January 19, 2017

The Use of Naloxone in Workers’ Compensation

A Workers’ Compensation Continuing Education Course

This course was previously presented on July 28, 2016. If you attended the course on that date and received continuing education credits from the CEU Institute, you cannot submit for the same credits for this offering.

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This course has been approved for 1-hour of CE for the following license types: Pre-approved Adjuster (AK, AL, CA, DE, FL, GA, ID, IN, KY, LA, MN, MS, NH, OK, OR, TX, UT, WY); Certified Case Manager (CCM); National Nurse; Certification of Disability Management Specialists (CDMS); Commission on Rehabilitation Counselor (CRC); and Certified Medicare Secondary Payer (CMSP) for CE accreditation. For states that do not require prior approval, the adjuster is responsible for submitting their attendance certificate to the appropriate state agency to determine if continuing education credits can be applied.

This course is not approved for the following credit types: Adjuster credits in North Carolina and Washington

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No planner, presenter or content expert has a conflicting interest affecting the delivery of

this continuing education activity. Optum does not receive any commercial advantage nor

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Medicine is an ever-changing science. As new research and clinical experience broaden our

knowledge, new treatment options and approaches are developed. The authors have checked with

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outside of approved labeling. Statements made in this presentation have not been evaluated by the

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• The display or graphic representation of any product or description of any product or

service within this presentation shall not be construed as an endorsement of that product

by the presenter or any accrediting body. Rather, from time to time, it may facilitate the

learning process to include/use such products or services as a teaching example.

• Accreditation of this continuing education activity refers to recognition of the educational

activity only and does not imply endorsement or approval of those products and/or

services by any accrediting body.

• CE credits for this course are administered by the CEU Institute. If you have any issues

or questions regarding your credits, please contact submissions@ceuinstitute.net.

Presenters

Susan Martin, BSPharm, RPh Senior Clinical Pharmacist

Adrienne Harris, PharmD, RPh Clinical Pharmacist Liaison

Objectives

• Review prevalence of opioid analgesic overdose epidemic

• Explain how naloxone works to reverse effects of opioid analgesics

• Describe legislation surrounding access to naloxone

• Provide overview of current naloxone products on market

• Summarize when and how naloxone should be administered

Meet Anne

A case study

• Anne is 45 year-old woman

• Injured lower back while moving heavy box at work

• Diagnosed with lumbar radiculopathy due to herniated disc

Dangerous combination

Opioid Related Deaths in the U.S.

Source: National Center for Health Statistics, CDC Wonder, Jan. 2017

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Prescription Opioid Related Deaths in U.S. (excluding non-methadone synthetics)

Source: National Center for Health Statistics, CDC Wonder, Jan. 2017

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

20,000

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

What is Naloxone?

Antidote for opioid-related overdoses

Naloxone

Heroin

Oxycodone

Hydrocodone

Morphine

What is naloxone?

• Opioid antagonist or antidote for opioid analgesic overdose only (includes heroin)

－Antagonizes the opioid analgesic mu, kappa, and delta receptors

• Displaces the opioid analgesic agonist for a short time

• Reverses the clinical and toxic effects of opioid analgesic overdose

• Little to no agonist activity (no potential for abuse)

• NO pharmacological effect or harm in those not taking opioid analgesics

Effects and duration

• Takes effect in approximately 3 minutes

• Wears off in approximately 30-90 minutes

－Duration depends on type of opioid analgesic

－Can go back into overdose if long-acting opioid analgesics were taken

－May feel withdrawal symptoms after naloxone wears off

－Should NOT take more opioid analgesics after naloxone is given to avoid overdose

Naloxone mechanism

Opioid analgesic receptors

Opioid analgesic

Opioid analgesic Opioid

analgesic

Opioid analgesic

Opioid analgesic

Opioid analgesics bind to opioid receptors to cause their effects. They can help relieve pain, but also cause sedation and hypoventilation.

Naloxone mechanism

Opioid analgesic receptors

Opioid analgesic

Opioid analgesic Opioid

analgesic

Opioid analgesic

Opioid analgesic

Naloxone

Naloxone "pushes" opioid analgesics off the receptors, thereby reversing their effects, and blocks further binding.

Naloxone mechanism

Opioid analgesic receptors

Naloxone Naloxone

Naloxone Naloxone Naloxone

Naloxone "pushes" opioid analgesics off the receptors, thereby reversing their effects, and blocks further binding.

