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

RA

PP

ER

RE

FE

RE

NC

ES

4

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

Opioid Misuse“Poppin’ Pills is all we know” Travis Scott-Antidote

Drug Interaction “I got Xanax, Percocet, Promethazine with Codeine”Lil Wayne ft. 2 Chainz- Rich

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

5Cnn: Celebrities who died from painkillers and heroin

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

7CDC. Wide-ranging online data for epidemiologic research (WONDER). Atlanta, GA: CDC, National Center for Health Statistics; 2016. Available at http://wonder.cdc.gov.

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

9

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

OPIOID PHARMACOLOGY

• Opioids exerts their action by binding to 3 opioid receptors:

• Opioids have a narrow therapeutic index

• With respiratory depression as the most serious toxic effect that can lead to fatality

10

Mu

Delta

KappaOpioids cause respiratory depression

via activation of the mu-receptor

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

12

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

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

15

Naloxone distribution would prevent 6.5% of all

overdose deaths for every 20% of heroin users

reached by a distribution program18

A 24-46 % decrease in opioid overdose was

observed in communities that distributed

naloxone devices17

Prevention of 2,000 overdose deaths in a population of 200,000 heroin

users18

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

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®)

17

• It possesses a strong affinity for the mu-opioid 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

18

Naloxone Delivery Devices

Non-FDA Approved

Assembly Required

FDA Approved

Provides Voice Instructions

No Assembly Required

FDA Approved

No Assembly Required

Naloxone Intranasal Rescue

Kit

Naloxone Auto-injector

(Evzio)

Narcan Nasal Spray

Each kit comes with a total of 2 doses

NALOXONE DELIVERY DEVICES

Evzio (Auto-Injector)

FDA Approved

Intramuscular or Subcutaneous Administration

90.5% successful use without training & 100% successful use with

training

Narcan Nasal Spray

FDA Approved

Intranasal

90.5% successful use without training

Intranasal Naloxone Rescue Kit

Not FDA Approved

Intranasal

0% successful use without training & 57.1% successful use with

training

19

CO

ST

OF N

AL

OX

ON

E D

EL

IVE

RY

D

EV

ICE

S 5

-7

$3750 per 2 auto-injectors

Evzio®

• $125 per dual package

• $37 per device for group purchasers such as law enforcement, fire fighters, collages

Narcan® Nasal Spray

~$50

Intranasal Naloxone Kit

20

RESPONSE TO OPIOID OVERDOSE

1 • Lightly shake the person and yell their name

2 • Give 1st dose of Naloxone

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

The proper response in the event of

an Opioid Overdose

NALOXONE AUTO-INJECTOR: EVZIO

1• Pull the auto-injector from the outer

case

2• Pull firmly to remove the red safety

guard

3

• 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

4• If no reaction in 2-3 minutes or if the

person stops breathing again, give the second dose

22

NALOXONE NASAL SPRAY: NARCAN

1• Remove naloxone nasal spray from the box & peel back the

tab with the circle to open the naloxone nasal spray

2• 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

3

• 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

4• 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

5• 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

25

Nausea/vomiting

Diarrhea

Tachycardia

Hypertension

Anxiety

Mydriais (enlarged pupils)

Rhinorrhea (runny nose)

Muscle spasms

Diaphoresis (sweating)

Gooseflesh

Lacrimation/Yawning

Bone and muscle pain

STEPWISE APPROACH TO COUNSELING PATIENTS ON NALOXONE

26

5

• Document counseling

4

• Review the assembly and administration of Naloxone

3

• Discuss how to Respond to an Opioid Overdose

2

• Outline the signs and symptoms of Opioid Overdose

1

• Discuss the risk factors for Opioid Overdose

WHAT ROLE CAN I PLAY AS A PHARMACIST ?

27

• 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

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 inMassachusetts: 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