Sammi:
Good evening everybody and welcome to this evening’s Guide to Naloxone for General Practitioners webinar. We are joined by our presenter this evening, Dr Hester Wilson and our facilitator, Dr Tim Senior, and my name is Samantha and I will be your host.
Before we start I would like to make an 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.
Okay, I would like to formally introduce our presenter this evening now, Dr Hester Wilson. Hester has a Masters Degree in Mental Health and 25 years’ experience working in the primary healthcare setting. She 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.
And our facilitator, Dr Tim Senior. Tim is a GP at Tharawal Aboriginal Corporation in South Western Sydney. He is also an RACGP Medical Advisor for the National Faculty of Aboriginal and Torres Strait Islander Health, as well as a lecturer in General Practice and Indigenous Health at UWS. So, thank you for joining us and welcome Hester and Tim. I am going to hand over to Tim now who is going to take us through our learning outcomes for this evening and then we will hand over to Hester to get started with the presentation.
Tim:
Thank you very much, Sammi. Good evening everyone. I hope you are all staying well. These are our learning outcomes. So this is what we are hoping to achieve over the next hour or so. So by the end of this activity, we should be able to discuss the value of naloxone for patients at risk of witnessing or experiencing opioid overdose. Be aware of the epidemiology of opioid overdose mortality in Australia and the role of GPs in reducing overdose harm. Be aware of the take home naloxone programs in New South Wales and how GPs can encourage patients at risk of witnessing or experiencing opioid overdose to obtain a free supply of naloxone and be able to recount the elements of an effective naloxone education intervention for relevant patients including opioid overdose prevention, identification and emergency response, including administration of naloxone. So Hester over to you. That is a lot to get through in one evening.
Hester:
Thanks, Tim. Hi everybody. Look, it is great to have so many people online to discuss this really important issue. I wanted to first of all start with Julie, aged 50 who has chronic non-malignant pain due to a previous motor vehicle accident and has pain in her neck and lower back. She is a smoker. She has chronic airways limitation, anxiety and insomnia and she is slightly overweight. She is on oxycodone 40 mg bd, mirtazapine 60 mg. The question is, is Julie at risk of overdose? And I will get Sammi to launch a poll. Is this Julie at risk of overdose? Just one question there, just tick yes, no, unsure. Have a go everybody.
Sammi:
And we will just give that a couple of seconds until we have got about 70% of people voted and then I will share those results so you can all see what our thoughts on Julie are. Perfect, a couple more seconds and I will close that one off there and I will share that up for you to see. So there you go Hester, 80% of people thought yes, Julie is at risk of overdose.
Hester:
Yes. Yes, thank you guys. So 80% yes, 10% no and 10% unsure. Really good to get a bit of a sense of where you guys are at. So Tim, I am going to ask you, is Julie at risk of overdose? What do you think and why?
Tim:
Yes, absolutely it is a really good question and we have not discussed this before tonight. So my automatic reaction is, she is on oxycodone 40 mg twice a day so she must be by definition of having oxycodone. But there is not particularly other features in there that would make me, that would ring alarm bells for me. Mirtazapine perhaps with some sedation and there may be an element of additive effect there so that the oxycodone she may be at higher risk. So my gut instinct says yes, but I cannot put my finger on exactly what features of that would be the case. Where there might be other patients where there would be clearer risk factors for overdose.
Hester:
Yes. I mean I guess the thing that I would add is that she is a smoker and does have some airways limitations. So that does increase her risk and perhaps you know, the BMI of 32 not terribly high but once again, being overweight or obese does increase it as well. And oxycodone is actually an oral morphine equivalent of 120 mg. So you are absolutely right Tim, on that dose there is an increased risk. But it is also understandable that there were some people saying, well I am not sure or I do not think so, because it is not, this Julie yes, she is at risk. But she is not you know, standing out like a sore thumb. Now certainly I was involved in a Corona’s case with a patient very similar to this who actually did overdose. Part of the reason that she died, she was in the Corona’s Court, part of the reason that that happened was because she had a significant respiratory infection and pneumonia and that was enough to actually, and she was younger than this Julie. But it is something to really think about and we will be talking this through throughout the session, around really thinking about are the patients that we are prescribing and prescribing medicines for good reasons. You know, does that put them at risk and do we need to consider naloxone? Thanks for that Tim, putting you on the spot there. Okay.
Tim:
I love it.
Hester:
Okay. I am not able to move the page. Oh, here we go. Now it is working. Going back. Alright. Do not put me in charge of technical things I think Sammi is the take-home message. But the bottom line is opioid overdose in Australia is common, unfortunately common. And in actual fact, in Australia, we have three deaths a day. Now that is nothing in comparison to the US which has epidemic proportions of issues with this, but even in Australia, three people die every day. And that is more people dying of opioid overdose than in traffic accidents. And it is the most common cause of accidental, second most common cause of accidental poisoning in 25 to 44 year olds. Higher in regional Australia. More often in men. And people of indigenous background are of higher risk as well. So it is a real issue and the important thing as well with this is that it is particular groups that we are seeing. People using high doses of pharmaceutical opioids and what we know is that it is dose dependent, so your risk goes up. Yes? So, anywhere from 50 oral morphine equivalents, 100 morphine equivalents, it goes up and gets much higher as it goes up. Using long acting opioids. Anybody who has recently overdosed. Anybody who is injecting or using other sedatives, alcohol, extra medical pharmaceutical opioids or other sedating pharmaceuticals. And benzodiazepines are really important. Other physical comorbidities. Do not forget people that have sleep apnoea, respiratory issues, anything that is going to compromise their respiratory condition. People on methadone and buprenorphine programs. Not so much buprenorphine, buprenorphine is much safer than methadone but I would just be flagging that with anybody who is using opioids you really do need to consider not only the risk of their opioids but their overall risk depending on them as an individual.
