AN OVERVIEW OF THE PRESENTATION AND TREATMENT OF OPIOID OVERDOSE Jasmine Carpenter, Pharm. D, BCPS, BCPP Clinical Pharmacy Specialist-PACT Mental Health Veterans Affairs Medical Center, Washington DC
OBJECTIVES Review and discuss the epidemiology of opioid overdose in the United States Explain the pharmacology of opioids and how these aspects contribute and affect the presentation of opioid overdose Identify the signs, symptoms, and risks factors for opioid overdose and its associated complications Explain the pharmacology, pharmacokinetics and available formulations of naloxone Demonstrate the use of a naloxone delivery device in the event of an opioid overdose 2
AUDIENCE QUESTION Why is it important for pharmacists to be educated on opioid overdose? 3
RAPPER REFERENCES High-Dose Drug Interaction Drug Diversion Pop a Perky just to start up (pop it, pot it pop it) Pop two cups of purple just to warm up (two cups, drank) Auntie Greta serve ya perkys Migos-Slippery Poppin Pills is all we know Travis Scott-Antidote Opioid Misuse Drug Interaction I got Xanax, Percocet, Promethazine with Codeine Lil Wayne ft. 2 Chainz- Rich 4
CELEBRITIES WHO HAVE DIED FROM PAINKILLERS AND HEROIN Janis Joplin Heroin Overdose Year: 1970 Age: 27 Elvis Presley Multiple Rx drugs (Codeine) Year: 1977 Age: 42 Heath Ledger Oxycodone, hydrocodone, alprazolam and diazepam Year: 2008 Age: 28 Philip Seymour Hoffman Heroin & BZDs Year:2014 Age 46 Prince Fentanyl Year: 2016 Age: 57 Cnn: Celebrities who died from painkillers and heroin 5
THE EPIDEMIOLOGY 6
OPIOID OVERDOSE IN THE US Drug overdose is the leading cause of accidental deaths in the United States, being greater than car accidents and homicide The majority of these deaths involve an opioid (6 out of 10) From 2000-2015, more than half a million people died from drug overdoses 91 Americans die every day from an opioid overdose CDC. Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2016. Available at http://wonder.cdc.gov. 7
Is this epidemic only showing an increase in prescription opioids? 8
NATIONAL OPIOID OVERDOSE EPIDEMIC One recent study found that 4 in 5 new heroin users started out misusing prescription painkillers The number of Americans who have used heroin in the past year has steadily increased from 2002 to 2014 As a consequence the rate of heroin overdose nearly quadrupled from 2000 to 2013 Hedegaard MD MSPH, Chen MS PhD, Warner PhD. Drug-Poisoning Deaths Involving Heroin: United States, 2000-2013. National Center for Health Statistics Data Brief. 2015:190:1-8 9
OPIOID PHARMACOLOGY Opioids exerts their action by binding to 3 opioid receptors: Mu Delta Kappa Opioids cause respiratory depression via activation of the mu-receptor Opioids have a narrow therapeutic index With respiratory depression as the most serious toxic effect that can lead to fatality 10
RISK FACTORS FOR OPIOID OVERDOSE Taking more than prescribed Taking high dose opioids and long acting opioids 100 mg or more daily (morphine equivalent) Comorbid compromising medical conditions COPD Sleep Apnea Severe Pulmonary Conditions Taking the opioid with interacting medications Benzodiazepines Alcohol Other opioids Loss of Tolerance After hospitalization/rehabilitation/jail Medication Non-Adherence 11
SIGNS AND SYMPTOMS OF OPIOID OVERDOSE Loss of consciousness/ The patient cannot be awakened from sleep or heavy nodding Blue fingernails or lips /pale skin Very slow or no breathing Very slow or no heartbeat Vomiting/gurgling noises 12
POP QUIZ How did Jesse s girlfriend die on Breaking Bad? a) From breast cancer b) From an opioid overdose c) From a car accident d) From a heart attack 13
NALOXONE 14
WHY NALOXONE? Studies are proving that naloxone distribution is effective in decreasing the amount of overdose related deaths A 24-46 % decrease in opioid overdose was observed in communities that distributed naloxone devices 17 Naloxone distribution would prevent 6.5% of all overdose deaths for every 20% of heroin users reached by a distribution program 18 Prevention of 2,000 overdose deaths in a population of 200,000 heroin users 18 Walley A, Xuan Z, Hackman H et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ. 2013;346:174-f174. Coffin PO, Sullivan SD. Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal. Ann Intern Med. 2013;158(1):1-9 15
TREATING OPIOID OVERDOSE Opioid overdoses, if caught on time, can be treated with a medication called Naloxone (Narcan ) Naloxone is an antidote for opioid overdose It knocks off the offending opioid and blocks the receptor Reverses respiratory depression 16
NALOXONE (NARCAN ) It possesses a strong affinity for the muopioid receptor Displaces the offending opioid and reversing it s central and peripheral effects Has a short half-life and the duration ranges from 20-90 minutes Routes of Administration: Intravenous (preferred)- ~2 minutes Intramuscular 2 to 5 minutes Subcutaneous 5 minutes Intranasal 8 to 13 minutes 17
Naloxone Intranasal Rescue Kit Non-FDA Approved Assembly Required Naloxone Auto-injector (Evzio) Naloxone Delivery Devices FDA Approved Provides Voice Instructions No Assembly Required Narcan Nasal Spray Each kit comes with a total of 2 doses FDA Approved No Assembly Required 18
NALOXONE DELIVERY DEVICES Evzio (Auto-Injector) Narcan Nasal Spray Intranasal Naloxone Rescue Kit FDA Approved FDA Approved Not FDA Approved Intramuscular or Subcutaneous Administration Intranasal Intranasal 90.5% successful use without training & 100% successful use with training 90.5% successful use without training 0% successful use without training & 57.1% successful use with training 19
