NC’s Statewide Standing Order for Naloxone:Working with Partners to Lead Change
2017 NC State Health Director’s Conference
Chris Hoke, JD and Anna Stein, JD, MPH
The Problem: Opioid Overdose
3
*Per 100,00, age-adjusted to the 2000 U.S. Standard Populationα - Transition from ICD-8 to ICD-9β – Transition from ICD-9 to ICD-10
National Vital Statistics System, http://wonder.cdc.gov, multiple cause datasetSource: Death files, 1968-2014, CDC WONDERAnalysis by Injury Epidemiology and Surveillance Unit
Death Rates* for Three Selected Causes of Injury, North Carolina, 1968-2014
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
1968 1970 1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014
Death
s p
er
100,0
00 p
op
ula
tio
n
Year
Motor Vehicle Traffic (Unintentional)
Drug Poisoning (All Intents)
Firearm (All Intents)
α
1989 – Pain added as 5th Vital Sign
4
Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 1999-2015Analysis by Injury Epidemiology and Surveillance Unit
Substances Contributing to Medication or Drug Overdose DeathsNorth Carolina Residents, 1999-2015
738
291
363
0
100
200
300
400
500
600
700
800
900
Num
ber
of death
s
Prescription Opioid
Cocaine
Heroin
884% increase in Heroin
deaths since 2010
Don’t forget
about cocaine
Prescription Opioid Analgesic Sales vs. DeathsNorth Carolina, 2000 - 2015
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015
Sales (kg per 10,000 population) Deaths (per 100,000)
Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 2000-2015. DEA ARCOs
data, North Carolina, 2000-2015. Analysis by Injury Epidemiology and Surveillance Unit
http://www.cdc.gov/vitalsigns/opioid-prescribing/index.html
7
Unintentional/Undetermined Prescription Opioid Overdose Deaths Rates & Outpatient Prescriptions Dispensed for Opioids Rates
North Carolina Residents, 2011-2015
8
Heroin DeathsNorth Carolina Residents, 2008-2015
Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 2008- 2015Analysis by Injury Epidemiology and Surveillance Unit
6172
37
76
147
179
246
364
0
50
100
150
200
250
300
350
400
2008 2009 2010 2011 2012 2013 2014 2015
Nu
mb
er
of
de
ath
s 565% increase from
2010 to 2014
884% increase from
2010 to 2015
Source: Paulozzi, LSource: CDC, Len Paulozzi, July 2014Source: CDC, Len Paulozzi, July 2014
Source: N.C. State Center for Health Statistics, Vital Statistics-Deaths, 2015Analysis by Injury Epidemiology and Surveillance Unit
N=1,251
Demographics of Medication or Drug Overdose Deaths
North Carolina Residents, 2015
One Response: Naloxone Access
CDC Vital Signs, July 2015
http://www.cdc.gov/vitalsigns/heroin/index.html
• Naloxone (Narcan®, Evzio®)
– A prescription medication used to treat an opioid overdose
– Works by reversing the effects of opioids by temporarily binding
to the same brain receptors as opioids
– Safe medication; few side effects other than putting people into
immediate withdrawal from opioids
– Can be administered intra-nasally or intra-muscularly
13
Naloxone
14
Death
Respiratory depression
Diminishing cognition/ Motor control
Nodding, unresponsive
Euphoria; Relief from dope sickness
Pain relief
Pain, withdrawal, craving, dope sickness, boredom
• In 2013, legislature passed the Good Samaritan law
–Provided immunity for possession of small amount of drugs for
people seeking help for an overdose
–Provided civil and criminal immunity for persons who administer
naloxone to someone experiencing an overdose
–Allowed health care practitioners to prescribe naloxone by
standing order and allowed 3rd party prescribing (to friends and
relatives of people at risk of an overdose)
“A practitioner acting in good faith and exercising reasonable care
may directly or by standing order prescribe an opioid antagonist to (i) a
person at risk of experiencing an opiate-related overdose or (ii) a
family member, friend, or other person in a position to assist a person
at risk of experiencing an opiate-related overdose.”
15
2013 Good Samaritan Law
16
Number of Naloxone Kits Distributed by the
North Carolina Harm Reduction Coalition by County 8/1/2013 – 12/31/2016 (39,451 total kits distributed)
Source: North Carolina Harm Reduction Coalition, January 2017
Analysis: Injury Epidemiology and Surveillance Unit
2 kits distributed in an unknown location in North Carolina.