The elderly are at increased risk. We know that as people get older, that their ability to metabolise and have a managed metabolism actually changes and they are at increased risk.
People leaving prison or drug treatment. So this is a group of people who may well have been using opioids for some period of time and have some tolerance. They do not realise that they have lost that tolerance and they start injecting, using again and they have an overdose. So a high risk time for people who have a history of injecting drug use. And as I said before, indigenous people, Aboriginal people, have a higher risk.
And the majority are due to pharmaceutical opioids only. Now there is no doubt that heroin injected, faster uptake, high risk of overdose. But the fact is that the majority of people who are dying from opioid overdoses are from pharmaceutical opioids. Morphine, codeine and oxycodone and as you can see, more than heroin. And also, the newer one, the fentanyl, the tramadol, there is not much information on tapentadol yet, but I am sure it is going to be in there somewhere. And also methadone. So the take-home message here is that opioids are a great drug. They work really well, they are fantastic for the treatment of acute pain. They are fantastic for the treatment of opioid dependency, but they are risky and we do need to consider the risk of every person that we are seeing when we are prescribing these medications, particularly in the high-dose ones, fentanyl and methadone, but also in combination with other sedating medications and other sedating substances for example alcohol.
And here we are just looking at the overall. Looking from 2000 to 2015, flagging just before 2000 was a period of time where there was a peak, and that peak was particularly heroin and other opioids as well at that time. And at that time, there was a push to open medically supervised injecting centres because of the opioid overdose crisis that happened in the late 1990s. But what we can see now is that it is rising again. And it is rising, there is a bit of heroin there but it is rising because of the natural and semi-synthetic opioids, the prescribed opioids that we as prescribers prescribe to our patients.
Once again, we are just seeing here the mid-blue exclusively pharmaceutical opioids. It is the biggest group. There is a group down the bottom that are just illicit, so just heroin and also a combination of the two. But the biggest group are the prescribed pharmaceutical opioids.
And once again, contributing with other drugs. So that previous page was just opioids. This is people at risk of death because they are using other sedating medicines. And I would flag once again what you see here is that top line with that dash-dot, is benzodiazepines. Diazepam particularly, it is the most commonly prescribed. Also alprazolam, Oxazepam, all of them really increase the risk as does alcohol, the sedating antidepressants, the sedating antipsychotics and paracetamol.
Okay. And the other interesting thing, back in 1999 when we had this overdose epidemic of deaths from opioids, it was likely to be a death for a young person with morphine, heroin and benzodiazepines, and they tended to be injectors. What we are seeing now, is a person who is more likely to be middle aged, living outside a capital city, prescribed drugs such as benzodiazepine and oxycodone and the death is most likely to be accidental. And they are most likely not to be injecting.
We also know that 4.8% of Australians use pharmaceuticals for what we call non-medical purposes and that is a bit of a vexed term I think. You know, what does non-medical purposes mean? It might be that they are getting them from friends, it might be that they are actually using them for issues that they are having other than what they were prescribed for. But it is a tricky, blurry area and it does not mean that somebody is not at risk of overdose if they are using the medicines as directed. And it is difficult, as with talking about overdose deaths in terms of the pharmaceutical drugs involved in those deaths, we do not know from that data which of those people are using medicines as prescribed, which are using extras, who are getting them from friends, borrowing, buying them on the streets. But we do know that it is the pharmaceutical medicines that we prescribe that are causing these issues.
What we know also is that if you can reverse an opioid overdose, you save people’s lives and this is something that we see really clearly at the injecting centres and back in the early 2000s I worked at a Sydney medically supervised injecting centre. It was a fascinating thing as a practitioner to watch people. They would come in, they would inject their opioids, they would start to become sedated and go on the nod as they would say, and you could see the respiratory rate would go down. You would put an oximeter on them and as their oximeter went down, as their respiratory rate went down, give them a little bit of Narcan, just wake them up enough so that they did not overdose. It was an extraordinary thing to watch. And what we know very clearly is that naloxone saves people’s lives. It has been much more widely used in the US and the figures in the US, they reckon that probably one in about 220 doses of naloxone save a life. You know, so it is not an awful lot of treatment to save a life. And in Australia, we know that around about 20% to 30% of the naloxone that is given out to people for the treatment of overdose, is actually used. And it is an incredible thing to be talking to someone and I have done this with patients that I see in the drug and alcohol clinic, who come back and say “I used the naloxone that I was given and I was able to save my mate’s life” and they will also have stories of in the past how they have had people that they care about overdose and die. So this extraordinary ability and this sense that they have that they have been able to save someone’s life, but also the fact that they have. You know, this is fantastic that they have been able to do that and save somebody’s life.
