2/2/2018 Opioids in 2018: What’s a • Conflict of Interest Pharmacist to do in the Opioid • Red Project Board member • Kent County Opioid Task Force member Public Health Crisis? • Ferris State University Opioid Task Force Committee member Susan DeVuyst ‐ Miller, B.S., PharmD., AE ‐ C Assistant Professor, Ferris State University College of Pharmacy Clinical Pharmacist, Cherry Health Heart of the City Center Objectives • Discuss the safety concerns of prescription opioids • Explain an opioid tapering program • Discuss the applications of naloxone in opioid overdose • Describe State and Local Opioid Task Force progress and Opioid Epidemic – A Brief Review recommendations 2016 62,000+ overdose deaths • Four in five new heroin users started out misusing prescription painkillers 15, 469 heroin 42, 249 opioid related Jones CM. Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers ‐ United States, 2002 ‐ 2004 and 2008 ‐ 2010. Drug Alcohol Depend. 2013 Sep 1;132(1 ‐ 2):95 ‐ 100. 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 2016;65:1445–1452. DOI: doi: 10.1016/j.drugalcdep.2013.01.007. Epub 2013 Feb 12. http://dx.doi.org/10.15585/mmwr.mm655051e1 1
2/2/2018 Opioids: Mechanism of Action Opioids Use, Morphine Equivalents, Side Effects, Overdose Risk Factors and Symptoms https://www.crimemuseum.org/crime ‐ library/drugs/opium/ Medical Uses of Opioids Starting Opioids…Not so fast! Define Treatment Success: • #1 reason patients seek medical attention •Weigh expected benefits vs. risks carefully before initiating opioids • Surgery Severe acute pain •Relieves pain while body heals and improves function • Trauma • Opioids indicated Opioids do not eliminate the pain: Severe cancer pain • Opioids indicated •Decreases the unpleasantness of pain (perception) •Patients will report that although pain is still present, it bothers them less Severe chronic pain • Very controversial Short acting • Dry, non ‐ productive •Can be used for severe acute pain Cough suppressant • Example: promethazine + codeine syrup •Start with the lowest dose • Dextromethorphan is a derivative of opioids •Start with easiest route (PO/IV/PR/PCA) • Tincture of Opium Long acting Diarrhea • Loperamide is a derivative of opioids •Not recommended upon initiation • Avoid in opioid ‐ naïve patients Sedation • Palliative care •Not used PRN •Reserved Cancer pain or palliative care Detoxification • Opioid abuse 9 •Controversial for chronic pain 10 Opioid Equivalence Chart Opioid Side Effects Opioid IV (mg) PO (mg) Duration of action ‐ Sedation Codeine 130 200 3 ‐ 4h ‐ Confusion Tramadol ‐‐‐ 50 ‐ 100 3 ‐ 7h ‐ Diaphoresis Hydrocodone ‐‐‐ 30 3 ‐ 5h ‐ Pruritus Morphine 10 30 3 ‐ 4h ‐ Respiration Oxycodone ‐‐‐ 20 3 ‐ 5h depression ‐ Constipation Hydromorphone 1.5 7.5 2 ‐ 3h ‐ Nausea Fentanyl 0.1 (100mcg) ‐‐‐ 1–3h All opioids are considered equipotent at these doses Can use to convert between opioids Total daily dose of opioids should not exceed 90 mg oral morphine equivalents 11 http://krvlegal.com/effects ‐ opiates ‐ heroin ‐ human ‐ body/ 2
2/2/2018 Signs leading to Opioid Overdose http://www.fraserhealth.ca/health ‐ info/health ‐ topics/harm ‐ reduction/overdose ‐ prevention ‐ http://www.fraserhealth.ca/media/Early_Overdose_Signs.png and ‐ response/recognizing ‐ an ‐ overdose / http://prescribetoprevent.org/wp2015/wp ‐ content/uploads/project ‐ lazarus ‐ community ‐ toolkit.pdf Greater Risk for Opioid Overdose Question: Only Addicts Overdose? Opioid naïve Dose >90MME Added opioid Poly ‐ pharmacy patients • Decrease in pharmacologic response Tolerance • Increase dose to achieve similar effects Substance Co ‐ morbid Genetic poly ‐ Age abuse conditions morphism • High or chronic doses are abruptly d/c’d Dependence • Withdrawal symptom Reduced Methadone De ‐ toxification Mixing, using tolerance after maintenance • Change in behavioral patterns Addiction programs alone, quality abstinence programs • Despite the potential side effects and harm Discontinuing Opioids Patient Ideal Family • Success of therapy + (Quick) cessation • Patient returns to normal daily function Health Less ideal Care • Failure of therapy (use alternatives) Team • Intolerable side effects (opioid rotation) • Discuss withdrawal symptoms and agree on exit strategy (scheduled taper) Not ideal at all • Opioid hyperalgesia • Development of opioid use disorder Worse case Plan to Modify Opioid Use • Overdose • Death 18 3
