you today. My name is Jenny Jarrett and I'm from the University of Illinois at Chicago, and I have with me today Abigail Elms who is also going to be helping participate as a part of this presentation. We're here today to talk a little bit about our program called Safe Home or Safe Home Opioid Management Education in older adults. We're really going to focus on naloxone and opioids throughout this presentation. To begin, Abigail and I have nothing to disclose at this point. The overarching goal of PCSS is to train healthcare professionals in evidence-based practices for the prevention and treatment of opiate use disorders, particularly in prescribing medications, as well as for prevention and treatment of substance use disorder. As a part of our presentation specifically, we're going to be focusing on the risks associated with opioid use, particularly in our older adults, and then describe how to recognize an opioid-related overdose and some of those challenges associated with opioid overdose, and then explain how to access and use naloxone for the reversal of opioid overdoses. One of the things that I welcome for you today is to interact with us. We have a few places within the presentation that we will be providing some interaction, and we want to hear from you, so please do have your cell phone potentially ready. There are some ways to interact that way, as well as please feel free to, at any time during the presentation, drop information in the chat. I'd love to speak to it if there's a question as a part of our presentation, and I also have Abigail who will be helping here, so we look forward to interacting and learning more from you as we talk about this important topic. We're going to start today by talking about the opioid epidemic as a whole. Here's the first point where we can interact together. We're going to drop in the chat where you can respond in the poll everywhere online, or please feel free to text the information there to the UIC office 878. Once you join, then you'll be able to send text messages to provide information for us. What I'd love for you to give us for this first component is what words come to mind when you hear the phrase opioid epidemic. We hear that lots of times in the news. You may see it in social media. You may have interactions with other people. I think some things come in the chat here as well as come in here. Death is definitely something we think of. Overdose. Crisis. Narcan. Purdue. Maybe some of you have watched some of the recent movies or series online regarding Purdue Pharma. Crisis. Global. Reduction. Harm. These are great words. Keep them coming. Overdose. These are great answers. These are all really big, important components of what's happening. I believe death and overdose, which are our two largest words here within our word cloud, are really great key indicators as a component of the opioid epidemic and some of the scariest features related to that. Thank you for participating and giving us more things. Addictive. Suffering. So many people are suffering right now. Family members. Caretakers. People themselves who may be using or misusing opioids. These are really important and critical components of that opioid epidemic. As we think about the opioid epidemic and its impact, we know that 136 people die every single day from an opioid overdose, whether that's from a prescription opioid or from some type of illicit opioid. This is an incredible impact on our country. When we think specifically to just the most recent period of time, whether before or after the COVID pandemic, we know that overall there have been, between 2019 April and April of 2020, that there were 78,000 deaths from overdose deaths. When we think about what percentage of those overdose deaths were related to opioids, over 70% or 56,000 people died within that year. Then we know the COVID-19 pandemic occurred starting in March of 2020. We had many shutdowns and so forth. We saw overdose deaths increase during that time since the initiation of the COVID-19 pandemic, with over 100,000 people dying from an overdose. And that percentage of patients who are related to an opioid has actually gone up in that time as well. We know more people now, even with the COVID pandemic, are dying from these opioids. Again, we're going to pose this back to you. We'd love for you to engage. Which of the following opioids do you think is contributing most to those overdose deaths? Do we think it's heroin or A, oxycodone, a prescription, which is B, C, methadone, or D, fentanyl? We'll give you a moment to answer. I see a lot of B's coming into the chat box right now. Some folks are answering heroin. We're getting a few answers across the board. This is great. Keep those answers coming in. Lots of B's coming through. Well, what's interesting about the opioid pandemic is it has actually shifted over time. So, the only answer that potentially is incorrect here is methadone, as methadone is actually a treatment for opiate use disorder. But heroin, oxycodone, and fentanyl have all contributed to overdose deaths. So, we're going to go ahead and move on to the next question. So, heroin, oxycodone, and fentanyl have all contributed to overdose deaths. When I think about overdose deaths from opioids, I can think about them across three different waves over time. The first wave started in the late 90s and early 2000s when we saw that increase of prescription opioid deaths starting to bring the rise to opioid overdose deaths. And this is somewhat related to the overprescribing of opioids at one point, particularly as marketed by different pharmaceutical companies. As we started to realize that the opioid prescriptions were potentially causing these misuse and overdose deaths, we saw that those prescriptions started to level off and patients were no longer able to receive those medications. And they started to see a rise at that point in heroin overdose deaths, where people were reaching towards heroin because they could no longer receive their opioid prescription. And so, around 2010 is where we started to see that second wave occur. And then, a few years later, we saw the introduction of these synthetic opioids or fentanyl, which are highly potent agents and are causing the third wave of opioid overdose deaths. So, those people who answered fentanyl in the last question are the most correct at this current moment. However, that's actually changed over time. When I think about prescription opioids in the most recent times, overdose deaths involving prescriptions have more than quadrupled in the 20-year period from 1999 through 2019. We also know that nearly 250,000 people have died from overdoses involving a prescription medication. 