Snohomish Health District

Health Alert From Snohomish Health District

Today’s topics:
•    Loperamide as opioid substitute
•    Fentanyl
•    Chronic pain training
•    Testing for Zika virus
•    Ticks

Loperamide as opioid substitute
Action requested:  Be aware that persons addicted to opioids may abuse loperamide to get high.

Background & Recommendations:
A recent article in the Annals of Emergency Medicine reported two deaths due to supratherapeutic use of the over the counter anti-diarrheal drug, loperamide.  Supratherapeutic doses of loperamide produce central nervous system opioid effects, leading some patients use loperamide to self-treat their opioid addiction.  However, supratherapeutic doses of loperamide can also cause ventricular dysrhythmias. Providers should be aware of potential loperamide abuse and its complications when caring for persons addicted to opioids.

Action requested:  Be aware that persons addicted to opioids may be using street drugs containing fentanyl, for which much higher doses of naloxone are needed to reverse overdoses.

Background & Recommendations:
Pharmaceutical fentanyl is a synthetic opioid pain reliever, approved for treating severe pain, typically advanced cancer pain. Prescribed as transdermal patches or lozenges, fentanyl is 50 to 100 times more potent than morphine and has increasingly been diverted for abuse in the United States.  However, most recent cases of fentanyl-related harm, overdose, and death in the U.S. are linked to illegally made fentanyl, often mixed with heroin and/or cocaine to increase the euphoric effects of those drugs.  As illegally made fentanyl confiscations have increased nationwide, so have fentanyl-related overdose deaths. Although fentanyl overdoses can be reversed with naloxone, providers should be aware that substantially higher doses or multiple doses of naloxone may be required.

For more information, click here.

Chronic Pain Training
Action requested:  Take advantage of free training about current recommendations for opioid management of chronic pain.

Background & Recommendations:
The Centers for Disease Control & Prevention (CDC) is offering a webinar/call presenting an overview of the recently released CDC guidelines. Learn when and how opioids should be initiated for chronic pain, how to assess risk and address harms of opioid use, and when and how opioids should be discontinued. This is the first in a series of four calls. Free continuing medical education credit is available. Registration is not required.  For details, click here.

Testing for Zika virus
Actions requested:  Include urine samples when testing for acute symptomatic Zika virus infection and be aware of guidance to properly interpret any Zika test results.

Based on increased experience when testing for Zika virus, CDC has updated its guidance for clinicians.  Real-time reverse transcription–polymerase chain reaction (rRT-PCR) is the preferred test for acute symptomatic Zika virus infection. rRT-PCR can be performed rapidly and is highly specific. However, Zika virus RNA is unlikely to be detected in serum after the first week of illness.  Several studies have documented prolonged detection of Zika virus in urine, including a recent study by the Florida Department of Health comparing Zika virus PCR results in serum, urine, and saliva.  The study concluded that urine specimens are more likely than serum specimens to test positive for Zika virus among persons with confirmed or probable Zika virus disease and who had traveled to areas with endemic Zika virus (see Comparison of Test Results for Zika Virus RNA in Urine, Serum, and Saliva Specimens from Persons with Travel-Associated Zika Virus Disease — Florida, 2016).  Consequently, CDC now recommends that rRT-PCR testing of urine should be performed in conjunction with serum testing.

Interpreting test results can be complicated.  A positive rRT-PCR result confirms Zika virus infection, but a negative rRT-PCR result does not exclude infection.

Immunoglobulin (Ig) M and neutralizing antibody testing may identify additional recent Zika virus infections among persons with negative rRT-PCR results, but cross-reactivity with other flaviviruses (e.g., dengue and West Nile) means the specific virus may not be identifiable.  In such situations, clinicians should test for both Zika and dengue.  (Note: For serum specimens collected <7 days after onset of symptoms, a negative rRT-PCR result and negative IgM antibody testing suggests that there was no recent infection.)  CDC specifically advises:

“Pregnant women with laboratory evidence of Zika virus infection should be evaluated and managed for possible adverse pregnancy outcomes and be reported to the U.S. Zika Pregnancy Registry or the Puerto Rico Zika Active Pregnancy Surveillance System for clinical follow-up.  All patients with clinically suspected dengue should have proper management to reduce the risk for hemorrhage and shock. If serologic testing indicates recent flavivirus infection that could be caused by either Zika or dengue virus, patients should be clinically managed for both infections because they might have been infected with either virus.”

1.    Continue to advise pregnant patients to avoid travel to areas where Zika virus transmission is ongoing because of the potential for microcephaly and other poor pregnancy outcomes in babies of mothers infected with Zika virus while pregnant.  Advise pregnant women who can’t postpone travel to an area with Zika virus transmission to strictly follow steps to avoid mosquito bites. Insect repellents containing DEET, picaridin, and IR3535 are considered safe for pregnant women when used as directed.  No specific antiviral treatment is available for Zika disease. Treatment is generally supportive and can include rest, fluids, and use of analgesics and antipyretics. Pregnant women who have a fever should be treated with acetaminophen.

2.    Collect serum for rRT-PCR testing from symptomatic patients with exposure to Zika virus who present within 7 days of illness onset.  Collect urine for Zika virus rRT-PCR testing on symptomatic patients with exposure to Zika virus who present within 14 days of illness onset.

3.    Collect serum for IgM antibody testing on symptomatic patients ≥4 days after symptom onset and asymptomatic pregnant patients 2-12 weeks following exposure.

4.    Contact the Health District at 425-339-5278 to determine eligibility for Zika virus testing and to arrange for testing.

5.    Be aware that the COPA America Centenario international soccer tournament is occurring in Seattle on June 4, June 14, and June 16.  Organizers anticipate a surge of international travelers, many from Zika-affected countries.  Consider the potential for Zika infections among tournament participants from other countries who present with Zika symptoms.

For more information about testing for Zika virus infection, see Interim Guidance for Zika Virus Testing of Urine — United States, 2016 and Interim Guidance for Interpretation of Zika Virus Antibody Test Results.

Tickborne diseases
Action requested:  Be aware of updated guidelines for the diagnosis and management of tickborne rickettsial diseases.

Background & Recommendations:
CDC has just issued a report “to assist health care providers and public health professionals to 1) recognize key epidemiologic features and clinical manifestations of tickborne rickettsial diseases, 2) recognize that doxycycline is the treatment of choice for suspected tickborne rickettsial diseases in adults and children, 3) understand that early empiric antibacterial therapy can prevent severe disease and death, 4) request the appropriate confirmatory diagnostic tests and understand their usefulness and limitations, and 5) report probable and confirmed cases of tickborne rickettsial diseases to public health authorities.”  Details can be found here.

You can find my recent health alerts posted on the Provider pages of our website.

Gary Goldbaum, MD, MPH 
Health Officer & Director