October 20 th , 2016 Integrated Care Conference Disclosure I do - PowerPoint PPT Presentation

Maggie Mendes, Pharm.D VA Academic Detailing Service October 20 th , 2016 Integrated Care Conference

Disclosure  I do not have relevant financial relationships with commercial interests.

Objectives   Clarify the purpose and importance of OEND programs  Identify the role naloxone has in opioid overdose prevention  Discuss the Recommendations For Use of Naloxone Rescue Kits from National PBM  Review different formulations of naloxone kits  Demonstrate patient education on overdose response 3

Examples of Prescription Opioids  NIDA www.drugabuse.gov

Statistics  6% of the US population is on chronic opioids 5% of the entire population of the World is in the US AND 80% of opioids are consumed in the US 5

Statistics  6

Alarming Statistics   Opioid death rates have quadrupled since 1999 Opioid Analgesic Poisoning Death Rates: United States, 1999-  CDC declared an 2011 epidemic  Veterans are twice as likely 16.917 deaths to die from accidental overdose compared to non- Veterans 4,030 deaths  Veterans at highest risk:  MH diagnosis/PTSD  ≥ 100mg MEDD + SUD • Drug-poisoning Deaths Involving Opioid Analgesics: United States, 1999 – 2011. Page last updated Sept 16, 2014. Bohnert AS, et al. Med Care 2011;49: 393 – 396. • • VA PBM Naloxone Kits RFU, Sept 2014

 http://teens.drugabuse.gov/blog/post/drug-overdoses-kill-more-cars-guns-and-falling-update

Why Do People Overdose?  8% 17% Accident Suicide Unknown 75% 75% of overdoses are ACCIDENTAL JAMA 2013;309(7):657.

Accidental opioid overdose can affect anyone including celebrities “We need to see the Prince in all of us. We need to see the Photo by Vince Bucci/Getty Images vulnerability. We are all vulnerable here. It’s a wake-up call for how we view these Prince drugs.” Musician - Dr. Kessler, former commissioner of Died June 2016, at age 57 from an the FDA accidental overdose of fentanyl

Timeline  2007 1998 VA 1996 Purdue 2008 Drug 2013 heroin and JCAHO Purdue plead guilty overdoses addiction adopt pain releases to false surpass has incresed as the 5th Oxycontin MVA 286% branding of vital sign Oxycontin

Heroin Addiction and Overdose

Heroin addiction can result from RX opioid pain killers

New Threat: Fentanyl and Carfentanil  https://www.drugabuse.gov/drugs-abuse/emerging-trends-alerts

Where do opioids come from?  15

Opioid Dose and Overdose Risk 14� 12� Chronic� Pain� Acute� Pain� 10� Hazard Ratio SUD� Cancer� 8� 6� 4� 2� 0� 1� -� 19� mg/d� 20� -� 49� mg/d� 50� -� 99� mg/d� ≥ � 100� mg/d� Morphine MG Equivalent Dose 16 Bohnert et al. JAMA. 2011;305(13):1315-1321.

Other consequences

Cost of US Prescription Opioid Epidemic Curtis S. Florence, Chao Zhou, Feijun Luo, Likang Xu. The Economic Burden of Prescription Opioid Overdose, Abuse, and Dependence in the United States, 2013 . Medical Care , 2016; 54 (10): 901 DOI: 10.1097/MLR.0000000000000625

Pain Management Is Important 19   It is important to manage  However… pain safely and effectively  Chronic opioid use is  Chronic pain is the most associated with higher common cause of work rates of disability, medical disability 6 cost and surgeries 7-10  Chronic pain is a serious  A population based cohort and highly prevalent study found that the odds condition among OIF/OEF of recovery from chronic service members 6 pain were almost 4 times higher among individuals  60% of OIF/OEF veterans not using opioids returning home list chronic compared with individuals pain as a problem using opioids 10 OIF=Operation Iraqi Freedom, OED=Operating Enduring Freedom

Patient and Family Strategies to Prevent Overdose  1) Encourage persons at high risk and family members to learn how to prevent and manage opioid overdose 2) Ensure safe medication handling and disposal 3) Know what you are taking 4) Encourage the public to call 911 5) Have an overdose plan 6) Remove stigma of addiction http://projectlazarus.org http://store.samhsa.gov/product/Opioid-Overdose-Prevention- Toolkit/SMA13-4742

Prescriber Strategies to Improve Opioid Safety   Obtaining informed consent  Re-examining high dose opioids  Annual urine drug screening for all patients on chronic opioid therapy  Participation in Prescription Drug Monitoring Program  Reassessing opioid + benzodiazepine combinations  Next steps....O.E.N.D

