Naloxone Rescue for Opioid Reversal

Transcription

1 Naloxone Rescue for Opioid Reversal Shannon Panther, PharmD, BCACP Washington State University October 8, 2015 Disclosures No relationships to disclose Intranasal use of naloxone is off label Objectives 1. Discuss the overdose epidemic on a national scale compare to local numbers 2. Recall the mechanism of action of naloxone and the effects on the body 3. Outline the Substance Abuse and Mental Health Services Administration (SAMHSA) Opioid Reversal Toolkit for training a rescuer 4. Describe the steps for responding to an overdose 5. Practice administration technique with a demonstration kit as part of a small group activity 1

2 Visualize Who comes to mind when you think about a person at risk for overdose? National Statistics Each day 46 people die from prescription opioid overdose About 2 per hour 2010, reported 1:20 people ( 12 years old) misused prescription opioids Majority Caucasian males Female numbers rising Source: CDC 1,2 Image source: CDC. Injury Prevention & Control: Prescription Drug Overdose

3 Opioid Prescriptions Sold (2010) Image source: CDC. Vital Signs Overdose Death Rate (2008) Image source: CDC. Vital Signs Overtime See Parallel Rates Image source: CDC. Injury Prevention & Control: Prescription Drug Overdose

4 Oregon Statistics Death rates due to overdose Heroin: 2012, 16% Prescription: 2013, 38% 1 death, for every 1,900 methadone and 20,300 other opioids prescribed Prescribing 2013, PDMP data shows 1:4 Oregonians prescribed opioids Misuse 2012 to 2013, est. 212,000 Oregonians non medically used Source: CD Summary 6, OHA 7 Pharmacology of Naloxone MOA of naloxone is not fully understood Strong antagonist of mu receptor Also kappa and delta Metabolized by liver Half life 30 to 81 min Requires more than one dose Stability Exposure to temperature extremes, shelf life Source: Clinical Pharmacology 8 Antagonism Image source: copeaustralia.com. Why Naloxone

5 Safety Safety profile of naloxone is remarkably high Low doses and titrate to effect Higher doses for rapid reversal can be unpleasant Not life threatening No opioid = no effect Source: Clinical Pharmacology 8 Options for Administration IV = 1 2 min IM/SQ = 2 5 min IN = 8 13 min In the field response, retrospective analysis by Robertson TM, et al. Bloodborne pathogen risk Source: Robertson 10, Teleflex 11 Auto injector 0.4 mg/0.4 ml IM or SC Anterolateral aspect of thigh, through clothing Single use ~$600, 2 doses and trainer Source: Evzio PI, Pharmacist s Letter, Evzio website 12,13,14 5

6 Prescriber Role Team up PMP Consider non opioid for mild, or ER form that cannot be abused Limit quantities Consider co prescribing naloxone Source: CDC 2, SAMHSA 15 Laws Rescuer must complete Naloxone Training and receive certificate Physician or NP (supervising professional) oversees training program Presence not required Training done by public health authority, entity or individuals who provide services to those who take opiates In compliance with supervising professional and protocols of OHA Immunity from civil liability for action or administration SB 839 immunity for contacting medical services Source: Oregon Statutes 16, Rules 17,18 Certificate 6

7 Pharmacy Upon presenting certificate Create hardcopy, using supervising professional information Create kit labeled with trainee name, trainer or supervising professional name and statement For use in Oregon Opiate Overdose Treatment Program Source: Oregon Statutes 16, Rules 17,18 Steps for Training Responders Review overdose and risk factors for prescribed and recreational use Tailor to rescuer need Review overdose prevention techniques SAMHSA action plan Source: SAMHSA 15 Risk Factors for Overdose Opioid naïve or changing to different drug Period of sobriety Health changes Prior overdose Mixing with other CNS depressants Unknown strength or quality Using alone Source: Chapman 19 7

8 Overdose Prevention Know tolerance, use as prescribed Do not mix multiple CNS depressants Know the strength/quality Do not use alone Source: Chapman 19 Fact or Fiction Getting high with prescription drugs is safer Using a friends prescription is not abusing Most overdoses occur when substances are mixed Most ODs take up to an hour It is best to let someone sleep it off A cold shower will wake them up They can walk it off Only new users OD Source: Overdose Facts and Myths 20 Signs and Symptoms of an Overdose Opioids Stop breathing Stimulants Heart stops Seizures Stroke 8

