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Bowman A, Domke C, Morton S. What is the Evidence for Using Intranasal Medicine in the Prehospital Setting? A Systematic Review. PREHOSP EMERG CARE 2024; 28:787-802. [PMID: 38848591 DOI: 10.1080/10903127.2024.2357598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 04/02/2024] [Accepted: 04/10/2024] [Indexed: 06/09/2024]
Abstract
OBJECTIVES Intranasal (IN) medications offer a safe non-invasive way to rapidly deliver drugs in situations where intravenous (IV) access and intramuscular (IM) administration is challenging or not feasible. In the prehospital setting, this can be an essential alternative in time critical situations including trauma management, seizures, and agitated patients. However, there is a paucity of evidence summarizing its efficacy in this environment. This systematic review aims to assess the current evidence supporting the use of IN medicine (midazolam, ketamine, fentanyl, morphine, glucagon, and naloxone) in the prehospital setting alone. METHODS A systematic literature search (PROSPERO CRD42023440713) of PubMed, Web of Science, OVID Medline, "Cochrane Central Register of Controlled Trials," Cochrane reviews and Embase was performed from inception to June 2023 to identify studies where IN medications were administered to patients in the prehospital setting. All randomized controlled trials, observational cohort studies, case series, and case reports were included. Papers not written in English, review articles, abstracts, and non-published data (including letters to the editor) were excluded. The methodological quality of the included studies was interpreted using the Cochrane risk of bias tool and rated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. No funding was received. RESULTS From 4818 studies, 39 were included (seven for midazolam, five for ketamine, twelve for fentanyl, one for diamorphine, two for glucagon, and twelve for naloxone). A total of 24,097 patients were treated with IN medications across all the studies. There were five moderate quality, four low quality, and thirty very low quality studies. The potential efficacy of IN fentanyl and ketamine was demonstrated consistently throughout the studies with less clear evidence for midazolam, morphine, glucagon, and naloxone. This review was severely limited by the study quality, with most studies demonstrating "high concerns" for bias. CONCLUSIONS Prehospital IN medication administration has wide-ranging potential, particularly for administering analgesia. There are likely to be certain populations, for example, pediatrics, that will benefit the most, although conclusions are limited by the quality of evidence currently available. We encourage additional research in this area, particularly with robust prospective double-blind RCTs.
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Mohtarami SA, Mostafazadeh B, Shadnia S, Rahimi M, Evini PET, Ramezani M, Borhany H, Fathy M, Eskandari H. Prediction of naloxone dose in opioids toxicity based on machine learning techniques (artificial intelligence). Daru 2024:10.1007/s40199-024-00518-x. [PMID: 38771458 DOI: 10.1007/s40199-024-00518-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 04/30/2024] [Indexed: 05/22/2024] Open
Abstract
BACKGROUND Treatment management for opioid poisoning is critical and, at the same time, requires specialized knowledge and skills. This study was designed to develop and evaluate machine learning algorithms for predicting the maintenance dose and duration of hospital stay in opioid poisoning, in order to facilitate appropriate clinical decision-making. METHOD AND RESULTS This study used artificial intelligence technology to predict the maintenance dose and duration of administration by selecting clinical and paraclinical features that were selected by Pearson correlation (filter method) (Stage 1) and then the (wrapper method) Recursive Feature Elimination Cross-Validated (RFECV) (Stage2). The duration of administration was divided into two categories: A (which includes a duration of less than or equal to 24 h of infusion) and B (more than 24 h of naloxone infusion). XGBoost algorithm model with an accuracy rate of 91.04%, a prediction rate of 91.34%, and a sensitivity rate of 91.04% and area under the Curve (AUC) 0.97 was best model for classification patients. Also, the best maintenance dose of naloxone was obtained with XGBoost algorithm with R2 = 0.678. Based on the selected algorithm, the most important features for classifying patients for the duration of treatment were bicarbonate, respiration rate, physical sign, The partial pressure of carbon dioxide (PCO2), diastolic blood pressure, pulse rate, naloxone bolus dose, Blood Creatinine(Cr), Body temperature (T). The most important characteristics for determining the maintenance dose of naloxone were physical signs, bolus dose of 4.5 mg/kg, Glasgow Coma Scale (GCS), Creatine Phosphokinase (CPK) and intensive care unit (ICU) add. CONCLUSION A predictive model can significantly enhance the decision-making and clinical care provided by emergency physicians in hospitals and medical settings. XGBoost was found to be the superior model.
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Affiliation(s)
| | - Babak Mostafazadeh
- Clinical Research Development Unit (CRDU) of Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
- Toxicological Research Center, Department of Clinical Toxicology, Excellence Center of Clinical Toxicology, Loghman Hakim University Hospital Poison Center, Shahid Beheshti University of Medical Sciences (SBMU), Tehran, Iran.
| | - Shahin Shadnia
- Clinical Research Development Unit (CRDU) of Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Toxicological Research Center, Department of Clinical Toxicology, Excellence Center of Clinical Toxicology, Loghman Hakim University Hospital Poison Center, Shahid Beheshti University of Medical Sciences (SBMU), Tehran, Iran
| | - Mitra Rahimi
- Clinical Research Development Unit (CRDU) of Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Toxicological Research Center, Department of Clinical Toxicology, Excellence Center of Clinical Toxicology, Loghman Hakim University Hospital Poison Center, Shahid Beheshti University of Medical Sciences (SBMU), Tehran, Iran
| | - Peyman Erfan Talab Evini
- Clinical Research Development Unit (CRDU) of Loghman Hakim Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Toxicological Research Center, Department of Clinical Toxicology, Excellence Center of Clinical Toxicology, Loghman Hakim University Hospital Poison Center, Shahid Beheshti University of Medical Sciences (SBMU), Tehran, Iran
| | - Maral Ramezani
- Department of Pharmacology, School of Medicine, Arak University of Medical Sciences, Arak, Iran
- Traditional and Complementary Medicine Research Center, Arak University of Medical Sciences, Arak, Iran
| | - Hamed Borhany
- Toxicological Research Center, Department of Clinical Toxicology, Excellence Center of Clinical Toxicology, Loghman Hakim University Hospital Poison Center, Shahid Beheshti University of Medical Sciences (SBMU), Tehran, Iran
| | - Mobin Fathy
- Toxicological Research Center, Department of Clinical Toxicology, Excellence Center of Clinical Toxicology, Loghman Hakim University Hospital Poison Center, Shahid Beheshti University of Medical Sciences (SBMU), Tehran, Iran
| | - Hamidreza Eskandari
- Toxicological Research Center, Department of Clinical Toxicology, Excellence Center of Clinical Toxicology, Loghman Hakim University Hospital Poison Center, Shahid Beheshti University of Medical Sciences (SBMU), Tehran, Iran
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Saari TI, Strang J, Dale O. Clinical Pharmacokinetics and Pharmacodynamics of Naloxone. Clin Pharmacokinet 2024; 63:397-422. [PMID: 38485851 PMCID: PMC11052794 DOI: 10.1007/s40262-024-01355-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2024] [Indexed: 04/29/2024]
Abstract
Naloxone is a World Health Organization (WHO)-listed essential medicine and is the first choice for treating the respiratory depression of opioids, also by lay-people witnessing an opioid overdose. Naloxone acts by competitive displacement of opioid agonists at the μ-opioid receptor (MOR). Its effect depends on pharmacological characteristics of the opioid agonist, such as dissociation rate from the MOR receptor and constitution of the victim. Aim of treatment is a balancing act between restoration of respiration (not consciousness) and avoidance of withdrawal, achieved by titration to response after initial doses of 0.4-2 mg. Naloxone is rapidly eliminated [half-life (t1/2) 60-120 min] due to high clearance. Metabolites are inactive. Major routes for administration are intravenous, intramuscular, and intranasal, the latter primarily for take-home naloxone. Nasal bioavailability is about 50%. Nasal uptake [mean time to maximum concentration (Tmax) 15-30 min] is likely slower than intramuscular, as reversal of respiration lag behind intramuscular naloxone in overdose victims. The intraindividual, interindividual and between-study variability in pharmacokinetics in volunteers are large. Variability in the target population is unknown. The duration of action of 1 mg intravenous (IV) is 2 h, possibly longer by intramuscular and intranasal administration. Initial parenteral doses of 0.4-0.8 mg are usually sufficient to restore breathing after heroin overdose. Fentanyl overdoses likely require higher doses of naloxone. Controlled clinical trials are feasible in opioid overdose but are absent in cohorts with synthetic opioids. Modeling studies provide valuable insight in pharmacotherapy but cannot replace clinical trials. Laypeople should always have access to at least two dose kits for their interim intervention.
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Affiliation(s)
- Teijo I Saari
- Department of Anaesthesiology and Intensive Care, University of Turku, Turku, Finland
- Division of Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital, Turku, Finland
| | - John Strang
- National Addiction Centre, Institute of Psychiatry Psychology and Neuroscience, King's College London, London, SE5 8BB, UK
| | - Ola Dale
- Department of Circulation and Medical Imaging, NTNU-Norwegian University of Science and Technology, Trondheim, Norway.
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Sandelich S, Hooley G, Hsu G, Rose E, Ruttan T, Schwarz ES, Simon E, Sulton C, Wall J, Dietrich AM. Acute opioid overdose in pediatric patients. J Am Coll Emerg Physicians Open 2024; 5:e13134. [PMID: 38464332 PMCID: PMC10920943 DOI: 10.1002/emp2.13134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 02/13/2024] [Indexed: 03/12/2024] Open
Abstract
Recent increases in pediatric and adolescent opioid fatalities mandate an urgent need for early consideration of possible opioid exposure and specific diagnostic and management strategies and interventions tailored to these unique populations. In contrast to adults, pediatric methods of exposure include accidental ingestions, prescription misuse, and household exposure. Early recognition, appropriate diagnostic evaluation, along with specialized treatment for opioid toxicity in this demographic are discussed. A key focus is on Naloxone, an essential medication for opioid intoxication, addressing its unique challenges in pediatric use. Unique pediatric considerations include recognition of accidental ingestions in our youngest population, critical social aspects including home safety and intentional exposure, and harm reduction strategies, mainly through Naloxone distribution and education on safe medication practices. It calls for a multifaceted approach, including creating pediatric-specific guidelines, to combat the opioid crisis among children and to work to lower morbidity and mortality from opioid overdoses.
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Affiliation(s)
- Stephen Sandelich
- Department of Emergency MedicinePenn State College of MedicinePenn State Milton S. Hershey Medical CenterHersheyPennsylvaniaUSA
| | - Gwen Hooley
- Department of Emergency MedicineChildren's Hospital of Los AngelesLos AngelesCaliforniaUSA
| | - George Hsu
- Department of Emergency MedicineAugusta University‐Medical College of GeorgiaAugustaGeorgiaUSA
| | - Emily Rose
- Department of Emergency MedicineKeck School of Medicine of the University of Southern CaliforniaLos Angeles General Medical CenterLos AngelesCaliforniaUSA
| | - Tim Ruttan
- Department of PediatricsDell Medical SchoolThe University of Texas at AustinUS Acute Care SolutionsCantonOhioUSA
| | - Evan S. Schwarz
- Division of Medical ToxicologyDepartment of Emergency MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
| | - Erin Simon
- Department of Emergency MedicineCleveland ClinicAkronOhioUSA
| | - Carmen Sulton
- Departments of Pediatrics and Emergency MedicineEmory University School of MedicineChildren's Healthcare of Atlanta, EglestonAtlantaGeorgiaUSA
| | - Jessica Wall
- Departments of Pediatrics and Emergency MedicineSeattle Children's HospitalHarborview Medical CenterSeattleWashingtonUSA
| | - Ann M Dietrich
- Department of Emergency MedicinePrisma HealthGreenvilleSouth CarolinaUSA
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Sparapani S, Authier S, Lowenthal R, Tanimoto S. The impact of anaphylaxis on the absorption of intranasal epinephrine in anaesthetized non-naive beagle dogs. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2023; 2:100165. [PMID: 38024850 PMCID: PMC10679764 DOI: 10.1016/j.jacig.2023.100165] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 06/10/2023] [Accepted: 06/30/2023] [Indexed: 12/01/2023]
Abstract
Background Epinephrine delivery via an intranasal spray (neffy) is being evaluated as an additional option to treat severe allergic reaction and may provide clinical benefit by reducing the time to dosing in community settings by avoiding needles. Given that hypotension is a hallmark symptom of severe allergic reactions, a preclinical study was conducted to evaluate the impact of this factor on epinephrine absorption via neffy. Objective The objective of this study was to evaluate the absorption of epinephrine via neffy in a dog model of anaphylaxis with severe hypotension. Methods Epinephrine absorption via neffy was evaluated in anesthetized beagle dogs under both normal conditions and hypotension associated with anaphylaxis. A total of 14 dogs (10 males and 4 females) were dosed with neffy, 1.0 mg, under normal conditions, followed by neffy, 1.0 mg, under conditions of anaphylaxis. Results The mean maximum concentration of epinephrine was higher during anaphylaxis than under normal conditions (2,670 ± 2,150 pg/mL and 1,330 ± 739 pg/mL [P < .05]). Relative to normal conditions, anaphylaxis resulted in higher overall epinephrine exposure (area under the curve from 0 to 45 minutes = 54,400 ± 18,100 min × pg/mL and 34,300 ± 21,500 minutes × pg/mL [P < .05]), which is likely due to the increase in vascular permeability commonly observed during severe allergic reactions. Conclusion Taken together with real-world evidence from nasal naloxone treatment for opioid overdose demonstrating that the reduced blood flow or hypotension associated with overdose does not appear to suppress naloxone's efficacy, the current findings demonstrate that epinephrine is well absorbed following neffy delivery during the hypotension associated with severe anaphylaxis reactions.
