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Provision of Naloxone Nasal Spray and
Harm Reduction Education to High Risk
ED Patients
Paula Kobelt, DNP, RN-BC, Outcomes Manager Pain Management
and Complementary Therapies, OhioHealth Grant Medical Center
Michelle Meyer, PharmD, BCPS, BSNSP, Clinical Pharmacist, OhioHealth Grant Medical Center, Columbus, Ohio
Objectives
• Discuss how increasing knowledge of substance use disorders as a chronic medical condition can address negative attitudes and improve care.
• Compare the pharmacokinetics of prescription and illicit opioids to reversal agents.
• Describe importance of providing naloxone for home use in preventing overdose deaths as part of the comprehensive response to the opioid overdose epidemic.
• Identify opportunities for responding to the epidemic at your care site.
Overview
*See appendix for description
Summary of Evidence: The Literature Review
• Stigma and negative attitudes towards patients with substance use disorders (SUD) exist among health care professionals Associated with suboptimal patient care
• SUD missing in curricula• Education can address knowledge gaps and
negative attitudes/stigma
• Substance Use Disorder is a medical condition
Addiction
• Naloxone Nasal Spray
Harm Reduction, prevent morbidity/mortality
Increase access to naloxone to save lives
Importance of home use, ↑ OD occur at
home/residence
• Significance to Nursing
Importance of ED setting
Project Implementation:
Intervention70 minute Education Intervention • Co-presented with the Director of Drug Abuse Outreach Initiatives and
Community Outreach Specialist from the Office of the Attorney General
Content Outline:• The scope and seriousness of the opioid overdose death epidemic • Substance use disorders as a medical condition • Pathway from prescription opioids to heroin • Treatment and recovery • Nasal naloxone product, harm reduction patient teaching, process
Discussion/Question/Answer Return Demonstration• Mannequin head- return demonstration of nasal spray• Older and newer naloxone nasal spray products• Syringes filled with water connected to atomizer
Project Implementation:
Objectives
• To address gaps in knowledge and improve attitudes
towards patients with substance use disorders.
• Measure the effects of the education intervention
Project Implementation:
Data Collection
• Quantitative data was collected via a survey prior to and
immediately following the education intervention
• Qualitative data was collected 30 days following the education
intervention, by telephone interview
National epidemic in drug
overdoses
Background of Problem
Centers for Disease Control and Prevention (2015). Leading causes of death report, national and regional, 1999-
2014, United States, Unintentional injuries, all ages, all races, both sexes total deaths,
http://webappa.cdc.gov/sasweb/ncipc/leadcaus10_us.html
“Drug overdose is leading cause of
accidental death in US, with 47,055
lethal drug overdoses in 2014” p.1
The U.S. age-adjusted drug overdose
death rate per 100,0000 persons has
more than doubled.
2000- 6.2
2014- 14.7
http://webappa.cdc.gov/sasweb/ncipc/leadcaus10_us.html
American Society of Addiction Medicine (2016). Opioid addiction 2016 facts & figures, 1-3.
Medicinehttp://www.cdc.gov/nchs/data/health_policy/AADR_drug_poisoning_involving_OA_Heroin_US
_2000-2014.pdf
Rudd, R. A., Aleshire, N., Zibbell, J. E., & Gladden, M. (2016, January 1). Increases in drug and opioid overdose
deaths - United States, 2000-2014. Centers for Disease Control and Prevention, Morbidity and Mortality Weekly
Report (MMWR), 64(50), 1-11. Retrieved from
www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm?s_cid=mm6450a3_w
Ohio has witnessed similar
trajectoriesOhio ranks 5th nationally in drug overdose deaths at 8 deaths/day, 7 from opioids
Background of problem
“Unintentional drug overdose continued to
be the leading cause of injury-related death
in Ohio in 2015, ahead of motor vehicle
traffic crashes- a trend which began in
2007.”p.1
Ohio’s escalating annual age-adjusted
death rate from unintentional drug
overdoses per 100,000 persons:
2013- 18.2
2014- 22.8
2015- 27.7
Ohio Department of Health (2016). 2015 Ohio drug overdose data general findings. http://www.healthy.ohio.gov/-/media/HealthyOhio/ASSETS/Files/injury-prevention/2015-Overdose-Data/2015-Ohio-Drug-Overdose-Data-Report-FINAL.pdf?la=en
Ohio Department of Health, Healthy Ohio (N.D.) Burden of injury in Ohio, 2000-2010,
http://www.healthy.ohio.gov/~/media/HealthyOhio/ASSETS/Files/injury%20prevention/Burdenreport/Motor%20Vehicl
e%20Crashes.pdf
Ohio Department of Health Bureau of Vital Statistics
Changing Demographics
In your neighborhood and mine
Ohio’s Opioid Epidemicwww.samquinones.com “DREAMLAND”
1998
Drug Cartels Target Ohio
Neighborhoods
Trends - Positive• Increased use of MAT/Medicaid• Increased use of Naloxone - rebate• Greater Awareness• Drug Courts• Community Engagement• Recovery Housing • Law Enforcement’s Response• Legislation
Ohio’s Opiate Epidemic
Background: Why Heroin?
