Overdose Response Program

for Pharmacist

s September 2016

Before we begin … Please fill out and turn in the following documents:• Training Application for Certificate• Consent Form (optional)• Pre-training survey – both sides (optional)

Program Overview:I. Maryland Statistics on Opioid Overdose and Death

II. What is Harm Reduction?III. What is an Opioid?

IV. Recognizing an Opioid Overdose V. Responding to an Opioid Overdose

VI. Dispensing Naloxone

Maryland Statistics on Opioid Overdose

and Death

Epidemiology & Impact – Maryland 2015

Opioid Related Deaths:

• 86% of all intoxication deaths were opioid-related, including deaths due to heroin, Rx opioids and non-pharmaceutical fentanyl.

• Opioid-related deaths increased by 23% between 2014 and 2015. Largely due to heroin and

fentanyl-related deaths, which have increased by 29% and 50% respectively from 2014 to 2015.

29% of heroin-related deaths occurred in combination with fentanyl.

Fentanyl-Related Deaths:• Increase since late 2013 due to

nonprescription fentanyl produced in covert labs and mixed with, or substituted for, heroin or other illicit substances.

• Fentanyl is 100x more potent than heroin, and increases the risk for overdose and death.

• Deaths have increased greatest in the Baltimore Metro area.

• 65% of fentanyl related deaths occurred in combination with heroin, and 20% in combination with cocaine.

Epidemiology & Impact – Maryland 2015

What is Harm Reduction?

What is harm reduction?

“A set of practical strategies and ideas aimed at reducing negative consequences associated with various behaviors--often stigmatized by society--such as using drugs or having sex.”

adapted from HRC.org

A harm reduction approach to patient care is:

• Rooted in reality• Cognizant of social & economic inequities that frame behavior • Patient-driven – they can decide what is best for them• Collaborative • Nonjudgmental – avoids stigmatizing language (e.g. addict; get clean)

“What is my patient ready, willing, & able to do?”

Harm Reduction is Based on Behavior Change Theory

Behavior change goals / options are on a spectrum:

1) Assess readiness to change

2) Meet patients “where they are at”

3) Suggest safer measures

- Success can be ↑ Qual. of Life

Pharmacists can make a difference!

• In communities with high implementation of Overdose (OD) Education & Naloxone Distribution, risk of dying of an opioid OD reduced by 46%.

• Non-fatal ODs did not increase meaning that giving naloxone doesn’t increase risky behavior.

Overdose Response Programs

Work

Project Lazarus / Wilkes County, NCWhat: Primary care providers prescribing take-home naloxone to chronic pain patients; coupled with safe opioid prescribing education.

Outcomes:• The OD death rate dropped from 46.6

per 100,000 people in 2009 to 29.0 per 100,000 people in 2010.

• Decrease in number of victims who received a prescription for the substance implicated in their fatal overdose from a Wilkes County phycisian.

• Only 10% of people who died from an OD received a prescription for an opioid from a Wilkes prescriber in 2010, vs. 82% in 2008. http://projectlazarus.org/project-lazarus-results-wilkes-county

What is an opioid?

Review of Opioids Opioid – a natural or synthetic drug containing opium (or a by-product of opium):Prescription medications AND illegal or “street” drugs

Effects can last from several minutes to 72+ hours (avg. 3-24 hours)

Natural Semi-synthetic (“Opiate”) Synthetic

codeine • morphine opium

heroin • hydrocodone hydromorphone

oxycodone • oxymorphone

fentanyl • methadone tramadol

Common Opiates & Opioids Drug Brand ® Slang Terms

Heroin ------- H, Dope, Dust, Smack, Dragon

Morphine MS Contin, Astromorph M, Miss Emma, Monkey, Dreamer, White Stuff

Fentanyl Duragesic, Apache, China girl, TNT, Goodfella, Jackpot

Oxycodone OxyContin, Percocet, Roxicodone 512s, OC, Oxy, 80s, Oxycotton, Hillbilly Heroin

Oxymorphone Opana Mrs. O, Pink/Blue, The O bomb, Heaven, Stop Signs

Hydrocodone Vicodin, Lorcet, Lortab, Norco Vikes, Hydro, Fluff, H bomb

Hydromorphone Dilaudid D, Juice, Dust, Footballs

Codeine Tylenol 3 & 4 Captain Cody, Syrup, T-3s, Purple drank

Methadone Methadose Jungle juice, Fizzies

Buprenorphine Suboxone, Subutex Bupes, Subs, Subbies

Recognizing an Opioid Overdose

An Overdose: • Happens when someone takes too much of one or more substances than their body is used to or can tolerate.