Opioid withdrawal symptoms

• Body aches

• Diarrhea

• Increased heart rate

• Increased blood pressure

• Runny nose

• Sneezing

• Goose bumps

• Sweating

• Yawning

• Fever • Nausea • Vomiting • Nervousness • Restlessness • Irritability • Weakness • Shivering or trembling • Abdominal cramps

CDC chronic pain guidelines

• Provides recommendations for primary care providers

－Does not include treatment for cancer, palliative care, end-of-life

• Addresses opioid analgesic use

－When to initiate and continue opioid analgesics

－Opioid analgesic selection, dosage, duration, follow-up, discontinuation

• Supports naloxone use when risk factors for opioid analgesic-related harms are present

• Improves communication between prescribers and claimants

－Risks and benefits of opioid analgesic therapy

－ Improve safety and effectiveness of treatment

－Reduce risks of long-term opioid analgesic use, abuse, overdose, death

Official Disability Guidelines

• Formulary Status

－Y drug (Naloxone Solution for Injection)

－N drug (Evzio Auto-Injector and Narcan Nasal Spray)

• Naloxone Recommendations per Chronic Pain Chapter

－ Injection: Recommended in hospital-based and emergency room settings for intravenous, intramuscular and subcutaneous administration

－Auto-Injector/Nasal Spray: Not generally recommended for outpatient, pre-hospital use by untrained lay users

*ODG Formulary status as of January 2017

Legislative Actions

Naloxone advocates

2016 state and federal legislative action State Policy/Action Description

Alaska SB 23 (passed) • Allows for prescribing and dispensing of opioid analgesic overdose drugs to individuals (or their family member) at risk for overdose, and provides immunity for individuals and practitioners administering the drug in good faith

Connecticut HB 5053 (passed) • Requires training of first responders in use of naloxone and protects them from civil liability

Indiana SB 187 (signed by governor Pence on March 21, 2016)

• Allows for the dispensing of naloxone as an over-the-counter drug ‒ Individuals at risk ‒ Family members or others close to individuals at risk

• Requires reporting of use by first responders

Iowa SF 2218 (signed by Governor Branstad on April 6, 2016)

• Allows for the prescribing and dispensing of opioid analgesic overdose drugs to individuals (or their family member) at risk for overdose, and provides immunity for individuals and practitioners administering the drug in good faith, and provides antagonists to first responders

Maine LD1547 (became law after veto override)

• Allows pharmacists to dispense naloxone without a prescription

• Makes naloxone available to first responders • Directs the Board of Pharmacy to create guidelines

Massachusetts HB 4056 (passed) • Comprehensive opioid analgesic bill that included provisions for training first responders on proper use of antagonists

North Carolina SB 734 (signed by Governor McCrory on June 20, 2016)

• Allows practitioners to dispense naloxone without a prescription

2016 state and federal legislative action

State Policy/Action Description

South Dakota HB 1079 (passed) • Allows for prescribing and dispensing of an opioid analgesic antagonist to a family member or friend who is in a position to intervene for a person in the event of an overdose, and provides immunity for prescribers and pharmacists who provide the antagonist to a person on reasonable belief

Utah HB 240 and HB 192 (passed)

• HB 240 - Enhanced current law expanding the prescribing to family members and others close to individual at risk for overdose, and provides immunity if acting in good faith when prescribing, dispensing or administering in good faith

• HB 192 - Creates a pilot program to make opioid analgesic antagonists available to family members, first responders, schools, counseling centers and other venues that work with individuals addicted to opioid analgesics

Vermont Regulatory Action (Effective July 1, 2017)

• Establishes a ceiling of 90 MME/day for treatment of chronic pain and when this level is exceeded imparts new requirements for possible co-prescribing of naloxone.

Federal S 524: Comprehensive Addiction and Recovery Act of 2016 (passed)

• Includes provisions in several grant areas that offer priority status to states that provide civil liability protection for first responders, health professionals, and family members administering naloxone to counteract opioid analgesic overdoses

• Provides funding for training first responders on the use of antagonists • Signed by the President

Federal HR 34: 21st Century Cures Act (passed)

• Provides $1 billion over a two year period in state grants to supplement their opioid abuse and prevention programs, such as:

• Improving state PDMP systems and processes • Implementing educational programs for healthcare providers • Expanding access to opioid addiction treatment programs • Signed by the President

Advocating to prevent opioid analgesic deaths

• Addiction Prevention

－ Promote and support laws aimed at reducing opioid analgesic prescriptions

• Creating Access to Naloxone

－ Promote and support laws that create better access to naloxone

Naloxone Availability

Naloxone intramuscular (IM)

• Naloxone 0.4 mg/mL solution

• How Supplied:

－Two single-use 1 mL vials, or

－1 X 10 mL multi-use vial

－Two syringes (1 inch long)

• Directions:

－ Inject 1 mL into shoulder or thigh

－Repeat after 2-3 minutes if no response

Kit (Vial + Syringe) Auto-injector

• Evzio (naloxone) 0.4 mg/0.4 mL

• How Supplied:

− Two-pack of single use auto-injectors plus 1 trainer

• Directions:

− Inject into outer thigh as directed by voice-activated system. Place black side firmly on outer thigh; depress and hold for five seconds.

