Transcript Part 3 - Patient Education - New Mexico Pharmacists Association

Part 3: Patient Counseling and
Education – Overdose Prevention
and Naloxone Use
New Mexico Pharmacists Association &
Project ECHO
2014
Learning Objectives
• To reinforce communication skills for patient
counseling and education
• To understand the principles of harm reduction
• To learn key overdose prevention messages
for patient education
• To learn to teach patients to use Naloxone
“Extensive research has shown that no
matter how knowledgeable a clinician
might be, if he or she is not able to open
good communication with the patient, he
or she may be of no help.”
Impact of Communication in Healthcare, Institute for Healthcare
Communication, July 2011.
How do you define
communication?
Communication
is…
Author: Romith Wikimedia Commons
• The transmission of
information
between individuals
or groups by any
means.
• A 2-way process –
sending and
receiving. If a
message that is sent
is not received,
communication has
not taken place.
Why are communication
skills important in
providing patient
education?
Research indicates strong positive
relationships between a healthcare provider’s
communication skills and a client’s capacity to:
• follow through with medical
recommendations
• self-manage a chronic medical condition
• adopt preventive health behaviors
All of the client actions identified above are
relevant to overdose prevention.
Impact of Communication in Healthcare,
Institute for Healthcare Communication, July 2011.
Strategies to improve patient education
• Use simple language → avoid use of medical
terms and acronyms
• Focus on 2-3 key messages and use brief
explanations
• Use Teach-Back → verify patient’s understanding
by asking him/her to repeat back or demonstrate
information (e.g., demonstrate naloxone use)
• Solicit questions → “what questions do you
have?” vs. “do you have any questions?”
• Provide patient-friendly handouts → low-literacy
level, pictures, “how-to” instructions, etc.
In addition to a current knowledge of pharmacotherapy,
pharmacists need to have the knowledge and skills to
provide effective and accurate patient education and
counseling.
Effective, open-ended questioning and active listening
are essential skills for obtaining information from and
sharing information with patients.
A patient may learn best by hearing spoken
instructions; by seeing a diagram, picture, or model; or
by directly handling medications and administration
devices.
ASHP Guidelines on Pharmacist-Conducted Patient Education and
Counseling http://www.ashp.org/DocLibrary/BestPractices/OrgGdlPtEduc.aspx
What does the term
Harm Reduction
mean to you?
Harm Reduction is…
…a health education and treatment strategy
aimed at reducing the negative consequences of
many human behaviors without eliminating the
behavior.
Common examples of harm reduction include
wearing seat belts to reduce injury or death
from motor vehicle accidents and using condoms
to decrease the risk of sexually transmitted
infections.
Harm Reduction for opioid users includes…
…any interventions, strategies or policies designed
to reduce the negative consequences of drug use
without requiring drug use cessation.
Harm reduction is a way of working with patients to
improve their health even if they are not ready,
willing or able to stop using drugs.
Syringe exchange and providing naloxone to opioid
users to prevent overdose are great examples of
harm reduction.
A key reason to talk about harm reduction
at this training…
• Some of your clients will have a history of
current or previous substance abuse.
• Relapse is often part of recovery - knowing this
helps you to help your clients.
• Relapse ≠ failure.
• Clients with a history of opioid abuse who
relapse are at high risk of overdose.
• Providing naloxone is a harm reduction
strategy that can save a life!
Can you think of some
Overdose
prevention messages for
patients?
Case 1: Ms. J
• Ms. J was in a serious car accident and recently
was released from the hospital after 5 days
• She had a concussion, several fractured ribs, and
a dislocated shoulder, plus numerous bruises
• She comes to your pharmacy with a prescription
for Oxycodone 30 mg q4hrs PRN and
cyclobenzaprine 10mg TID PRN for pain and
muscle spasms
• What are some questions you might ask Ms. J?
• What are some overdose prevention and safety
messages you might provide to Ms. J?
• Would you offer her naloxone?
Responding to overdose:
New Mexico ranks #2 in the nation in opioid overdose
deaths. All clients using opioids (prescription pain
medication, methadone, heroin or buprenorphine)
should be taught about:
1. safe use of opioids (e.g., not mixing with alcohol
or benzodiazepines)
2. risk factors for overdose
3. recognizing signs of overdose
4. what to do in case of overdose:
a)
b)
c)
d)
calling 911
recovery position
rescue breathing
using naloxone
1. Safe Use of Opioids
• Take only the prescribed dose
• Avoid unsafe combinations of drugs:
• Opioids + alcohol
• Opioids + benzodiazepines
• Opioids + alcohol + benzodiazepines
• Alcohol + benzodiazepines
Author: Super Raptor1
Wikimedia Commons
Mixing drugs is the main cause of overdose in
New Mexico.
Alcohol can also be very dangerous when used with
many OTC drugs. Educate clients about the dangers
of mixing alcohol with other drugs or medications.
