Challenges of the Opioid Overdose Crisis Gloria Baciewicz MD Strong Recovery Dept of Psychiatry University of Rochester 2018 Challenges of the Opioid Overdose Crisis The changing nature of the opioid overdose crisis ID: 768455
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Challenges of the Opioid Overdose Crisis Gloria Baciewicz MD Strong Recovery, Dept of Psychiatry, University of Rochester 2018
Challenges of the Opioid Overdose Crisis The changing nature of the opioid overdose crisis Opioid use disorder What happens in an opioid overdose? Laws supporting distribution of naloxone kits Challenges in a college population Referral to treatment for opioid use disorder
The Overdose Epidemic Opioid overdose deaths 115 Americans die every day from an opioid overdose Risk factors for overdose: Use after a period of abstinence Use with other sedating drugs especially benzodiazepines
Source: CDC PBSS, 2017
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Preventing Opioid Overdose Deaths Encourage providers, persons at high risk, family members, and others to learn how to prevent and manage opioid overdose. Ensure access to treatment for individuals who are misusing opioids or who have a substance use disorder. Ensure ready access to naloxone. Encourage the public to call 911. Encourage prescribers to use state prescription drug monitoring programs (PDMPs). Source: SAMHSA Opioid Overdose Toolkit 2018
Naloxone ( Narcan ) Displaces opiates from receptor sites in the brain Reverses the respiratory depression that usually is the cause of opioid overdose deaths Lasts about one hour Approved by FDA Used by EMS services for over 40 years AMA, ONDCP, APHA, WHO, SAMHSA have all made statements in support BMJ Evidence Centre. Treatment of opioid overdose with naloxone. Updated 10/23/12. http:// bmj.com
Methods of administering naloxone:
Resources: SAMHSA.gov Harmreduction.org Getnaloxonenow.org Overdosepreventionalliance.org Naloxoneinfo.org Prescribetoprevent.org Projectlazarus.org Stopoverdose.org
NYS Laws NY Public Health Law 3309 (2006) Protects the non-medical person who administers naloxone in setting of overdose from liability. “shall be considered first aid or emergency treatment”. “shall not constitute the unlawful practice of a profession”. Allows the medical provider (physician, PA, NP) to provide naloxone for secondary administration. 911 Good Samaritan Law (2011) addresses fears about a police response to an overdose. legal protection against criminal charge and prosecution for possession of controlled substances, as well as possession of marijuana and drug paraphernalia protection applies to both the person seeking assistance in good faith as well as to the person who has overdosed.
Source: The Network for Public Health Law, July 2017
N-CAP Participating Pharmacies For a list of Participating Pharmacies go to: www.health.ny.gov/overdose CVS RITE-AID WALGREENS WAL MART WEGMANS
Signs of Opioid Overdose Unconsciousness or inability to awaken. Try to call the person’s name vigorously grind knuckles into the sternum (sternal rub) Slow or shallow breathing. Breathing difficulty such as choking sounds or a gurgling/snoring noise from a person who cannot be awakened. Fingernails or lips turning blue/purple.
Steps to Administer Narcan (Naloxone) Identify Opioid Overdose & Check for Response Give NARCAN Nasal Spray Call for emergency medical help, evaluate, and support Repeat Step 2, as needed.