• Can--but does not have to--cause serious negative reactions or death.

• Brain damage may start after 3 to 5 minutes without oxygen.

• Can be caused by many kinds of substances, incl. those prescribed by a doctor

• e.g. opioids; alcohol; stimulants (cocaine); benzodiazepines (‘benzos’); OTC medications like acetaminophen (Tylenol®)

•Often results from a mix of substances

Risk Factors for Overdose Lapse in time since last use

– Even short periods of abstinence lower tolerance– So: high risk after detox, rehab, jail, prison

Mixing opioids– Especially with benzos or alcohol

Using Alone – In an unfrequented location

Quality of the drug(s)

How one takes a drug– Injecting in vein, smoking higher risk than swallowing, injecting in muscle

Medical History & Physical Health problems– Due to age; recent illness; chronic conditions – Previous Overdose

Educate

You can help prevent opioid overdose:

Refer for Medication Assisted Treatment

• Screen patients for OD risk • Educate patients, their families, & caregivers about

recognizing + • responding to OD

• May help to talk about ‘opioid poisoning’ or ‘bad reactions’• In ED: Create Overdose Safety Plan

Methadone Buprenorphine Vivitrol (Naltrexone)• Full opioid agonist • Avg. dose: 65mg• Have to go to specific clinic every day• Cheap (≈$80/wk)• More likely to OD on

• Partial agonist & partial antagonist• Avg. dose: 16-24mg• Prescribers must have special training • Expensive (≈$20/day)• Easier to detox from

• Full opioid antagonist • Monthly injection• Very expensive

Signs and Symptoms of an Opioid Overdose

• During an Opioid OD:• Suppression of respiratory drive • Oxygen levels in the blood decrease• Cyanosis, unconsciousness, coma, hypoxic-ischemic brain

injury, or death• Process may take several hours

• Many victims using a combination of substances (e.g.

• benzodiazepines, alcohol, speedball)

Signs and Symptoms of an Opioid Overdose

❑ Snoring or gurgling noises ❑ Very limp body❑ Shallow, slow, or no breathing ❑ Unresponsive to stimuli ❑ Pale, clammy skin❑ Blue or ashen lips or fingertips ❑ Slow or erratic pulse ❑ Unconscious (passed out)

If victim shows these symptoms, could be reaction to stimulants (e.g. cocaine, ecstasy, speed):

✓ Racing heartbeat✓ High temperature w/ sweating✓ Chest pain or tightening feeling

✓ Nausea, vomiting✓ Convulsions, seizure, or limb jerking✓ Psychosis

Responding to an Opioid Overdose

Responding to an Opioid Overdose

1. Rouse & Stimulate 2. Call for emergency help3. Give Naloxone4. Perform Rescue Breathing 5. Continue providing care

Step 1: Rouse & Stimulate Try to wake the person up.

• If the person does not respond to their name being shouted or gentle shaking…

Do a sternal rub make a fist and rub your knuckles firmly up and down the front of their breast bone.

• Look, listen and feel for signs of breathing: Put your ear near the victim’s mouth and listen

for breathing OR Look at the chest to see if it is rising an falling.

Step 2: Call 9 – 1 – 1 • State your location

• Say what you observe about the person’s condition (i.e. not breathing, blue, unconscious, unresponsive)

You do NOT need to tell the 911 operator that someone is overdosing

• After Emergency Medical Service (EMS) professionals arrive, let them know about the substances the person may have used and if you administered naloxone.

Step 3: Give Naloxone Naloxone is a safe and effective prescription

medication to treat an opioid overdose. • If the person does NOT have opioids in their system, Naloxone will have NO effect and will NOT cause harm.

• There is NO potential for abuse and side effects are rate.