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Lavonas EJ, Akpunonu PD, Arens AM, Babu KM, Cao D, Hoffman RS, Hoyte CO, Mazer-Amirshahi ME, Stolbach A, St-Onge M, Thompson TM, Wang GS, Hoover AV, Drennan IR. 2023 American Heart Association Focused Update on the Management of Patients With Cardiac Arrest or Life-Threatening Toxicity Due to Poisoning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2023; 148:e149-e184. [PMID: 37721023 DOI: 10.1161/cir.0000000000001161] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/19/2023]
Abstract
In this focused update, the American Heart Association provides updated guidance for resuscitation of patients with cardiac arrest, respiratory arrest, and refractory shock due to poisoning. Based on structured evidence reviews, guidelines are provided for the treatment of critical poisoning from benzodiazepines, β-adrenergic receptor antagonists (also known as β-blockers), L-type calcium channel antagonists (commonly called calcium channel blockers), cocaine, cyanide, digoxin and related cardiac glycosides, local anesthetics, methemoglobinemia, opioids, organophosphates and carbamates, sodium channel antagonists (also called sodium channel blockers), and sympathomimetics. Recommendations are also provided for the use of venoarterial extracorporeal membrane oxygenation. These guidelines discuss the role of atropine, benzodiazepines, calcium, digoxin-specific immune antibody fragments, electrical pacing, flumazenil, glucagon, hemodialysis, hydroxocobalamin, hyperbaric oxygen, insulin, intravenous lipid emulsion, lidocaine, methylene blue, naloxone, pralidoxime, sodium bicarbonate, sodium nitrite, sodium thiosulfate, vasodilators, and vasopressors for the management of specific critical poisonings.
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Argenyi MS, Evans JK, Gay Y, Epstein DH, Weiss ST. The Opioid Overdose Resuscitation Education for Addiction Counselors and Trainees (Opioid Overdose REACT) naloxone response education pilot project improved confidence and knowledge among addiction counselors and trainees. Clin Toxicol (Phila) 2023; 61:509-517. [PMID: 37427894 PMCID: PMC10528373 DOI: 10.1080/15563650.2023.2229508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 06/12/2023] [Accepted: 06/20/2023] [Indexed: 07/11/2023]
Abstract
INTRODUCTION Community programs to teach nonmedical laypeople how to recognize an opioid overdose and effectively resuscitate the victim using naloxone have proliferated recently as a significant component of harm-reduction efforts. Although many such programs target laypeople like first responders or friends and family members of people who use drugs, there are currently no programs that specifically target addiction counselors, despite their work with a client population at high risk of an opioid overdose. METHODS The four-hour curriculum designed by the authors covered opioid agonist and antagonist pharmacology; opioid toxidrome signs; legal implications and indications for using the naloxone kits; and hands-on training. Participants were two cohorts of addiction counselors and addiction counseling trainees at our institution and an affiliated Opioid Treatment Program methadone clinic. Surveys testing participant knowledge and confidence were conducted at baseline, immediately post-training, six months post-training, and 12 months post-training. RESULTS Overall, opioid and naloxone pharmacology knowledge, as well as the confidence to intervene in an overdose emergency, improved among participants in both cohorts. Knowledge scores at baseline (n = 36, median 5/10) improved significantly immediately post-training (n = 31, median 7/10, P < 0.0001, Wilcoxon signed-rank test) and were sustained six (n = 19) and 12 months (n = 11) later. Two participants reported using their naloxone kits to successfully reverse a client overdose in the 12 months after taking the course. DISCUSSION These results from our knowledge translation pilot project suggest that our educational program to train addiction counselors in opioid pharmacology and toxicology, allowing them to recognize and respond to an opioid overdose, is feasible and could be effective. Specific barriers to implementing such educational programs include cost, stigma, and unclear best practice for designing and conducting these programs. CONCLUSIONS Further study of providing opioid pharmacology education and overdose and naloxone training to addiction counselors and counseling trainees appears to be warranted.
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Affiliation(s)
- Michael S. Argenyi
- Wake Forest Addiction Research and Clinical Health Program, Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
- Department of Psychiatry, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Joni K. Evans
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC
| | - Yasmin Gay
- Wake Forest Addiction Research and Clinical Health Program, Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | - David H. Epstein
- Translational Addiction Medicine Branch, Intramural Research Program, National Institute on Drug Abuse, National Institutes of Health, Baltimore, MD
| | - Stephanie T. Weiss
- Wake Forest Addiction Research and Clinical Health Program, Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
- Translational Addiction Medicine Branch, Intramural Research Program, National Institute on Drug Abuse, National Institutes of Health, Baltimore, MD
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Dale O. Pharmacokinetic considerations for community-based dosing of nasal naloxone in opioid overdose in adults. Expert Opin Drug Metab Toxicol 2022; 18:203-217. [PMID: 35500297 DOI: 10.1080/17425255.2022.2072728] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The administration of the opioid antagonist naloxone in the community is a measure to prevent death from opioid overdose. Approved nasal naloxone sprays deliver initial doses of 0.9 to 8 mg. The level of the initial community dose is controversial, as the scientific base is weak.In this review knowledge of the pharmacokinetics of nasal, both approved and improvised nasal sprays, and intramuscular naloxone will be utilized to evaluate dose-effect relationships in previous studies of opioid overdose outcomes. AREAS COVERED The aim was to present scientifically based considerations on the initial nasal naloxone doses currently available, which reasonably balances the effect and adverse outcomes, given that at least two doses are at hand. Also included in these considerations is the challenge by illicitly manufactured fentanyl and analogs.This paper is based on both peer-reviewed and grey literature identified by several searches, of such as naloxone pharmacokinetics/formulations/outcomes/emergency medical services, in PubMed and Embase. EXPERT OPINION There is little scientific evidence that supports the use of initial systemic dosing that exceeds 0.8 mg in the community. Higher doses increase the risk of withdrawal symptoms feared in people who use opioids. Many obstacles may reduce the potential of community-administered naloxone.
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Affiliation(s)
- Ola Dale
- Department of Circulation and Medical Imaging, NTNU - Norwegian University of Science and Technology, Trondheim, Norway
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Pergolizzi JV, Dahan A, Ann LeQuang J, Raffa RB. Overdoses due to fentanyl and its analogues (F/FAs) push naloxone to the limit. J Clin Pharm Ther 2021; 46:1501-1504. [PMID: 34111307 DOI: 10.1111/jcpt.13462] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 05/22/2021] [Indexed: 11/30/2022]
Abstract
WHAT IS KNOWN AND OBJECTIVE Food and Drug Administration (FDA) risk evaluation and mitigation strategies (REMs) encourage emergency responders, paramedics, law enforcement agents, and even laypeople to be trained in the administration of naloxone with the intent of rescuing individuals from a known or suspected opioid overdose. COMMENT Although naloxone is generally safe and effective at reversing respiratory depression caused by a conventional opioid such as morphine or heroin by competing with the opioid and displacing it from the μ-opioid receptor, questions increasingly are arising as to whether naloxone can adequately reverse opioid overdoses that may involve the potent opioids fentanyl and its analogues (F/FAs). In other words, as more and more opioid overdoses involve F/FAs, can naloxone keep up? WHAT IS NEW AND CONCLUSION As a competitive antagonist at μ-opioid receptors, naloxone is often a life-saving agent in cases of overdose caused by conventional opioids, but it may not be versatile or powerful enough to combat the rising tide of overdoses due to fentanyl and its illicit analogues, or in cases of overdose involving combinations of opioids and non-opioids.
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Affiliation(s)
- Joseph V Pergolizzi
- NEMA Research Inc, Naples, FL, USA.,Neumentum Inc, Summit, NJ, USA.,Enalare Therapeutics Inc, Princeton, NJ, USA
| | - Albert Dahan
- Leiden University Medical Center, Leiden, The Netherlands
| | | | - Robert B Raffa
- Neumentum Inc, Summit, NJ, USA.,Enalare Therapeutics Inc, Princeton, NJ, USA.,College of Pharmacy (Adjunct), University of Arizona, Tucson, AZ, USA.,Temple University School of Pharmacy, Philadelphia, PA, USA
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Maloney LM, Alptunaer T, Coleman G, Ismael S, McKenna PJ, Marshall RT, Hernandez C, Williams DW. Prehospital Naloxone and Emergency Department Adverse Events: A Dose-Dependent Relationship. J Emerg Med 2020; 59:872-883. [PMID: 32972788 DOI: 10.1016/j.jemermed.2020.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 06/05/2020] [Accepted: 07/01/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND The purpose of this study was to evaluate prehospital and emergency department (ED) interventions and outcomes of patients who received prehospital naloxone for a suspected opioid overdose. OBJECTIVES The primary objective was to evaluate if the individual dose, individual route, total dose, number of prehospital naloxone administrations, or occurrence of a prehospital adverse event (AE) were associated with the occurrence of AEs in the ED. Secondary objectives included a subset analysis of patients who received additional naloxone while in the ED, or were admitted to an intensive care or step-down unit (ICU). METHODS This was a retrospective, observational chart review of adult patients who received prehospital naloxone and were transported by ambulance to a suburban academic tertiary care center between 2014 and 2017. Descriptive, univariate, and multivariate statistics were used, with p < 0.05 indicating significance. RESULTS There were 513 patients included in the analysis, with a median age of 29 years, and median total prehospital naloxone dose of 2 mg. An increasing number of prehospital naloxone doses, an occurrence of a prehospital AE, and a route of administration other than intranasally for the first dose of prehospital naloxone were significantly associated with an increased likelihood of an ED AE. Patients who received < 2 mg of prehospital naloxone had the least likelihood of being admitted to an ICU, whereas patients who received at least 6 mg had a dramatically increased likelihood of ICU admission. CONCLUSIONS Our results suggest that an increasing number of prehospital naloxone doses was significantly associated with an increased likelihood of an ED adverse event.
