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

2. 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)

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

4. 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

5. 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

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

10. 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

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

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

19. 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

20. 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

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

22. 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

23. 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

24. 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

25. 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

26. 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
day lag time
Not quite real time report
States with similar programs 10% decrease OD deaths

28. 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