Download Opioid Overdose - Baylor College of Medicine

September 13, 2016
Grand Rounds
Department of Family & Community Medicine
Baylor College of Medicine
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Discuss indications for having a naloxone
overdose kit
List risk factors for opioid overdose
Describe how to respond to an opioid
overdose in a non medical setting
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Number one cause of accidental death in the
United States (exceeding MVAs) since 2009
q36 minutes, 1 person in US dies of opioid OD
60% of opioid overdoses in “medical users”
 They are are OUR patients
 “Primum Non Nocere”
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Knowledge gap
Might encourage increased risk taking
Might offend
Uncomfortable self reflection on prescribing
patterns
J Gen Intern Med. 2015 Dec;30(12):1837-44. doi: 10.1007/s11606-015-3394-3.
Overdose Education and Naloxone for Patients Prescribed Opioids in Primary Care: A Qualitative Study of Primary Care
Staff.
Binswanger IA1,2,3, Koester S4,5, Mueller SR6,7,5, Gardner EM8, Goddard K6, Glanz JM6,9.
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Patients can’t afford it
‘Nonrandomized Intervention Study of Naloxone
Coprescription for Primary Care Patients Receiving LongTerm Opioid Therapy for Pain.’
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6 safety net, primary care practices in SF
1985 patients, 38% co-prescribed naloxone
47% and 63% fewer opioid-related ED visits
at 6 and 12 mos (cw those not co-prescribed)
Co-prescription more likely if:
 Higher opioid dose
 Opioid-related ED visit in past 12 months
Ann Intern Med. 2016 Aug 16;165(4):245-52. doi: 10.7326/M15-2771. Epub 2016 Jun 28.
Nonrandomized Intervention Study of Naloxone Coprescription for Primary Care Patients Receiving Long-Term Opioid Therapy for Pain.
Coffin PO, Behar E, Rowe C, Santos GM, Coffa D, Bald M, Vittinghoff E.
‘Primary Care Patient Experience with Naloxone Prescription’
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60 patients interviewed, 90% new to naloxone
87% successfully filled script
97% believed patients Rx chronic opioids
should be offered naloxone
57% positive response, 22% neutral response
37% reported + behavior changes, 0% 37% had hx of ‘opioid poisoning event’
5% reported use of their naloxone
77% estimated personal OD risk as low
Ann Fam Med September/October 2016 vol. 14 no. 5 431-436
Emily Behar, MS1,2⇑, Christopher Rowe, MPH1, Glenn-Milo Santos, PhD, MPH1,2, Sheigla Murphy, PhD3 and Phillip O. Coffin, MD, MIA
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Prior hx of OD
OUD or misuse, known
or suspected
Rx methadone or
buprenorphine
Rx >50 MEQ daily
Poor access to EMS
Voluntary request
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Rx < 50 MEQ daily AND
 Lung infection or dz
 Liver Disease
 Kidney Disease
 Heart Disease
 HIV/AIDS
 Drinking ETOH
 Using Benzo/sedatives
 Antidepressants
 Rotated Rx opioid
ALLOWED/PROTECTED
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Prescribe to person at risk
NOT ALLOWED/PROTECTED
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 Autoinjector
 IM vial/syringe kit
 Nasal spray formulation
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Prescribe to
bystander/friend/family
Dispense/distribute via
standing order: CVS and
Walgreens, currently
Prescriber immunity
Bystander immunity
 From giving naloxone
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Dispense without Rx or
standing order
Bystander immunity
 From non violent offense
outstanding warrants
 From new charges
▪ Possession
▪ Distribution
▪ Public Intoxication
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Codeine +
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3-4 Hours
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Demerol ++
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2-4 Hours
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Fentanyl +++++
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2-4 Hours
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Heroin +++++
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6-8 Hours
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Hydrocodone+++
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4-6 hours
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Methadone ++++
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24-32 Hours
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Morphine +++
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3-6 Hours
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OxyContin+++++
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8-12 Hours
+ Potency
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Natural opioids: contained in resin of
opium poppy (morphine, codeine)
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Semi-synthetic opioids: created from
natural opioids such as
hydromorphone, hydrocodone,
oxycodone, heroin etc.,
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Fully Synthetic Opioids: Methadone,
Fentanyl
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Rarely instantaneous
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Typically 1-3 hours after use
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Opioids slow receptors that control breathing
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Low O2 levels to the brain as resp rate slows
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Unconscious, Coma, Death
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Long-term Brain/Nerve/Physical Damage
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Alternative terminology may be important: poisoning,
unintentional overdose, toxicity
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Tolerance
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Mixing
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Alone
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Purity
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Route
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Health
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History
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Number one time to OD:
Just out of treatment, no MAT
Just out of prison/jail
New user
Only takes several days of not using for
tolerance to drop significantly
Go low, go slow
MAT when available, especially with relapse
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Especially other respiratory depressants:
 BENZOS
 ETOH
 sleeping rx eg ambien
 Muscle relaxants eg Soma