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Affiliation(s)
- Lauren M Maloney
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York
| | - Timur Alptunaer
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York
| | - Gia Coleman
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York
| | - Suleiman Ismael
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York
| | - Peter J McKenna
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York
| | - R Trevor Marshall
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York
| | - Cristina Hernandez
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York
| | - Daryl W Williams
- Department of Emergency Medicine, Stony Brook University Hospital, Stony Brook, New York
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Topjian AA, Raymond TT, Atkins D, Chan M, Duff JP, Joyner BL, Lasa JJ, Lavonas EJ, Levy A, Mahgoub M, Meckler GD, Roberts KE, Sutton RM, Schexnayder SM. Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S469-S523. [PMID: 33081526 DOI: 10.1161/cir.0000000000000901] [Citation(s) in RCA: 198] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Merchant RM, Topjian AA, Panchal AR, Cheng A, Aziz K, Berg KM, Lavonas EJ, Magid DJ. Part 1: Executive Summary: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S337-S357. [DOI: 10.1161/cir.0000000000000918] [Citation(s) in RCA: 190] [Impact Index Per Article: 47.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Panchal AR, Bartos JA, Cabañas JG, Donnino MW, Drennan IR, Hirsch KG, Kudenchuk PJ, Kurz MC, Lavonas EJ, Morley PT, O’Neil BJ, Peberdy MA, Rittenberger JC, Rodriguez AJ, Sawyer KN, Berg KM, Arafeh J, Benoit JL, Chase M, Fernandez A, de Paiva EF, Fischberg BL, Flores GE, Fromm P, Gazmuri R, Gibson BC, Hoadley T, Hsu CH, Issa M, Kessler A, Link MS, Magid DJ, Marrill K, Nicholson T, Ornato JP, Pacheco G, Parr M, Pawar R, Jaxton J, Perman SM, Pribble J, Robinett D, Rolston D, Sasson C, Satyapriya SV, Sharkey T, Soar J, Torman D, Von Schweinitz B, Uzendu A, Zelop CM, Magid DJ. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2020; 142:S366-S468. [DOI: 10.1161/cir.0000000000000916] [Citation(s) in RCA: 371] [Impact Index Per Article: 92.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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Troberg K, Isendahl P, Blomé MA, Dahlman D, Håkansson A. Protocol for a multi-site study of the effects of overdose prevention education with naloxone distribution program in Skåne County, Sweden. BMC Psychiatry 2020; 20:49. [PMID: 32028921 PMCID: PMC7006080 DOI: 10.1186/s12888-020-2470-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 01/30/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Continuously high rates of overdose deaths in Sweden led to the decision by the Skåne County to initiate the first regional take-home naloxone program in Sweden. The project aims to study the effect of overdose prevention education and naloxone distribution on overdose mortality in Skåne County. Secondary outcome measures include non-fatal overdoses and overdose-related harm in the general population, as well as cohort-specific effects in study participants regarding overdoses, mortality and retention in naloxone program. METHODS Implementation of a multi-site train-the-trainer cascade model was launched in June 2018. Twenty four facilities, including opioid substitution treatment units, needle exchange programs and in-patient addiction units were included for the first line of start-up, aspiring to reach a majority of individuals at-risk within the first 6 months. Serving as self-sufficient naloxone hubs, these units provide training, naloxone distribution and study recruitment. During 3 years, questionnaires are obtained from initial training, follow up, every sixth month, and upon refill. Estimated sample size is 2000 subjects. Naloxone distribution rates are reported, by each unit, every 6 months. Medical diagnoses, toxicological raw data and data on mortality and cause of death will be collected from national and regional registers, both for included naloxone recipients and for the general population. Data on vital status and treatment needs will be collected from registers of emergency and prehospital care. DISCUSSION Despite a growing body of literature on naloxone distribution, studies on population effect on mortality are scarce. Most previous studies and reports have been uncontrolled, thus not being able to link naloxone distribution to survival, in relation to a comparison period. As Swedish registers present the opportunity to monitor individuals and entire populations over time, conditions for conducting systematic follow-ups in the Swedish population are good, serving the opportunity to study the impact of large scale overdose prevention education and naloxone distribution and thus fill the knowledge gap. TRIAL REGISTRATION Naloxone Treatment in Skåne County - Effect on Drug-related Mortality and Overdose-related Complications, NCT03570099, registered on 26 June 2018.
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Affiliation(s)
- Katja Troberg
- Department of Clinical Sciences, Psychiatry, Faculty of Medicine, Lund University, Lund, Sweden. .,Division of Psychiatry, Addiction Center Malmö, Region Skåne, Malmö, Sweden. .,Malmö Addiction Centre, Clinical Research Unit, Södra Förstadsg. 35, Plan 4, S-205 02, Malmö, Sweden.
| | - Pernilla Isendahl
- grid.411843.b0000 0004 0623 9987Department of Infectious Disease, University Hospital Skåne, Malmö, Sweden
| | - Marianne Alanko Blomé
- grid.411843.b0000 0004 0623 9987Department of Infectious Disease, University Hospital Skåne, Malmö, Sweden ,Regional Office for Communicable Disease Control, Malmö, Sweden
| | - Disa Dahlman
- grid.4514.40000 0001 0930 2361Department of Clinical Sciences, Psychiatry, Faculty of Medicine, Lund University, Lund, Sweden ,grid.4514.40000 0001 0930 2361Department of Clinical Sciences, Center for Primary Health Care Research, Lund University/Region Skåne, Malmö, Sweden
| | - Anders Håkansson
- grid.4514.40000 0001 0930 2361Department of Clinical Sciences, Psychiatry, Faculty of Medicine, Lund University, Lund, Sweden ,grid.426217.40000 0004 0624 3273Division of Psychiatry, Addiction Center Malmö, Region Skåne, Malmö, Sweden
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Take-Home Naloxone for the Emergency Interim Management of Opioid Overdose: The Public Health Application of an Emergency Medicine. Drugs 2020; 79:1395-1418. [PMID: 31352603 PMCID: PMC6728289 DOI: 10.1007/s40265-019-01154-5] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Naloxone is a well-established essential medicine for the treatment of life-threatening heroin/opioid overdose in emergency medicine. Over two decades, the concept of 'take-home naloxone' has evolved, comprising pre-provision of an emergency supply to laypersons likely to witness an opioid overdose (e.g. peers and family members of people who use opioids as well as non-medical personnel), with the recommendation to administer the naloxone to the overdose victim as interim care while awaiting an ambulance. There is an urgent need for more widespread naloxone access considering the growing problem of opioid overdose deaths, accounting for more than 100,000 deaths worldwide annually. Rises in mortality are particularly sharp in North America, where the ongoing prescription opioid problem is now overlaid with a rapid growth in overdose deaths from heroin and illicit fentanyl. Using opioids alone is dangerous, and the mortality risk is clustered at certain times and contexts, including on prison release and discharge from hospital and residential care. The provision of take-home naloxone has required the introduction of new legislation and new naloxone products. These include pre-filled syringes and auto-injectors and, crucially, new concentrated nasal sprays (four formulations recently approved in different countries) with speed of onset comparable to intramuscular naloxone and relative bioavailability of approximately 40-50%. Choosing the right naloxone dose in the fentanyl era is a matter of ongoing debate, but the safety margin of the approved nasal sprays is superior to improvised nasal kits. New legislation in different countries permits over-the-counter sales or other prescription-free methods of provision. However, access remains uneven with take-home naloxone still not provided in many countries and communities, and with ongoing barriers contributing to implementation inertia. Take-home naloxone is an important component of the response to the global overdose problem, but greater commitment to implementation will be essential, alongside improved affordable products, if a greater impact is to be achieved.
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Carpenter J, Murray BP, Atti S, Moran TP, Yancey A, Morgan B. Naloxone Dosing After Opioid Overdose in the Era of Illicitly Manufactured Fentanyl. J Med Toxicol 2020; 16:41-48. [PMID: 31471760 PMCID: PMC6942078 DOI: 10.1007/s13181-019-00735-w] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 08/01/2019] [Accepted: 08/21/2019] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Illicitly manufactured fentanyl (IMF) is responsible for a growing number of deaths. Some case series have suggested that IMF overdoses require significantly higher naloxone doses than heroin overdoses. Our objective was to determine if the naloxone dose required to treat an opioid overdose is associated with the finding of fentanyl, opiates, or both on urine drug screen (UDS). METHODS A retrospective chart review was conducted at a single emergency department and its affiliated emergency medical services (EMS) agency. The charts of all patients who received naloxone through this EMS from 1/1/2017 to 6/15/2018 were reviewed. The study included patients diagnosed with a non-suicidal opioid overdose whose UDS was positive for opiates, fentanyl, or both. Data collected included demographics, vital signs, initial GCS, EMS and ED naloxone administrations, response to treatment, laboratory findings, and ED disposition. The fentanyl-only and fentanyl + opiate groups were compared to the opiate-only group using the stratified (by ED provider) variant of the Mann-Whitney U test. RESULTS Eight hundred and thirty-seven charts were reviewed, and 121 subjects were included in the final analysis. The median age of included subjects was 38 years and 75% were male. In the naloxone dose analysis, neither the fentanyl-only (median 0.8 mg, IQR 0.4-1.6; p = 0.68) nor the fentanyl + opiate (median 0.8 mg, IQR 0.4-1.2; p = 0.56) groups differed from the opiate-only group (median 0.58 mg, IQR 0.4-1.6). CONCLUSION Our findings refute the notion that high potency synthetic opioids like illicitly manufactured fentanyl require increased doses of naloxone to successfully treat an overdose. There were no significant differences in the dose of naloxone required to treat opioid overdose patients with UDS evidence of exposure to fentanyl, opiates, or both. Further evaluation of naloxone stocking and dosing protocols is needed.
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Affiliation(s)
- Joseph Carpenter
- Georgia Poison Center, 50 Hurt Plaza SE, Suite 600, Atlanta, GA, 30303, USA.
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA.
| | | | - Sukhshant Atti
- Georgia Poison Center, 50 Hurt Plaza SE, Suite 600, Atlanta, GA, 30303, USA
| | - Tim P Moran
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Arthur Yancey
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Brent Morgan
- Georgia Poison Center, 50 Hurt Plaza SE, Suite 600, Atlanta, GA, 30303, USA
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, GA, USA
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Intranasal versus Intramuscular/Intravenous Naloxone for Pre-hospital Opioid Overdose: A Systematic Review and Meta-analysis. ADVANCED JOURNAL OF EMERGENCY MEDICINE 2019; 4:e27. [PMID: 32322795 PMCID: PMC7163267 DOI: 10.22114/ajem.v0i0.279] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Context: The present systematic review and meta-analysis aims to perform an extensive search in databases to compare the efficacy of the intranasal administration of naloxone with its intramuscular/intravenous administration in the pre-hospital management of opioid overdose. Evidence acquisition: This meta-analysis included controlled trials conducted on the efficacy of naloxone administration in the pre-hospital management of opioid overdose. A search was carried out in electronic databases on relevant articles published by the end of 2018. After data collection, analyses were performed in STATA 14.0 software and the efficacy and side-effects of the two administration routes of naloxone, i.e. intranasal and intramuscular/intravenous, were compared. An overall effect size with 95% confidence interval (95% CI) was provided for each section. Results: Eventually, data from six studies were included in this meta-analysis. The success rate of the intranasal and intramuscular/intravenous administration of naloxone in the management of opioid overdose in pre-hospital settings was 82.54% (95% CI: 57.97 to 97.89%) and 80.39% (95% CI: 57.38 to 96.04%), respectively. There was no difference between injectable (intramuscular/intravenous) naloxone and intranasal naloxone in the pre-hospital management of opioid overdose (Odds Ratio=1.01; 95% CI: 0.42 to 2.43; P=0.98). The onset of action of intranasal naloxone, however, was slightly longer than injectable naloxone (Standardized Mean Difference=0.63; 95% CI: 0.07 to 1.19; P=0.03). Additionally, the odds of needing a rescue dose was 2.17 times higher for intranasal naloxone than intramuscular/intravenous naloxone (OR=2.17; 95% CI: 1.53 to 3.09; P<0.0001). The prevalence of major side-effects was non-significant for both intranasal (0.00%) and intramuscular/intravenous (0.05%) routes of naloxone administration and there was no difference in the prevalence of major (OR=1.18; 95% CI: 0.38 to 3.69; P=0.777) and minor (OR=0.64; 95% CI: 0.17 to 2.34; P=0.497) side-effects between the two routes. Conclusion: The present meta-analysis demonstrated that intranasal naloxone is as effective as injectable naloxone in the pre-hospital management of opioid overdose complications. Consequently, intranasal naloxone may be an appropriate alternative to injectable naloxone.
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Hsu HJ, Yang Y, Pavuluri V, Abraham C, Naraharisetti SB, Ashraf M, Al-Ghabeish M. Effect of Formulation Variables on the Nasal Permeability and Stability of Naloxone Intranasal Formulations. AAPS PharmSciTech 2019; 20:232. [PMID: 31236738 DOI: 10.1208/s12249-019-1452-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 06/11/2019] [Indexed: 02/02/2023] Open
Abstract
Naloxone is an opioid antagonist with high affinity for μ-opioid receptor, and for this reason it is used for the emergency treatment of opioid overdose. Originally, it was available only as an injectable product. However, for the ease of administration, intranasal (IN) formulations have also become available. These IN formulations contain preservatives and stabilizers such as benzalkonium chloride (BKC), benzyl alcohol (BA), and ethylenediaminetetraacetic acid (EDTA). Some of these ingredients are known to affect permeability of drugs. This study focuses on investigating the effect of formulation variables including choice of preservatives, stabilizer, and pH on the permeability and stability of naloxone IN formulations. The in vitro permeability of naloxone was evaluated employing EpiAirway™ tissue-mounted Ussing chambers. BKC was found to enhance the apparent permeability (Papp) of naloxone significantly (p < 0.05) at very low concentration, while BA caused similar enhancement at a much higher concentration. EDTA was found to decrease Papp of naloxone by lowering the pH, and the Papp of naloxone was found to decrease approximately 51-fold with the decrease in formulation pH from 6.0 to 4.0. The product stability was, however, found optimal only below pH 5.0. Thus, selection of formulation ingredients, buffering agent, and pH of IN formulation is a balancing act for achieving desired permeability and optimal stability to achieve reasonable shelf life of naloxone IN formulation.
