chin hwa (gina) dahlem phd, fnp-c, faanp [email protected]
TRANSCRIPT
Chin Hwa (Gina) Dahlem PhD, FNP-C, [email protected]
Objectives
qDescribe the current opioid epidemiology, legislation, and community naloxone programs
qIdentify the core components of opioid overdose prevention education
qDescribe the different formulations and pharmacokinetics of naloxone
qDiscuss how to incorporate co-prescribing naloxone into routine clinical practice
Acknowledgement• Materials adapted from SAMHSA Opioid
Overdose Toolkit, Harm Reduction Coalition, and University of Michigan School of Nursing in partnership with Washtenaw County Sheriff’s Office Home of New Vision, and Community Mental Health Partnership of Southeast Michigan.
Alarming Statistics
• Provisional opioid-related DEATHS in 2018: • 47, 092
CDC. National Center for Health Statistics. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htmAccessed on September 27th, 2019
https://mi-suddr.com/opioids/ accessed on Sept 27th, 2019
Death Rate = 27.8/100K
14
11 Million2016
CDC Evidence-Based Strategies for Opioid Overdose Prevention
Naloxone Medication-Assisted Treatment (MAT)
Other
Targeted distribution Eliminate PA requirements
Syringe services programs
Distribution in treatment centers
Initiate MAT in criminal justice settings and upon release
911 Good Samaritan Laws
Distribution in criminal justice settings
Initiate MAT in EDs Screening for fentanyl in routine clinical toxicology testing
Academic detailing (CDC, 2018)
Slide adapted & used with permission: Walley, A.
Naloxone Prescriptions
Coffin PO, Sullivan SD. Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal. Annals Internal Medicine. 2013;158(1):1-9.Coffin PO et al. Nonrandomized intervention study of naloxone coprescription for primary care patients receiving long-term opioid therapy for pain. Annals Internal Medicine. 2016; 165(4): 245-52.Behar, E. et al. Acceptability and feasibility of naloxone prescribing in primary care settings: a systematic review. PreventiveMedicine. 2018; 114: 79-87.
• Cost Effective:• 1 death prevented for every 227 naloxone kits
distributed• $438/per quality-adjusted life-year gained
• 47% fewer opioid-related ED visits compared to those who did not receive naloxone prescription for patients on long-term opioid pain therapy
• Patients and PCPs find offer of naloxone prescription acceptable and feasible
The person who receives naloxone will react violently when the medication is administered and his/her overdose is reversed.
People experience withdrawal symptoms which makes them feel lousy. In majority of overdoses, people are often disoriented and shocked when waking up to people they don’t know.
Myth Fact
Myths and Facts
Using naloxone will delay entry into drug treatment and encourage riskier drug use.
• Studies show reduction or no change in drug use (Seal et al, 2005; Doe-Simkins et al, 2014; Wagner et al., 2010)
• Naloxone does not enable – it only enables OD victim to breathe.
• Dead people don’t recover.
Myth Fact
Myths and Facts
It is really hard to prevent a person from dying of an opioid overdose since people usually use drugs in private.
The majority of overdoses occur in the presence of others (Strang et al., 2000)
Myth Fact
Myths and Facts
Michigan LegislationHouse Bill 5406; Public Act 313 of 2014
A person that administers an opioid antagonist to an individual who he or she believes is suffering an opioid-related overdose and that acts in good faith and with reasonable care isimmune from criminal prosecution or sanction under any professional licensing act for that act.
Good Samaritan Law
• House Bill 5649, 5650; Public Act 307 of 2016• Gives overdosing drug user limited criminal
immunity (from possession charges and illicit use of controlled substances) when seeking treatment for him / herself or summoning medical assistance for someone else
• Does not apply if you have a warrant for your arrest, possesses more drug than personal use.
Michigan Legislation
• Allows naloxone to be prescribed to friends and families • Requires emergency medical personnel to carry
naloxone and be trained to administer• Allows pharmacists to dispense naloxone with standing
order • Gives school boards the option to obtain a prescription
for naloxone to be administered by a school nurse or other trained employee in case of a student overdose.
