Office of National Drug Control Policy

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1 Addressing Opioid Misuse and Abuse: ONDCP and SAMHSA Partnership to Reduce Risk of Overdose September 30, 2014 APA Webinar Michael Botticelli, Acting Director Office of National Drug Control Policy Office of National Drug Control Policy Component of the Executive Office of the President Coordinates drug-control activities and related funding across the Federal Government Produces the annual National Drug Control Strategy National Drug Control Strategy The President s science-based plan to reform drug policy: 1) Prevent drug use before it ever begins through education 2) Expand access to treatment for Americans struggling with addiction 3) Reform our criminal justice system 4) Support Americans in recovery Coordinated Federal effort on 112 action items Signature initiatives: Prescription Drug Abuse Prevention Drugged Driving 1

2 Prescription Drug Abuse Prevention Plan Coordinated effort across the Federal Government Four focus areas: 1) Education 2) Prescription Drug Monitoring Programs 3) Proper Disposal of Medication 4) Enforcement High Utilizers Declined When Prescribers Required to Consult PDMPs Tennessee s PDMP Law went into effect at the start of Prescribers now must access the PDMP before prescribing opioids to a new patient. High utilizer defined as a person who used 5 prescribers and 5 pharmacies in a 90-day period. High utilizers decreased 47 percent from the fourth quarter of 2011 to the fourth quarter of Source: Tennessee Department of Health Controlled Substance Monitoring Database Committee. Controlled Substance Monitoring Database 2014 Report to the 108 th Tennessee General Assembly, February 1, Page 5. Available at Linked to

3 Overdose Prevention and Education The National Drug Control Strategy supports comprehensive overdose prevention efforts, to include: More extensive public education campaigns about overdose, including the signs of overdose, emergency interventions, information about Good Samaritan laws where they exist, and the importance of connecting individuals with substance use disorders to treatment. Expanded training and availability of emergency interventions, such as naloxone (Narcan) for first responders. Increased education among health care providers about informing patients using opioids (and their family members/caregivers) about potential for, signs of, and interventions in case of overdose. Heroin Use and Non-Medical Use of Pain Relievers in the Past Year among Persons Aged 12 or Older: Persons Aged 12 or Older 14,000 1,400 Number of Users (Thousands) 12,000 10,000 8,000 6,000 4,000 2,000 0 Non medical users of pain relievers Heroin users ,200 1, Source: SAMHSA, 2013 National Survey on Drug Use and Health (September 2014). 9/2014 Source of Prescription Pain Relievers Source: SAMHSA, Center for Behavioral Health Statistics and Quality, National Survey on Drug Use and Health, Unpublished special tabulations (March 2012). 3

4 Naloxone The Administration supports the use of naloxone by public health and law enforcement professionals to prevent drug-related deaths because we have seen how effective the drug can be. It is legal to prescribe naloxone to patients at risk for overdose to be administered by family members or others who are available. ONDCP understands some have concerns that widespread availability of naloxone does not further the objective of reducing opioid misuse directly. However, ONDCP supports naloxone distribution along with overdose education because some victims are in circumstances which make obtaining or succeeding at treatment difficult, and overdose education with naloxone may save a life and enable eventual participation in treatment. Naloxone Autoinjector FDA recently approved a new autoinjector that provides verbal instructions out loud to the rescuer during the rescue (similar to the technology used for defibrillators). 1 Approval was specifically for lay rescue without requirement for training; The medication is prescribed to the patient but can be used by either caregiver or as law permits by first responder; Comes with a trainer to practice sham rescues ; This may mitigate concerns about administration by non-medical personnel; Using traditional needle & syringe; or Off-label use of nasal inhaler kits. 1. Drug Label source: Image source: Naloxone in the Community: Quincy, MA In late 2010, the Massachusetts DPH, Quincy PD, and mental health/addiction organizations partnered to create a program to train and equip police officers with nasal naloxone. Since 2010, officers have administered naloxone in more than 220 overdose events, almost all of them resulting in successful overdose reversals. I believe we have spread the word that no one should fear calling the police for assistance, and that the option of life is just a 911 call away. We have also reinforced with the community that the monster is not in the cruiser. Indeed, the officer represents a chance at life. Lt. Det. Patrick Glynn, Quincy PD Now, approximately 15 Police/Sheriff agencies with naloxone programs nationwide (e.g., NYPD/Staten Island; Lorain, OH; Vermont State Police) 4

