The Opioid Crisis: From Misuse to Abuse to Death

Transcription

1 The Opioid Crisis: From Misuse to Abuse to Death Lisa Booze, PharmD, CSPI Live Activity Handout 4 slides per page

2 The Opioid Crisis: From Misuse to Abuse to Death ACTIVITY DESCRIPTION Opioid overdoses and deaths have been increasing at an alarming rate. The overprescribing and misuse of prescription opioids in recent years has led to heroin abuse, overdoses and deaths in numbers never seen before. Contributing to these deaths has been the contamination of heroin with fentanyl, fentanyl analogs, and other synthetic opioids. Abuse-deterrent formulations, prescription drug monitoring programs and "bystander" naloxone availability are some of the strategies being used to attempt to prevent opioid overdose deaths. TARGET AUDIENCE The target audience for this activity is pharmacists, pharmacy technicians, and nurses in hospital, community, and retail pharmacy settings. LEARNING OBJECTIVES After completing this activity, the pharmacist will be able to: List reasons why opioid overdoses and deaths are increasing Recognize non-pharmaceutical synthetic opioids that are being added to heroin or sold as heroin substitutes. Describe the clinical effects that occur following an opioid overdose Outline steps being taken to combat the opioid epidemic After completing this activity, the pharmacy technician will be able to: List reasons why opioid overdoses and deaths are increasing Recognize non-pharmaceutical synthetic opioids that are being added to heroin or sold as heroin substitutes Outline steps being taken to combat the opioid epidemic ACCREDITATION Pharmacy PharmCon, Inc. is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. Nursing PharmCon, Inc. is approved by the California Board of Registered Nursing (Provider Number CEP 13649) and the Florida Board of Nursing (Provider Number ). Activities approved by the CA BRN and the FL BN are accepted by most State Boards of Nursing. CE hours provided by PharmCon, Inc. meet the ANCC criteria for formally approved continuing education hours. The ACPE is listed by the AANP as an acceptable, accredited continuing education organization for applicants seeking renewal through continuing education credit. For additional information, please visit: Universal Activity No.: L05-P Credits: 1.0 contact hour (0.1 CEU) Release Date: 6/19/2017 freece Expiration Date: 6/19/2020 ACPE Expiration Date: 6/19/2020 ACTIVITY TYPE Knowledge-Based Live Webinar FINANCIAL SUPPORT BY Pharmaceutical Education Consultants, Inc.

3 Lisa Booze, PharmD, CSPI Clinical Coordinator, Maryland Poison Center, Univ of MD School of Pharmacy ABOUT THE AUTHOR Dr. Lisa Booze is a certified Specialist in Poison Information (CSPI) and Clinical Coordinator at the Maryland Poison Center, a program of the University of Maryland School of Pharmacy. Lisa received her B.S. in Pharmacy and Doctor of Pharmacy degrees from the University of Maryland School of Pharmacy. She has been providing poison information, assessment and treatment recommendations to Maryland Poison Center callers since In her role as Clinical Coordinator, she develops and presents toxicology education programs for health professionals. Lisa is also co-coordinator of the Poison Center Surveillance for Chemical and Bioterrorism and Public Health Program, supported by the Maryland Department of Health and Mental Hygiene. FACULTY DISCLOSURE It is the policy of PharmCon, Inc. to require the disclosure of the existence of any significant financial interest or any other relationship a faculty member or a sponsor has with the manufacturer of any commercial product(s) and/or service(s) discussed in an educational activity. Lisa Booze reports no actual or potential conflict of interest in relation to this activity. Peer review of the material in this CE activity was conducted to assess and resolve potential conflict of interest. Reviewers unanimously found that the activity is fair balanced and lacks commercial bias. Please Note: PharmCon, Inc. does not view the existence of relationships as an implication of bias or that the value of the material is decreased. The content of the activity was planned to be balanced and objective. Occasionally, faculty may express opinions that represent their own viewpoint. Participants have an implied responsibility to use the newly acquired information to enhance patient outcomes and their own professional development. The information presented in this activity is not intended as a substitute for the participant s own research, or for the participant s own professional judgement or advice for a specific problem or situation. Conclusions drawn by participants should be derived from objective analysis of scientific data presented from this activity and other unrelated sources. Neither freece/pharmcon nor any content provider intends to or should be considered to be rendering medical, pharmaceutical, or other professional advice. While freece/pharmcon and its content providers have exercised care in providing information, no guarantee of it s accuracy, timeliness or applicability can be or is made. You assume all risks and responsibilities with respect to any decisions or advice made or given as a result of the use of the content of this activity.