• Safe for children and pregnant women.

Mechanism of Action

Naloxone displaces

opioids from opioid

receptors.

The effects are temporary, and

wear off in 30-90 minutes.

Opioid Receptor

Naloxone

Opioids

Types of Naloxone Intravenous (IV/IM)

Need syringe, needle & vial ORAuto-injector

Intranasal (IN)Two types Narcan and Amphastar

Practice Stations: • You will get into 4 groups

• Each group will go through 2 stations: Station 1: Injectable Naloxone Station 2: Intranasal Naloxone

Administering IM Naloxone: Step 1: Remove the cap from one vial, than one syringe.

Step 2: Insert the needle through the rubber stopper on the vial.

Step 3: Pull back on the plunger until all of the liquid (1cc/mL) is drawn into the syringe.

Step 4: Inject straight into a large muscle (upper arm, thigh, or buttocks) and then push the plunger.

• Allow 1-3 minutes for the naloxone to take effect

• Naloxone lasts 30-90 minutes

• If the person is still not breathing on their own after 1-2 minutes – give a 2nd dose

Administering IM Evzio®: Voice instruction guides use.

Step 1: Pull Evzio® from the outer case.

Step 2: Pull off the red safety guard.

Step 3: Place the black end against the middle of the thigh (clothing does NOT need to be removed).

Step 4: Press firmly and hold in place for 5 seconds.

• If minimal or no response in 2-3 minutes, administer a 2nd dose.

Administering Intranasal NARCAN®:Step 1: Remove NARCAN® Nasal Spray from

the box and peel back the tab to open.

Step 2: Hold with your thumb on the bottom of the plunger and your first and middle fingers on either side of the nozzle.

Step 3: Tilt the person’s head back and support the neck.

Step 4: Insert the tip of the nozzle into one nostril.

Step 5: Press plunger firmly to give the dose.

• If minimal or no response in 2-3 minutes, administer a 2nd dose.

Administering Amphastar Nasal Naloxone:Step 1: Pull or pry off the yellow caps from syringe.

Step 2: Pry off the red cap off of the naloxone capsule.

Step 3: Grip the clear plastic wings of the atomizer and screw into top of syringe.

Step 4: Screw capsule of naloxone into the barrel of the syringe.

Step 5: Insert white atomizer into nostril and push naloxone capsule into the syringe so that one half of the tube goes into each nostril.

• If minimal or no response in 2-3 minutes, administer a 2nd dose.

Storage & Disposal Storage:

• Keep in original packaging & do not open until ready to use • Keep at room temperature, 59°F - 86°F (avoid extreme temp. changes)• Avoid exposure to light (keep in black bag)

Expiration: • Effectiveness decreases after 2 years

Disposal of Syringes and Naloxone:• Place in a sharps container (if not available use an empty glass or hard

plastic bottle with lid) • Recycle empty vials

Step 4: Preform Rescue Breathing

If breathing is very shallow, slow, or stopped begin rescue breathing ASAP.1. Place the person flat on their back and

tilt chin up to open the airway.2. See if anything is blocking the airway

if so, remove it.3. Pinch the person’s nose closed.4. Cover their mouth with your mouth and

give 2 regular breaths.5. Continue with 1 breath every 5 seconds.

Tip: Victim’s chest should rise after each breath. If it is not, tilt the head back more to open the airway.

Step 5: Evaluate & Continue Care

• After breathing resumes, place the person into recovery position.

• Give another dose of naloxone if the person stops breathing again.

• Stay with the person until the EMS arrives.Note: After being revived with naloxone, a person may…

o Experience withdrawal (NOT life threatening)

o Feel sicko Have a seizure (rare)

…but they will be alive!

What are your rights – Criminal Procedure • Being at the scene of an OD is not by itself reason for arrest

• You may not be prosecuted for possession or paraphernalia

• You may be detained + prosecuted for outstanding warrants

• The victim’s housing, financial aid, etc. may be jeopardized

-- Do not talk about the person’s full name, citizen status, school/job affiliations

What are your rights – Good Samaritan Law• An individual who administers naloxone to an individual believed to be experiecing an overdose shall have immunity from liability under the Courts and Judicial Proceedings Article

• You cannot be held liable for a good faith attempt to help someone

Dispensing Naloxone

Information for the Pharmacist

The LawNaloxone can be dispensed two ways…1. With a person specific prescription

OR2. Without a prescription to people with an ORP certificate due to

the standing order in Maryland

Pharmacists are protected under the ORP from civil lawsuit when dispensing to an ORP certificate holder in good faith and in accordance to the requirements.

