Travis Irvan MPH Adam R Howard MPH RS Common Terms Opiate chemical compounds from natural plant matter Eg opium morphine codeine and heroin Opioid chemical compounds typically made in a lab Eg hydrocodone hydromorphone oxycodone fentanyl carfentanil ID: 934076
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Slide1
Opioids and Public Health
Travis Irvan, MPH
Adam R. Howard, MPH, R.S.
Slide2Common Terms
Opiate
-
chemical compounds from natural plant matter. E.g. opium, morphine, codeine, and heroin
Opioid
-
chemical compounds typically made in a lab. E.g. hydrocodone, hydromorphone, oxycodone, fentanyl, carfentanil
Slide3Addiction, Use Disorder, and Substance Abuse
Addiction
-
the state of being enslaved to a habit or practice or to something that is psychologically or physically habit-forming, as narcotics, to such an extent that its cessation causes sever trauma
Opioid Use Disorder-
a problematic pattern of opioid use that causes significant impairment of distress
Substance Abuse
-
long term, pathological use of alcohol or drugs, characterized by daily intoxication, inability to reduce consumption, and impairment in social or occupational functioning: broadly, alcohol or drug addition
Slide4Addiction
Characterized by
Compulsion to seek and take
No control in limiting intake
Negative emotional state when substance is not available
Cycle
Binge/intoxication
Withdrawal
Craving
Slide5Where did they Come From?
http://oz.wikia.com/wiki/Poppies
https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=2ahUKEwiTr-rMhrvdAhXn54MKHSXeA6wQjxx6BAgBEAI&url=https%3A%2F%2Fwww.nme.com%2Fblogs%2Ftv-blogs%2Fgame-thrones-season-8-release-date-casting-trailers-theories-2129812&psig=AOvVaw2Aq_p2EyZxFAyA73hZgX8C&ust=1537033318647255
Slide6Where did they Come From?
Slide7Where did they come from?
Sumerians
2000 BC
700 AD
India and China
Europe
900-1200
1500s
Addiction & Tolerance Observed
Morphine Isolated
1806
1850s
Surgery & Chronic Pain
1898
Heroin Created
Nalorphine Created
1940s
1
st
U.S. Opioid Epidemic
1890s
1990s
Opioid
Pain Pills
Slide8Morphine
Active Ingredient in Opium
Used for Potency Comparison (MME)
Slide9Heroin
Opiate
Mode: injection and inhalation
Risk Factors
Those addicted to opioid pain relievers, cocaine, marijuana, or alcohol. Living in large metropolitan areas. 18-25 years of age. Males. Non-Hispanic whites. Those without insurance or Medicaid.
2-4 times more powerful than morphine
2010-2016 heroin related deaths are up 5 times
Slide10Fentanyl
Opioid
Approved to treat severe pain (cancer)
Mode: Oral, transdermal patch, intranasally, or mixed with heroin or cocaine
50-100 times more powerful than morphine
Slide11Carfentanil
Opioid
Approved as elephant tranquilizer
Mode: Oral or mixed with heroin or cocaine
10,000 times more powerful than morphine
Slide12Slide13Incidental Exposure
Airborne
Dermal
PPE
Gloves when presence is suspected
Respirators/Eye protection with potential for airborne distribution
https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=2ahUKEwiy26nh77rdAhWJ7IMKHciYAQ4Qjxx6BAgBEAI&url=https%3A%2F%2Fwww.webstaurantstore.com%2Fpurell-9625-04-advanced-2-liter-instant-hand-sanitizer-case%2F381P962504.html&psig=AOvVaw3X4dfCB6OxZiAfirp0561D&ust=1537027492081659
Slide14How do they Work?
http://biology4alevel.blogspot.com/2016/06/122-synapses.html
https://www.pinterest.com/plaidcows/brains/
Slide15How do they Work?
video.nationalgeographic.com/video/short-film-showcase/this-is-what-happens-to-your-brain-on-opioids
Slide16When should Opioids be Prescribed?
Cancer Treatment
Palliative Care
End-of-Life Care
Severe Chronic Pain?
