2014 opioids eastern or ems conference

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Information about 2014 opioids eastern or ems conference

Published on March 3, 2014

Author: croaker260

Source: slideshare.net


"Among the remedies which it has pleased Almighty God to give to man to relieve his sufferings, none is so universal and so efficacious as opium." -THOMAS SYDENHAM (1624 -1689)

Objectives Discuss the basic pharmacology of opioids Discuss the epidemiology of illicit opioid use Describe common treatment modalities Describe treatment variations for uncommon presentations Describe common pitfalls in the emergency care of opioid overdoses

Who am I? Steve Cole croaker260@gmail.com Ada County Paramedics for 15 years EMS for 23 (and counting) years

Disclaimer I have no financial conflicts of interest This presentation is not a substitute for basic clinical judgment. Follow your protocols!

Educatingstarted….. Before we get Yourself…. Doing your own research… Knowing where to look Staying up to date

EMS Textbooks SUCK!

http://www.samhsa.gov/data/DAWN.aspx Hundreds of Metropolitan/Suburban Hospitals and Coroners/ME offices across the US. A DAWN case is any ED visit or death related to recent drug use. The criteria for inclusion in DAWN are intentionally broad and simple, with few exceptions Thousands of drugs of all types are included in DAWN. These include: ◦ ◦ ◦ ◦ ◦ ◦ Illegal drugs of abuse; Prescription and over-the-counter medications; Dietary supplements; Non-pharmaceutical inhalants; Alcohol in combination with other drugs (adults and children) Alcohol alone (age < 21).


Epidemiology Opioids of all types are a significant cause of ED visit (approximately 35%) ◦ ◦ ◦ ◦ Heroin accounts for approximately 9% of opioid related visits Heroin has resulted in a 67% increase of ED related visits from 2004 though 2011 Illicit use of pharmaceutical opioids accounts for about 26% Oxycodone containing products had a 158% increase from 2004 through 2011 Source: 2011 DAWN statistics

What is Diversion? Diversion is the use of prescribed substances (Opioids are just one drug class that is often diverted) for illicit or recreational use. How are Drugs Diverted? ◦ ◦ ◦ ◦ ◦ ◦ Hospice/Home Health Care Visitors Family Health Care providers Public Safety Workers Professional Patients.

Opioids: What are we talking about? Illicit vs. Legal? Synthetic vs. naturally occurring opioids? Clinical vs Recreational use?

The Opium Poppy Use/Abuse goes back At least to 4000 BC The poppy contains numerous opioid alkaloids The most common Opioid Alkaloids are: ◦ ◦ ◦ ◦ Morphine (1-10%) Codeine Thebaine Oripavine

Opioid Receptors Source: http://www.iuphar-db.org/DATABASE/FamilyIntroductionForward?familyId=50

Opioid Receptors (Continued) μ (MU) receptors: ◦ Located in the CNS (Brain/Spinal Cord) AND the digestive tract. ◦ CNS depression ◦ Analgesia ◦ ↓ GI Motility (Constipation) ◦ ↑ Euphoria ⱪ (Kappa) Receptors: ◦ Located in CNS ◦ Analgesia, Dissascoiation ◦ DYSphoria,

What is a Toxidrome? syn·drome (ⱪ sinⱪdrōm /) tox·i·drome (ⱪ täksiⱪdrōm /) noun noun 1. a group of symptoms that consistently occur together or a condition characterized by a set of associated symptoms. 1. a group of signs and symptoms constituting the basis for a diagnosis of poisoning. In other words: A toxidrome is a “syndrome” that specifically relates to a specific toxin Be cautious, many syndromes/toxidromes are subtle and overlap their symptoms. Thorough assessment is essential

Opioid Toxidrome The Opiate Toxidrome consists of: ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ Altered mental status Miosis* Unresponsiveness Shallow respirations Slow respiratory rate Decreased bowel sounds Hypothermia Hypotension* * these symptoms are very subjective, and may not be present in polypharmacy overdoses. KEY POINT: Miosis and Hypotension are not definitive for ruling in or ruling out a opioid overdose.

