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14 Articles in Volume 18, Issue #2
Ask the Expert: Is there evidence to prescribe cyclobenzaprine long-term?
Challenging the Chronic Pain Personality Profile
Designer Peptide May Prevent Chemo-Induced Neuropathy
Inside the Cancer Pain Research Consortium
Intrathecal Drug Therapy for Cancer-Related Pain
Managing Cancer Pain in an Era of Modern Oncology
Mapping Complex Pain: A Case Study
Medication Overuse Headache: Inaccurate and Overdiagnosed
Pain and Fall Risk in the Elderly
Reporting Quality of Care in Cancer Pain Management
Sharing the Risk: An Update to DEA & Doctors Working Together
The Intensifying Conflict Between Opioid Control and Pain Control
Two Mobile Apps Aim to Target Patient Compliance & Safety
Why Prescribers Need to Adopt Abuse-Deterrent Opioids

Two Mobile Apps Aim to Target Patient Compliance & Safety

As the focus on opioid abuse grows, healthcare providers and patients alike are becoming more aware of the need to be able to adequately track opioid dosages and have emergency plans, such as naloxone administration, in place. Two apps offer solutions.

NOverdose Enables Emergency OD Response


About the Device

Product: NOverdose
Overview: This smartphone application has the potential to connect opioid overdose victims with naloxone carriers anonymously, with the goal of supporting the substance abuse community and those at elevated risk of opioid induced respiratory depression receiving prescribed opioids.
Price: Free download and usage
Developers: Jeffrey Fudin, PharmD,* Nadia Shahzad, PharmD, and Nicholas Jarrett, PhD, of Remitigate LLC, Delmar, NY
Availability: Beta testing of the app is ongoing and expected to conclude early spring 2018. Staged studies before a national market entrance are expected immediately following, contingent on study results and funding.

In the early 1970s, FDA approved naloxone to treat a known or suspected opioid overdose; after some evolution with the product, generic versions have been on the market since 1985. (Editor's Note: In April 2018, the US Surgeon-General advised that patients currently taking high doses of prescribed opioids as well as other members of the medical community and general public carry naloxone as a preventative measure.) Available as an intramuscular or subcutaneous injectable, and more recently via auto-injector and commercialized nasal spray, the emergency medication is typically administered by a third party, whether that may be a friend, caregiver, emergency medical technician, or Good Samaritan.

In recent years, Jeffrey Fudin, PharmD, and colleagues noticed a gap in the growing smartphone marketplace for patient compliance with regard to overdose response. With the NOverdose app, a caregiver, friend, peer, or bystander can locate and summon close-by naloxone carriers and emergency responders in the case of a potential or confirmed opioid overdose with the tap of one button.

How it Works

Patients taking opioids, as well as individuals certified to administer/carry naloxone (eg, via local or county pharmacy-led Good Samaritan programs) can download the app. Potential responders must have their “available to respond” button activated to receive the emergency notification.

Another option in the app called Dose Monitor allows opioid users to set a timer for 10, 20, 30, or up to 60-minute intervals, for example, immediately after they take a dose of their opioid. When the timer reaches two minutes, the patient will be notified to turn off the timer, essentially providing a failsafe to ensure the patient is OK after consuming the medication. If the timer reaches its countdown, without being turned off, it will automatically send alerts to those who have designated themselves as naloxone carriers within a specific GPS radius—or to the patient’s pre-selected emergency contacts—that the patient has not responded to the alarm, and a potential overdose has occurred.

Additionally, if the “Opioid Overdose Emergency” button is activated—presumably by a caregiver or one of those responders, an automated text will be sent to 911, a preprogrammed significant other, and the nearest naloxone carrier. The 911 call may be inactivated in advance, but this option comes with a warning against; in this case, Good Samaritan responders will be made aware that they are responding to a situation in which professional emergency help has not been summoned.

Once a naloxone carrier answers “Yes” to responding, a map with GPS coordinates opens, along with a chatbox for communication between the victim’s caregiver and the naloxone carrier. If there are no nearby responders within 1 minute, the app automatically expands the search field to notify the next closest naloxone carriers. On scene, the app provides step-by-step instructions for administering naloxone, according to the type (eg, injectable, spray).