And it has been an ongoing strategy as part of the National Drug Strategy and it is both S3 so it is over the counter pharmacy only, and it is S4 on prescription. And the idea behind that is to make it as accessible as possible. The other important part of the take home naloxone is that it is given with the intention that someone will give it to the person that needs it. So you are getting a medicine and you might dispense it to a person that is high risk, but you know that in the event of an overdose, a carer, a friend is going to give it or that the person you have given to is going to give it to someone else who is having an overdose. And one of the things that people have worried about in the past is look, if people are injecting or they are using opioids you know, for non-medical reasons, if we give them naloxone they are going to use more. Their use is going to be more dangerous. And in fact, that is not the case. The reality is that people who are using these medicines and the majority of these are accidental overdoses, they are not intentional. It is not their intention to become hypoxic, to have a respiratory arrest and a cardiac arrest and die. So they do not take more risks, it is a very safe treatment. And if you give it and somebody has overdosed or is sleeping or something else is happening, then naloxone does not cause any harm in itself. You do need to make sure that the other issue is causing the presentation is treated, and we will come back to that, but the naloxone itself is really low in risk.
New South Wales Health has done some great work increasing naloxone access, so thank you New South Wales Health. There are certain health workers other than doctors and pharmacists who can supply take-home naloxone and it can be targeting NSP programs and drug treatment patients as well. So the needle and syringe programs may be in the context of a drug treatment service or may be in a community setting. And so that really increases access. There has been a priority for those really high risk people as I mentioned before, people leaving prison, come out of prison quite often, will go back to using and use high amounts because they do not realise that they are not tolerant anymore and they are at high risk of overdose. So quite a lot of work around making sure that they have access. And supplying this naloxone at no cost to these disadvantaged groups. And the other thing that is important is that, in terms of the way that we can get it in New South Wales, New South Wales is also involved in a pharmacy program as is South Australia and Western Australia, that supplies naloxone at no cost to high risk groups, and also it is available on the PBS. So it is a schedule 4 PBS. You can write a script and people that have a healthcare card or Close the Gap, can get it at the $6.40 or with Close the Gap, for free. And that is for our indigenous patients. So really working very hard at ensuring that it is available and people can access it.
So now I just want to quickly look at working with people who are at risk of overdose. So, once again, this is the take-home naloxone program. The New South Wales Health program which I have mentioned before, and also running through needle and syringe programs and alcohol and other drug programs, and it is free. And the important part of this is doing a very brief intervention for those people accessing that medicine for their carers, for their families, for their communities and groups of people that may be using drugs together so that people can actually intervene. When we first started doing this, we started doing this very long kind of teaching session, and what we realised was it did not need to be long. It was a brief intervention and the packs that we give out actually have the information of how to assess and how to do some CPR, but the most important thing is, if you are concerned, dial triple zero. Do that, do not be afraid about calling for help. Give the injection, but dial triple zero anyway so that the person can be assessed by the ambulance. And certainly, this program has been operating since 2018 and has expanded. It is now offered in needle and syringe programs and drug and alcohol services as we said.
I mentioned the Australian Government’s PBS subsidised naloxone pilot and a number of community pharmacies are involved in this. And community pharmacies can continue to sign up to the pilot, so if you are in a town where one of your pharmacies is not involved in this pilot, you as a prescriber can advocate and say come on, you know certainly quite often I am talking to the pharmacies that I work quite closely with. You know, why don’t you get involved in this pilot, why don’t you ensure that we can ensure access for our most vulnerable and at risk people. And as I said before, it is for people who are at risk of witnessing or experiencing an overdose, can ask for or be supplied for free at participating pharmacies. The pharmacist can once again do a brief intervention to counsel the patient or the carer, friend, other community member who may be witnessing overdoses, how to do this, what to do if there is an overdose. And as I said before, if you are in an area where there is not a participating pharmacy or NSP, you know, have a chat to your pharmacist and encourage them to be part of it, but also for you as GPs to prescribe naloxone for your patients.
This is something that I guess when I talk to some of my colleagues, they go, oh I am not sure about whether I should do this for my patient? Would they want me to do it? It feels wrong to be doing this. The latest data on this is actually that the majority of patients are very open to being prescribed this. And it really needs to be part of that comprehensive assessment around you know, so do you need this medication? You know, are opioids appropriate? And there are times when it is, but it may be because of the person’s other issues, there is a risk there. And so flagging that and putting the family and the patient in control of actually managing that so they can ensure that there is not an overdose is incredibly important.
I was involved in another Corona’s case which was a group of four people who had overdosed from opioids, and a number were opioids and benzodiazepines. But the terrible thing about it was for three out of the four people, there were people in the house when they overdosed who did not realise that they were overdosing. So there is a really important education message there around what does overdose look like? And letting our patients know and letting their families know. You are on this medication, you need to be on this medication, however we do want to give you this. It is like the EpiPen of opioid overdose. You know, in case of emergency. If this person does have an overdose, this is what they will look like and this is what you can do and please call the ambulance. It is a lifesaving, low risk measure that we really do need to consider in our patients when we prescribe any at risk medication.
The YourRoom website. YourRoom website, let me just say is a brilliant website. It has lots of information around all kinds of things drug and alcohol, and I really encourage you to go and take a look. There is a really good alcohol metre on there. There is lots of stuff that you can look at. But this particular stuff for the page here is around naloxone. And it links to needle and syringe programs and help for community members. And also the list of participating pharmacies who are prescribing naloxone free. And one of the questions that I ask, so this is New South Wales, ACT, there may be some of you dialling in from ACT, there is one community pharmacy in Queanbeyan which is not that far from Canberra.
