Illinois State Opioid Antagonist Training March 11, 2016 Program State Agencies Approval PA99-0480 Version 1.0 1
Illinois State Opioid Antagonist Training March 11, 2016 Program ACPE Information The Illinois Pharmacists Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. The online training is approved for 1.75 hours (0.175 CEUs) of continuing pharmacy education credit. UAN: 0135-0000-16-002-H04-P Contact Hours: 1.75 Hours Initial Release Date: March 11, 2016 Planned Expiration Date: March 11, 2019 Target Audience: Pharmacists in all practice settings Continuing Pharmacy Education Requirements This activity is structured to meet knowledge-based educational needs and acquire factual knowledge. Information in knowledge-type activities is based on evidence as accepted in the literature by the health care professions. Continuing pharmacy education (CPE) credit will be earned based on participation in the activity. Participation is required before obtaining CPE credit. Participants must complete an activity evaluation and posttest (if applicable) with a passing score of 70 percent or greater. This activity is accredited through ACPE for pharmacist continuing pharmacy education credit. If all requirements are met, participants will receive continuing pharmacy education credit in the following manner. Partial credit will not be awarded. Please allow 60 days for processing. Pharmacists CPE Monitor, a national, collaborative effort by ACPE and the National Association of Boards of Pharmacy (NABP) to provide an electronic system for pharmacists and technicians to track their completed CPE credits, went into effect on January 1, 2013. IPhA, as an ACPE-accredited provider, is required to report pharmacist CPE credit using this tracking system. Pharmacist participants must provide their NABP e- Profile Identification Number and date of birth (in MMDD format) when they register for a CPE activity or complete activity evaluations. It will be the responsibility of the pharmacist to provide the correct information (e-Profile Identification Number and Date of birth in MMDD Format). If this information is not provided, NABP and ACPE prohibit IPhA from issuing CPE Credit. Online access to their inventory of completed credits will allow pharmacists to easily monitor their compliance with CPE requirements and print statements of credit. Therefore, IPhA will not provide individual printed statements of credit to pharmacists. For additional information on CPE Monitor, including e-Profile set-up and its impact on pharmacists and pharmacy technicians, go to www.nabp.net. Program Faculty Kelly Gable, PharmD, BCPP Associate Professor, Department of Pharmacy Practice Southern Illinois University Edwardsville kgable@siue.edu Chris Herndon, PharmD, BCPS Associate Professor, Department of Pharmacy Practice Southern Illinois University Edwardsville cherndo@siue.edu Jessica Kerr, PharmD, CDE Assistant Chair and Associate Professor, Department of Pharmacy Practice Southern Illinois University Edwardsville jekerr@siue.edu Garth Reynolds, BSPharm, RPh Executive Director Illinois Pharmacists Association greynolds@ipha.org Version 1.0 2
Illinois State Opioid Antagonist Training March 11, 2016 Program Disclosures/Conflicts of Interest • The Speakers of this continuing education program, do not have financial relationships or conflicts of interests. • The content of this webinar may include information regarding the use of products that may be inconsistent with, or outside the approved labeling for, these products in the United States. Pharmacists should note that the use of these products outside current approved labeling is considered experimental and are advised to consult the prescribing information for these products Learning Objectives Describe the opioid abuse and overdose epidemic on a state and national level. 1. Review unique pharmacological properties of commonly prescribed opioids and heroin. 2. Discuss the neurobiology of addiction and opioid use disorder. 3. Understand risk factors, signs of an opioid overdose, and the role of opioid antagonist 4. therapy. Describe the role of pharmacy personnel in opioid overdose management. 5. Evaluate key elements of patient and caregiver education on opioid overdose 6. management. Discuss standardized procedures, naloxone standing order sets, and clinical 7. documentation. Version 1.0 3