28% of overdose deaths involve the prescription opioid. And then, we know that every single day, 38 people died from a prescription overdose death. These are incredible statistics of preventable deaths and overdoses that we're seeing occur. We're going to start to move a little bit into a fact or fiction rapid fire component. We want to ask the first question, is this fact or is this fiction? Because there's so much misinformation about opioids out there. Someone can still overdose even if they follow the directions on an opioid prescription. Do you believe that that's fact or fiction? We're seeing great answers coming in. Many answers. We have some people that think it's a fact and a few that think that it's fiction. As a pharmacist myself, I can tell you all medications have risk, but let's talk a little bit more about how prescription opioids may have risk. And specifically, what's that risk in older adults? Most recently, we learned it was published in JAMA, the journal JAMA. You can find here that they did an interesting look at opioid overdose death, particularly in older adults, or those 55 years and older. And looking back at the staggering statistics that we went over and what percentage is that changing in our older adult population, you can see here from this important graph from that study that the rate of older adults and opioid overdose deaths in 1999 was actually fairly low at around one per 100,000 persons. However, over that 20-year period, we can see a significant increase in older adults being affected by opioid overdose death. And as we know from the ways that we talked about, many of those are because they're switching from prescription opioids to potentially other types of opioid agents, whether heroin or other synthetic products. So this is an important component of understanding that opioid overdose deaths are not just occurring in younger populations, but really it's affecting older adults as well. And we need to be cognizant of that as we're thinking about opioid use in these patients. We know that opioids can cause opioid overdose, so it is a fact that even if they're taking it appropriately, that it's important that they can still have an overdose complication with their medication. So why are opioids affecting older adults? Older adults are actually more likely to be prescribed a long-term opioid for chronic pain because they have more chronic pain in that older adult population. So they're giving opioids more often and for longer periods of time. They're also more likely to take other medications that may interact with those opioids. So some of those medications may be related to treating their nerve pain or taking a gabapentin, which also has some central nervous system depressant effects, or potentially they need to take medication like zolpidem for sleep, and those are sleeping agents, or they have to take a muscle relaxant of some kind for muscle pain or spasm that they may be having. And those things when taken together can actually interact and increase the risk of opioid overdose. Not only can their medications interact with opioids, but also many older adults have comorbidities or other diseases that may increase their risk of opioid overdose. So those might be dementia, where if a patient doesn't know if they took their opioid or not, they may be more likely to take an extra by accident, increasing their risk for opioid overdose. Additionally, some have lung disease or lung problems, sleep apnea, which may increase their risk for respiratory depression or slowing of their breathing, which could increase their risk of opioid overdose as well. Finally, older adults we know in general with medications are more likely to experience worse side effects and opioids are not excluded from that. And so older adults can potentially see some of those adverse effects occurring when they're taking their opioids, even if they're taking their medication as prescribed. Now, how does opioid overdose occur and where do the opioids work in the body? So we can see here that there are three receptors in the body, the Mu, the Delta and the Kappa, which all innervate into our central nervous system. Opioids work on that Mu receptor, which is why it's darkened there with the darker purple most commonly. And when it works on that Mu receptor, it slows that central nervous system down. And so what does that actually cause the body to do? It can cause the body brain slowing the drive of the brain to breathe. And so again, it's going to cause someone to breathe a little bit more slowly. Additionally, it can slow the level of consciousness. So making someone a little bit less aware of what's going on or more sleepy. And it also can slow the heart rate. And so when you slow the heart rate down all the way and you slow the respiratory drive or ability to breathe, that's when an opioid overdose can occur. So what does an opioid overdose actually look like? Here are some of the classic signs that you can think of to tell if someone is overdosing from an opioid type medication. Their pupils will become very pinpoint like. So when you're looking at someone, you can see through their eyes. Additionally, they're not going to have the circulation as much as possible because again, their heart might have slowed them. And so you may see that they're having blue lips or blue fingernails so that you can see that they're actually not as warm in those extremity areas. Additionally, we know it lowers that respiratory drive, or you can see some slow breathing or even potentially stop breathing when someone is overdosing from an opioid. Further, they may become unresponsive. So they may not respond when