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1 Slide 1 Opioid Update: What s Happening at the National, State and Local Level? Susan DeVuyst-Miller, PharmD, AE-C Assistant Professor, Ferris State University Clinical Pharmacist, Cherry Health Services Slide 2 No conflict of interest Slide 3 Objectives: Recall the role of opioids according to the CDC guidelines Describe the symptoms, risk factors, and reversal agent for opioids Discuss State of Michigan and Local Opioid Task Force progress and recommendations

2 Slide 4 Slide 5 Slide ,404 overdose deaths 12,989 heroin 33,091opioid related Rudd RA, Seth P, David F, Scholl L. Increases in Drug and Opioid-Involved Overdose Deaths United States, MMWR Morb Mortal Wkly Rep 2016;65: DOI:

3 Slide 7 Four in five new heroin users started out misusing prescription painkillers Slide 8 Slide 9 CDC Concerns Effective Risk assessment & mitigation Harm Effects on long term use Opioid dosing strategies

4 Slide 10 CDC Guidelines When to initiate or continue opioids for chronic pain Opioid selection, dosage, duration, follow-up & discontinuation Assessing risk and addressing harms of opioid use Slide 11 End of life & Cancer Cognitive impairment Elderly Risk? Racial women Ethnic minority groups Slide 12 Initiate or Continue Opioids for Chronic Pain Non pharmacological therapy & non opioid pharmacological therapy Treatment goals with each patient Discuss Risks & Benefits

5 Slide 13 Dose, Duration, Follow-up, Discontinuation Immediate release Lowest effective dose 3 days, 7 days Evaluate benefits and harms Optimize other therapies Taper off Slide 14 Assessing Risk & Addressing Harms Evaluate risk Review documentation Urine drug testing Avoid concurrent Benzos Opioid use disorder Slide 15 Opioid Warnings & Precautions

6 Slide 16 Risk for opioid overdose Reduced tolerance after abstinence Opioid naïve patients Dose >90MED Added opioid Polypharmacy Substance abuse Co-morbid conditions Genetic polymorphism Age Detoxification programs Methadone maintenance programs Mixing, using alone, quality Slide 17 Signs leading to Opioid Overdose vdifficulty staying awake and/or awakening vintoxicated behavior including mental confusion and slurred speech vslowed and/or shallow breathing vpinpoint pupils vslowed heartbeat and/or low blood pressure Slide 18 Loss of consciousness or inability to awaken verbally or with sternal rub/infliction of pain Breathing problems ranging from slow, shallow breaths to no breathing Lips and/or fingernails turning blue Pinpoint pupils (extremely small pupil size) Very slow heartbeat and/or low blood pressure

7 Slide 19 Tolerance, Addiction & Dependence Tolerance Dependence Addiction Decrease in pharmacologic response Increase dose to achieve similar effects High or chronic doses are abruptly d/c d Withdrawal symptom Change in behavioral patterns Despite the potential side effects and harm Slide 20 Naloxone Opioid reversal agent Photo courtesy of Grand Rapids Red Project. Redproject.com Slide 21

8 Slide 22 Naloxone vemergency treatment of known or suspected opioid overdose as manifested by respiratory and/or CNS depression vintended for immediate administration as emergency therapy in settings where opioids may be present. vnot a substitute for emergency medical care v No potential for abuse Slide 23 Slide 24 Naloxone vdelayed onset ²2 to 5 minutes for IM, SubQ, Nasal ²8 to 13 for nasal atomization vduration of action ²30 minutes to two hours ²Shorter than opioids ²Repeat doses at different site/nostril ²Seek medical treatment

9 Slide 25 Naloxone Kits Photo courtesy of Grand Rapids Red Project. Redproject.com Slide 26 Michigan Naloxone Standing Order Public Act 383 of 2016 Slide 27

10 Slide 28 Current Status May 3, 2017 Not released Rules Promulgation Process Naloxone Standing Order Reporting/Monitoring Slide 29 Slide 30 Rules, Regulations, Laws

11 Slide 31 Professional Immunity Good Samaritan Law Definitions Lay administrator Standing order Third party prescribing Slide 32 Laws Graphic modified from Slide 33 Michigan Laws Immunity Prescribing Lay Prescribers Dispensers Permitted Administrator Lay Possessio Distributio n w/o Rx 3 Disciplinar Disciplinar Civi rd Civil Criminal Civil Criminal n Standin Criminal part y y l g Order y Ye Yes - - Yes Yes Yes Yes Yes s Citation: Mich. Comp. Laws ; Mich. Comp. Laws e,b

12 Slide 34 Local responses Slide 35 Families Against Narcotics Throughout Michigan Executive boards Slide 36

13 Slide 37 Local - Kent Red Project Opioid Task Force Medical Law Enforcement Front Lines Slide 38 Kent County Opioid Task Force Increase community awareness of evidence based options to reduce fatality from overdose Minimum of 2 overdose prevention rescue trainings targeted at family and friends in K.C annually Slide 39 Kent County Opioid Task Force Provide at least 25 trainings to local law enforcement on recognizing and responding to opioid overdose situations with naloxone rescue kits Equip 300 local law enforcement vehicles with naloxone rescue kits

14 Slide 40 Kent County Opioid Task Force Expand the good Samaritan law to protect anyone requesting medical aid for a person overdosing on opioids from criminal prosecution Slide 41 Kent County Opioid Task Force Increase the number of physicians who are coprescribing take home naloxone rescue kits along with prescriptions of opioids. One major health center 20 private practices Slide 42

15 Slide 43 References 1. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain United States, MMWR Recomm Rep 2016;65(No. RR-1):1 49. DOI: Rathmell JP, Fields HL. Pain: Pathophysiology and Management. In: Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J. eds. Harrison's Principles of Internal Medicine, 19e. New York, NY: McGraw-Hill; 2015 [cited 2016 Jan 26]. 3. Hooten WM, Timming R, Belgrade M, Gaul J, Goertz M, Haake B, Myers C, Noonan MP, Owens J, Saeger L, Schweim K, Shteyman G, Walker N. Assessment and Management of Chronic Pain. Institute for Clinical Systems Improvement; Updated 2013 Nov [cited 2016 Jan 26]; World Health Organization. Cancer Pain Relief. 2nd ed. Geneva: WHO; 1996 [cited 2016 Jan 26]. 5. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain - United States, MMWR Recomm Rep. epub: 15 March 2016 [cited 2016 Mar 16]. 6. Division of Workers' Compensation. Chronic Pain Medical Treatment Guidelines. 8 C.C.R Oakland, CA: MTUS; 2009 Jul [cited 2016 Jan 25]; Lexi-comp [Internet]. Hudson, OH; Wolters Kluwer (Lexi-Drugs); [cited 2016 Mar 23]. Available from: U. S. Food and Drug Administration [Internet]. FDA News Release: FDA announces enhanced warnings for immediate-release opioid pain medications related to risks of misuse, abuse, addiction, overdose and death. Washington, DC: FDA; Updated 2016 Mar 22 [cited 2016 Mar 23]. Available from: Newsroom/PressAnnouncements/ucm htm 11. U. S. Food and Drug Administration [Internet]. Opioid Pain Medicines: Drug Safety Communication - New Safety Warnings Added to Prescription Opioid Medications. Washington, DC: FDA; Updated 2016 Mar 22 [cited 2016 Mar 23]. Available from: HumanMedicalProducts/ucm htm Substance Abuse and Mental Health Services Administration. SAMHSA Opioid Overdose Prevention Toolkit. HHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration,