Opioid Overdose OD Prevention for the Primary Care

Opioid Overdose (OD) Prevention for the Primary Care Clinician September 13, 2016 Grand Rounds Department of Family & Community Medicine Baylor College of Medicine

Objectives Discuss indications for having a naloxone overdose kit List risk factors for opioid overdose Describe how to respond to an opioid overdose in a non medical setting

Why Opioid Overdose Prevention Number one cause of accidental death in the United States (exceeding MVAs) since 2009 q 36 minutes, 1 person in US dies of opioid OD 60% of opioid overdoses in “medical users” They are OUR patients “Primum Non Nocere”

Why we don’t do it Knowledge gap Might encourage increased risk taking Might offend Uncomfortable self reflection on prescribing patterns J Gen Intern Med. 2015 Dec; 30(12): 1837 -44. doi: 10. 1007/s 11606 -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 it

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: Higher opioid dose Opioid-related ED visit in past 12 months Ann Intern Med. 2016 Aug 16; 165(4): 245 -52. doi: 10. 7326/M 15 -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.

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, Ph. D, MPH 1, 2, Sheigla Murphy, Ph. D 3 and Phillip O. Coffin, MD, MIA

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 opioid

Naloxone Legal Status In Texas ALLOWED/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 Intoxication

Opioids � Codeine + � 3 -4 Hours � Demerol ++ � 2 -4 Hours � Fentanyl +++++ � 2 -4 Hours � Heroin +++++ � 6 -8 Hours � Hydrocodone+++ � 4 -6 hours � Methadone ++++ � 24 -32 Hours � Morphine +++ � 3 -6 Hours � Oxy. Contin+++++ � 8 -12 Hours + Potency

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, Fentanyl

What is an OPIOID Overdose? Rarely instantaneous Typically 1 -3 hours after use Opioids slow receptors that control breathing Low O 2 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, toxicity

Risk Factors � Tolerance � Mixing � Alone � Purity � Route � Health � History

Tolerance Number 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 relapse

Mixing Especially 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 edema

Alone Using alone raises risk Always use with “partner”: responding to OD educate them on Notify close contact of planned use if using alone

Purity Adulterations common and can raise or lower risk of OD Some adulterants are fillers, decrease potency Others are active eg fentanyl, increase potency Use same dealer Listen to “word on the street” Test dose

Route of Administration User 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 overdose

Health Status Decline in health raises risk of overdose Pneumonia 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 Health

History Prior OD increases risk of another OD Take 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/acquaintance

What are the Signs/Symptoms of an OD? � Blue skin tinge- usually lips and fingertips show first REALLY HIGH OVERDOSE Muscles become relaxed Deep snoring or gurgling (death rattle) Very infrequent or no breathing � Body very limp � Face very pale � Pulse (heartbeat) is slow, erratic, or Speech is slowed/slurred not there at all Sleepy looking Pale, clammy skin � Throwing up Nodding � Passing out � Choking sounds or a Heavy nod, not responsive to stimulation Will respond to stimulation like yelling, sternal rub, pinching, etc. Slow heart beat/pulse gurgling/snoring noise � Breathing is very slow, irregular, or has stopped � Awake, but unable to respond Slow heart beat/pulse

How to respond to an opioid OD Identify OD happening Call 911 Rescue Breathing Naloxone administration Rescue Breathing Recovery Position

Response � Are you alright? � Are you ok? � Pain Stimulus � If no response call 9 -1 -1 � Rescue Breathing � Naloxone � Rescue Breathing

Response Myths � Salt Water � Suboxone � Ice On Body � Cold Shower � Cocaine � Milk � Burning Skin � Punching � Slapping

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, etc

Naloxone Hydrochloride (Narcan) � Opioid Antagonist � Medication that reverses only OPIOID Heroin 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 Opioid receptor 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.

Naloxone Hydrochloride (Narcan) Formulations Parenteral (IV/IM/SC) ▪ ~$40 Generic: ▪ 0. 4 mg/ml vials and syringes or 1 mg/ml syringes ▪ ~$700+ Evzio (for 2 doses): ▪ 0. 4 mg/0. 4 ml autoinjector Intranasal ▪ ~$100 Narcan nasal spray: ▪ 4 mg/0. 1 ml nasal spray

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 Medicine

Opioid Overdose and Families

Resources www. prescribetoprevent. org www. texasoverdosenaloxoneinitiative. com

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!!