you're talking to them or using a loud voice. So you may have to potentially touch the person or shake the person to gain their responsiveness. There also can have pale or clammy skin or a slowed heartbeat or lower blood pressure. I see here there's a really important comment in the chat about what do we see for persons of color? Because some of these things may be more challenging to see with different color pigments. And you're correct there. I would note that for some of the things that may be more challenging to see with our skin pigments, you look for some of these other signs and symptoms of opioid overdose, like slowed or stopped breathing, unresponsiveness, or a slower heartbeat, which you can physically be able to feel on the patient. So these are some of the most common ways that we can see opioid overdose can occur. So what do we do about opioid overdoses? One of the approaches that you can take is a harm reduction approach. And I'd love to hear from you. When I say the word harm reduction, what words come to mind? I think this is something that we hear commonly. We should be doing more harm reduction. So I would love to hear what words come to mind when you think of harm reduction. Person-centered, support. I see things coming in the chat here. Reduced risk. Secondary prevention. No death. Cost effective. That's interesting. Preventative. Supervised injection. I see that coming in. Some of these things are new things here happening across the country. I see syringe. I see substance use disorder or FEP here. I see testing sites. I see Norcan. Monitoring. Preventing from harm. Recovery. As you can see from this word cloud, you can definitely see that harm reduction is broad and significant for reducing potential harm for patients who use substances or potentially misuse substances, and specifically opioids. There are some main principles, six main principles that I think of when we think of harm reduction. The first principle of harm reduction is recognize. We have to recognize first and foremost that drug use is complex and is multifaceted. Drug related harm is also affected many times by social inequities or social determinants of health. And we have to recognize that it's not just one issue, but really there are many components of those issues. We have to also prioritize as a principle of harm reduction, that quality of life and wellbeing over just complete abstinence or sustenance of drug use altogether. So harm reduction is about really improving the lives of people who may use drugs and their wellbeing and meeting them where they are for their goals. Their goals may not be stopping their drug use altogether. Furthermore, principle of harm reduction is minimize. We want to minimize the harmful effects of drug use rather than just ignoring them or condemning them. There's much stigma related to harm reduction. And again, we want to recognize and prioritize patients overall and recognize that, yeah, there are many components here. We also want to provide non-judgmental and non-coercive services. There is no one right way for harm reduction, as we noted in the word cloud there momentarily. And so there are many different types of services or ways that we can talk about that. Further, we want to empower people who use drugs to be the primary agents of their reducing harm. We want to make sure that they have access to these things so that they can choose to reduce their harm when they choose to use or misuse drugs. Additionally, we want to ensure that people who use drugs have a voice in the programs and policies that serve them. We know that it's critical in order to engage those who may use drugs to ensure that they can have a voice and have the type of care that they may be looking for. Some examples, and I think we saw a bit about this in the word cloud that we saw, that different types of needle exchange or syringe exchange components. We see that there have been some new inputs of safe consumption sites where people can go and be monitored when they're using so that they can stay safe. Also safe substance disposal. So getting rid of something can also reduce the potential harm. Furthermore, from a healthcare perspective, we can refer to types of different treatments as well as having access to naloxone, which can be life-saving, which is a part of the crux of what we're going to be talking more about today. So let's go directly towards naloxone specifically and how it can reduce opioid overdoses. How does naloxone work? As a pharmacist, I find this part to be some of the most exciting components. So when someone is using an opioid, you can see that it attaches there at the opioid receptor, or again, that new opioid receptor, and that's where it can cause its pain relieving effects, but also can cause some of its overdose effects in the sense that it can cause that slowing of breathing or slowing of the heart rate. So how does naloxone work to mitigate that risk? What happens is naloxone will come in and displaces that opioid out of that new receptor. So no longer can that opioid drive that slowing of the central nervous system or drive that slowing of the breathing or their heart rate. So reversing the risk of that overdose potentially. Further, if there continues to be opioids in the system, you can see that opioid bounces off of that naloxone, which has covered that receptor. So it's going to prevent further overdose while the naloxone is in the system. Now there's lots of questions about naloxone overall. And so let's talk about some of the facts and the fictions surrounding naloxone use. Let's start with a fact or fiction. Naloxone can harm someone who does not have opioids in their system. This is really speaking to, is naloxone safe? Say you're not sure if someone is having an overdose, you know, and do need to be concerned about giving naloxone to somebody who doesn't have opioids in their system. Fact or fiction? You can see over 95% right now are saying B that it's fiction. I'm seeing quite a few B's come through here. We'll give a moment for others to answer. It looks fairly resounding that folks are saying B that is fiction. And that's correct. Naloxone will not harm someone who