8/28/2017

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Ashel Kruetzkamp, MSN, RN, SANE

Headlines

How Did We Get Here?

• Pain is the number one reason patients go the

doctors office, urgent care and/or emergency room.

• Opiates are the most effective pain medication for

acute-moderate to serve pain and are used in

treating chronic pain.

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Why the Epidemic?

• State of Kentucky Passed HB (House Bill) 1

in 2012. • State’s landmark prescription drug abuse bill

• Impacts • Fewer “Pill Mills”

• New pain management clinics must be owned and licensed

medical provider, must employ medical director in good

standing with professional licensure boards.

• More KASPER reports

HB1 expanded the Kentucky All Schedule Prescription

Electronic Reporting (KASPER) system, the state’s

prescription monitoring system, by requiring all prescription

providers of controlled substances to register. Regulations

promulgated by the various medical professional licensure

boards mandate that licensees use the KASPER system

before prescribing controlled substances.

What Are Opioids?

• Opioids are derived from or stimulate the effects of

the pain-relieving compounds found in opium.

• Opium is the dried sap of the opium poppy, which

grows throughout Asia, North Africa, South America

and the Middle East.

• Opium has been used for thousands of years to

relieve pain and calm anxiety.

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What Are Opioids?

• Morphine was the first drug refined from opium in

1803, followed by heroin and codeine.

• Some opioids are semi-synthetic or synthetic, they

are partially or completely manufactured using

chemicals with similar properties that act on the

body in similar ways to opium.

• The most widely abused opioids include heroin, and

prescription medications-Vicodin, Dilaudid, Percocet

and OxyContin and Codeine.

• Opioids replicate on a much greater scale.

They create a rush of this good feeling,

called a “high”.

• Regular use, the brain develops a tolerance,

needing more and more of the drug to get

the same high.

• Stopping use creates an unpleasant

withdrawal.

Opioids

It is now harder to get

these…

Pain Relief

You can easily get this…

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Northern Kentucky

Data

Heroin Overdoses St. Elizabeth Emergency Departments

(Covington, Edgewood, Florence, Ft. Thomas, Grant and Owen)

16 10

31

20 24

20

29

16 20

24

16

26 24 28

46

28

66

33 29

37

20

39

48 49 44

34

50 56

51 50 48 52

33

41 37

49 45

54 44

75

55

63 60 61

52 58

55

123

97

60

122

101

132

53

77

110

94

121

107

94

82 80

108 105

114

65

139

174

308

209

91

109 110

179

297

245 232

175

141

0

50

100

150

200

250

300

350

January February March April May June July August September October November December

2011 2012 2013 2014 2015 2016 2017252 745

116

8

1584

447

545

1379

Data provided by: Ashel Kruetzkamp, MSN, RN St. Elizabeth Healthcare

Emergency Department Visits Edgewood, Covington, Grant, Ft. Thomas, Florence, & Owen

HeroinOverdoses

OpiateOverdoses*

Opiate Use**

2016 1584 350 1031

2017 (Jan-July) 1379 404 515

0

200

400

600

800

1000

1200

1400

1600

1800

*Opiate Overdose-(Fentanyl, Methadone, Percocet, Norco): denied heroin use, responded to Narcan

**Opiate Use ED Visit (complications related to use of opiates): withdrawal, suicidal, abscess, request

detox/treatment, and other medical related issues).

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Heroin Overdoses St. Elizabeth Emergency Departments

(Covington, Edgewood, Florence, Ft. Thomas, Grant and Owen)

252

447 545

745

1168

1584

1379

0

200

400

600

800

1000

1200

1400

1600

1800

2011 2012 2013 2014 2015 2016 2017(Jan-July)

Data provided by: Ashel Kruetzkamp, MSN, RN St. Elizabeth Healthcare

1

4

ASHEL TO

ADD HIV

SLIDE

Opiates

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Heroin

• Is a drug made from morphine, a “natural substance”

in the seedpod of the Asian poppy plant

• White Power, Brown Power or Black Tar

• It can be injected, smoked or snorted

• Individuals of all ages and lifestyles have used

heroin

Fentanyl

• Fentanyl is a potent synthetic opioid and is 100 times

more potent than morphine.

• Fentanyl rapidly crosses the blood-brain barrier. It is

similar to other opioid receptor agonist (like

morphine or oxycodone).

Carfentanil

• Carfentanil or carfentanyl (Wildnil) is an analogue of

the popular synthetic opioid analgesic fentanyl, and

is one of the most potent opioids known (also the

most potent opioid used commercially).

• Carfentanil was first synthesized in 1974 by a team

of chemists

• It has a quantitative potency approximately 10,000

times that of morphine and 100 times that of fentanyl

• Carfentanil is intended for large-animal use only as

its extreme potency makes it inappropriate for use in

humans

National Center for Biotechnology Information. PubChem Compound Database

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Understanding the

Disease

The Effects of Opiates

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Signs of Heroin Overdose:

• Nodding Off

• Breathing is slow and the person shows difficulty. Breathing

may also be shallow.

• Pupils may become very small. This is sometimes called

"pinpoint pupils." It is a very serious sign of heroin overdose.

• The tongue may be discolored.

• Mouth is very dry.

• Pulse weakens with heroin overdose, and the victim's blood

pressure will drop.

• Watch for the lips and fingernails to be tinged with blue.

• Muscle spasms in various parts of the body.

