Sammi: Good evening everybody and welcome to this evening’s A Guide to naloxone for General Practitioners webinar. My name is Samantha and I am your host for this evening. Before we jump in, I would just like to make a quick Acknowledgement of Country. We recognise the traditional custodians of the land and sea on which we live and work and we pay our respects to Elders past and present.
Alrighty, so in saying that I would like to introduce our presenters for this evening. So tonight we are joined by Dr Hester Wilson and Dr Linda Mann. Hester has a Master’s degree in Mental Health and 25 years’ experience working in the primary healthcare setting. Hester is also a Staff Specialist in Addiction at Sydney’s Langton Centre Drug and Alcohol Clinic and has facilitated training for doctors and other healthcare workers since 2001. Linda is a Fellow of the RACGP and a member of the RACGP’s Antenatal and Postnatal Care Network. Linda has both local and international medical experience, especially in genetics and women’s health. She is a GP representative on various national and local government committees and is an experienced medical educator. So, welcome Hester and Linda and thank you for joining us this evening.
Linda: Hi everybody.
Sammi: Alrighty, I am going to hand over to Linda now to take us through our learning outcomes for this evening, and then we will jump over to Hester to kick of the presentation.
Linda: By the end of this QI and CPD activity, you should be able to be aware of the current scheduling of naloxone, identify patients who may benefit prescribed naloxone, describe the role of GPs in prescribing naloxone and the required counselling and that is in relation to overdose prevention, identification and response. And explain how to administer intramuscular and intranasal naloxone products, which you may not have known now exists. Hester.
Hester: Hi. Yes, okay so case one. This is just to get you guys thinking. Just imagine you have a patient, Julie aged 50, who has chronic non-malignant pain which is due to a previous motor vehicle accident. So she has chronic pain in her neck and her lower back. And she has recurrences of this pain and, sorry it is not recurrences, it is daily pain and flare ups as well. She is a smoker, has chronic obstructive airways disease, anxiety, insomnia and I cannot, sorry, and she is overweight as well. Her medications include oxycodone 40 mg bd and mirtazapine 60 mg at night. So that oxycodone 40 mg bd is about a dose of 120 oral morphine equivalent dose. So the question, just thinking about someone like Julie, is Julie at risk of opioid, or at risk of overdose? So we are going to a poll. So just give us a sense.
So look we are seeing some strongly agrees there, some agrees, some neither agree nor disagree, some disagrees and some strongly disagrees. I am really interested in the people that are either the strongly agree or the disagree. You know, and maybe this will become something that becomes clearer over time as we run through the presentation. I did make Julie someone who was not someone who was clearly, absolutely someone that you had to be super, super worried about, but she is on a high dose opioid and she does have some respiratory issues and is overweight. So there is some risk there. We will talk more about this as we go on. We want to move on from there.
Opioid overdoses in Australia. And so this is a study looking at 2016 when there were more than 1,000 opioid-induced deaths among Australians from 15 to 64. So it has gone up. It has gone up, it has doubled just about from 2007 to 2016. And it is much higher in regional New South Wales. And the vast majority are accidents. People are not trying to kill themselves, these are accidents. It is more common in men than in women. But there are significant numbers of women there as well.
Moving onto the next page. Okay, and so there are some groups that are especially vulnerable. Different people will have an idea of what a high dose of pharmaceutical opioids is, but what we know from the literature is that there is a dose related curve. So if you are on high dose, your risk of harm from your opioids is much higher. And the sort of levels that we are looking at is somewhere around 50, five zero, daily morphine equivalent, so it is not a huge dose and as it goes up, 60, 80, 100, this is definitely high risk and anybody that is on more than a dose of an oral morphine equivalent of 100 mg a day is by definition high dose and therefore at increased risk. People using long-acting opioids are more at risk, just because that load of opioid in the system is more. People with recent overdose, they are at high risk of having another overdose. People that are using other medicines, other sedating pharmaceuticals, other opioids, alcohol, you know quetiapine, the sedating anti-depressants. And mirtazapine is sedating as well. Itself, it is not a particularly high risk medication, but it can contribute to the risk. Alcohol is another one and heroin is, look it is another opioid. The issue is it is very quick onset and so it reaches a peak very soon and people are more at risk of overdose using that one as well.
Thinking about the comorbidities, thinking about people who have respiratory issues, cardiac issues, you know other frailties, other things that put them at risk of overdose. People on methadone or buprenorphine programs like with say particularly methadone because it is a full agonist. Buprenorphine is actually protective on its own, but in combination with other medicines there can be an issue, and the big one I have forgotten to mention of course is benzodiazepines. And people on the sedating medications. And the elderly. So people that have decreased capacity to metabolise and the elderly - more and more we are moving away from using that term and talking about older Australians, and that really means anybody over the age of 65 and it increases with time.