does not necessarily have opioids in their system, except for an extremely rare case like Jill was noting here of a potential allergy. But that is still rare. It's not necessarily something to be significantly concerned about. We can see here there's different naloxone formulations. As you can see, the naloxone injection is the original formulation of naloxone and was traditionally used in the hospital setting when potentially you needed to reverse opioid over use, potentially in the hospital if somebody was, say, had a surgery or had been given more opioids. And that's the traditional formulation of how it was given. Many times it can still be given out in the community at this point. It just can be a little bit more challenging to use, particularly if somebody doesn't know how to use a syringe or is comfortable with using needles to inject it. The naloxone with the atomizer, as you can see, is the second formulation that was released. And you can see, what you can see here is there is a atomizer which screws on the top of the naloxone there on the right hand component. And that actually can be used within the nose. And so it takes some of that naloxone from an injection type capability to then being able to be used just intranasally, which can be sometimes more useful for people who feel less comfortable with syringes. The naloxone with the atomizer, while it is less cumbersome of a syringe and trying to pull up or draw up that naloxone out of the vial, it can still be a little bit challenging if someone doesn't know how to use or attach the atomizer there to the naloxone. So secondarily the Narcan product is the brand name, also known as naloxone was released, which comes as a nasal spray and is much easier to use. As you can see there, it's somewhat self-explanatory with which component goes into the nostril and which component is the plunger in which you can spray into the nose. These are nice components, the way that it's formulated in the sense that it is a one-time use and easy to use for many people, particularly for those lay persons who may be in the community and come to see somebody who has a potential opioid overdose. Finally, the last formulation here is Avizio, which is an auto injector. What's nice about the Avizio product or formulation is that it actually, once you open the cap, it actually would talk to you. So it would tell someone how to use it, just like a defibrillator might tell someone in the community how to use it. Unfortunately, the Avizio product, because it was so expensive, it was not commonly used in the community and had hence been discontinued by the manufacturer. So unfortunately that product is not available. So you can see here the three types of naloxone formulations that are available and that you can find out there in the community. So what do I do in the event that I come across someone who is potentially having an opioid overdose? I think first and foremost, it's kind of like if you found someone down otherwise from some other type of cardiovascular pulmonary type problem, if you want to first check their responsiveness, if you know the person you can call their name, maybe you touch them on the shoulder and try to give them a little bit of a shake. Are they conscious? Are they responsive? If they're not responsive, you definitely want to call 911. If they potentially need more support or medical attention. And so it's critical to make sure that you have those other types of health professionals on board. Then once you've called 911 and you've got the dispenser on the line, I would recommend giving that naloxone if they're unresponsive, because you want to reverse that opioid overdose as soon as possible. Don't necessarily wait again. That naloxone is not going to harm the patient. And as we know with some of the more potent synthetic type products that are on the market, like fentanyl, they need maybe more than one dose of naloxone. So if you can start that first dose, that can be helpful. But like I said, patients may need more than one dose, which is why it's great to have the first responders who will arrive and be able to potentially give that second dose. And then as instructed by the dispatcher, if they feel like you potentially need to, you can provide a rescue breath and chest compressions. One of the things that's most important though, is make sure that you stay until help arrives, making sure that the patient or the person who is potentially having an overdose is there. All right, let's go to our next fact or fiction. We want you to put your thinking hat on here. The first factor fiction, I can only get naloxone if I have a prescription from my doctor. I see many people in the chat here saying B or fiction. I see one A in there. What's important about this talk today and talking about Naloxone is talking a bit about access to Naloxone. And so, for most states, and I'll show you here in a map in just a moment, for most states, this is actually fiction, that you don't necessarily need a prescription from a doctor. Now, you can receive a prescription from your doctor, but there are some other mechanisms in most states where you can access Naloxone. So, the correct answer here for the majority of states in the United States of America is B, or fiction. So, we have many correct answers there. So, what is that mechanism that many people can access Naloxone without a physical prescription from their physician? It's what we call a standing order. And a standing order is one prescription order that can be used for a large group of people or for multiple people. Any person can obtain a medication at a pharmacy without a prescription based on using this standing order. Let's go through what that looks like. Say, in a traditional prescription model, there's a patient who sees that they think that they need a medication. They go to their doctor to talk through what the issue is, and then that prescriber can then identify what is the correct medication potentially for a patient. Then that patient would then take that prescription from the doctor's office to their pharmacy, where their pharmacy may fill that prescription and access that medication for their patient. That's