Pharmacists can play a vital role in helping to fight the opioid epidemic in our state by providing education about overdose risks, ensuring appropriate medication management, and providing naloxone to the community
Join Dr. Amanda Isac as she explores how pharmacists can improve community access to naloxone
For a comprehensive read regarding all things naloxone in North Carolina, see the North Carolina Division of Public Health’s, Injury and Violence Prevention Branch naloxone toolkit
Naloxone is not a new medication! It has been used safely and effectively since the early 60’s to reverse opioid overdose. Today, worried parents, grandparents, students, and even law enforcement carry naloxone in case of an opioid emergency. Yet there are still misconceptions surrounding its use.
Myth
Fact
“Drug users view Naloxone as a ‘safety net’ thus enabling more drug use”
Research shows no evidence use of naloxone encourages drug use. In fact, with appropriate education and counseling, one pilot found the frequency of heroin use actually decreased.
“Naloxone prevents drug users from seeking treatment”
There is also no evidence to support naloxone prevents a person from seeking treatment for their opioid use disorder. On the contrary, the near-death experience often catalyzes someone to want professional help.
NALOXONE ACCESS LAW
A Historical Perspective
2013 - NC Legislature Passes Naloxone Access Law To address increasing deaths from heroin, fentanyl, and other synthetic narcotics
2014 - NCBOP Expands Naloxone To its list of drugs and devices that can be dispensed by local health department registered nurses that have training specific for medication dispensing
2016 - Law Amended To establish authority of the State Health Director to issue a statewide standing order for naloxone
2017 - Law Added A Provision, as part of the STOP ACT, to allow health care providers to write standing orders to allow organizations, including local health departments, to distribute naloxone in the community
NC State Health Director’s Naloxone Standing Order for Pharmacists
Authorizes any pharmacist practicing in the state of NC and licensed by the NC Board of Pharmacy to dispense naloxone to any person at risk of an overdose OR who might be in a situation to help someone at risk of an overdose
The standing order is written to be AS BROAD AS POSSIBLE so anyone can access naloxone
While the standing order provides examples of high-risk patients suitable for naloxone, the lists is not all inclusive.
Beware of the phrase “Persons who voluntarily request”! Pharmacists often misinterpret this language thinking they need to wait for a person to request naloxone before they can dispense it under the standing order. Not true!
Pharmacists are highly encouraged to utilize the CSRS and other validated screening tools to proactively assess a patients need for naloxone
FDA-Approved Naloxone Products available for Dispensing Under the Standing Order
Given the rise in potency of synthetic opioids found in today’s drug supply, it has been theorized higher doses of naloxone may be needed to reverse an opioid overdose. While the NC naloxone standing order has updated its list of approved agents to include the newly marketed high dose naloxone formulations, understand there is still skepticism surrounding their use. More potent, longer-acting naloxone may have unintended consequences. Input from patients should be solicited and carefully considered before embracing higher dose agents.
Pharmacists should recommend products based on patient preference, availability, insurance coverage, and other pertinent factors.
KNOW YOUR PATIENTS Develop a Strategy to PROACTIVELY ASSESS Your Patients at Risk for an Opioid Overdose Consider Using These Tools to Aid in Your Assessment
Population-Based Opioid Utilization Reporting
Population reporting provides pharmacists valuable insight into the opioid burden that exist within the confines of their own practice. PioneerRx was one of the first pharmacy software vendors to bring this type of reporting to its users.
NARX Report Provides type-specific use scores based on a person’s controlled substance fill history. Helps pharmacists assess in 3 seconds or less if their patient could benefit from carrying naloxone.
PATIENTS WITH OPIOID RISK SCORES (ORS) ABOVE 450 COUNSEL ON THE BENEFITS AND NEED TO CARRY NALOXONE
Click on the video image below for a brief tutorial on how you can use CSRS enhancements to identify your patients at risk for overdose
RIOSORD Risk Index for Overdose or Serious Opioid-Induced Respiratory Depression
RIOSORD Screening Tool 17-Item validated method for determining risk of overdose. Most favorable tool among pharmacists Many of the questions in the RIOSORD can be gleaned from patient’s medication fill history.
PATIENTS WITH 25 OR MORE POINTS COUNSEL ON THE BENEFITS AND NEED TO CARRY NALOXONE
Click on the video image below for a brief tutorial on use of both the ORT and RIOSORD to identify your patients at risk for overdose
Opioid Risk Tool- Revised (ORT-R)
ORT-R Screening Tool 9-item validated method to help pharmacists quickly assess if a person is at risk for developing opioid use disorder.
PATIENT SCORES > 3 COUNSEL ON THE BENEFITS AND NEED TO CARRY NALOXONE PROVIDE ENHANCED MONITORING WHILE ON OPIOIDS CONSIDER RECOMMENDATIONS FOR NON-OPIOID ALTERNATIVES
CONVERSATION MATTERS
Keep the Stigma Out of Your Conversation and Become a Pro at Conveying the Benefits of Naloxone to Your Patients
The American Pharmacists Association (APhA) has a fantastic guide for helping pharmacists to normalize conversations and convince patients of their need to carry naloxone in 3 easy steps.
Steps
Examples
Step 1: Learn how to personalize your naloxone discussion based on certain patient characteristics
“Pain medications can be helpful, but they also have a range of side effects, including slowing down or even stopping your breathing. Because you have COPD you are especially at risk for this happening. Naloxone is a medicine I can give you should you have a breathing emergency.”
Step 2: Ask Permission
“Would you mind if I talk to you about naloxone?”
Step 3: Compare naloxone to other life-saving medications or situations to which a person might relate. Describe it as a medication that’s only to be used in a worst-case scenario.
“Carrying naloxone is just like someone with asthma carrying a Ventolin inhaler in case they have an asthma attack” “Naloxone can save your life, it just like having a fire extinguisher in your home in case of a fire. It’s something we hope we never have to use, nor do we purchase it with the intent of using it, but it certainly gives us piece of mind knowing its around just in case.”
Discuss the Various Naloxone Formulations Available for Dispensing
Employ informed decision making, solicit patient feedback and preference when choosing an agent. Other factors to consider might include, costs, insurance coverage as well as product availability.
Make Sure Education Aligns With the Requirements in the Standing Order
Every person provided naloxone under the standing order shall receive education regarding the risk factors of overdose, signs of an overdose, overdose response steps, and the use of naloxone.
Take advantage of the Opioid Action Plan provided below when dispensing naloxone Customize it by adding your pharmacy name and contact information should patients have questions or need to reach out to you for replacement naloxone.
The Opioid Emergency Action Plan Serves Three Purposes:
It ensures pharmacist cover the patient education required in the naloxone standing order
It reinforces the pharmacist counseling to the patient once they leave your store
It gives patients a take home tool to train others in the event of an opioid emergency Remember, patients are not going to administer naloxone to themselves. They must understand the need to identify and train a partner in what to do should they become unconscious or stop breathing.