2. Risk factors for overdose - in addition to mixing
prescription opioids with other drugs or alcohol,
other risk factors for overdose include:
•
Increased opioid tolerance → patients increasing
dosages on their own without medical oversight
• Decreased opioid tolerance for patients with a
history of opioid abuse, including:
• Relapse after completion of opioid detox, inpatient
or intensive outpatient program
• Recent release from incarceration
• Any other period of either chosen or enforced
sobriety
• Overdosing when alone increases risk of fatal
overdose
3. Recognizing signs of overdose
• unconscious or unresponsive (no response to
shouting or shaking)
• pale or blue lips, face and fingertips (from lack of
oxygen)
• skin feels cold to the touch
• slow, shallow or raspy breathing or no breathing
• gurgling or snore-like sounds when a person
appears to be sleeping, especially if they have
blue or purple-tinged lips or face
• pinpoint pupils
OVERDOSE:
WHAT TO DO
In case of overdose:
• try to wake the person by calling their name,
shaking them, or causing pain by rubbing your
knuckles over their sternum (breastbone) → if
this works, get them up and walking around →
call 911
• if no response, check their breathing by
listening for breath sounds and seeing if their
chest rises
• if no breath → call 911 and begin rescue
breathing
• prepare Naloxone if you have it
Calling
911
• Overdose is a medical emergency and
patients should be strongly
encouraged to call 911, but….many
patients with a history of substance
abuse have had negative interactions
with either first responders and/or
emergency departments and are wary
of calling 911.
• Patients with a history of substance
abuse may also be on probation or
parole and be afraid of a violation if
they call 911 and police respond.
• On the next page are some tips to
pass on to patients about calling 911.
Tips for calling 911
• Stay calm and tell the 911 operator that someone is not
breathing. If multiple people are at the scene, keep the
noise down. Lots of yelling in background will definitely
send the police!
• Give good directions so EMS can find you → address,
intersecting streets, etc. Send someone out to the street
to wait for EMS if possible.
• If applicable, remove any drugs or drug paraphernalia
before EMS arrives. Place the person in the recovery
position while you do this.
• When EMS arrives, give them as much information as
possible. Tell them that you gave Narcan (if you did) and
how much.
NM’s Good Samaritan 911 Law
• In 2007, NM passed the 1st Good Samaritan 911 law
in the nation.
• It allows someone to call 911 or take someone to the
hospital for a drug overdose without being charged
for possession.
• The law covers both the caller and person who OD’d.
• The law does NOT protect someone if:
• they are on probation, parole, or have arrest warrants
• there is evidence of drug dealing → scales, baggies,
drugs or money in plain sight
• there is evidence of other crimes, including weapons’
possession or DUI
Recovery Position
The recovery position is used if a person is unconscious,
vomiting, or in danger of choking on vomit or saliva.
Place the person on their side, with legs bent, and head
resting on the arm on the floor. The recovery position
lets fluid drain from the person’s mouth so they do not
choke.
An unconscious person should be placed in the
recovery position whenever rescue breathing is not
being done.
Author: Rama Wikimedia Commons
Rescue Breathing
Rescue breathing means breathing for a person unable
to breathe on his own. If someone is not breathing or
only breathing a few times per minute, rescue breathing
must be started immediately.
Steps in
Rescue
Breathing
Picture used by permission
Harm Reduction Coalition
1. Place the person on their back
with head tilted back and chin lifted
(1 hand on forehead and 1 under
their chin).
2. Pinch their nose shut and breathe
into their mouth 2 times (normal
breaths).
3. Check to make sure their chest is
rising. If not, lift chin a little higher
and be sure nose is pinched shut.
4. Give 1 slow breath every 5 seconds
(count: 1-1,000, 2-1,000, 3-1,000, 41,00. Take a breath after 4-1,000 and
give another breath on 5-1,000).
Steps in
Rescue
Breathing
(continued)
Picture used by permission
Harm Reduction Coalition
5. Continue for 12 breaths (1 minute)
and recheck breathing.
6. If still no breathing, give Naloxone.
If the person wakes up, get them up
and moving.
7. If still no response, give another
dose of Naloxone and continue rescue
breathing until the person responds or
until EMS arrives.
Naloxone: a little assembly required
• Pull off the long yellow top of
syringe.
• Open the white spray top and screw
it slowly onto the top of the syringe.
• Pop-off the red or purple cap on the
medicine vial and the yellow cap on
the base of the syringe and gently
screw the glass vial into the plastic
syringe until you feel slight
resistance (about 3 turns).
• Naloxone will start to spray out of
the syringe - STOP!
Using Naloxone
• Place the spray top in one nostril of
the overdosing person.
• Push quickly on the glass vial and squirt half of the
liquid up the person’s nose (pushing slowly will
prevent the liquid from misting correctly).
• Place the spray top in the other nostril and squirt
what’s left in the vial up the person’s nose.
• If no response, use a 2nd box of naloxone.
• Continue to do rescue breathing until the person
responds or EMS arrives.
NOTE: more than 1 dose of naloxone is often needed for
multi-drug overdoses, especially those combining opioids
with alcohol and/or benzodiazepines.
Example: explaining •
OD and Narcan use
to a patient - 1
Picture from NIDA website
Prescription Drugs: Abuse and Addiction
Opioids go to receptors in
your brain that control pain
(or “that make you feel
good” for clients who abuse
opioids).
