28, 2023 the American College of Medical Toxicology and American Academy of Clinical Toxicology wrote a joint statement that nalmefene should not replace naloxone since the longer duration of action could be potentially harmful to patients. 

The groups offered four recommendations including: (1) continue using naloxone as the preferred first line medication and, if other data becomes available, support nalmefene in routine care, (2) conduct effectiveness trials on nalmefene in various clinical settings, (3) evaluate safety outcomes related to nalmefene such as complications with opioid reversal, and (4) perform comparative studies between naloxone and nalmefene. 

Read full statement here: https://www.acmt.net/news/acmt-aact-joint-position-statement-on-nalmefene-should-not-replace-naloxone-as-the-primary-opioid-antidote-at-this-time/ 

In 2022, our country tragically witnessed the loss of nearly 111,000 lives to fatal overdoses. Heartbreakingly, among those were 1,000 young children and adolescents under the age of 18.

President Joseph Biden has officially declared October 2023 as National Youth Substance Use Prevention Month. This month is dedicated to taking decisive action by implementing evidence-based prevention strategies to enhance the well-being of our nation’s children and adolescents.

October marks National Youth Substance Use Prevention Month, a time for us to unite and focus on securing a brighter future for America’s youth, while we honor the memory of those we’ve lost. This month, we extend our support to those battling substance use and the families who have suffered the pain of losing a loved one to an overdose, as we work to end this ongoing crisis.

Addressing prevention also necessitates spreading awareness about the opioid epidemic, especially the role of fentanyl which marks the majority of youth overdoses. It is our responsibility to continue to educate the young and the older about the risks associated with these drugs, including the lifesaving potential of opioid-reversal medications like Naloxone.

Throughout National Youth Substance Use Prevention Month, we recognize the importance of communities coming together to raise awareness of the importance of prevention. We salute those in recovery and the families, parents, and friends who support them.

No family should endure the anguish of losing a child to the opioid and overdose crisis.

To learn more about the proclamation on National Youth Substance Use Prevention Month, 2023, including prevention strategy programs, visit https://www.whitehouse.gov/briefing-room/presidential-actions/2023/09/29/a-proclamation-on-national-youth-substance-use-prevention-month-2023/#:~:text=BIDEN%20JR.%2C%20President%20of%20the,Youth%20Substance%20Use%20Prevention%20Month.

Written by: Bridget Murphy, September 25, 2023

You may have heard about xylazine in the press recently. Here are a few things to know.

What is Xylazine?

Xylazine is a veterinary tranquillizer. It isn't an opioid. It has similar properties to clonidine. Clonidine lowers blood pressure and can decrease anxiety. Unlike clonidine, xylazine is not approved for human use due to safety issues. 

Why should public health be concerned?

On the east coast, increases in xylazine have been detected in the drug supply. It has been detected throughout the United States. People who use drugs may knowingly or unknowingly ingest xylazine mixed in with other drugs such as fentanyl. There are health consequences with xylazine use such as skin and soft tissue infections. People may access healthcare locations with these wounds which aren't necessarily associated with injection drug sites. 

If someone is experiencing a overdose, xylazine does not respond to naloxone. If naloxone is administered to someone who has used opioids and xylazine, they may continue to remain sedated. Please remember, naloxone is a life saving drug. If you suspect someone is overdosing, please administer it to potentially save their life. Its important to get medical help as soon as possible. 

People can develop a use disorder after prolonged and consistent use. Withdrawal symptoms from xylazine can include increased heart rate or blood pressure, anxiety, and/or panic. Assessing for anxiety treatments may be an important consideration for people seeking care. 

To learn more visit these websites:

Center for Disease Control and Prevention: https://www.cdc.gov/drugoverdose/deaths/other-drugs/xylazine/faq.html 

National Harm Reduction Coalition: https://harmreduction.org/

Penn Medicine Center for Addiction Medicine and Policy: https://www.pennmedicine.org/for-health-care-professionals/for-physicians/physician-education-and-resources/center-for-addiction-medicine-and-policy 

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This blog draws heavily from the work of the Homeless & Housing Resource Center from this fact sheet: https://hhrctraining.org/knowledge-resources/fact-sheet/17897/xylazine-basics?utm_source=newsletter&utm_medium=email&utm_content=Screenshot%20of%20the%20Fact%20Sheet&utm_campaign=UA-179397308-1  

The Arizona Center for Rural Health is inviting personnel who work in Arizona community health centers, rural health clinics, and critical access hospitals to participate in an assessment. The purpose of the assessment is to identify barriers and facilitators associated with integrating the opioid prescribing guidelines into the electronic health record (EHR). Learn more here:  https://redcap.uahs.arizona.edu/surveys/?s=TDWLEPX947TPHY4P

Relevance: 

More than 5 people a day die from an overdose in Arizona; primarily from opioids. Health information technology has the potential to support healthcare organizations in increasing safety by standardizing workflows, offering provider recommendations, and other decision making tools. See more at the Center for Disease Control and Prevention (CDC).

Prescribing Guidelines:

In 2018, Arizona published its opioid prescribing guidelines (herein referred to as the Guidelines). The Guidelines provide recommendations for opioid prescriptions for acute and chronic pain and risk mitigation strategies. The Guidelines acknowledge the importance of clinical judgement while providing tools and strategies to support whole person care. From my perspective, the Arizona Guidelines build off of the 2016 CDC Guidelines. In 2022, the CDC released an updated version of the prescribing guidelines.

Integrating opioid prescribing guidelines into EHRs support best practice for mitigating opioid related risk and enhancing patient safety. Its also critical to ensure EHRs meet the industry standards for security. Protecting patients and their families from unintentional disclosure of private information must be prioritized. Yet, its recognized barriers exist to meeting these goals.

