Pharmacist response to emerging epidemics and embracing principles of harm reduction

coon 8/14

Who is at risk for opioid overdose

• risk for overdose is complex

• there are intuitive and less intuitive touchpoints that increase risk

Rx opioids (first wave)

• 1990/2000s opioids overprescribed and aggressively marketed

• pain is complex and requires a multimodal, interprofessional management with realitic goals and expectations

• pts today: provider abandonment abritrary opioid tapers, coverage denials, new PA requirements, state laws

Heroin fatal overdoses

• second wave

• 2018: DEA rates availability as HIGH

• higher in purity today

• lower in price today

• can be inhaled (snorted/smmoked) or injected → broadening appeal

• increasing heroin prevalence in suburban and rural areas

• increased heroin purity/potency + reduced rx opioid access → increased heroin access and appeal

• not all heroin is the same: differences in pH balance, physical state, cold/hot water solubility, heat staibility, texture, and purity (some more/less suitable for IV use)

Oxycontin

• after oxycontin reformulated as ADF, <5% stopped using all drugs to get high in cohort of pts misusing ocycontin

• shift in drug use to heroin

Fentanyl fatal overdoses

• third wave

• increasing presence within last 5 years

• areas seeing fentanyl “first” include NE and FL

• regular heroin use increased likelihood of fentanyl exposure in the past year four fold

How is Fentanyl different from heroin/oxycodone?

• high lipid solubility-fast CNS penetration

• stronger downstream signaling affecting respiratory drive

• wooden chest

• atypical micro-pharmacokinetic profile

• reduced cross tolerance

Is there strong demand for fentanyl?

only 27% of people who use opioids for non-medical purposes expressed a preference for fentanyl (vs different opioid such as heroin)

Implementing new OUD tx services

• primary goal: enable equitable access

Methadone

• very effective

• most long-term data

• many federal regulations for opioid treatment programs (OTPs)

• more CYP interactions and serious ADRs

• stigma

Buprenorphine

• one of 3 approved meds for OUD

• opioid agonist

• prescribed in PCP setting and/por specialized addiction tx settings