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Stimulants (eg cocaine “speed balling”)
 Don’t counteract the respiratory depression
 Add stress to cardiac system
 High doses may cause pulmonary edema
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Using alone raises risk
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Always use with “partner”: educate them on
responding to OD
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Notify close contact of planned use if using
alone
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Adulterations common and can raise or lower
risk of OD
 Some adulterants are fillers, decrease potency
 Others are active eg fentanyl, increase potency
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Use same dealer
Listen to “word on the street”
Test dose
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User changing route of administration at
higher risk of overdose:
 IV injection riskier than IM/SC “skin popping”
riskier than smoking riskier than snorting riskier
than oral
 Risk greatest with “first time” change
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But taking by mouth does not eliminate risk
of overdose
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Decline in health raises risk of overdose
 Pneumonia or other respiratory illness
 Liver disease or decreased liver function
 Kidney disease or decreased kidney function
 Heart disease
 HIV/AIDS
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Post hospital discharge = Double Risk
 Tolerance AND Health
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Prior OD increases risk of another OD
Take an Overdose History:
 Personal history of OD: accidental or intentional
▪ Drug/s involved, route of use, treatment if any, outcome
 Witnessed OD: common traumatic event
 Non witnessed OD of friend/family/acquaintance
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Blue skin tinge- usually lips and
fingertips show first
REALLY HIGH
OVERDOSE
Muscles become
relaxed
Deep snoring or
gurgling (death
rattle)
Very infrequent or
no breathing
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Body very limp
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Face very pale
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Pulse (heartbeat) is slow, erratic, or
Speech is
slowed/slurred
not there at all
Sleepy looking
Pale, clammy skin
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Throwing up
Nodding
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Passing out
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Choking sounds or a
Heavy nod, not
responsive to
stimulation
Will respond to
stimulation like
yelling, sternal rub,
pinching, etc.
Slow heart
beat/pulse
gurgling/snoring noise
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Breathing is very slow, irregular, or
has stopped
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Awake, but unable to respond
Slow heart
beat/pulse
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Identify OD happening
Call 911
Rescue Breathing
Naloxone administration
Rescue Breathing
Recovery Position
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Are you alright?
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Are you ok?
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Pain Stimulus
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If no response call 9-1-1
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Rescue Breathing
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Naloxone
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Rescue Breathing
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Salt Water
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Suboxone
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Ice On Body
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Cold Shower
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Cocaine
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Milk
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Burning Skin
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Punching
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Slapping
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Fear of judgment from family/ community
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Fear of legal risk
 outstanding warrants, TDCJ involvement, loss of public housing
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Personal embarrassment/shame ESPECIALLY in early recovery
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Other punitive measures (students loose federal financial aid)
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‘Street myths’
 homicide charge for being at an OD, being deported
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Acknowledge these are REAL CONCERNS
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Stress options: staying, leaving with clear path to victim, etc
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Opioid Antagonist
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Medication that reverses only OPIOID
Heroin
overdose
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Can not get high on it
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Can not abuse it
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Stays active for 20-90 minutes
depending on metabolism, amount of
drug used
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If they use before the naloxone wears off
Narcan
Opioid
receptor
Narcan has a stronger
affinity to the opioid
receptors than the heroin,
so it knocks the heroin off
the receptors for a short
time and lets the person
breathe again.
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Formulations
 Parenteral (IV/IM/SC)
▪ ~$40 Generic:
▪ 0.4mg/ml vials and syringes
or 1 mg/ml syringes
▪ ~$700+ Evzio (for 2 doses):
▪ 0.4mg/0.4ml autoinjector
 Intranasal
▪ ~$100 Narcan nasal spray:
▪ 4mg/0.1ml nasal spray
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Not just people who inject at risk for OD
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Not just people who misuse at risk for OD
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Take an OD history
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Know the myths about response
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Know some street slang
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(does not mean YOU have to use it)
Remember we practice FAMILY Medicine
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www.prescribetoprevent.org
www.texasoverdosenaloxoneinitiative.com
Thank You!!