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Shaw LV, Moe J, Purssell R, Buxton JA, Godwin J, Doyle-Waters MM, Brasher PMA, Hau JP, Curran J, Hohl CM. Naloxone interventions in opioid overdoses: a systematic review protocol. Syst Rev 2019; 8:138. [PMID: 31186071 PMCID: PMC6560883 DOI: 10.1186/s13643-019-1048-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 05/20/2019] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND North America is in the midst of an unabated opioid overdose epidemic due to the increasing non-medical use of fentanyl and ultra-potent opioids. Naloxone is an effective antidote to opioid toxicity, yet its optimal dosing in the context of fentanyl and ultra-potent opioid overdoses remains unknown. This review aims to determine the relationship between the first empiric dose of naloxone and reversal of toxicity, adverse events, and the total cumulative dose required among patients with undifferentiated opioid overdoses and those with suspected toxicity from ultra-potent opioids. Secondary objectives include evaluating the relationship between the cumulative naloxone dose and toxicity reversal and adverse events, among patients with undifferentiated opioid overdoses and those with suspected toxicity from ultra-potent opioids. METHODS To identify studies, we will search MEDLINE, Embase, CENTRAL, DARE, CDAG, CINAHL, Science Citation Index, multiple trial registries, and the gray literature. Included studies will evaluate patients with suspected or confirmed opioid toxicity from undifferentiated opioids and ultra-potent opioids, who received an empiric and possibly additional doses of naloxone. The main outcomes of interest are the relationship between naloxone dose and toxicity reversal and adverse events. We will include controlled and non-controlled interventional studies, observational studies, case reports/series, and reports from poison control centers. We will extract data and assess study quality in duplicate with discrepancies resolved by consensus or a third party. We will use the Downs and Black and Cochrane risk of bias tools for observational and randomized controlled studies. If we find sufficient variation in dose, we will fit a random effects one-stage model to estimate a dose-response relationship. We will conduct multiple subgroup analyses, including by type of opioid used and by suspected high and low prevalence of ultra-potent opioid use based on geographic location and time of the original studies. DISCUSSION Our review will include the most up-to-date available data including ultra-potent opioids to inform the current response to the opioid epidemic, addressing the limitations of recent reviews. We anticipate limitations relating to study heterogeneity. We will disseminate study results widely to update overdose treatment guidelines and naloxone dosing in Take Home Naloxone programs.
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Affiliation(s)
- Lindsay Victoria Shaw
- School of Social Dimensions of Health, University of Victoria, 3800 Finnerty Road, Victoria, BC V8P 5C2 Canada
- Canadian Institute for Substance Use Research, 2300 McKenzie Ave, Victoria, BC V8P 5C2 Canada
| | - Jessica Moe
- Department of Emergency Medicine, University of British Columbia, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
- Vancouver General Hospital, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
| | - Roy Purssell
- Department of Emergency Medicine, University of British Columbia, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
- Vancouver General Hospital, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
- BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC V5Z 4R4 Canada
| | - Jane A. Buxton
- Department of Emergency Medicine, University of British Columbia, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
- BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC V5Z 4R4 Canada
- School of Population and Public Health, 2329 West Mall, Vancouver, BC V6T 1Z4 Canada
| | - Jesse Godwin
- Department of Emergency Medicine, University of British Columbia, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
- Vancouver General Hospital, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
| | - Mary M. Doyle-Waters
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, 828 West 10th Avenue, Vancouver, BC V5Z 1M9 Canada
| | - Penelope M. A. Brasher
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, 828 West 10th Avenue, Vancouver, BC V5Z 1M9 Canada
| | - Jeffrey P. Hau
- Department of Emergency Medicine, University of British Columbia, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
| | - Jason Curran
- BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BC V5Z 4R4 Canada
- School of Population and Public Health, 2329 West Mall, Vancouver, BC V6T 1Z4 Canada
| | - Corinne M. Hohl
- Department of Emergency Medicine, University of British Columbia, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
- Vancouver General Hospital, 855 West 12th Avenue, Vancouver, BC V5Z 1M9 Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, 828 West 10th Avenue, Vancouver, BC V5Z 1M9 Canada
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Lenglard F, Berger-Vergiat A, Ragonnet D, Duvernay N, Lack P, Poulet E, Zoulim F, Chappuy M. [Feedback from two French addiction centers and national survey on the intranasal naloxone (Nalscue ®) in the prevention of opioid overdoses]. Therapie 2019; 74:477-486. [PMID: 30792078 DOI: 10.1016/j.therap.2019.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2018] [Revised: 12/18/2018] [Accepted: 01/17/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVE France has temporarily authorized addictology centers to use a form of intranasal naloxone (Nalscue®) to prevent opioid overdoses. The objectives of this work are to present both the characteristics of the patients included in this device in two hospitals centers and the results of the national survey on addiction center's contribution to this new risk reduction tool. METHODS Patient data are those requested under Nalscue® study (inclusion period July 2016 to January 2018). The survey is an online questionnaire distributed to all addiction centers with an email address. RESULTS Over this period, in the two addiction centers, 370 kits (35% of the national total) were distributed to 330 patients including 312 opioid users. Of these users, 15% report injecting and 85% are poly-consumers. In 14% of the cases, a patient's relative was formed to administrate the Nalscue®. Forty kits (30 given away, 6 lost, 4 administered) were renewed to 35 users. Of the 462 addiction centers contacted, 82 (18%) responded. Among 76 structures specialized in opioid addictions, two did not feel concerned and one had no knowledge of the antidote. Fifty-five structures were formed by the pharmaceutical firm. Nine hundred forty-seven patients (58% of the total) were included by 37 centers. Forty-four centers ordered 2458 kits and dispensed 1116 (including kits given out of study). Thirteen structures reported use of Nalscue®. CONCLUSION The interest of intranasal naloxone is no longer to be demonstrated in a context of opioid overdose, but the preauthorized framework did not allow a major diffusion of the antidote within the population most at risk. Let us hope that the availability in pharmacy can promote its distribution and thus reduce the number of deaths.
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Affiliation(s)
- Flavy Lenglard
- Institut des sciences pharmaceutiques et biologiques de Lyon, 69008 Lyon, France; Service pharmaceutique, groupement hospitalier Centre, hospices civils de Lyon, 69003 Lyon, France
| | - Aurélie Berger-Vergiat
- Service d'addictologie, centre de soins, d'accompagnement et de prévention en addictologie, groupement hospitalier Centre, hospices civils de Lyon, 69003 Lyon, France
| | - Delphine Ragonnet
- Service d'addictologie, centre de soins, d'accompagnement et de prévention en addictologie, groupement hospitalier Centre, hospices civils de Lyon, 69003 Lyon, France
| | - Nathalie Duvernay
- Centre de soins, d'accompagnement et de prévention en addictologie, groupement hospitalier Nord, hospices civils de Lyon, 69004 Lyon, France
| | - Philippe Lack
- Centre de soins, d'accompagnement et de prévention en addictologie, groupement hospitalier Nord, hospices civils de Lyon, 69004 Lyon, France
| | - Emmanuel Poulet
- Service de psychiatrie, groupement hospitalier Centre, hospices civils de Lyon, 69003 Lyon, France
| | - Fabien Zoulim
- Service d'hépatologie et gastro-entérologie, groupement hospitalier Nord, hospices civils de Lyon, 69004 Lyon, France
| | - Mathieu Chappuy
- Service pharmaceutique, groupement hospitalier Centre, hospices civils de Lyon, 69003 Lyon, France; Service d'addictologie, centre de soins, d'accompagnement et de prévention en addictologie, groupement hospitalier Centre, hospices civils de Lyon, 69003 Lyon, France; Centre de soins, d'accompagnement et de prévention en addictologie, groupement hospitalier Nord, hospices civils de Lyon, 69004 Lyon, France; Service pharmaceutique, groupement hospitalier Nord, hospices civils de Lyon, 69004 Lyon, France.
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Clemency BM, Eggleston W, Shaw EW, Cheung M, Pokoj NS, Manka MA, Giordano DJ, Serafin L, Yu H, Lindstrom HA, Hostler D. Hospital Observation Upon Reversal (HOUR) With Naloxone: A Prospective Clinical Prediction Rule Validation Study. Acad Emerg Med 2019; 26:7-15. [PMID: 30592101 DOI: 10.1111/acem.13567] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Revised: 08/27/2018] [Accepted: 08/30/2018] [Indexed: 01/11/2023]
Abstract
OBJECTIVE St. Paul's Early Discharge Rule was derived to determine which patients could be safely discharged from the emergency department after a 1-hour observation period following naloxone administration for opiate overdose. The rule suggested that patients could be safely discharged if they could mobilize as usual and had a normal oxygen saturation, respiratory rate, temperature, heart rate, and Glasgow Coma Scale score. Validation of the St. Paul's Early Discharge Rule is necessary to ensure that these criteria are appropriate to apply to patients presenting after an unintentional presumed opioid overdose in the context of emerging synthetic opioids and expanded naloxone access. METHODS In this prospective, observational validation study, emergency medicine providers assessed patients 1 hour after administration of prehospital naloxone. Unlike in the derivation study the threshold for normal oxygen saturation was set at 95% and patients were not immediately discharged after a normal 1-hour evaluation. Patients were judged to have a normal 1-hour evaluation if all six criteria of the rule were met. Patients were judged to have an adverse event (AE) if they had one or more of the preestablished AEs. RESULTS A total of 538 patients received at least one administration of prehospital naloxone, were transported to the study hospital, and had a 1-hour evaluation performed by a provider. AEs occurred in 82 (15.4%) patients. The rule exhibited a sensitivity of 84.1% (95% confidence interval [CI] = 76.2%-92.1%), a specificity of 62.1% (95% CI = 57.6%-66.5%), and a negative predictive value of 95.6% (95% CI = 93.3%-97.9%). Only one patient with a normal 1-hour evaluation subsequently received additional naloxone following a presumed heroin overdose. CONCLUSION This rule may be used to risk stratify patients for early discharge following naloxone administration for suspected opioid overdose.
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Affiliation(s)
- Brian M. Clemency
- Department of Emergency Medicine; Jacobs School of Medicine and Biomedical Sciences; University at Buffalo; Buffalo NY
- Department of Exercise and Nutrition Science; University at Buffalo; Buffalo NY
- Erie County Medical Center; Buffalo NY
| | | | - Evan W. Shaw
- Department of Emergency Medicine; Jacobs School of Medicine and Biomedical Sciences; University at Buffalo; Buffalo NY
| | - Michael Cheung
- Department of Emergency Medicine; Jacobs School of Medicine and Biomedical Sciences; University at Buffalo; Buffalo NY
| | - Nicholas S. Pokoj
- Department of Emergency Medicine; Jacobs School of Medicine and Biomedical Sciences; University at Buffalo; Buffalo NY
| | - Michael A. Manka
- Department of Emergency Medicine; Jacobs School of Medicine and Biomedical Sciences; University at Buffalo; Buffalo NY
- Erie County Medical Center; Buffalo NY
| | | | | | - Han Yu
- Department of Biostatistics; University at Buffalo; Buffalo NY
| | - Heather A. Lindstrom
- Department of Emergency Medicine; Jacobs School of Medicine and Biomedical Sciences; University at Buffalo; Buffalo NY
| | - David Hostler
- Department of Emergency Medicine; Jacobs School of Medicine and Biomedical Sciences; University at Buffalo; Buffalo NY
- Department of Exercise and Nutrition Science; University at Buffalo; Buffalo NY
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Barré T, Vorspan F, Fortias M, Veyrier M, Cavagna P, Azuar J, Nicolas L, Naccache F, Barreteau H, Bellivier F, Bloch V. Pratique de l’ATU de cohorte de la naloxone intranasale (Nalscue®) : mise en place dans un CSAPA parisien. Therapie 2018; 73:495-500. [DOI: 10.1016/j.therap.2018.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 03/08/2018] [Accepted: 03/27/2018] [Indexed: 11/30/2022]
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Grover JM, Alabdrabalnabi T, Patel MD, Bachman MW, Platts-Mills TF, Cabanas JG, Williams JG. Measuring a Crisis: Questioning the Use of Naloxone Administrations as a Marker for Opioid Overdoses in a Large U.S. EMS System. PREHOSP EMERG CARE 2018; 22:281-289. [DOI: 10.1080/10903127.2017.1387628] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Rzasa Lynn R, Galinkin JL. Naloxone dosage for opioid reversal: current evidence and clinical implications. Ther Adv Drug Saf 2017; 9:63-88. [PMID: 29318006 DOI: 10.1177/2042098617744161] [Citation(s) in RCA: 210] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 11/03/2017] [Indexed: 12/18/2022] Open
Abstract
Opioid-related mortality is a growing problem in the United States, and in 2015 there were over 33,000 opioid-related deaths. To combat this mortality trend, naloxone is increasingly being utilized in a pre-hospital setting by emergency personnel and prescribed to laypersons for out-of-hospital administration. With increased utilization of naloxone there has been a subsequent reduction in mortality following an opioid overdose. Reversal of opioid toxicity may precipitate an opioid-withdrawal syndrome. At the same time, there is a risk of inadequate response or re-narcotization after the administration of a single dose of naloxone in patients who have taken large doses or long-acting opioid formulations, as the duration of effect of naloxone is shorter than that of many opioid agonists. As out-of-hospital use of this medication is growing, so too is concern about effective but safe dosing.