• In addition to pain control,
opioids make you sleepy and
slow your breathing and
heart rate (even prescribed
doses).
• When you take more than
your body can handle, your
breathing gets slower and
slower over time.
• You might actually stop
breathing = overdose.
Explaining OD and Narcan use to a patient - 2
• Narcan goes to the same receptors
in the brain where the opioid is
attached.
• The receptors like Narcan better
than the opioid, so the Narcan
pushes the opioid off the receptor,
which allows you to start breathing
again.
• Usually 1 dose of Narcan is enough
to get someone breathing again, but
you might need to use more if they
were mixing opioids with alcohol or
other drugs.
Explaining OD and Narcan use to a patient - 3
• Narcan only lasts for about 1 hour
and most opioids last much longer
than that in your body.
• When Narcan wears off, the opioid
still in your body will go back to
receptors in your brain and you
could overdose again.
• I strongly recommend that 911 be
called for any overdose, but if not,
someone MUST remain with the
person for at least 2 hours.
• What questions do you have for
me?
Notes on Narcan
• Narcan: Clients who are familiar with naloxone
will most likely know it as Narcan.
• How long it lasts: Narcan will only be effective for
45-60 minutes. Because most opioids last longer,
when the Narcan wears off, the person can OD
again from the drug still in their system. The
person needs to be observed for several hours to
ensure their safety.
• Withdrawal: Although the doses suggested here
usually will not cause severe withdrawal
symptoms, they are possible, and may include
sweating, nausea/vomiting, shaking, and agitation.
More Notes on Narcan
• Storage: Narcan needs to be stored away from
extreme heat or cold and kept away from direct
sunlight.
• Color: Narcan should be clear in color. Ask
clients to return for a refill if it appears cloudy.
• Expiration Date: Tell clients to check expiration
date on the box of Narcan on a regular basis
(maybe once a month) and ask them to return
for a refill if it is expired.
Miscellaneous notes for prescribers
• Ensure that patients know that naloxone only works
on opioids, BUT that it will work on combination drug
overdoses which include opioids (e.g., mixing opioids
with benzodiazepines or alcohol).
• Make sure patients know what opioids are! (e.g.,
“opioids include morphine, codeine, oxycodone,
Percocet, Darvon, Vicodin, hydrocodone and most
other prescription pain medications, as well as
methadone, buprenorphine, and heroin.”)
• Suggestion: tape an atomizer bag to each box of
naloxone. That way both pieces are together if
needed in an emergency.
Case Studies
 Which of the following patients might be offered
naloxone? Why or why not?
 What questions might you ask these patients?
1. Mr. K is an Iraq war veteran on long-term opioids for
pain related to combat injuries.
2. Ms. T is filling a suboxone prescription for 16mg QD X
30 days.
3. John is a 20-year old college student filling a
prescription for Vicodin #30 after dental surgery.
4. Mrs. S is 62-years old and has a history of chronic
migraines and anxiety disorder. She has been using
oral opioids for many years and now has a new
prescription for a long-acting Fentanyl patch.
“Act as if what you do makes
a difference. It does.”
― William James, American philosopher and
psychologist (1842-1910)
Questions?????
Resources
• Substance Dependence, Abuse and Treatment Need, Chapter 5,
National Survey on Drug Use and Health, SAMHSA, 2008-2009.
http://www.samhsa.gov/data/2k9State/Ch5.htm#fig5.20
• Harmful Interactions: Mixing Alcohol with Medicines, National
Institute on Alcohol and Alcoholism, NIH Publication No. 03-5329,
Revised 2007
http://pubs.niaaa.nih.gov/publications/Medicine/Harmful_Interacti
ons.pdf
• Good communication helps to build a therapeutic relationship,
Nursing Times.net, June 2009
http://www.nursingtimes.net/nursing-practice/clinicalzones/educators/good-communication-helps-to-build-atherapeutic-relationship/5003004.article
• Impact of Communication in Healthcare, Institute for Healthcare
Communication, July 2011. http://healthcarecomm.org/aboutus/impact-of-communication-in-healthcare/
Resources
• Alston, C., Paget, L., Halvorson, G., Novelli, B., Guest, J., McCabe, Pl,
Hoffman, K., Koepke, C., Simon, M., Sutton, S., Okun, S., Wicks, P.,
Underm, T., Rohrbach, V., and Kohorn, V. Communicating with
Patients on Healthcare Evidence, Institute of Medicine, September
2012.
http://www.iom.edu/Global/Perspectives/2012/~/media/Files/Pers
pectives-Files/2012/Discussion-Papers/VSRT-Evidence.pdf
• ASHP Guidelines on Pharmacist-Conducted Patient Education and
Counseling
http://www.ashp.org/DocLibrary/BestPractices/OrgGdlPtEduc.aspx
• Harm Reduction Coalition, Opioid Overdose Basics
http://harmreduction.org/issues/overdoseprevention/overview/overdose-basics/
• Prescribe to Prevent website http://prescribetoprevent.org/