University Times

Drug overdose deaths have outnumbered vehicle fatalities in the United States since 2009. Now an Allegheny County program to train patients’ loved ones, physicians and pharmacists to use the life-saving drug naloxone, led in part by Pitt pharmacy faculty members Janice L. Pringle and Michael A. Zemaitis, may revive those overdosing from the most addictive kind of prescription drugs, opioids.

The program, Project Lifeline, was created by the Allegheny County Overdose Prevention Coalition (ACOPC), a volunteer group that aims to bring new and effective overdose prevention and treatment strategies to the region. ACOPC — comprised of 22 local health-care agencies and systems, rehabilitation centers, county offices, pharmacy chains and physicians — “is a real good old-fashioned community effort,” says Pringle, “harking back to the ’60s, where people said, ‘We want to find a solution, and we’re just going to keep trying until we do.’”

Janice Pringle

How great is the need? In 2011, the last year for which complete data are available for Allegheny County, four of the top eight drugs found in the bodies of those who died from overdoses here were opioids: heroin in 95 cases, oxycodone in 51 cases, methadone in 26 cases and morphine in 24 cases. (Opioids are a class of drugs that produce an analgesic or numbing effect and depress users’ respiration; the more commonly used term opiates indicates a particular kind of opioid.)

In a 2008 report, ACOPC noted that the number of overdose fatalities in Allegheny County increased from 104 in 1998 to 252 in 2006. In 2000, legal drugs accounted for only 20 percent of the overdose deaths, while the remaining deaths were caused almost evenly by illegal drugs or a combination of licit and illicit substances.

Michael Zemaitis

By 2006, those proportions had been reversed: Legal drugs alone accounted for 40 percent of the deaths; illegal drugs caused only 25 percent of overdose fatalities, and a combination of licit and illicit drugs took 35 percent of lives due to overdose.

While the total number of drug deaths in the latter half of the decade dropped from their mid-2000s apex (reaching only 235 in 2008, 223 in 2009 and 227 in 2010), they peaked again in 2011, at 262. Averaging 2008-2010, 52 percent of county drug deaths involved two or three drugs, and 21 percent involved four or more drugs.

“It’s a major, major epidemic,” says county medical examiner Karl Williams. “It’s an increasing national as well as local problem. Over the last 15 years, we’ve had a steady increase in mixed-drug overdoses.” According to Williams’s statistics, while 48 percent of all accidental deaths in the county were drug deaths in 2006, that had increased to 60 percent in 2011.

But prescription naloxone (tradename Narcan) could have a major impact on these numbers because when it is administered properly and in time, it can rescue overdose victims from death.

“There is a school of thought that there should be a dose of naloxone in every first-aid kit,” says Zemaitis. “It’s an area that has become a big public-health issue.”

According to the federal Centers for Disease Control and Prevention, naloxone begins to work in one to three minutes when given intravenously.

However, a nasal atomizer, or nebulizer, that delivers naloxone “has been shown to be almost as effective as an injection,” says Zemaitis. “It removes the stigma and potential danger of having to give someone an injection,” particularly for opioid users’ loved ones. Project Lifeline is encouraging physicians to prescribe intranasal kits to high-risk opioid patients and urging pharmacies to stock them.

Already, say Zemaitis and Pringle, Giant Eagle is seeking approval to have its pharmacists trained by Project Lifeline on the best ways to educate patients regarding safe opioid and naloxone use, while Walgreens has agreed to institute Project Lifeline training in several area stores. Officials from both Giant Eagle and Walgreens did not return University Times phone calls to discuss their participation in the project. Zemaitis also is working with state pharmacy agencies to get independent pharmacies and other chains to participate in Project Lifeline.

Thus far, one UPMC-affiliated physicians’ practice and another associated with West Penn Allegheny Health System have signed on for Project Lifeline training, says Pringle. “We need all physicians, regardless of where they practice, to commit to prescribing naloxone,” she says.

Pringle and other faculty have collaborated with several Duquesne University pharmacy faculty on the training program, which instructs physicians and pharmacists on the SBIRT model: screening, brief intervention and referral to treatment. The training covers an overview of addiction and its warning signs, how to talk to patients who may be abusing opioids and screen for referrals, and the legal issues involved with opioid prescriptions.

“Pharmacy has changed a lot over the past 10 to 15 years,” says Vincent Giannetti, one of the Duquesne pharmacy faculty involved in devising the training. “The pharmacist is the most accessible health-care provider. The emphasis is now on more of a clinical role for the pharmacist. We believe there is a lot of opportunity for counseling and assessing the patients at the point of sale.”

Beginning in May, Pitt’s pharmacy students will meet with working physicians and pharmacists to encourage them to prescribe naloxone or counsel patients about it. Zemaitis anticipates that Pitt likely will incorporate naloxone use training into its regular curriculum as well.

Project Lifeline will link pain clinics to specific pharmacists who have had naloxone training to make patient referrals as smooth as possible. They also will seek to train Allegheny County police departments. While Pittsburgh Police conduct their own behavioral health training, ACOPC already has received training requests from other local urban and suburban municipalities. “They very much want to get the training,” Pringle says.

ACOPC project manager Sherry Rickard-Aasen is the training coordinator for Pitt’s Program Evaluation Research Unit (PERU) in the School of Pharmacy, working under Pringle. She notes that a second, complementary ACOPC program, Safe Landing, has begun to train emergency department staff to identify patients at risk for overdose and encourage them to connect with recovery support staff at agencies offering everything from peer groups to rehabilitation, in an effort to reduce their potential for overdose.

An expert in the use of naloxone in an overdose protection program in Boston, Alex Walley of the Boston University School of Medicine, will be the keynote speaker at the ACOPC annual conference on July 24.

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Project Lifeline’s success will be monitored by the Institute for Evaluation Science in Community Health (IESCH) in Pitt’s Graduate School of Public Health’s Department of Behavioral and Community Health Sciences, under senior associate director Beth Nolan.

IESCH will assess not only how well the training works, Nolan says, and whether participants use the training, but how the naloxone has been distributed and how well it is received by patients and their caregivers. In many cases, the physicians and pharmacists will be advising patients, families and friends who have no experience with addiction or overdose.

“Opioid overdose can be accidental as well,” Nolan says. “The face of addiction is changing. Addiction is something that can happen to anyone. There but for the grace of God go I.”

But she adds: “Guess what? There is a mechanism by which we don’t have to die. So even if there isn’t an addiction issue, there is a way to keep somebody alive — if this program works.”

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To better track opioid users, and catch abusers who seek multiple prescriptions from different doctors and try to get them filled at different pharmacies, Pennsylvania is considering upgrading its statewide prescription-monitoring program. This would provide a better prescription database for use by physicians, pharmacists and other health-care practitioners, as well as law enforcement and government agencies.

Pennsylvania’s current program, in existence for decades, is very limited in the data it can collect, tracking only schedule II type drugs (considered to have the highest potential for abuse and dependence) and giving data access only to law enforcement.

House Bill 317, now in committee in Harrisburg, would create a new “Pharmaceutical Accountability Monitoring System.” According to chief sponsor Rep. Gene DiGirolamo of Bucks County, “Prescription monitoring programs … improve patient care and prescribing practices, help uncover drug diversion, identify ‘doctor shopping’ and will provide training of health-care professionals in prevention, identification of drug problems and referral when appropriate.”

—Marty Levine