• Heroin is cheaper and easier to obtain than RX
(Heroin is 10 cents/mg, RX drugs are $1.00/mg)
• Similar effects as OxyContin®, Vicodin®
• Smoke, inject, snort or sniff,
white or brown powder, sticky “black tar heroin”
• All routes deliver drug to brain quickly
National Institute on Drug Abuse: National Institutes of Health; U.S. Department of Health and Human Services. (2014). Drug facts: Heroin. Retrieved July 13, 2016, from https://www.drugabuse.gov/publications/drugfacts/heroin; Rook, E. J., Huitema, A. D., Van den Brink, W., Van Ree, J. M., & Beijnen, J. H. (2006). Population pharmacokinetics of heroin an its major metabolites. Clinical Pharmacokinetics, 45, 401-417. http://dx.doi.org/10.2165/00003088-200645040-00005https://www.dea.gov/pr/multimedia-library/image-gallery/images_heroin.shtml
https://www.dea.gov/pr/multimedia-library/image-gallery/images_heroin.shtml
https://www.dea.gov/pr/multimedia-library/image-gallery/images_heroin.shtml
Heroin Pharmacokinetics
• Heroin is rapidly absorbed and crosses the blood brain barrier, lacks affinity for mu receptors.
• 5% of IV morphine will cross the blood brain barrier compared to 68% of heroin.
• Heroin is hydrolyzed to 6-monoacetylmorphine (6MAM) associated with rapid euphoria.
• Morphine and morphine-6-glucuronide(m-6-g) are both active long circulating metabolites.
Heroin 6-monoacetylmorphine Morphine morphine-6-glucuronide
Sporer, K. A. (1999). Acute heroin overdose. Annals of Internal Medicine, 130, 584-590
Rook, E. J., Huitema, A. D., Van den Brink, W., Van Ree, J. M., & Beijnen, J. H. (2006). Population pharmacokinetics of heroin an its major metabolites.
Clinical Pharmacokinetics, 45, 401-417. http://dx.doi.org/10.2165/00003088-200645040-00005
www.dea.gov
Heroin Pharmacokinetics
Duration of heroin and metabolites
Heroin = 2-5 min (onset)
6MAM = 10-30 min (peak euphoria)
Morphine/m-6-g = 30-120min (start trending down)
Co-administration
Benzodiazepines competitively inhibit glucuronidation of morphine (extends lingering high)
Alcohol delay the metabolism of heroin to 6MAM (in vitro studies) (delays onset of euphoria)
Cocaine inhibits the transition of 6MAM to morphine, prolonging the half-life of 6MAM (most dangerous as extends peak euphoria)
Overall onset and duration with injection
Onset 2-4 minutes
Peak at 10-30 minutes
Duration of 120-180 min
Sporer, K. A. (1999). Acute heroin overdose. Annals of Internal Medicine, 130, 584-590
Rook, E. J., Huitema, A. D., Van den Brink, W., Van Ree, J. M., & Beijnen, J. H. (2006). Population pharmacokinetics of heroin an its major metabolites.
Clinical Pharmacokinetics, 45, 401-417. http://dx.doi.org/10.2165/00003088-200645040-00005
www.DEA.gov
Centers for Disease Control and Prevention. (2015). CDC vital signs: Today’s heroin epidemic: More people at risk, multiple drugs
abused. Retrieved from www.cdc.gov/vitalsigns/heroin
Why Fentanyl?