Onset, Potency, Duration of OpioidsOral (potency compared to Morphine)
Onset Duration
Morphine 15-60min 4-6 hrs
Hydrocodone 10-30min 4-6 hrs
Heroin (2x) Intense euphoria 45sec-several mins; peak effect 1-2hrs
3-5 hrs
Methadone 30-60mins 22-48 hrs
Fentanyl (100x) 5-15mins 1-2 hrs
Carfentanil (10,000x) In moose, elk: 2-20mins
But what is DEADLY?
Fentanyl Forms
Fentanyl in PowderFentanyl Crystals and Pills
• Can be found in powder, pill, patch, solutions, and rocks
• Mostly found mixed with or sold as heroin•
Fentanyl Precautions
• Cases of fentanyl overdoses among first responders and community laypersons are RARE
• This should NOT delay our responsibility to respond to overdoses or cause fear
• 1000s of lives have been saved without increasing reports of fentanyl overdoses among first responders
American College Medical Toxicology and American Academy of Clinical Toxicology Position Statement• 2017 Position Statement: Prevention Occupational
Fentanyl and Fentanyl Analog Exposure to Emergency Responders
• “We have not seen reports of emergency responders developing signs or symptoms consistent with opioid toxicity from incidental contact with opioids. Incidental dermal absorption is unlikely to cause opioid toxicity”
• “At the highest airborne concentration encountered by workers, an unprotected individual would require nearly 200 minutes of exposure to reach a dose of 100mcg of fentanyl.”
Fentanyl Exposure• For POSSIBLE EXPOSURES:
• Prevent further contamination and notify other first responders and dispatch
• Do NOT touch your eyes, mouth, nose, or any skin after touching any potentially contaminated surface.
• Wash skin thoroughly with cool water, and soap if available
• Do NOT use hand sanitizers as they may enhance absorption
Who is at risk?
USER
Risk Factors to Overdose• Prior history of overdose (Darke et al., 2007; Kinner et al, 2012)
• Tolerance changes• 1-4weeks post-discharge from jail, prison, and/or
detox (Ranapurwala et al., 2018; Maughan & Becker, 2019)
• Potency of opioid• Daily opioid dosages higher than 50 MME (Dunn et al, 2010;
Bohnert et al, 2011)
• Using extended-release and long-acting opioids (Miller et al., 2015)
• Street drugs are unpredictable. Higher purity, greater risk.
Identifying At-Risk PatientsChronic Pain Patient Survey:• nearly 1 in 5 had experienced an
overdose • >half engaged in high-risk
behaviors• only 3% reported having a
naloxone prescription or being trained to deliver naloxone
• nearly 40% had witnessed an overdose.
Dunn KE , et al. Opioid Overdose History, Risk Behaviors, and Knowledge in Patients Taking Prescribed Opioids for Chronic Pain. Pain Medicine. 2017; 18 (8): 1505–1515.
Risk Factors to Overdose• Mixing opioids with other drugs (Park et al., 2016; Gladden et al.
2019)
• Alcohol• Benzodiazepines, anti-anxiety• Stimulants: cocaine, methamphetamine
• History of medical conditions (Brady et al., 2017; Zedler et al., 2014; Nadpara et al., 2018)
• Mental health illness: bipolar, schizophrenia, depression
• Respiratory (COPD/asthma, sleep apnea)• Cardiac, renal, HIV/AIDS
How Do Opioids Affect Breathing?
Lung
muscles
relax
Breathing Slows
Lack of oxygen to brain
Unres-ponsive
Uncon-scious
Breath-ing
Stops
Heart Stops Death
Breathing slows down until it stops. Occur seconds to minutes to hours after drug use.