− Repeat with second device after 2-3 minutes if no response

Naloxone intranasal

• Naloxone 2 mg / 2 mL

• How Supplied:

－2 X 2 mg/2 mL Luer-Lock prefilled needleless syringes

－Two mucosal atomization devices

• Directions:

－Spray 1 mL (1/2 syringe) into each nostril

－Repeat after 2-3 minutes if no response

Naloxone with atomizer Narcan Nasal Spray

• Naloxone 4 mg / 0.1 mL

• How Supplied:

‒ Two-pack of single-use nasal sprays

‒ Needle-free intranasal device

• Directions:

‒ Spray into one nostril

‒ Repeat with second device into other nostril after 2-3 minutes if no response

Naloxone practice pearls

• Check expiration dates

－Before dispensing (pharmacist)

－Periodically after being dispensed (claimant/caregiver)

• Store naloxone at room temperature

－Most expire in about 12 – 18 months

• Keep out of reach of children

• Periodically check solution to make sure it is clear

Overdose Risk Factors

Common risk factors for overdose

• Addiction or substance abuse history

• Suspected or known illicit drug use

• Previous overdose

• Enrolled in methadone or buprenorphine detox program

• Isolation from others (living in rural areas)

• Obtaining opioid analgesics from multiple prescribers and multiple pharmacies

Common risk factors for overdose

• High doses of opioid analgesics

• Opioid initiation or rotation

• Concurrent use of other CNS depressants, including but not limited to:

－ Benzodiazepines

－ Sedative-Hypnotics

－Muscle relaxants

• Comorbid conditions

－ Smoking, COPD, asthma, sleep apnea, depression, anxiety, insomnia

－ Kidney or liver disease

－ Alcohol abuse

Next Steps

Steps to Prevent Overdose

•

• Secure opioid analgesics in safe place

• Avoid higher risk combinations

• Ensure prescribers and pharmacists know of all medications being taken

• Dispose of medications properly

• Teach family and friends how to respond to an overdose

Use Available Clinical Services/Early Intervention

• Treatment agreements

• Urine drug testing

Industry Tools

• Prescription Drug Monitoring Programs (PDMPs)

• Abuse-deterrent opioid analgesics

• Naloxone access

Naloxone only an adjunct

• Naloxone is NOT a magic bullet for opioid analgesic overdose or substitute for medical care

• Overdose can occur with or without substance abuse

• Prescribers should monitor claimant for potential misuse and abuse

－ Understand guidelines and associated risks

－ Use screening tools to determine potential for drug abuse

－ Limit quantities of opioid analgesics

－Monitor and treat co-morbid conditions appropriately

－ Do not prescribe dangerous combinations of medications

－ Use opioid analgesic treatment agreements with claimant

－ Perform random urine drug testing

－ Consider abuse-deterrent opioid analgesics when warranted

－ Check state PDMPs if available

－ Know state laws and how to prescribe naloxone

－ Educate claimants (and families/loved ones) on the risk of overdose and what to do in case of overdose

Some questions to ask when reviewing medications

• What is the current dose of opioid analgesics?

• Is the claimant taking more than one opioid analgesic?

• Are the opioid analgesics prescribed by different physicians?

• Has the claimant recently switched to a different opioid analgesic?

• What other medications are being prescribed?

• Is the claimant taking respiratory medications for asthma, COPD, etc?

• Has the claimant been abstinent from taking opioid analgesics for a period of time due to detoxification?

Some questions to ask when reviewing progress notes

• Does the claimant have a history of substance or alcohol abuse?

• Does the claimant suffer from mental illness?

• Does the prescriber and claimant have a signed treatment agreement?

• Are pain scores and function being documented?

• Is there documentation of side effects?

• Is urine drug testing being performed periodically?

• Is there evidence of illicit drug use or non-prescribed medications on UDT?

• Does the claimant have an underlying respiratory condition that makes him/her more susceptible to overdose?

• Was the claimant recently discharged from emergency medical care for opioid analgesic overdose or intoxication?

What can you do?

• ASSESS and MONITOR your claimant who is prescribed opioid analgesics

• LOOK FOR Risk Factors for Opioid Overdose

• ENGAGE the prescriber and/or your clinical resources as needed

• COMMUNICATE and EDUCATE with your claimant to ensure safety

• UNDERSTAND your company policies surrounding approval of naloxone

Thank you! Questions?

CE credits for this course are administered by the CEU Institute. If you have any issues or questions regarding your

credits, please contact submissions@ceuinstitute.net.

Register for additional Continuing Education Opportunities www.HeliosComp.com/Resources/Continuing-Education

You will receive an email from the CEU Institute on our behalf approximately 24 hours after the webinar. This email will contain a link that you will use to submit for your CE credits. You must complete this task within 72 hours.