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Affiliation(s)
| | - J L Galinkin
- University of Colorado at Denver, Anschutz Medical Campus, 13123 East 16th Avenue, B090, Aurora, CO 80045-0508, USA
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Gulec N, Lahey J, Suozzi JC, Sholl M, MacLean CD, Wolfson DL. Basic and Advanced EMS Providers Are Equally Effective in Naloxone Administration for Opioid Overdose in Northern New England. PREHOSP EMERG CARE 2017; 22:163-169. [DOI: 10.1080/10903127.2017.1371262] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Lewis CR, Vo HT, Fishman M. Intranasal naloxone and related strategies for opioid overdose intervention by nonmedical personnel: a review. Subst Abuse Rehabil 2017; 8:79-95. [PMID: 29066940 PMCID: PMC5644601 DOI: 10.2147/sar.s101700] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Deaths due to prescription and illicit opioid overdose have been rising at an alarming rate, particularly in the USA. Although naloxone injection is a safe and effective treatment for opioid overdose, it is frequently unavailable in a timely manner due to legal and practical restrictions on its use by laypeople. As a result, an effort spanning decades has resulted in the development of strategies to make naloxone available for layperson or "take-home" use. This has included the development of naloxone formulations that are easier to administer for nonmedical users, such as intranasal and autoinjector intramuscular delivery systems, efforts to distribute naloxone to potentially high-impact categories of nonmedical users, as well as efforts to reduce regulatory barriers to more widespread distribution and use. Here we review the historical and current literature on the efficacy and safety of naloxone for use by nonmedical persons, provide an evidence-based discussion of the controversies regarding the safety and efficacy of different formulations of take-home naloxone, and assess the status of current efforts to increase its public distribution. Take-home naloxone is safe and effective for the treatment of opioid overdose when administered by laypeople in a community setting, shortening the time to reversal of opioid toxicity and reducing opioid-related deaths. Complementary strategies have together shown promise for increased dissemination of take-home naloxone, including 1) provision of education and training; 2) distribution to critical populations such as persons with opioid addiction, family members, and first responders; 3) reduction of prescribing barriers to access; and 4) reduction of legal recrimination fears as barriers to use. Although there has been considerable progress in decreasing the regulatory and legal barriers to effective implementation of community naloxone programs, significant barriers still exist, and much work remains to be done to integrate these programs into efforts to provide effective treatment of opioid use disorders.
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Affiliation(s)
- Christa R Lewis
- Maryland Treatment Centers, Baltimore, MD, USA.,Department of Psychology, Towson University, Towson, MD, USA
| | - Hoa T Vo
- Maryland Treatment Centers, Baltimore, MD, USA
| | - Marc Fishman
- Maryland Treatment Centers, Baltimore, MD, USA.,Department of Psychiatry, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Klebacher R, Harris MI, Ariyaprakai N, Tagore A, Robbins V, Dudley LS, Bauter R, Koneru S, Hill RD, Wasserman E, Shanes A, Merlin MA. Incidence of Naloxone Redosing in the Age of the New Opioid Epidemic. PREHOSP EMERG CARE 2017; 21:682-687. [PMID: 28686547 DOI: 10.1080/10903127.2017.1335818] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
STUDY OBJECTIVE Naloxone, an opioid-antagonist deliverable by an intra-nasal route, has become widely available and utilized by law enforcement officers as well as basic life support (BLS) providers in the prehospital setting. This study aimed to determine the frequency of repeat naloxone dosing in suspected narcotic overdose (OD) patients and identify patient characteristics. METHODS A retrospective chart review of patients over 17 years of age with suspected opioid overdose, treated with an initial intranasal (IN) dose of naloxone and subsequently managed by paramedics, was performed from April 2014 to June 2016. Demographic data was analyzed using descriptive statistics to identify those aspects of the history, physical exam findings. Results: A sample size of 2166 patients with suspected opioid OD received naloxone from first responders. No patients who achieved GCS 15 after treatment required redosing; 195 (9%) received two doses and 53 patients received three doses of naloxone by advanced life support. Patients were primarily male (75.4%), Caucasian (88.2%), with a mean age of 36.4 years. A total of 76.7% of patients were found in the home, 23.1% had a suspected mixed ingestion, and 27.2% had a previous OD. Two percent of all patients required a third dose of naloxone. CONCLUSION In this prehospital study, we confirmed that intranasal naloxone is effective in reversing suspected opioid toxicity. Nine percent of patients required two or more doses of naloxone to achieve clinical reversal of suspected opioid toxicity. Two percent of patients received a third dose of naloxone.
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Faul M, Lurie P, Kinsman JM, Dailey MW, Crabaugh C, Sasser SM. Multiple Naloxone Administrations Among Emergency Medical Service Providers is Increasing. PREHOSP EMERG CARE 2017; 21:411-419. [PMID: 28481656 PMCID: PMC6026856 DOI: 10.1080/10903127.2017.1315203] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 03/30/2017] [Accepted: 03/30/2017] [Indexed: 12/03/2022]
Abstract
BACKGROUND Opioid overdoses are at epidemic levels in the United States. Emergency Medical Service (EMS) providers may administer naloxone to restore patient breathing and prevent respiratory arrest. There was a need for contemporary data to examine the number of naloxone administrations in an EMS encounter. METHODS Using data from the National Emergency Medical Services Information System, we examined data from 2012-5 to determine trends in patients receiving multiple naloxone administrations (MNAs). Logistic regression including demographic, clinical, and operational information was used to examine factors associated with MNA. RESULTS Among all events where naloxone was administered only 16.7% of the 911 calls specifically identified the medical emergency as a drug ingestion or poisoning event. The percentage of patients receiving MNA increased from 14.5% in 2012 to 18.2% in 2015, which represents a 26% increase in MNA in 4 years. Patients aged 20-29 had the highest percentage of MNA (21.1%). Patients in the Northeast and the Midwest had the highest relative MNA (Chi Squared = 539.5, p < 0.01 and Chi Squared = 351.2, p < 0.01, respectively). The logistic regression model showed that the adjusted odds ratios (aOR) for MNA were greatest among people who live in the Northeast (aOR = 1.18, 95% CI = 1.13-1.22) and for men (aOR = 1.13, 95% CI = 1.10-1.16), but lower for suburban and rural areas (aOR = 0.76, 95% CI = 0.72-0.80 and aOR = 0.85, 95% CI = 0.80-0.89) and lowest for wilderness areas (aOR = 0.76, 95% CI = 0.68-0.84). Higher adjusted odds of MNA occurred when an advanced life support (ALS 2) level of service was provided compared to basic life support (BLS) ambulances (aOR = 2.15, 95% CI = 1.45-3.16) and when the dispatch complaint indicated there was a drug poisoning event (aOR = 1.12, 95% CI = 1.09-1.16). Reported layperson naloxone administration prior to EMS arrival was rare (1%). CONCLUSION This study shows that frequency of MNA is growing over time and is regionally dependent. MNA may be a barometer of the potency of the opioid involved in the overdose. The increase in MNA provides support for a dosage review. Better identification of opioid related events in the dispatch system could lead to a better match of services with patient needs.
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Jeffery RM, Dickinson L, Ng ND, DeGeorge LM, Nable JV. Naloxone administration for suspected opioid overdose: An expanded scope of practice by a basic life support collegiate-based emergency medical services agency. JOURNAL OF AMERICAN COLLEGE HEALTH : J OF ACH 2017; 65:212-216. [PMID: 28059635 DOI: 10.1080/07448481.2016.1277730] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Opioid abuse is a growing and significant public health concern in the United States. Naloxone is an opioid antagonist that can rapidly reverse the respiratory depression associated with opioid toxicity. Georgetown University's collegiate-based emergency medical services (EMS) agency recently adopted a protocol, allowing providers to administer intranasal naloxone for patients with suspected opioid overdose. While normally not within the scope of practice of basic life support prehospital agencies, the recognition of an increasing epidemic of opioid abuse has led many states, including the District of Columbia, to expand access to naloxone for prehospital providers of all levels of training. In particular, intranasal naloxone is a method of administering this medication that potentially avoids needlestick injuries among EMS providers. Universities with collegiate-based EMS agencies are well positioned to provide life-saving treatments for patients acutely ill from opioid overdose.
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Affiliation(s)
- Ryan M Jeffery
- a Georgetown Emergency Response Medical Service , Georgetown University , Washington , District of Columbia , USA
| | - Laura Dickinson
- a Georgetown Emergency Response Medical Service , Georgetown University , Washington , District of Columbia , USA
| | - Nicholas D Ng
- a Georgetown Emergency Response Medical Service , Georgetown University , Washington , District of Columbia , USA
| | - Lindsey M DeGeorge
- b MedStar Washington Hospital Center/Georgetown University Hospital , Washington , District of Columbia , USA
| | - Jose V Nable
- a Georgetown Emergency Response Medical Service , Georgetown University , Washington , District of Columbia , USA
- c Department of Emergency Medicine , MedStar Georgetown University Hospital, Georgetown University School of Medicine , Washington , District of Columbia , USA
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Rapid widespread distribution of intranasal naloxone for overdose prevention. Drug Alcohol Depend 2017; 173:17-23. [PMID: 28182982 DOI: 10.1016/j.drugalcdep.2016.12.013] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 12/07/2016] [Accepted: 12/10/2016] [Indexed: 11/22/2022]
Abstract
BACKGROUND Take home naloxone programs have been successful internationally in training bystanders to reverse an opioid overdose with naloxone, an opioid antagonist. A multi-site naloxone distribution program began in Norway in 2014 as part of a national overdose prevention strategy. The aim of this study was to a) describe the program, and b) present findings from the government-supported intervention. METHODS From July 2014 to December 2015, staff from multiple low-threshold facilities trained clients on how to use intranasal naloxone. Distribution occurred without an individual prescription or physician present. Questionnaires from initial and refill trainings were obtained, and distribution rates were monitored. RESULTS There were 2056 naloxone sprays distributed from one of the 20 participating facilities, with 277 reports of successful reversals. Participants exhibited known risks for overdosing, with injecting (p=0.02, OR=2.4, 95% CI=1.14, 5.00) and concomitant benzodiazepine use (p=0.01, OR=2.6, 95% CI=1.31, 5.23) being significant predictors for having had high rates of previous overdoses. Suggested target coverage for large-scale programs was met, with an annual naloxone distribution rate of 144 per 100,000 population, as well as 12 times the cities mean annual number of opioid-related deaths. CONCLUSION A government-supported multisite naloxone initiative appears to achieve rapid, high volume distribution of naloxone to an at-risk population.