So, from my point of view as I was saying before, there is a really important role for GPs in this area. Yes, there are the New South Wales free naloxone programs targeting those groups, so prisons, needle and syringe programs, drug treatment services. But for other people who are at risk, and we know they are at risk, GPs and pharmacies are a more appropriate point. And for some of my patients, working in the general practice setting, it may be that a needle and syringe program or drug treatment service is a place for them to access naloxone. But for many of them, they would not be seen dead there. They are not injectors, they do not have drug and alcohol issues, but they do have risk because of their medications. And so you know, pharmacies are a more appropriate access point, so either through the free pharmacy or via a script. They are S3 and you can buy it but it is around about $60, so it is quite expensive. But that is another way that people can access it.
I think the other thing that can be useful too is part of our assessment of risk which is something that we need to do with our patients who are on opioids and other high risk medications, because of the risk of overdose is, as we do that risk assessment the naloxone can be part of the conversation around the need to actually change. The need to actually decrease the dose because of the risk. And it can be you know, for example when we are thinking about decreasing risk we may look at staged supply and supervised dosing. Naloxone provision is part of that. But it also can be a really good talking point around “with the doses that you are on with your risks, I am so concerned about overdose that I am at the point where I am going to start prescribing you emergency management to prevent overdose. I am going to do this but given this amount of risk, I think it is a really great idea if you think about working with me to cut down this dose, to look at other ways that we can manage your condition if that is appropriate.”
Supporting families is another really important thing and I do see this in the general practice setting and it is an important measure because if a person is overdosing, they cannot give the naloxone themselves, so it does take education of families. Really, really important. And as we said before, promoting those free access options for patients who are low waged or cannot afford the prescription.
So, which patients could benefit? I mean, the simple answer is anybody that is at risk of overdose. Patients using prescription opioid medicines, particularly with the bigger doses, and that is when you look at the data from 50 oral morphine equivalents. So that is a dose of around about 35 oxycodone. 35 mg of oxycodone a day. You know, from 50 oral morphine equivalents a day, the risk increases. Above 100 oral morphine equivalents, it is higher. As it goes up it is even higher. And really you know, those times in the past where doses of opioids were taken up and up and up to help people manage their chronic non-cancer pain, really we know that the risks versus benefit just does not weigh up, and I really strongly encourage any of you who may have some patients who are on those higher doses to really consider first of all, you know getting some naloxone for them, teaching them and their families how to use it, but really look at starting to bring those doses down and look at other options to manage their pain. And it certainly is different for people who you are managing end of life care, for palliative care, but once again, really considering the risk versus the benefit any time we are prescribing opioids in people. So, anybody that has previously overdosed. So a really important part of your risk assessment is to be looking at, well have you ever had times where you have overdosed? Now how would somebody know? It could be that you are going to be talking to the partner. Are there times when they have snored really loudly, been hard to rouse? Where there might have been a level of overdose which was not actually fatal, but led to hypoxia. And that is another really important outcome of overdose for the people who do not die from their overdose, is having periods of hypoxia that actually cause cognitive impairment on an ongoing basis because of levels of hypoxia. It is really important to think about that. And to talk with patients and to raise those concerns with not only the patient, but the family member. And involve the family member in those conversations.
Tim:
We have got a good question being asked by a few people actually about residential care facilities and nursing homes, and whether it could be on the nurse initiated lists in residential aged care?
Hester:
Yes, look certainly residential aged care is outside of my expertise I have to say, but certainly we know the elderly are at risk. We know that there is a high percentage of elderly with chronic pain who will be on opioids. You know, I tend to be moving more towards the lower risk ones like the buprenorphine, the Norspan and Temgesic options, but they certainly are at increased risk and they may well have polypharmacy with other sedating medications. So once again, I think it is a really good question to be thinking through the patients that you are seeing in aged care facilities. You know, what is their risk, is there a risk? And you know, looking at that from a services perspective. Do the nurses there know how to diagnose an overdose, and how to manage that? And you know, it is something that you can prescribe and that nurses can give. It is certainly as I say, I think it would be good for you as the prescribers to have conversations with the nursing homes that you are involved with and really look at that across the board, across the service, with some training. But really, really good question and I think really, really important.
Tim:
Because it is on the PBS, as prescribers we could actually do a PBS prescription with education for the nurses about the situation in which to use it.
Hester:
Yes. Absolutely. Absolutely. So, which patients could benefit? And once again, are they going to be the first responder, are they going to be the person who is going to be witnessing the overdose, or the person at risk of overdose? You know, so once again, there are some really important conversations there around limiting risk. If you are prescribing opioids, talk to people about their use of other sedating medicines, other sedating drugs, particularly alcohol and the risk that that can place. You know, really in terms of their other comorbidities, the risk that that can place them at and really working to improve those other comorbidities. Stopping smoking, losing weight, those kinds of things that can improve that. And also, that as a witness or a first responder, that they are offering a first aid, physical first aid, the EpiPen of overdose, and so they need to understand what an overdose looks like. So start the conversation about overdose risk and just be aware that it is really important to flag that this is a medical risk, this is not because they are an addict or a bad person or anything like that, it is actually just about managing risk, because we want them to be well and this medication is safe, it is available, it is cheap. You know, there is no down side and if you never have to use it, that is fantastic. You just do need to keep an eye on the expiry date and make sure that you get a new script when it does expire if you have it for that long, if you do not need to use it. And you know, if they do use it, you know, call the ambulance but also follow up with you. You know, let us have a conversation about how it went, what happened, what went wrong, how did you do it, fantastic that you were able to respond, that your carer was able to respond. Let us give you another prescription and let us look at how we can decrease the risk of it happening again.