Challenges in a College Population
Challenges in a College Population “It can’t happen here” Initial resistance re naloxone kit distributio n
Trajectory of Opioid Use Guarino H, Mateu-Gelabert P et al. Young adults' opioid use trajectories: From nonmedical prescription opioid use to heroin, drug injection, drug treatment and overdose. Addict Behav. 2018 Nov;86:118-123 1 st Nonmedical PO Use Mean Age: 16.7 y/o 1 st Heroin Use Mean Age: 19.1 y/o 1 st Heroin Injection Mean Age: 20.3 y/o Drug Treatment OD 1 st Drug Treatment Mean Age: 19.7 y/o 1 st Overdose Mean Age: 20.2 y/o 25
Making the diagnosis of Opioid Use Disorder DSM 5 – at least 2 of 11 criteria within a 12 month period (2-3 mild, 4-5 moderate, 6 or more severe) Loss of control of quantity used Repeated failed efforts to control use Large amount of time spent using/ recovering from use Failure to fulfill “major role obligations” Craving Use despite physical or mental consequences Use despite negative effects on relationships Repeated use in a physically dangerous situation Activities given up Tolerance Withdrawal
Our understanding of substance use disorder as a chronic medical condition keeps improving Elias D, Kleber HD. Minding the brain: the role of pharmacotherapy in substance use disorder treatment. Dialogues in Clinical Neuroscience. 19(3):289-297, 2017 Sep Brain–based vulnerabilities develop, intensify and complicate use. Transition from “you control drugs” to “drugs control you”. Brain–based adaptation to repeated drug consumption occurs. Tolerance Withdrawal Craving Attenuated motivation for nondrug rewards Stress sensitivity Heightened response to drug-related cues Impulsivity and delay discounting (reduced value placed on deferred rewards) “Tenuous motivation for changing destructive behavior”.
Meds for Opioid Use Disorder Evidence remains strongest for agonist treatments (methadone, buprenorphine) Evidence for antagonist treatments is weaker (naltrexone) Connery HS Medication-assisted treatment of opioid use disorder: review of the evidence and future directions. .Harvard Review of Psychiatry. 23(2):63-75, 2015 Mar-Apr. 29
Actions at the Opiate Receptor Full agonists : Increasing dose = increasing effect Abusable opioids tend to be full agonists (eg heroin) Partial agonists Increasing dose = LESS than maximal effect Buprenorphine, Pentazocine (Talwin), Butorphanol (Stadol), Nalbuphine (Nubain) Antagonists Naltrexone (ReVia) Injectable naltrexone (Vivitrol) Naloxone (Narcan) 30
Opioid Replacement Treatment Methadone Buprenorphine/Naloxone (Suboxone, Zubsolv, Bunavail) Buprenorphine (Subutex) Probuphine (Implanted buprenorphine) Monthly Injectable buprenorphine (Sublocade) 31
Probuphine indications Already clinically stable on no more than 8 mg buprenorphine or 8/2 buprenorphine / naloxone Approved for single insertion in each arm (thus will cover 12 months) Rosenthal et al. Effect of Buprenorphine Implants on Illicit Opioid Use Among Abstinent Adults With Opioid Dependence Treated With Sublingual Buprenorphine: A Randomized Clinical Trial . JAMA 2016
The Meaning of Success in ORT SUCCESS = TREATMENT RETENTION Goals of Treatment: Stop opioid use Decrease criminality Address other substance use disorders. Address other health problems Improve employability and educational development. Identify and treat mental health problems and alleviate homelessness, family substance abuse and child and family dysfunction. 34
Opioid antagonists Opioid antagonist meds: Naltrexone (oral form) Poor adherence Significant opioid overdose mortality following discontinuation of med IM naltrexone (Vivitrol) Lee, J et al. Extended-release naltrexone to prevent opioid relapse in criminal justice offenders. NEJMED 2016 Rate of opioid relapse was lower than with usual treatment 35
Pharmacotherapy for alcohol and opioid use disorders can reduce some public health consequences of use Molero , Yasmina et al. Medications for alcohol and opioid use disorders and risk of suicidal behavior, accidental overdose, and crime. Am J Psychiatry 175:10 Oct 2018, 970-978 >21,000 individuals in Sweden using population-based registers Within-individual design Acamprosate —no association with any of the primary outcomes Naltrexone —reduction in accidental overdose Buprenorphine —reduction in crime and accidental overdose Methadone —reduction in crime and in suicidal behavior but increased risk of accidental overdose
Components of Comprehensive Drug Addiction Treatment www.drugabuse.gov