Slide17Signs and Symptoms of Opioid Use
Pain sense lowered
Agitation, drowsiness or sedation
Slurred speech
Attention or memory problems
Constricted pupils
Lack of awareness or inattention to surroundings
Coordination problems
Depression
Confusion
Constipation
Nose runny/soresIndications of needle use
Slide18Signs and Symptoms of an Overdose
Pinpoint pupils
Falling asleep or loss of consciousness
Slow, shallow breathing
Choking or gurgling sounds
Limp body
Pale, blue, or cold skin
Slide19A Public Health Crisis
In 2016, 63,632 Americans died from a drug overdose
174 deaths every day
7 deaths every hour
One death every 8.5 minutes
The projections are getting worse, not better
Slide20A Public Health Crisis
In 2016, the states with the highest rates of death due to drug overdose were:
West Virginia (52.0 per 100,000)
Ohio 39.1
New Hampshire 39.0
District of Columbia 38.8
Pennsylvania 37.9
Slide21A Public Health Crisis
Slide22A Public Health Crisis
Slide23A Public Health Crisis
Slide24A Public Health Crisis
Delaware County
Ranked healthiest county in Ohio for both health outcomes and health behaviors
Wealthiest county in Ohio
Most educated county in Ohio
Surely this problem won’t affect us……right?
Slide25A Public Health Crisis
Slide26A Public Health Crisis
From January-March 2018:
In Delaware County, Ohio
Six overdose deaths
5 deaths had cocaine + fentanyl
1 death was just fentanyl
Slide27Slide28A Public Health Crisis
Hepatitis C
What is it?
Liver infection
Caused by a blood-borne virus
70-85% of people develop chronic infection
Can cause long-term health problems, even death
Slide29A Public Health Crisis
Hepatitis C
What are the symptoms?
Fever
Fatigue
Dark urine
Clay-colored stool
Abd pain
Loss of appetite
Nausea
VomitingJoint painJaundice
Slide30A Public Health Crisis
Hepatitis C
How do I get it?
IV Drug use (most common)
Receive contaminated blood or organs
Needlestick
Birth from a Hep C positive mother
Slide31A Public Health Crisis
Hepatitis C
How do I prevent from getting it?
There is no vaccine for Hep C
The best way to prevent Hepatitis C is by avoiding behaviors that can spread the disease, especially injecting drugs.
Slide32A Public Health Crisis
Hepatitis C
Can it be treated?
Yes- over 90% of HCV infected persons can be cured with 8-12 weeks of oral therapy
However…..
This 12 weeks of therapy can cost close to $100,000.
Slide33A Public Health Crisis
Hep C
For every 100 persons infected with Hep C…
75-85 will develop chronic infection
10-20 will develop cirrhosis in the next 20-30 years
Slide34Slide35A Public Health Crisis
Slide36A Public Health Crisis
Slide37A Public Health Crisis
Slide38A Public Health Crisis
Slide39A Public Health Crisis
Slide40Slide41A Public Health Crisis
HIV outbreak
Scott County, Indiana
Rural county in SE Indiana
Historically, less than 5 HIV cases reported/year
Jan. 2015- 11 cases HIV reported
By April 21, over 135 cases for a community of 4,200 persons
IV drug use
Slide42A Public Health Crisis
HIV outbreak
Coinfection with hepatitis C virus has been diagnosed in 114 (84.4%) patients.
Injection drug use in this community is a multi-generational activity, with as many as three generations of a family and multiple community members injecting together.
Syringes and drug preparation equipment are frequently shared The reported daily numbers of injections ranged from four to 15
Slide43Slide44A Public Health Crisis
Hep A
Symptoms similar to Hep C
However normally short-term illness and no chronic state
Rare cases can cause liver damage and death
Long incubation period- 2 to 7 weeks
Can make it difficult to obtain exposure info
Special restrictions if case of Hep A works in sensitive occupation, such as a food handler
Slide45A Public Health Crisis
Hep A
Is vaccine preventable
Hep A rates have decreased 95% since the Hep A vaccine became available in 1995
In 2016, 4,000 cases of Hep A in the U.S.