Non-pharmaceutical Opioid Overdose Non-pharmaceutical fentanyl has been implicated in overdoses since
2006.
Carfentanil first implicated in presumed heroin overdoses in August
2016.
New synthetic fentanyls (acrylfentanyl, tetrahydrofuran fentanyl) are
continuing to be found mixed with heroin, cocaine, and counterfeit
sedatives.
Nonpharmaceutical Fentanyl-Related Deaths—Multiple States, April 2005-March 2007. MMWR. CDC. www.cdc.gov/mmwr/preview/mmwrhtml/mm5729a1.htmEmerging Trends and Alerts. National Institute on Drug Abuse. www.drugabuse.gov/drugs-abuse/emerging-trends-alerts. Accessed July 3, 2017https://www.dea.gov/druginfo/Fentanyl_BriefingGuideforFirstResponders_June2017.pdfDEA Issues Carfentanil Warning to Police and Public. www.dea.gov/divisions/hq/2016/hq092216 Issued 9/22/16. Accessed July 3, 2017.Ohio Mental Health & Addiction Services (2017) Fentanyl, and the deadlier carfentanil, now outpacing heroin sales in many areas. March 2017. Fenantyl-Carfentanil-OSAM-O-Gram_March 2017.pdf
https://www.dea.gov/pr/multimedia-library/image-gallery/images_fentanyl.shtml
Fentanyl – Related Cases
Fentanyl Precautions
• www.dea.gov• Emerging Trends and Alerts. National Institute on Drug Abuse. www.drugabuse.gov/drugs-abuse/emerging-trends-alerts. Accessed July 3, 2017• DEA Issues Carfentanil Warning to Police and Public. www.dea.gov/divisions/hq/2016/hq092216 Issued 9/22/16. Accessed July 3, 2017• Mike Dewine Criminal Intelligence Unit Public Bulletin (2017). Cleaning fentanyl spills with OxiClean. August 17, 2017, http://www.ohioattorneygeneral.gov/Files/Law-
Enforcement/BCI/BCI-CIU-Public-Bulletin_Cleaning-Fentanyl-Spills-w.aspx Accessed September 3, 2017
OxiCleanTM Versatile Stain Remover
• Clean spills
https://www.dea.gov/druginfo/Fentanyl_BriefingGuideforFirstResponders_June2017.pdf
First Responders PPE Kit• Nitrile gloves• N-95 dust masks• Sturdy eye protection• Paper coveralls- shoe
covers• Naloxone
Rook, E. J., Huitema, A. D., Van den Brink, W., Van Ree, J. M., & Beijnen, J. H. (2006). Population pharmacokinetics of heroin an its major metabolites. Clinical Pharmacokinetics, 45, 401-417.
http://dx.doi.org/10.2165/00003088-200645040-00005
Emerging Trends and Alerts. National Institute on Drug Abuse. www.drugabuse.gov/drugs-abuse/emerging-trends-alerts. Accessed July 3, 2017https://www.dea.gov/druginfo/Fentanyl_BriefingGuideforFirstResponders_June2017.pdf
Fowler, Murray. Restraint and Handling of Wild and Domestic Animals, Third Edition. 2008. Chapter 20
DEA Issues Carfentanil Warning to Police and Public. www.dea.gov/divisions/hq/2016/hq092216 Issued 9/22/16. Accessed July 3, 2017
Pharmacokinetics Comparison Chart
DRUG Heroin Fentanyl Carfentanil NaloxoneNasal Spray
Relative
Potency
to morphine
2 100 Up to 10,0000
Onset/
Duration
2-4 min/
120-180minutes
< 1 min/
30-60 minutes
1-2 min/
hours?
Within 2 min/30-60 minutes
23
www.drugabuse.gov
Long-Term Damage/EffectsAddiction
Infection/Infection disease: Hepatitis B, Hepatitis C, HIV, Endocarditis, Abscesses, Bacterial infection
Arthritis/rheumatologic
Liver disease
Kidney disease
Pneumonia, Tuberculosis
Insomnia
Constipation
Depression, antisocial personality disorder
Sexual dysfunction- Men
Menstrual cycle irregularities- Women
Nasal tissue damage (mucosal, septum)
NIH: National Institute on Drug Abuse, Heroin, What are the medical complications of chronic heroin use? https://www.drugabuse.gov/publications/research-reports/heroin/what-are-
medical-complications-chronic-heroin-use, September, 7, 2017.