No kits distributed
1000-6877
100-999
10-99
1-9
17
Number of Opioid Overdose Reversals with Naloxone Reported to
the North Carolina Harm Reduction Coalition by Date8/1/2013 - 12/31/2016
Source: North Carolina Harm Reduction Coalition, January 2017
Analysis: Injury Epidemiology and Surveillance Unit
35 189 1,548 3,684
22 6 1 6 7 6 5 15 12 20 16 15 25 1340
1534
97
47 50
125
34
143
187
128
204197
302290
204
307275
343
251255
687
255241
316
260
0
100
200
300
400
500
600
700
800A
ug-1
3
Oct-
13
De
c-1
3
Feb
-14
Ap
r-1
4
Ju
n-1
4
Au
g-1
4
Oct-
14
De
c-1
4
Feb
-15
Ap
r-1
5
Ju
n-1
5
Au
g-1
5
Oct-
15
De
c-1
5
Feb
-16
Ap
r-1
6
Ju
n-1
6
Au
g-1
6
Oct-
16
De
c-1
6
Nu
mb
er
of o
pio
id o
ve
rdo
se
re
ve
rsa
ls
with
Na
loxo
ne
re
po
rte
d to
NC
HR
C
5,456 reported reversals
18
Number of Opioid Overdose Reversals with Naloxone Reported by
the North Carolina Harm Reduction Coalition by County 8/1/2013 - 12/31/2016 (5,456 total reversals reported)
17 reversals in an unknown location in North Carolina and 81 reversals using NCHRC kits in other states reported to NCHRC.
Source: North Carolina Harm Reduction Coalition, January 2017Analysis: Injury Epidemiology and Surveillance Unit
No reversals reported
10-99
100-499
500-1360
1-9
19
Source: North Carolina Harm Reduction Coalition, January 2017
Analysis: Injury Epidemiology and Surveillance Unit
Counties with Law Enforcement Carrying NaloxoneAs of December 31, 2016 (60 Counties, 136 Agencies)
20
Source: North Carolina Harm Reduction Coalition, January 2017Analysis: Injury Epidemiology and Surveillance Unit
1 1
8
1 02
5
0
52
5 6
25
14 13
2220
12
55
39
16
5861
0
10
20
30
40
50
60
70
Ja
n-1
5
Feb
-15
Ma
r-1
5
Apr-
15
Ma
y-1
5
Ju
n-1
5
Ju
l-1
5
Au
g-1
5
Se
p-1
5
Oct-
15
No
v-1
5
De
c-1
5
Ja
n-1
6
Feb
-16
Ma
r-1
6
Ap
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6
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6
Ju
n-1
6
Ju
l-1
6
Au
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6
Se
p-1
6
Oct-
16
No
v-1
6
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c-1
6
Nu
mb
er
of o
pio
id o
ve
rdo
se
re
ve
rsa
ls
with
Na
loxo
ne
re
po
rte
d to
NC
HR
C b
y
N
C L
aw
En
forc
em
en
t 373 reported reversals
Number of Opioid Overdose Reversals with Naloxone Reported by
NC Law Enforcement by Date1/1/2015 - 12/31/2016
20 reported reversals with unknown date
36 317
21
Source: North Carolina Harm Reduction Coalition, January 2017
Analysis: Injury Epidemiology and Surveillance Unit
Number of Opioid Overdose Reversals with Naloxone Reported by
NC Law Enforcement by Date1/1/2015 - 12/31/2016 (373 total reversals reported)
No reversals reported
10-24
25-49
50-98
1-9
• Fall 2015: NC Injury and Violence Prevention
Branch(IVBP) received Prevention for States grant from
CDC
–A 4-year grant to work on prescription drug overdose prevention
• IVPB had been investigating possibility of statewide
standing order for naloxone by State Health Director
under the Good Samaritan law
• October 2015: Pennsylvania’s Physician General signed
statewide standing order
• December 2015: Maryland’s Deputy Secretary for state
health department signed statewide standing order
22
Statewide Standing Order Initiative
• Injury and Violence Prevention Branch approached State
Health Director Dr. Randall Williams about creating a
Statewide Standing Order for Naloxone
• Dr. Williams indicated need to consult partners
–NC Medical Board
–NC Medical Society
–NC Pharmacy Board
• After talking with partners, decided to seek legislative
change to specifically allow State Health Director to issue
a statewide standing order
23
What about North Carolina?