How to dispense… 1. Obtain a faxed copy of the standing order by emailing

dhmh.naloxone@maryland.gov – include name, address and fax # of the pharmacy.

2. Keep the standing order on file at the pharmacy 3. Verify the requestor’s ORP certificate. It must include…

Name of certificate holder Name, address and telephone # of authorized organization that issued

the certificate Date of issue and expiration Serial number the phrase …

“is hereby authorized to obtain a prescription for naloxone in the certificate holder’s name, and possess and administer naloxone in accordance with Health-General Article,

Title 13, Subtitle 31, Annotated Code of Maryland.”

**If you are unsure about the certificate’s validity, call the authorized organization to verify**

4. Select appropriate formulation 5. Bill the insurance like a normal

prescription under:

Dr. Howard Haft, NPI #: 1639132152

6. Provide counseling on how to use naloxone

Insurance CoverageMaryland Medical Assistance:

$1 co-pay Injectable Naloxone single dose vial (0.4 mg/mL) Amphastar Naloxone pre-filled syringe (2 mg/mL)

The atomizer needed must be billed as DME using procedure code A4210 – additional cost applies

Evzio® requires prior authorization to be covered

NARCAN® Nasal Spray (4 mg/0.4 mL) is not covered

Commercial Insurance:• Most insurers cover naloxone, but products covered vary.

Estimated Cash Price Product Cost/dose

Evzio® $2250.00 (2 per pack)IM Naloxone Vial (0.4mg/mL)

Needle + Syringe $18.71$0.16

NARCAN® Nasal Spray $75.00 (2 per pack)Amphastar Nasal Naloxone Pre-filled

SyringeAtomizer

$47.00$4.85

Potential Barrier to Dispensing:

• A prescription or ORP certificate is needed to dispense naloxone…….

• What if neither is present and naloxone is needed immediately……

• Request the patient/caregiver to go to http://dontdie.org/.

13 minute video 5 question quiz (must pass with 100%) ORP certificate

Resources

Overdose Response Programs Who to refer:- Recent care for OD or intoxication or history of non-medical opioid OD- On high-dose opioids (>100 mg/day morphine equivalent)- Are receiving methadone - Recent release from abstinence program, prison, jail, detox- Have concurrent alcohol, benzodiazepine, or antidepressant use- Comorbidities incl. COPD, sleep apnea, asthma, renal or hepatic disease- Individuals/families with difficulty accessing or low use of traditional healthcare

Overdose Response Programs - Staying Alive (Baltimore City): recent user

only; free IN naloxone - BSHRC Pilot Project: any user-status;

collects data; free IM naloxone- Other ORPs: visit DHMH-ADAA website

Dontdie.org

Resources Opioid Overdose Toolkit (from SAMHSA)

http://store.samhsa.gov/shin/content//SMA13-4742/Toolkit_Survivors.pdf

Tips for Talking to Friends and Family about Overdosehttp://odprevention.org/for-family-friends/how-do-i-talk-to-my-loved-one/

Treatment Options in Maryland & Opioid Overdose Prevention Plan

http://adaa.dhmh.maryland.gov

Baltimore Student Harm Reduction CoalitionBaltimoreHarmReduction.org

Email us: overdosebaltimore@gmail.com

Case Scenario

Case Scenario Simulation and Practice • You will go into group of twos to counsel a patient/caregiver

about the following: Signs and symptoms of overdose How to respond to an overdose Counsel on dosing, administration, storage, expiration, and disposal of

naloxone • Please refer to the rubric handout and you may use any of the

handout resources given today. • You will have 10 mins • Once you have finished, please fill out the post survey and

assessment • Bring it to the front and we will review your certification

Overdose Respons

e Program

September 2016