The other groups that we need to particularly think about and we may not think about this in a GP setting, is people leaving prison or leaving drug treatment. So if they are coming out of a treatment program, or if they are leaving prison. Now, the reason for that with leaving prison, is that people may in fact be using while they are in prison or they may not. And when they come out of prison, one of the things that they may well be doing is going back to their communities where there may be a lot of drug use and they may want to be having a bit of fun, and they do tend to use them. So those first two weeks after coming out of jail, men and a little bit longer for women, are particularly risky for overdose, because people will come back to their communities, will go, “Well I have always used this amount of drug” and used that same amount when in fact they are not as tolerant, they are more opioid naïve, and so they are much more likely to overdose. And people coming out of treatment, this is one of the things about treatment for opioid dependence, it is great to keep people on treatment for a longer period of time, for some years, because they do want to get off and sometimes they will get off too early before they are ready and their tolerance is low and once again they are likely to overdose.
Aboriginal people are particularly at risk. Now, once again when you look at Aboriginal people as a whole the actual group of people that have issues with drug and alcohol is actually less, but when they do use it is really risky, really harmful and their risk is much higher. This would also be perhaps because of where they are living. They are living in rural regional and remote areas and that is a risk factor in itself.
So moving onto the next page. So this is some data from a trial from 2018 from the National Drug and Alcohol Research Centre. 65% of accidental opioid deaths were attributed to pharmaceutical opioids only. Okay? The majority are more of those than anything else were due to morphine, codeine and oxycodone. There were a significant number attributable to heroin and what I would say is, that is a more dangerous drug than the others, but the others are still dangerous. And we are having increasing deaths from synthetic opioids like fentanyl. Tramadol is a weaker opioid but it has been implicated in deaths. Fentanyl we are not seeing a huge amount of that, but it is increasing and we are certainly seeing it in Canada particularly and the US where very strong illicit fentanyl is hitting the city and lots of people are dying. Methadone in itself is an issue. It is a great treatment for opioid dependency but it is a very idiosyncratic drug and it is a full opioid agonist and it does increase your risk of death.
Move onto the next one. So here we have a graph. This graph is brilliant because it shows us the trends over time from before 2000. Now around 1999 to 2000, we had a huge peak in overdose, opioid overdose deaths and there was a drug summit that happened as a result of that. And there were some changes that happened in terms of drug strategy and certainly in Sydney one of the outcomes of that was actually the medically supervised injecting centre opening. And we see in 2001 to about 2005, the level of deaths actually dropped considerably. Now I would like to be able to say that was because the medically supervised injecting centre did its job very well, but it was actually more about the war in Afghanistan and the fact that people could not access heroin particularly. And so it was a time when there were much less deaths. What we have seen since that time is the increase in deaths due to the pharmaceutical opioids. So particularly once again, morphine, codeine and oxycodone. So you can see that kind of magenta line, where the rates are increasing. With heroin, you can see the rates are starting to come back up from about 2013. Now this may well be that one of the unintended consequences from people becoming more aware of the risk of pharmaceuticals, is that people are more reluctant to prescribe pharmaceuticals. However, you have individuals who are already on this medication and who are already dependent and they cannot access the pharmaceuticals and so they turn to heroin which is a more dangerous drug.
Moving on. So once again, this is looking just at opioids. And if we compare exclusively illicits which is your dark blue and exclusively your mid blue, you can see that really the pharmaceutical opioids are big players in the overdose deaths. And this is something that we are really concerned with. We can see that their overall deaths are increasing and a big portion of that is due to prescribed pharmaceutical opioids.
Moving on. This one is interesting as well because this looks at the rates of death and that is another really important thing. As I was saying before, with something like mirtazapine which is in itself not a high risk medication. It is used quite a lot by people to help them sleep. In my sense it is not a particularly good antidepressant. It is sedating. On its own it is not a huge risk, although if people take big doses of course it can be. But mixing it with opioids and it is the mixing it that is the issue. So what we are seeing, you know for example in these we have got you know, 40% of the deaths were due to opioids and alcohol. 45% of the deaths were due to opioids and benzodiazepines. So we can really see that mixing of medications and in some of the deaths that I have been involved in in being a witness at coroner’s courts, we are seeing multi-drug toxicity. So we are seeing opioids, we are seeing benzodiazepines. We are seeing alcohol. We are seeing sedating antidepressants, sedating antipsychotics. So we really do need to be aware of everything the person is taking not just their opioids in terms of risk.
Moving on. A little slow with the slide changes, I am not sure what is happening there.
Sammi: Sorry, there is a little bit of a delay going on. It has been changed, but not at your end, Hester?
Hester: No worries. Yes, beautiful. So one of the things that is interesting is to look at how things have changed since 1999. When I was first working in Sydney in the Kings Cross area, we were seeing people in their early thirties and morphine and heroin and benzodiazepines were the drugs we were seeing, that were being detected after death. What we are seeing now is that it is benzodiazepines and oxycodone. It is an older person. It is a middle aged man living outside a capital city. So you know it is a really important shift and quite often these are not people that started their drug careers early in life in their teens. They are more likely to have started later and quite often it starts with an injury with chronic non-malignant pain and then it becomes a safety issue in terms of the overdose risk.