the traditional prescription model, which I think most of the people here have been through that process and understand how that works. Now, as we think about a standing order mechanism, you can see that it removes the need to go to that physician's office or have a telehealth visit of some sort, but that the patient can actually see that they may potentially need that medication, go directly to their pharmacy and access that medication. So it skips that step there by having a standing order. So thinking about what states and how that standing order may or may not be different, here is a map across the United States where you can access naloxone without a prescription. So all of these blue states, which is the majority of the states, have an active statewide standing order that you can access naloxone without a prescription. You can also see those red states. They have standing orders that are allowed, but there's not necessarily one that is statewide. And so there may be standing orders among different pharmacies with physician groups or health systems to allow for that standing order. And then you can see in Oregon and Idaho that pharmacists actually have prescriptive authority where they can use that. And then rarely in Oklahoma there, you can see the direct authority is by a statute or an administrative order. So overwhelmingly, most states have a standing order that a person, a layperson, community member, a patient who is on an opioid could go and actually access naloxone to have in case of an emergency or an opioid overdose. Now, you get to the pharmacy, you want to have that naloxone through that standing order. Here's a big question. Fact or fiction? My insurance will not cover naloxone if I do not have a prescription. What do people think? Do we think that people are going to have to pay out of pocket to access this naloxone? Or will their insurance cover it through the standing order mechanism? I see some A's, I see some B's. We'll give everyone a moment. Thank you for responding and participating. This is wonderful. So the majority is saying fiction, but there are quite a few people here that are saying that it's a fact that my insurance will not cover naloxone. This is actually a really emerging area at this point as to insurer requirements for naloxone, particularly related to those with a standing order. So you can see here in this map that those states that are shaded in blue, that there are requirements in those states for health insurers to actually cover naloxone. So in any of these states, your health insurer should be covering naloxone through the standing order mechanism as well as through a prescription mechanism. There also have been some questions if you've received naloxone, there has been some stigma or bias related or applied by life insurers that they don't necessarily want to pay, allow for life insurance because of a person who has received naloxone, potentially assuming that they have an opioid misuse problem. And so some of these states that are shaded in red have actually placed requirements on life insurers that they cannot actually make assumptions in those settings and that they are required to still provide life insurance for patients who have received naloxone. So that's an interesting component. Only in the state of Rhode Island are there requirements for both life and health insurers at this point. But as you can see with many of these states shaded in a gray way, that this is an emerging area where there could be potential advocacy for coverage of naloxone as a lifesaving medication for the community overall. Now, let's think of something that I think can be really scary or upsetting for community members about whether or not they're going to get potentially arrested or fined if they give naloxone for someone. So fact or fiction, I can get arrested or fined for giving naloxone to someone I don't know. Seeing some answers come in here through the chat. Many Bs or fictions coming through. I can be arrested but not necessarily charged. So, Tanya is making a nice input here about is it depending on states and that is correct. The layperson immunity or some of the good Samaritan laws that are across some states do have a place here when thinking about utilizing naloxone. Overwhelmingly, as noted in these blue shaded states, there is civil and criminal immunity if you were to give someone who you might have found down and suspect a potential opioid overdose. So, there is immunity for you if you've provided that naloxone. If you're in one of these red shaded states, as you can see here, there is civil immunity only at this point, but there is not necessarily criminal immunity. Additionally, in the green states of Nebraska and Ohio, there is criminal immunity, but not necessarily civil immunity. And those folks who may be in the state of South Dakota, unfortunately, this has not yet been addressed by a statute in your state. But I would say the majority of states and people across the country have immunity and are covered by these good Samaritan laws, but you can provide naloxone and not necessarily have any criminal or civil intent. Let's think about another question that I think can sometimes hold people back from wanting to access naloxone or even implement some of these laws or statutes across the country about naloxone. So, fact or fiction, by increasing access to naloxone will only enable people who use drugs to use more drugs. So if someone has access to naloxone, they may choose to use drugs or misuse more. Thank you so much for all of this interaction, I'm seeing quite a few Bs come in or fiction. A few people think that that may be a fact. Let's go to the literature and think about naloxone and how it relates to use or increase or decrease. We actually know over time that accessing naloxone overwhelmingly saves lives. I'll say that again. Naloxone saves lives. Those states with naloxone access laws as well as good Samaritan laws, as we've noted across these last couple of slides here, actually had a decrease in opioid related mortality or deaths between the 15 years of 2000 to 2014. We know this access is decreasing deaths. Additionally, estimates predict