Methods of use: Shooting Skin Popping Muscle Popping Chasing the dragon Freebasing Dirty Hit Tea ◦ With Grapefruit Juice Tincture ◦ Laudanum and Perigoric

So why do people overdose? IV opioid use Poly-pharmacy Overdose Returning to opioid use from abstinence ◦ Jail? ◦ Detox? The Weekend Warrior Using opioids alone New supply of Drug

Types of Opioids

Opium The raw Latex (sap) of the poppy plant Source: http://www.aaronhuey.com/#/editorial-archive/afghanistan-drugwar/Opium_032

Morphine Naturally occurring in raw opium ◦ First isolated in 1804 ◦ First IV opioid in 1857 The gold standard by which other opioids are judged Potent Respiratory / CNS depressant “Equipotent” euphoria to Heroin, though slower onset. Intermediate Duration (3-6 hours) Many “ER” (extended release) formulations

Codeine, Hydrocodone Codeine naturally occurs in the poppy plant Hydrocodone is a semi-synthetic derivative of codeine. Often taken as a oral tablet or an elixir ◦ Often co-ingested with an NSAID (such as APAP, Motrin or ASA) ◦ Norco, Vicodin

Heroin Black Tar China White Speed Ball Homicide, Buick, super Buick, twilight sleep

Old verses New

Oxycontin/Oxycodone Oxycodone is Another semi-synthetic Derived from Thebaine Roughly twice as potent as Morphine Also More potent than Hydrocodone Most often available in Tablet form ◦ Like Hydrocodone, Often co-ingested with an NSAID (such as APAP, Morin or ASA) ◦ Percocet Extended release versions known as Oxycodone ◦ “Oxy”

Oxycontin /Oxycodone Time released capsules, some may have more than 100 mg Often crushed and snorted, eliminating the “time release” May be crushed, diluted, and injected like traditional heroin Becoming much more common

Methadone Synthetic opioid Comparable with Oxycontin and Dilaudid. Longer acting than most other Analgesic ◦ Typically 4-8 hours Like other prescription opiates, WIDELY Available One study showed of 18 methadone related deaths: ◦ Less than ½ were prescribed methadone ◦ Only three were prescribed methadone through a methadone tx program

Dilaudid Hydromorphone Semi-Synthetic Opioid ◦ Technically found in small quantities in the poppy plant ◦ Synthesized in 1924 directly from Morphine Very potent analgesic Very Euphoric Very potent CNS/ Respiratory Depressant Faster acting than Morphine (similar to Heroin for rate of onset) ◦ 10 times more potent than Morphine ◦ 5 times more potent than Heroin

Fentanyl Citrate Very common medically, Increasingly common recreational abuse ◦ Difficult to detect on standard drug assays ◦ Purely Synthetic Potent Analgesic ◦ 80-100 times potency of Morphine Low Euphoric properties Moderate respiratory/CNS depressant Both pharmaceutical and illicitly prepared Rapid Onset, short Duration Comes in multiple formulations ◦ Typically IV/IM ◦ Oral (lollypops) ◦ Transdermal (Duragesic)

Duragesic Fentanyl Citrate Synthetic opioid Transdermal Absorption Used in chronic pain patients 100 times the potency of morphine Commonly Used for chronic pain Easily Acquired Easily abused

Duragesic- methods of abuse Almost 70 fold increase in use from 1995-2002 (DAWN) Rate of use is increasing. Street price between $10-100/PATCH Methods of abuse ◦ Topical ◦ Injected – increased Mortality (Woodall et al, 2007) ◦ Chewed Oral Conversion ◦ ◦ ◦ ◦ ◦ ◦ Up to 50% may be lost in conversion, so it is often frozen first. Preservatives may cause liver problems 25 ug/hr = 2.5 mg avail 50 ug/hr = 5 mg avail 75 ug/hr = 7.5 mg avail 100 ug/hr = 10 mg avail


Krocodil Desomorphine ◦ ◦ ◦ ◦ Synthetic Opioid , first described in 1932 Clandestinely produced and derived from Codeine in a method similar to Methamphetamine production (Relatively) new trend in Eastern Europe/Western Asia Since early 2000’s Incidence is more directly related to Heroin use than Prescription opioid use Important note: Huge difference in pharmaceutical Desomophine and illicit “Krocodil” ◦ Actual Krocodil is only 5-20% opioid Fast Acting (similar to Heroin) Short Duration Strong analgesic, Strong Euphoric ◦ 8-10 times analgesia of Morphine, no data on other properties Potent sedative but Low respiratory depressant