Facing Addiction in AmericaThe Surgeon General’s Report on Alcohol, Drugs, and Health
U.S. Department of Health & Human Services
Surgeon General.gov
2016
Treat SUD with sensitivity and compassion
Provide evidence based care (↑access to
naloxone)
25
Vivek H. Murthy, M.D., M.B.A.
Former U.S. Public Health Service
Surgeon General
Facing Addiction in AmericaThe Surgeon General’s Report on Alcohol, Drugs, and Health
U.S. Department of Health & Human Services
Surgeon General.gov
2016, p.5-6
“Prolonged, repeated misuse of drugs/alcohol can produce changes to the brain that can lead to a substance use disorder, an independent illness that significantly impairs health and function and may require specialty treatment. Disorders can range from mild to severe.”
“Addiction: The most severe form of substance use disorder, associated with compulsive or uncontrolled use of one or more substances.”
“Addiction is a chronic brain disease that has the potential for both recurrence (relapse) and recovery”
26
Vivek H. Murthy, M.D., M.B.A.
Former U.S. Public Health Service Surgeon
General
Substance Use Disorder
Harm Reduction
Substance Use Disorder- “Substance use disorders occur when the recurrent
use of alcohol and/or drugs causes clinically and functionally significant
impairment, such as health problems, disability, and failure to meet major
responsibilities at work, school, or home.” p.1 Substance Abuse and Mental Health Services Administration.
(2016). Mental and Substance Abuse Disorders. Retrieved July, 24 2016, from http://www.samhsa.gov/disorders/substance-use
Harm Reduction- “A set of practical strategies and ideas aimed at reducing
negative consequences associated with drug use. Harm Reduction is also a
movement for social justice built on a belief in, and respect for, the rights of
people who use drugs.” p.1 Principles of Harm Reduction. (n.d.). Retrieved July 24, 2016, from
http://harmreduction.org/about-us/principles-of-harm-reduction/
27
Stigma and Negative Attitudes
Stigmatizing and/or negative attitudes towards patients with
substance use disorders by health care professionals exist and can
perpetuate suboptimal care:
Substance Use Disorder is missing
from nursing and medical
school curricula
Education can improve the negative attitudes/stigma
and knowledge gaps in health care professionals 28
Lack of Trust
Not wiling to share
info
Feeling disrespected,
ignored
Misdiagnoses
Under-treatment
Avoid Seeking
Care
Situation
• Deaths due to opioid overdose is a national health care epidemic
is US
• Ohio leads US in # of fentanyl overdose deaths; Top 5 states in
overall deaths
• Leading cause of injury-related fatality in Ohio
• Patients identified as “high risk” are not provided with opioid
antidote, naloxone; harm reduction education and resources
at discharge, despite recommendations to improve access to
naloxone
Overdose Reversal- Harm Reduction- Increase Access to Naloxone:
Federal, state and local endorsement of this evidence based approach
to prevent morbidity and mortality from opioid overdose
• Federal– CDC
– Michael Botticelli, Director of the White House Office of National Drug Control Policy “drug czar”
– FDA
• State– Ohio Attorney General
– Department of Health
– Board of Pharmacy
– Ohio Hospital Association (OHA)
• County– Community Action Plan
• City– Central Ohio Hospital Council
• High level standard of care “Opiate protocols in the ED”
Research has shown 1 death prevented for every 227 naloxone kits dispensed*
*Coffin PO, Sullivan SD. (2013) Cost-effectiveness of distributing naloxone to
heroin users for lay overdose reversal. Ann Intern Med; 158:1–9.
Harm Reduction:
Saves Lives
Coffin PO, Sullivan SD. (2013) Cost-effectiveness of distributing naloxone to heroin users for lay
overdose reversal. Ann Intern Med; 158:1–9.
