Overdose Prevention

Overdose Prevention

In November 2020, the California Department of Public Health released a vulnerability assessment report for fatal overdose, HIV and HCV infections in each of the California counties. The purpose of the vulnerability assessment project is to 1) identify California counties at risk for a rapid increase of fatal opioid overdose or HIV or HCV infections associated with injection drug use; 2) develop tools and resources for local health officials to prevent and respond to these overlapping epidemics; and 3) share findings to inform local public health action.

From the report:

In California rates of newly reported chronic hepatitis C infections and heroin-related emergency department visits among young adults (25 to 29 years of age) are increasing together, at a similar rate: rates of newly reported cases of chronic hepatitis C increased 159 percent and heroin-related emergency department visits increased 139 percent, respectively, between 2012 and 2016, likely due to increases in injection drug use. Nationally and in California there is no evidence of an increase in newly acquired HIV among people who inject drugs (PWID), but transmission through unsterile injection drug use is possible and clusters of injection-mediated HIV infection have been documented in Boston, Massachusetts; Northern Kentucky and the Greater Cincinnati Region of Ohio; Multnomah County, Oregon; Seattle, Washington; and West Virginia. In California, in 2017, eight percent of new diagnosis of HIV were among PWID.

In 2015, Scott County, Indiana, a town with less than 25,000 population that had five HIV infections diagnosed in the past 10 years, experienced an unprecedented HIV outbreak, with 181 new HIV infections attributed to the outbreak in three months.^4,5 Public health investigators found the rapid increase in HIV infections was largely tied to sharing of syringes and drug injection equipment in a setting with no access to sterile syringes.

Following the Scott County HIV outbreak, CDC conducted a national analysis assessing the county-level vulnerability to a rapid increase in HCV or HIV infections related to injection drug use. Two counties in California (Lake County and Plumas County) were identified as having high vulnerability, which was defined as being in the top five percent among all counties nationwide.

In the HIV or HCV risk model, 12 counties out of 58 total counties in California (21 percent) were categorized as having high risk; 24 (41 percent) as medium risk; and 22 (38 percent) as having some risk. Seven of the 12 counties (58 percent) with high HIV or HCV vulnerability had less than 100,000 population; nine of the 12 (75 percent) were in Northern California; with one each in the Bay Area, Central Valley, and Southern California.† The results show a concentration in Northern California and low population counties but also include urban counties in the Bay Area and Southern California, some of which have robust harm reduction infrastructure but nonetheless face high fatal opioid overdose, HIV, and/or HCV vulnerability.

Fortunately, a number of evidence-based prevention strategies can mitigate individual and community-level risk for fatal opioid overdose HIV, and/or HCV.

1)        Medication assisted treatments (MAT) for opioid use disorder (such as buprenorphine) can reduce fatal overdose risk; prevent HIV by reducing injecting; and have been shown to reduce hepatitis C rates among young PWID by as much as 50 percent.

2)        Naloxone, a medication used to reverse an opioid overdose, can be safely administered by lay persons, and is available from multiple different sources for distribution to PWID, who are both at highest risk for a fatal opioid overdose and likely to witness and respond to an overdose among peers.

3)        Syringe services programs (SSPs) effectively reduce HIV and HCV transmission among PWID; SSPs are most effective at preventing HCV transmission when offered at scale and in combination with other harm reduction services, such as MAT.23 SSPs are ideal locations for distributing naloxone to PWID, and for serving as a health hub for other health services, including MAT, wound care, hepatitis A and hepatitis B vaccination, and HCV and HIV testing and treatment.

4)        HIV testing, linkage to care, and treatment can keep people with HIV healthy for many years and viral suppression helps reduce their risk of transmitting HIV to others, although the effect of HIV viral load suppression on preventing transmission via sharing syringes is not well understood. HIV pre-exposure prophylaxis (PrEP) reduces the risk of getting HIV by at least 74 percent when taken daily.

