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To the Rescue:Naloxone Rescue and other Harm
Reduction Strategies for Opioid Overdose
Patricia McGuire, MD
Collaborative Family Healthcare Association 16th Annual ConferenceOctober 16-18, 2014 Washington, DC U.S.A.
Session # E3bOctober 17, 2014
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Faculty Disclosure
I have not had any relevant financial relationships during the past 12 months.
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Learning Objectives
At the conclusion of this session, the participant will be able to:
• Identify evidence about risks of illicit and prescription opioid misuse
• Integrate harm reduction strategies for opioid in the patient centered medical home
• Discuss Naloxone rescue techniques
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Bibliography / Reference
1. Belesky LB, Rich JD, Walley AY. Prevention of fatal opioid overdose; JAMA, 2013: 308 (180): 1863-1864
2. Centers for Disease Control and Prevention (CDC); Community-based opioid overdose prevention programs providing naloxone – United States, 2012. MMWR Morb Mortal Wkly Rep. 2012; 261 (6): 101-105.
3. Harvard Medical School. Painkillers fuel growth in drug addiction: Opioid overdoses now kill more people that cocaine or heroin. Harvard Ment Hlth Let. 2011; 27 (7): 4-5.
4. Coffin PO, Sullivan SD, Cost effectiveness of distributing Naloxone to heroin users for lay overdose reversal. Ann Intl Med. 2013; 158: 1-9
5.Coffin P, Banta-Green C; The Dueling Obligations of Opioid Stewardship; Ann Intern Med. 2014;160(3):198-200. doi:10.7326/M13-2209
5. SAMHSA; Opioid Overdose ToolKit; http://store.samhsa.gov/shin/content/SMA13-4742/Overdose_Toolkit_2014_Jan.pdf
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Learning Assessment
• A learning assessment is required for CE credit.
• A question and answer period will be conducted at the end of this presentation.
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Opioids• Illegal drugs: heroin• Prescription meds:
– oxycodone– hydrocodone– fentanyl– morphine– codeine– hydromorphone– methadone– buprenorphone
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Opioids
• Bind to receptors in brain, spinal cord, GI tract• Affect body systems which regulate breathing,
blood pressure, mood• Minimize perception of pain• Stimulate brain reward centers• Overdose can lead to Classic Triad
– pinpoint pupils– respiratory depression– Coma, death
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Opioid Overdose
• Miscalculation of heroin dose• Deliberate misuse• Misunderstanding directions for Rx opioid
dosing• Combining opioids with other substances
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Opioid pain reliever-related overdose deaths increasing at a faster rate than deaths from any major cause
Aortic Aneurysm Influenza & Pneumonia Cerebro-vascular Motor vehicle traffic
Heart disease Perinatal Period Homicide Diabetes Mellitus Pneumonitis Malignant Neoplasms
HIV Septicemia Chronic Lower Respiratory disease Liver Disease
Suicide Nephritis Parkinson's Disease Hypertension Alzheimer's Rx opioid overdose
-50% 0% 50% 100% 150% 200% 250% 300%
-34%-23%-23%-22%
-16%-14%
-3%0%
2%4%
7%11%13%
20%31%
36%40%
47%68%
276%
% change in number of deaths, United States, 2000-2010
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Opioid prescribing rates correlate with drug overdose death rates
Death rate, 2008, National Vital Statistics System. Opioid pain reliever sales rate, 2010, DEA’s Automation of Reports and Consolidated Orders System
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Scope of the Problem
2 million individuals with opioid analgesic use disorders
The Dueling Obligations of Opioid Stewardship Phillip Coffin, MD, MIA; and Caleb Banta-Green, PhD Ann Intern Med. 2014;160(3):198-200. doi:10.7326/M13-2209
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Scope of the Problem
• There was a 4-fold increase in opioid prescriptions for pain in the last 10 years
• Deaths from prescription opioids have doubled in the last 10 years
• 17,000 in 2010, up from 14,800 in 2008
CDC MMWR November 4, 2011 / 60(43);1487-1492
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Principles of Harm Reduction
• Pragmatism – Are we going to eliminate drug use?
• Humanistic Values – Not approval but not moral judgment
• Focus on Harms – Not the use itself
• Balancing Costs and Benefits • Priority of Immediate Goals
Hunt, Neil. “A review of the evidence-base for harm reduction approaches to drug use” IHRA, http://www.ihra.net/files/2010/05/31/HIVTop50Documents11.pdf
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Harm Reduction
• Conceptualized as set of compassionate and pragmatic approaches for:– Reducing harm associated with high risk behaviors– Improving quality of life
• Goals– Decrease use or abstinence– Decrease harm associated with use
Harm Reduction, 2nd edition, edit by Marlatt GA, et.al.; 2012, Guilford Press, NY
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UPMC St. Margaret Behavioral Health IntegrationHarm Reduction Strategies
2011SBIRT Universal Screening for SUD
2011 SBIRT curriculum development
2012Integrated Behavioral Health Team
2013
Controlled Substances Protocol revision
2014
Naloxone Rescue Project development
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Integrated Behavioral Health Services
• Multi-disciplinary team• Warm hand-off• Short-term Behavioral Health therapy
– CBT approach to mental health issues– Harm reduction approach to substance misuse
• Psychiatric consultation• Referral to specialty mental health/substance
abuse treatment, as needed
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Control Substance Protocol
• Revision of Controlled Substance Policy– Avoid Controlled Substance Rx on first clinic visit– Controlled Substance Agreement– Urine Drug Screening– Pain Clinic Referral– SBIRT: Referral to specialty SA treatment– Controlled Substance letter of concern– Naloxone counseling letter
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Harm Reduction Counseling• Ask permission • Give personalized feedback about harms/risks
of drug use• Use collaborative approach to help patients
identify their goals re: drug use and related behaviors – Decrease use or abstinence– Decrease associated harms
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Harm Reduction Counseling
• Have patient develop options for change to meet their goals
• Help patient consider as many harm reduction strategies as possible
• Utilize SMART goal setting– Specific; Measurable; Achievable; Realistic; Timed
• Assist patient with follow-up plan
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Naloxone Counseling Letter
• Educates patients about dangers of opioid overdose– Motivates patients to accept naloxone prescriptions– Encourages patients to ask for help to wean down opioid
use, if appropriate
• Helps providers counsel new patients who request opioid refills at 1st visit– Decreases contentious tenor of those visits– Improves provider satisfaction/feelings of empowerment
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Naloxone (Narcan) reversing an overdose
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Endorsement, Policy and Legal Support
• http://prescribetoprevent.org/medical-legal/
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Comprehensive overdose prevention, recognition and response, including intramuscular and intranasal Naloxone rescue kit demonstrations
http://prescribetoprevent.org/video/http://vimeo.com/37778160 http://vimeo.com/22647688
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Naloxone Rescue Teaching
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Evzio
• http://evzio.com/patient/?gclid=CL7voL_2sMACFStk7Aod3h0AJg
http://evzio.com/videos/ITJ001_Evzio_Interactive_V2B-HD.mp4
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Patient Education
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Barriers to Implementation
• Cost • Insurance coverage• Availability• Buy-in• Perceptions• Limited availability of Suboxone dispensing
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Questions / Discussion
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Session Evaluation
Please complete and return theevaluation form to the classroom
monitor before leaving this session.
Thank you!