approximately 20% reduction in overdose deaths when you have these high distribution naloxone programs or those programs that are distributing a large quantity of naloxone. So naloxone can save lives. It actually reduces the risk of death. There is no evidence whatsoever that easier access to naloxone actually increases opioid use or makes people feel like that they can use more. So there's no evidence to support that. And unfortunately, that is complete fiction at this point. We know that increasing access to naloxone is really important across all of these states. And so understanding these different mechanisms are critical. Another way in which you can access naloxone, aside from that standing order where you can receive it going into a pharmacy of some kind, is through this co-prescribing mechanism. So co-prescribing is when a prescriber or a physician or an advanced practice provider like a physician assistant or nurse practitioner can actually co-prescribe naloxone as a prescription with their prescription of opioids. So a physician writes a prescription for an opioid pain medication and also writes a prescription for naloxone. We know that when co-prescribing occur, there are significant benefits to co-prescribing with a much lower or 63% fewer emergency department visits within one year. And furthermore, patients feel a sense of security when they have the naloxone. So if a patient potentially is concerned about how an opioid might affect them, they actually can feel more secure to know, I have naloxone in my home. And if something happens, a family member or a caregiver or a friend could actually save my life with this naloxone. So there are significant benefits for co-prescribing naloxone as an access point. Now what's interesting is there has been less movement across the country. And again, this is another great area for advocacy with potentially your work where you are, is having requirements for co-prescribing. Those states that are shaded in blue here are states where a requirement is necessary for co-prescribing naloxone when prescribing opioid medications of some kind. Those states that are red may co-prescribe and potentially have recommendations to do so in accordance with the CDC recommendations for co-prescribing recommendations of naloxone. There's also states like the state of Colorado where they have to notify the patient about naloxone. This is an interesting concept in the idea of empowering in a harm reduction strategy of empowering those patients with information about naloxone so that then they can make the choice what they think might be best for them. Those states that green is New Jersey, they must co-prescribe naloxone, particularly related around COVID-19. So that's an interesting concept of how they increase that harm reduction strategy based on the pandemic. Overwhelmingly though, co-prescribing we know can have significant benefits when prescribing it with an opioid. So what's the real problem here? Older adults taking opioids really can be unaware of their risks and particularly the risks as we talked about earlier of interaction with other medications that they have, potential interactions with other diseases that they may have, and they might just not know how to access naloxone, whether by talking to their doctor for a co-prescription or potentially not knowing how to access naloxone by through a standing order and just going in their state to their local pharmacy or even asking for it when they're picking up their opioid medication. There's a few communication strategies we can think of specifically with older adults where we can help support their education and understanding of how naloxone works and why it's important. I think one of the most critical components that we can do is we could really use, avoid using medical jargon. So I think that CNS depression or central nervous system slowing in a more patient-friendly way can be easy ways of connecting to patients so that they understand what it is. We find that medical jargon for those medical professionals in the group here can really limit that interaction and communication with patients. For older adults, it's really important that we speak slowly and loudly and clearly. Many times, older adult patients may have cognitive slowing or potentially have hearing problems where they can't actually even hear the information. By sitting down face-to-face, that can be really useful to gauge their attentiveness and engagement in the discussion, and it can be very helpful to write something down for those patients and check for their understanding going back and forth. This can help guide that discussion of the critical components of understanding naloxone use and opioid risks associated with taking them. Patients many times will have questions, and I think it's important that we make sure that we allow that time for questions when they're meeting with their provider. Some educational tools that we've used here in the city of Chicago and across rural areas of Illinois are other places that you can think about providing this for patients. Here we have a patient handout that we can provide that talks specifically about opioid medications and what their risks are, specifically in older adults, things that they may be able to do, such as other pain management strategies or things that they could talk to their physician about or family member. Additionally, we tend to use handouts as well that talk specifically about naloxone, what it is, what to look for for an opioid overdose for patients. This can be an important time for actually giving them the signs and symptoms to look for in other people. We know that 25% to 30% of people, which is a growing number, are living in multi-generational homes. For those older adults, they may not need the naloxone for their own use with their opioid medications. Potentially, they have a family member, whether a daughter, a granddaughter, who may be using or misusing opioid prescriptions or illicit products. This can be a life-saving component as a part of their multi-generational living. These are all really important educational topics to talk about and can sometimes be challenging conversations