Naloxone: What You Need to Know About Overdose Reversal In the Midst of an Opioid Epidemic Kyle Troksa, Pharm.D., AE-C PGY1 Resident Community Medical Center March 4th, 2018
Conflicts of Interest No conflicts of interest to disclose Accolades Sherrill Brown, Pharm.D., DVM, BCPS University of Montana Skaggs School of Pharmacy Community Medical Center
Objectives 1. Assess scenarios in which naloxone may be administered or prescribed and how to educate patients and providers about its use 2. Analyze similarities and differences amongst naloxone products, resources regarding their use, and current/future applications
Pre-Question #1 What is the mechanism of action of naloxone and common side effects associated with its use? A. Non-competitive opioid antagonist / agitation, hypotension, tachycardia B. Competitive, partial opioid agonist / sedation, hypertension, bradycardia C. Competitive opioid antagonist / agitation, hypertension, tachycardia D. Non-competitive, full opioid agonist / sedation, hypotension, bradycardia
Pre-Question #2 You are the first responder to what was called in as an overdose. The patient is lying on the ground, has constricted pupils, slurred speech, normal breathing and responds to your questions. What is an appropriate action to take? A. Administer one dose of IN naloxone B. Administer two sequential naloxone doses ASAP C. Call EMS and monitor patient for worsening symptoms D. Call law enforcement to arrest patient
Pre-Question #3 A patron comes to you concerned that they will have legal repercussions for calling 911 for their friend who recently overdosed on opioids. What would be your best response? A. Find a good lawyer B. You are covered under the Good Samaritan Law C. Talk to your state representative D. Discuss the matter with your friend first to see if they want to press charges
Pre-Question #4 How soon after the first naloxone dose is given can another be administered if no response? A. 2-5 minutes B. 7-10 minutes C. 12-15 minutes D. 17-20 minutes E. 27-30 minutes
Pre-Question #5 A Russian speaking patient with no health insurance is requesting a recommendation for naloxone product to treat opioid overdose for her mother in the event it is needed. What is the best product to recommend? A. Intranasal Spray B. Intranasal Syringe C. Intramuscular Autoinjector D. A or B E. B or C
Agenda What is the landscape of the opioid epidemic? What is naloxone and its role in therapy? What are the differences in naloxone products? Who can give or receive naloxone? How do you administer naloxone? What are the access laws? What are resources available to providers/patients?
The Opioid Epidemic- Global
The Opioid Epidemic- National 115 Americans die daily from opioid overdose Economic burden: $78.5 Billion annually 2015: 33,000 deaths, 2M opioid related substance use disorders (likely more) 80% of people who use heroin tend to first abuse prescription opioids Epidemic designation from President Trump in 2017 drugabuse.gov
The Opioid Epidemic- National https://www.cdc.gov/mmwr/volumes/66/ss/ss6619a1.htm?s_cid=ss6619a1_w
The Opioid Epidemic- National https://www.cdc.gov/mmwr/volumes/66/ss/ss6619a1.htm?s_cid=ss6619a1_w
This image cannot currently be displayed. https://www.cdc.gov/drugoverdose/images/data/opioiddeathsbytypeus.png
This image cannot currently be displayed. https://drugabuse.com/wp-content/uploads/1annualdeaths_animated.gif
The Opioid Epidemic- Montana This image cannot currently be displayed. Not as bad as national average Between 2000 and 2015, 700 people in MT died of overdoses Pain protocols and limiting discharge opioids could be contributing to benefit Still room for improvement http://nbcmontana.com/news/local/statewide-efforts-aim-to-combat-opioid-epidemic
Naloxone Brand names: Narcan, Evzio Mechanism of Action: competitive, pure opioid antagonist (mainly targets μ-opioid receptors) Onset- 2-5 min Duration- 30-120 min Absorption- IN, IM, SC, IV Distribution- weakly albumin bound, crosses BBB Metabolism- hepatic (glucuronidation) Excretion- urine Lexicomp
This image cannot currently be displayed. Harm Reduction Coalition
Naloxone Adverse reactions (immediate withdrawal): HTN, tachycardia, agitation, dizziness, headache, irritability, seizure, hot flash, abdominal cramps, vomiting, muscle spasm/pain, yawning Injection site reaction Pregnancy risk factor: C (crosses placenta) Breastfeeding: unknown if present in breast milk (lipophilic, so likely) Lexicomp
prescribetoprevent.org
This image cannot currently be displayed. prescribetoprevent.org
Shelf Life Store at RT (59 F-77 F), excursions 39 F-104 F allowed for up to 24 hours 12-18 months (if stored properly, can use until expiration date) Once naloxone vial/amp is inserted into syringe, expires in 2 weeks Monitor expiration date- as last resort, can use expired product, but will likely not be as effective Naloxone Package Insert https://www.accessdata.fda.gov/drugsatfda_docs/label/2015/208411lbl.pdf
Signs of an overdose HIGH OVERDOSE Pupils constricted Muscles relaxed Responsive to stimulus Pruritus (scratch at skin) Slurred speech Harm Reduction Coalition Awake, but unable to talk Limp body Pale skin Cyanosis Respiratory depression Bradycardia Choking sounds Vomiting Loss of consciousness Unresponsive to outside stimulus