The use of non-stigmatising language is incredibly important. We know that this is an area of medicine where people do feel very stigmatised. Now for someone who is an injecting drug user, absolutely we know that that is the case, but it is also for people that are using opioids, prescribed opioids and they are increasingly having the experience of feeling stigmatised. And so it is really important to be aware of that difficulty, that sensitivity that many people have and to be careful around the language.
Just moving to this. I really like this document that really looks at better language to use. And certainly some of the language that we look at, you know instead of the ones that are not so good to use, are some that are actually being used medically. And so I get that, but they do have a certain, they can have a certain kind of feel, a certain kind of stigma or judgement you know, so really think about how the language you use can actually help you to have conversations that are really to the benefit of the patient and their family and really kind of help them to actually understand and take on what you are saying. So you know, things like “substance use” or “non-prescribed use” as compared to “problem use” or “non-compliant use.” Things like you know, “suffering from addiction”, “has a drug habit” as compared to “a person experiencing drug dependence.” “Lacks insight”, “in denial”, “resistant”, “unmotivated” as compared to “a person who disagrees.” Now sometimes it can feel like you might be tripping over your feet around what is the language to use, but it is just really thinking, what is this really open, non-judgemental language that can actually help you get your message across, which after all is a message around I am your doctor, I want you to be well, I want you to have the best quality life. We do not want to have any disasters or anything go wrong. We do not want anybody to have hypoxia and brain damage or death. We really, really want you know, you to be as well as you can, and using that language. You know, the choice of language is important and there is very good evidence that it does affect people using medicines in the right way, accessing treatment, maintaining treatment, and health outcomes and wellbeing outcomes as well.
Okay. So as I discovered in the Corona’s case. These family members had their family member die, their loved one die in the same house, sometimes in the same bed, because they did not know about overdose. So there is a really important role for us as practitioners to talk to our patients and their families about the risk of overdose and what overdose looks like. And really kind of turning it around to this is a positive thing that we are doing. We are prescribing this, it is the EpiPen of overdose, to ensure that you remain well. It is about prevention. Yes? So it is really looking at it as a treatment that they can do to prevent and recognise an overdose. And really working with them around what would an overdose look like? The person is unarousable. The person is blue. The person is not breathing or breathing very slowly or shallowly. The person is snoring very deeply. You know, so recognising that. And teaching them how to administer the naloxone. So we will go through the two types, which are muscular and intranasal.
Okay so there are three products available. The one in the middle, naloxone ampoules. We would have all been aware of in the medical setting. The ones where you have got to break the top and then you know, get the naloxone liquid out. Not the best form. You know, okay for clinical settings but much better to use one that is either the pre-filled or the intranasal. So, Prenoxad and intranasal are the ones that we would be saying are appropriate. You know, you do need to give an IM injection. Some people are not that comfortable around needles, but it works really well and it is packed with the needle, the syringe and how to use it. The intranasal Nyxoid is also designed specifically for use in the community for opioid overdose. Very easy to administer. Sorry, it is PBS listed, that is a bit out of date. My apologies I missed that, it is now PBD listed and has been used over the last year very successfully.
Just looking at how you use them. Okay, so Prenoxad has the issue of handling sharps. So it does come in a specific box and so you can put the sharp back in there and there are five doses, so you can re-dose after no response after two to three minutes. Thinking about you need to say the best locations. You can give it through clothes, you do not need to undress, but you know, legs, buttocks, upper arms. And the product as I said before has clear, simple pictorial instructions.
Nyxoid has two devices with one spray in each, and one spray is one dose. Do not do a test because otherwise you know, that certainly has happened where people kind of do a little test and then they have used it up. And you can re-dose with the second dose if no response after two to three minutes. And once again, it is the same simple pictorial instructions. Now I have to say that on the whole, my patients prefer the Nyxoid just because it is super easy. You know when you are in that situation where you are panicking and it is a very good, very easy to use application, just up the nostril. Really great.
Okay. So now I wanted to come to Jack. So let us look at Jack. Aged 56. Past family history of alcohol dependence. Injured in a workplace accident 15 years ago and has only worked occasionally since. He was started on OxyContin for his hip pain and he moved to injecting oxycodone as he found this helped more, and he is right. When you inject oxycodone, you get a bigger amount of drug. With the change in oxycodone formulation which happened, where it was no longer easy to dissolve and inject the oxycodone, he started accessing heroin and fentanyl to inject. Living alone in metro Sydney since his marriage broke down, not seeing his family and has some drug offenses and recently came out of jail. He has had a recent admission to ED after being found slumped unconscious on the street. Now, Sammi if we can go to the poll.
Sammi:
We certainly can. I am sending that off now. So that will pop up.
Hester:
Beautiful. So exactly the same as the last one. Is he at risk of overdose? Yes, no, unsure.
Sammi:
And we have responses coming through nice and quickly on this one. And so far, everybody is saying the same thing. So I will give it a couple more seconds until we have got about 70% of people voted. And then I will share that with you. Alright, the clicks are slowly stopping coming through. So I will give it another few seconds. Alrighty, let us close that off. And I will share that up there now.
Hester:
Oh, somebody said no. Somebody is a rebel. Tim, I am going to ask you, what do you think?
