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transplant.bc.ca
Live Life. Pass It On.
The Opiate Epidemic and
Organ Donation
November 7, 2018
Sean Keenan MD
Provincial Medical Director,
Donation Services
BC Transplant
transplant.bc.ca
Faculty/Presenter Disclosure
• Faculty: Sean Keenan
• Relationships with financial interests:– Grants/Research Support: none
– Speakers Bureau/Honoraria: none
– Consulting Fees: none
– Patents: none
– Other: Provincial Medical Director, Donation Services, BC
Transplant
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Plan for today
• Background on Opiate Crisis in North America
• Impact on Donation and Transplantation
– Volume and composition of cases
– NDD Declaration of Death
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Case Presentation
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Case Presentation (case altered to protect identity)
• 20 year old man found unresponsive at 10:30
am, Day 0– Known use of Percocet/Oxycontin
– Last seen 1 hour earlier at 9:30 “snoring”
– PEA
• CPR x 1 hour, Epi x 10
• In ER continued loss of pulse – Epi infusion
• Drug screen– Positive Fentanyl, Cannaboids
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Case Presentation
• After resuscitation
– Profound shock – High doses vasopressors
– Marked acidosis
• 6.80/85/81/9 – lactate 17
– Hypothermic T 30 C
– Hypoglycemic – 1.1
– ARDS secondary to aspiration
– Multiorgan injury
• AST/ALT – 4000/3800
• AKI – Cr 148
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Opiate Crisis
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What makes this a Crisis?
• In US
– 2000-2014 overdose rate doubled
– 2015 further 15% increase
– Drug overdose overtakes firearms, MVC as
number 1 cause of accidental death
– Life expectancy dropped for < 65 years old
Weiner et al. Transplantation 2017;101:678-681
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What is the Opioid Crisis
Canadian Institute for Health Information. Opioid-Related Harms in Canada. Ottawa, ON: CIHI; 2017.
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Illicit Drug Overdose Deaths in BC January 1, 2008 to January 31, 2018
Coroner’s Report
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National View of Number and Rate of Overdose Deaths
Special Advisory Committee on the Epidemic of Opioid
Overdoses. National report: Apparent opioid-related deaths
in Canada (January 2016 to June 2017) Web-based Report.
Ottawa: Public Health Agency of Canada; 2017.
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Proportion of Opioid Deaths due to FENTANYL
0
10
20
30
40
50
60
70
80
90
100
BC Alberta Manitoba Ontario Quebec NovaScotia
2016
2017
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These Opiod overdose deaths are accidental ….
Special Advisory Committee on the Epidemic of Opioid
Overdoses. National report: Apparent opioid-related deaths
in Canada (January 2016 to June 2017) Web-based Report.
Ottawa: Public Health Agency of Canada; 2017.
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Why has this happened?
• In the US
– Initial rise in prescription of opioids
• 3 DRIVING FORCES
– Moral imperative for physicians to treat pain
and relieve suffering
» Access to pain management is a
fundamental right
– Perceived under-treatment of pain
“oligoanalgesia”
» Focus on adequate pain management,
linked to reimbursement
Weiner et al. Transplantation 2017;101:678-681
transplant.bc.ca
Why has this happened?
• Impact of Pharma marketing
– OxyContin
• $200 million in 2001
• 10 fold increase by 2002Weiner et al. Transplantation 2017
Dowell et al. JAMA 2017
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Opioid Crisis
• Tracking of increased opiate prescriptions noted
• Out of proportion to documented amount of pain
– Increased scrutiny
» CDC guidelines
» Prescription monitoring
» More stringent laws on prescribing
Weiner et al. Transplantation 2017;101:678-681
transplant.bc.ca
What next?
• Opioid prescriptions fall
– 2015 16.6 million fewer than 2014
• Concern now is lack of access leading to
increased use of illicit opiates
– Heroin
– Fentanyl and others
Dowell et al. JAMA 2017
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US data
Dowell et al. JAMA 2017
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Illicit Drug Overdose Deaths in BC January 1, 2008 to January 31, 2018
Coroner’s Report
BC Data – Coroner’s Office
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Overdose impact on Organ Donation
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Impact of Overdose on Organ Donation
• Goldberg et al. Am J of Transplantation 2016
– Organ Procurement and Transplantation Network
(OPTN)
– 2003-2014 … 2.2% to 7.3% of total donors
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2003 2007
20102014
Increasing number of overdose organ donors
Goldberg et al. Am J of Transplantation 2016
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Durand et al.
Data from Scientific Registry of Transplant Recipients
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1.3%
13.7%
Mehra et al.
Proportion of Organ Donors following Overdose
United States vs Eurotransplant
<1% all years for Eurotransplant
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2017 BC Overdose Deaths and Donors
0
20
40
60
80
100
120
140
160
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Series1
Series2
Deaths
Donors
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Number of Organ Donors with positive Toxicology
(presumed overdose)
0
10
20
30
40
50
60
2013 2014 2015 2016 2017
OD donors
OD donors
2017
46 Overdose
25 positive Fentanyl
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BC increase in Deceased Donors 2013-2017
0
20
40
60
80
100
120
140
2013 2014 2015 2016 2017
Overdose
Other
2017
38%
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Southern Alberta … with permission Andreas Kramer
0
5
10
15
20
25
30
35
40
2011 2012 2013 2014 2015 2016 2017
OD
None OD
2017
37%
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TGLN data … with permission Andrew Healey
0
50
100
150
200
250
300
350
400
2014 2015 2016 2017
OD opiate
OD
Non OD
2017
8% / 12.7%
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Durand et al.