Slide46Public Health Crisis
Slide47A Public Health Crisis
Hep A outbreak
From January 2017 to April 2018, CDC has received more than 2,500 cases from multiple states.
68% report drug use, homelessness, or both
Slide48A Public Health Crisis
Slide49Prevention Strategies
Primary-1˚
Onset
Symptoms
Remission
Relapse
Death
Secondary- 2˚
Tertiary- 3˚
Slide50Prevention
Slide511˚ Prevention Strategies
Change in Schedule III to Schedule II
Slide521˚ Prevention
Hep A prevention
Offer vaccinations at drug rehab facilities
Slide531˚ Prevention
Hep A prevention
Partner with community agency’s to offer prevention tools to our homeless population
Slide541˚ Prevention
Prescribing guidelines - CDC
Slide551˚ Prevention
Alternatives to Prescribing Opioids
Non-opioid pain relievers
Exercise
Antidepressants/Anticonvulsants
Cognitive Behavioral Therapy
Slide561˚ Prevention
OpioidCalc - NYC
Slide571˚ Prevention
Laws and Rules - Ohio
Slide581˚ Prevention
HealingNYC - NYC
Slide592˚ Prevention
HIV prevention
Free, confidential HIV testing
Walk in, appointment, Maryhaven, or at a health/wellness festival
Slide601˚ Prevention
HIV prevention
Free condoms
http://ohiv.org/learn/free-condoms/
Slide612˚ Prevention
HIV prevention
DIS does follow-up on newly infected persons
Slide622˚ Prevention
OARRS
Ohio Automated Rx Reporting System
collects information on all outpatient prescriptions for controlled substances
Slide632˚ Prevention
OARRS
https://ohiopmp.gov/County.aspx
Slide64Slide652˚ Prevention
SBIRT
Screening, Brief Intervention, and Referral to Treatment
Allows providers to code for reimbursement
https://www.samhsa.gov/sbirt/about
Slide663˚ Prevention
Drug overdose
Slide673˚ Prevention
What is Project DAWN?
Community-based overdose education and naloxone distribution program
Slide683˚ Prevention
What is Naloxone?
Naloxone (also known as Narcan) is a medication that can reverse an overdose caused by an opioid drug (street drug or prescription).
When administered during an overdose, naloxone blocks the effects of opioids on the brain and quickly restores breathing
Slide69Slide703˚ Prevention
Slide713˚ Prevention
Fentanyl test strips
Can be used to test for the presence or absence of fentanyl and fentanyl analogs
Cost about $1/strip
Some agencies are giving these out for free
Utilize a QR code to a two question survey
Slide723˚ Prevention
Syringe Exchange Programs
Main focus is to reduce infections
Can also offer other prevention materials and services
Slide733˚ Prevention
Syringe Exchange Programs
Is a community-based public health program
Public health
Mental health
Law enforcement
Who can tell me why law enforcement has a seat at the table?
Slide743˚ Prevention
Syringe Exchange Programs
Benefits
Reduce drug use
Reduce needlestick injuries to first responders
Reduce overdose deaths
Reduce HIV and Hep C infections
Saves money
Slide753˚ Prevention
Surveillance
ER/Urgent care chief complaints
Overdose deaths
Slide763˚ Prevention
EpiCenter
Uses syndromic surveillance
Delaware County- we see 0-4 related visits a day- very low volume
Central Ohio sees anywhere from 15-30 a day
Slide773˚ Prevention
Overdose deaths
Collaboration between DGHD and county coroner
Data reviewed quarterly
Shared with partner agencies- i.e. mental health
Slide783˚ Prevention
Slide793˚ Prevention
Drug rehabilitation
Approx. 2/3 relapse
Slide803˚ Prevention
BUPE - NYC
Slide81References
Aschengrau
, A.,
Seage
, G.R., (2014). Epidemiology in public health, third edition. Jones & Bartlett Learning. Burlington, MA
Brownstien
, M.J. (1993). A brief history of opiates, opioid peptides, and opioid receptors. Proc. Natl. Acad. Sci. 90, 5391-5393.