Tim:
I thought it might come to me. Definitely yes. Jack is at risk. He has all sorts of red flags in here. He is on oxycodone, I think 40 mg twice a day, so that is a significant dose as well as diazepam.
Hester:
No. Are you on the same page?
Tim:
Oh sorry. No it does not say that. I jumped on. Anyway, still yes because he is accessing heroin and fentanyl to inject, so he is diverting multiple opiates. So he is at high risk. The previous overdose also puts him at high risk and he has been in jail which also puts him at high risk. So, I am worried about this gentleman.
Hester:
Yes, absolutely. And he has also had a recent admission after being found unconscious, so probably an overdose in the street. Heroin is a high risk opioid for overdose. As I said before, when you inject it, it is quick onset, quick through the blood brain barrier and very quickly peaks. Fentanyl is a very potent opioid and when you inject it, it is even more potent. So you know, he lives alone. He has got the full gamut of things. The only thing we have not got in here probably because I have not put it in, but is alcohol, benzodiazepines, sedating antidepressants and antipsychotics that once again would be I think the full hand. And we do not really talk about his medical history, so he is probably a smoker as well with some respiratory limitations as well that would put him at risk.
Let us move to Jack number 2. Jack aged 56. So he has a past family history of alcohol dependence. And he also was injured in a workplace accident 15 years ago and has only worked occasionally since. He started on oxycodone for his chronic hip pain, and yes, Tim he is the one who is on oxycodone 40 mg bd, and also on diazepam 10 mg bd. He is a smoker, 20 a day, first one 30 minutes after waking so he has got a significant nicotine dependency there. And cannabis. He is having a joint at night to sleep. He does not drink alcohol because he saw what it did to his dad. He lives with his wife Jill and his granddaughter Zoe aged five. Now we are going to go to a poll again.
Sammi:
We certainly are and that will be popping up hopefully now.
Hester:
Is Jack at risk of overdose?
Sammi:
Perfect. Lots of answers coming through quickly here again. We have got 70 people voted already so we will give it a couple more seconds for those that have not yet clicked. And we have got a few more on this one that are maybe not so sure. So I am going to close off that polling there and I will share that up with you now.
Hester:
Okay. So 86% yes, 6% no, 8% unsure. Fantastic. So Tim, what is your thought about this Jack?
Tim:
Interesting. So this Jack, and I am checking my patient records surname, because I get confused between my Jacks who have had workplace accidents 15 years ago and are on oxycodone. But, yes he is also at risk I think because of his significant oxycodone dose and also on diazepam, smoking tobacco and cannabis. Again, I would not be surprised if he had other co-existing conditions as well. If I opened the right notes, I may be able to see that as well. So, yes, I am worried about Jack 2.
Hester:
Yes, so he is on 40 mg bd of oxycodone which is an oral morphine equivalent of 120 mg. So certainly from the point of view of that morphine dose, or oxycodone dose, he is at increased risk. So, you know, the answer that I would say to this is yes. And I would want to be having first of all, thinking with Jack, is that an appropriate dose? It is a little high, and certainly in the past we would not have thought twice about it, but really at that dose we do know that there is increased risk. And thinking about the diazepam as part of that. It is great that he is not drinking alcohol, but just really looking at first of all, do we need to rethink his management strategies? Are there other things we can put in place? Non-opioid pharmacological options, but also the non-pharmacological altogether. You know, physiotherapy, stretching, walking, talking therapies, all those things that can be really terrific for chronic hip pain. And for him, having that conversation around naloxone. So naloxone for him would be a really great idea. And I really want you to seriously think about how you might talk to the Jacks that you have in your practice, I have Jacks as well, around how you might decrease that risk. You certainly do need to think about how he might be taking his oxycodone, you know, is he losing scripts? Is he taking more than he is prescribed? Is he coming in early for additional scripts? Is he injecting his doses? Is he on other medications that are sedating other than these? Are there other risk factors that are not in place here? Or is he someone that is absolutely taking one tablet twice a day as you have prescribed? But you do need to do that risk assessment. And talk to him and his wife around whether he might be actually becoming hypoxic on this. What is happening? Does he spend a lot of time just snoozing on the couch and not doing very much with his life, which is not going to be great for his hip pain. You know, really thinking about what his life is actually like and what his experience of being on this oxycodone is actually like. And considering naloxone for him.
Moving to Jill. You know, Jill is the wife of Jack and you routinely see them with Zoe their granddaughter. She is concerned about Jack and his medication use. She has read that his medication may increase his risk of overdose and wonders what she can do. So this is not an uncommon thing, and as I have said before, it is really great to include family members or carers, people that are in the community who may witness an overdose. And really talking to her about his risk. I would also be wanting to assess her risk as well. You know, so is she on medications? What is her history? Is she a drinker? You know, are they sharing medications which happens quite often. But really, you know how sedated is he? And is he snoring or is there sleep apnoea? Are there other risk factors for sedation? What is his risk? And I would be saying, “Jill it is so fantastic that you are concerned. We really do know that these medications are a risk. We are reassessing the dose. We are going to do it really gently and carefully together collaboratively. I am not going to stop your dose straight away, but we really need to look at how we can manage your hip pain and ensure that you have the best possible life, and part of that is decreasing the risk of harm.” And in terms of this, you know, if there are, is he is clearly sedated and snoring and his breathing is dropping then that is a really good flag for we need to get this dose down straight away. But really asking her to look for those risks and if she is worried that she can use the naloxone. And explaining to her how to use it. You know the Nyxoid, the intranasal is fantastic. Or if she would prefer to do injections. You know, either of those are fantastic. But we really want to work with them as a family. They are caring for a five year old, they need to make sure that they remain well and ensure that there is not an overdose death as a result of his medication. So I really want you guys to think about how you might have those conversations and how this is a really important part of what you can do to assist your patients, whether it is a Jack who is taking his medications as prescribed or whether it is a Jack whose life is much more complicated and he is much more vulnerable, and much more at risk. Really you know, for that other Jack I would be really looking at I really want him to actually get into opioid treatment for his very high risk opioid use. He would do very well on a buprenorphine, either the sublingual buprenorphine or the depot injectable buprenorphine, long-acting depot injectable buprenorphine, or even methadone would be really good options. So, if you do see Jack number 1, you may not want to manage the way he is presenting at the moment, but I would really encourage you to support him to get into opioid treatment and for you as a GP to continue to support him with his other healthcare needs.