What is OEND?   Opioid Overdose Education and Naloxone Distribution  A harm reduction and risk mitigation initiative that aims to decrease opioid-related overdose deaths  Key Components  Education and training regarding opioid overdose prevention  Recognition of opioid overdose  Opioid overdose rescue response  Issuing naloxone kits VA PBM Naloxone Kits RFU, Sept 2014

Opioid receptors  Mu: Kappa:  Analgesia  Mild analgesia  Sedation  Less respiratory depression  Euphoria  Respiratory depression Delta:  Constipation  Mild analgesia  Physical Dependence

What is Naloxone?   Competitive opioid antagonist Opioids  Bystander administered like epinephrine or glucagon  Routes: IV, IM, SC, IN  Onset: 2-3 min  DOA: 30-90 min  Bioavailability: 4% IN, 36% IM  Metabolism: hepatic Naloxone  Antagonist at mu, kappa, and delta receptors  Shows little to no Opioid pharmacological effect in patients receptor who have not received opioids • Dowling J, et al. Ther Drug Monit. 2008;30(4):490-6. • Naloxone package insert • VA PBM Naloxone Kits RFU, Sept 2014

Naloxone Safety and Tolerability  Can induce acute withdrawal • Agitation/aggression ⁻ NV ⁻ Tremor ⁻ Sweating ⁻ Confusion ⁻ • Rare Adverse Effects: Seizures • • Pulmonary edema • Arrhythmias • Naloxone package insert • Mariana PJ. Am J Emerg Med. 1989:7:127-29VA PBM • Naloxone Kits RFU, Sept 2014

Highest Risk for Overdose   After a period of abstinence (hospital, residential, detox., or jail /prison)  When using multiple drugs or multiple opioids , especially respiratory depressants (downers, benzodiazepines, barbiturates, alcohol, other opioids, cocaine)  When illness is present (liver/cirrhosis, heart, lung)  When using long-acting opioids or potent / strong opioids (fentanyl)  When using high doses of opioids  When using alone and distressed  Previous overdose UNODC Opiate Overdose SAMHSA Opiate Overdose Toolkit Harm Reduction Coalition: Opiates

Who Seems to Benefit from OEND?  Heroin or other injection Direct Association with drug use Benefit  Substance use  Opioid or drug use Risk criteria used in community health OEND disorder diagnosis programs associated with reduction in opioid overdose  High likelihood of opioid deaths* overdose or witnessing an opioid overdose. VA PBM Recommendations for OEND 2016

Who May Potentially Benefit from OEND? Identified Patient Risk Factors • SUD diagnosis Indirect Association with • PTSD or other MH diagnosis Suspected or confirmed history of heroin or nonmedical • Potential Benefit opioid use • Male Veterans 30 – 59 years old • Any opioid prescription and known or suspected Factors associated with an smoking, COPD, emphysema, asthma, sleep apnea, other respiratory system disease; renal or hepatic increased risk for fatal or disease; alcohol use nonfatal opioid overdose or Identified Prescription Risk Factors • High-dose opioid prescription (50 to 100 mg or more any drug overdose death in MEDD) • Long-acting non-tramadol opioid U.S. Veterans. Some of these Methadone initiation in opioid-naïve patients • • Opioid prescription with concomitant benzodiazepine criteria have been used by an use or concurrent antidepressant prescription established OEND program Situational Risk Factors or Criteria • Loss of opioid tolerance and likely to restart opioids without outcome data. (e.g., recent release from jail or prison / post- incarceration re-entry programs) • Remoteness from or difficulty accessing [emergency] VA PBM Recommendations for OEND medical care 2016 • Voluntary patient request

Who May Potentially Benefit from OEND? Identified Patient Risk Factors Clinical Judgment of • Previous suicide attempt or on high-risk suicide list Potential Benefit • Outpatient opioid prescription with the following: • Unstable renal or hepatic disease Common factors found in • Cardiac illness drug overdose deaths in • HIV/AIDS Age 65 years or older, cognitive impairment or • nonveterans; factors associated debilitated condition with increased risk for • Voluntary caregiver request Identified Prescription Risk Factors nonfatal overdose or for • Home-based continuous intraspinal opioid respiratory depression from infusion Home-based patient-controlled opioid infusion • opioid therapy, and other • Opioid rotation to methadone clinical factors suggested by • Opioid induction, upward titration or rotation (for SUD or pain) experts Situational Risk Factors Fear of police arrest (reluctance to call 911) • • Aberrant opioid use / misuse (e.g., early fills; VA PBM Recommendations for OEND 2016 extra doses; overlapping, multi-site fills).