Reducing harm for addicts

On average, 115 Americans die every day from an opioid overdose, according to the Centers for Disease Control and Prevention (CDC), which also notes that the number of overdose deaths involving opioids — including prescription as well as illegal opioids like heroin and illicitly manufactured fentanyl — was five times higher in 2016 than in 1999.

Reducing the prescription of opioids by physicians, preventing misuse of the drugs and treating opioid-use disorder are imperative to slowing the loss of life, says William Eggleston, a clinical toxicologist and clinical assistant professor of pharmacy practice in Binghamton University’s School of Pharmacy and Pharmaceutical Sciences.

That’s why he is working to expand the use of Narcan — a nasal spray form of naloxone, a medication designed to rapidly reverse an opioid overdose — and educate the public about its use. His research is focusing on harm reduction. “We know we have a lot of patients in the U.S. who use opioids every day, and we don’t have enough resources to treat all of those patients right now.

“The idea behind harm reduction is, ‘Let’s put some measures in place that will give patients a chance to live long enough to get the treatment that they need,’” Eggleston says. “So I’m studying things like which type of naloxone should we give to members of the community? What is the best way to distribute that naloxone?”

One project he’s completed was determining how more people without medical training could use naloxone to prevent deaths from overdoses.

Patients can be given naloxone via nasal spray (Narcan) or intramuscular injection, but no one knew which method people would be able to use comfortably and with the highest degree of success, he says.

“Over the course of two years, we were at the New York State Fair having randomized individuals use one of these methods. They watched a training video, and then we watched to see if they could give naloxone successfully to a mannequin,” he says.

Later, when naloxone became available without prescription, Eggleston realized people might be administering it without training. So he went back to the study to reassess which means of administering the drug would result in the best outcome.

“We did the same project without video training and found that the single-step nasal spray had the greatest amount of success, and with training, nasal sprays in general had a higher degree of success than the shot. Even if it seemed to us it was a no-brainer that we should be using nasal sprays, we had no data before, so now we have a little bit to support that,” he says.

Spurring research

Eggleston’s work on opioid harm reduction has really taken off since he joined the new pharmacy school.

“We’re establishing an opioid research center at Binghamton University. I’m coordinating that effort with Eric Hoffman [professor of pharmaceutical sciences and associate dean for research]. The center is a collaborative effort between Binghamton and SUNY Upstate Medical University in Syracuse, N.Y., with the goal of creating a multi-institutional center — the Opioid Research Center for Central New York — that can look at both clinical and research aspects of the opioid epidemic. Initial seed funding has come through SUNY, and there are interested collaborators on the Binghamton campus and in the community,” Eggleston says.

Eggleston spends about 60 percent of his time at the pharmacy school and the remaining 40 percent at SUNY Upstate, where his clinical responsibilities include direct patient care through a toxicology consult service. “When I’m in Syracuse, my primary role is leading that service,” he says. “When a patient comes into the hospital for any sort of exposure reason — whether that’s an intentional overdose, an unintentional overdose in which someone takes an extra medication because they forgot they took it, or their kidneys stopped working well and they’ve been accumulating a drug in their body — we see those patients.”

Eggleston says there have been plenty of Tide pod patients, but no teenagers ingesting them on a dare.

“We started seeing Tide pods three or four years ago, but there’s been a pretty aggressive public-health campaign to try and make parents more aware of the problem.”

Industrial exposures also bring patients in. “I saw a guy recently who was at work and a nozzle blew off a vat full of chemicals, and he got sprayed with the chemicals. We get called for those and for the occasional homicide or attempted homicide, so it’s always interesting,” Eggleston says.

Seeing these patients has spurred Eggleston’s research interests.

When Eggleston is at the pharmacy school, other clinical toxicologists and physicians assume responsibility for running the toxicology consult service. One of those colleagues is Ross Sullivan, assistant professor of emergency medicine and director of medical toxicology at SUNY Upstate, where he is board-certified in addiction medicine.

“Willie and I are both toxicologists, but we’re different in how we treat addiction,” Sullivan says. “I do a lot of taking care of patients with medically assisted treatments, such as using a methadone alternative, while he does more of the education and outreach.”