Prevention/Treatment/Overdose Reversal
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Unintentional Injury Prevention, March 23, 2016
https://www.deadiversion.usdoj.gov/drug_disposal/takeback
Centers for Disease Control (CDC) (2015) Vital signs, Today’s heroin epidemic more people at risk, multiple drugs abused, July, https://www.cdc.gov/vitalsigns/pdf/2015-07-
vitalsigns.pdf, Retrieved September, 8, 2017.
Average EMS response time in Ohio
is 34.8 minutes
4.6 minutes to arrive at scene18 minutes spent at scene
12.2 minutes for transport to hospital
Most overdoses occur at homeNasal Naloxone Spray for Home Use →Harm Reduction → Saves Lives
Ohio Emergency Medical Services. (2016). Administration of naloxone by emergency medical services in Ohio- 2014. Retrieved from ems.ohio.gov
Protocol for Provision of Naloxone Nasal Spray
and Education to High Risk ED Patients
1. Collaboration with nursing, medical staff, pharmacy, social services,
information services, patient education, finance, administration
2. Screen High Risk Pts:
• Discharged from ED following OD
• Per prescriber discretion
3. Use Smart Order Set
4. Provide naloxone nasal spray to patient (may be alone) and instruction
5. Provide Patient Teaching: Use instructions on the product box, Project DAWN brochure and Crisis Text Line in Ohio
6. Workflow chart created
Patient Teaching folder
ED Protocol
Identify High Risk Individuals
SAMHSA High Risk Individuals:
• Discharged from ED following overdose
• Using illicit drugs such as heroin and/or misusing prescription
opioids, or using someone else’s opioids
• Taking high opioid doses for treatment of chronic pain;
extended-release or long acting opioids
• Lower opioid tolerance following some type of abstinence
or opioid detoxification including recently being released from prison, treatment, hospitalization or rehabilitation
Substance Abuse and Mental Health Services Administration. (2016). SAMHSA opioid overdose prevention toolkit HHS Publication No. (SMA) 16-4742. Retrieved April 3, 2016, from store.samhsa.gov/shin/content//SMA16-4742/SMA16-4742.pdf
Call 911Recovery PositionMonitor breathing
Repeat dose if needed
35
Product Instructions
Call 911
36
38"Crisis Trends." www.crisistrends.org. Crisis Text Line, December 2016. Web. Sept 6, 2017.
https://crisistrends.org/#faq
National Crisis Text Line Informationhttps://www.crisistextline.org/
Project Findings:
Knowledge/Attitude outcomes from pre-post survey
Improvement:
• EDRNs had overall good knowledge of naloxone and improved knowledge of
pharmacokinetics of naloxone
• Attitudes of EDRNs positive
Verbal and Written Feedback not captured in survey
Frequently asked questions included:
Would providing naloxone for home use encourage drug use or give false
reassurance,
and what other aspects of the opioid epidemic are being addressed
(Chappel et al.,1985; Williams et al., 2013a; Williams et al., 2013b)
The Comprehensive Addiction and Recovery Act
(CARA) Public Law 114-198
Comprehensive Approach
Prevention Treatment Recovery Law
Enforcement
Criminal
Justice
Reform
Overdose
Reversal
Opioid Prescribing
Guidelines
Strengthen PMP
(Prescription
monitoring programs)
Expand education to
prevent abuse of
drugs and promote
treatment and
recovery
Expand disposal sites
and take back
programs
Pain Management
Task Force-
chronic/acute
Medicated
Assisted
Treatment
Evidence
based
treatment
programs
throughout
USA
Communities
Monitor
collateral
consequences
of drug
convictions
(state and
federal)
Alternatives e.g.
treatment to
incarceration
Combat distribution
of illicit drugs
Drug Courts
Evidence
based
treatment for
those
incarcerated
Enhance
work
between
state and
criminal
justice
agencies
Harm Reduction
Increase Access to
naloxone to first
responder/law
enforcement
Standing order for
opioid reversal
agent
CADCA Community Anti-Drug Coalitions of America, The Comprehensive Addiction and Recovery Act (CARA).