for patients who are concerned or don't understand fully some of those products. We know that it takes a village as well, as we think about the opioid epidemic as a whole, and that as an interprofessional healthcare team, it's important to surround the patient with similar messaging and other components and ideas. You can see here, there's lots of different people who can help to provide access of that knowledge to patients. It could be a pharmacist, like myself, when in the pharmacy and receiving their opioid medications, or someone who potentially may need naloxone to have at their home. Those are great educational components and places to get that medication information. However, we're not the only people who can provide medication education. It's great to think about nurses, primary care providers, additionally, social workers who may be working with patients, but one area that we feel could be a great component for education, and specifically in older adults, are home healthcare workers, those people who interact with patients in their own home. Some of you today may be home health workers. And when we think about home health workers, they may have many different names across different types of health systems. They may be home health worker, like I mentioned, or they could be a care coordinator or a patient navigator. There's lots of different names for these people, but they're great access points for patients. They typically have unique training, whether as a social worker or nurse, potentially as a licensed counselor. So they have great opportunities and skills to meet with patients and discuss some of these exciting opportunities. Additionally, home health workers may be great components for educating patients about opioid risks, as related to providing services, including assisting with different tasks, whether medical or social needs, and act as a really nice liaison between older adults and providers as they're moving through the healthcare system. And so we can think about lots of different components for that. There are lots of references related to some of the things that we talked about today with our Safe Home Program, as you can see here. And there's lots more to know about naloxone, and specifically how naloxone is accessed within your own community. I highly encourage and recommend that you learn what the rules are and stipulations for naloxone access in your state, where you are. I also recommend that you find out at different pharmacies, which ones can provide the access to naloxone to your patients. This will help to empower you to provide this harm reduction strategy through naloxone access in your community. There's other places for you to get more information, specifically through PCSS. And I want to make you aware of two resources offered specifically through PCSS. First is PCSS's Mentor Program. And that's designed to offer mentoring assistance to those in need of more one-on-one interactions with one of our colleagues to address any clinical questions that you may have. You have the option of requesting a mentor from our mentor directory right online, and we're happy to pair you with one of them. To find out more information, please visit the website using the link right there on the slide. And you can find out more information about this mentor program. It's a great way to get personalized assistance. There's no cost to you. Further, a second opportunity PCSS offers is a discussion forum, which is comprised of our PCSS mentors and other experts in the field who may help provide prompt responses to clinical cases or questions. So if something comes up and you need an immediate answer, and this is a great opportunity to access this. They also have a mentor call each month, so ongoing in a longitudinal fashion, you can get more information and learning through this discussion forum. This person is available to address any submitted questions through the discussion forum. And you can create a login account by clicking the image of the slide to access the registration page. This is a great opportunity for things for you to be able to interact and engage further with the PCSS community. This slide simply notes a consortium of lead partner organizations that are a part of PCSS. As you can see here, there are many different people who come together. And this collaboration is led by the American Academy of Addiction Psychiatry. Finally, please reference this slide for our contact information, website, and Twitter and Facebook handles to find out more about our resources and educational offering. There's lots of opportunities out here to talk more about all parts of the opioid epidemic and problems. So now we have a few minutes that we can take some questions. I would welcome folks to unmute themselves or drop any questions you may have here in the chat. Jenny, we had a couple of comments. I was wondering if you could comment on the use of naloxone in children and also pets. Oh, that's an interesting question. Excuse me. Excuse me. So naloxone overwhelmingly really interacts on that new opioid receptor. And so if there are not opioids on that new receptor, there's really no challenge with using naloxone on those receptors. Excuse me. So what I would say is for children, naloxone is actually safe to be used in children. For pets, I'm not as clear about the data on pets. Abigail, do you have information about using naloxone in pets? I was trying to look that up as you were presenting. I'm finding that it is used for pets, but that the dose is kind of undetermined at this point. I would recommend if you think that your pet has gotten into an opioid of some kind that you're concerned and you would like to use naloxone on a pet, that you contact your veterinary provider at that point. That would be somebody that would be important. Unfortunately, I don't think EMS services can supply information on pets. So I would recommend contacting your veterinary provider. But I agree with Sherry in the chat here. It doesn't matter what age, you can use naloxone on a child if they potentially access medication. That wasn't necessarily a large component of this presentation, but making sure that opioids