2016 62,000+ overdose deaths Four in five new heroin users started - - PDF document

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2016 62,000+ overdose deaths Four in five new heroin users started - - PDF document

May 02, 2023 245 likes •350 views

2/2/2018 Opioids in 2018: Whats a Conflict of Interest Pharmacist to do in the Opioid Red Project Board member Kent County Opioid Task Force member Public Health Crisis? Ferris State University Opioid Task Force Committee member

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Opioids in 2018: What’s a Pharmacist to do in the Opioid Public Health Crisis?

Susan DeVuyst‐Miller, B.S., PharmD., AE‐C Assistant Professor, Ferris State University College of Pharmacy Clinical Pharmacist, Cherry Health Heart of the City Center

  • Conflict of Interest
  • Red Project Board member
  • Kent County Opioid Task Force member
  • Ferris State University Opioid Task Force Committee member

Objectives

  • Discuss the safety concerns of prescription opioids
  • Explain an opioid tapering program
  • Discuss the applications of naloxone in opioid overdose
  • Describe State and Local Opioid Task Force progress and

recommendations

Opioid Epidemic – A Brief Review

2016

62,000+ overdose deaths

42, 249 opioid related

Rudd RA, Seth P, David F, Scholl L. Increases in Drug and Opioid‐Involved Overdose Deaths — United States, 2010–2015. MMWR Morb Mortal Wkly Rep 2016;65:1445–1452. DOI: http://dx.doi.org/10.15585/mmwr.mm655051e1

15, 469 heroin

  • Four in five new heroin users started out

misusing prescription painkillers

Jones CM. Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers ‐ United States, 2002‐2004 and 2008‐2010. Drug Alcohol Depend. 2013 Sep 1;132(1‐2):95‐100.

doi: 10.1016/j.drugalcdep.2013.01.007. Epub 2013 Feb 12.

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Opioids

Use, Morphine Equivalents, Side Effects, Overdose Risk Factors and Symptoms

https://www.crimemuseum.org/crime‐library/drugs/opium/

Opioids: Mechanism of Action Medical Uses of Opioids

Severe acute pain

  • #1 reason patients seek medical attention
  • Surgery
  • Trauma
  • Opioids indicated

Severe cancer pain

  • Opioids indicated

Severe chronic pain

  • Very controversial

Cough suppressant

  • Dry, non‐productive
  • Example: promethazine + codeine syrup
  • Dextromethorphan is a derivative of opioids

Diarrhea

  • Tincture of Opium
  • Loperamide is a derivative of opioids

Sedation

  • Palliative care

Detoxification

  • Opioid abuse

9

Starting Opioids…Not so fast!

  • Weigh expected benefits vs. risks carefully before initiating opioids
  • Relieves pain while body heals and improves function

Define Treatment Success:

  • Decreases the unpleasantness of pain (perception)
  • Patients will report that although pain is still present, it bothers them less

Opioids do not eliminate the pain:

  • Can be used for severe acute pain
  • Start with the lowest dose
  • Start with easiest route (PO/IV/PR/PCA)

Short acting

  • Not recommended upon initiation
  • Avoid in opioid‐naïve patients
  • Not used PRN
  • Reserved Cancer pain or palliative care
  • Controversial for chronic pain

Long acting

10

Opioid Equivalence Chart

Opioid IV (mg) PO (mg) Duration of action Codeine 130 200 3‐4h Tramadol ‐‐‐ 50‐100 3‐7h Hydrocodone ‐‐‐ 30 3‐5h Morphine 10 30 3‐4h Oxycodone ‐‐‐ 20 3‐5h Hydromorphone 1.5 7.5 2‐3h Fentanyl 0.1 (100mcg) ‐‐‐ 1–3h

All opioids are considered equipotent at these doses Can use to convert between opioids Total daily dose of opioids should not exceed 90 mg oral morphine equivalents

11

‐Sedation

‐Confusion ‐Diaphoresis ‐Pruritus ‐Respiration depression ‐Constipation ‐Nausea

http://krvlegal.com/effects‐opiates‐heroin‐human‐body/

Opioid Side Effects

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SLIDE 3

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Signs leading to Opioid Overdose

http://www.fraserhealth.ca/media/Early_Overdose_Signs.png http://prescribetoprevent.org/wp2015/wp‐content/uploads/project‐lazarus‐community‐toolkit.pdf http://www.fraserhealth.ca/health‐info/health‐ topics/harm‐reduction/overdose‐prevention‐ and‐response/recognizing‐an‐overdose/

Greater Risk for Opioid Overdose

Opioid naïve patients Dose >90MME Added opioid Poly‐pharmacy Substance abuse Co‐morbid conditions Genetic poly‐ morphism Age

Reduced tolerance after abstinence

De‐toxification programs

Methadone maintenance programs

Mixing, using alone, quality

Question: Only Addicts Overdose?

  • Decrease in pharmacologic response
  • Increase dose to achieve similar effects

Tolerance

  • High or chronic doses are abruptly d/c’d
  • Withdrawal symptom

Dependence

  • Change in behavioral patterns
  • Despite the potential side effects and harm

Addiction

Plan to Modify Opioid Use

Health Care Team Family Patient

Discontinuing Opioids

  • Success of therapy + (Quick) cessation
  • Patient returns to normal daily function

Ideal

  • Failure of therapy (use alternatives)
  • Intolerable side effects (opioid rotation)
  • Discuss withdrawal symptoms and agree on exit strategy (scheduled taper)

Less ideal

  • Opioid hyperalgesia
  • Development of opioid use disorder

Not ideal at all

  • Overdose
  • Death

Worse case

18

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Clinical Pharmacy Opioid Taper Algorithm Clinical Pharmacy Opioid Taper Algorithm

Tapering and Discontinuing COAT | 9

APPENDIX 3 : Tapering Methadone (in the setting

  • f chronic, non-cancer pain)

Suggested Steps for Tapering Methadone: 1.Decrease dose by 20-50% per day until you reach 30mg/day. 2.Then decrease by 5mg/day every 3-5 days to 10mg/day. 3.Then decrease by 2.5mg/day every 3-5 days.