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Implementing take-home naloxone in an urban community pharmacy. J Am Pharm Assoc (2003) 2017; 57:S161-S167. [PMID: 28202384 DOI: 10.1016/j.japh.2017.01.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 01/12/2017] [Accepted: 01/12/2017] [Indexed: 11/22/2022]
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Alosaimy S, Santo RA, Fanikos J. Prescribing Naloxone: Managing and Preventing Opioid-Related Overdoses. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2017. [DOI: 10.1007/s40138-017-0124-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Bailey AM, Baum RA, Horn K, Lewis T, Morizio K, Schultz A, Weant K, Justice SN. Review of Intranasally Administered Medications for Use in the Emergency Department. J Emerg Med 2017; 53:38-48. [PMID: 28259526 DOI: 10.1016/j.jemermed.2017.01.020] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 12/13/2016] [Accepted: 01/22/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Intranasal (IN) medication delivery is a viable alternative to other routes of administration, including intravenous (IV) and intramuscular (IM) administration. The IN route bypasses the risk of needle-stick injuries and alleviates the emotional trauma that may arise from the insertion of an IV catheter. OBJECTIVE This review aims to evaluate published literature on medications administered via the IN route that are applicable to practice in emergency medicine. DISCUSSION The nasal mucosa is highly vascularized, and the olfactory tissues provide a direct conduit to the central nervous system, bypass first-pass metabolism, and lead to an onset of action similar to IV drug administration. This route of administration has also been shown to decrease delays in drug administration, which can have a profound impact in a variety of emergent scenarios, such as seizures, acutely agitated or combative patients, and trauma management. IN administration of midazolam, lorazepam, flumazenil, dexmedetomidine, ketamine, fentanyl, hydromorphone, butorphanol, naloxone, insulin, and haloperidol has been shown to be a safe, effective alternative to IM or IV administration. As the use of IN medications becomes a more common route of administration in the emergency department setting, and in prehospital and outpatient settings, it is increasingly important for providers to become more familiar with the nuances of this novel route of medication delivery. CONCLUSIONS IN administration of the reviewed medications has been shown to be a safe and effective alternative to IM or IV administration. Use of IN is becoming more commonplace in the emergency department setting and in prehospital settings.
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Affiliation(s)
- Abby M Bailey
- Department of Pharmacy, University of Kentucky HealthCare, Lexington, Kentucky
| | - Regan A Baum
- Department of Pharmacy, University of Kentucky HealthCare, Lexington, Kentucky
| | - Karolyn Horn
- Department of Pharmacy, University of Kentucky HealthCare, Lexington, Kentucky
| | - Tameka Lewis
- Department of Pharmacy, Charleston Area Medical Center, Charleston, West Virginia
| | - Kate Morizio
- Department of Pharmacy, University of Kentucky HealthCare, Lexington, Kentucky
| | - Amy Schultz
- Department of Pharmacy, Charleston Area Medical Center, Charleston, West Virginia
| | - Kyle Weant
- Department of Pharmacy, Medical University of South Carolina, Charleston, South Carolina
| | - Stephanie N Justice
- Department of Pharmacy, St. Claire Regional Medical Center, Morehead, Kentucky
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Weiner SG, Mitchell PM, Temin ES, Langlois BK, Dyer KS. Use of Intranasal Naloxone by Basic Life Support Providers. PREHOSP EMERG CARE 2017; 21:322-326. [DOI: 10.1080/10903127.2017.1282562] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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35
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Suzuki J, El-Haddad S. A review: Fentanyl and non-pharmaceutical fentanyls. Drug Alcohol Depend 2017; 171:107-116. [PMID: 28068563 DOI: 10.1016/j.drugalcdep.2016.11.033] [Citation(s) in RCA: 250] [Impact Index Per Article: 35.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2016] [Revised: 11/22/2016] [Accepted: 11/24/2016] [Indexed: 11/26/2022]
Abstract
BACKGROUND Fentanyl and non-pharmaceutical fentanyls (NPFs) have been responsible for numerous outbreaks of overdoses all over the United States since the 1970s. However, there has been a growing concern in recent years that NPFs are contributing to an alarming rise in the number of opioid-related overdoses. METHODS The authors conducted a narrative review of the published and grey literature on fentanyl and NPFs in PubMed, Google Scholar, and Google using the following search terms: "fentanyl", "non-pharmaceutical fentanyl", "fentanyl analogs", "fentanyl laced heroin" and "fentanyl overdose". References from relevant publications and grey literature were also reviewed to identify additional citations for inclusion. RESULTS The article reviews the emergence and misuse of fentanyl and NPFs, their clinical pharmacology, and the clinical management and prevention of fentanyl-related overdoses. CONCLUSIONS Fentanyl and NPFs may be contributing to the recent rise in overdose deaths in the United States. There is an urgent need to educate clinicians, researchers, and patients about this public health threat.
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Affiliation(s)
- Joji Suzuki
- Brigham and Women's Hospital, 60 Fenwood Rd., Boston, MA 02115, United States; Brigham and Women's Faulkner Hospital, 1153 Centre St., Boston, MA 02130, United States; Harvard Medical School, 25 Shattuck St., Boston, MA 02115, United States.
| | - Saria El-Haddad
- Brigham and Women's Hospital, 60 Fenwood Rd., Boston, MA 02115, United States; Brigham and Women's Faulkner Hospital, 1153 Centre St., Boston, MA 02130, United States; Harvard Medical School, 25 Shattuck St., Boston, MA 02115, United States
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36
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Tylleskar I, Skulberg AK, Nilsen T, Skarra S, Jansook P, Dale O. Pharmacokinetics of a new, nasal formulation of naloxone. Eur J Clin Pharmacol 2017; 73:555-562. [PMID: 28144724 DOI: 10.1007/s00228-016-2191-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 12/28/2016] [Indexed: 11/30/2022]
Abstract
PURPOSE Nasal naloxone is wanted for bystander administration in opioid overdose and as a needle-free alternative for emergency medical personnel. Epidemiologic studies have indicated a therapeutic effect of bystander administration of low-concentration/high-volume formulations. The objective for this study was to describe the nasal pharmacokinetics of a new high-concentration/low-volume nasal formulation of naloxone. METHODS This was an open, randomized triple crossover trial in healthy, human volunteers (n = 12) where two doses of nasal naloxone (0.8 and 1.6 mg) and one intravenous dose (1.0 mg) were compared. Fifteen serum samples were collected before and until 6 h after naloxone administration. Quantification of naloxone was performed by a validated liquid chromatography-tandem mass spectrometry method. RESULTS Bioavailability was 0.54 (0.45-0.63) for the 0.8 mg and 0.52 (0.37-0.67) for the 1.6 mg nasal naloxone formulation. Maximum concentration levels (C max) were 1.45 ng/ml (1.07-1.84) for 0.8 mg and 2.57 ng/ml (1.49-3.66) for the 1.6 mg. Time to maximum concentrations (T max) were reached at 17.9 min (11.4-24.5) and 18.6 min (14.4-22.9) for the 0.8 mg and the 1.6 mg doses, respectively. CONCLUSION This nasal naloxone formulation had a rapid, systemic uptake and higher bioavailability than naloxone formulations not designed for IN use. This indicates that an optimized high-concentration/low-volume nasal spray formulation may deliver a therapeutic dose. The 1.6 mg nasal dose provided serum concentrations that surpassed those of 1.0 mg IV after 15-20 min and stayed above for the rest of the study period.
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Affiliation(s)
- Ida Tylleskar
- Department of Circulation and Medical Imaging, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Arne Kristian Skulberg
- Department of Circulation and Medical Imaging, NTNU, Norwegian University of Science and Technology, Trondheim, Norway.,Division of Emergencies and Critical Care, Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway
| | - Turid Nilsen
- Department of Circulation and Medical Imaging, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Sissel Skarra
- Department of Circulation and Medical Imaging, NTNU, Norwegian University of Science and Technology, Trondheim, Norway
| | - Phatsawee Jansook
- Faculty of Pharmaceutical Sciences, Chulalongkorn University, Bangkok, Thailand
| | - Ola Dale
- Department of Circulation and Medical Imaging, NTNU, Norwegian University of Science and Technology, Trondheim, Norway. .,Department of Research and Development, St. Olav's University Hospital, Trondheim, Norway.
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Das S, Shah N, Ghadiali M. Intravenous use of intranasal naloxone: A case of overdose reversal. Subst Abus 2016; 38:18-21. [DOI: 10.1080/08897077.2016.1267686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Smita Das
- Department of Addiction Psychiatry, University of California San Francisco, San Francisco, California, USA
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California, USA
- Department of Psychiatry, University of California San Francisco, San Francisco, California, USA
- San Francisco VA Medical Center, San Francisco, California, USA
| | - Nina Shah
- Chemical Dependency Recovery Program, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Murtuza Ghadiali
- Department of Addiction Psychiatry, University of California San Francisco, San Francisco, California, USA
- Department of Addiction Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
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Purviance D, Ray B, Tracy A, Southard E. Law enforcement attitudes towards naloxone following opioid overdose training. Subst Abus 2016; 38:177-182. [DOI: 10.1080/08897077.2016.1219439] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Affiliation(s)
- Donna Purviance
- Department of Advanced Practice Nursing, Indiana State University, Terre Haute, Indiana, USA
| | - Bradley Ray
- School of Public and Environmental Affairs, Indiana University–Purdue University Indianapolis, Indianapolis, Indiana, USA
- School of Public and Environmental Affairs, Indiana University–Purdue University Indianapolis, Indianapolis, Indiana, USA
| | - Abigail Tracy
- School of Public and Environmental Affairs, Indiana University–Purdue University Indianapolis, Indianapolis, Indiana, USA
| | - Erik Southard
- Department of Advanced Practice Nursing, Indiana State University, Terre Haute, Indiana, USA
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Corrigan M, Wilson SS, Hampton J. Safety and efficacy of intranasally administered medications in the emergency department and prehospital settings. Am J Health Syst Pharm 2016; 72:1544-54. [PMID: 26346210 DOI: 10.2146/ajhp140630] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The safety and efficacy of medications that may be administered via the intranasal route in adult patients in the prehospital and emergency department (ED) settings are reviewed. SUMMARY When medications of appropriate molecular character and concentration are delivered intranasally, they are quickly transported across this capillary network and delivered to the systemic circulation, thereby avoiding the absorption-limiting effects of first-pass metabolism. Therapeutic drug concentrations are rapidly attained in the cerebrospinal fluid, making intranasal administration a very effective mode of delivery. To optimize the bioavailability of intranasally administered drugs, providers must minimize the barriers to absorption, minimize the volume by maximizing the concentration, maximize the absorptive surface of the nasal mucosa, and use a delivery system that maximizes drug dispersion and minimizes drug runoff. Medications can be instilled into the nasal cavity with syringes or droppers by applying a few drops at a time or via atomization. The intranasal route of administration may be advantageous for patients who require analgesia, sedation, anxiolysis, termination of seizures, hypoglycemia management, narcotic reversal, and benzodiazepine reversal in the ED or prehospital settings. Medications that have been studied in the adult population include fentanyl, sufentanil, hydromorphone, ketamine, midazolam, haloperidol, naloxone, flumazenil, and glucagon. The available data do indicate, however, that intranasal administration may be a safe, effective, and well tolerated route of administration. CONCLUSION Based on the published literature, intranasal administration of fentanyl, sufentanil, ketamine, hydromorphone, midazolam, haloperidol, naloxone, glucagon, and, in limited cases, flumazenil may be a safe, effective, and well-tolerated alternative to intramuscular or intravenous administration in the prehospital and ED settings.
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Affiliation(s)
- Megan Corrigan
- Megan Corrigan, Pharm.D., BCPS, is Emergency Medicine Clinical Pharmacist, Department of Pharmacy, Advocate Illinois Masonic Medical Center, Chicago. Suprat Saely Wilson, Pharm.D., BCPS, is Emergency Medicine Clinical Pharmacist Specialist, Department of Pharmacy Services, Detroit Receiving Hospital, Detroit, MI. Jeremy Hampton, Pharm.D., BCPS, is Clinical Specialist Emergency Medicine, Truman Medical Center, Kansas City, MO, and Clinical Assistant Professor, School of Pharmacy, University of Missouri-Kansas City, Kansas City
| | - Suprat Saely Wilson
- Megan Corrigan, Pharm.D., BCPS, is Emergency Medicine Clinical Pharmacist, Department of Pharmacy, Advocate Illinois Masonic Medical Center, Chicago. Suprat Saely Wilson, Pharm.D., BCPS, is Emergency Medicine Clinical Pharmacist Specialist, Department of Pharmacy Services, Detroit Receiving Hospital, Detroit, MI. Jeremy Hampton, Pharm.D., BCPS, is Clinical Specialist Emergency Medicine, Truman Medical Center, Kansas City, MO, and Clinical Assistant Professor, School of Pharmacy, University of Missouri-Kansas City, Kansas City
| | - Jeremy Hampton
- Megan Corrigan, Pharm.D., BCPS, is Emergency Medicine Clinical Pharmacist, Department of Pharmacy, Advocate Illinois Masonic Medical Center, Chicago. Suprat Saely Wilson, Pharm.D., BCPS, is Emergency Medicine Clinical Pharmacist Specialist, Department of Pharmacy Services, Detroit Receiving Hospital, Detroit, MI. Jeremy Hampton, Pharm.D., BCPS, is Clinical Specialist Emergency Medicine, Truman Medical Center, Kansas City, MO, and Clinical Assistant Professor, School of Pharmacy, University of Missouri-Kansas City, Kansas City.