• Disorientation is a sign of heroin overdose. This

disorientation may even heighten to delirium.

• A victim of heroin overdose may even slip into a coma.

Naloxone (Narcan)

• Opioid antagonist-Binds to receptors to prevent

neurotransmitters from activation

serum half-life in adults ranged from 30 to 81 minutes

How Does Narcan Work?

https://www.narcan.com/

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Naloxone (Narcan)

• Naloxone only works on overdoses caused by an

opioid • Heroin

• Oxycontin

• Fentanyl

• Methadone

• Vicodin

• Percocet

• Naloxone will not reverse overdose resulting from

non-opioid drugs • Cocaine

• Benzodiazepines (Xanax, Valium)

• Alcohol

Symptoms of Heroin Withdrawal: Heroin abusers and addicts feel compelled to continue using the drug both because of its pain

relieving effects, and because of fear of symptoms they may experience if they stop. Heroin

withdrawal symptoms can start a few hours to one day after sustained use of the drug stops.

Withdrawal symptoms can include:

Intense heroin cravings

Profuse sweating (not explained by environment or physical activity)

Severe muscle, joint and bone aches

GI Symptoms: Nausea, diarrhea and vomiting

Feeling of heaviness

Intense cramping in limbs, resulting in "kicking"

Crying/Anxiety/Irritability/Depression

Insomnia/Restlessness

Cold sweats

Chills/Goosebumps

Runny nose or tearing

Yawning

Fever

Increased Pulse Rate

Tremors

Pupil dilation

Addiction and

Treatment Options

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Substance Use Order

Substance use disorders occur when the recurrent

use of alcohol and/or drugs causes clinically and

functionally significant impairment, such as health

problems, disability, and failure to meet major

responsibilities at work, school, or home.

• According to the DSM-5 (Diagnostic and Statistical Manual of Mental

Disorders, Fifth Edition) , a diagnosis of substance use disorder

is based on evidence of impaired control, social

impairment, risky use, and pharmacological criteria.

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Behavioral Signs and Symptoms • Always uses substance to intoxication

• Uses substance at inappropriate times such as before driving, at work,

or at school

• Misses work or school

• Damages relationships

• Poor performance at school or work

• Steals or borrows money from work, home, or friends

• Secretive, defensive behavior about activities and possessions

• Unusual mood changes

• Abrupt temper outbursts

• Changes in eating or sleeping habits

• Changes in peer group or social group

• Loss of interest in usual activities, pastimes, and hobbies

• Aggressive or physical behavior

• Money or valuables missing from home

• Traveling to locations outside of normal range

Three Medication Pathways

12 Step Facilitated Groups in

Conjunction With…

No Medication

Buprenorphine/Naloxone

Naltrexone

Potential Outcomes of

Medication Assisted Treatment

• Decreases impulsive behavior

• Helps to develop structure

• Decreases criminal activity

• Increases retention in treatment

• Increases engagement in socially productive roles

• Increases employability

• Decreases overall chaos in patient’s life/family

MAT can help improve overall function of patients and assist living a

‘normal’ and productive life.

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First Pathway - No Medication

Short Term Medications

Detox

Residential Treatment

Intensive Outpatient Treatment

Outpatient Therapy

Sober Living

Therapeutic Techniques

Cognitive Behavioral Therapy

Motivational enhancement therapy

Contingency Management

12 Step Facilitated Therapy

Second Pathway- Medication Assisted Treatment

Opiate Substitution Therapy

Methadone

Long acting opioid receptor

agonist

Reduces withdrawal

symptoms and cravings

Buprenorphine

Opioid partial agonist, like

opioids

Long acting opioid agonist

• Suboxone (buprenorphine

and Naloxone)

Reduces the withdrawal

symptoms and cravings

Third Pathway Naltrexone/Vivitrol

Vivitrol (Naltrexone)

Opiate antagonists

Decreases the desire to use opiates

Used after opiate detoxification to prevent

relapse to opiate abuse.

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Barriers to Treatment

Work restraints Transportation

Childcare

Abusive

relationship

Addicted

Partner

Homeless Stigma

Access Time Conflicts Depression

Legal Issues Denial

Ways to Respond

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Ways You Can Respond

• Talk about it

• Plan an addiction-and-recovery worship service

• Start an on-going addiction and recovery ministry

Ways You Can Respond

• Support and help fund the program development for treatment

of pregnant women and their children.

• Support residential recovery programs in your area.

• Support and help grow community educational programs. o Stigma/empathy education

o Awareness education on the complexity of the epidemic

• Assist people in recovery with:

o Employment opportunities

o Transportation

o Housing post residential treatment

o Childcare assistance while in recovery

o Life skills assistance

Resources

SAMHSA - Substance Abuse and Mental Health Services Administration.”

SAMHSA - Substance Abuse and Mental Health Services

Administration, 9 Aug. 2017, www.samhsa.gov/.

“Professional Resources for Prevention and Addiction Treatment.” Professional

Resources for Prevention and Addiction Treatment -- Hazelden,

www.hazelden.org/web/public/pub_keyresources.page.

“Power to Help Reverse an Opioid Overdose.” NARCAN® (Nalaxone HCl) Nasal

Spray, www.narcan.com/.

National Institute on Drug Abuse (NIDA).” National Institutes of Health, U.S.

Department of Health and Human Services, 1 Mar. 2017,

www.nih.gov/about-nih/what-we-do/nih-almanac/national-institute-drug-

abuse-nida.