4 Hello, Poison Center? My husband has been taking oxycodone for many years for back pain. He has been taking a lot more lately, and this morning I can t wake him up The Opioid Crisis: From Misuse to Abuse to Death This is 911. I have a caller on the line with a friend who is unconscious but breathing after injecting what he thought was heroin. Paramedics have been dispatched. I can t wake up my 2 year old granddaughter. She might have gotten into her mother s buprenorphine tablets Faculty: Lisa Booze, PharmD, CSPI The U.S. Accounts For 4% of World s Population but Uses 80% of its Rx Opioids Source of Rx Opioids for Nonmedical Use >30% Americans have pain 245 million opioid prescriptions dispensed in ,000 each day 3,900 start using Rx opioids non-medically each day 1 in 4 people who receive Rx s for non cancer pain struggle with addiction 2 million Americans abused or were dependent on Rx opioids in 2014 CDC Opioid Fact Sheet Volkow ND. NEJM 2016;374(13): National Survey on Drug Use & Health 2014; DEA 1

5 Prescription Opioid Overdoses & Deaths 1000 Americans treated in emergency departments each day for non-medical use 52 Americans die every day from overdosing on prescription opioids Most common Rx opioids involved in deaths: methadone, oxycodone, hydrocodone Route of Administration Abuse Deterrent Formulations OxyContin reformulated in 2010 Abuse decreased Old Imprint New Imprint OC OP 2

6 Abuse Deterrent Formulations Abuse Deterrent Formulations Addition of an opioid antagonist Talwin NX - pentazocine + naloxone; 1982 Suboxone buprenorphine + naloxone; 2002 Embeda morphine + naltrexone; October 2014 Targiniq ER oxycodone + naloxone; July 2014 Troxyca ER oxycodone + naltrexone; August 2016 Embeda Physical/chemical barriers (crush/extraction resistant) Exalgo - hydromorphone; March 2010 OxyContin - oxycodone; April 2010 Oxecta oxycodone; June 2011 Hysingla ER hydrocodone; November 2014 Zohydro ER hydrocodone; January 2015 MorphaBond - morphine; October 2015 Arymo ER morphine; January 2017 Vantrela ER hydrocodone; January 2017 Abuse Deterrent Formulations- Not the Magic Bullet! 1960 s First opioid used was heroin (80%) > 2/3 prefer IR opioids- quicker high, easier to abuse 66-97% OxyContin users had used it orally before reformulation (9 different studies) 91.8% of US poison center callers used OxyContin orally Ways to defeat the abuse-deterrent mechanism Many use OxyContin after reformulation or replace it with other Rx opioids or heroin 2000 s First opioid used was Rx opioid (75%) 4/5 heroin users have abused Rx pain pills 1/15 people who take Rx pain relievers nonmedically will try heroin within 10 years RADARS Sys Tech Report 2016-Q2; Cicero TJ. JAMA Psych 2015;72: Cicero TJ. NEJM 2012;367:187-9; RADARS Sys Tech Report 2016-Q4 JAMA Psychiatry 2014;71: NEJM 2015;373:

7 Why Switch to Heroin? Rx Opioids Aren t the Only Reason Rx opioids are harder to get Changes in prescribing habits PDMPs Heroin is cheap An opioid tablet is >3x the cost of a dose of heroin Heroin is easy to buy Online, social media, texting, in school, widespread geographical areas Rate of heroin use and heroin deaths started to increase before OxyContin was reformulated and before changes in Rx opioid policies Higher purity Flooding the market Low cost $3,000 $2,500 $2,000 $1,500 $1,000 $500 $0 Price per gram Who Uses Heroin? 51% increase in the number of current heroin users between (SAMHSA) > But the rate in women is increasing ~90% who tried heroin for the first time in the past decade are white 109% increase in years olds ( ) 96% report using at least one other drug in addition to heroin 4

8 It s Not Just Heroin! Fentanyl Fentanyl added to heroin to increase potency 50 x more potent than heroin Lethal dose = 2 mg Fentanyl and precursors mostly made in China DEA DEA >700 fentanyl-related deaths late 2013-late 2014 DEA nationwide alert, March 18, 2015 June 2016: DEA warning to law enforcement and first responders about the dangers of handling fentanyl DEA 3 rd Q 2016: 70% of samples that tested positive for opioids contained fentanyl Also sold as cocaine New Haven, CT, June 2016 Typical urine drug screens don t test for fentanyl CDC MMWR 2017;66: Furanyl Fentanyl Carfentanil- Elephant Sedative powder, tablets, nasal spray July 2016: 43 ODs transported to 1 hospital in 4 days in British Columbia furanyl fentanyl in crack cocaine Nov 29, 2016 : Became a Schedule I drug >12 other fentanyl analogs 20 mcg (<1 grain of salt) can be fatal Mixed with heroin, in tablets, on blotter paper Used by Russians in Moscow theatre hostage crisis (2002) 850 hostages, 125 deaths 5

