Naloxone for Opioid
Safety
Phillip O Coffin MD MIA
San Francisco Department of Public Health
University of California San ...
Disclosures
• No financial
disclosures
Oxycontin
Dilaudid/
Duragesic
Kadian
Norco
Atiq
HMO enrollment
>80 million
FDA lifts rules
on Direct-to-
Consumer
advertis...
Naloxone Timeline
Naloxone Programs and OD Rate, 2010
Naloxone Programs and OD Rate, 2014
Number* and location of local drug overdose prevention programs providing naloxone to ...
Naloxone Effectiveness
(10) Walley et al., BMJ 2013
(13) Davidson et al., Naloxone distribution to drug users in Californi...
Needle Atomizer / assembly
Expensive High dose?
HeroinOverdoseDeaths:
SF1997-1999
Naloxone Distribution & Heroin Deaths in San
Francisco
0
20
40
60
80
100
120
140
160
2000 2003 2004 2005 2006 2007 2008 20...
Census tracts near DOPE site
s
Naloxone Sites and Reversals
2010-2012
• 9% involved heroin
• Primary care data
accessible for 50%
of decedents, 80%
of whom were
prescribed opioids
Census tract...
• 6 safety net clinics
• Staff trained
• Atomizer/brochure in
ziplock bag
• IM or IN naloxone
prescribed (covered by
all p...
All Patients Using Opioids Chronically Risk-Stratification
Simple to remember Less costly
Clinicians are poor at predictin...
Provider Themes Regarding Naloxone Prescribing
Strengthen patient/provider relationship
• “The ability to prescribe naloxo...
Patient Themes Regarding Naloxone (N=60)
Frustration:
• “It felt like they think I’m gonna overdose…I don’t think I’m gonn...
Opioid
Refugees?
Opioid Safety Initiatives
Reduce
morbidity &
mortality
Opioid Safety Initiatives
Reduce
morbidity &
mortality
Modify prescribing
practice
• Staged treatment (FDA relabeling)
• M...
Opioid Safety Initiatives
Reduce
morbidity &
mortality
Modify prescribing
practice
• Staged treatment (FDA relabeling)
• M...
Opioid Safety Initiatives
Reduce
morbidity &
mortality
Modify prescribing
practice
• Staged treatment (FDA relabeling)
• M...
Opioid Safety Initiatives
Reduce
morbidity &
mortality
- Naloxone
Modify prescribing
practice
• Staged treatment (FDA rela...
Opioid Stewardship and Naloxone
Prescribing
restrictions
initiated
Naloxone
distribution
initiated
Trends in opiate-relate...
Inevitable
Preventable
phillip.coffin@ucsf.edu
prescribetoprevent.org
Acknowledgments
• Funding from:
• NIDA R21DA036776
• NIDA R03DA038084
• California Healthcare Foundation
• The many people...
Naloxone for Opioid Safety by Phillip Coffin, MD, MIA
Naloxone for Opioid Safety by Phillip Coffin, MD, MIA
Naloxone for Opioid Safety by Phillip Coffin, MD, MIA
Naloxone for Opioid Safety by Phillip Coffin, MD, MIA
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Naloxone for Opioid Safety by Phillip Coffin, MD, MIA

Presentation delivered at the University of Michigan Injury Center Opioid Overdose Summit, Ann Arbor, MI, December 1, 2015
Published on: Mar 3, 2016
Published in: Health & Medicine      
Source: www.slideshare.net


