1. To the Rescue: Naloxone Rescue and other Harm Reduction Strategies for Opioid Overdose Patricia McGuire, MD Collaborative Family Healthcare Association 16 th Annual Conference October 16-18, 2014 Washington, DC U.S.A. Session # E3b October 17, 2014

2. Faculty Disclosure I have not had any relevant financial relationships during the past 12 months.

3. Learning Objectives At the conclusion of this session, the participant will be able to: Identify evidence about risks of illicit and prescription opioid misuse Integrate harm reduction strategies for opioid in the patient centered medical home Discuss Naloxone rescue techniques

4. Bibliography / Reference 1.Belesky LB, Rich JD, Walley AY. Prevention of fatal opioid overdose; JAMA, 2013: 308 (180): 1863-1864 2. Centers for Disease Control and Prevention (CDC); Community-based opioid overdose prevention programs providing naloxone – United States, 2012. MMWR Morb Mortal Wkly Rep. 2012; 261 (6): 101-105. 3. Harvard Medical School. Painkillers fuel growth in drug addiction: Opioid overdoses now kill more people that cocaine or heroin. Harvard Ment Hlth Let. 2011; 27 (7): 4-5. 4. Coffin PO, Sullivan SD, Cost effectiveness of distributing Naloxone to heroin users for lay overdose reversal. Ann Intl Med. 2013; 158: 1-9 5.Coffin P, Banta-Green C; The Dueling Obligations of Opioid Stewardship; Ann Intern Med. 2014;160(3):198-200. doi:10.7326/M13-2209 5. SAMHSA; Opioid Overdose ToolKit; http://store.samhsa.gov/shin/content/SMA13- 4742/Overdose_Toolkit_2014_Jan.pdf

5. Learning Assessment A learning assessment is required for CE credit. A question and answer period will be conducted at the end of this presentation.

6. Opioids Illegal drugs: heroin Prescription meds: – oxycodone – hydrocodone – fentanyl – morphine – codeine – hydromorphone – methadone – buprenorphone

7. Opioids Bind to receptors in brain, spinal cord, GI tract Affect body systems which regulate breathing, blood pressure, mood Minimize perception of pain Stimulate brain reward centers Overdose can lead to Classic Triad – pinpoint pupils – respiratory depression – Coma, death

8. Opioid Overdose Miscalculation of heroin dose Deliberate misuse Misunderstanding directions for Rx opioid dosing Combining opioids with other substances

9. Opioid pain reliever-related overdose deaths increasing at a faster rate than deaths from any major cause

11. Opioid prescribing rates correlate with drug overdose death rates Death rate, 2008, National Vital Statistics System. Opioid pain reliever sales rate, 2010, DEA’s Automation of Reports and Consolidated Orders System

12. Scope of the Problem 2 million individuals with opioid analgesic use disorders The Dueling Obligations of Opioid Stewardship Phillip Coffin, MD, MIA; and Caleb Banta-Green, PhD Ann Intern Med. 2014;160(3):198-200. doi:10.7326/M13-2209

13. Scope of the Problem There was a 4-fold increase in opioid prescriptions for pain in the last 10 years Deaths from prescription opioids have doubled in the last 10 years 17,000 in 2010, up from 14,800 in 2008 CDC MMWR November 4, 2011 / 60(43);1487-1492

14. Principles of Harm Reduction Pragmatism – Are we going to eliminate drug use? Humanistic Values – Not approval but not moral judgment Focus on Harms – Not the use itself Balancing Costs and Benefits Priority of Immediate Goals Hunt, Neil. “A review of the evidence-base for harm reduction approaches to drug use” IHRA, http://www.ihra.net/files/2010/05/31/HIVTop50Documents11.pdf

15. Harm Reduction Conceptualized as set of compassionate and pragmatic approaches for: – Reducing harm associated with high risk behaviors – Improving quality of life Goals – Decrease use or abstinence – Decrease harm associated with use Harm Reduction, 2 nd edition, edit by Marlatt GA, et.al.; 2012, Guilford Press, NY

16. UPMC St. Margaret Behavioral Health Integration Harm Reduction Strategies 2011 SBIRT Universal Screening for SUD 2011 SBIRT curriculum development 2012 Integrated Behavioral Health Team 2013 Controlled Substances Protocol revision 2014 Naloxone Rescue Project development

17. Integrated Behavioral Health Services Multi-disciplinary team Warm hand-off Short-term Behavioral Health therapy – CBT approach to mental health issues – Harm reduction approach to substance misuse Psychiatric consultation Referral to specialty mental health/substance abuse treatment, as needed

18. Control Substance Protocol Revision of Controlled Substance Policy – Avoid Controlled Substance Rx on first clinic visit – Controlled Substance Agreement – Urine Drug Screening – Pain Clinic Referral – SBIRT: Referral to specialty SA treatment – Controlled Substance letter of concern – Naloxone counseling letter

19. Harm Reduction Counseling Ask permission Give personalized feedback about harms/risks of drug use Use collaborative approach to help patients identify their goals re: drug use and related behaviors – Decrease use or abstinence – Decrease associated harms

20. Harm Reduction Counseling Have patient develop options for change to meet their goals Help patient consider as many harm reduction strategies as possible Utilize SMART goal setting – Specific; Measurable; Achievable; Realistic; Timed Assist patient with follow-up plan

21. Naloxone Counseling Letter Educates patients about dangers of opioid overdose – Motivates patients to accept naloxone prescriptions – Encourages patients to ask for help to wean down opioid use, if appropriate Helps providers counsel new patients who request opioid refills at 1st visit – Decreases contentious tenor of those visits – Improves provider satisfaction/feelings of empowerment

22. Naloxone (Narcan) reversing an overdose

23. Endorsement, Policy and Legal Support http://prescribetoprevent.org/medical-legal/

24. Comprehensive overdose prevention, recognition and response, including intramuscular and intranasal Naloxone rescue kit demonstrations http://prescribetoprevent.org/video/ http://vimeo.com/37778160 http://vimeo.com/22647688

25. Naloxone Rescue Teaching

26. Evzio http://evzio.com/patient/?gclid=CL7voL_2sM ACFStk7Aod3h0AJg http://evzio.com/patient/?gclid=CL7voL_2sM ACFStk7Aod3h0AJg http://evzio.com/videos/ITJ001_Evzio_Inter active_V2B-HD.mp4

27. Patient Education

28. Barriers to Implementation Cost Insurance coverage Availability Buy-in Perceptions Limited availability of Suboxone dispensing

29. Questions / Discussion

30. Session Evaluation Please complete and return the evaluation form to the classroom monitor before leaving this session. Thank you!