9 Carfentanil CBC News Aug 9, kg fentanyl 1 million x 1 mg $10/tablet $10 million responsible for more than 170 overdoses in Cincinnati that occurred during one week last month. Sept 21, 2016 Sept 22, 2016 Centre Daily Times, Jan 22, 2017 U.S. ICE One Pill Can Kill U ( pink, pinky, U-4 ) March 2016, 18 patients in 8 days with exaggerated opioid effects after taking their normal dose of hydrocodone/acetaminophen tablets bought on the street 5 required CPR, 6 required ventilatory support, 1 died 17 given naloxone, 4 required prolonged naloxone infusions All tested positive for fentanyl Tablet analysis: 600-6,900 mcg fentanyl/tablet > 56 cases & 15 fatalities within 3 months White powder, tablets, liquid Purchased as a research chemical 7.5 times more potent than morphine (rodents) >46 confirmed deaths, Oct 2015-Sept 2016 Washington Post, November 4, 2016 DEA Acad Emerg Med 2017;24:

10 Opioid Overdoses Greater Risk of an Overdose Drowsy, slurred speech, coma Slow and shallow respirations ( snoring ) or not breathing, apnea, hypoxia, non-cardiogenic pulmonary edema Constricted pupils (not always evident) Also possible: bradycardia, hypotension, hypothermia, aspiration Methadone QTc prolongation Tramadol - seizures With IV heroin- How potent? What else is in it? After a period of abstinence - unable to get Rx opioids or heroin After drug treatment Leaving prison Ethanol - respiratory depression Taking CYP450 3A4 inhibitors (e.g. erythromycin, antifungals, protease inhibitors) Discontinuing CYP450 3A4 inducers (e.g. rifampin, carbamazepine, phenytoin) Jones CM. Am J Prev Med 2015 Oct;49(4): ; Van der Schrier. Anesthesiology. Early online February 7, 2017 The Youngest Victims Opioid poisoning hospitalizations in 1-4 year olds increased 205%, Buprenorphine/naloxone ingestions top medication causing hospitalizations in young children, Pediatrics 2017;139(3):e Gaither JR. JAMA Pediatr 2016;170(12): CDC MMWR Oct 21, 2016;65(41):

11 Naloxone Naloxone Formulations Opioid antagonist: blocks opioid receptors Administer and titrate so respiratory efforts return mg IV, IM, SC, intranasal, nebulized Some opioids (e.g. fentanyl, carfentanil) will require high doses (>2 mg) Duration of action = minutes; symptoms may recur Infusion for long-acting opioids Injectable - vial or prefilled syringe 0.4 mg/ml, 2 mg/2ml Naloxone auto-injector (Evzio ) 0.4 mg, 2 mg Concentrated intranasal device (Narcan ) 2 mg, 4mg/0.1 ml Nasal spray - Prefilled capsule +luer lock syringe + atomizer 2mg/2mL Bystander Naloxone Programs Unanswered Questions Law enforcement naloxone administration Physician education; 3 rd party Rx s for naloxone Overdose Response Programs for bystanders : family, friends, school staff, associates of anyone who is at risk of overdosing Standing orders at pharmacies Non-prescription status Who should receive naloxone kits? Should all patients receiving opioid therapy be offered naloxone? Does naloxone availability alter opioid prescribing practices? Will having a rescue kit increase risky behaviors? How should naloxone be administered and at what dose? Is there any liability after giving it? What happens after an overdose has been reversed? Is it affordable? Will this decrease overdoses and deaths? Addict Sci Clin Pract 2017;12:4 8

12 What Can We Do? What Can We Do? Discuss the benefits and risks with opioids Counsel patients about the importance of taking drugs as prescribed, including the possibility of addiction, withdrawal and overdose Recommend alternative therapies Counsel patients on how to safeguard their medicines at home Encourage disposal of drugs Recognize signs and symptoms of medication misuse Refer to naloxone training programs Encourage the patient to get treatment for addiction Give names and phones numbers of agencies and treatment programs Don t be judgmental; deliver motivational messages SAMHSA What Can We Do? Use Prescription Drug Monitoring Programs Reduction of days of Rx opioid and heroin misuse; decline in doctor-shopping Watch for over-prescribing Promote safe-prescribing and/or use of alternative drugs, especially in patients with drug abuse history CDC Guidelines for Prescribing Opioids for Chronic Pain Addictive Behaviors 2017;69: