Prescribe to Prevent: Overdose Prevention and …

1 Prescribe to Prevent: Overdose Prevention and naloxone Rescue Kits for Prescribers and Pharmacists AUDIO TRANSCRIPT. SLIDE 1 Prescribe to Prevent Title Slide Welcome to Prescribe to Prevent: Overdose Prevention and naloxone Rescue Kits for Prescribers and Pharmacists. This program consists of three presentations and illustrative videos. Through the program, you'll meet a prescriber and a pharmacist, and their patient. You will learn from expert faculty, including a prescriber, a pharmacist, and a lawyer, how to educate your patients about Overdose Prevention and how to Prescribe naloxone rescue kits. Core topics include: Risk factors for opioid Overdose How to recognize and respond to an opioid Overdose How to incorporate naloxone into that Overdose response And the medico-legal issues surrounding the distribution of naloxone , including third party prescribing and Good Samaritan laws. At the conclusion of the program is you wish to receive CME, CNE, or ACPE credit, you must register in order to take a post-test and complete an evaluation.

2 With a passing score of 70% or greater, you'll be able to print your certificate. This program is provided by Boston University School of Medicine, and is supported by an unrestricted educational grant from the Substance Abuse and Mental Health Services Administration of the US Department of Health and Human Services. SLIDE 2 Educational Objectives At the conclusion of this activity, participants will be better able to: Explain the epidemiology of Overdose Explain the rationale for and scope of Overdose Prevention education and naloxone rescue kit distribution Incorporate Overdose Prevention education and naloxone rescue kits into medical and pharmacy practice by o Educating patients about Overdose risk reduction and o Furnishing naloxone rescue kits Explain the legal issues around furnishing naloxone rescue kits. SLIDE 3. Dr. Bird: I keep hearing about these overdoses in the news, but I'm not sure how it really relates to my patients.

3 Ms. Johnson: Well, we have been dispensing more and more opioids for pain, and we're definitely filling more buprenorphine prescriptions. 1 SLIDE 4. SLIDE 5 Epidemiology and Overdose Risks Hi, my name is Alex Walley. I am a general internist and an addiction medicine specialist on faculty at Boston University School of Medicine. I take care of patients in primary care, I am a buprenorphine prescriber and I am a Medical Director at a methadone maintenance program. With the Department of Public Health in Massachusetts I serve as the Medical Director for the opioid Overdose Prevention pilot program. I am going to start off talking about the epidemiology of Overdose and Overdose risks. SLIDE 6 Drug Overdose Deaths in 1990-2008 More Than Tripled Overdose is increasingly recognized as a major public health problem. Over the last several years there's been increasing number of deaths associated with opioid Overdose to the point where Overdose is the number one cause of accidental injury death.

4 SLIDE 7 Drug Overdose Deaths Outnumber Motor Vehicle (1). Here we have a map of the United States in 2005, which shows 10 states in red where Overdose deaths exceed traffic crash deaths. SLIDE 8 Drug Overdose Deaths (2). By 2010 there were 31 states here represented in red where Overdose death exceeded traffic crash deaths and it was in this year that Overdose deaths became the number one cause of accidental injury death in the United States. SLIDE 9 Opioid Overdose costs, 2009. Not only is Overdose causing deaths, it is also costing a lot of money. So opioid overdoses, which represent about 75% of all overdoses, are responsible for billion dollars in cost to society in a study that looked at costs in 2009. Breaking these costs down, billion dollars came from direct cost for inpatient, emergency department, physician, and ambulance services; where billion dollars was connected to indirect cost from lost productivity, from absenteeism, and from mortality.

5 This works out to, for every Overdose event both nonfatal and fatal, $37,000 in costs to our society. Much of this increase in overdoses have been linked to the increases in prescription opioids so there has been dramatic increases, many times increases in opioid prescribing for chronic pain conditions and hopefully this has resulted in better control of chronic pain for many of our patients, but it also has resulted in unintended costs, which include increases in addiction and increases in Overdose death. SLIDE 10 Where Prescription Opioids are Obtained So where do people obtain their opioids? If you look at the patients who are having opioid problems, those people who are having problems with prescription opioids, where do they obtain these prescription opioids? And 71% of the time they obtain these from family or friend. They are not getting them primarily off the internet, they are getting them from people they know, people in their social network.