• Working with DHHS legislative liaisons
• Trying to find way to introduce legislation in the short
session
• Dealing with concerns regarding cost neutrality from
Medicaid
–Decision to exclude Evzio (auto-injector version) from standing
order
• Committee hearings in House and Senate
–Dr. Williams served as effective champion of the bill
–Legislators very receptive to bill on a bi-partisan basis
24
Legislative Maneuvering
• Wrote draft standing order and shared with multiple
partners to get feedback
–NC Medical Board
–NC Medical Society
–NC Pharmacy Board
–NC Retail Merchants Association
•All major pharmacy chains
–Community pharmacies representatives
–NC Division of Medical Assistance
–Community Care of NC
• Pharmacies praised simplicity of standing order
compared to those in other states; greatly appreciated
ability to give input
25
Advanced Preparation for the Passage of the Bill
• Working on very tight deadline (one month); needed to
have website up and running as soon as law effective
• NC Injury Prevention Research Center helped design
website
• Created FAQs document
• Created searchable map with plan to populate with
pharmacies dispensing under the standing order
• Had a call organized by NC Retail Merchants Association
with pharmacy chains and community pharmacy
representatives to explain website and the process of
“signing up” to dispense under the standing order, and to
get feedback before website was “official”
26
Creation of NaloxoneSaves.org Website
27
www.NaloxoneSaves.Org
• Urgent messages to pharmacies and pharmacists to be
prepared for the statewide standing order
–Determine whether they intended to dispense under the standing
order
–Put in place any internal protocols they desired for standing order
–Order naloxone and have it in stock
• Worked NC Pharmacy Board and NC Retail Merchants
Association to get the word out quickly
• Gave DPH attorney email to all NC pharmacists for help
with questions
28
Spreading the Word to Pharmacies in Advance of the Law’s Passage
29
Authorizes any pharmacist practicing in the state and licensed by the N.C. Board of
Pharmacy to dispense naloxone to:
• A person at risk of experiencing an opiate-related overdose
• A family member or friend of a person at risk of experiencing an opiate-related
overdose.
• A person in the position to assist a person at risk of experiencing an opiate-related
overdose.
June 20, 2016: Gov. McCrory signed legislation authorizing State Health Director
to issue statewide standing order for naloxone and standing order signed by Dr.
Randall Williams immediately afterward
30
NaloxoneSaves.Org
1,300+ NC Pharmacies operating under standing
order listed on the website. More added each week.
31
Number of Pharmacies Selling Naloxone Under Standing Order by County, Sept 2016
1,330 Pharmacies in the state selling naloxone
About 60% of retail pharmacies in NC
Most of the large chains
• Multiple chains and independent pharmacies dispensing
by standing order
–CVS, Rite-Aid, Harris Teeter, Walgreen’s, Kroger, Ingles, others
• Have not run into implementation hurdles
• Standing order being used by law enforcement in some
locations to obtain naloxone
• Need for evaluation of law
–UNC Injury Prevention Research Center working with UNC School
of Pharmacy to conduct a survey of NC pharmacies about the
standing order
–Need to determine how much naloxone has been dispensed
under the standing order
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Post Script
NC Counties with Local Health Department Standing
Order/Protocol for Naloxone
• Alexander
• Cabarrus
• Davidson
• Duplin
• Durham
• Forsyth
• Hoke
• Johnston
• Lenoir
• Madison
• Orange
• Pender
• Pitt
• Union
• Wake
• Wilkes
• Others?
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• Bill passed July 11, 2016 to legalize syringe exchanges (Three weeks after standing order bill signed)
• Any governmental or nongovernmental organization can start a SEP
• Legal protections: No employee, volunteer or participant of the syringe exchange can be charged with possession of syringes or other injection supplies, or with residual amounts of controlled substances in them, obtained from or returned to a syringe exchange
• NC Safer Syringe Initiative of the Division of Public Health
https://www.ncdhhs.gov/north-carolina-safer-syringe-initiative
34
NC Syringe Exchange Programs (SEP)
35
Source: North Carolina Division of Public Health, January 2017Analysis: Injury Epidemiology and Surveillance Unit
Counties with Syringe Exchange ProgramsAs of December 31, 2016 (16 SEPs covering 20 counties)
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