The Washington
State Pharmacist
Perspective
Jenny Arnold, PharmD, BCPS
Director of Pharmacy Practice Development
Washington State Pharmacy Association
Objectives
Describe Washington State’s Opiate Deaths
Discuss the Scope of Practice of Pharmacy
Explain Collaborative Practice Agreements
Analyze the challenges of initiating a CPA
Examine alternatives for pharmacy involvement
Opioid Sales in WA State, Estimated # daily doses sold annually
Methadone does not include methadone dispensed by narcotic treatment programs. Methadone data provided by DEA for 2007-2010 included narcotic treatment programs, estimates removing
expected NTP use are shown with a dashed line
Source: Drug Enforcement Administration Automation of Reports and Consolidated Orders System, data include medications prescribed and dispensed.
Data provided to and analyzed by Caleb Banta-Green Alcohol & Drug Abuse Institute, University of Washington
Defined Daily Dose utilized from WHO http://www.whocc.no/atcddd/
Outpatient, Inpatient, MMT,
•
•
At the population level rx opiate abuse appears to precede heroin abuse
King county data show that 40% of heroin users were “hooked on” Rx opiates first
Surpassed traffic fatalities
600
505
Number of deaths
500
400
300
200
100
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
0
1995
23
Prescription Opioid + alcohol or illicit drug
Prescription Opioid +/- Other Prescriptions
Source: Washington State Department of Health, Death Certificates, Jennifer Sabel, PhD
Medic One Responses
45 serious opiate
overdoses per month
responded to by SFD in
2011*
• Approximately 1:1
Heroin:Rx Opiate
32 cardiac arrest cases
per month responded
to by SFD in 2010**
*268 serious opiate overdoses per our chart abstraction for 6 months in 2011
** “384 out of hospital cardiac arrest cases treated by SFD in 2010”
Drug Caused Deaths, King County WA
180
# of Times Drug Identified
150
120
90
60
30
0
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Other Opiate
22
38
29
43
49
63
79
115
127
144
147
154
161
130
Benzo Barb Tricylic MuscRlx GHB
48
53
34
42
46
58
66
76
74
82
77
98
94
79
Alcohol
90
112
70
113
93
132
97
127
68
60
70
71
59
62
111
144
117
102
61
87
62
76
74
71
65
59
50
50
Cocaine
66
69
76
89
49
79
52
92
80
111
86
71
60
46
Methamphetamine
3
3
13
10
5
13
18
18
24
19
18
13
19
15
178
221
197
215
150
195
186
252
240
286
272
257
254
240
Heroin_mophine_opiate
Total
Source: King County Medical Examiner Public Health- Seattle & King County
Drug Caused Deaths, Most Common Pharmaceuticals King County WA
100
90
80
70
60
50
40
30
20
10
0
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Methadone
14
20
19
25
24
37
47
67
81
94
82
88
85
65
Antidepressant
30
52
40
42
50
50
78
77
85
76
80
75
80
58
Benzodiazepine
26
31
16
18
19
34
34
42
44
52
43
66
67
57
Oxycodone
1
5
4
12
18
20
14
32
31
44
51
44
58
33
Tri-cyclic anti-depressant
20
36
23
26
21
23
32
28
29
25
18
17
16
16
Source: King County Medical Examiner Public Health- Seattle & King County
Opioid Overdose Risk by Average Daily
Dose of Prescribed Opioids Received
Current average daily
dose in morphine
equivalents (MED)
preceding event
0 mg MED
Overdose events,
Persons age 18+
(N=9,940)
Hazard Ratio
(95% Confidence
Interval)
Rate per 100 person
years (%)
(# of person years)
1.0
0.047 % (16,980)
1-19 mg MED
2.4 (1.0, 5.5)
0.15 % (14,263)
20-49 mg MED
4.1 (1.5, 11.8)
0.29 % (2,401)
50-99 mg MED
6.1 (1.8, 20.9)
0.44 % (910)
100+ mg MED
22.1 (8.3, 58.5)
1.75 % (628)
Pharmacists
• Doctor of Pharmacy Degree is now the minimum degree to
enter practice.
• This entails normally 7 years minimum of education
• Pharmacists are the medication experts in healthcare
• Post graduate training opportunities include residencies and
fellowships.
Pharmacists as Mid-level
Prescribers
o Dependent prescribing
o Collaborative Prescriptive Agreements
o Similar to PA’s
o The laws vary in in each state.
Collaborative Prescriptive
Agreements
o A legal agreement between a prescriber and pharmacist
o Agreement must list:
o Where and who
o Which drugs or diseases
o Policies and procedures
o Liability insurance
o RI Pharmacy Laws Section 25.0
Pharmacist Participating in
CPA in RI
o A pharmacist participating in CPA must
o Have post graduate training/experience
o Access to patient information
o 5 hours of CE in the area each year
Washington State
Washington Model
o Public Health- Seattle & King County began distributing in
February in 2012
o Recruitment via needle exchange
o OD prevention and intervention training at Needle Exchange
o Narcan prescribing and dispensing by Public Health pharmacist
o CPA facilitates this
o Police training video recently released based on survey
findings
Expanded Washington Model
o Partnering with Community Pharmacies
o Target those either at risk of having, or witnessing an
overdose
o Utilizing web based patient education and other
handouts to limit impact on pharmacist time
Opportunities to engage
pharmacists
o Show the pharmacists what their practices will look like if they
prescribe and dispense naloxone
o Screening forms
o Example CPA
o Physician Partners to sign CPAs and refer patients
o Education – make the pharmacists the experts in naloxone
o Resources and references for questions and further education
o Students
o Teach this material in schools, so that students come out
expecting to do this
o Partner with faculty members to include in curriculum
Challenges
o Evolution of pharmacy practice
o Pharmacists can be black and white
o Medicaid coverage
Other ways pharmacy can help
o Stock Naloxone injections or kits
o Cash payment
o Overdose education, especially to patients on more than 100
morphine equivalents daily
o Other Public Health Opportunities
o Immunizations
o Emergency Response
Questions?