9 Recognize the Risk Unresponsive to yelling or sternal rub Slow or no breathing Snoring/gurgling Turning blue (esp. lips and fingernails) Slow pulse Image source: eatingintuitively.com SAMHSA Five Steps for Response 1. Check for signs of opioid overdose 2. Call for help 3. Rescue breathing 4. Naloxone 5. Monitor Step 1: Check for Overdose Slow/stopped breathing, gurgling/snoring Pale, clammy skin Limp body Blue lips of fingernails Cannot wake with shouting With, or without pulse 9

10 Access similar to CPR Try to arouse Rescue position Image source: Stopoverdose.org Opiate Safety Education Brochure Step 2: Get Help Call 911 First response need to arrive 2 doses of naloxone Required by law for immunity (WA, OR?) State to 911 operator someone is not breathing Give address of location Image source: alpabetworld.wordpress.com. Telephone Step 3: Breathing Overdose suppresses respiratory center of brain (µ receptor) Does not stop pulse Need to assist with breathing, oxygen in blood Verify airway is clear Head tilt, chin life Pinch nose closed Give 2 breaths Verify chest rises, avoid stomach bloating Continue 1 breath every 5 sec Image source: Photobucket.com. Rescue Breathing

11 Step 4: Naloxone Administer with known or suspected overdose Duration of action min May require more than 1 dose after 5 min Continue rescue breathing Be ready to move away quickly if patient is combative Be ready to comfort patient, rescue position Image source: Baristanet.com. Essex County Police Supplied with Kits to Prevent Heroin Overdoses Step 5: Monitor Remain with patient until EMTs arrive Patient will need hospital monitoring 11

12 Assembly Image sources: harmreduction.org. Administer Naloxone. 2015, and intranasal.net. Intranasal Naloxone Oregon Resources Multnomah County Health Department Videos on IM and IN administration Opiate Training Protocol Statement of Completed Training Available on website: MSTraumaSystems/Pages/Naloxone Training Protocol.aspx Practice with Demo Kit 12

13 References 1. CDC: Vital Signs Opioid Painkiller Prescribing. Atlanta: Centers for Disease Control and Prevention, Division of Unintentional Injury Prevention. c2014 [cited 2015 June 10]. Available from: prescribing/. 2. CDC: Prescription Painkiller Overdoses in the US. Atlanta: Centers for Disease Control and Prevention, Division of Unintentional Injury Prevention; c2011 [cited 2013 Dec 2]. Available from: 3. CDC: Prescription Drug Overdose Data. Atlanta: Centers for Disease Control and Prevention, Division of Unintentional Injury Prevention; c2015 [cited 2015 June 10]. Available from: 4. CDC: Prescription Painkiller Overdoses in the US. Atlanta: Centers for Disease Control and Prevention, Division of Unintentional Injury Prevention; c2011 [cited 2013 Dec 2]. Available from: 5. CDC: Data Overview. Atlanta: Centers for Disease Control and Prevention, Division of Unintentional Injury Prevention. C2015. [cited 2015 June 10]. Available from: 6. Drug Overdose in Oregon. CD Summary Sept 9; 63, Oregon Health Authority. Prescription Drug Poisoning/Overdose in Oregon Apr 24. [cited 2015 June 9]. 8. Naloxone. Clinical Pharmacology. Goldstandard. [cited 2013 Dec 13]. Available from: ip.com/default.aspx Robertson TM, et al. Intranasal Naloxone is a Viable Alternative to Intravenous Naloxone for Prehospital Narcotic Overdose. Prehosp Emerg Care 2009; 13: LMA MAD Nasal Intranasal Mucosal Atomization Device. Teleflex. Research Triangle Park, NC Evzio [package insert]. Richmond, VA, Kaleo; PL Detail Document, Evzio (Naloxone) for Opioid Overdose: FAQs. Pharmacist s Letter/Prescriber s Letter. July Evzio. Kaleo Dec [cited 2015 June 8]. Available from: evzio.com. 15. Substance Abuse and Mental Health Services Administration. SAMHSA Opioid Overdose Prevention Toolkit. HHS Publication No. (SMA) Rockville, MD: Substance Abuse and Mental Health Services Administration, Opiate Overdose, ORS (2013). 17. Distribution of Emergency Medication, OAR Opiate Overdose, OAR through Chapman L. Opioid Overdose Risk Factors Ontario; OHRDP Aug 26 [cited 2013 Dec 13]. Available from: overdose risk factors/. 20. Nonmedical Use of Prescription Drugs Myths vs. Facts. Elks National Foundation, Inc. Chicago. [cited 2014 Feb 13]. Available from: 13