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New Resources to Combat Opiod Overdoses in san Joaquin County

As a follow up to the article entitled “Public Health Update: A Look at the Opioid Crisis in San Joaquin County” in the Winter 2019 issue of San Joaquin Physician, this Update will share new opportunities for physicians in helping to mitigate the evolving opioid overdose epidemic.

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In early 2016 in California, the epidemic began to see a steep rise in fentanyl overdose deaths. Fentanyl is a powerful synthetic opioid that is about 100 times more potent than morphine, 30-50 times more potent than heroin. Just two milligrams of fentanyl can be lethal depending on a person’s body size. It is often mixed in with heroin and/or cocaine and meth as a combination drug with or without the user’s knowledge. Illicitly produced fentanyl has also been identified in counterfeit pills, mimicking pharmaceutical drugs such as oxycodone.1

While pharmaceutical fentanyl has been around for years as a transdermal patch or lozenge used to treat severe pain, such as in advanced cancer, the number of overdose deaths as a result of diversion to misuse and abuse had been relatively low. However, cases of fentanyl-related overdoses and deaths have now been associated with illegally made fentanyl and its analogs. As a result, the state saw a 9.5 times increase in overdose deaths from synthetic opioids (excluding methadone) through the third quarter of 2020. Locally, San Joaquin County also saw a steep 15-fold increase in the rate of overdose deaths in just a short period, between the end of 2018 (0.37 per 100K residents) to quarter 3 of 2020 (5.63). In December 2020, the Centers of Disease Control and Prevention (CDC) issued a Health Alert Network (HAN) Advisory to alert public health departments, healthcare professionals, first responders, harm reduction organizations, laboratories, and medical examiners and coroners that substantial increases in drug overdose deaths starting in 2019 through now have primarily been driven by synthetic opioids (excluding methadone) such as fentanyl. In addition, the advisory also noted that the acceleration of increase in overdose deaths occurred from March 2020 to May 2020, coinciding with the nationwide implementation of COVID-19 mitigation strategies. Finally, CDC provided targeted recommendations for communities and organizations to respond to the evolving overdose crisis. The need for broadly disseminated overdose prevention education was emphasized. The recommendations also urged expanding the provision of naloxone, a drug antagonist that is easy to administer as a nasal spray and reverses the effects of opioids within minutes, albeit temporarily.

Naloxone Distribution Program (NDP)

Three years ago, the California Department of Health Care Services (DHCS) created a Naloxone Distribution Program (NDP) to provide free naloxone, in its nasal spray formulation, Narcan. Doses have been distributed broadly across the state, ranging from first responders, fire and law enforcement to harm reduction organizations and homeless programs, to religious organizations, and schools, as well as

County Public Health and Behavioral Health Agencies. Since October 2018, the NDP has distributed over 600,000 units of naloxone and recorded over 30,000 overdose reversals.

Where do physicians fit in the response to the opioid crisis?

Healthcare providers are often in a position not only to identify individuals who are at risk for substance use disorders and potential overdose but also to provide the necessary resources to educate and prevent overdose deaths. Counseling patients about the changing illicit drug supply and the risks for overdose and exposure to fentanyl can be supported with prescribing or coprescribing naloxone. Individuals who are at risk for overdose, such as those with a prior history of overdose, those with opioid use disorder (OUD), and individuals using illicit opioids and other drugs that might be mixed with illicitly manufactured fentanyl would benefit in having naloxone available so that others around them could potentially reverse an overdose situation, thus avoiding accidental death. Link for application for “free” naloxone:

https://www.dhcs.ca.gov/individuals/Documents/NDP-Application. pdf

Healthcare providers can expand access to and provide treatment for individuals with OUD. Treatment with the FDA-approved medications methadone, buprenorphine, suboxone, or naltrexone are lifesaving and the most effective forms of treatment for OUD. Assistance through referrals to ensure treatment access can be critical for those transitioning from institutional settings, such as the criminal justice system, residential treatment, or a recent hospitalization.

Medication Assisted Treatment (MAT) Services

While illicit opioids, including heroin and fentanyl, and some prescribed opioids that are misused are the most commonly utilized that result in overdoses, it is necessary to acknowledge that opioid use disorder behaviors are responsible for these situations and can be treated through the initiation and referral to medication assisted treatment (MAT) services. One objective for San Joaquin County is to increase the availability and access to Buprenorphine/Naloxone (Suboxone) and other FDA-approved medications, including counseling and behavioral therapies designed to reduce opioid dependency.

How can physicians prescribe Buprenorphine for OUD?

The Drug Addiction Treatment Act of 2000 (DATA 2000), part of the Children’s Health Act of 2000, permits physicians who meet certain qualifications to treat opioid dependency with narcotic medications approved by the Food and Drug Administration (FDA)—including buprenorphine—in treatment settings other than Opioid Treatment Programs (OTPs). Physicians need to obtain a waiver from the separate registration requirements of the Narcotic Addict Treatment Act – 1974. The SUPPORT Act (2018) now affords practitioners greater flexibility in the provision of MAT and extends the privilege of prescribing buprenorphine in office-based settings to qualifying other practitioners such as Nurse Practitioners and Physician Assistants.

DATA 2000 requires training but it has never been easier! Under new US HHS Practice Guidelines, physicians are no longer required to complete an eight-hour training course to prescribe buprenorphine if they are treating no more than 30 patients at a time. They are also exempt from certification requirements related to counseling and other ancillary services. These clinicians still must be licensed under state law and have a valid Drug Enforcement Administration registration, and they are required to submit a notice of intent to the Substance Abuse and Mental Health Services Administration (SAMHSA)

stating their intention to prescribe the drug to receive a federal waiver.

Pain Management Guidelines

Many prescribers involved in pain management may be feeling the pressure of medical boards, law enforcement, and thirdparty payers, not to mention patients that are often demanding and who have unreasonable and unrealistic expectations for their opioid analgesia treatments. Current guidelines for pain management and national prescriber best practice recommendations are readily available.

In summary, this is a call for providers to intervene early with those individuals who are at the highest risk for overdose. Instituting overdose prevention education, treatment and/or linkage to care and medications for OUD, as well as naloxone distribution can all help to reduce the deadly toll exacted by misuse and abuse of opioids.

References • San Joaquin Physician. Public Health Update: A Look at the Opioid Crisis in San Joaquin County https://issuu.com/sjms/docs/sjp_winter_web_2019/56?e=1446001/72667860 • CDC. Fentanyl: CDC’s Response to the Opioid Overdose Epidemic. https://www.cdc.gov/opioids/basics/fentanyl.html • California Opioid Dashboard https://skylab.cdph.ca.gov/ODdash/ • SAMHSA MAT Statutes, Regulations, and Guidelines https://www.samhsa.gov/medication-assisted-treatment/statutes-regulations-guidelines • DATA 2000 Waiver Training Payment Program FAQs https://help.hrsa.gov/plugins/servlet/mobile?contentId=127402850#content/ view/127402850 • US HHS Practice Guidelines for the Administration of Buprenorphine for Treating Opioid Use Disorder. 2021 Apr 28. https://www.federalregister.gov/documents/2021/04/28/2021-08961/practiceguidelines-for-the-administration-of-buprenorphine-for-treating-opioid-use-disorder

Authors: Daniel Kim, MPH, CHES Supervising Health Educator and Coordinator, SJC Opioid Safety Coalition San Joaquin County Public Health Services dkim@sjcphs.org

Adam Kaye, Pharm.D., PhC, FASCP, FCPhA Clinical Professor of Pharmacy University of the Pacific akaye@pacific.edu

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