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Strang J, McDonald R, Alqurshi A, Royall P, Taylor D, Forbes B. Naloxone without the needle - systematic review of candidate routes for non-injectable naloxone for opioid overdose reversal. Drug Alcohol Depend 2016; 163:16-23. [PMID: 26996745 DOI: 10.1016/j.drugalcdep.2016.02.042] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 02/24/2016] [Accepted: 02/28/2016] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Deaths from opioid overdose can be prevented through administration of the antagonist naloxone, which has been licensed for injection since the 1970s. To support wider availability of naloxone in community settings, novel non-injectable naloxone formulations are being developed, suitable for emergency use by non-medical personnel. OBJECTIVES 1) Identify candidate routes of injection-free naloxone administration potentially suitable for emergency overdose reversal; 2) consider pathways for developing and evaluating novel naloxone formulations. METHODS A three-stage analysis of candidate routes of administration was conducted: 1) assessment of all 112 routes of administration identified by FDA against exclusion criteria. 2) Scrutiny of empirical data for identified candidate routes, searching PubMed and WHO International Clinical Trials Registry Platform using search terms "naloxone AND [route of administration]". 3) Examination of routes for feasibility and against the inclusion criteria. RESULTS Only three routes of administration met inclusion criteria: nasal, sublingual and buccal. Products are currently in development and being studied. Pharmacokinetic data exist only for nasal naloxone, for which product development is more advanced, and one concentrated nasal spray was granted licence in the US in 2015. However, buccal naloxone may also be viable and may have different characteristics. CONCLUSION After 40 years of injection-based naloxone treatment, non-injectable routes are finally being developed. Nasal naloxone has recently been approved and will soon be field-tested, buccal naloxone holds promise, and it is unclear what sublingual naloxone will contribute. Development and approval of reliable non-injectable formulations will facilitate wider naloxone provision across the community internationally.
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Affiliation(s)
- John Strang
- National Addiction Centre, Addictions Department, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, 4 Windsor Walk, Denmark Hill, London SE5 8BB, UK.
| | - Rebecca McDonald
- National Addiction Centre, Addictions Department, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), King's College London, 4 Windsor Walk, Denmark Hill, London SE5 8BB, UK.
| | - Abdulmalik Alqurshi
- Institute of Pharmaceutical Science, King's College London, 150 Stamford Street, London SE1 9NH, UK.
| | - Paul Royall
- Institute of Pharmaceutical Science, King's College London, 150 Stamford Street, London SE1 9NH, UK.
| | - David Taylor
- Institute of Pharmaceutical Science, King's College London, 150 Stamford Street, London SE1 9NH, UK; Pharmacy Department, South London and Maudsley NHS Foundation Trust (SLaM), Maudsley Hospital, Denmark Hill, London SE5 8AZ, UK.
| | - Ben Forbes
- Institute of Pharmaceutical Science, King's College London, 150 Stamford Street, London SE1 9NH, UK.
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Fisher R, O'Donnell D, Ray B, Rusyniak D. Police Officers Can Safely and Effectively Administer Intranasal Naloxone. PREHOSP EMERG CARE 2016; 20:675-680. [PMID: 27218446 DOI: 10.1080/10903127.2016.1182605] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Opioid overdose rates continue to rise at an alarming rate. One method used to combat this epidemic is the administration of naloxone by law enforcement. Many cities have implemented police naloxone administration programs, but there is a minimal amount of research examining this policy. The following study examines data over 18 months, after implementation of a police naloxone program in an urban setting. We describe the most common indications and outcomes of naloxone administration as well as examine the incidence of arrest, immediate detention, or voluntary transport to the hospital. In doing so, this study seeks to describe the clinical factors surrounding police use of naloxone, and the effects of police administration. METHODS All police officer administrations were queried from April 2014 through September 2015 (n = 126). For each incident we collected the indication, response, and disposition of the patient that was recorded on a "sick-injured civilian" report that officers were required to complete after administration of naloxone. All of the relevant information was abstracted from this report into an electronic data collection form that was then input into SPSS for analysis. RESULTS The most common indication for administration was unconscious/unresponsive (n = 117; 92.9%) followed by slowed breathing (n = 72; 57.1%), appeared blue (n = 63; 50.0%) and not breathing (n = 41; 32.5%). After administration of naloxone the majority of patients regained consciousness (n = 82; 65.1%) followed by began to breath (n = 71; 56.3%). However, in 17.5% (n = 22) of the cases "Nothing" happened when naloxone was administered. The majority of patients were transported voluntarily to the hospital (n = 122; 96.8%). Lastly, there was only one report where the patient became combative. CONCLUSION Our study shows that police officers trained in naloxone administration can correctly recognize symptoms of opioid overdose, and can appropriately administer naloxone without significant adverse effects or outcomes. Furthermore, the administration of police naloxone does not result in a significant incidence of combativeness or need for scene escalations such as immediate detention. Further research is needed to investigate the impact of police naloxone; specifically, comparing outcomes of police delivery to EMS alone, as well as the impact on rural opioid overdoses.
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Doyon S, Benton C, Anderson BA, Baier M, Haas E, Hadley L, Maehr J, Rebbert-Franklin K, Olsen Y, Welsh C. Incorporation of poison center services in a state-wide overdose education and naloxone distribution program. Am J Addict 2016; 25:301-6. [DOI: 10.1111/ajad.12384] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Revised: 05/07/2016] [Accepted: 05/07/2016] [Indexed: 11/27/2022] Open
Affiliation(s)
- Suzanne Doyon
- Department of Emergency Medicine; Johns Hopkins School of Medicine; Baltimore Maryland
| | - Carleigh Benton
- University of Maryland School of Medicine; Baltimore Maryland
| | | | - Michael Baier
- Department of Health and Mental Hygiene; Behavioral Health Administration; Baltimore Maryland
| | - Erin Haas
- Department of Health and Mental Hygiene; Behavioral Health Administration; Baltimore Maryland
| | - Lisa Hadley
- Department of Health and Mental Hygiene; Behavioral Health Administration; Baltimore Maryland
| | - Jennifer Maehr
- Maryland Department of Juvenile Services; Baltimore Maryland
| | | | - Yngvild Olsen
- Institutes for Behavioral Resources; Baltimore Maryland
| | - Christopher Welsh
- Department of Psychiatry; University of Maryland School of Medicine; Baltimore Maryland
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Strang J, McDonald R, Tas B, Day E. Clinical provision of improvised nasal naloxone without experimental testing and without regulatory approval: imaginative shortcut or dangerous bypass of essential safety procedures? Addiction 2016; 111:574-82. [PMID: 26840916 DOI: 10.1111/add.13209] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2015] [Revised: 08/06/2015] [Accepted: 10/12/2015] [Indexed: 10/22/2022]
Abstract
CONTEXT Take-home naloxone is increasingly provided to prevent heroin overdose deaths. Naloxone 0.4-2.0 mg is licensed for use by injection. Some clinicians supply improvised nasal naloxone kits (outside licensed approval). Is this acceptable? AIMS (1) To consider provision of improvised nasal naloxone in clinical practice and (2) to search for evidence for pharmacokinetics and effectiveness (versus injection). METHODS (1) To document existing nasal naloxone schemes and published evidence of pharmacokinetics (systematic search of the CINAHL, Cochrane, EMBASE and MEDLINE databases and 18 records included in narrative synthesis). (2) To analyse ongoing studies investigating nasal naloxone (WHO International Clinical Trials Registry Platform and US NIH RePORT databases). FINDINGS (1) Multiple studies report overdose reversals following administration of improvised intranasal naloxone. (2) Overdose reversal after nasal naloxone is frequent but may not always occur. (3) Until late 2015, the only commercially available naloxone concentrations were 0.4 mg/ml and 2 mg/2 ml. Nasal medications are typically 0.05-0.25 ml of fluid per nostril. The only published study of pharmacokinetics and bioavailability finds that nasal naloxone has poor bioavailability. QUESTIONS FOR DEBATE: (1) Why are pharmacokinetics and bioavailability data for nasal naloxone not available before incorporation into standard clinical practice? (2) Does nasal naloxone have the potential to become a reliable clinical formulation? (3) What pre-clinical and clinical studies should precede utilization of novel naloxone formulations as standard emergency medications? CONCLUSIONS The addictions treatment field has rushed prematurely into the use of improvised nasal naloxone kits. Evidence of adequate bioavailability and acceptable pharmacokinetic curves are vital preliminary steps, especially when effective approved formulations exist.
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Affiliation(s)
- John Strang
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Rebecca McDonald
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Basak Tas
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Ed Day
- National Addiction Centre, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Sivilotti MLA. Flumazenil, naloxone and the 'coma cocktail'. Br J Clin Pharmacol 2016; 81:428-36. [PMID: 26469689 PMCID: PMC4767210 DOI: 10.1111/bcp.12731] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Revised: 07/29/2015] [Accepted: 07/31/2015] [Indexed: 01/14/2023] Open
Abstract
Flumazenil and naloxone are considered to be pharmacologically ideal antidotes. By competitive binding at the molecular target receptors, they are highly specific antagonists of two important drug classes, the benzodiazepines and opioids, respectively. Both antidotes enjoy rapid onset and short duration after parenteral administration, are easily titrated and are essentially devoid of agonist effects. Yet only naloxone is widely used as a component of the 'coma cocktail', a sequence of empirical treatments to correct altered mental status, while experts discourage the use of flumazenil for such patients. This review contrasts the history, indications, published evidence and novel applications for each antidote in order to explain this disparity in the clinical use of these 'ideal' antidotes.
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Affiliation(s)
- Marco L A Sivilotti
- Emergency Medicine and Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario
- Ontario Poison Centre, Hospital for Sick Children, Toronto, Ontario, Canada
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Brodrick JE, Brodrick CK, Adinoff B. Legal regimes surrounding naloxone access: considerations for prescribers. THE AMERICAN JOURNAL OF DRUG AND ALCOHOL ABUSE 2016; 42:117-28. [DOI: 10.3109/00952990.2015.1109648] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Callaway CW, Soar J, Aibiki M, Böttiger BW, Brooks SC, Deakin CD, Donnino MW, Drajer S, Kloeck W, Morley PT, Morrison LJ, Neumar RW, Nicholson TC, Nolan JP, Okada K, O'Neil BJ, Paiva EF, Parr MJ, Wang TL, Witt J. Part 4: Advanced Life Support: 2015 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations. Circulation 2016; 132:S84-145. [PMID: 26472860 DOI: 10.1161/cir.0000000000000273] [Citation(s) in RCA: 234] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Lavonas EJ, Drennan IR, Gabrielli A, Heffner AC, Hoyte CO, Orkin AM, Sawyer KN, Donnino MW. Part 10: Special Circumstances of Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2016; 132:S501-18. [PMID: 26472998 DOI: 10.1161/cir.0000000000000264] [Citation(s) in RCA: 172] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Cobaugh DJ, Gainor C, Gaston CL, Kwong TC, Magnani B, McPherson ML, Painter JT, Krenzelok EP. The opioid abuse and misuse epidemic: implications for pharmacists in hospitals and health systems. Am J Health Syst Pharm 2015; 71:1539-54. [PMID: 25174015 DOI: 10.2146/ajhp140157] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
PURPOSE The current epidemic of prescription opioid abuse and misuse in the United States is discussed, with an emphasis on the pharmacist's role in ensuring safe and effective opioid use. SUMMARY U.S. sales of prescription opioids increased fourfold from 1999 to 2010, with an alarming rise in deaths and emergency department visits associated with the use of fentanyl, hydrocodone, oxycodone, and other opioid medications. Signs and symptoms of opioid toxicity may include altered mental status, hypoventilation, decreased bowel motility, central nervous system and respiratory depression, peripheral vasodilation, pulmonary edema, hypotension, bradycardia, and seizures. In patients receiving long-term opioid therapy for chronic pain, urine drug testing is an important tool for monitoring and assessment of therapy; knowledge of opioid metabolic pathways and assay limitations is essential for appropriate use and interpretation of screening and confirmatory tests. In recent years, there has been an increase in federal enforcement actions against pharmacies and prescription drug wholesalers involved in improper opioid distribution, as well as increased reliance on state-level prescription drug monitoring programs to track patterns of opioid use and improper sales. Pharmacies are urged to implement or promote appropriate guidelines on opioid therapy, including the use of pain management agreement plans; policies to ensure adequate oversight of opioid prescribing, dispensing, and waste disposal; and educational initiatives targeting patients as well as hospital and pharmacy staff. CONCLUSION Pharmacists in hospitals and health systems can play a key role in recognizing the various forms of opioid toxicity and in preventing inappropriate prescribing and diversion of opioids.
