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Expanding prescription naloxone. Alex Walley & Maya Doe- Simkins on behalf of prescribetoprevent.org. prescribetoprevent.org: Jenny Arnold, PharmD , BCPS Leo Beletsky , JD, MPH Alice Bell, LCSW Sarah Bowman, MPH Jef Bratberg , PharmD , BCPS Scott Burris, JD.

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Expanding prescription naloxone

Expanding prescription naloxone

Alex Walley & Maya Doe-Simkins on behalf of prescribetoprevent.org

prescribetoprevent.org:

Jenny Arnold, PharmD, BCPS

Leo Beletsky, JD, MPH

Alice Bell, LCSW

Sarah Bowman, MPH

JefBratberg, PharmD, BCPS

Scott Burris, JD

NabarunDasgupta, MPH

Maya Doe-Simkins, MPH

Traci Green, MSc, PhD

Sammy McGowan

Alexander Y. Walley, MD, MSc


Getting naloxone in overdose bystanders hands community models
Getting naloxone in overdose bystanders’ hands: Community models

  • Varies: person who gets nlx can be potential overdose bystander or must be potential overdose victim?

Distribution Model

Modified Prescription Model

Nlx not dispensed from pharmacy

Records establish provider-pt relationship

Provider or on-site delegate gives nlx

No billing for nlx/svcs

Less legal gray area

Standing order:

Off site dr authorized nonmedical person to train/give nlx

  • Nonmedical hand out nlx

  • Nlx not at pharmacy

  • Minimal record keeping

  • No billing for nlx/services

  • Legal gray area


Legal barriers to prescription model
Legal modelsBarriers to Prescription Model

“Prescribing naloxone in the USA is fully consistent with state and federal laws regulating drug prescribing. The risks of malpractice liability are consistent with those generally associated with providing healthcare, and can be further minimized by following simple guidelines presented.”

  • Prescribe to a person who is at risk for overdose (except IL, MA, WA, CT)

  • Ensure that the patient is properly instructed in the administration and risks of naloxone

Burris S at al. “Legal aspects of providing naloxone to heroin users in the United States. Int J of Drug Policy 2001: 12; 237-248.


Challenges for community programs
Challenges for community programs models

Opportunities for prescription naloxone

  • Naloxone cost increasing, funding minimal

  • Missing people who don’t identify as drug users, but have high risk

  • Missing people who may periodically misuse opioids=no tolerance

  • Co-prescribe naloxone with opioids for pain

  • Co-prescribe with methadone/ buprenorphine for addiction

  • Insurance should fund this

  • Increase patient, provider & pharmacist awareness

  • Universalize overdose risk

  • One person can start a program


Traditional p rescription model elements
Traditional modelsprescription model elements


Practical barriers to prescribing naloxone
Practical barriers to prescribing naloxone models

  • Patient at risk for OD

  • Pt and/or prescriber must recognize OD risk


Practical barriers to prescribing naloxone1
Practical barriers to prescribing naloxone models

  • Prescriber gives rx for naloxone rescue kit + education

  • Prescriber comfort

  • Patient inclusion criteria

  • How to write prescription

  • Institutional approval(?)


Practical barriers to prescribing naloxone2
Practical barriers to prescribing naloxone models

  • Pt pharmacy of choice to fill

  • Groundwork necessary inhibitive-focus on main pharmacy(ies) patients use or internal (hospital) pharmacy


Practical barriers to prescribing naloxone3
Practical barriers to prescribing naloxone models

  • Pharmacist “compounds” rescue kit, offers education

  • Informed pharmacist

  • Naloxone & delivery devices (MAD or syringes) in stock?

  • Literature for patient(?)


Barriers to traditional prescription
Barriers to Traditional Prescription models

  • Pharmacist bills insurance (or pt)

  • Medicaids often pay, private ins varies

  • Doesn’t cover MAD (~$4)

  • Some pharmacies absorb cost


Traditional prescription
Traditional Prescription models

  • Pt gets naloxone rescue kit!


Site visits
Site visits models

  • > 5000 visits


Questions

Questions? models

Thank you!






Overdose education in medical settings
Overdose Education in Medical Settings models

Where is the patient at as far as overdose?

Ask your patients whether they have overdosed, witnessed an overdose or received training to prevent, recognize, or respond to an overdose

Overdose history:

Have you ever overdosed?

What were you taking?

How did you survive?

What strategies do you use to protect yourself from overdose?

How many overdoses have you witnessed an overdose?

Were any fatal?

What did you do?

What is your plan if you witness an overdose in the future?

Have you received a narcan rescue kit?

Do you feel comfortable using it?


Overdose education in medical settings1
Overdose Education in Medical Settings models

What patients need to know:

Prevention - the risks:

Mixing substances

Abstinence- low tolerance

Using alone

Unknown source

Chronic medical disease

Long acting opioids last longer

Recognition

Unresponsive to sternal rub with slowed breathing

Blue lips, pinpoint pupils

Response - What to do

Call for help

Rescue breathe

Deliver naloxone

Continue rescue breathing for 3-5 minutes

Stay until help arrives


Expanding prescription naloxone
Passed modelsMassachusetts in August 2012:An Act Relative to Sentencing and Improving Law Enforcement Tools

Good Samaritan provision:

  • Protects people who overdose or seek help for someone overdosing from being charged or prosecuted for drug possession

    • Protection does not extend to trafficking or distribution charges

      Patient protection:

  • A person acting in good faith may receive a naloxone prescription, possess naloxone and administer naloxone to an individual appearing to experience an opiate-related overdose.

    Prescriber protection:

  • Naloxone or other opioid antagonist may lawfully be prescribed and dispensed to a person at risk of experiencing an opiate-related overdose or a family member, friend or other person in a position to assist a person at risk of experiencing an opiate-related overdose. For purposes of this chapter and chapter 112, any such prescription shall be regarded as being issued for a legitimate medical purpose in the usual course of professional practice.


Patient selection
Patient Selection models

  • After emergency medical care involving opioid intoxication or poisoning

  • Suspected hx of substance abuse or nonmedical opioid use

  • Patients taking methadone or buprenorphine

  • Any patient receiving an opioid prescription for pain and:

    • higher-dose (>50 mg morphine equivalent/day) opioid

    • rotated from one opioid to another= poss incomplete cross tolerance

    • Smoking, COPD, emphysema, asthma, sleep apnea, respiratory infection, or other respiratory illness or potential obstruction.

    • Renal dysfunction, hepatic disease, cardiac illness, HIV/AIDS

    • Known or suspected concurrent heavy alcohol use

    • Concurrent benzodiazepine or other sedative prescription

    • Concurrent antidepressant prescription

  • Patients who may have difficulty accessing emergency medical services (distance, remoteness)

  • Voluntary request from patient or caregiver