The Use of Naloxone in Workers Compensation. A Workers Compensation Continuing Education Course

Transcription

1 The Use of Naloxone in Workers Compensation A Workers Compensation Continuing Education Course January 19, 2017

2 This course was previously presented on July 28, If you attended the course on that date and received continuing education credits from the CEU Institute, you cannot submit for the same credits for this offering. If you have any questions regarding your continuing education credits received from Optum webinars, please contact This course has been approved for 1-hour of CE for the following license types: Pre-approved Adjuster (AK, AL, CA, DE, FL, GA, ID, IN, KY, LA, MN, MS, NH, OK, OR, TX, UT, WY); Certified Case Manager (CCM); National Nurse; Certification of Disability Management Specialists (CDMS); Commission on Rehabilitation Counselor (CRC); and Certified Medicare Secondary Payer (CMSP) for CE accreditation. For states that do not require prior approval, the adjuster is responsible for submitting their attendance certificate to the appropriate state agency to determine if continuing education credits can be applied. This course is not approved for the following credit types: Adjuster credits in North Carolina and Washington

3 Administrative Details

4 To receive continuing education credit 1. Remain logged on for the entire webinar.

5 To receive continuing education credit 1. Remain logged on for the entire webinar. 2. Answer all three poll questions.

6 To receive continuing education credit 1. Remain logged on for the entire webinar. 2. Answer all three poll questions. 3. You will receive an from the CEU Institute on our behalf approximately 24 hours after the webinar. This will contain a link that you will use to submit for your CE credits. You will need to complete this task within 72 hours.

7 Webinar controls Questions will be answered at the end of the presentation as time allows. Sample of Webinar Controls Use this button to expand or collapse the webinar control window Type questions here

8 Technical issues? Let us know if you experience an issue that causes you to: Miss a poll question Have audio problems Log out Any other technical issue Send a message using the webinar controls question panel or ceprogram@optum.com The sooner we know about an issue, the faster we can take the steps needed to make sure you get the continuing education credits you require.

9 Disclosure No planner, presenter or content expert has a conflicting interest affecting the delivery of this continuing education activity. Optum does not receive any commercial advantage nor financial remittance through the provided continuing education activities.

10 Medical disclaimer Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, new treatment options and approaches are developed. The authors have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at time of publication. However, in view of the possibility of human error or changes in medical sciences, neither Optum nor any other party involved in the preparation or publication of this work warrants the information contained herein is in every respect accurate or complete, and are not responsible for errors or omissions or for the results obtained from the use of such information. Readers are encouraged to confirm the information contained herein with other sources. This educational activity may contain discussion of published and/or investigational uses of agents that are not approved by the Food and Drug Administration (FDA). We do not promote the use of any agent outside of approved labeling. Statements made in this presentation have not been evaluated by the FDA.

11 Disclaimer The display or graphic representation of any product or description of any product or service within this presentation shall not be construed as an endorsement of that product by the presenter or any accrediting body. Rather, from time to time, it may facilitate the learning process to include/use such products or services as a teaching example. Accreditation of this continuing education activity refers to recognition of the educational activity only and does not imply endorsement or approval of those products and/or services by any accrediting body. CE credits for this course are administered by the CEU Institute. If you have any issues or questions regarding your credits, please contact submissions@ceuinstitute.net.

12 Presenters Adrienne Harris, PharmD, RPh Clinical Pharmacist Liaison Susan Martin, BSPharm, RPh Senior Clinical Pharmacist

13 Objectives Review prevalence of opioid analgesic overdose epidemic Explain how naloxone works to reverse effects of opioid analgesics Describe legislation surrounding access to naloxone Provide overview of current naloxone products on market Summarize when and how naloxone should be administered

14 Meet Anne

15 A case study Anne is 45 year-old woman Injured lower back while moving heavy box at work Diagnosed with lumbar radiculopathy due to herniated disc

16 Dangerous combination

17 Opioid Related Deaths in the U.S. 35,000 30,000 25,000 20,000 15,000 10,000 5, Source: National Center for Health Statistics, CDC Wonder, Jan. 2017

18 Prescription Opioid Related Deaths in U.S. (excluding non-methadone synthetics) 20,000 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2, Source: National Center for Health Statistics, CDC Wonder, Jan. 2017

19 What is Naloxone?

20 Antidote for opioid-related overdoses Heroin Morphine Naloxone Oxycodone Hydrocodone

21 What is naloxone? Opioid antagonist or antidote for opioid analgesic overdose only (includes heroin) -Antagonizes the opioid analgesic mu, kappa, and delta receptors Displaces the opioid analgesic agonist for a short time Reverses the clinical and toxic effects of opioid analgesic overdose Little to no agonist activity (no potential for abuse) NO pharmacological effect or harm in those not taking opioid analgesics

22 Effects and duration Takes effect in approximately 3 minutes Wears off in approximately minutes -Duration depends on type of opioid analgesic -Can go back into overdose if long-acting opioid analgesics were taken -May feel withdrawal symptoms after naloxone wears off -Should NOT take more opioid analgesics after naloxone is given to avoid overdose