2/2/2018 Clinical Pharmacy Opioid Taper Algorithm Clinical Pharmacy Opioid Taper Algorithm APPENDIX 3 : Tapering Methadone (in the setting of chronic, non-cancer pain) Suggested Steps for Tapering Methadone: 1.Decrease dose by 20-50% per day until you reach 30mg/day. 2.Then decrease by 5mg/day every 3-5 days to 10mg/day. 3.Then decrease by 2.5mg/day every 3-5 days. Tapering and Discontinuing COAT | 9 Appendix 2: Morphine Equianalgesic Clinical Pharmacy Opioid Taper Algorithm Dose Chart and Calculator Taper Conversion Link Opioid Withdrawal Symptom Management http:www.hca.wa.gov/medicaid/pharmacy/documents/taperschedule.xls Opioid withdrawal symptoms should not be treated with opioids or benzodiazepines • • First step to management of withdrawal symptoms = SLOW THE TAPER • If needed, adjunctive therapy options: • Clonidine 0.1mg PO two to three times daily as needed for hypertension, nausea, cramps, diaphoresis, tachycardia • Trazodone 25 ‐ 50 mg PO at bedtime as needed for insomnia • Diphenhydramine 25 ‐ 50 mg PO every four hours as needed for insomnia, restlessness • Ibuprofen 200 ‐ 400 mg PO every eight hours as needed for muscle aches Acetaminophen 500 ‐ 1000 mg PO every six hours as needed for muscle aches; do not exceed 4000 mg / • 24 hours • Loperamide 2 mg PO after each loose stool; do not exceed 16 mg/day Tapering and Discontinuing COAT | 23 Tapering and Discontinuing COAT | 24 4
2/2/2018 Naloxone Opioid reversal agent Photo courtesy of Grand Rapids Red Project. Redproject.com http://ijhs2.deonandan.com/wordpress/wp ‐ content/uploads/2015/09/Untitled.png Delayed onset Naloxone Naloxone 2 to 5 minutes for IM, SubQ, Nasal 8 to 13 for nasal atomization Emergency treatment of known or suspected opioid overdose as Duration of action manifested by respiratory and/or CNS depression 30 minutes to two hours Intended for immediate administration as emergency therapy in settings Shorter than opioids where opioids may be present Repeat doses at different site/nostril Not a substitute for emergency medical care Seek medical treatment No potential for abuse Withdrawal/Pain Crisis Naloxone kits Naloxone Kits • Advising clinicians to co ‐ prescribe with long ‐ term or high dose opioid use Photo courtesy of Grand Rapids Red Project. Redproject.com 29 5
2/2/2018 Naloxone In MI: 2016 http://www.michigan.gov/mdhhs/0,5885,7 ‐ 339 ‐ 71550_2941_4871_79584_80133_80135_80309 ‐ 426713 ‐‐ ,00.html Michigan Prescription Drug & Opioid Abuse Task Force Recommendations • Prevention • Treatment • Regulation • Policy & Outcomes State & Local Action • Enforcement 6
2/2/2018 Prevention Treatment • Pharmacist dispensing naloxone • Controlled substance prescriber training • Public awareness regarding laws • Immunity in reported overdose or calling for help • State & local agencies • Collaboration • Increase access to care • Increase the number of addiction specialists • Eliminate doctor & pharmacy shopping • Public awareness campaign • Best practice guidelines Regulation Policy & Outcomes • Legislation to better define & identify pain management • Ongoing task force or commission • Tiered system of licensing • State Dashboard • Exempt from civil liability • Continuity of Care with abrupt closures • Review Michigan Colleges of Emergency Physician policy • Document law enforcement efforts • Review limitation of pseudoephedrine Enforcement The Law • MAPS replacement and • MAPS access expansion Naloxone • Enhance licensing sanctions 7
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