Tim:
And would you be asking Jack for permission to talk to Jill about it?
Hester:
Of course. Of course, Tim. How would you do that?
Tim:
It is such a good question. Jack probably knows that he is snoring or is sleepy during the day, and may recognise that he is getting tired with the opiates, and so I would raise that as a possibility and say, we can have this preventative treatment that reverses the effects in case you do overdose, but we need to talk about that with the other people who will be around. Do you mind if we talk to Jill about that? Because the other thing that occurs to me for example with Jack number 1, is that I might be asking him, thinking about naloxone as the EpiPen of this, who would be the best people to get involved in having that or knowing that you have got that on you? Who might be around you should you overdose?
Hester:
Absolutely. Absolutely and he lives alone and so certainly the other thing for Jack number 1, is here in Sydney, he could go and use his drugs at the injecting centre and be cared for in that medical setting to ensure that he does not overdose. The other thing that we would always say to people who are using at risky levels and injecting, is do not inject alone. You know, make sure that somebody knows what you are doing. You know, if you are injecting with other people make sure that one person does not inject or stays straight or injects later. You know, so that you can look after each other, because none of you want to die. None of you want your mates to die. But it is a really important point, because if you are overdosing you are not going to be able to give yourself the medication. So it maybe that there is a neighbour or a friend. You know, really looking at what are those ways that you can assist Jack to decrease his risk. And as I say, core for him is actually accessing opioid replacement treatment.
Tim:
There is also a helpful comment pointing out that in Jack and Jill’s scenario, it may well be Jill who should be doing the driving rather than Jack.
Hester:
Absolutely. Absolutely. I mean, certainly it may be that you know, with your assessment with Jack that he is one of those people where this dose is working very well, there is no sedation, there is no risk. And certainly we know if people are on a stable dose of opioids, and there is no sedation, that they are safe to drive. But you certainly want to be making those assessments. And you know, certainly with Jack number 2, I would be really very diligently working towards getting that dose down and looking at other options to help him manage his chronic hip pain. Not underestimating how debilitating chronic everyday pain can be.
So Tim have you got a Jack or a Jill in your practice? And I am thinking particularly for you working in indigenous health and the increased risk there? How would it work in your setting?
Tim:
That is right. So some of these patients feel very familiar actually. We do have quite a few patients who have multiple factors and we are trying to work on reducing the number of patients who we have on long-term opiates at the moment and we are using the depot buprenorphine as well. So I think this is something we have not been doing and I think we do have patients who would be at risk, who would really benefit from having naloxone available.
Hester:
And as I was saying before, you know, when you start to have conversations with people who are in high risk communities, the terrible, emotional stories that they tell about losing people that they loved or cared about. You know, it is devastating for them. And the ability to be able to save someone’s life is absolutely fantastic. The other thing that I always flag to people is, call the ambulance. Do not worry about whether you know, if what you have done is illegal or not, the ambulance do not care, they have got an agreement with the police, the police will not be called, you will not be arrested. They just want to make sure that you and whoever is there is okay. Please call them. Even if the person responds, please call the ambulance anyway. Now naloxone comes on very quickly and can last up to about an hour but it is a short acting opioid antagonist. So you know, if somebody has taken long acting opioids, it may be that it will not last, you know, so please you have to tell them to dial triple zero, follow the instructions, let them know that you are giving the naloxone, but make sure the ambulance can come and do a check and maybe you know, your loved one needs to go or your friend needs to go to the Emergency Department for follow up. Really important. This is first aid, it is not the be all and end all. And it is also a flag that things are not going well with your treatment and you need to go back and see your doctor and reassess what is safe for you.
Tim:
I have got a question as well. Whether we can get it for our Emergency Doctor’s Bag?
Hester:
Well certainly you can get the ampoules. The ampoules of naloxone are Doctor’s Emergency Bag. That is not something I know. I reckon the Nyxoid is a great one to have in the Emergency Bag, but that is something you would need to check. It is not something that I have on the tip of my tongue. I can certainly check it and Sammi can send it out to everybody if you wish.
Tim:
And we could always purchase it I guess.
Hester:
Yes.
Tim:
But maybe not for free. And someone else was asking, is there a risk of seizure with naloxone?