5)        HCV testing, linkages to care, treatment, and cure among PWID, in combination with expanded access to SSPs and MAT, has the potential to dramatically reduce community- level hepatitis C prevalence.

What does this mean for Sonoma County?

Sonoma County’s vulnerability is categorized as medium for both fatal overdose and HIV/HCV infections. However, given our proximity to Lake and Mendocino counties high vulnerability categorizations, and Lake County’s categorization as being in the top five percent among all counties nationwide, Sonoma County should continue to be on high alert.

In 2019, Sonoma County had the 10^th highest overdose rate among the 58 California counties (Lake County was number 1). This is down from 6^th in 2018. (https://skylab.cdph.ca.gov/ODdash/)

What is F2F doing to respond to this?

F2F is currently providing all of the services outlined by the CDPH to mitigate risk in our community. Our syringe service program, which includes overdose prevention and naloxone distribution, is the largest in Sonoma County and serves over 3,000 individual PWID annually. Our program also serves people from neighboring counties, including Lake, Mendocino, Napa and Solano counties. In 2020, we distributed 398,000 syringes with a 79% return rate, more than 1,800 naloxone kits, linked 47 people to medicated assisted treatment, and over 979 HIV tests (including 45 in-home tests during COVID-19).

Our Strategic Plan outlines what more we need to do to address these issues. We know we need to scale up our SSP and Naloxone distribution, particularly since COVID-19 and anecdotal increases we’ve seen in drug use and overdoses. We also plan to get mobile, and expand our satellite distribution services farther north in the county in more rural areas. To be successful, we will continue to and expand engagement with our community partners to better reach those who need services, and make the most of our community resources. This includes other MAT providers, homeless service providers, and other providers and pharmacies of HIV and HCV prevention medications (PrEP and PEP).

This includes expanding access to community members with higher rates of overdose and new HIV/HCV infections. For example, we have begun collaborating with Native American communities, working with key leaders in the community and making meaningful connections. We were invited to be part of a harm reduction collaboration for Tribal communities. We continue to expand our engagement with youth, including developing working partnerships with Positive Images and LGBTQ Connections.

We have also provided guidance to Any Positive Change on Peer to Peer satellite services in Lake County. We continue to provide support to developing and expanding Lake County SSP and overdose prevention programs.

We continue to provide linkages to PrEP, and starting in 2021 will be offering bilingual PrEP Navigation services. As always, we are available to link people to PrEP medication with local medical providers. In 2021, we will begin providing telehealth services on site, meaning anyone who is interested in PrEP can get a prescription right away. In this way we will be a “one stop shop” – you can come in for sterile injection equipment, get an HIV test, and be linked to PrEP, all in a single day.

 CDC HEALTH ADVISORY 

 Increase in Fatal Drug Overdoses Across the United States Driven by Synthetic Opioids Before and During the COVID-19 Pandemic 

Summary 

The purpose of this Health Alert Network (HAN) Advisory is to alert public health departments, healthcare professionals, first responders, harm reduction organizations, laboratories, and medical examiners and coroners to— 

(1) substantial increases in drug overdose deaths across the United States, primarily driven by rapid increases in overdose deaths involving synthetic opioids excluding methadone (hereafter referred to as synthetic opioids), likely illicitly manufactured fentanyl; o(2) a concerning acceleration of the increase in drug overdose deaths, with the largest increase recorded from March 2020 to May 2020, coinciding with the implementation of widespread mitigation measures for the COVID-19 pandemic;

(3) the changing geographic distribution of overdose deaths involving synthetic opioids, with the largest percentage increases occurring in states in the western United States; 

(4) significant increases in overdose deaths involving psychostimulants with abuse potential (hereafter referred to as psychostimulants) such as methamphetamine; and 

(5) recommendations for communities when responding to the evolving overdose crisis. 