Moving on. So this is the National Drug Strategy Household Survey from 2016. So in this survey, it is a telephone survey. It is around 25 thousand households around Australia. And 4.8% of Australians who answered that survey told us that they had used pharmaceuticals, particularly prescription opioids but not limited to that, for non-medical purposes in the last 12 months. So that is non-medical. It is non-prescribed. It is not for medical purposes, it is for some other non-medical reason. And look, and some people actually use the drugs in a non-medical way with their own medicines. Some people get it from friends, borrow it, grandma. Not uncommon for it to be grandma is getting it from her GP and then people are getting it from grandma. And it is difficult for us to know when we look at overdose deaths, it is difficult to know where that medication, the pharmaceutical opioid actually came from. Whether it was prescribed or whether it was something that was obtained from friends or bought from people’s circles or on the street.
Linda: Hester, just a question mark. I am just wondering whether maybe GPs should be willing to talk to the patients like grandma, who have what the GP thinks is a very legitimate reason for having their regular medicine which never changes, and just saying, do you ever give any to anybody else? And just have a safety conversation in that way. Would that be something that you think might be helpful?
Hester: Oh absolutely. Absolutely. And it is about safety. So it is not that you are giving grandma a hard time, but the thing that I always say with anybody that is on medications that are high risk for any reason, is keep it secret, keep it safe. You know so do not discuss it with your mates. Keep it in a locked box high up in a cupboard. Keep them secret, keep them safe. But in terms of having a conversation, you know it is actually, one of the issues that we have with consumers around opioids is that they might not realise that they are prescribed opioids, or any of their prescribed medicines for that matter, that are right for them, may not actually be right for other people. And we know that around 30% of medications get shared. So you know, people will get a medication that works for them and their friend will have a similar problem so “oh use some of my medication.” You know it is about sharing and looking after each other, and people not understanding why medicines are prescription and they may be perfect for the individual but they may not be safe for other people. So I think it is a really good idea to have those conversations around “Do you ever you know, share those medications with someone else because they may not be safe for other people”.
Moving onto scheduling. In February 2016, Naloxone preparations for overdose were down-scheduled from S4 to S3. So there are two medications now available, the first one and we are using the trade names because there is only one brand. Prenoxad which is the intramuscular naloxone and Nyxoid which is intranasal. So they are both on the S3. Prenoxad is still on the S4 as well and we will talk a little bit about that. The Nyxoid we are hoping will go on to the S4 as well, but at the moment it is available on the S3. I just would note that at the moment they are still setting up their wholesaling and pharmacies may not have this easily available just now, but it is here. It has been approved and we will talk more about its place in overdose management as we go.
Next page. So in terms of the National Drug Strategy 2017 – 2026, increasing naloxone access is one of the really important harm reduction strategies. It is not the only one and I would not want people to think, you know as long as we have got naloxone that is all we have to do. And that is one of the issues that is happening in the States at the moment. You know, it has got to be part of an overall plan. The rescheduling to S3 aims to make naloxone more accessible. There are issues with cost though which is an issue for us. The other thing is take home naloxone, where community members take home naloxone, are trained to use naloxone and can successfully resuscitate other people while they are waiting for the ambulance to arrive. And people use opioids, the thing we sometimes worry about, oh if they have naloxone then they are going to really push it and be more unsafe. Actually they do not. It is not what they are doing. They are not intending to overdose, it is an accidental overdose and they are not intending to push it. They are actually just trying to achieve a state and they sometimes cannot realise that what they are doing is incredibly risky. So we do not need to worry about giving people naloxone will push them to actually behave in a more risky way.
Moving on. So New South Wales Health has been working on increasing naloxone access. We have been involved in the New South Wales Drug and Alcohol Services with trials and programs to support people to take home naloxone so people can actually give it to people who are overdosing. So it is drug treatment patients and needle syringe programs. And really looking at those particularly high risk groups, people leaving prison and people coming out of treatment or people coming into treatment and really one of the things is we give it out free. So we are promoting that free access, encouraging people to learn how to give the injection and how to respond when somebody overdoses. And what we are looking at now, is helping GPs to understand how they might have conversations and whether their patients might be at risk and how they might support people with the harm reduction measure of providing naloxone.
Next page. Okay. So working with people who are at risk of overdose. Okay. Alright. Yes. So once again, this is kind of going back to what we were talking about, so I will tell you a little bit of my experience working with people. I think one of the fascinating things working with people in the drug and alcohol sector who are at high risk, they are in treatment, they may well have had overdoses themselves. One of the things that became clear to us when we started talking to people about overdose and overdose management, is that many of them have had family members, friends, people that they cared about in their life and their community who have died of overdose. Some of them had actually been in a situation where they had come across somebody who had overdosed and they did not know what to do. And so helping people to have those skills so that they can intervene, they can give the injection and importantly call the ambulance, this is not a replacement for calling the ambulance, is really, really important. And people would come back and say, “Do you know what, thank you so much for giving me that naloxone because I was able to save my mate’s life. Give me some more so that I can do it again next time.” So it is a really important harm reduction measure that it actually empowers people to think about risk and that is the other thing, is that you can engage people in conversation about risk and help them to make choices that are perhaps less risky. So if they have had an overdose, or if they have a mate who has had an overdose, they may well be engaged in your service. You can then have a conversation around what happened, what went wrong, what can you do next time so that you are not at risk? Because people do not want to harm themselves, they do not want to die but they do sometimes get it wrong because the drugs and the medicines they use do have risk.