http://www.cadca.org/comprehensive-addiction-and-recovery-act-cara. Retrieved September 8, 2017
Pillar: Treatment
Opioid Withdrawal
72 hours-peak of acute
symptoms
30 hours-withdrawal from long-
acting agents
6-12 hours-withdrawalfrom short-
acting agents
Acute phase
withdrawal
symptoms:
• Nausea
• Vomiting
• Diarrhea
• Watery eyes
• Myalgias
• Agitation
• Anxiety
• Insomnia
• Fever/chills
• Yawning
• Hypertension
• Drug cravings
He
roin
Me
tha
do
ne
American Addition Centers(AAC) Opiate withdrawal timeline and treatment. Retrieved
July, 7, 2017. http://americanaddictioncenters.org/withdrawal-timelines-
treatments/opiate/
Pillar: Treatment
Opioid Replacement Therapy
Medication Assisted Treatment (MAT)
Methadone long-acting opioid agonist
onset of action is approximately 1 hour
half-life is 8-59 hours
Maximum starting dose of 30 mg a day
Buprenorphine (with and without naloxone) Partial opioid agonist
naloxone is an opioid antagonist, but is inactive if taken as prescribed
onset of action is 30-60 minutes
half-life is 27-36 hours
http://www.naabt.org/education/literature.cfm
LexiComp, Inc. (Lexi-drugs) LexiComp, Inc. Version 4.0.1 2017
Non-Opioid Treatment
LexiComp, Inc. (Lexi-drugs) LexiComp, Inc. Version 4.0.1 2017
Medication Class
Alpha 2 agonist
Antihistamine Anti-psychotic
Anti-emetic Anti-diarrheal
Anti-cholinergic
Anti-depressant
Analgesic
Commonly
prescribed
clonidine hydroxyzine quetiapine Ondansetron
or
prochlorper-
azine
loperamide dicyclomine trazodone APAP or
ibuprofen
Usual
dosing
0.1-0.2mg Q6-8 hours
25mg Q4-6 hours
25mg QHS or TID
Ondan: 4mgQ6 hoursProchl: 5-
10mg Q6 hours
2-4mg after each loose stool (max
16mg/day)
10-20mg Q6hours
50-100mg QHS
650mg Q4 hours
600-800mg Q6hours
Symptom
(s) treated
All
autonomic
symptoms
(sweating,
diarrhea,
abdominal
cramps,
nausea,
anxiety,
and
agitation)
Helps with
anxiety and
agitation
through
generalized
sedation
Antagonist of
multiple
neuro-
transmitters,
skin crawling,
sedation
helps with
agitation and
insomnia
Nausea, if
using a 1st
generation
anti-psychotic
will also have
some sedation
which would
treat anxiety
and agitation
Diarrhea Abdominal
cramping,
watery eyes,
diarrhea
Anti-SLUDGE
Salivation
Lacrimation
Urination
Defecation
Gastric
empting
Insomnia,
agitation
myalgias
Overarching Goals: Patients with
Substance Use Disorders
• Manage addiction so patient will complete
medical care
• Use opportunity to educate, prevent further
harm and successfully link to treatment and
recovery resources
• Access naloxone to prevent death (Harm
Reduction)
Opportunities for responding to the
epidemic
• Engage with community, local, state, and national resources
• Continue to educate and inform
• Increase access to nasal naloxone spray
• Approach SUD as a medical condition
• SBIRT- MI, Non-judgmental language
• Medication Reconciliation, PMP, Handoff communication
Words to Avoid Words that Work
AddictAbuserJunkieUserAbuseClean/DirtyHabit/Drug HabitReplacement Therapy
AddictionAddiction Free, Addiction SurvivorAlcohol and drug disorderAddictive Disorder/Addictive DiseaseMedication-Assisted TreatmentMisuse, harmful use, inappropriate usePatientPeople with….RemissionSubstance misuse disorder
naabt.orgThe National Alliance of Advocates for Buprenorphine Treatment (NAABT) (2008). The words we use matter. Reducing stigma through language. Accessed September 6, 2017, http://www.naabt.org/documents/NAABT_Language.pdf
Recovery Resources
• List of local resources for referral
• September is National Recovery Month
• Recovery resources vary
• Growing Awareness
• Recovery communities
• APPs that help you find meetings
Law Enforcement – extended role
HOPE TASK Force
•
Increase awareness: Understand the signs
50
Conflict of Interest Disclosure
Authors Conflicts of Interest:
Paula Kobelt, DNP, RN-BC, No Conflict of Interest
Michelle Meyer, PharmD. BCPS, BSNSP, No Conflict of Interest
References