Medical Director Kent County Health Department December 2 2016 Goals Review terminology Discuss Kent County fatal overdose data Review benefits and precautions with naloxone Identify unique and dangerous characteristics of carfentanil ID: 671090
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Slide1
Opioid Overdose
Mark R. Hall, MD, MPH
Medical Director
Kent County Health
Department
December 2, 2016Slide2
Goals
Review terminology
Discuss Kent County fatal overdose data
Review benefits and precautions with naloxone
Identify unique and dangerous characteristics of carfentanil
Discuss the Michigan Automated Prescription Service (MAPS)Slide3
Terms
Narcotics, Opiates or Opioids?
Opiates: derived directly from opium
Heroin, morphine, codeine, opiumSlide4
Opioids
Opioids: synthetically derived to act as an opiate
Oxycodone (Percocet®)
Hydrocodone (Vicodin®)
Hydromorphone
(
Dilaudid®)FentanylMethadone
Practical standpoint: has evolved to include opiates and opioidsSlide5
Terms
What’s a narcotic?
Depends on whose talking
Legal: a drug that is wholly prohibited or used in violation of government regulations
Public at large: pretty much the same
Medical community
A very specific group of drugsSimilar molecular structure and pharmacologyOnly a part of narcotics as legally definedVery strongly ingrainedSlide6Slide7Slide8
Fatal opioid overdose by race, 2011-15White 85.2% (264)
Black 11.0% (34)
American Indian 2.6% (8)
Asia/Pac. Island 1.0% (3)
Mixed race 0.3% (1)
Slide9Slide10
Kent County non-opioid fatal overdoses (2011-15)
Drug
Examples
Number of deaths
Cocaine
29
Ethanol
15Serotonin Re-uptake inhibitorsEffexor®, Paxil®10
Acetaminophen
Tylenol®
9
Cyclic
antidepressants
Elavil®
8
Hydrocarbon inhalants
difluorethane
(aerosols), toluene
8
Benzodiazepines
Xanax®,
Ativan®
7
Bupropion
Wellbutrin
®
6Slide11
Non-opioid fatal overdoses – the rest
Cyclobenzaprine (
Flexeril
®)
Anti-
hypertensivesQuetiapine (Seroquel®)AspirinInsulinDiphenhydramine (Benadryl®)Olanzapine (Zyprexa
®)Slide12Slide13Slide14Slide15Slide16
Effects of Opioids
Euphoria
Sedation
Analgesia
Widely prescribed and effective
Circulatory compromise
Direct respiratory suppressionThe usual cause of death in overdoseSlide17Slide18Slide19
Opioid duration of activity
Short duration, < 1hour
Fentanyl (not patch)
Medium duration, 2-4 hours
Heroin, morphine, oxycodone (Percocet®), hydrocodone (Vicodin®), hydromorphone (
Dilaudid
®)Intermediate, 4-6 hoursSustained release products: MS Contin®, OxyContin®Fentanyl patch, even after removalLong, 8-12 hours or more:
MethodoneNaloxone: 45 minutesSlide20
Naloxone (Narcan®)
Competitively inhibits opiates/opioids
No effects of its own
Blocks the effects of circulating opioid
Much stronger affinity for the opiate receptor
Works within minutes, but depends on routeSlide21
Naloxone onset by route
Route
Onset
in minutes
Intravenous
2
Intramuscular6Intranasal
8Slide22
Naloxone
Safe
Effective
Relatively easy to administer
Minimal training required
Wears off quickly
Variable onset and dose requirement ExpensiveSupply and demandUser friendly kits
Nasal formulationSlide23
Naloxone
Life saving
Needs to be a key strategy
BUT…
Need for medical evaluation following naloxone needs to be stressed
Half life mismatch, onset of action
Common co-ingestions, especially acetaminophen (Tylenol®)Common mental health instability and suicidalitySlide24
Carfentanil
1 kg seized in Calgary 50 million lethal doses
10,000 x morphine potency
Affected areas
Western Pennsylvania
2o deathsMilwaukee19 deathsOhio (Cincinnati, Cleveland)8 deaths confirmed, likely more
174 “heroin” ODs in 6 daysMichigan19 deaths Wayne CountySlide25
Carfentanil – Observations from Ohio experience
“People are saying”
High naloxone requirement for reversal.
Has been cut with stimulants to counteract toxicity
Results in profound agitation with reversal
Mini-mass casualty incidentsMultiple overdose victims at on seenNo first responder effectsMay be distinguished from heroin by blue or pink tintSlide26
MAPS
Michigan Automated Prescription System
Requires provider to register
Fairly rapid reporting of controlled substances prescribed
Test on 2/19/2016, 0832: 2 minutes and 7 seconds
10-14 day lag time
Not quite real time reportStates with similar programs 10% decrease OD deathsSlide27Slide28
Provider dilemma with pain management
Recent major initiative for under treatment of pain
Joint Commission
Pain score as vital sign
Performance evaluation based on pain management
Limited options
Now under fire for over prescribing opioids