Background 

The most recent provisional data available from the Centers for Disease Control and Prevention’s (CDC) National Center for Health Statistics (NCHS) indicate that approximately 81,230 drug overdose deaths occurred in the United States in the 12-months ending in May 2020 (Figure 1).i This represents a worsening of the drug overdose epidemic in the United States and is the largest number of drug overdoses for a 12-month period ever recorded.1 After declining 4.1% from 2017 to 2018,2 the number of overdose deaths increased 18.2% from the 12-months ending in June 2019ii to the 12-months ending in May 2020 (Figure 1).3 Drug overdose deaths during this time increased more than 20% in 25 states and the District of Columbia, 10% to 19% in 11 states and New York City, and 0% to 9% in 10 states. Drug overdose deaths decreased in four states.

The recent increase in drug overdose mortality began in 2019 and continues into 2020, prior to the declaration of the COVID-19 National Emergency in the United States in March. The increases in drug overdose deaths appear to have accelerated during the COVID-19 pandemic. Provisional overdose death estimates indicate that the largest monthly increases in drug overdose deaths occurred in the 12-months ending in February 2020 (74,185 deaths) and the 12-months ending in March 2020 (75,696 deaths), the 12-months ending in March 2020 (75,696 deaths) to the 12-months ending in April 2020 (77,842 deaths), and from the 12-months ending in April 2020 (77,842 deaths) to the 12-months ending in May 2020 (81,230 deaths). These one-month increases of 2,146 deaths and 3,388 deaths, respectively for the 12-month periods are the largest monthly increases documented since provisional 12-month estimates began to be calculated in January 2015.3 

Synthetic opioids are the primary driver of the increases in overdose deaths. The 12-month count of synthetic opioid deaths increased 38.4% from the 12-months ending in June 2019 compared with the 12-months ending in May 2020  of the 38 jurisdictions with available synthetic opioid data, 37 jurisdictions reported increases in synthetic opioid overdose deaths for this time period. Eighteen of these jurisdictions reported increases greater than 50%, 11 reported increases of 25% to 49%, 7 reported increases of 10% to 24%, 1 reported an increase <10% (See Figure 3). State and local health department reports indicate that the increase in synthetic opioid-involved overdoses is primarily linked to illicitly manufactured fentanyl.4-6 Historically, deaths involving illicitly manufactured fentanyl have been concentrated in the 28 states east of the Mississippi River, where the heroin market has primarily been dominated by white powder heroin.5,7 In contrast, the largest increases in synthetic opioid deaths from the 12-months ending in June 2019 to the 12-months ending in May 2020 occurred in 10 western states (98.0% increase).iii This is consistent with large increases in illicitly manufactured fentanyl availability in western states8 and increases in fentanyl positivity in clinical toxicology drugs tests in the West after the COVID-19 pandemic.9 Increases in synthetic opioid overdose deaths were also substantial in other regions: 12 southern states and the District of Columbia (35.4%), 6 midwestern states (32.1%), and 8 northeastern states and New York City (21.1%) 

Overdose deaths involving cocaine also increased by 26.5% from the 12-months ending in June 2019 to the 12-months ending in May 2020 (Figure 1). Other data have shown that recent increases in overdose deaths involving cocaine are primarily related to overdose deaths that involved both cocaine and synthetic opioids (primarily illicitly manufactured fentanyl).10 These deaths are likely linked to co-use of cocaine among people injecting opioids such as illicitly manufactured fentanyl or heroin.11 In contrast, overdose deaths involving psychostimulants, such as methamphetamine, have been increasing with and without synthetic opioid co-use and at a rate faster than overdose deaths involving cocaine.10 Provisional 12-month counts of overdose deaths involving psychostimulants in the United States increased by 34.8% from the 12-months ending in June 2019 compared to the 12-months ending in May 2020. The number of deaths involving psychostimulants now exceeds the number of cocaine-involved deaths. These increases are consistent with the increased availability of methamphetamine in the illicit drug supply and increases in methamphetamine-related treatment admissions.