Transcripts - Naloxone for Opioid Safety by Phillip Coffin, MD, MIA

  • 1. Naloxone for Opioid Safety Phillip O Coffin MD MIA San Francisco Department of Public Health University of California San Francisco
  • 2. Disclosures • No financial disclosures
  • 3. Oxycontin Dilaudid/ Duragesic Kadian Norco Atiq HMO enrollment >80 million FDA lifts rules on Direct-to- Consumer advertising Welfare reform State law/boards liberalize opioids for chronic pain JCAHO 5th Vital Sign Fentora Subsys Abstral Roxicodone Embeda Exalgo Acuroxgeneric morphinesPalladone Avinza generic hydrocodone generic fentanyl lozenge generic oxycodones Opana Opana ER Dilaudid (lower dose) Onsolis Lazanda Oxecta Zohydro Hysingla generic oxymorphone Targiniq CDC reports rising Rx deaths Policy and practice changes to reduce OA prescribing begin 19951990
  • 4. Naloxone Timeline
  • 5. Naloxone Programs and OD Rate, 2010
  • 6. Naloxone Programs and OD Rate, 2014 Number* and location of local drug overdose prevention programs providing naloxone to laypersons, as of June 2014, and age-adjusted rates† of drug overdose deaths§ in 2013 — United States * Total N = 644; numbers on map indicate the total number of programs within each state. † Per 100,000 population. § CDC, National Center for Health Statistics; Compressed Mortality File 1999–2013 on CDC WONDER Online Database, released January 2015.
  • 7. Naloxone Effectiveness (10) Walley et al., BMJ 2013 (13) Davidson et al., Naloxone distribution to drug users in California, unpublished data
  • 8. Needle Atomizer / assembly Expensive High dose?
  • 9. HeroinOverdoseDeaths: SF1997-1999
  • 10. Naloxone Distribution & Heroin Deaths in San Francisco 0 20 40 60 80 100 120 140 160 2000 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 0 200 400 600 800 1000 1200 New Enrollments Reversals Heroin deaths (no 2013/14 data) Naloxone distribution begins, 2003 ? ?
  • 11. Census tracts near DOPE site s Naloxone Sites and Reversals 2010-2012
  • 12. • 9% involved heroin • Primary care data accessible for 50% of decedents, 80% of whom were prescribed opioids Census tracts near DOPE site s Opioid Overdose Deaths 2010-2012
  • 13. • 6 safety net clinics • Staff trained • Atomizer/brochure in ziplock bag • IM or IN naloxone prescribed (covered by all public insurance) • Pharmacists trained as needed Clinical Program
  • 14. All Patients Using Opioids Chronically Risk-Stratification Simple to remember Less costly Clinicians are poor at predicting risk Potentially less work for clinician / clinic Risks are based on retrospective data analyses Patients do not perceive a risk of “overdose” from prescribed medications1 ~40% of deaths result from diverted medications2; co-prescribed naloxone may go with the opioids 1) Coffin PO, unpublished data; 2) Hirsch A, Proescholdbell SK, Bronson W, Dasgupta N. Prescription histori es and dose strengths associated with overdose deaths. Pain Med. 2014;15(7):1187-95.
  • 15. Provider Themes Regarding Naloxone Prescribing Strengthen patient/provider relationship • “The ability to prescribe naloxone has been the most positive change to our management of chronic pain.” Leads to more open discussion about opioids • “[Naloxone] has allowed me to … keep them engaged in care … and has opened up conversations about substance use treatment options.”
  • 16. Patient Themes Regarding Naloxone (N=60) Frustration: • “It felt like they think I’m gonna overdose…I don’t think I’m gonna overdose on something that’s prescribed” Appreciation: • “I felt great. I felt like she really cared about me.” Community benefits: • “I wasn’t sure if I’d ever use it. But on the other hand, because I live in the tenderloin … it might be a good thing to have with me.” More cautious with opioids: • “I’ve probably been a little more cautious. Just being careful to take the right amount, count the hours, you know, just thinking more cautiously about dosing.”
  • 17. Opioid Refugees?
  • 18. Opioid Safety Initiatives Reduce morbidity & mortality
  • 19. Opioid Safety Initiatives Reduce morbidity & mortality Modify prescribing practice • Staged treatment (FDA relabeling) • Med reconciliation • Risk factor screens • Dose limits Reduce diversion •PDMP •Pharmacy reviews •Take-back programs •Pain Agreements •Abuse deterrents
  • 20. Opioid Safety Initiatives Reduce morbidity & mortality Modify prescribing practice • Staged treatment (FDA relabeling) • Med reconciliation • Risk factor screens • Dose limits Reduce diversion •PDMP •Pharmacy reviews •Take-back programs •Pain Agreements •Abuse deterrents Expand non-opioid pain management • PT/OT • Behavioral therapy • Acupuncture • Massage • Non-opioid medications
  • 21. Opioid Safety Initiatives Reduce morbidity & mortality Modify prescribing practice • Staged treatment (FDA relabeling) • Med reconciliation • Risk factor screens • Dose limits Reduce diversion •PDMP •Pharmacy reviews •Take-back programs •Pain Agreements •Abuse deterrents Manage substance use • Opioid agonist treatments • Good Sam laws • Comorbid SUD treatment • Other harm reduction services Expand non-opioid pain management • PT/OT • Behavioral therapy • Acupuncture • Massage • Non-opioid medications
  • 22. Opioid Safety Initiatives Reduce morbidity & mortality - Naloxone Modify prescribing practice • Staged treatment (FDA relabeling) • Med reconciliation • Risk factor screens • Dose limits Reduce diversion •PDMP •Pharmacy reviews •Take-back programs •Pain Agreements •Abuse deterrents Manage substance use • Opioid agonist treatments • Good Sam laws • Comorbid SUD treatment • Other harm reduction services Expand non-opioid pain management • PT/OT • Behavioral therapy • Acupuncture • Massage • Non-opioid medications
  • 23. Opioid Stewardship and Naloxone Prescribing restrictions initiated Naloxone distribution initiated Trends in opiate-related deaths in Multnomah County, 2014
  • 24. Inevitable Preventable
  • 25. phillip.coffin@ucsf.edu prescribetoprevent.org
  • 26. Acknowledgments • Funding from: • NIDA R21DA036776 • NIDA R03DA038084 • California Healthcare Foundation • The many people lost to overdose and those who have helped save a life

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