where do we go from here? · 2019. 11. 5. · thank you! buprenorphine/naloxone standard dosing vs....
TRANSCRIPT
WHERE DO WE GO FROM
HERE?
Image Credit: https://www.methadoneman.org
BUPRENORPHINE
UNIQUE
PHARMACOLOGY #1
Partial Agonist
Image Credit: Provincial Opioid Addiction Treatment Support Program, UBC CPD
Respiratory Depression
(Morphine, Heroin)
(Buprenorphine)
(Naloxone)
BUPRENORPHINE
UNIQUE
PHARMACOLOGY #2
High Affinity
Image Credit: Wheeler K MD, Dept of Anesthesiology, University of Ottawa
Heroin
STANDARD DOSING BUPRENORPINE/NALOXONE
TO AVOID:
Withdrawal First!
No opioids x 12-24h
PRECIPITATED
WITHDRAWAL RISK
MICRODOSING BUPRENORPHINE/NALOXONE
“Bernese Method” (2010): 0.2mg initial dose + concurrent heroin; 12mg by day 9
Case studies, n=4 : Safe & well-tolerated (Hammig 2016, Klaire 2019)
No rigorous studies
https://www.bern.com/
EQUIPOISE: STANDARD DOSING VS. MICRODOSING
Standard dosing
No opioid use x 12-24h
≥Moderate withdrawal (barrier)
Reach therapeutic dose in 24h
Microdosing
May concurrently use opioids
No withdrawal required
6-7 days to therapeutic dose (risk?)
VGH FEASIBILITY STUDY: STANDARD & MICRODOSING
SCREENING
Selected presenting complaints
or Clinician referral
CONSENT/ENROLL & COUNSEL
RAs; Pharmacists, ER/CPAS addictions physicians
Standard Dosing Package
3 days
n=10
Microdosing Package
6 days
n=10
Follow-up 7d (RA) & 30d (SW)
Feasibility Outcomes: Enrollment; Qualitative Interviews/Focus groups
RAAC Referral
SCREENING
PROCEDURE:
DATA-DRIVEN
(BCCDC OVERDOSE
COHORT)
Substance misuse/intoxication
Abdominal pain
Localized swelling/redness
Depression/suicidal/deliberate self-harm
Prescription/medication request
Bizarre behavior
Overdose ingestion
Lower extremity pain
Shortness of breath
Chest pain, non-cardiac features
Back pain
Substance withdrawal
Anxiety/situational crisis
Altered level of consciousness
Head injury
Lower extremity injury
Laceration/puncture
Upper extremity injury
Headache
Chest pain, cardiac features
RAPID OPIOID DEPENDENCY SCREEN (RODS)
TAKE-HOME PROTOCOLS FOR INDUCTION DOSING
STUDY PROGRESS
May 2019-present: Physician/nurse/pharmacist education
July-Aug 2019: Rollout Standard Dosing Average 2 patients enrolled/week
Sept 2019: Hiatus due to RA availability
Oct 2019: Rollout Microdosing Standard dosing phase complete
Healthcare provider focus groups
EARLY LESSONS
Opioid use disorder: a cross-cutting issue 25-58 years
Homeless to high income
Varied presenting complaints: e.g., head injury, assault, weakness, bug bites, bizarre behavior, cellulitis, overdose, withdrawal
Small window to engage
Complex clinical cases = the norm! Pregnant
Acute pain/trauma
EtOH withdrawal
PATIENT FEEDBACK: STANDARD DOSING PHASE
6 contacted in 30d follow-up
2/6: remained on buprenorphine/naloxone at 30 days “Makes me feel better emotionally, physically, socially”
“Suboxone was my fresh start” and “changed my life”
1/6: on and off buprenorphine/naloxone during 30 days
3/6: “I was not ready”
6/6: Continue offering from the ED, others may benefit
CHALLENGES
Delays & Leaving AMA
Care spaces lacking
High volume/long waits
Social instability
Lost/stolen packages
Difficult follow-ups
INTENSIVE OVERDOSE OUTREACH TEAM FOLLOW-UP
T-1: 1-year pre ED visit
MoH data linkage
Pharmanetdays on OAT
T=0: Index ED visit
Offer BTG
Intake survey
Within 1 week
OOT contact for linkage to care
1,2,6, 12 months
OOT contact & follow-up survey
T+1: 1 year post ED visit
MoH data linkage; Pharmanet
SPH PI: A. Kestler
VGH lead: J. Moe
NALOXONE DOSING IN ERA OF ULTRA-POTENT
OPIOIDS
In overdoses due to suspected fentanyl/ultra-potent opioid (UPO),
are higher naloxone doses required to reverse toxicity?