So, while we are looking at those marginalised groups in the environment that I work in, in the drug treatment services, there are other people being seen in the GP service who may actually be using. May be injecting occasionally. May be using a non-medical use of the medications and we know from the survey that you know, nearly 5% of Australians do, or did in 2016 over a one year period. So that GPs having that information and pharmacies also having that information are a really important other part of this. And we as GPs, because we see people over time, we can have those non-judgemental supportive conversations around risk and help individuals and carers to have some skills to actually manage risky situations.
Moving on. So one of the questions and I have kind of covered this a little bit, but you know really I would love all of us who have prescribed opioids and will continue to do, you know opioids are a fantastic lifesaving medicine. They are on the WHO list of essential drugs. They are fantastic for acute pain. They are fantastic for palliative care. Their place in the management of non-malignant pain is contentious and we really do need to think hard about how much benefit our patients are getting from using opioids for their chronic non-malignant pain. And part of that is really assessing the risk. How safe is this for this person? And if we do have someone that is on a high dose and we are concerned around safety, what can we do to make it more safe? And it may be that we are working with the patient around getting the dose down a little, starting to think about other options. And at the same time, we can put some safety structures in which could include things like supervised dosing or staged supply or looking at other medications. You know, education around the risks, including naloxone, to the individual and to their families. And looking to promote, if they cannot afford it because as I said at the moment they are a little expensive, the cost for both of them over the counter is around about somewhere between $40 and up to depending on what the pharmacy charges, up to about $75. So it is quite expensive. With the Prenoxad injection, you actually get five doses in the one ampoule so that is another important thing to note. But if we know that we have patients who are at risk and we cannot, we know that they will struggle to pay for it, we can direct them to drug and alcohol services, to needle syringe programs to actually access that medication for free.
Moving on. So, which patients could benefit? So you know, some patients as I have said using prescription opioid medicines are at risk. So, who are those that are at risk? Look, you know, if somebody has had a previous overdose they are at risk. If they have a history of illicit opioid drug use, possibly, possibly they are at increased risk, particularly if they are injecting, if they have been in jail, coming out of treatment. You know, you do need to think about the risk. More than anything else it is the dose and one of the things that is important to remember about drugs that are injected, is that if I take an OxyContin orally, I get a certain dose. If I inject it, I get a much bigger dose, because I do not have it, it is all absorbed into my blood, it does not need to go through the liver. So it is a bigger dose. And it is more quickly delivered. So, you know, so people who inject are at higher risk as well. But that does not mean that people who are on oral medications are not at risk and it really is related to the dose. The other one is patients who are concerned about a family member’s opioid use, and one of the coroner’s cases I was involved with as a professional witness, was a group of people who had died of multidrug toxicity and one of the really sad things about it was that three out of the four of them had family members at home with them who did not realise that they were overdosing. Who thought that they were sleeping heavily. Who thought they were just snoring. And so helping families to understand if they do have someone in their family who is at risk of overdose, what to look out for and how to intervene. Because that is an absolute tragedy for a family member, that if only they had known, they could have made a difference, and they could have saved their family member’s life.
Moving on. So, once again, it is important to think about who is it that is at risk and who could benefit. So are you looking at the patient that you are seeing being the one that is at risk of overdose, or is your patient the family friend, the carer who will be a first responder? And how do we start a conversation about overdose risk? Using sensitive, non-stigmatising language is really, really important here and the Language Matters thing that we have got up here is brilliant. I really, really love this. Now I know that there are times in the past when I have used some of the terms that are on the “instead of this, try something else” list, and I think sometimes it can feel like changing this is, look it is just changing the window dressing. And we have got to work on the underlying stigma and discrimination that is implicit in this. One of the really lovely things about this for me is that it is person-centred. So it is about a person who is experiencing drug dependence. It is about a person who uses drugs. It is not a drug user. Drug using is part of their identity, it is not who they are. And it is the same these days where we are moving away from calling someone a hypertensive or a diabetic. They are a person who has diabetes or hypertension. Things like, you know, they are staying clean, or their urines are clean. You are better off saying that they are no longer using drugs. You know, or that it is a positive or negative urine drug screen. So really, it really is a lovely graph. I would really encourage you to have a bit of a look at it and it is available on line. If you just google Language Matters it will come up. NADA and NUAA are the two groups that have done a lot of work putting this together. There has been a lot of consultation with people who have used drugs, or use drugs and yes, just a really lovely way. So when you are talking about, thinking about that non-stigmatising, non-judgemental language. And I suggest something that you need to think about with everybody that you are seeing. If they are on any high-risk medications, just have that thought in your head, is this person at risk of overdose? What could it be about this presentation that puts them at risk? And how do I have a conversation around it? It is not about being punitive. It is about really trying to make sure that that person stays safe and stays well.