Illinois State Opioid Antagonist Training March 11, 2016 Program Opioid Abuse and the Overdose Epidemic Kelly Gable, PharmD, BCPP Associate Professor, Department of Pharmacy Practice Southern Illinois University Edwardsville Alarming Statistics - An Epidemic • The CDC has officially declared prescription drug abuse in the US an epidemic • 1 in 20 people report using prescription opioids for non-medical reasons • In 2010, enough opioid pain relievers were sold to medicate every adult in the US with 5 mg of hydrocodone every 4 hours for 1 month • In 2014, ~1.9 million people had an opioid use disorder related to prescription pain relievers and ~586,000 had an opioid use disorder related to heroin use • Only 16% of Americans believe that the US is making progress in its efforts to reduce prescription drug abuse Version 1.0 4
Illinois State Opioid Antagonist Training March 11, 2016 Program Version 1.0 5
Illinois State Opioid Antagonist Training March 11, 2016 Program Overdose Deaths • Each day, ~46 people in the United States die from overdose of prescription pain medications • >47,000 Americans died of a drug overdose in 2014, an increase of 7% from 2013 • >50% were related to pharmaceuticals (~70% involved opioid analgesics and 30% involved benzodiazepines) • The increase was driven largely by deaths from heroin + prescription opioids • Women who lost their lives opioid overdoses rose 415% between 1999 and 2010 Heroin Use Rising Version 1.0 6
Illinois State Opioid Antagonist Training March 11, 2016 Program Heroin Abuse Risk Factors • Male gender, aged 18–25 years • Non-Hispanic white race/ethnicity • Residence in a large urban area • <$20,000 annual household income with no health insurance or Medicaid • Past-year abuse or dependence on alcohol, marijuana, cocaine, or opioid pain relievers National Survey on Drug Use and Health (NSDUH), 2002-2013. CDC Vital Signs, July 2015. Opioid Abuse - Illinois 12 th lowest drug overdose mortality rate in the US, with 10 per 100,000 • drug overdose fatalities Drug overdose deaths increased by 49% since 1999 • ~8 people die from prescription drug overdoses/week in Illinois (81% • involve opioid pain relievers) Hydrocodone was the most available opioid to nonprescribed users • for nonmedical use in 2013 In 2012, there were 15,350 primary heroin treatment admissions in • Chicago Heroin purity at the street level remains between 10 and 20%- cut • with quetiapine, diphenhydramine, fentanyl Illinois Department of Human Services. Prescription Drug Abuse: Strategies to Stop the Epidemic. Version 1.0 7
Illinois State Opioid Antagonist Training March 11, 2016 Program Top Abused Prescription Drugs in America Clinical Pharmacology of Opioids Chris Herndon, PharmD, BCPS Associate Professor, Department of Pharmacy Practice Southern Illinois University Edwardsville Morphine Version 1.0 8
Illinois State Opioid Antagonist Training March 11, 2016 Program Opioid Receptors • μ – mu (MOR) • κ – kappa (KOR) • δ – delta (DOR) • N/OFQ (Noceptin) Commercially Available Opioids Pure MOR (mu) agonists morphine, methadone, codeine, hydrocodone, fentanyl, oxycodone, oxymorphone, levorphanol, hydromorphone, heroin, dihydrocodeine, sufentanil, alfentanil, remifentanyl Partial MOR (mu) agonist buprenorphine Mixed agonist-antagonists nalbuphine, butorphanol, pentazocine Centrally acting MOR agonists tramadol, tapentadol Nonselective antagonists naloxone, naltrexone Peripherally acting MOR opioid antagonists alvimopan, methylnaltrexone, naloxegol MOR = mu-opioid receptor Version 1.0 9
Illinois State Opioid Antagonist Training March 11, 2016 Program What is “High Dose” for Opioids? Canadian Guidelines 200mg/day OME American Pain Society Guideline 200mg/day OME Washington State Work Comp 120mg/day OME OME = Oral Morphine Equivalent Prescription Opioids and Illicit Heroin • Quantitative questionnaire using street outreach, venue-recruitment, and needle-exchange advertisement (n = 123) • Median age 29 yrs (75% male, 53% white, 28% hispanic, 19% black or other) • 39.8% reported problematic prescription opioid use prior to first heroin use • Heroin rapidly metabolized to morphine in CNS Version 1.0 10
Illinois State Opioid Antagonist Training March 11, 2016 Program Relative Equianalgesia Drug IV (mg) Oral (mg) 10 30 Morphine Buprenorphine 0.3 0.4 (SL) 100 200 Codeine Fentanyl 0.1 — — 30 Hydrocodone Hydromorphone 1.5 7.5 100 300 Meperidine 10 20 Oxycodone Oxymorphone 1 10 IV = intravenous; mg = milligram; SL = sublingual Let’s Get Some Practice…. CH is a 42 year old male who is currently using opioid and non-opioid analgesics for severe low back pain (failed back surgery syndrome). His current regimen includes: • CR morphine 60mg by mouth every 8 hours • IR oxycodone 15mg by mouth every 4 to 6 hours as needed • Pregabalin 50mg by mouth every 12 hours What is CH’s total daily Oral Morphine Equivalent (OME) ? CR = controlled-release; IR = immediate-release Version 1.0 11
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