SYSTEMATIC REVIEWINCLUSION & SEARCH
P: >12 yo w opioid toxicity
Non-medical opioid use
I: Naloxone + dose
C: None necessary
O: Reversal or Adverse effect
D: Interventional
Observational
Case reports/series
Records identified from
literature searches
(n = 14,038)
Records screened by titles and
abstracts
(n = 8,929)
Records excluded
(n = 7,903)
Full-text articles
assessed for eligibility
(n = 1,026)
Studies excluded
(n = 865)
• Population ineligible (n =140)
• No naloxone dose reported (n=8)
• No outcomes of interest (n = 94)
• Study design ineligible (n =522)
• Not retrievable (n = 64)
• Language exclusion (n= 33)
Studies included
(n = 174)
Duplicates removed
(n = 5,109)
Grey Literature
(n = 14)
CUMULATIVE DOSE IN RESPONDERS: N. AMERICA
Studies 1974-2014 Studies 2015 or later
Drug Type Median (IQR) Median (IQR)
Fentanyl/
Ultra-Potent Opioids1.8 (1.0, 4.0) 3.4 (3.0, 4.1)
Heroin 0.8 (0.4, 0.8) 2 (1.4, 2.0)
CONCLUSIONS
In opioid toxicity due to fentanyl/UPOs vs. other opioids,
higher cumulative naloxone doseshave been used by providers in North America to achieve adequate reversal
CLINICAL & POLICY IMPLICATIONS
Titrate naloxone doses to clinical effect
Ensure adequate doses in Take-Home Naloxone kits
(3x 0.4mg in B.C.)
EMERGING PROVINCIAL
TRENDS
Food for thought
↑ DECLINED EHSTRANSPORTS
POST-OVERDOSE
Figure Credit: Slaunwhite A, BC Centre for Disease Control
Reasons for trends?
Patient outcomes?
Engagement opportunities?
↑ METHAMPHETAMINE USE
Figure Credit: Buxton J, BC Centre for Disease Control
Transitions vs concurrent use?
Methods/patterns of use?
Harm reduction implications?
CONCLUSION: KEY MESSAGES
ED based interventions for OUD workMultiple EDs around BC actively engaged
Coordination & scale-up needed in BC
New directionsMicro-dosing
Increased Outreach
Fentanyl/Ultra-potent opioids & Naloxone Dosing
Understanding OUD & stimulant use combo better
THANK YOU!
Buprenorphine/naloxone Standard Dosing vs. Microdosing Feasibility Study
Katherin Badke PharmD, Megan Pratt MSW, Barbara Harvey RN, Lara Gurney RN, Pouya Azar MD, Heather Flemming MD, Anne Sutherland MD, Gord Garner, Logan Carroll, Deb Bailey, Barbara Lee PhD, Andy Kestler MD, Keith Ahamad MD, Emma Garrod RN, Misty Bath RN, Corinne HohlMD MSc, Penny Brasher PhD, Jane Buxton MD, Amanda Slaunwhite PhD. Funding: VCHRI, UBC.
Naloxone Dosing in the Era of Fentanyl/UPO Overdoses
Jesse Godwin MD, Roy Purssell MD, Fiona O’Sullivan PhD, Jeffrey Hau MSc, Elizabeth Purssell MD MSc, Jason Curran MSc, Mary Doyle-Waters PhD, Penelope Brasher PhD, Jane Buxton MD, Corinne Hohl MD MSc. Funding: CIHR.
St. Paul’s BTG implementation team
Keith Ahamad MD, Tanya Campbell RN, Emma Garrod RN, Brad Ho PharmD, Arnold Leung, Aylar Macarai PharmD, & Cindy San Pharm D
BTG iOOT team
K. Ahamad MD, Misty Bath RN, Jane Buxton, Jim Christenson MD, E. Garrod RN, Eric Grafstein MD, Reka Gustafson MD, Isabelle Miles MD, Jess Moe MD, Seonaid Nolan MD, Roy Purssell MD, Frank Scheuermeyer MD, Christy Sutherland MD, Kelsey van Pelt MPH, & Evan Wood MD
Regional & provincial collaborators
K. Ahamad MD, Melissa Allan MD, Britt Bailey MD, Brendan Behan RN, Floyd Besserer MD, Brighid Cassidy MD, Miranda Compton MSW, E. GarrodRN, Leslie Lappalainan MD, Sophie Low-Beer MD, Ian Mitchell MD, Jess Moe MD, Devon Tucker MD, Jason Wale MD, & Josh Williams MD