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Affiliation(s)
- Daniel J Cobaugh
- Daniel J. Cobaugh, Pharm.D., DABAT, FAACT, is Vice President, ASHP Research and Education Foundation, Bethesda, MD. Carl Gainor, J.D., Ph.D., is Clinical Assistant Professor of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA. Cynthia L. Gaston, Pharm.D., BCPS, is Medication Use Policy Analyst, UW Health, Madison, WI. Tai C. Kwong, Ph.D., is Professor of Pathology and Laboratory Medicine, University of Rochester School of Medicine and Dentistry, and Director, Hematology and Chemistry Labs, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY. Barbarajean Magnani, Ph.D., M.D., is Chair and Pathologist-in-Chief, Department of Pathology and Laboratory Medicine, Tufts Medical Center, and Professor and Chair, Department of Anatomic and Clinical Pathology, Tufts University School of Medicine, Boston, MA. Mary Lynn McPherson, Pharm.D., BCPS, CPE, is Professor and Vice Chair, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore. Jacob T. Painter, Pharm.D., M.B.A., Ph.D., is Assistant Professor of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock. Edward P. Krenzelok, Pharm.D., FAACT, FEAPCCT, DABAT, is Professor Emeritus, School of Pharmacy, University of Pittsburgh.
| | - Carl Gainor
- Daniel J. Cobaugh, Pharm.D., DABAT, FAACT, is Vice President, ASHP Research and Education Foundation, Bethesda, MD. Carl Gainor, J.D., Ph.D., is Clinical Assistant Professor of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA. Cynthia L. Gaston, Pharm.D., BCPS, is Medication Use Policy Analyst, UW Health, Madison, WI. Tai C. Kwong, Ph.D., is Professor of Pathology and Laboratory Medicine, University of Rochester School of Medicine and Dentistry, and Director, Hematology and Chemistry Labs, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY. Barbarajean Magnani, Ph.D., M.D., is Chair and Pathologist-in-Chief, Department of Pathology and Laboratory Medicine, Tufts Medical Center, and Professor and Chair, Department of Anatomic and Clinical Pathology, Tufts University School of Medicine, Boston, MA. Mary Lynn McPherson, Pharm.D., BCPS, CPE, is Professor and Vice Chair, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore. Jacob T. Painter, Pharm.D., M.B.A., Ph.D., is Assistant Professor of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock. Edward P. Krenzelok, Pharm.D., FAACT, FEAPCCT, DABAT, is Professor Emeritus, School of Pharmacy, University of Pittsburgh
| | - Cynthia L Gaston
- Daniel J. Cobaugh, Pharm.D., DABAT, FAACT, is Vice President, ASHP Research and Education Foundation, Bethesda, MD. Carl Gainor, J.D., Ph.D., is Clinical Assistant Professor of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA. Cynthia L. Gaston, Pharm.D., BCPS, is Medication Use Policy Analyst, UW Health, Madison, WI. Tai C. Kwong, Ph.D., is Professor of Pathology and Laboratory Medicine, University of Rochester School of Medicine and Dentistry, and Director, Hematology and Chemistry Labs, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY. Barbarajean Magnani, Ph.D., M.D., is Chair and Pathologist-in-Chief, Department of Pathology and Laboratory Medicine, Tufts Medical Center, and Professor and Chair, Department of Anatomic and Clinical Pathology, Tufts University School of Medicine, Boston, MA. Mary Lynn McPherson, Pharm.D., BCPS, CPE, is Professor and Vice Chair, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore. Jacob T. Painter, Pharm.D., M.B.A., Ph.D., is Assistant Professor of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock. Edward P. Krenzelok, Pharm.D., FAACT, FEAPCCT, DABAT, is Professor Emeritus, School of Pharmacy, University of Pittsburgh
| | - Tai C Kwong
- Daniel J. Cobaugh, Pharm.D., DABAT, FAACT, is Vice President, ASHP Research and Education Foundation, Bethesda, MD. Carl Gainor, J.D., Ph.D., is Clinical Assistant Professor of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA. Cynthia L. Gaston, Pharm.D., BCPS, is Medication Use Policy Analyst, UW Health, Madison, WI. Tai C. Kwong, Ph.D., is Professor of Pathology and Laboratory Medicine, University of Rochester School of Medicine and Dentistry, and Director, Hematology and Chemistry Labs, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY. Barbarajean Magnani, Ph.D., M.D., is Chair and Pathologist-in-Chief, Department of Pathology and Laboratory Medicine, Tufts Medical Center, and Professor and Chair, Department of Anatomic and Clinical Pathology, Tufts University School of Medicine, Boston, MA. Mary Lynn McPherson, Pharm.D., BCPS, CPE, is Professor and Vice Chair, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore. Jacob T. Painter, Pharm.D., M.B.A., Ph.D., is Assistant Professor of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock. Edward P. Krenzelok, Pharm.D., FAACT, FEAPCCT, DABAT, is Professor Emeritus, School of Pharmacy, University of Pittsburgh
| | - Barbarajean Magnani
- Daniel J. Cobaugh, Pharm.D., DABAT, FAACT, is Vice President, ASHP Research and Education Foundation, Bethesda, MD. Carl Gainor, J.D., Ph.D., is Clinical Assistant Professor of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA. Cynthia L. Gaston, Pharm.D., BCPS, is Medication Use Policy Analyst, UW Health, Madison, WI. Tai C. Kwong, Ph.D., is Professor of Pathology and Laboratory Medicine, University of Rochester School of Medicine and Dentistry, and Director, Hematology and Chemistry Labs, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY. Barbarajean Magnani, Ph.D., M.D., is Chair and Pathologist-in-Chief, Department of Pathology and Laboratory Medicine, Tufts Medical Center, and Professor and Chair, Department of Anatomic and Clinical Pathology, Tufts University School of Medicine, Boston, MA. Mary Lynn McPherson, Pharm.D., BCPS, CPE, is Professor and Vice Chair, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore. Jacob T. Painter, Pharm.D., M.B.A., Ph.D., is Assistant Professor of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock. Edward P. Krenzelok, Pharm.D., FAACT, FEAPCCT, DABAT, is Professor Emeritus, School of Pharmacy, University of Pittsburgh
| | - Mary Lynn McPherson
- Daniel J. Cobaugh, Pharm.D., DABAT, FAACT, is Vice President, ASHP Research and Education Foundation, Bethesda, MD. Carl Gainor, J.D., Ph.D., is Clinical Assistant Professor of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA. Cynthia L. Gaston, Pharm.D., BCPS, is Medication Use Policy Analyst, UW Health, Madison, WI. Tai C. Kwong, Ph.D., is Professor of Pathology and Laboratory Medicine, University of Rochester School of Medicine and Dentistry, and Director, Hematology and Chemistry Labs, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY. Barbarajean Magnani, Ph.D., M.D., is Chair and Pathologist-in-Chief, Department of Pathology and Laboratory Medicine, Tufts Medical Center, and Professor and Chair, Department of Anatomic and Clinical Pathology, Tufts University School of Medicine, Boston, MA. Mary Lynn McPherson, Pharm.D., BCPS, CPE, is Professor and Vice Chair, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore. Jacob T. Painter, Pharm.D., M.B.A., Ph.D., is Assistant Professor of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock. Edward P. Krenzelok, Pharm.D., FAACT, FEAPCCT, DABAT, is Professor Emeritus, School of Pharmacy, University of Pittsburgh
| | - Jacob T Painter
- Daniel J. Cobaugh, Pharm.D., DABAT, FAACT, is Vice President, ASHP Research and Education Foundation, Bethesda, MD. Carl Gainor, J.D., Ph.D., is Clinical Assistant Professor of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA. Cynthia L. Gaston, Pharm.D., BCPS, is Medication Use Policy Analyst, UW Health, Madison, WI. Tai C. Kwong, Ph.D., is Professor of Pathology and Laboratory Medicine, University of Rochester School of Medicine and Dentistry, and Director, Hematology and Chemistry Labs, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY. Barbarajean Magnani, Ph.D., M.D., is Chair and Pathologist-in-Chief, Department of Pathology and Laboratory Medicine, Tufts Medical Center, and Professor and Chair, Department of Anatomic and Clinical Pathology, Tufts University School of Medicine, Boston, MA. Mary Lynn McPherson, Pharm.D., BCPS, CPE, is Professor and Vice Chair, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore. Jacob T. Painter, Pharm.D., M.B.A., Ph.D., is Assistant Professor of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock. Edward P. Krenzelok, Pharm.D., FAACT, FEAPCCT, DABAT, is Professor Emeritus, School of Pharmacy, University of Pittsburgh
| | - Edward P Krenzelok
- Daniel J. Cobaugh, Pharm.D., DABAT, FAACT, is Vice President, ASHP Research and Education Foundation, Bethesda, MD. Carl Gainor, J.D., Ph.D., is Clinical Assistant Professor of Pharmaceutical Sciences, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA. Cynthia L. Gaston, Pharm.D., BCPS, is Medication Use Policy Analyst, UW Health, Madison, WI. Tai C. Kwong, Ph.D., is Professor of Pathology and Laboratory Medicine, University of Rochester School of Medicine and Dentistry, and Director, Hematology and Chemistry Labs, Strong Memorial Hospital, University of Rochester Medical Center, Rochester, NY. Barbarajean Magnani, Ph.D., M.D., is Chair and Pathologist-in-Chief, Department of Pathology and Laboratory Medicine, Tufts Medical Center, and Professor and Chair, Department of Anatomic and Clinical Pathology, Tufts University School of Medicine, Boston, MA. Mary Lynn McPherson, Pharm.D., BCPS, CPE, is Professor and Vice Chair, Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore. Jacob T. Painter, Pharm.D., M.B.A., Ph.D., is Assistant Professor of Pharmaceutical Evaluation and Policy, University of Arkansas for Medical Sciences, Little Rock. Edward P. Krenzelok, Pharm.D., FAACT, FEAPCCT, DABAT, is Professor Emeritus, School of Pharmacy, University of Pittsburgh
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Davis CS, Carr D. Legal changes to increase access to naloxone for opioid overdose reversal in the United States. Drug Alcohol Depend 2015; 157:112-20. [PMID: 26507172 DOI: 10.1016/j.drugalcdep.2015.10.013] [Citation(s) in RCA: 110] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 10/06/2015] [Accepted: 10/06/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Opioid overdose, which has reached epidemic levels in the United States, is reversible by administration of the medication naloxone. Naloxone requires a prescription but is not a controlled substance and has no abuse potential. In the last half-decade, the majority of states have modified their laws to increase layperson access to the medication. METHODS We utilized a structured legal research protocol to systematically identify and review all statutes and regulations related to layperson naloxone access in the United States that had been adopted as of September, 2015. Each law discovered via this process was reviewed and coded by two trained legal researchers. RESULTS As of September, 2015, 43 states and the District of Columbia have passed laws intended to increase layperson naloxone access. We categorized these laws into three domains: (1) laws intended to increase naloxone prescribing and distribution, (2) laws intended to increase pharmacy naloxone access, and (3) laws intended to encourage overdose witnesses to summon emergency responders. These laws vary greatly across states in such characteristics as the types of individuals who can receive a prescription for naloxone, whether laypeople can dispense the medication, and immunity provided to those who prescribe, dispense and administer naloxone or report an overdose emergency. CONCLUSIONS Most states have now passed laws intended to increase layperson access to naloxone. While these laws will likely reduce overdose morbidity and mortality, the cost of naloxone and its prescription status remain barriers to more widespread access.
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Affiliation(s)
- Corey S Davis
- Network for Public Health Law, 3701 Wilshire Blvd. #750, Los Angeles, CA 90010, United States.
| | - Derek Carr
- Network for Public Health Law, 101 E. Weaver St. #G-07, Carrboro, NC 27510, United States.
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