5 Recognizing and Responding to an Opioid Overdose Overdose education may be billed using codes for Brief Intervention SAMHSA permits states to use block grant funds for this activity The American Society of Anesthesiologists (ASA) has created a card explaining how to recognize and respond to an opioid overdose. The card, called Opioid Overdose Resuscitation, is available for download on the ASA Web site. We ask all of you to disseminate this card as widely as possible. To download the card, go to: Leadership Opportunities for MAT Physicians Sign up for and use PDMPs, and encourage residents to follow this practice, where allowed. Expand screening to identify patients at risk for overdose or other escalations (including transition to heroin). Use Screening, Brief Intervention, and Referral to Treatment (SBIRT) billing codes for screening, intervention, and when needed to refer to treatment. This may be used for identifying substance use problems and for those at risk for overdose. Work with payers (e.g., Medicaid) to ensure screening and SBIRT codes are funded and a variety of medicines are on payer formularies (naloxone). Leadership Opportunities for MAT Physicians (cont d) Consider abuse-deterrent formulations and safety profiles of medicines on formularies when prescribing. Consider diversion risk when prescribing. Counsel patients concerning overdose risk and signs, particularly among high-risk patient populations. Facilitate access to EMTs, first responders, and co-prescription when needed and allowed. 5

6 Overdose Law Policy Infographic For More Information: WHITEHOUSE.GOV/ONDCP Diversion Report DISPOSAL REGULATION LINK: SAMHSA Opioid Overdose Prevention Toolkit: Overview of Information for Prescribers and for Patients Elinore F. McCance-Katz, MD, PhD Chief Medical Officer SAMHSA 6

7 What s In the Toolkit? Succinct information for prescribers, patients, first responders, community members and survivors Prescribers: considerations in use of opioid therapies, safe opioid prescribing, naloxone use in opioid overdose Patients: safety advice, preventing overdose, naloxone for overdose, how to avoid overdose Most frequently involved in deaths: oxycodone, hydrocodone, methadone, in combination with alcohol or other drugs, often benzodiazepines Drug overdose death rates increased five-fold since By 2009, drug overdose deaths outnumbered deaths due to motor vehicle crashes for the first time in the U.S. led by opioid analgesics. Opioid analgesics were involved in 30% of drug overdose deaths where a drug was specified in 1999, compared to nearly 60% in ,000 opioid overdose deaths in 2012 (CDC: MMWR, 61:10, 2012) Healthcare providers can help to improve safety with opioid use Care in opioid prescribing Careful monitoring of patients prescribed opioids Continuing education ( Consider prescribing of opioid overdose antidote: naloxone 7

8 SAMHSA Opioid Overdose Prevention Toolkit: Prescribers Provides information on safe opioid prescribing: What is the disease or disorder to be treated with an opioid? Are opioids effective in the treatment of the disorder under consideration? Are there other medications that might be effective and present less risk than opioids? Are the severity of symptoms such that the patient is likely to benefit from opioids? SAMHSA Opioid Overdose Prevention Toolkit: Prescribers Can the patient be expected to use opioids safely: assessment for risk with opioid use Current misuse of medications (to alter mood, relieve anxiety, insomnia) History of drug/alcohol issues, mental health issues Use of alcohol and OTCs, CNS depressants Is the patient likely to experience a drug interaction based on use of other drugs and alcohol? Is the patient likely to take the opioids reliably and as prescribed? Safe use of opioids Prescribers need to be aware of the risks and benefits of opioid therapy Prescribers must educate patients about opioid use Use a Treatment Agreement Informed Consent Risks/benefits Fosters adherence May reduce inadvertent drug misuse Improves efficacy of medication treatment Risk of physical dependence and cognitive impairment Guidelines for use: one doctor/one pharmacy Agreement to take as prescribed Responsibility for safekeeping of medication (opioids and naloxone) Refills on time (not early), by appointment (no call ins/use of ED) Drug screens when asked Checking of PDMP Circumstances under which no further opioids will be prescribed (evidence of misuse, accidental/intentional overdose, altering/selling prescriptions, doctor shopping) If opioid misuse/abuse is occurring; explain safety issues that prevent further prescribing and refer to substance abuse treatment 8

