Opioid Overdose (OD) Prevention for the Primary Care Clinician - PowerPoint Presentation

Slide1

Opioid Overdose (OD) Prevention for the Primary Care Clinician

September 13, 2016

Grand Rounds

Department of Family & Community Medicine

Baylor College of MedicineSlide2

ObjectivesDiscuss indications for having a naloxone overdose kitList risk factors for opioid overdoseDescribe how to respond to an opioid overdose in a non medical settingSlide3

Why Opioid Overdose PreventionNumber one cause of accidental death in the United States (exceeding MVAs) since 2009

q36 minutes, 1 person in US dies of opioid OD

60% of opioid overdoses in “medical users”

They are are OUR patients

“Primum Non Nocere”Slide4

Why we don’t do itKnowledge gap Might encourage increased risk takingMight offend

Uncomfortable self reflection on prescribing patterns

J Gen Intern Med.

2015 Dec;30(12):1837-44.

doi

: 10.1007/s11606-015-3394-3.

Overdose Education and Naloxone for Patients Prescribed Opioids in Primary Care: A Qualitative Study of Primary Care Staff.

Binswanger IA

1,2,3

,

Koester S

4,5

,

Mueller SR

6,7,5

,

Gardner EM

8

,

Goddard K

6

,

Glanz

JM

6,9

.

Patients can’t afford itSlide5

The Coffin et al study (#1)‘Nonrandomized Intervention Study of Naloxone

Coprescription

for Primary Care Patients Receiving Long-Term Opioid Therapy for Pain.’

6 safety net, primary care practices in SF

1985 patients, 38% co-prescribed naloxone

47% and 63% fewer opioid-related ED visits at 6 and 12

mos

(

cw

those not co-prescribed)

Co-prescription more likely if:

H

igher opioid dose

Opioid-related ED visit in past 12 months

Ann

Intern Med.

2016 Aug 16;165(4):245-52.

doi

: 10.7326/M15-2771.

Epub

2016 Jun 28.

Nonrandomized Intervention Study of Naloxone

Coprescription

for Primary Care Patients Receiving Long-Term Opioid Therapy for Pain.

Coffin PO

,

Behar E

,

Rowe C

,

Santos GM

,

Coffa

D

,

Bald M

,

Vittinghoff

E

.Slide6

The Coffin study (#2) –Behar, et al

‘

Primary Care Patient Experience with Naloxone

Prescription’

60 patients interviewed, 90% new to naloxone

87% successfully filled script

97% believed patients Rx chronic opioids should be offered naloxone

57% positive response, 22% neutral response

37% reported + behavior changes, 0% -

37% had

hx

of ‘opioid poisoning event’

5% reported use of their naloxone

77% estimated personal OD risk as low

Ann Fam Med September/October 2016 vol. 14 no. 5 431-436

Emily Behar

, MS

1

,

2

⇑

,

Christopher Rowe

, MPH

1

,

Glenn-Milo Santos

, PhD, MPH

1

,

2

,

Sheigla

Murphy

, PhD

3

and

Phillip O. Coffin

, MD, MIASlide7

Inclusion Criteria for Naloxone Kit

Prior hx of OD

OUD or misuse, known or suspected

Rx methadone or buprenorphine

Rx >50 MEQ daily

Poor access to EMS

Voluntary request

Rx < 50 MEQ daily AND

Lung infection or dz

Liver Disease

Kidney Disease

Heart Disease

HIV/AIDS

Drinking ETOH

Using Benzo/sedatives

Antidepressants

Rotated Rx opioidSlide8

Naloxone Legal Status In TexasAllowed/Protected

Prescribe to person at risk

Autoinjector

IM vial/syringe kit

Nasal spray formulation

Prescribe to bystander/friend/family

Dispense/distribute via standing order: CVS and Walgreens, currently

Prescriber immunity

Bystander immunity

From giving naloxone

NoT

Allowed/Protected

Dispense without Rx or standing order

Bystander immunity

From non violent offense outstanding warrants

From new charges

Possession

Distribution

Public IntoxicationSlide9

Opioids

Codeine +

Demerol ++

Fentanyl

+++++

Heroin +++++

Hydrocodone

+++

Methadone ++++

Morphine +++

OxyContin

+++++

+ Potency

3-4 Hours

2-4 Hours

2-4 Hours

6-8 Hours

4-6 hours

24-32 Hours

3-6 Hours

8-12 HoursSlide10

Opioids

Natural opioids: contained in resin of opium poppy (morphine, codeine)

Semi-synthetic opioids: created from natural opioids such as hydromorphone, hydrocodone, oxycodone, heroin etc.,

Fully Synthetic Opioids: Methadone, FentanylSlide11

What is an OPIOID Overdose?