Our Assessment:

The assessment aims to better understand these barriers. We recognize not all EHRs, organizational resources, and patient populations are the same. If you work in one of these healthcare organizations and have oversight for, or regularly use the EHR please consider participating!

At the beginning of the year, some important policy changes occurred related to the opioid use disorder (OUD) treatment. Until recently, qualified healthcare providers needed to have what was commonly referred to as an X-waiver. The X-waiver allowed providers to dispense certain types of opioid medications for the treatment of OUD. Obtaining an X-waiver required special training and registration with the Drug Enforcement Administration (DEA). Many argued that the X-waiver process created barriers for providers to offer patients life saving treatment. Today, qualified providers no longer have to obtain an X-waiver. 

What might this mean for the treatment of OUD?

• More qualified providers who are licensed to dispense controlled substances may offer buprenorphine to treat patients with OUD.

• Patients have the potential to access treatment in many more settings. 

• Families may have greater access to services and support for their loved ones.

While the X-waiver has been eliminated, training is still required. As of June 27, 2023, new or renewing DEA registrants must meet the training requirements. Visit the Substance Abuse and Mental Health Services Administration's (SAMHSA) website: https://www.samhsa.gov/medications-substance-use-disorders/waiver-elimination-mat-act. This is a great opportunity for healthcare providers to learn or refresh their knowledge about substance use and opioid use disorders. 

To learn more about medications to treat opioid use disorder visit the Providers Clinical Support System, https://pcssnow.org/medications-for-opioid-use-disorder/

People are overdosing at high rates across the country. This is primarily driven by the powerful opioid - fentanyl. Fentanyl is a potent synthetic opioid. It is used to treat severe pain. Unregulated markets are mixing fentanyl into other drugs such as other opioids, cannabis, or stimulants. 

To learn more about fentanyl visit the National Institute on Drug Abuse website: https://nida.nih.gov/publications/drugfacts/fentanyl 

What are fentanyl test strips (FTS)?

FTS are small strips that can be used to detect the presence of fentanyl in drugs such as cocaine, methamphetamine in different forms (e.g., pills, powder). This allows the person who is about to use the drug the opportunity to determine if fentanyl is present. This helps reduce harm associated with poisoning related to unknowingly ingesting fentanyl. 

Visit the Center for Disease Control and Prevention's website to learn more about fentanyl test strips: https://www.cdc.gov/stopoverdose/fentanyl/fentanyl-test-strips.html 

Why does this matter?

In 2021, Arizona decriminalized FTS given the significant risks and potential for fatal consequences among people who use drugs. (See more here: https://thehill.com/homenews/state-watch/554419-arizona-legalizes-test-strips-that-detect-fentanyl/). Decriminalizing FTS respects the autonomy of people who use drugs to make informed decisions and provide them tools to reduce harm. Succinctly, it can save lives. 

The evidence about FTS is limited. One study found three FTS technologies accurately detected the presence or absence of fentanyl in drugs (https://americanhealth.jhu.edu/fentany). More research is needed. Yet, like all public health harm reduction strategies (e.g., seat belts; helmets), nothing is absolute. Based on the (a) current public health conditions and (b) available evidence it can be argued FTS save lives. 

FTS can be found through public health departments and organizations that offer harm reduction services. 

Things to consider. 

Those of us in public health work to ensure health maximization for people, communities, and the nation through evidence-based and population informed policies and programs. For people who misuse drugs or have a substance use disorder, ultimately, we want them to live their full potential through human connections, fulfilling work and/or education, and access to quality care. 

Change takes time. Have you ever wanted to change something, say for instance, increasing exercise or sleeping more? You, like many of us, may have had a series of starts and stops which may or may not have resulted in achieving your goal. Change is a complex process that is influenced by a variety of factors (individual; interpersonal; community/organizations; policies/environment). 

If you're interested in change theories such as the Transtheoretical Model of Change, Health Belief Model, Social Cognitive Theory, and the Social Ecological Model, consider visiting the National Institute on Health's Office of Behavioral and Social Science eSource training page: (https://obssr.od.nih.gov/training/online-training-resources/esource. 

People who use drugs should have access to harm reduction strategies so that when, and if, they decide to reduce or eliminate their drug use they can because they are alive.  

You may have heard, over-the-counter (OTC) naloxone will be available soon! The Food and Drug Administration approved the first OTC nasal spray naloxone (https://www.fda.gov/news-events/press-announcements/fda-approves-first-over-counter-naloxone-nasal-spray). This is great news for expanding access to this life saving drug. Here are some things to know and think about: 

What is naloxone?

Naloxone reverses the effects of an opioid overdose. Naloxone can be administered either through the nose or injection. The FDA approved the OTC nasal spray in the amount of 4 milligrams. 

Why does this matter?

Naloxone saves lives. The United States continues to be experiencing an overdose crisis. Until this approval, naloxone has been available by prescription or through state and community distribution efforts. Arizona has a standing order for naloxone prescriptions (https://www.azdhs.gov/opioid/#naloxone). This means if you go to a pharmacy and request naloxone you should be able to get it. Yet, we know accessing naloxone through pharmacy may be challenging for some folks. In public health, offering interventions and resources in a variety ways using multiple strategies helps promote health and access to effective services and support.  

What should we think about and plan for?

We may see similar accessibility issues with OTC naloxone as we have with pharmacy locations. That is, people will still need to visit a location that carries naloxone and pay for it. Keeping in mind those social determinants of health, it is important for public health to continue to provide no-cost naloxone kits. 

Timeline. 

Don't expect to see naloxone on the store shelves in the next couple of weeks. In fact, it may take months. Nevertheless, this is a victory for people and families affected by substance use and public health.