2018 APM Winter Meeting San Antonio, TX

Transcription

1 Moving target: The opioid crisis in the era of illicit fentanyl Alexander Y. Walley, MD, MSc Associate Professor of Medicine, BUSM Director, Addiction Medicine Fellowship, BMC Medical Director, Opioid Overdose Prevention Pilot Program, MDPH 2018 APM Winter Meeting San Antonio, TX Tuesday, March 20, 2018

2 Disclosures Alexander Y. Walley, MD, MSc The following personal financial relationships with commercial interests relevant to this presentation existed during the past 12 months: None My presentation will include discussion of off-label use of the following: Naloxone is FDA approved as an opioid antagonist Naloxone delivered as an intranasal spray with a mucosal atomizer device has not been FDA approved and is off label use

3 Learning objectives At the end of this session, you will learn: 1. To integrate seizure, death toxicology and information of people using opioids to understand changing overdose risk 2. The implications of higher potency opioids on overdose prevention strategies New Hampshire State Police Forensic Lab

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6 Romney Care Naloxone via public health programs Expansion of buprenorphine treatment Police/Fire naloxone Safe opioid education mandated Pharmacy SO

7 Safer opioid prescribing

8 Cicero TJ, Ellis MS, Kasper ZA. Increased use of heroin as an initiating opioid of abuse. Addictive Behaviors May 23.

9 od%20deaths%20mass%20residents%20nov 17.pdf

10 Katz, J. The First Count of Fentanyl Deaths in 2016: Up 540% in Three Years. NYT The UpShot 9/2/2017.

11 Prescription opioids for pain Transitioning to heroin and illicitly made fentanyl Erratic and more deadly heroin and fentanyl supply Overdose response window has shrunk from minutes to hours to seconds to minutes Polysubstance use (including polypharmacy)

12 Fully synthetic opioid About Fentanyl Not detected by opiate screening immunoassays Schedule II Monitored settings for acute pain and/or peri procedural sedation Transdermal for chronic pain times more potent than heroin Illicitly manufactured fentanyl (IMF) mixed with or sold as heroin Unable to differentiate IMF from pharmaceutical fentanyl after human ingestion

13 Armenian P et al. Fentanyl, fentanyl analogs and novel synthetic opioids: A comprehensive review. Neuropharmacology 2017.

14 Fentanyl seized as heroin

15 Fentanyl sold as cocaine Fentanyl sold as powder cocaine resulted in 12 patients presenting to ED within 8 hours with opioid overdose responsive to naloxone. Three died. Fentanyl sold as crack cocaine resulted in 43 patients presenting to ED over 4 days with opioid overdose responsive to naloxone. One died.

16 Fentanyl sold as prescription pills March 25 April 5, 2016, 7 cases of counterfeit Norco ingestion and intoxication were identified by the San Francisco Division of the California Poison Control System. Whereas Norco typically contains acetaminophen and hydrocodone, these counterfeit tablets predominantly contained fentanyl and promethazine. From October 15 to December 31, 2015, the California Poison Control System San Francisco division identified 8 patients who experienced adverse effects associated with the ingestion of counterfeit alprazolam tablets found to contain fentanyl and, in some cases, etizolam.

17 Carfentanyl + furanyl fentanyl sold as heroin Huntington, West Virginia, on August 15, 2016, 20 nonfatal overdose cases in a 53 hour period (14 overdoses occurred within 5 hours) and provided evidence that carfentanil and furanyl fentanyl was present in heroin supply. None received referral for substance use disorder treatment or harm reduction services.

18 Fentanyl analogues mixed with fentanyl 2016 Montgomery County, OH 57.7 overdose deaths per 100,000 (40% increase from 2015) Jan Feb 2017 Fentanyl analogue toxicology in 24 OH counties of 281 overdose deaths 90% Fentanyl POS 48% Acrylfentanyl POS 31% Furanyl fentanyl POS 8% Carfentanil POS 23% Pharmaceutical opioids 6% Heroin