• Opioids bind to opioid receptors (mu) in the brain and in the spinal cord• When too many opioids are bound to the receptors in the brain, your:
Really High vs Overdose SignsREALLY HIGH OVERDOSE
Nodding off but responsive to stimulation
Unresponsive to pain
Breathing 8 or more times/minute Blue to purple or grayish lips and fingertips
Sleepy looking Very infrequent or no breathing (<8breaths/min)
Speech is slowed/slurred Deep snoring or gurgling (death rattle)
Very small (pinpoint) pupils
Overdose and Naloxone• Used by medical professionals since 1971• Opioid antagonist: Blocks the receptor and
prevents the body from experiencing the effects of opioid
Naloxone Formulations
IN:Prefilled requires atomizer
IM: requires needle syringe
IM: Auto-Injector
IN:Nasal Spray
What is Naloxone?
• Only reverses opioid overdoses• No effect if you do NOT have opioids in
your body• No abuse potential
• Can’t get high, or modified for recreational use• Not a scheduled drug• Pregnancy Category C
• Recommended for suspected OD emergencies• Shelf life = 18-24 months
What is Naloxone?• Acts quickly, 2-5 mins, often in <3mins
• Works for only 30-120 minutes• Depending on amount, type of drug used, and type of
naloxone formulation
• Overdose symptoms may RETURN
• May be repeated every 2-3 minutes
Naloxone nasal spray (Narcan®)4mg/0.1mL
Injectable (IM)naloxone
Autoinjector naloxone (Evzio®)0.4mg/0.4mL or 2mg/0.4 mL
Injectable (IN) Pre-filled syringe
Rx and Quantity
#1 two-pack of two 4mg/0.1mL intranasal device
#2 single-use 1 mL vials PLUS #2 3 mL syringe w/23-25 gauge 1-1.5 inch IM needles
#1 two-pack of two 0.4mg/0.4 mL prefilled auto-injector devices
#2 2 mL luer-Jet Luer-Lock needleless syringe plus #2 mucosal atomizer devices (MAD-300)
Sig. for suspected overdose
Spray into onenostril. Repeat with second device into other nostril after 2-3 minutes if no or minimal response
Inject 1 mL in shoulder or thigh. Repeat in 2-3 minutes if no or minimal response
Inject into outer thigh as directed by voice-prompt. Hold for 5 seconds. Repeat with 2nd
device if no or minimal response
Spray 1 ML (1/2 of syringe) into each nostril. Repeat after 2-3 minutes if no or minimal response
Duration About 120 minutes
30-90 mins 30-90 mins 30-90 mins
StorageProtect from light
Room temp59-77F
Room temp68--77F
Room temp 59-77F
Room temp59-77F
Cost Approx
$169 1 syringe $40 1 atomizer $5
1 vial $13-$40 $4600
Naloxone: Side Effects
Withdrawal symptoms illustrations by Corneail, D. (2017).
Arouse the person-3 “S” : shout, shake, sternal rub
Check for signs of opioid overdoseTelephone 911Intranasal/Intramuscular NaloxoneO: Oxygen
-2 rescue breath, and/or CPR if you know how, or follow dispatch instructions
N: Naloxone again in 2-3 mins-Recovery position if you must leave or person vomits-Position of comfort if breathing again-Stay with the person till help arrives
Narcan Nasal Spray Instructions
Peel open Place the tip in the person’s nostril
Push on the plunger to administer.
NO TEST SPRAYIS NEEDED
Narcan nasal spray illustrations by Song, W. 2017.
What NOT to do during an Overdose
• Do not put the victim in a bath of cold/ice water• Wastes time, slows the heart down and increase risk for
arrhythmia and drowning• Do not induce vomiting. • Do not give the victim something to drink.