Moving on. Now as I have said before, sometimes people, it is surprising, have limited knowledge about overdose and when they know what the naloxone is for, they are really positive about it. This is you know, my patients that have come back to me and been able to save a mate. It is an amazing thing to be able to intervene and save somebodies life. You know, and preventing an overdose. And do not forget, not only is it fatal overdoses which are a tragedy, but the other thing is non-fatal overdoses that lead to hypoxia that actually can particularly with repeated non-fatal overdoses lead to acquired brain injury and cognitive impairment. Recognising an overdose. So it is important that we talk to patients and to carers about how to recognise an overdose. What does normal breathing look like when someone is sleeping? How is that different from an overdose? Overdoses do not happen suddenly. They happen over time and it was one of the fascinating things for me working down at the injecting centre and watching someone start to overdose. The way that they would start to become more relaxed and their breathing would get more deep, and then it would get slower and then it would, you know the breathing rate would really drop down and we could put an oximeter on and just watch the oxygen level come down. And quite often you could just give them a little bit a shake and they would wake up and their oxygen would go up. We would say, would you like some naloxone? And generally they would say, no, no, no I am fine, I am fine, I am fine and then they would start to fall asleep and their respiratory rate would go down and they would start to become hypoxic. Would you like some naloxone? And if they did not say no, no, no I do not want any, then we would give them 400 mcg which once again, would just bring them up so they did not actually become hypoxic and you get any brain damage and die. So really, having that conversation with our patients and carers around what that looks like and how they can respond and the importance then of putting the person in the recovery position and calling an ambulance. And that you can give repeated doses of naloxone. And even if you got it wrong and it is not an overdose from opioids, it is not going to do them any harm.
Talking about how you administer, it is the intramuscular injection and as I said in the ampoule you get 2 mg. Now ideally you do not want to give a full 2 mg. Back in the day we used to give 2 mg. The ambos used to give 2 mg, and what it does is it is actually a huge dose that wakes the person up and sends them into precipitated withdrawal which is really, really uncomfortable and nasty, you know with pains and aches and sweating and vomiting and diarrhoea. It is nasty. And so we would generally give 0.4 so one fifth of the ampoule of the intramuscular and then repeat if it does not actually have an effect. The intranasal is a once off. And it is so much easier. We are so glad that it has come to Australia and hopefully we can get it on the S4 so we can get a decent price for it for people who need it and do not have the money. And it is very easy for family members to give it as well so you just actually squeeze the little container up the nose. So, but for the intramuscular, it is an intramuscular injection. No different to any other. Generally we give it in the outer thigh or the upper arm or we can give it in the buttock as well.
Moving on. Okay. So yes, Prenoxad has the prefilled syringe designed to be used by community members. It is listed on the PBS so you can get it on S3 over the counter or you can get it S4 and if somebody is on a healthcare card, they will get it for their $6.30. Through the PBS it is listed at $40, so it is a little bit more expensive there if you do not have a healthcare card. It includes the equipment and instructions.
Linda: Hester, whatever happened to Narcan?
Hester: Narcan is still available.
Linda: Is that the same?
Hester: Narcan is an ampoule. You have to break the top. There is a picture of the Prenoxad. Sorry I am not quite sure where it is. It is a prefilled syringe. So it is a different, naloxone Narcan is in one of those little ampoules. You have got to break the glass on the top. So whereas this one is an ampoule.
Linda: So for our purposes in the practice, we can order Narcan ampoule and suck it up into a syringe and administer as necessary. If we are going to provide this parenteral method for patients, this prefilled syringe is obviously much better for them, it is one less step and they do not know how to open an ampoule so this is better, but probably the better one is the intranasal one that you are going to talk about.
Hester: Yes, absolutely. Absolutely. But yes it is, it has got the needles there. The idea is that they only give one fifth each time they do an injection so it is not difficult and certainly what we have been doing in terms of the trials that we are involved in, is we have had the 2 ml syringes but we have also had the 400 mcg Minijets as well, so you know my preference would be for the intranasal spray just because it is so easy and if you are a carer and you are a bit anxious and you are trying to do needles and things, it is so much easier for the intranasals. But this one is available and it is really important that we know that we can prescribe it for our patients.
Linda: I am sorry to be going on about this. Does this prefilled syringe have any markers about where a fifth of it is?
Hester: Good question. I have not actually thought about that.
Linda: My friend here tells me it does. Because I am just thinking, I can just imagine some anxious person who has never done this before and I said to them, do not give all 2 mg because they will be ratty. You do not want ratty, you just want them alive. Five lines up the syringe and I guess what you would be doing is saying to the parent or the friend, just up to the first line, wait and see what happens. You can always give the second line down the track.
Hester: Yes, absolutely.
Linda: Thank you.
Hester: Okay, moving on. Yes, so naloxone ampoules. So we already talked about that. That is clinical setting. So PBS listed. The patient is to buy and keep track of multiple pieces of injecting, it does not provide the consumer information like the other one dose. Yes, so we have kind of been through that. Beautiful.