Krocodil in the US? Much hype, few questions Production and availability directly tied to availability of pre-cursers (Codiene) ◦ Typically $30-50 of product will render about $500 of end product (European/Western Asia Reports) Predictions (also known as educated guesses): ◦ ◦ ◦ ◦ ◦ Much hype, most likely will fizzle out Predominantly an IV drug market Will be misbranded as heroin and mixed with heroin Will be most common in the users of Black Tar and Low end heroin out of Mexico We will not see the extensive morbidity and mortality patterns seen in the former USSR due to the differences in health care and social safety nets as well as differences in Opioid use/abuse demographics ◦ Will still see some (rare) dramatic cases in the homeless/forgotten populations

Much Hype, Little actual Bite to this Krocodil

Poly-Opioid Mixes Increasingly common practice of mixing one type of opioid (typically Heroin) with another , more potent opioid. ◦ This increases the “potency” (increasing profit) without increasing the “purity” (i.e. the cost) ◦ Retains the eurphoric effects of some opioids while getting the heavier nod of others.


REMEMBER: Opioid overdoses are AMS calls first, opioid overdoses last • A - alcohol, alcohol withdrawal, and anoxia • E . epilepsy and other neurological disorders • I - insulin (Hyper or Hypo-glycemia) • O- overdose (Poly-pharmacy?) • U - uremia, underdose of current medications. • T- trauma • I - infection • P - psychiatric • S . stroke, shock states

Important note: According to DAWN Data: ◦ About 18% of opioid related cases will also have alcohol. ◦ This is about 137% more common now than 10 years ago. ◦ About 10% of opioid related cases will also involve another pharmaceutical or illicit substance ◦ This is about 84% more common today than 10 years ago Why?

Treatment In order to treat an opioid patient we need to understand HOW opioids kill… Primary Causes of Mortality: ◦ Respiratory failure ◦ Airway Failure Secondary Causes of Mortality ◦ ◦ ◦ ◦ Aspiration (Rarely) hypothermia and hypotension Situational Factors MIS-TREATMENT by providers

Effect Potential Respiratory Effect of Certain Opioids (i.e. Heroin, Dilaudid) Potential Respiratory Effect of Other Opioids (i.e. Morphine, Methadone) Threshold of Respiratory Arrest/Failure NOTE: Sufficient quantities of ANY opioid may induce respiratory compromise! Time


Narcan (Naloxone) Narcan is a Competitive Opioid Antagonist ◦ Synthetic, derived from Thebain since the 1960’s ◦ Competitive means it will KICK OFF Opioids from receptors Predominantly works on μ (MU) receptors ◦ Minimal effects on other opioid receptors It will NOT work on other CNS depressants (with few exceptions) Clinical effects last 20-45 minutes depending on circumstances ◦ Most opioids last longer (exception IV fentanyl) Some studies on use in Septic Shock and other situations

Narcan (Naloxone) Ventilation/stimulation first Slow admin of Narcan, just enough to make them breath ◦ ABSOLUTELY NO PUNATIVE ADMINISTRATION!!! Adult: ◦ IV, SL: 0.1-2 mg PRN to a max of 10 mg.* ◦ IN/IM/ETT, IV in cardiac arrest: 2 mg. Pediatrics: ◦ 0.01-0.05 mg/kg IV, IO, IM, SubQ, ET. Repeat PRN. ◦ MAX 2 mg/dose High doses may be needed if drug is synthetic Watch for re-sedation due to Narcan’s short duration (about 20-30 minutes)

KEY POINT: It should be noted that a response to (or failure to respond) naloxone is not considered a reliable diagnostic tool in determining if a patient has consumed opoiods. Failure to respond to a total dose of 10 mg of naloxone usually indicates: ◦ That poisoning is not due to opioids (or opioids alone); ◦Or that hypoxic brain damage has occurred. ◦Or that the AMS is not opioid related at all ◦ (A-E-I-O-U-T-I-P-S)