• Could choke, aspirate – more difficult to breathe• Do not put ice down the victim’s pants• Do not slap too hard, kick them in the testicles, burn the
bottom of their feet• Can cause long term damage
• Do not inject (saltwater, cocaine, milk) the victim with anything
Talking Tips
Strategies to Incorporate Co-Prescribing
Into Your Clinical Practice
CDC RecommendationsConsider co-prescribing naloxone to:
• History of overdose• History of SUD• Concurrently using benzos• Opioid dosages higher
than 50 MME/dayAnyone otherwise at risk of experiencing or witnessing an opioid overdose* (expert opinion)
Karnath, L. (2018). MOON Study and Prevent-Protecthttp://prevent-protect.org/community-resources-1/posters/
50 MME/day 90 MME/day
50 mg hydrocodone = 10 tabs of hydrocodone/acetaminophen 5/300)
90 mg of hydrocodone = 9tabs of hydrocodone/acetaminophen 10/325
33 mg oxycodone = ~2 tabs of oxycodone SR 15mg
60 mg of oxycodone = ~ 2 tabs of oxycodone SR 30mg
Naloxone Screening??• None exist• Screening tools for substance use disorders
• https://www.drugabuse.gov/nidamed-medical-health-professionals/screening-tools-resources/chart-screening-tools
• One item screener in primary care• “How many times in the past year have you used an
illegal drug or used a prescription medication for nonmedical reasons?” (Smith et al, 2010)
• Consider: Are you concerned about a family and friend who is using opioids?
Devries, J et al., 2016
Talking TipsThe word overdose can have negative connotations. People who use prescription opioids may not see themselves as being at risk of overdose (Coffin et al., 2016)
Instead, use:• Accidental overdose• Bad reaction• Opioid safety
Conversation Starters• I care about your
safety. • All medications have
side effects and one harmful side effect of taking too many opioids is that it will slow or even stop your breathing.
Conversation StartersJust like we prescribe an epi-pen to someone who has an allergy, we prescribe naloxone to someone who may have an accidental overdose or bad reaction to the opioid medication.Have you heard of naloxone? Naloxone is a lifesaver, like having a fire extinguisher. Hopefully, you will not need it, but it is important to have just in case you do need it.
Conversation Starters“It is also important to share with your family and friends where you keep naloxone and how to administer it.”
“You can even use naloxone to give it someone else as there are laws to protect you in Michigan to release you from any liability.“
Reducing Risks to Overdose
• Do not mix with other drugs especially alcohol, benzos, and anything that makes you sleepy
• Store medication out of reach of children and pets
• Dispose unused medications properly
Reducing Risks to Overdose
• Go slow, never use alone, and carry naloxone
• Alternate injection sites• Reduce substance
amounts• Be aware of tolerance
changes• Train friends to call for
help and give naloxone
Patient Education Content• Brief 5-10 min training sufficient• Brochures/Videos
• How to respond• How to use naloxone
• Videos/Online Training:resources OVERDOSE ACTION NALOXONE TRAINING: overdoseaction.org For opioid overdose naloxone training
TREATMENT CENTERS HOME OF NEW VISION homeofnewvision.org 734.975.1602 - Even Month Birthdays
DAWN FARMS dawnfarm.org 734.669.8265 - Odd Month Birthdays
If you live in: Livingston County, MI - 517.546.4126 Monroe County, MI - 734.243.7340 Lenawee County, MI - 517.263.8905
HARM REDUCTION AND SYRINGE ACCESS UNIFIED miunified.org 734.961.1082
Opioid Overdose Deaths are Preventable.
If you suspect someone is experiencing an opioid overdose,
have your naloxone accessible and take immediate A-C-T-I-O-NFunding was provided by Michigan Institute for Clinical & Health
Research UL1TR000433, Michigan Department of Health and Human Services and Community Mental Health Partnership of Southeast
Michigan
© 2017 The Regents of the University of Michigan
All rights reserved.
opioid safety & naloxoneTAKE A.C.T.I.O.N. AND SAVE A LIFEwww.overdoseaction.org
WHAT ARE OPIOIDS?Opioids are a class of drugs that reduce pain and promote feelings of pleasure and relaxation. Taking too many opioids slows your breathing which leads to lack of oxygen in your brain, coma, heart stopping, and death. This process can be fast, so time is critical to saving a life.
Common opioids include prescription opioids, heroin, and illicit fentanyl.