23 Naloxone mechanism Opioid analgesics bind to opioid receptors to cause their effects. They can help relieve pain, but also cause sedation and hypoventilation. Opioid analgesic Opioid analgesic Opioid analgesic Opioid analgesic Opioid analgesic Opioid analgesic receptors

24 Naloxone mechanism Naloxone "pushes" opioid analgesics off the receptors, thereby reversing their effects, and blocks further binding. Naloxone Opioid analgesic Opioid analgesic Opioid analgesic Opioid analgesic Opioid analgesic Opioid analgesic receptors

25 Naloxone mechanism Naloxone "pushes" opioid analgesics off the receptors, thereby reversing their effects, and blocks further binding. Naloxone Naloxone Naloxone Naloxone Naloxone Opioid analgesic receptors

26 Opioid withdrawal symptoms Body aches Diarrhea Increased heart rate Increased blood pressure Runny nose Sneezing Goose bumps Sweating Fever Nausea Vomiting Nervousness Restlessness Irritability Weakness Shivering or trembling Abdominal cramps Yawning

27 CDC chronic pain guidelines Provides recommendations for primary care providers -Does not include treatment for cancer, palliative care, end-of-life Addresses opioid analgesic use -When to initiate and continue opioid analgesics -Opioid analgesic selection, dosage, duration, follow-up, discontinuation Supports naloxone use when risk factors for opioid analgesic-related harms are present Improves communication between prescribers and claimants -Risks and benefits of opioid analgesic therapy -Improve safety and effectiveness of treatment -Reduce risks of long-term opioid analgesic use, abuse, overdose, death

28 Official Disability Guidelines Formulary Status -Y drug (Naloxone Solution for Injection) -N drug (Evzio Auto-Injector and Narcan Nasal Spray) Naloxone Recommendations per Chronic Pain Chapter -Injection: Recommended in hospital-based and emergency room settings for intravenous, intramuscular and subcutaneous administration -Auto-Injector/Nasal Spray: Not generally recommended for outpatient, pre-hospital use by untrained lay users *ODG Formulary status as of January 2017

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30 Legislative Actions

31 Naloxone advocates

32 2016 state and federal legislative action State Policy/Action Description Alaska SB 23 (passed) Allows for prescribing and dispensing of opioid analgesic overdose drugs to individuals (or their family member) at risk for overdose, and provides immunity for individuals and practitioners administering the drug in good faith Connecticut HB 5053 (passed) Requires training of first responders in use of naloxone and protects them from civil liability Indiana SB 187 (signed by governor Pence on March 21, 2016) Allows for the dispensing of naloxone as an over-the-counter drug Individuals at risk Family members or others close to individuals at risk Requires reporting of use by first responders Iowa SF 2218 (signed by Governor Branstad on April 6, 2016) Allows for the prescribing and dispensing of opioid analgesic overdose drugs to individuals (or their family member) at risk for overdose, and provides immunity for individuals and practitioners administering the drug in good faith, and provides antagonists to first responders Maine LD1547 (became law after veto override) Allows pharmacists to dispense naloxone without a prescription Makes naloxone available to first responders Directs the Board of Pharmacy to create guidelines Massachusetts HB 4056 (passed) Comprehensive opioid analgesic bill that included provisions for training first responders on proper use of antagonists North Carolina SB 734 (signed by Governor McCrory on June 20, 2016) Allows practitioners to dispense naloxone without a prescription

33 2016 state and federal legislative action State Policy/Action Description South Dakota HB 1079 (passed) Allows for prescribing and dispensing of an opioid analgesic antagonist to a family member or friend who is in a position to intervene for a person in the event of an overdose, and provides immunity for prescribers and pharmacists who provide the antagonist to a person on reasonable belief Utah HB 240 and HB 192 (passed) HB Enhanced current law expanding the prescribing to family members and others close to individual at risk for overdose, and provides immunity if acting in good faith when prescribing, dispensing or administering in good faith HB Creates a pilot program to make opioid analgesic antagonists available to family members, first responders, schools, counseling centers and other venues that work with individuals addicted to opioid analgesics Vermont Regulatory Action (Effective July 1, 2017) Establishes a ceiling of 90 MME/day for treatment of chronic pain and when this level is exceeded imparts new requirements for possible co-prescribing of naloxone. Federal S 524: Comprehensive Addiction and Recovery Act of 2016 (passed) Includes provisions in several grant areas that offer priority status to states that provide civil liability protection for first responders, health professionals, and family members administering naloxone to counteract opioid analgesic overdoses Provides funding for training first responders on the use of antagonists Signed by the President Federal HR 34: 21 st Century Cures Act (passed) Provides $1 billion over a two year period in state grants to supplement their opioid abuse and prevention programs, such as: Improving state PDMP systems and processes Implementing educational programs for healthcare providers Expanding access to opioid addiction treatment programs Signed by the President

34 Advocating to prevent opioid analgesic deaths Addiction Prevention - Promote and support laws aimed at reducing opioid analgesic prescriptions Creating Access to Naloxone - Promote and support laws that create better access to naloxone

