Community pharmacists and those working in hospital settings are being trained to help make naloxone easier to obtain and use for people who are at risk for an opioid overdose. In western New York, for instance, the University at Buffalo is partnering with public health and a national advocacy group to train community pharmacists on dispensing the opioid reversal agent.
The free online training course allows pharmacists to dispense naloxone without a patient-specific prescription based on standing orders sponsored by the nonprofit advocacy group Harm Reduction Coalition. The orders will eventually be issued by the Erie County Department of Health.
Although an increasing number of jurisdictions are establishing standing orders that apply to an entire county or state and allow pharmacists to distribute naloxone without a prescription, the Buffalo training program goes a step further, according to Edward Bednarczyk, PharmD, the chairman of the Department of Pharmacy Practice at the University at Buffalo School of Pharmacy and Pharmaceutical Sciences. “What makes this a novel approach is the pharmacist is [also] serving in a trainer role in working with patients and families of patients to handle either accidental or intentional overdoses,” Dr. Bednarczyk said.
The online module shows pharmacists how to train patients and families in how to use the nasal-delivery form of naloxone, which involves drawing the dose into a syringe and using a nasal administration device. Usually the drug is dispensed upon request from a family member. “They know a child, a spouse, a cousin or someone in the family who is at risk of dying because of a behavior,” Dr. Bednarczyk said. The requester, he noted, may have seen news coverage about dangerous combinations of nonmedical use of fentanyl and heroin, and want to know what to do in case of an overdose.
Even though the training is aimed at community pharmacists, Dr. Bednarczyk said it can be viewed by pharmacists in other settings, including inpatient settings where there are at-risk patients (those in substance abuse rehabilitation or who are given high doses of opioids) being discharged with opioids.
Pharmacists are also being engaged in expanding naloxone distribution through their inpatient clinical work, in the emergency department (ED) and in on-site ambulatory pharmacies that serve clinic patients. Massachusetts General Hospital, in Boston, has had an institution-wide standing order to dispense nasal naloxone from outpatient pharmacies to anyone who asks for it, according to Karen Ryle, MS, RPh, the associate chief of pharmacy for ambulatory care at the hospital. The order requires that pharmacists be trained in dispensing and use of nasal naloxone, which was provided through a webinar on the Prescribe to Prevent website (prescribetoprevent.org), which also maintains other useful resources on naloxone.
The nasal naloxone kit comes with directions, but pharmacists are trained to show the process to the user. “We go over the naloxone pamphlet with them, specify how to put the atomizer on it, how to administer it and to call 911,” Ms. Ryle said.
Pharmacists at Massachusetts General are involved in a variety of other ways, she said: Naloxone can be delivered to the bedside for at-risk patients at discharge; anyone who comes into the ED with an overdose is given a rescue kit; and the ED makes the kits available to any family member on request. The hospital’s ambulatory pharmacy also sponsors drug take-back events both in the community and on-site for employees to dispose of unused opioids.
Kevin Kaucher, PharmD, is a clinical specialist in emergency medicine who works directly with patients in the ED of Denver Health Medical Center. He estimated that the hospital’s ED naloxone distribution program has dispensed about 1,000 naloxone rescue kits in the past three years. Dr. Kaucher works with other pharmacists and health educators to intervene with high-risk patients.
Initially, the program focused on patients who had come in with an opioid overdose, who identified themselves as a substance user or who were using 100 mg morphine equivalent. Dr. Kaucher and his colleagues now approach patients who have been flagged in triage as saying they use illicit drugs and others who may be on methadone maintenance for previous substance abuse, or those prescribed high doses of oxycodone or benzodiazepines for chronic pain. Physicians in the ED also work with patients who have overdosed or come to the psychiatry unit with suicidal ideation.
Pharmacists throughout the Denver area are able to dispense naloxone without a prescription through standing orders, Dr. Kaucher said, and most major retail pharmacies, independent pharmacies and public health departments participate. Pharmacists in retail settings need to know how to identify, dispense and educate a patient on naloxone as part of the annual competencies, he said, as do those at Denver Health Medical Center. “These requests and consults can come from any patient in the hospital, from internal medicine, the psych service,” he said. “Every hospital service has pharmacists trained in identifying patients who might need a naloxone prescription.”
Maryland has also established a standing order for naloxone, Nina Bemben, PharmD, a pain specialty pharmacist at the University of Maryland, in Baltimore, said. “Under this standing order, pharmacists may dispense naloxone and required administration supplies to anyone with a training certificate from the Maryland Overdose Response Program. There have been a lot of questions from community pharmacists about how they should handle this,” said Dr. Bemben, who attended a state Board of Pharmacy meeting where the topic was discussed. Patients need to know, for instance, whether the prescription is covered by insurance and whether to contact emergency medical services along with administering naloxone, she said. (The answer is an emphatic “yes, call 911,” she noted.)
Community pharmacists also want help in recognizing an illegitimate or risky prescription, Dr. Bemben said. Furthermore, they need training in how to identify patients who may be at risk, as they may have an outdated idea of the stereotypical substance user.
Dr. Bemben specializes in pain treatment and palliative care, and pointed out that even patients with a life-threatening diagnosis may be at risk for abuse or overdose. “We’ve had some direction from our state Department of Health about who we should be providing naloxone to, coprescribed with their opioid,” she said. “It turns out pretty much everybody could potentially benefit from having access to naloxone.”
Leave a Reply
You must be logged in to post a comment.