Dictionary.com. (2018). Available from https://www.dictionary.com/
Dowell D, Haegerich TM, Chou R. (2016). CDC guideline for prescribing opioids for chronic pain — United states, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49. DOI:
http://dx.doi.org/10.15585/mmwr.rr6501e1
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Drug Enforcement Agency. DEA Issues carfentanil warning to police and public. September 22, 2016. Retrieved from https://www.dea.gov/press-releases/2016/09/22/dea-issues-carfentanil-warning-police-and-public
Kolodny
, A., Courtwright, D.T., Hwang, C.S., Kreiner, P., Eadie, J.L., Clark T.W., Alexander, G.C. (2015). The prescription opioid and heroin crisis: A public health approach to an epidemic of addiction. Annu. Rev. Public Health, 36, 559-574. doi:10.1146/annurev-publhealth-031914-122957
Koob, G.F., Volkow, N.D. (2010). Neurocircuitry of addiction. Neuropsychopharmacology Reviews 25, 217-238.
Lawriter
. (2018). Ohio Laws and Rules. Available from http://codes.ohio.gov/
Okie, S. (2010). A flood of opioids, a rising tide of deaths. The New England Journal of Medicine, 363(21), 1981-1985.
Mayo Clinic. (2017). Drug addiction (substance use disorder). Retrieved from https://www.mayoclinic.org/diseases-conditions/drug-addiction/symptoms-causes/syc-20365112
National Institutes of Health. (2018). Drugs, brains, and behavior: The science of addiction. Retrieved from https://www.drugabuse.gov/publications/drugs-brains-behavior-science-addiction/drugs-brain
New York City Department of Health and Mental Hygiene. BUPE. Retrieved from
https://www1.nyc.gov/assets/doh/downloads/pdf/basas/opioid-bupe-brochure.pdf
Bassett, M.T. (2017). New York City Department of Health and Mental Hygiene. Opioid pain relievers: what you need to know. Retrieved from https://www1.nyc.gov/assets/doh/downloads/pdf/basas/opioid-pain-relievers.pdfOregon Alcohol and Drug Policy Commission. Opiates or opioids – What’s the difference. Retrieved from https://www.oregon.gov/adpc/Pages/Opiate-vs.-Opioid.aspxOxford Treatment Center. Fentanyl: What is a Lethal Dosage. 2018 https://www.oxfordtreatment.com/fentanyl/lethal-dose/Reichle, C.W., Smith, G.M., Gravenstein, J.S., Macris, S.G., Beecher, H.K. (1962). Comparative analgesic potency of heroin and morphine in postoperative patients. Journal of Pharmacology and experimental therapeutics, April 1962 V136 (1) 43-46. U.S. Centers for Disease Control and Prevention. (2017). Commonly used terms. Retrieved from www.cdc.gov/durgoverdose/opioids/terms.htmlU.S. Centers for Disease Control and Prevention. (2017). Heroin. Retrieved from www.cdc.gov/drugoverdose/opioids/heroin/htmlU.S. Centers for Disease Control and Prevention. (2016). Synthetic opioid overdose data. Retrieved from www.cdc.gov/drugoverdose/data/fentanyl.htmlU.S. Centers for Disease Control and Prevention. (2017). Prescription opioids. Retrieved from www.cdc.gov/drugoverdoes/opioids/prescribed.htmlWally, A.Y., Xuan, Z., Hackman, H.H., Quinn, E., Doe-Simkins, M., Sorensen-
Alawad, A., Ruiz, S., Ozonoff, A. (2013). Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in massachussetts: interrupted time series analysis. BMJ, 346. Doi:10.1136/bmj.f174Wilson, F.P., (2018). Opioid tactic gone wrong. Medscape. Retrieved from https://www.medscape.com/viewarticle/900937?nlid=124825_439&src=WNL_mdplsfeat_180904_mscpedit_publ&uac=299005SJ&spon=42&impID=1729975&faf=1