Clinical Pharmacy Opioid Taper Algorithm

Appendix 2: Morphine Equianalgesic Dose Chart and Calculator

Taper Conversion Link

http:www.hca.wa.gov/medicaid/pharmacy/documents/taperschedule.xls

Tapering and Discontinuing COAT | 23

Opioid Withdrawal Symptom Management

  • Opioid withdrawal symptoms should not be treated with opioids or benzodiazepines
  • First step to management of withdrawal symptoms = SLOW THE TAPER
  • If needed, adjunctive therapy options:
  • Clonidine 0.1mg PO two to three times daily as needed for hypertension, nausea, cramps, diaphoresis,

tachycardia

  • Trazodone 25‐50 mg PO at bedtime as needed for insomnia
  • Diphenhydramine 25‐50 mg PO every four hours as needed for insomnia, restlessness
  • Ibuprofen 200‐400 mg PO every eight hours as needed for muscle aches
  • Acetaminophen 500‐1000 mg PO every six hours as needed for muscle aches; do not exceed 4000 mg /

24 hours

  • Loperamide 2 mg PO after each loose stool; do not exceed 16 mg/day

Tapering and Discontinuing COAT | 24

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Naloxone

Opioid reversal agent

Photo courtesy of Grand Rapids Red Project. Redproject.com http://ijhs2.deonandan.com/wordpress/wp‐content/uploads/2015/09/Untitled.png

Naloxone

Emergency treatment of known or suspected opioid overdose as manifested by respiratory and/or CNS depression Intended for immediate administration as emergency therapy in settings where opioids may be present Not a substitute for emergency medical care  No potential for abuse Withdrawal/Pain Crisis

Naloxone

Delayed onset 2 to 5 minutes for IM, SubQ, Nasal 8 to 13 for nasal atomization Duration of action

30 minutes to two hours

Shorter than opioids

Repeat doses at different site/nostril

Seek medical treatment

Naloxone kits

  • Advising clinicians to co‐prescribe with long‐term or high dose opioid

use

29

Naloxone Kits

Photo courtesy of Grand Rapids Red Project. Redproject.com

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Naloxone In MI: 2016

http://www.michigan.gov/mdhhs/0,5885,7‐339‐71550_2941_4871_79584_80133_80135_80309‐426713‐‐,00.html

State & Local Action

Michigan Prescription Drug & Opioid Abuse Task Force Recommendations

  • Prevention
  • Treatment
  • Regulation
  • Policy & Outcomes
  • Enforcement
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Prevention

  • Controlled substance prescriber training
  • State & local agencies
  • Collaboration
  • Eliminate doctor & pharmacy shopping
  • Public awareness campaign

Treatment

  • Pharmacist dispensing naloxone
  • Public awareness regarding laws
  • Immunity in reported overdose or calling for help
  • Increase access to care
  • Increase the number of addiction specialists
  • Best practice guidelines

Regulation

  • Legislation to better define & identify pain management
  • Tiered system of licensing
  • Exempt from civil liability
  • Review Michigan Colleges of Emergency Physician policy
  • Review limitation of pseudoephedrine

Policy & Outcomes

  • Ongoing task force or commission
  • State Dashboard
  • Continuity of Care with abrupt closures
  • Document law enforcement efforts

Enforcement

  • MAPS replacement
  • MAPS access expansion
  • Enhance licensing sanctions

The Law and Naloxone

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Michigan Laws

Immunity Prescribing Permitted Prescribers Dispensers Lay Administrator Lay Distributio n Possession w/o Rx Civil Criminal Disciplinary Civil Criminal Disciplinary Civil Criminal 3rd party Standing Order Yes ‐ ‐ Yes ‐ ‐ Yes ‐ Yes Yes Yes Yes Citation: Mich. Comp. Laws § 691.1503; Mich. Comp. Laws § 333.17744e,b

Ingham Opioid Work Group

  • Focus
  • Long‐term solution
  • Education
  • Pooling of resources, data and knowledge

http://www.lansingstatejournal.com/story/news/local/2016/01/07/lansing‐area‐group‐address‐epidemic‐heroin‐

  • verdoses/78410392/

Mason Capital Area Prescription Drug Task Force

The Mason‐Capital Area Prescription Drug Task Force mission is to raise awareness of our country’s fastest growing narcotic problem, prescription drug abuse. Through networking with medical professionals, legislators, public safety, courts, civic groups, schools, families and friends we are advocating prescription medication practices that enhance family and community safety.

Mason Capital Area Rx Taskforce Large Brochure(2).pdf.

Kent County Opioid Task Force

  • Medical
  • Law Enforcement
  • Front Lines
  • Grand Rapids Red Project – Do less harm

Families Against Narcotics

  • Throughout Michigan
  • Executive boards
  • http://www.familiesagainstnarcotics.org/

Other task forces

  • Collegiate
  • Ferris State University
  • Internal
  • Community
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Public Acts

  • 246
  • 247
  • 248
  • 249
  • 250
  • 251
  • 253

https://neuroethicscanada.wordpress.com/tag/dsm/ https://www.bmc.org/research/maximizing‐opioid‐safety‐naloxone‐moon‐study/moon‐study‐opioid‐safety‐and‐naloxone‐public/2016‐winners