This image cannot currently be displayed. prescribetoprevent.org
Who can access or administer naloxone Law enforcement Emergency departments Parents/siblings/friends Firefighters School administration Senior centers Military personnel etc. This image cannot currently be displayed. https://www.substance.com/wp-content/uploads/2014/04/stoughton2.png
Approach to Treating an Overdosed Patient SCARE ME: Stimulation Call 911 Airway Rescue Breathing Evaluate the Situation Muscular Injection (or intranasal) Evaluate Again This image cannot currently be displayed. Harm Reduction Coalition http://cdn.ahchealthenews.com/wp-content/uploads/2016/05/naloxone-reverses-opioid-overdose-saves-lives.jpg
Administration- Intranasal Spray How supplied: 4 mg/0.1 ml 2 pack single spray device Sig: Spray entire contents of device into 1 nostril upon signs of opioid overdose. Call 911 May repeat x1 in other nostril This image cannot currently be displayed. CPNP Naloxone Access Guideline
This image cannot currently be displayed. Administration- Intranasal Spray Narcan Package Insert
Administration- Intranasal Syringe How supplied: 2 mg/2 ml 2 pack syringes Also need Rx for atomizer No. 2 Sig: One spray into each nostril upon signs of opioid overdose. Call 911 May repeat x1. This image cannot currently be displayed. CPNP Naloxone Access Guideline
Administration- Intranasal Syringe http://prescribetoprevent.org/patient-education/videos/ CPNP Naloxone Access Guideline
Administration- Intramuscular Vials How supplied: 0.4 mg/ml 2 pack single dose vial Need Rx for 3 ml x 25G 1 in. No. 2 Sig: Inject 1 ml IM upon signs of opioid overdose. Call 911 May repeat x1. This image cannot currently be displayed. CPNP Naloxone Access Guideline
Administration- Intramuscular Vials CPNP Naloxone Access Guideline
Administration- Intramuscular Auto Injector How supplied: 0.4 mg/0.4 ml 2 pack Sig: Inject IM into outer thigh upon signs of opioid overdose. Listen to English prompts--hold in place for 5 seconds. Call 911 May repeat x1. CPNP Naloxone Access Guideline
Administration- Intramuscular Auto Injector This image cannot currently be displayed. EVZIO Package Insert
Insurance Coverage Cost: Intranasal spray- $75.00 Intranasal syringe- $39.60 Intramuscular vials- $18.71 Intramuscular autoinjector- $2,250.00 Coverage: CMS and private plans will pay for naloxone. Atomizer typically not covered (provided free or $10 for 2 atomizers). CPNP Naloxone Access Guideline
Access Laws Good Samaritan Laws MT-HB 333: Help Save Lives From Overdose Act Immunity from legal prosecution for calling for help Standing Orders (to be discussed by Dr. John Douglas) Allows for increased access to naloxone without prescription Liability protection/third party administration: Protects prescriber, pharmacist, and naloxone administrator CPNP Naloxone Access Guideline
Resources https://www.drugabuse.gov/ http://prescribetoprevent.org/ https://www.cdc.gov/drugoverdose/index.html https://www.hhs.gov/opioids/about-the-epidemic/ https://www.samhsa.gov/ CPNP Naloxone Access Guide Project Lazarus Community Toolkit
Resources Drug Take-back Days 1-2 times per year- patients can bring unused/expired medications for disposal Rx drop-boxes Missoula Police Department Granite Pharmacy Other takeback centers: https://dojmt.gov/consumer/prescriptiondrugabuse/rxdropbox-locations
Post-Question #1 What is the mechanism of action of naloxone and common side effects associated with its use? A. Non-competitive opioid antagonist / agitation, hypotension, tachycardia B. Competitive, partial opioid agonist / sedation, hypertension, bradycardia C. Competitive opioid antagonist / agitation, hypertension, tachycardia D. Non-competitive, full opioid agonist / sedation, hypotension, bradycardia
Post-Question #2 You are the first responder to what was called in as an overdose. The patient is lying on the ground, has constricted pupils, slurred speech, normal breathing and responds to your questions. What is an appropriate action to take? A. Administer one dose of IN naloxone B. Administer two sequential naloxone doses ASAP C. Call EMS and monitor patient for worsening symptoms D. Call law enforcement to arrest patient
Post-Question #3 A patron comes to you concerned that they will have legal repercussions for calling 911 for their friend who recently overdosed on opioids. What would be your best response? A. Find a good lawyer B. You are covered under the Good Samaritan Law C. Talk to your state representative D. Discuss the matter with your friend first to see if they want to press charges
Post-Question #4 How soon after the first naloxone dose is given can another be administered if no response? A. 2-5 minutes B. 7-10 minutes C. 12-15 minutes D. 17-20 minutes E. 27-30 minutes
Post-Question #5 A Russian speaking patient with no health insurance is requesting a recommendation for naloxone product to treat opioid overdose for her mother in the event it is needed. What is the best product to recommend? A. Intranasal Spray B. Intranasal Syringe C. Intramuscular Autoinjector D. A or B E. B or C
Preguntas? This image cannot currently be displayed.