WHAT ARE THE SIGNS OF AN OVERDOSE?• Blue lips/fingernails (ashen if darker skin)• Breathing that is infrequent, uneven or
has stopped• Deep snoring or gurgling noises• Unresponsive to pain stimulus• Pinpoint pupils
WHAT IS NALOXONE?• Naloxone (Narcan,® Evzio®) is a drug that
temporarily reverses the dangerous effects of an opioid overdose
• Naloxone can be given every 2-3 minutes, but only works if opioids are in your body
• Works for reversing fentanyl overdoses• A person cannot get high on it or become
addicted to it
EFFECTIVE ONLY FOR 30 TO 120 MINUTES
www.prescribetoprevent.orgwww.overdoseaction.org
naloxoneaccess
Standing Order from State RegisteredPharmacies
michigan.gov/mdhhs and search "naloxone"
Agencies that distribute naloxone for free:hopeandrecovery.org
High Schools & Colleges/Universities:
https://www.narcan.com/partnerships
Kaleo Cares Program:evzio.com/patient/in-chronic-pain/kaleo-cares/
Evzio 2 You Program:evzio.com/patient/in-chronic-pain/evzio2you/
Prescription from a physician, physicianassistant, or nurse practitioner
Limited supply of intranasal narcan sprayavailable for community trainings & individualswho would have financial difficulties when usingthe pharmacy standing order
michigan.gov/documents/PIHPDIRECTOR_97962_7.pdf
How to Access Naloxone:
• Pharmacy Standing Order• http://www.michigan.gov/mdhhs/0,5885,7-
339-71550_2941_4871_79584_80133_80135_80309-426713--,00.html
• Harm Reduction Agencies• PIHP• Community Organizations
Inaugual naloxone training class Washtenaw County Sheriff’s Office, Personal Photo, August 7th, 2015
ReferencesBehar E, Bagnulo R, Coffin PO. Acceptability and feasibility of naloxone prescribing in primary care settings: A systematic review. Prev Med (Baltim). 2018;114:79-87. doi:10.1016/j.ypmed.2018.06.005
Bohnert ASB, Valenstein M, Bair MJ, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA. 2011;305(13):1315-1321. doi:10.1001/jama.2011.370
Brady JE, Giglio R, Keyes KM, DiMaggio C, Li G. Risk markers for fatal and non-fatal prescription drug overdose: a meta-analysis. Inj Epidemiol. 2017;4(1):24. doi:10.1186/S40621-017-0118-7
CDC. National Center for Health Statistics. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm Accessed on September 27th, 2019
Centers for Disease Control and Prevention. Evidence-Based Strategies for Preventing Opioid Overdose: What’s Working in the United States. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, U.S. Departmentof Health and Human Services, 2018. Accessed February 21st, 2019 from http://www. cdc.gov/drugoverdose/pdf/pubs/2018-evidence-based-strategies.pdf
Coffin, P. O., & Sullivan, S. D. (2013). Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal. Annals of Internal Medicine, 158(1), 1-9. 10.7326/0003-4819-158-1-201301010-00003 [doi]
Coffin, P.O., Behar, E., Rowe, C., Santos, G.M., Coffa, D., Bald, M., et al. (2016). Nonrandomized intervention study of naloxone coprescription for primary care patients receiving long-term opioid therapy for pain. Annals of Internal Medicine, 165(4), 245-52.
Doe-Simkins, M., Quinn, E., Xuan, Z., Sorensen-Alawad, A., Hackman, H., Ozonoff, A., & Walley, A. Y. (2014). Overdose rescues by trained and untrained participants and change in opioid use among substance-using participants in overdose education and naloxone distribution programs: A retrospective cohort study. BMC Public Health, 14, 297-2458-14-297. 10.1186/1471-2458-14-297 [doi]
Darke S, Duflou J, Kaye S. (2007). Comparative toxicology of fatal heroin overdose cases and morphine positive homicide victims. Addiction 102(11): 1793-7.
Devries J, Rafie S, Polston G. Implementing an overdose education and naloxone distribution program in a health system. J Am Pharm Assoc. 2017;57(2):S154-S160. doi:10.1016/j.japh.2017.01.002
ReferencesDunn KE , et al. Opioid Overdose History, Risk Behaviors, and Knowledge in Patients Taking Prescribed Opioids for Chronic Pain. Pain Medicine. 2017; 18 (8): 1505–1515.