Hester:
No. No, this is reversing opioids. If you give big doses of opioids and we used to do this, I remember back in the 90s when we were attending overdoses and back when I was a younger doctor, we would give 2 mg of naloxone and people would have an opioid overdose would go into a nasty precipitated withdrawal and jump off the bed and run down the road. You know, be very, very upset. And understandably because they had you know, have severe pain, they would be vomiting, they would have gut aches, and they would be sweating. You know, terrible, terrible. We used to use 2 mg. These doses are 400 mcg doses. So they are enough to take the peak off of the opioid, but they are not enough to send people into a nasty precipitated withdrawal. Opioid withdrawal itself is not unsafe, but precipitated withdrawals where you go from zero to 100 very, very quickly with opioid antagonists can make people very, very sick. But with these doses, that is not a risk.
Okay, looking at the time. We are perfectly on time. I want to do a plug for DASAS. DASAS seems to be New South Wales’s best kept secret. It is fantastic, okay? There is a Sydney metro number and a regional rural number, but if you do not have those numbers with you, you just google DASAS or even ADIS. D.A.S.A.S. or A.D.I.S. Drug and Alcohol Specialist Advisory Service. In New South Wales it is a 24/7 phone number that provides advice for us as health professionals. When you ring it, you get onto an intake person who is a nurse who takes your details, can talk about your concerns and quite often, they are very, very experienced and can give you the information that you need. But if they cannot give you the information that you need then they will say, I will take your number and there will be a drug and alcohol specialist who calls back. And generally they call back pretty quickly within 20 minutes or so when I have done it in the past. And then they are able to have in depth clinical conversations with you around management of drug and alcohol issues including naloxone, including prescribed opioids. I just want to flag that it is 24/7, but it is with drug and alcohol specialists from around New South Wales. So it might be that you are in Lismore and when you ring up you get a doctor that is working down in southern New South Wales. So they might not know what your local referral options are, but they can certainly give you all the kind of the clinical scenarios and help you to make decisions and support you in terms of options and medications and where you can go if you have got any concerns. It is a brilliant, brilliant service. I really strongly support it and certainly I have had a number of conversations with some GPs who have used the service recently, who have had really positive experiences. So, I really, really want to flag that it is a great service.
Okay. You can go and have a look at these instructional videos and resources for Prenoxad and Nyxoid. So the injectable and the intranasal. There are great resources for you as prescribers, but also for patients as well. So, I find that they can be quite useful to actually just run through the little video with my patients. So they kind of describe and show exactly what to do and how, and they are really, really useful. So they will go out in your pack that Sammi will send to you all.
A whole heap of resources here. The Pain Management Network, the ACI, there are fantastic resources there in their pain bite series looking at the brief pain inventory and the red and yellow flags for aberrant behaviours. A contract for management. There are lots of consumer videos. It is a wealth of fabulous things. Prescription shopping information line. Do not forget that in New South Wales we do not have real time prescribing yet. That will be in the future. But at the moment, if you do have concerns you can ring and then you can get your results back through the HPOS, the online Health Professionals portal. PRU is our state regulatory unit. Really helpful pharmacists that you can talk to if you have got concerns about what do I need to fill in forms, do I need to get an authority, do I need to apply for an authority for a person with chronic pain and an S8? The clinical guidelines for methadone buprenorphine. The abbreviated guidelines, about a 14 page guide for busy GPs. Connections also has some really good stuff on their take-home naloxone programs. NDARC has some great resources for pharmaceutical opioids. There is the brief pain inventory, the PEG pain, the opioid risk tool, clinical opioid withdrawal scale which is really brilliant in terms of helping people understand if they actually do have some dependency. Lots of other stuff there and some PBS authorities. Do remember that the authority is for PBS which is Federal and is different to a State authority which is to do with a drug dependent person or a person that is on a specific opioid or has been on one for a specific period of time. That is the end of the webinar. Were there any other questions that we quickly wanted to just run through, Tim?
Tim:
Two quick ones. The cost for patients if they buy it over the counter?
Hester:
Yes, it is about $60 if you get it as an S3. But if you get it on a script and you are on a healthcare card, it is about $6.40, or it is around somewhere between $30 to $40 if you do not have a healthcare card. But also remember that there are those pharmacies and other places where people can access it for free as well.
Tim:
And because it is on the PBS, then Aboriginal patients who are on Close the Gap have access it through that, too.
And final question, can GPs from other states call the DASAS number for advice?
Hester:
No, call your own. Every state and territory has its own. Best kept secret. Down in Victoria it is DACAS. Up in Queensland it is DASAS I think. But just have a look. Look on your State Government websites for your 24/7 drug and alcohol specialist advice. Every state and territory has one. So, sure you could ring us in New South Wales, but go to your own one which will have your state-specific information.
Tim:
So that will be important in terms of state legislation and things.
Hester:
Exactly.
Tim:
But I am sure they are all competitive and compete with each other.
Hester:
They just love it when people ring. It is like, oh somebody has rung us! So do ring them, they are really great. They are really approachable and keen to actually support all of us working out at general practice.
Tim:
Okay. So think there is another question which we will leave for after the webinar because we are out of time. On your screen are the learning outcomes for tonight. We hope that we have achieved all of those. Thank you very much Hester, that was a really good scoot through that. Thank you Sammi for all the organisation. I think you will all be getting an evaluation questionnaire after the close of the webinar.
Sammi:
That is great. I would just like to thank Tim and Hester again for joining us this evening, especially Hester for presenting, and also to everybody that joined us online. We really hope that you enjoyed the session and enjoy the rest of your evening.