Opioid Overdose Mark R. Hall, MD, MPH Medical Director Kent County Health Department December 2, 2016 Opioid Overdose

Goals Review terminology Discuss Kent County fatal overdose data Review benefits and precautions with naloxone Identify unique and dangerous characteristics of carfentanil Discuss the Michigan Automated Prescription Service (MAPS)

Terms Narcotics, Opiates or Opioids? Opiates: derived directly from opium Heroin, morphine, codeine, opium

Opioids Opioids: synthetically derived to act as an opiate Oxycodone (Percocet®) Hydrocodone (Vicodin®) Hydromorphone (Dilaudid®) Fentanyl Methadone Practical standpoint: has evolved to include opiates and opioids

Terms What’s a narcotic? Depends on whose talking Legal: a drug that is wholly prohibited or used in violation of government regulations Public at large: pretty much the same Medical community A very specific group of drugs Similar molecular structure and pharmacology Only a part of narcotics as legally defined Very strongly ingrained

Fatal opioid overdose by race, 2011-15 White 85.2% (264) Black 11.0% (34) American Indian 2.6% (8) Asia/Pac. Island 1.0% (3) Mixed race 0.3% (1)

Kent County non-opioid fatal overdoses (2011-15) Drug Examples Number of deaths Cocaine 29 Ethanol 15 Serotonin Re-uptake inhibitors Effexor®, Paxil® 10 Acetaminophen Tylenol® 9 Cyclic antidepressants Elavil® 8 Hydrocarbon inhalants difluorethane (aerosols), toluene Benzodiazepines Xanax®, Ativan® 7 Bupropion Wellbutrin® 6

Non-opioid fatal overdoses – the rest Cyclobenzaprine (Flexeril®) Anti-hypertensives Quetiapine (Seroquel®) Aspirin Insulin Diphenhydramine (Benadryl®) Olanzapine (Zyprexa®)

Effects of Opioids Euphoria Sedation Analgesia Circulatory compromise Widely prescribed and effective Circulatory compromise Direct respiratory suppression The usual cause of death in overdose

Opioid duration of activity Short duration, < 1hour Fentanyl (not patch) Medium duration, 2-4 hours Heroin, morphine, oxycodone (Percocet®), hydrocodone (Vicodin®), hydromorphone (Dilaudid®) Intermediate, 4-6 hours Sustained release products: MS Contin®, OxyContin® Fentanyl patch, even after removal Long, 8-12 hours or more: Methodone Naloxone: 45 minutes

Naloxone (Narcan®) Competitively inhibits opiates/opioids No effects of its own Blocks the effects of circulating opioid Much stronger affinity for the opiate receptor Works within minutes, but depends on route

Naloxone onset by route Onset in minutes Intravenous 2 Intramuscular 6 Intranasal 8

Naloxone Safe Effective Relatively easy to administer Minimal training required Wears off quickly Variable onset and dose requirement Expensive Supply and demand User friendly kits Nasal formulation

Naloxone BUT… Life saving Needs to be a key strategy Need for medical evaluation following naloxone needs to be stressed Half life mismatch, onset of action Common co-ingestions, especially acetaminophen (Tylenol®) Common mental health instability and suicidality

Carfentanil 1 kg seized in Calgary 50 million lethal doses 10,000 x morphine potency Affected areas Western Pennsylvania 2o deaths Milwaukee 19 deaths Ohio (Cincinnati, Cleveland) 8 deaths confirmed, likely more 174 “heroin” ODs in 6 days Michigan 19 deaths Wayne County

Carfentanil – Observations from Ohio experience “People are saying” High naloxone requirement for reversal. Has been cut with stimulants to counteract toxicity Results in profound agitation with reversal Mini-mass casualty incidents Multiple overdose victims at on seen No first responder effects May be distinguished from heroin by blue or pink tint

MAPS Michigan Automated Prescription System Requires provider to register Fairly rapid reporting of controlled substances prescribed Test on 2/19/2016, 0832: 2 minutes and 7 seconds 10-14 day lag time Not quite real time report States with similar programs 10% decrease OD deaths

Provider dilemma with pain management Recent major initiative for under treatment of pain Joint Commission Pain score as vital sign Performance evaluation based on pain management Limited options Now under fire for over prescribing opioids