Narcan in Cardiac Arrest Poorly studied but very reasonable In one AHA study: ◦ ◦ ◦ ◦ ◦ ◦ Small study , 36 patients Asytole and PEA were predominant rhythm. Down times varied but were typically extended. 42% of cardiac arrest patients with a suspected opioid etiology showed improvement in EKG rhythm s/p Narcan administration 27% had ROSC by arrival at ER 1% had survival to discharge. “…Although we cannot support the routine use of naloxone during cardiac arrest, we recommend its administration with any suspicion of opioid use. Due to low rates of return of spontaneous circulation and survival during cardiac arrest, any potential intervention leading to rhythm improvement is a reasonable treatment modality.” Why? ◦ Inhibits the adverse effects of the opioids in cardiac arrest, specifically hypotension ◦ Narcan may cause a endogenous sympathetic response (i.e. release of endogenous epinephrine) in the opioid addicted patient ◦ May have indirect, poorly understood antiarrhythmic effects Source : Resuscitation. 2010 Jan;81(1):42-6. doi: 10.1016/j.resuscitation.2009.09.016. Epub 2009 Nov 13. Naloxone in cardiac arrest with suspected opioid overdoses. Saybolt MD1, Alter SM, Dos Santos F, Calello DP, Rynn KO, Nelson DA, Merlin MA.



Smaller doses of Narcan? “The short time between naloxone administration and the occurrence of complications, as well as the type of complications, are strong evidence of a causal link. In 1000 clinically diagnosed intoxications with heroin or heroin mixtures, from 4 to 30 serious complications can be expected. “ “…Development of ventricular tachycardia or fibrillation; atrial fibrillation; asystole; pulmonary edema; convulsions; vomiting; and violent behavior within ten minutes after parenteral administration of naloxone.” “Such a high incidence of complications is unacceptable and could theoretically be reduced by artificial respiration with a bag valve device (hyperventilation) as well as by administering naloxone in minimal divided doses, injected slowly.” Source: ◦ Osterwalder JJ. “Naloxonefor intoxications with intravenous heroin and heroin mixtures: harmless or hazardous? A prospective clinical study.” J Toxicol Clin Toxicol 34 (1996): 409-416 ◦ Cuss FM, Colaço CB, & Baron JH Cardiac arrest after reversal of effects of opiates with naloxone. Br Med J, 288(1984): 363-364

Narcan Infusions? Narcan infusions are a MAINTANANCE therapy, ideal for LONG transports (20-30 minutes or greater) Many different methods/compositions/protocols Administer NARCAN as normal to achieve respiratory and airway stability Mix the TOTAL effective dose in 100 cc (or 250 cc) NS Set rate to infuse over 1 hour ◦ 100 cc Bag: 90 gtts a minute ( 1.5 gtt/sec) ◦ 250 cc Bag: 250 gtts a minute (4 gtts / sec) If re-sedation occurs: ◦ Evaluate for other causes ◦ Titrate upward for effect ◦ Rebolus IV Narcan


Thoughts IM clinically safer than IN ◦ Both should be an option Protocols/Training should mandate BVM/Airway Management first

NARCAN Treat & Release Criteria ◦ Criteria: ◦ The patient can mobilize as usual; ◦ The patient has an oxygen saturation on room air of >92%; 3) have a respiratory rate >10 breaths/min and <20 breaths/min; ◦ The patient has a temperature of >35.0°C and <37.5°C; ◦ The patient has a heart rate >50 beats/min and <100 beats/min; and ◦ The patient has a Glasgow Coma Scale score of 15. ◦ Follow up with IM (or SQ) Narcan References: ◦ Christenson J, Etherington J, Grafstein E, et al. Early discharge of patients with presumed opioid overdose: development of a clinical prediction rule. Acad Emerg Med 2000;7(10);1110-18. ◦ Wanger K, Brough L, MacMillan I, et al. Intravenous vs subcutaneous naloxone for out-of-hospital management of presumed opioid overdose. Acad Emerg Med 1998;5(4);293-9.

When to avoid Narcan all together Semi- Awake patients Pregnancy Aspiration POLY PHARM OD’s

It is generally unwise to treat these patients with an opioid antagonist unless life threatening respiratory depression is a reasonable concern.. "Inappropriate use of naloxone in cancer patients with pain.." J Pain Symptom Manage. 11(2)(1996): 131-134. Source: http://www.elephantjournal.com/2013/10/love-it-all-a-husbands-farewell-to-his-dying-wife-photos/

In the End Stay up to date Don’t believe the Hype Overdose patients are AMS patients first, opioid overdoses last CORRECT HYPOXIA, ACIDOSIS , HYPERCARBIA BEFORE NARCAN When giving Narcan: SLOW and LOW (Slow Push and Low Doses repeated) ◦ Goal is airway and respiratory correction, not to wake them up

Questions? Source: http://paindr.com/wp-content/uploads/2013/04/Poppy-smiley-157x195.jpg

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