Rarely instantaneous

Typically 1-3 hours after use

Opioids slow receptors that control breathing

Low O2 levels to the brain as resp rate slows

Unconscious, Coma, Death

Long-term Brain/Nerve/Physical Damage

Alternative terminology may be important: poisoning, unintentional overdose, toxicitySlide12

Risk Factors

Tolerance

Mixing

Alone

Purity

Route

Health

HistorySlide13

ToleranceNumber one time to OD:

Just out of treatment, no MAT

Just out of prison/jail

New user

Only takes several days of not using for tolerance to drop significantly

Go low, go slow

MAT when available, especially with relapseSlide14

MixingEspecially other respiratory depressants:

BENZOS

ETOH

sleeping rx eg ambien

Muscle relaxants eg Soma

Stimulants (eg cocaine “speed balling”)

Don’t counteract the respiratory depression

Add stress to cardiac system

High doses may cause pulmonary edemaSlide15

AloneUsing alone raises risk

Always use with “partner”: educate them on responding to OD

Notify close contact of planned use if using aloneSlide16

PurityAdulterations common and can raise or lower risk of ODSome adulterants are fillers, decrease potency

Others are active eg fentanyl, increase potency

Use same dealer

Listen to “word on the street”

Test doseSlide17

Route of AdministrationUser changing route of administration at higher risk of overdose:IV injection riskier than IM/SC “skin popping” riskier than smoking riskier than snorting riskier than oral

Risk greatest with “first time” change

But taking by mouth does not eliminate risk of overdoseSlide18

Health StatusDecline in health raises risk of overdosePneumonia or other respiratory illness

Liver disease or decreased liver function

Kidney disease or decreased kidney function

Heart disease

HIV/AIDS

Post hospital discharge = Double Risk

Tolerance AND HealthSlide19

HistoryPrior OD increases risk of another ODTake an Overdose History:Personal history of OD: accidental or intentional

Drug/s involved, route of use, treatment if any, outcome

Witnessed OD: common traumatic event

Non witnessed OD of friend/family/acquaintanceSlide20

What are the Signs/Symptoms of an OD?

Blue skin tinge- usually lips and fingertips show first

Body very limp

Face very pale

Pulse (heartbeat) is slow, erratic, or not there at all

Throwing up

Passing out

Choking sounds or a gurgling/snoring noise

Breathing is very slow, irregular, or has stopped

Awake, but unable to respond

REALLY HIGH

OVERDOSE

Muscles become relaxed

Deep snoring or gurgling (death rattle)

Speech is slowed/slurred

Very infrequent or no breathing

Sleepy looking

Pale, clammy skin

Nodding

Heavy

nod, not responsive to stimulation

Will respond to stimulation like yelling, sternal rub, pinching, etc.

Slow heart beat/pulse

Slow heart beat/pulse Slide21

How to respond to an opioid ODIdentify OD happening

Call 911

Rescue Breathing

Naloxone administration

Rescue Breathing

Recovery PositionSlide22

Response

Are you alright?

Are you ok?

Pain Stimulus

If no response call 9-1-1

Rescue Breathing

Naloxone

Rescue BreathingSlide23

Response Myths

Salt Water

Suboxone

Ice On Body

Cold Shower

Cocaine

Milk

Burning Skin

Punching

SlappingSlide24

What are barriers to calling 911 from the perspective of a patient, bystander or family?

Fear of judgment from family/ community

Fear of legal risk

outstanding warrants, TDCJ involvement, loss of public housing

Personal embarrassment/shame ESPECIALLY in early recovery

Other punitive measures (students loose federal financial aid)

‘Street myths’

homicide charge for being at an OD, being deported

Acknowledge these are REAL CONCERNS

Stress options: staying, leaving with clear path to victim, etcSlide25

Naloxone Hydrochloride (Narcan)

Opioid Antagonist

Medication that reverses only OPIOID overdose

Can not get high on it

Can not abuse it

Stays active for 20-90 minutes depending on metabolism, amount of drug used

If they use before the naloxone wears off

Narcan has a stronger affinity to the opioid receptors than the heroin, so it knocks the heroin off the receptors for a short time and lets the person breathe again.

Heroin

Narcan

Opioid receptorSlide26

Naloxone Hydrochloride (Narcan)

Formulations

Parenteral (IV/IM/SC)

~$40 Generic:

0.4mg/ml vials and syringes or 1 mg/ml syringes

~$700+ Evzio (for 2 doses):

0.4mg/0.4ml autoinjector

Intranasal

~$100 Narcan nasal spray:

4mg/0.1ml nasal spraySlide27

Talking with Patients/Clients

Not just people who inject at risk for

OD

Not just people who misuse at risk for OD

Take an OD history

Know the myths about response

Know

some

street slang

(does not mean YOU have to use it

)

Remember we practice

FAMILY

MedicineSlide28

Opioid Overdose and FamiliesSlide29

Resourceswww.prescribetoprevent.org

www.texasoverdosenaloxoneinitiative.comSlide30

These slides edited and adapted from:

Mary Wheeler

Street Outreach Coordinator and

Christian Alba

Health Educator

CAB Health and Recovery Services Inc.,

Healthy Streets Outreach Program

280 Union Street

Lynn, MA

01901

By: Alicia

Kowalchuk

, DO

Assistant Professor

Baylor College of Medicine Department of Family & Community Medicine

Houston, TX

Thank You!!