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20 A comprehensive public health response to address overdoses related to IMF 1. Fentanyl should be included on standard toxicology screens 2. Adapt existing harm reduction strategies, such as direct observation of anyone using illicit opioids, and ensuring bystanders are equipped with naloxone 3. Enhanced access and linkage to medication for opioid use disorders So, now what they [people selling illicit drugs] are doing is they re cutting the heroin with the fentanyl to make it stronger. And the dope [heroin] is so strong with the fentanyl in it, that you get the whole dose of the fentanyl at once rather than being time released [like the patch]. And that s why people are dying plain and simple. You know, they [people using illicit drugs] are doing the whole bag [of heroin mixed with fentanyl] and they don t realize that they can t handle it; their body can't handle it. Overdose bystander

21 Overdose Outbreak Public Health Messaging Freeman and French Public Health Reports 1995 survey 21% surveyed had actively searched for fentanyl after hearing about the overdoses during 1991 NY NJ outbreak Kerr et al. Addiction 2013 qualitative interviews A 2011 overdose warning campaign appeared to be of limited effectiveness and also produced unintended negative consequences that exacerbated overdose risk Soukup Baljak et al. IJDP 2015 qualitative interviews Communication guidelines for consideration: Use language on drug alert postings that implies harm Indicate what drug effects to look for Suggest appropriate responses to overdose, such as the use of naloxone Date posters and remove them in a timely manner so as to not desensitize

22 At the end of this session, you will learn: 1. To integrate seizure, death toxicology and information of people using opioids to understand changing overdose risk 2. The implications of higher potency opioids on overdose prevention strategies

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24 Public health public safety surveillance and rapid response Post overdose outreach Pharmacy interventions Safe spaces for oversedation Bathroom safety Supervised consumption spaces Injectable opioid agonist treatment diacetylmorphine, hydromorphone

25 22 police and fire departments were interviewed 2016 Qualitative analysis defined four program types: 1. Home Visit first responder and collaborator go to the home of the overdose victim and offer support and resources 2. Prescriptive Treatment first responder goes to the home and offers entry to treatment, including court mandated treatment 3. Clinician based Outreach clinician embedded in the department outreaches to OD victim with limited participation of public safety 4. Drop In stations offer access to treatment without threat of arrest for people voluntarily presenting Formica et al. IJDP 2018

26 Bathrooms are injection facilities: How to make them safer? Make your bathrooms safer outfit bathrooms with: Secure biohazard boxes Good lighting and Mirrors Doors that open out Call button Intercomm system Reverse motion detector with timer Safer injection equipment Naloxone rescue kits

27 Among people seeking treatment who have Rx opioid misuse 4% were truly substance naïve 70% had experience before first opioid, other than ETOH, tob or MJ Cicero TJ, Ellis MS, Kasper ZA. Psychoactive substance use prior to the development of iatrogenic opioid abuse: A descriptive analysis of treatmentseeking opioid abusers. Addictive behaviors Feb 28;65:242-4.

28 Prescribed opioids at and before overdose death : June 2013 December 2015 (n=2,916) Opioids commonly prescribed within 1 year of death, but uncommonly prescribed at time of death Walley et al. Under Review 28

29 Opioids present in toxicology at death and active prescription: proportion prescribed among MA residents who died of an opioid overdose: June 2013 December 2015 (n=2916) Active prescriptions for drugs found in toxicology are uncommon at death, especially fentanyl Walley et al. Under Review 29

30 Active opioid prescriptions at time of death for people with post mortem toxicology: substance in toxicology vs. not in toxicology Opioids prescribed were commonly NOT present on overdose toxicology Walley et al. Under Review MMT = Methadone Maintenance within 1 month of death 30

31 Risk Compensation and Moral Hazard >> Narcan Party Urban Legend = Fake News 'Drug dealers are throwing Narcan parties' Aug previous assertions by two legislators in PA: hesitant to expand narcan access html The TV story March 2017 in PA: raising concerns about narcan parties offeringdrugs and antidote to users/ Naloxone distribution does not increase drug use Maxwell et al.,journal of Addictive Diseases, 2006; Seal et al., Journal of Urban Health, 2005; Wagner et al., 2010 International Journal of Drug Policy; Doe Simkins et al, BMC Public Health, 2014 Jones et al. Addictive Behaviors 2017:71:104 6 Similar examples: Seat belts do not cause more motor vehicle deaths, but reduce them Syringe distribution does not increase HIV transmission, but reduces Vaccinations & condoms do not increase sexually transmitted infections Fire extinguishers do not cause fires, but reduce their consequences