The Opioid Epidemic

144 drug overdose deaths per day The CDC has reported 52,404 total overdose deaths in 2015 and 33,091 (63.1%) involved opioids 144 drug overdose deaths per day The number is up 11.4% in just one year (up from 129/day in 2014) Overdose deaths is the leading cause of injury death in the United States, surpassing those deaths due to gun violence or automobile injuries. The death rates from synthetic opioids (other than methadone) increased by 72.2% from 2014-2015 Deaths caused by heroin overdose increased by 20.6% 19 states showed significant increases in drug overdose deaths from 2014. Source: Rudd RA, Seth P, David F, Scholl L. Increases in Drug and Opioid-Involved Overdose Deaths—United States, 2010-2015. MMWR Morb Mortal Wkly Rep.ePub: 16 December 2016. DOI: http://dx.doi.org/10.15585/mmwr.mm655051e1

The Impact of Opioids in South Carolina 5,702 patients were discharges from emergency departments (EDs) with issues related to opiate abuse/dependence in 2015. 2,398 patients were discharged from EDs with issues related to opiate overdose/poisoning in 2015. 135% increase in service utilization at state-funded substance use disorder treatment programs for individuals looking for help with an opiate use disorder- from CY 2006 (2,469) – to CY 2016 (5,803). Opioid-Related Deaths In 2015, there were 594 opioid-related deaths in SC vs. 311 homicides. Up 16.9% from 2014 (508).

Growing opioid epidemic in the US with increase in drug overdoses driven largely by an explosion in addiction to prescription painkillers and heroin. Estimated Age-adjusted Death Rates for Drug Poisoning by County, United States1 1999 2014 Active surveillance at the state level finds prevalence rates and incidence rates significantly higher than CDC estimates Revised estimated range of 2,146-8,584 annual incident cases among people under 30 years in Massachusetts (16 – 24X the CDC estimate) Many IDU cases in rural America where Public Health infrastructure is not in place 1 Rossen LM, et al. (2016) “Drug poisoning mortality: United States, 1999–2014.” National Center for Health Statistics, CDC.

Overview of Opioids What are Opioids How opioids work: Includes illegal drugs like heroin as well as prescription meds used to treat pain such as Percocet, Oxycontin, etc. (more examples on following slides) How opioids work: They bind to specific receptors in the brain, spinal cord and GI tract and also: Minimizes the “perception of pain” Stimulates the “reward centers” in the brain Effects other systems that regulate mood, breathing and blood pressure.

Opiates Are Drugs Derived from/similar to opium Opioids Not opioids Cocaine or crack Methamphetamines Benzodiazepines (Xanax, Valium, Ativan, Klonopin) Phenergan Seroquel Neurontin Muscle Relaxers (Soma, Flexeril) Alcohol Heroin Morphine (named after Morpheus-Greek God of sleep) Methadone OxyContin (long acting oral opioid) Oxycodone (Percocet) Hydrocodone (Lortab, Vicodin) Fentanyl Many others…. Often, overdoses involve one or more of the drugs on the right in combination with opioids.

How Does Overdose Occur? Taking meds originally prescribed for someone else Dosing error: by prescriber, pharmacist or patient’s misunderstanding of directions for use Deliberate misuse of a prescription opioid or illicit drug like heroin Heroin on market today is extremely inexpensive yet so pure it can be snorted. We are seeing synthetic forms of fentanyl being mixed into heroin that is then snorted or injected. Both forms of administration can be deadly! When mixing opioids with alcohol or certain other meds (even over- the-counter meds)

Who Is At Risk? Main categories include persons who: Are using prescription opioids for long-term cancer management Are using prescription opioids for non-medical use Use heroin-- mainly due to: Variation in strength/purity of “street” drugs or lack of knowledge of dosage/strength of pharmaceuticals (ex. may be laced with fentanyl) Switching mode of administration (eating pills to snorting/snorting to injecting) Inexperienced or new users Using alone

Who Is at Risk Continued Others at risk include persons: Receiving rotating opioid medication regimens (risk for incomplete cross-tolerance) Discharged from emergency medical care following opioid overdose/poisoning With a known/legitimate medical need for analgesia and a suspected or confirmed history of substance abuse With a lowered tolerance: Completing mandatory or voluntary detoxification or abstinence only treatment program Past user or abuser of opioids and recently released from incarceration Mixing various drugs: opioids and benzodiazepines Who have poor physical health: (i.e. liver damage, asthma, immune deficiency/AIDS, malnutrition, etc.)

What Is Being Done in SC to Address the Opioid Epidemic?

Narcan ©(Naloxone HCI) Nasal Spray 4mg

How Naloxone Works Opioids attach to brain receptors that minimizes pain but that also effects breathing Naloxone reverses the effects of opioids by binding more strongly to the same receptors and temporarily “taking over” and knocking the drug off these sites so that breathing can be restored. Only works on opioids. It does not work for overdoses caused by substances such as cocaine, amphetamines, ecstasy, GHB, or alcohol. It does not have the potential for abuse and does not increase risk-taking behavior. (cannot be used to get high and it is not addictive) It has a long safety history and reported side effects are rare. It can be easily and safely administered by laypersons.

See copy of joint protocol in handouts The Joint Protocol The joint protocol authorizes any pharmacist practicing in the State of South Carolina and licensed by the South Carolina Board of Pharmacy to dispense the following Naloxone-Hydrochloride products to persons without a prescription as directed pursuant to § 44-130-40 of the South Carolina Code of Law. http://www.llr.state.sc.us/pol/pharmacy/news/Joint_Naloxone_Protocol.pdf See copy of joint protocol in handouts

The SC Overdose Prevention Project Funding amount: $3,192,772 Project Period: Five years Partner Agencies: SC Department of Health and Environmental Control (SC DHEC): Bureau of Emergency Medical Services (EMS) SC DHEC, Office of Public Health Statistics and Information Services (PHSIS) The Fifth Judicial Circuit Solicitor’s Office Overview of The SC Overdose Prevention Project Role of the PDO Advisory Council

Suggested Reading Resource Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs and Health Dreamland: by Sam Quinones A True Tale of America’s Opiate Epidemic