Moving onto the next. Nyxoid. Yes, so this is, it is available in Australia, it is not PBS listed yet but we are hoping that that will change. And it is really easy to use. I have used one of the placebos. There is a picture I think coming up. Yes. So basically as you can imagine, the kind of the nostril shape there at the top, you basically just push the bottom and out comes the naloxone and you would use the whole of that dose, because it is intranasal you do not have the same issues. So it is a 1.8 mg dose, but you do not have the same issues in terms of a huge dose that makes people go into a nasty precipitated withdrawal. So it is easy to use.
Moving on. Yes, so once again, you need to say look this is emergency, first responder, but call an ambulance. You know, get the ambos coming in, they can speak to the person, they can take them to hospital if it is needed. The other thing is just expiry dates and certainly one of the things that I you know, keep a log of, if is I have handed out some naloxone or Nyxoid in the future, I will actually just put in a little reminder that says you know, due to come back here in a recall, to come back here and replace it when it expires.
Linda: Sorry, Hester. That nasal one, I guess the whole if I pressed it with my thumb, that is the whole dose. You would not want to do a trial, would we?
Hester: No, no.
Linda: You do not prime it like you do with a puffer or something like that.
Hester: Yes, you know thinking about you know other things that people might worry about, the hole will get all bunged up. The answer is no, give it. Just give it.
Hester: Moving on. Okay, yes. So we have really been through this. I mean it does come in, the Prenoxad comes in a package so that you can actually, you can put the sharps back in there to safely dispose of the sharps. It is five doses and you can re-dose. If there is no response you know after two or three minutes, just give another dose. The other thing is, if there is no response, you know, your recovery position or even giving CPR if it is needed. Best locations as we said are the upper arms and the outer side of the thighs. And it does come with really simple instructions. So, one of the things that we are looking at doing is getting some dummies of the Nyxoid - sorry, this is the intramuscular. It comes with simple instructions around how to give it. Beautiful. Okay.
Moving on. The intranasal. Two devices with one spray each. So yes, as you have said Linda, do not give a test spray because that will be gone. Once again you would give the second one two to three minutes afterwards and it comes with instructions. So as I was going to say for this one, I am going to have some of the dummies with the instructions so I can actually show people, same as I do with all my puffers. I have got a little bag of all the different puffers and inhalers so that I can show people what it looks like so they have got a bit of a sense. Because you do not want to be kind of fumbling about when you are trying to use it for the first time. So I really encourage people to have the dummy there to show people if they are going to prescribe.
Moving on. So let’s go to Jack. Let’s have another case. So here is Jack, a patient of ours aged 56. He has got a past family history of alcohol dependence, but not a personal history. He was injured in a workplace accident 15 years ago and has only worked occasionally since. He started OxyContin for his chronic hip pain as a result of the injury and he moved to injecting OxyContin. His mates told him that this was more effective and he found that it helped more. With the change in OxyContin formulation which happened back in 2016, he started accessing heroin and illegal fentanyl to inject. So he was living alone in metro Sydney because his marriage broke down. He is estranged from his family and he has recently been released from jail due to some drug offences. He had a recent admission to the Emergency Department after being found slumped unconscious on the street. So do we have a poll associated with Jack?
Sammi: We certainly do and that will be popping up on your screens now, same as with Julie we are just asking what you think.
Hester: Fantastic. Yes, look, strongly agree. For those of you who put neither agree nor disagree, let’s go back and look at Jack’s risk. Can we go back to Jack? Here we go. Aged 56. Family history, so he has got the dependency gene let us say, he has had a significant injury 15 years ago and he has been using oxycodone for his hip pain and moving to injecting. So he is someone who has escalated his dose and has moved towards injecting because he finds it works better. So he is at risk there. And when he could no longer get the OxyContin formulation that he was looking for that was easy to inject, he moved to heroin and fentanyl. These are stronger opioids, they are quick onset. They are lipophilic. They pass through the blood-brain barrier very quickly so they are high risk for injecting. He is on his own. He has only been recently released from jail. And he has had a recent overdose. So he is someone, he is high, high risk. I am really worried about this guy and I really want to get him into opioid agonist treatment. I would really love to get him better managed and you know, that is my take home message for someone like Jack. He is absolutely someone that would do very well with opioid agonist treatment, opioid substitution treatment if you wish to call it with methadone or buprenorphine naloxone combination. He will do a lot better. He will be a lot happier. So if you come across someone like Jack, encourage him to get into treatment. GPs can start people on Suboxone which is a buprenorphine and naloxone combination in New South Wales. I would however say that he is probably a tricky one with complex issues and so he would be one that we would be very, very happy to see in the specialist drug and alcohol service to get his life back on track.
So moving on from that. So here we have Jack. He is another one. Aged 65. Past family history of alcohol dependence. Injured in his workplace 15 years ago and has not worked very much since. So he was started on OxyContin. And he is currently on OxyContin 40 mg bd. So 80 mg OxyContin is about 120 mg oral morphine equivalent and he is also taking 20 mg of diazepam a day. He is smoking 20 a day, first one 30 minutes after waking and he is having cannabis. He is having one joint a night to sleep so he is probably smoking about five to ten dollars of cannabis a day. He does not drink alcohol. He saw what it did to his dad. He lives with his wife Jill and their grandchild, Zoe aged five. So have we got a poll for this Jack?