Dunn KM, Saunders KW, Rutter CM, et al. Opioid Prescriptions for Chronic Pain and Overdose. Ann Intern Med. 2010;152(2):85. doi:10.7326/0003-4819-152-2-201001190-00006
Gladden RM, O’Donnell J, Mattson CL, Seth P. Changes in Opioid-Involved Overdose Deaths by Opioid Type and Presence of Benzodiazepines, Cocaine, and Methamphetamine - 25 States, July-December 2017 to January-June 2018. MMWR Morb Mortal Wkly Rep. 2019;68(34):737-744. doi:10.15585/mmwr.mm6834a2
Kinner SA, Milloy M-J, Wood E, Qi J, Zhang R, Kerr T. Incidence and risk factors for non-fatal overdose among a cohort of recently incarcerated illicit drug users. Addict Behav. 2012;37(6):691-696. doi:10.1016/j.addbeh.2012.01.019
Maughan BC, Becker EA. Drug-related mortality after discharge from treatment: A record-linkage study of substance abuse clients in Texas, 2006-2012. Drug Alcohol Depend. 2019;204:107473. doi:10.1016/j.drugalcdep.2019.05.011
Michigan Department of Health and Human Services. https://mi-suddr.com/opioids/ Accessed on Sept 27th, 2019
Miller M, Barber CW, Leatherman S, et al. Prescription opioid duration of action and the risk of unintentional overdose among patients receiving opioid therapy. JAMA Intern Med. 2015;175(4):608-615. doi:10.1001/jamainternmed.2014.8071
Nadpara PA, Joyce AR, Murrelle EL, et al. Risk Factors for Serious Prescription Opioid-Induced Respiratory Depression or Overdose: Comparison of Commercially Insured and Veterans Health Affairs Populations. Pain Med. 2018;19(1):79-96. doi:10.1093/pm/pnx038
Park TW, Lin LA, Hosanagar A, Kogowski A, Paige K, Bohnert ASB. Understanding Risk Factors for Opioid Overdose in Clinical Populations to Inform Treatment and Policy. J Addict Med. 2016;10(6):369-381. doi:10.1097/ADM.0000000000000245
ReferencesRanapurwala SI, Shanahan ME, Alexandridis AA, et al. Opioid Overdose Mortality Among Former North Carolina Inmates: 2000-2015. Am J Public Health. 2018;108(9):1207-1213. doi:10.2105/AJPH.2018.304514Seal, K. H., Thawley, R., Gee, L., Bamberger, J., Kral, A. H., Ciccarone, D., . . . Edlin, B. R. (2005). Naloxone distribution and cardiopulmonary resuscitation training for injection drug users to prevent heroin overdose death: A pilot intervention study. Journal of Urban Health : Bulletin of the New York Academy of Medicine, 82(2), 303-311. jti053 [pii]Strang J, McCambridge J, Best D, et al. Loss of tolerance and overdose mortality after inpatient opiate detoxification: follow up study. BMJ. 2003;326(7396):959-960. doi:10.1136/bmj.326.7396.959Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. A Single-Question Screening Test for Drug Use in Primary Care. Arch Intern Med. 2010;170(13):1155-1160. doi:10.1001/archinternmed.2010.140Wagner, K. D., Valente, T. W., Casanova, M., Partovi, S. M., Mendenhall, B. M., Hundley, J. H., . . . Unger, J. B. (2010). Evaluation of an overdose prevention and response training programme for injection drug users in the skid row area of los angeles, CA. The International Journal on Drug Policy, 21(3), 186-193. 10.1016/j.drugpo.2009.01.003 [doi]Zedler B, Xie L, Wang L, et al. Risk factors for serious prescription opioid-related toxicity or overdose among Veterans Health Administration patients. Pain Med. 2014;15(11):1911-1929. doi:10.1111/pme.12480