DEVICES 5-7 COST OF NALOXONE DELIVERY Evzio Narcan Nasal Spray Intranasal Naloxone Kit $3750 per 2 auto-injectors $125 per dual package $37 per device for group purchasers such as law enforcement, fire fighters, collages ~$50 20
RESPONSE TO OPIOID OVERDOSE 1 Lightly shake the person and yell their name 2 Give 1st dose of Naloxone The proper response in the event of an Opioid Overdose 3 Call 911- ALWAYS 4 Open the airways and give 1 breath every 5 seconds 5 Consider naloxone again if: The patient does not start breathing in 2-3 minutes The patient responds to the first dose and then stops breathing again 6 Place the patient on his/her side to prevent choking
NALOXONE AUTO-INJECTOR: EVZIO 1 2 3 4 Pull the auto-injector from the outer case Pull firmly to remove the red safety guard Place the black end against the middle of the outer thigh, through clothing if necessary, then press firmly and hold in place for 5 seconds If no reaction in 2-3 minutes or if the person stops breathing again, give the second dose 22
NALOXONE NASAL SPRAY: NARCAN 1 2 3 4 5 Remove naloxone nasal spray from the box & peel back the tab with the circle to open the naloxone nasal spray Hold the naloxone nasal spray with thumb on the bottom of the plunger and your first and middle finger on either side of the nozzle Do NOT PRIME OR TEST the spray device. Tilt the person s head back and provide support under the neck with your hand. Gently insert the tip of the nozzle into one nostril until your fingers on either side of the nozzle are against the bottom of the person s nose Press the plunger firmly to give the entire dose of naloxone nasal spray. Remove the naloxone nasal spray from the nostril after giving the dose If no reaction in 2-3 minutes or if the person stops breathing again, give the second dose of naloxone in the other nostril using a new naloxone spray 23
DEMONSTRATION TIME!!!! 24
NALOXONE ADVERSE REACTIONS When naloxone is given, the patient may experience precipitated opioid withdrawal Nausea/vomiting Diarrhea Tachycardia Hypertension Anxiety Mydriais (enlarged pupils) Rhinorrhea (runny nose) Muscle spasms Diaphoresis (sweating) Gooseflesh Lacrimation/Yawning Bone and muscle pain 25
STEPWISE APPROACH TO COUNSELING PATIENTS ON NALOXONE 1 2 3 4 5 Discuss the risk factors for Opioid Overdose Outline the signs and symptoms of Opioid Overdose Discuss how to Respond to an Opioid Overdose Review the assembly and administration of Naloxone Document counseling 26
WHAT ROLE CAN I PLAY AS A PHARMACIST? Identify patients who are at high risk for an opioid overdose Provided counseling on opioid overdose Risk Factors Clinical presentation Provide counseling on the use of naloxone in the event of an opioid overdose 27
COMMON PATIENT COMPLAINTS I have been on these medications for years, I am not at risk for an opioid overdose I take my medications as prescribed. Does my doctor think that I am abusing my pain medications? You are making me feel like I am a junkie. This is another excuses for my doctor not to give me my pain medications. Having naloxone would be a trigger for me to relapse 28
CONCLUSION The rates of opioid overdose within the United States has drastically increased over the past decade Naloxone distribution in the community can helpful in decreasing the prevalence of opioid overdose deaths Pharmacists can play a major role in providing education on the risk factors and signs and symptoms of opioid overdose and the administration of naloxone in the event of an opioid overdose 29
QUESTIONS?? 30
REFERENCES 1. CDC. Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2016. Available at http://wonder.cdc.gov. 2. Hedegaard MD MSPH, Chen MS PhD, Warner PhD. Drug-Poisoning Deaths Involving Heroin: United States, 2000-2013. National Center for Health Statistics Data Brief. 2015:190:1-8 3. Walley A, Xuan Z, Hackman H et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ. 2013;346:174-f174. 4. Coffin PO, Sullivan SD. Cost-effectiveness of distributing naloxone to heroin users for lay overdose reversal. Ann Intern Med. 2013;158(1):1-9 5. Thomson Reuters Micromedex Clinical Evidence Solutions. Thomson Reuters; c2011. RED BOOK Drug References; 2016. http://thomsonreuters.com/products_services/healthcare/healthcare_products/clinical_deci_support/micromedex_clinical_evidence_sols/med_ safety_solutions/red_book/. Accessed May 25, 2016. 6. Therapeutic Research Center. PL detail-document #320537, naloxone for opioid overdose (FAQs). Pharmacist s Letter/Prescriber s Letter. 2016;May:1-10. 7. College of Psychiatric & Neurologic Pharmacists. Pharmacy basics. Prescribe to Prevent website. http://prescribetoprevent.org/pharmacists/pharmacy-basics/. Published 2015. Updated February 2015. Accessed June 2, 2016. 8. Adapt Pharma facilitates Narcan (naloxone hydrochloride) nasal spray access to state and local public entities [news release]. Dublin, Ireland: Adapt Pharma; January 14, 2016. http://adaptpharma.com/adapt_press_release/january-14-2016/. Accessed May 25, 2016. 31
AN OVERVIEW OF THE PRESENTATION AND TREATMENT OF OPIOID OVERDOSE Jasmine Carpenter, Pharm. D, BCPS, BCPP Clinical Pharmacy Specialist-PACT Mental Health Veterans Affairs Medical Center, Washington DC