are safely stored at home is a really critical component. If there are children or pets who may access those. I also had another comment, I was wondering if you have a good perspective on your thoughts on naloxone as over-the-counter versus standing order versus prescription. That's a great question. I have high hopes that in the coming year that naloxone will be accessible in an over-the-counter fashion so that anyone can just access it at any community pharmacy that you may go into or grocery store or whatnot. I have seen in the literature, they have tested and approved different educational labeling components so that this can move forward as that product can potentially be provided in over-the-counter fashion. So I think that's something to be looking for in the near future. But at this point, it's not accessible as an over-the-counter product in a pharmacy. Good question. We all have high hopes for that. What other questions can I answer? Does anybody want to come off of mute and ask a question? Feel free to drop it here in the chat. We also had one commenter asking about the increased doses of naloxone. I know there's a nasal spray that's eight milligrams. Didn't know if you wanted to comment on that. That's an interesting question. And there's a lot of debate among academics and clinicians across the country. It's my understanding that those higher doses are actually not necessary and that a standard dosing is actually just as useful to reverse an opioid overdose. So don't necessarily think that the bigger dosage is the better dosage. NNR can be given, and it can be given in multiple doses. So if you think that one dose is not enough, then give more. As a pharmacist, we have a mantra that is start low and go slow. Maybe you don't want to go slow in the middle of an acute opioid overdose, but starting low and providing more doses as needed can be important. I would caution the number necessary for certain cases and certain products for how many doses of naloxone is necessary, depending on what the product is for use. Fentanyl necessarily does not need multiple doses compared to other types of products. And so it's really challenging as well to know what a patient has actually taken from an opioid, whether that's an illicit product or a prescription product. So we don't really have great answers on that information. We have a couple Q&A questions just asking about how naloxone works in terms of reducing the pain-reducing effects of opioids and then also its duration of action. So from a perspective of duration of action, naloxone comes on and comes off fairly quickly. So it's one of those things if a patient has taken a long-acting opioid product of some kind, the naloxone may wear off and patients can actually go back into an opioid overdose even though they've received that naloxone. So it's important, again, to interact with potential EMS or medical professionals if you've provided naloxone in that case so that they can continue to monitor that patient. From a pain-reduction component, unfortunately, if someone has taken too much opioid and you reverse naloxone and you give naloxone, you will reverse all of the pain-relieving effects of that opioid. So you can find that some people who, when given naloxone, can become in a lot of pain because you've removed all of those opioids from your system, from those receptors, so it's not blocking that pain anymore. I'm seeing lots of things come through the chat about people who are using products, giving products in the community. This is great. There's lots of opportunities for people to provide more access to naloxone in really unique ways across the country. And I welcome the advocacy for doing that. What other questions can I answer? I think I noted a couple of things in the chat about making naloxone as available as an AED or a defibrillator like we've seen. Many places you go these days, you can find a defibrillator in an airport, in a stadium. Unfortunately, at this point, many places are not providing naloxone in that same way. I think that's an incredible opportunity to speak with local businesses as well as your officials in order to try to provide naloxone in that way. Again, there are immunity laws to protect people who potentially use naloxone for people in the community. So I really welcome that, and I think that's a great opportunity for harm reduction where you are. All right, maybe we have time for one more question if anybody wants to either enter their question in the Q&A. The chat box quick before we wrap up. There's a question here about commenting on prevalence and complications of synthetic fentanyl analogs in terms of potency and long duration of action. It's challenging to comment on that. I think that's an important component. I know here in the city of Chicago that our drug supply is 90% fentanyl. So as a clinician here in the city, and I do quite a bit of street medicine and mobile units, we assume every patient is potentially using fentanyl products. And I think understanding what the drug supply is in your area can be really useful for understanding naloxone and also providing more access in places where they may potentially have more potent products to cause an opioid overdose. I see a great question about prescribing in persons who may be pregnant. Naloxone is safe in pregnancy. Thanks so much for the positive feedback here in the chat. This is great. I'm glad this was helpful. This webinar will be available online for, I believe, up to 12 months. So if you think that this was useful or you think others might find this useful, we really welcome as many people as possible to take this educational component. Yes, thank you all for joining. On behalf of Abigail and Jenny, as well as the PCSS team here, we thank you all again so much for taking the time to participate and ask your questions today, and thank you, Jenny and Abigail, for joining us and hosting this great presentation. We hope you all have a wonderful day, and thank you so much again.

Safe Home Opioid Management Education

older adults

naloxone

opioids

opioid use disorders

opioid overdose

COVID-19 pandemic

harm reduction approaches

communication strategies