“In a panicked situation, or one in which the initial naloxone administration did not completely work, if someone arrives at the scene quickly, the chances of initial and subsequent reversal could be improved,” said Dr. Fudin.

Looking ahead, the NOverdose developers plan to add a feature for sending follow-up alerts to those that pressed the emergency button, encouraging them to seek counseling and, if needed, substance abuse help. Information on local rehabilitation clinics will be made available according to proximity of local rehabilitation facilities.

“Likewise, app users will be able to anonymously report bad batches of street drugs that may then be shared with other app users within the same geographic area,” said Dr. Fudin. “The primary purpose of the app is to provide both patients who are prescribed opioids and the substance abuse community a platform for community-based and emergency support with opioid overdose reversal to help save lives.”


Observation Therapy App Targets Opioid Use Disorder

About the Device

Product: emocha
Overview: This HIPAA-compliant mobile app records videos of patients taking their medication, creating accountability and encouraging communication with providers when needed. Prescribers benefit from dose-by-dose adherence data to better serve patient needs.
Price: Free for patients; provider costs vary based on volumes
Developers: emocha Mobile Health Inc., Baltimore, MD. Partners include the National Institute on Drug Abuse, National Institute on Minority Health and Health Disparities, Maryland TEDCO, BioHealth Innovation, Kapor Capital, and Propel Fund Baltimore.
Availability: emocha entered the market in 2014 for tuberculosis treatment adherence, and is gaining ground in the opioid use disorder space.

In 2015, emocha Mobile Health won a small business innovation research award from the National Institutes of Health for its work on patient adherence to tuberculosis treatment using a smartphone and web application for video Directly Observed Therapy. Today, the app is widely used across the country and abroad with the goal of improving medication compliance, most recently with regard to prescribed buprenorphine, and physician-patient communication.

As described above, emocha enables patients to record themselves taking a prescribed dose of medication, automatically capturing date and time. The video is then made available to the healthcare provider via a portal to track and monitor adherence, following up with the patient via the app, phone, or in-person as needed.

For pain practitioners and prescribers, the app has the potential to help reduce opioid use disorder (OUD), or opioid addiction. “A major concern for prescribers of buprenorphine is potential medication diversion,” explained Andrew Saxon, MD, professor of psychiatry at the University of Washington and Director of the CESATE VA Puget Sound Health Care System. He served as one of the app team’s clinical advisors and has worked in substance abuse treatment and addiction medicine for more than 30 years. “DOT cannot totally prevent diversion, but if it is confirmed that the patient is taking the proper dosage each day, it makes diversion much less likely. This may, in turn, make providers more comfortable in prescribing higher, more therapeutic doses as well.”

In some cases, a patient who is misusing or abusing opioids may simply skip one or more doses of their medication so that they can use them together to get high, explained Dr. Saxon. Directly Observed Therapy may help reduce this possibility by alerting the provider that doses have been missed.

One downside of the app may be the time involved for the provider to watch the videos. But, said Dr. Saxon, it “would likely ease the provider’s anxiety level” in the long run and might ultimately reduce the provider’s time commitment “because patients do not become destabilized.” One might speculate that healthcare costs overall could be reduced, he noted, assuming that better adherence translates to fewer emergency room visits and hospitalizations.

Looking forward, Dr. Saxon said there may be opportunities for directly observed therapy apps like emocha to have application in treatment plans beyond pain and OUD. “Think about its use in treatment of Hepatitis C, for example,” he said. “The medication is very expensive. If a patient misses even a few days over an 8- to 12-week treatment course, that could render the treatment ineffective and waste the resources. Wouldn’t we all feel better knowing the patient is taking it?” There may also be beneficial application for conditions such as first-episode psychosis. “The best predictor of outcomes is medication adherence, but most patients don’t stick with their oral antipsychotics,” he said. “DOT would help assure that they do.”

Last updated on: April 12, 2019
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