Collaboration is built into their work.

“We have a system in place where we can simultaneously get in touch with everyone and say, ‘Hey, I’m stuck. Can we talk about it?’ And every single day we have what we call fellow rounds, so our fellows sit down with all of the attendings and present cases and we discuss them,” Eggleston says. “We have folks sign in remotely via our web service, so we have relationships with the toxicologists in Albany, in Rochester, and all of those people will be present. That’s a lot of brains that we bring together.”

It’s unknown whether people who are rescued from an overdose by naloxone go on to get treatment for their addiction, but it’s clear that the naloxone is saving lives, Sullivan says.

“Onondaga County saw about a 30 to 40 percent drop in opioid-related deaths from 2016 to 2017, which is a reflection of the efforts in the county. A large part of that is naloxone training, and we’re part of that program.”

Clinical rotations

Eggleston’s clinical role will begin impacting pharmacy school students in their third year when they complete their final introductory pharmacy practice-experience rotation in advanced clinical pharmacy. “I will have students up here once a week who will get to see what I do clinically at the bedside and get involved with helping to take care of those patients. They’ll start to get their first taste of one of the many different things a pharmacist can do,” he says.

In their fourth year, students will complete six-week rotations with Eggleston. “They’ll get to see all the things that we do and get very involved in the clinical care of patients and use the skills they’ve been learning in school.

“We’re working very hard to ensure that students have the broadest experience possible with pharmacy because we know there are a lot of options out there. How you envision yourself as a pharmacist when you’re a student can change as you go through these experiences,” he says. “We want to make sure our students have as many experiences as possible so they can find the area that they truly believe is best-suited for them and where they can have the highest impact on patients.”

The pharmacy school has made toxicology a requirement, Eggleston says. “It’s not something that’s taught everywhere. Some schools have taken the approach of making it an elective or a rotation experience, but I thought it was important that it got worked into the curriculum because we, as pharmacists, are the medication experts. We are the ones who are supposed to know how these medicines work and how they are going to affect the body, which medicines are best to treat a problem, what side effects you might see.”

Eggleston is also teaching in the medical marijuana and gastrointestinal courses, which challenges him in a good way. “I had to relearn some of that information because it’s not what I do every day,” he says. “That’s one of the things I enjoy most about being on a campus and being with our students, is that they challenge me day in and day out and, as a result, I get to learn new things or relearn things that I once knew.”

Eggleston’s other roles

Education

William Eggleston, a clinical toxicologist and clinical assistant professor of pharmacy practice in Binghamton University’s School of Pharmacy and Pharmaceutical Sciences, teaches emergency medical residents, SUNY Upstate fellows and EMS students at SUNY Upstate Medical University in Syracuse.

“Education from the perspective of drugs of abuse is two-fold,” he says. “A big part of education is making individuals aware of what the true risks of taking the drug are. I try to highlight the things that can kill you, to make people aware of how dangerous they truly are. And the hope is that you’ll prevent someone from using it in the first place.

“And for individuals who are already using opioids, the education focuses more on what resources are available to help that person? It’s not a willpower or a lack-of-knowledge issue,” Eggleston says.

Addiction is prompted by a change in brain chemicals. People who are addicted need medication and a comprehensive treatment program if they’re going to be able to get through it. “So making patients aware of what is out there that can help them is really important,” he says.

The last critical piece of education, Eggleston says, is educating the public on the realities of what addiction is and how it happens, in the hope of reducing some of the stigma surrounding it. “Part of why patients with opioid use disorder don’t reach out is because they don’t want friends or family or colleagues to know because there is such a strong stigma,” he says.

New York State Poison Control Center

New York state has two poison control centers, one in New York City and one in Syracuse; the latter responds to calls from 54 counties, including 114 hospitals. William Eggleston’s clinical site is in Syracuse. This poison center has nurses and pharmacists working as information specialists 24/7. “When mom or dad calls, freaking out because a child has eaten that silica packet from inside the shoe box that says ‘Do not eat!’, we can reassure them that it is nontoxic and that the child will be fine,” he says. And that saves a trip to the ER.