Sammi: Certainly do and that is coming up on your screens now. So same as the last one.
Hester: So where do we put this Jack? So this Jack is different to Jack number one. Still the same age, still the same medical conditions, however he lives with his family and he has got a granddaughter that lives with him as well. Just waiting to see how people are going to vote.
So I agree that he is less at risk than our other Jack who is injecting, who is isolated, however he is on an oral morphine equivalent of 120 mg morphine a day and he is on a dose of benzodiazepines as well. Can we go back to his page, is that possible? Yes.
Sammi: See how long it takes.
Hester: Yes. So, he is certainly not as high risk as our first Jack was, but there is a risk here. He is using some cannabis at night. I am not that concerned about that, but what that tells me also is that he is a smoker and he has significant smoking. He has got significant nicotine dependence. He is probably mixing some cigarettes or tobacco in with his cannabis, so he is likely to have some issues with his respiratory system as well. Some chronic airways limitation. He is at risk. And so, moving on from that.
And Jill comes in. You know Jill. So this is Jack’s wife, Jill. You know them very well, you see Jack and Jill a lot and you look after their granddaughter, Zoe. She says that she is concerned about Jack and his medication use and she has read that his medication may increase his risk of overdose, and wonders what she could do. Now this is not an uncommon presentation that I see in my general practice with family members being concerned. And so once again, this is a great opportunity to be working with Jill and with Jack around the things that they can do and you can do to increase that risk. And certainly one of the questions and it is not what this webinar is about, but is to rethink his management. What would be another way to help him manage his pain? Given this risk is it time to think about decreasing that dose or changing his medication or putting some other medications in place? But also looking at psychological management and the other active forms that we know can really help people with chronic non-malignant pain and actually improve his life. Jack is a man who is really engaged and looking after his granddaughter after the death of their daughter and he really wants to be a good granddad that can race around and play with Zoe and take her to school and he is struggling with that. He gets quite sedated on the dose that he is on and has a nap in the afternoon. We do need to be thinking about the risk of sleep apnoea in someone like Jack. Are there other risk factors for sedation? Is he using any other medications that we have not had here? And really starting to look at, is there a risk here and do we think that giving Jill some naloxone, whether it be in the Prenoxad as we have now or the Nyxoid when it becomes available if we can get it, just in case something happens? And giving her the skills that she needs to look after him if something does happen.
Moving on. So, support. Look, this is really important. Something that I am surprised unfortunately many GPs are not aware of is DASAS which is the Drug and Alcohol Specialist Advisory Service. It is a 24/7 phone service which is run out of St. Vincent’s Hospital in Sydney for the whole of New South Wales. It provides advice to health professionals. And when you ring up, you get a really very, very competent intake officer who may in fact be able to answer your questions, but if not what they will do is they will take your details, take the details of the issue and you get a call back from a drug and alcohol specialist, generally within half an hour. You know, and look you know, the bottom line is if you have got someone who is acutely unwell and needs to be in the Emergency Department, send them to the Emergency Department. But if you have got someone that you are just thinking, I am a bit concerned about this or not sure, should I prescribe them some Narcan or naloxone, you know, what do I need to do? This is a great service. They are drug and alcohol experts from around the whole of New South Wales, so they may not be able to give you local information, you may ring up and get someone, if you are up in Lismore you may get someone in Sydney or if you are in Sydney, get someone who lives up in Lismore. But it is a really good service and with really knowledgeable clinicians, many of whom are GPs as well, to actually give you some advice around how to manage patients. So you know, take the numbers, be aware that there is the 1800 number, and you can look it up on the web. Just put in DASAS St Vincent’s and it will come up. There is lots of support out there, educational videos and brochures for naloxone products, so there is a nice little video to show how to do the injection and that is something that can be really useful to show your patients or to direct them to look at that at home themselves. And there are consumer resources for both the products as well. So I really encourage you to start thinking you know, is this something that my patients might be at risk of, and yes, if they are at risk then maybe think about changing the dose and helping them to do that more safely. But this is also a really fantastic harm minimisation or harm reduction process that you can put in place. It also flags really clearly to the person that there is risk. It flags really clearly to their family that this is a risk, a real risk, and can actually be part of the way you begin to have that conversation around changing perhaps some of the risky things that are happening.
I think that might be getting towards the end there.
Linda: Hester I have a question there. Some of the listeners have a little bit of discomfort about confidentiality in relation to talking with family. For example, if like the case you suggested where the wife comes, perhaps without the presence of the husband. How do you manage that?