6 SLIDE 11 Where Family and Friends Get Opioids But where do the people in their social network get their prescription opioids? Do they get them from the internet or from drug dealers? No. 82% of friends and family get their prescription opioids from one doctor and so as prescribers and pharmacists we have a responsibility to think about what's happening to the opioids that we're distributing to patients. SLIDE 12 Prescription Opioid to Heroin What has been increasingly recognized in the last couple of years is the connection between prescription opioids and re-emerging heroin use epidemic. So here is a study that just came out this year with the title of Every Never I Ever Said Came True : Transitions from Opioid Pills to Heroin Injecting. This is a qualitative study which shows the stories of how people transition from prescription opioids to heroin. We are seeing that more and more, particularly with the changes in formulations that are occurring with long-acting opioids like OxyContin which occurred the fall of 2010.

7 SLIDE 13 Reformulation of Extended-Release Oxycodone So the story with OxyContin and its reformulation is that there was a dramatic change in how and who was getting OxyContin prescriptions after the reformulation. Along with that we've heard increasing reports of people transitioning to heroin. SLIDE 14 US Heroin Use, 2007-2012. And you can see that from this graph from the Substance Abuse and Mental Health Services Administration, which shows the rises in heroin use among persons greater than 12 years from 2007 to 2012. SLIDE 15 How do opioids affect breathing (1). How do opioids actually cause Overdose , how do they affect the breathing? Well there are opioid receptors which control our breathing that exists in the brainstem, here represented in this cartoon . SLIDE 16 How do opioids affect breathing (2). and when an opioid occupies those receptors it causes euphoria, pain relief, and sedation. SLIDE 17 How do opioids affect breathing (3).

8 When the opioid receptors are flooded with opioids then we have too many opioids and that's what causes an Overdose , which results from decrease respirations, loss of consciousness and eventually the victim stops breathing due to lack of oxygen to the brain, the person dies. SLIDE 18 Opioid Overdose Opioid Overdose is caused by reduced sensitivity to changes in oxygen and carbon dioxide outside of normal ranges, and therefore there is a decreased tidal volume and respiratory frequency. With this respiratory failure we have death that results from the hypoventilation. This all occurs due to opioid receptors being stimulated in the respiratory center in the brainstem. It's important to understand that in opioid Overdose develops over minutes to hours. It is not usually instantaneous and what we see when we observe somebody who is having an opioid Overdose is decreased respiratory rate, decreased level of consciousness, lower blood pressure, heart rate, and body temperature, there's myosis or pinpoint pupils and often times the skin takes on a blue or gray tinge including the lips and the nail beds.

9 SLIDE 19 Common Risks for Opioid Overdose (1). It is crucial as prescribers and pharmacists that we understand the risks of opioid Overdose and we are able to convey those to our patients. Many of the risks for opioid Overdose are well established and these can be helpful in educating patients. We need to ask our patients and learn their history to understand what their own risks are. SLIDE 20 Common Risks for Opioid Overdose (2). The risk of Overdose increases as the dose of prescription opioids increases. For our patients who use heroin unexpected changes in purity, which can occur all the time, can lead to an Overdose . SLIDE 21 Common Risks for Opioid Overdose (3). Mixing psychoactive substances and polypharmacy substances including alcohol, stimulants, marijuana, prescribed and non-prescribed medications are also major contributors to Overdose risk. While opioids are typically involved in three quarters of Overdose death at least one other substance is usually involved in addition to the opioid.

10 Psychoactive medications of particular concern include controlled medications like benzodiazepines, barbiturates, and stimulants, but also medications that are relatively benign when used on their own, but have synergistically sedating effects when used with opioids; examples include clonidine, the blood pressure medication; promethazine, a medication an anti-nausea medication; and gabapentin. SLIDE 22 Common Risks for Opioid Overdose (4). We also need to think about people who are socially isolated; whether they are using illicit or prescribed opioids they are at increased risk of dying from Overdose because if and when they Overdose there is no one there to rescue them. So we need to educate patients that if they are going to use opioids, whether they are illicit or prescribed opioids, someone else should be around so that they can respond if they use too much. SLIDE 23 Common Risks for Opioid Overdose (5).