To the Rescue:Naloxone Rescue and other Harm

Reduction Strategies for Opioid Overdose

Patricia McGuire, MD

Collaborative Family Healthcare Association 16th Annual ConferenceOctober 16-18, 2014 Washington, DC U.S.A.

Session # E3bOctober 17, 2014

Faculty Disclosure

I have not had any relevant financial relationships during the past 12 months.

Learning Objectives

At the conclusion of this session, the participant will be able to:

• Identify evidence about risks of illicit and prescription opioid misuse

• Integrate harm reduction strategies for opioid in the patient centered medical home

• Discuss Naloxone rescue techniques

Bibliography / Reference

1. Belesky LB, Rich JD, Walley AY. Prevention of fatal opioid overdose; JAMA, 2013: 308 (180): 1863-1864

2. Centers for Disease Control and Prevention (CDC); Community-based opioid overdose prevention programs providing naloxone – United States, 2012. MMWR Morb Mortal Wkly Rep. 2012; 261 (6): 101-105.

3. Harvard Medical School. Painkillers fuel growth in drug addiction: Opioid overdoses now kill more people that cocaine or heroin. Harvard Ment Hlth Let. 2011; 27 (7): 4-5.

4. Coffin PO, Sullivan SD, Cost effectiveness of distributing Naloxone to heroin users for lay overdose reversal. Ann Intl Med. 2013; 158: 1-9

5.Coffin P, Banta-Green C; The Dueling Obligations of Opioid Stewardship; Ann Intern Med. 2014;160(3):198-200. doi:10.7326/M13-2209

5. SAMHSA; Opioid Overdose ToolKit; http://store.samhsa.gov/shin/content/SMA13-4742/Overdose_Toolkit_2014_Jan.pdf

Learning Assessment

• A learning assessment is required for CE credit.

• A question and answer period will be conducted at the end of this presentation.

Opioids• Illegal drugs: heroin• Prescription meds:

– oxycodone– hydrocodone– fentanyl– morphine– codeine– hydromorphone– methadone– buprenorphone

Opioids

• Bind to receptors in brain, spinal cord, GI tract• Affect body systems which regulate breathing,

blood pressure, mood• Minimize perception of pain• Stimulate brain reward centers• Overdose can lead to Classic Triad

– pinpoint pupils– respiratory depression– Coma, death

Opioid Overdose

• Miscalculation of heroin dose• Deliberate misuse• Misunderstanding directions for Rx opioid

dosing• Combining opioids with other substances

Opioid pain reliever-related overdose deaths increasing at a faster rate than deaths from any major cause

Aortic Aneurysm Influenza & Pneumonia Cerebro-vascular Motor vehicle traffic

Heart disease Perinatal Period Homicide Diabetes Mellitus Pneumonitis Malignant Neoplasms

HIV Septicemia Chronic Lower Respiratory disease Liver Disease

Suicide Nephritis Parkinson's Disease Hypertension Alzheimer's Rx opioid overdose

-50% 0% 50% 100% 150% 200% 250% 300%

-34%-23%-23%-22%

-16%-14%

-3%0%

2%4%

7%11%13%

20%31%

36%40%

47%68%

276%

% change in number of deaths, United States, 2000-2010

Opioid prescribing rates correlate with drug overdose death rates

Death rate, 2008, National Vital Statistics System. Opioid pain reliever sales rate, 2010, DEA’s Automation of Reports and Consolidated Orders System

Scope of the Problem

2 million individuals with opioid analgesic use disorders

The Dueling Obligations of Opioid Stewardship Phillip Coffin, MD, MIA; and Caleb Banta-Green, PhD Ann Intern Med. 2014;160(3):198-200. doi:10.7326/M13-2209

Scope of the Problem

• There was a 4-fold increase in opioid prescriptions for pain in the last 10 years

• Deaths from prescription opioids have doubled in the last 10 years

• 17,000 in 2010, up from 14,800 in 2008

CDC MMWR November 4, 2011 / 60(43);1487-1492

Principles of Harm Reduction

• Pragmatism – Are we going to eliminate drug use?

• Humanistic Values – Not approval but not moral judgment

• Focus on Harms – Not the use itself

• Balancing Costs and Benefits • Priority of Immediate Goals

Hunt, Neil. “A review of the evidence-base for harm reduction approaches to drug use” IHRA, http://www.ihra.net/files/2010/05/31/HIVTop50Documents11.pdf

Harm Reduction

• Conceptualized as set of compassionate and pragmatic approaches for:– Reducing harm associated with high risk behaviors– Improving quality of life

• Goals– Decrease use or abstinence– Decrease harm associated with use

Harm Reduction, 2nd edition, edit by Marlatt GA, et.al.; 2012, Guilford Press, NY

UPMC St. Margaret Behavioral Health IntegrationHarm Reduction Strategies

2011SBIRT Universal Screening for SUD

2011 SBIRT curriculum development

2012Integrated Behavioral Health Team

2013

Controlled Substances Protocol revision

2014

Naloxone Rescue Project development

Integrated Behavioral Health Services

• Multi-disciplinary team• Warm hand-off• Short-term Behavioral Health therapy

– CBT approach to mental health issues– Harm reduction approach to substance misuse

• Psychiatric consultation• Referral to specialty mental health/substance

abuse treatment, as needed

Control Substance Protocol

• Revision of Controlled Substance Policy– Avoid Controlled Substance Rx on first clinic visit– Controlled Substance Agreement– Urine Drug Screening– Pain Clinic Referral– SBIRT: Referral to specialty SA treatment– Controlled Substance letter of concern– Naloxone counseling letter

Harm Reduction Counseling• Ask permission • Give personalized feedback about harms/risks

of drug use• Use collaborative approach to help patients

identify their goals re: drug use and related behaviors – Decrease use or abstinence– Decrease associated harms

Harm Reduction Counseling

• Have patient develop options for change to meet their goals

• Help patient consider as many harm reduction strategies as possible

• Utilize SMART goal setting– Specific; Measurable; Achievable; Realistic; Timed

• Assist patient with follow-up plan

Naloxone Counseling Letter

• Educates patients about dangers of opioid overdose– Motivates patients to accept naloxone prescriptions– Encourages patients to ask for help to wean down opioid

use, if appropriate

• Helps providers counsel new patients who request opioid refills at 1st visit– Decreases contentious tenor of those visits– Improves provider satisfaction/feelings of empowerment

Naloxone (Narcan) reversing an overdose

Endorsement, Policy and Legal Support

• http://prescribetoprevent.org/medical-legal/

Comprehensive overdose prevention, recognition and response, including intramuscular and intranasal Naloxone rescue kit demonstrations

http://prescribetoprevent.org/video/http://vimeo.com/37778160 http://vimeo.com/22647688

Naloxone Rescue Teaching

Evzio

• http://evzio.com/patient/?gclid=CL7voL_2sMACFStk7Aod3h0AJg

http://evzio.com/videos/ITJ001_Evzio_Interactive_V2B-HD.mp4

Patient Education

Barriers to Implementation

• Cost • Insurance coverage• Availability• Buy-in• Perceptions• Limited availability of Suboxone dispensing

Questions / Discussion

Session Evaluation

Please complete and return theevaluation form to the classroom

monitor before leaving this session.

Thank you!