9 Safe use of opioids: patient education Consider naloxone prescription with first opioid prescription Discuss avoiding overdose by using opioids only as prescribed and only for the condition for which they were prescribed Discuss overdose: clinical characteristics and antidote use; describe how naloxone works Safe use of opioids: Provider Measures Universal precautions Urine toxicology screen: baseline and as clinically indicated Check state PDMP: baseline and periodically thereafter Safe use of opioids: Provider Measures Once patient is taking chronic opioids: Check patient response to treatment Monitor analgesic effect Increase in function Adverse events Opioids should be considered a trial; not a lifelong commitment 9

10 Who could benefit from naloxone? Those new to treatment with low tolerance Taking high doses of opioids for long-term management of chronic pain Those receiving rotating opioid regimens (incomplete cross-tolerance) Discharged from ED after treatment for opioid intoxication/poisoning Recently detoxified or in an abstinence based program for opioid dependence/at risk for relapse History of opioid use disorder and recent release from incarceration Over-Medication Significant sleepiness Confusion Slurred speech Pinpoint pupils Slow heartbeat Low blood pressure Difficult to arouse Important for patients to understand as these symptoms may be predictive of overdose Opioid Overdose Recognize signs of overdose/educate patients and their families: Cannot be awakened/cannot speak Slow (or no), labored breathing; loud snoring Slow or no heartbeat Vomiting Lips and fingernails purple Pale, clammy to touch Limp body 10

11 Emergency Treatment of Opioid Overdose Call 911 Support respiration Administer naloxone (IM/autoinjector/nasal) Most with overdose return to spontaneous breathing/mild withdrawal within 3-5 minutes of administration Effect min. Monitor response for re-emergence of overdose symptoms (4 hours) Continue rescue breathing/ventilation as needed Reassurance if withdrawal occurs Get medical care Help person get to treatment if they feel they have a problem with opioids Legal considerations/payment Issues Use of naloxone for opioid overdose is consistent with FDA label State laws may prohibit prescribing to a caregiver/third party need to prescribe to patient Medicare, Medicaid and most private insurance will cover but check with insurer May use an SBIRT billing code for time to counsel patient on how to recognize overdose and use of naloxone for those with substance use problem Use E&M/CPT code that reflects time/complexity for counseling patients receiving opioids for chronic pain who need naloxone Legal considerations/payment Issues States are passing laws that remove legal liability for administration of naloxone 17 states and Washington DC: have passed Good Samaritan laws providing limited legal immunity for drug users who call 911 RI: Walgreen and CVS Caremark will provide naloxone to anyone who requests it under a collaborative practice agreement-prescription written by a physician can apply to anyone. New Mexico: State Board of Pharmacy has added naloxone to a list of drugs that pharmacists can prescribe 11

12 Information for Patients: Avoiding Overdose Only take medicine prescribed to you Take only as prescribed No alcohol with pain medications Avoid sleeping pills Store medication in a safe place Dispose of unused medications safely Learn how to use naloxone Teach friends/family how to respond to overdose Information for Patients: Naloxone Information in Toolkit Description of naloxone and how it works What naloxone does not work for: e.g.: benzodiazepine or other drug overdose Naloxone side effects including description of withdrawal symptoms that can occur if naloxone is given to a regular user of opioids Information for the Community An overview of the epidemic of opioid abuse and overdoses Encourage prescribers, patients, family, friends of those at risk for overdose to learn how to prevent and manage overdose Assure access to treatment for opioid use disorders Ensure access to naloxone Encourage public to call 911 in suspected overdoses Encourage prescribers to use state PDMPs 12

13 Summary Opioid Overdose Prevention Toolkit brings together important considerations in the treatment of patients with chronic opioid therapies to help in assuring safe opioid treatment The Toolkit is short and to the point making it easy to use in clinical practice Its language is easy to understand making it a resource for a broad audience: clinicians, patients, caregivers, and first responders Opioid Overdose Prevention Toolkit Impact Has been downloaded over 45,000 times since August Consumers include BH professionals from educational institutions, non-profits, treatment facilities, and governments. The publication has an average rating of 5 stars (out of 5) on the SAMHSA Store web page. Collaborations Dept. of Justice: Will produce a toolkit specifically for law enforcement Will use information from SAMHSA Opioid Overdose Prevention Toolkit for training on symptoms of opioid overdose and emergency response in addition to covering topics specific to law enforcement SAMHSA/state collaborations on opioid overdose prevention programs 13

14 SAMHSA Opioid Overdose Prevention Toolkit Available at: Prevention-Toolkit-Updated-2014/SMA

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