Overdose Deaths
Trauma Deaths
Medical Deaths
Infection Risk Deaths (IRDs)
Change in the Donor pool
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Hepatitis C
• In US
– Resurgence in Hepatitis C related to increased IVDU
in younger addicts … avg age donor 12 years
overdose deaths Hep C Donors
Gonzales et al. Hepatology 2018;67(4)1600-1608
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Durand et al.
Overdose Deaths
Trauma Deaths
Medical Deaths
Increase in Hepatitis C positive organ donors
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Utilization Rates Hepatitis C positive kidneys & livers
Li et al. Diseases 2018, 6, 62; doi:10.3390
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Hepatitis C positive into Hepatitis C negative
Gonzales et al. Hepatology 2018;67(4)1600-1608
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Recipient Outcomes are very good …
Durand et al.
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Impact on Organ Donation
• Increased volume of missed opportunities?
Work load
• Inability to do proper MRR
follow up of missed cases
• “Donor fatigue”
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BCKA
Neurological Determination of Death
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That afternoon …
• Shock – PEA x further 3 times
• Profound hypoxemia
– O2sats in 70% range for several hours
– Unresponsive to PEEP, recruitment attempts,
NO
• ECMO – on VV at 17:30
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Patient transfer
• Patient moved to regional ECMO centre and
more stable
– Arrived early evening Day 0
– On Propofol overnight – dc 07:00 Day 1
– Weaned off vasopressors by Day 2
– AKI resolved by Day 2
– LFTs normalizing
– ECMO – decannulated Day 3 15:50
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Neurological status
• On presentation
– Pupils fixed, dilated, no brainstem reflexes, no
response to painful stimuli
• After resuscitation
– Pupils no longer dilated or fixed, spontaneous resp
noted
• Further re-arrest x 3, profound hypoxemia, on ECMO
– Pupils fixed, no brainstem reflexes, no response to
painful stimuli throughout remainder of stay
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Neurostatus
• CT on Day 0 – diffuse cerebral edema
• CT on Day 2 – diffuse edema with evolving
changes of hypodensities within basal ganglia
and white matter
– Compatible with severe anoxic brain injury
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End of Life Discussions
• Very guarded prognosis from beginning
– Parents very interested in donation
• Day 4 post presentation
– 3 days without any sedation
• Propofol off 76 hrs
• Last Versed/Fentanyl 89 hrs
– On Fentanyl at 50 mic/hr x 2 hrs
– Midazolam at 10 mg/hr x 1 hr, 40 mins
• 22 hours off ECMO
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Brain Death Assessment
• 13:30 Day 4
– No brainstem reflexes
– No response to painful stimuli
– No spontaneous resp on Apnea test
• 16 minutes
• PaCO2 40 to 74, pH in expected range
• Pronounced dead
• BC Transplant contacted and NDD management put in
motion
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Next 24 hours
• Noted difficulty with recruitment maneuvers
• Question whether some spontaneous breathes
• With MRP present placed on T-piece and
occasional breathes noted @ ~ 08:30 Day 5
• Nuclear Med Brain Scan Day 5
– Flow to brain noted
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Next 24 hours
• Discussion with family
– MRP and 2nd colleague both of opinion patient has had a severe
anoxic brain injury and no hope of recovery
– Family do not wish life support to be continued
– Agree to DCD
• Day 5, extubated at 20:08 –
– > 108 hrs off Propofol, 120 hours since Versed, Fentanyl and ~
129 hours post-event
– No resp noted
– Asystole at 20:15
– To OR for recovery at 20:21
• 2 kidneys, liver recovered.
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Neurological Determination of Death of Overdose
• Challenge
– Uncertainty around what and how much taken
– Difficult to know when clearance sufficient
• Clinical assessment perhaps more to rule out
brain death
• Strongly consider ancillary testing
– Unclear how long to wait
– Don’t want to wait long
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Summary
• Opiate Crisis continues
– organ donors
• Canadian study of regional impact
– Increase in high risk / Hep C
– Stress on resources
– Need to focus on MRR
– Challenge of NDD in OD setting
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Thank you!
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The Opiate Epidemic and Organ Donation
1. Opiate epidemic is a real crisis
increasing number of deaths
decrease in life expectancy
no solution as yet
2. Opiate epidemic and organ donation
Increase in volume of donors
Change in donors
- more “increased” risk donors
- increase in Hep C organs available
- potential underuse of these organs
Declaration of Brain Death a challenge
- use of ancillary testing suggested
transplant.bc.ca
NDD versus DCD Organs Utilized
0
10
20
30
40
50
60
70
80
Kidney Liver Lung Heart
NDD
DCD
2017 OD donors
37 NDD
9 DCD (19.6%)
Non-OD donors
32% DCD
87 29 23 17
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Durand et al.
Transplant from Donors dying of Overdose
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