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36 Naloxone Availability

37 Naloxone intramuscular (IM) Kit (Vial + Syringe) Auto-injector Naloxone 0.4 mg/ml solution How Supplied: - Two single-use 1 ml vials, or - 1 X 10 ml multi-use vial - Two syringes (1 inch long) Directions: - Inject 1 ml into shoulder or thigh - Repeat after 2-3 minutes if no response Evzio (naloxone) 0.4 mg/0.4 ml How Supplied: Two-pack of single use auto-injectors plus 1 trainer Directions: Inject into outer thigh as directed by voice-activated system. Place black side firmly on outer thigh; depress and hold for five seconds. Repeat with second device after 2-3 minutes if no response

38 Naloxone intranasal Naloxone with atomizer Narcan Nasal Spray Naloxone 2 mg / 2 ml How Supplied: - 2 X 2 mg/2 ml Luer-Lock prefilled needleless syringes - Two mucosal atomization devices Directions: - Spray 1 ml (1/2 syringe) into each nostril - Repeat after 2-3 minutes if no response Naloxone 4 mg / 0.1 ml How Supplied: Two-pack of single-use nasal sprays Needle-free intranasal device Directions: Spray into one nostril Repeat with second device into other nostril after 2-3 minutes if no response

39 Naloxone practice pearls Check expiration dates -Before dispensing (pharmacist) -Periodically after being dispensed (claimant/caregiver) Store naloxone at room temperature -Most expire in about months Keep out of reach of children Periodically check solution to make sure it is clear

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41 Overdose Risk Factors

42 Common risk factors for overdose Addiction or substance abuse history Suspected or known illicit drug use Previous overdose Enrolled in methadone or buprenorphine detox program Isolation from others (living in rural areas) Obtaining opioid analgesics from multiple prescribers and multiple pharmacies

43 Common risk factors for overdose High doses of opioid analgesics Opioid initiation or rotation Concurrent use of other CNS depressants, including but not limited to: - Benzodiazepines - Sedative-Hypnotics - Muscle relaxants Comorbid conditions - Smoking, COPD, asthma, sleep apnea, depression, anxiety, insomnia - Kidney or liver disease - Alcohol abuse

44 Next Steps

45 Steps to Prevent Overdose Secure opioid analgesics in safe place Avoid higher risk combinations Ensure prescribers and pharmacists know of all medications being taken Dispose of medications properly Teach family and friends how to respond to an overdose Use Available Clinical Services/Early Intervention Treatment agreements Urine drug testing Industry Tools Prescription Drug Monitoring Programs (PDMPs) Abuse-deterrent opioid analgesics Naloxone access

46 Naloxone only an adjunct Naloxone is NOT a magic bullet for opioid analgesic overdose or substitute for medical care Overdose can occur with or without substance abuse Prescribers should monitor claimant for potential misuse and abuse - Understand guidelines and associated risks - Use opioid analgesic treatment agreements with claimant - Use screening tools to determine potential for drug abuse - Limit quantities of opioid analgesics - Monitor and treat co-morbid conditions appropriately - Do not prescribe dangerous combinations of medications - Perform random urine drug testing - Consider abuse-deterrent opioid analgesics when warranted - Check state PDMPs if available - Know state laws and how to prescribe naloxone - Educate claimants (and families/loved ones) on the risk of overdose and what to do in case of overdose

47 Some questions to ask when reviewing medications What is the current dose of opioid analgesics? Is the claimant taking more than one opioid analgesic? Are the opioid analgesics prescribed by different physicians? Has the claimant recently switched to a different opioid analgesic? What other medications are being prescribed? Is the claimant taking respiratory medications for asthma, COPD, etc? Has the claimant been abstinent from taking opioid analgesics for a period of time due to detoxification?

48 Some questions to ask when reviewing progress notes Does the claimant have a history of substance or alcohol abuse? Does the claimant suffer from mental illness? Does the prescriber and claimant have a signed treatment agreement? Are pain scores and function being documented? Is there documentation of side effects? Is urine drug testing being performed periodically? Is there evidence of illicit drug use or non-prescribed medications on UDT? Does the claimant have an underlying respiratory condition that makes him/her more susceptible to overdose? Was the claimant recently discharged from emergency medical care for opioid analgesic overdose or intoxication?

49 What can you do? ASSESS and MONITOR your claimant who is prescribed opioid analgesics LOOK FOR Risk Factors for Opioid Overdose ENGAGE the prescriber and/or your clinical resources as needed COMMUNICATE and EDUCATE with your claimant to ensure safety UNDERSTAND your company policies surrounding approval of naloxone

50 Thank you! Questions? You will receive an from the CEU Institute on our behalf approximately 24 hours after the webinar. This will contain a link that you will use to submit for your CE credits. You must complete this task within 72 hours. Register for additional Continuing Education Opportunities CE credits for this course are administered by the CEU Institute. If you have any issues or questions regarding your credits, please contact submissions@ceuinstitute.net.