Hester: Yes, so certainly you are absolutely right, that if Jill came in and said look I am worried about my husband, if Jack is not there then I would be very clearly saying, look Jill you know I cannot discuss Jack’s issues without him being here, but let us talk about what your concerns are. And then let us get Jack back in to have a talk together. Because nobody wants Jack to come to harm, so you are absolutely right you are not going to be disclosing to Jill all the ins and outs of Jack’s treatment that she may not know, but it is absolutely an opportunity to support a family member who is concerned and then to set up another appointment with the two of them. And it may well be that you do need to send Jill out of the room and have a chat to Jack and say look, what are you concerned about? You know, do you, and really working with them as a family is really important. I think sometimes, I absolutely understand the confidentiality stuff, however families and carers are really important in our patients’ lives and they are a big part of their community. And so it is finding a way to have that conversation and make sure that Jack is happy for that conversation to happen with his wife in the room and putting a plan together for them which is going to keep him safe.
Linda: Thanks a lot.
Hester: Look there are a heap of resources on this page. So, I would really encourage you. I am hoping I am understanding, that these are ones that are going to be sent out so that people can actually have a look at them.
Sammi: That is correct. They will be sent to everybody and all these links will be included so you can go and have a look at them.
Hester: Yes. Yes, so in terms of the ACI, the first one, a really brilliant website with the painbytes website as well, and it has got a stepped approach, you know, so if there is issue, then these are the issues you need to worry about. There is a whole heap of resources for practitioners and for patients. Prescription shopping information line, do not forget that in New South Wales, it is as good as it gets at the moment. It is limited but if you are concerned about somebody’s use and you are think they might be accessing from somewhere else, it is a really good idea to give them a call and find out if that is an issue under the prescription shopping program. The Pharmaceutical Regulatory Unit, fabulous pharmacists that work for New South Wales Health. There is lots of information on their pages as well. And they are happy to have conversations with GPs. We have new guidelines on helping people who need to go on methadone and buprenorphine treatment for opioid use disorder, and there are abbreviated guidelines which are fantastic for us in general practice. There is some take home naloxone more information, there is some research there from NDARC led by Suzi Nielson looking at the research on pharmaceutical opioids and the benefits and the risks. The Brief Pain Inventory, the PEG score, the Opioid Risk Tool. They are useful ones, particularly the Brief Inventory and the PEG score, around helping to assess people’s pain and whether the treatment they are on is actually effective. People are complaining about pain and they are on pain treatment and it is not effective and you need to rethink it, not just put up with those. The Opioid Risk Tool can be one that can be a help in terms of sorting out who it is that might actually be more at risk of getting into problems with opioid use. The Clinical Opioid Withdrawal Scale, a simple clinical scale that helps you to assess if somebody is actually going into withdrawal with opioids. There is some, I think these ones down the bottom are, are they webinars that we have been involved in? Opioid use part 1 and part 2?
Sammi: Yes, they are.
Hester: Yes. And also down the bottom there, the Alcohol and Drug Foundation. Also I would add, the oh, the Community Drug Team for Families. Family Drug Support are really great if you have got someone who has a family member that they are really worried about. They can give lots of support to that family member. And PBS Authorities, understanding the legal obligations that we have in terms of our prescribing. There is PBS authority, but there are also state authorities for prescribing S8 drugs and drugs of dependence. And all that information is available on the PRU site.
Linda, you have been very, very quiet tonight.
Linda: I have been typing away. Answering people’s questions. Can I just raise a couple of questions that people have asked?
Hester: Yes, absolutely.
Linda: About diversion of naloxone. Is there any value?
Hester: No, nobody diverts naloxone. It has absolutely no potential to be a drug that people want to take. Absolutely none. Absolutely none. The worst that will happen is that if you have someone who is unconscious and you think, “oh my goodness is this an opioid overdose?” and you give them some naloxone and it is not due to opioids, it might wake them up, it is not going to hurt them. It is really a very, very safe drug and it will not be diverted. And look, if people want to take it and keep it in their bag just in case someone else overdoses, you know one of the things that we want the naloxone to be out there so that people who are at risk, you know, it can actually be used to save their life.
Linda: One of the other questions that someone asked was, the comment was that naloxone should be like EpiPen. Is there any? Naloxone, Narcan for us, is that on our free list?
Hester: It is in Doctor’s Bag, the Narcan.
Linda: And one of the other people commented that is a conversation that I had with you before, is, as a GP I have never actually administered Narcan in my practice and I would think that most GPs have not. But that does not stop us taking on board this webinar and thinking about being able to raise people’s consciousness for its use in the community.
Hester: Oh, look absolutely. And look you know, it is an intramuscular injection and while we might not have used naloxone in our setting and look, I have in my life working with people at high risk and on the streets of Kings Cross, doing outreach at the injecting centre, I have used it. But it is an intramuscular injection. It is simple, simple. You know, and so you know, I am hoping that there are not many GPs that have used naloxone in their practice, but it really is a very simple thing to give as an intramuscular injection and to teach people how to do it.
Linda: Fabulous. Thank you, Hester. I think we would all agree that we could say that our learning objectives which were, being aware of the current schedule of naloxone, identifying patients who may benefit from prescribed naloxone, discussing the role of GPs in prescribing naloxone and the required counselling and explaining how to administer intramuscular and intranasal naloxone products have been met. Thank you.
Sammi: That is great, thank you Linda and Hester for joining us tonight and also to everybody online. We really hope you have enjoyed the session and enjoy the rest of your night.