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
Nabarun Dasgupta, MPH
Maya Doe-Simkins, MPH
Traci Green, MSc, PhD
Sammy McGowan
Alexander Y. Walley, MD, MSc
Getting naloxone in overdose
bystanders’ hands: Community models
Distribution Model
• Nonmedical hand out nlx
• Nlx not at pharmacy
• Minimal record keeping
• No billing for nlx/services
• Legal gray area
Varies: person who gets nlx
can be potential overdose
bystander or must be
potential overdose victim?
Modified Prescription Model
• Nlx not dispensed from
pharmacy
• Records establish providerpt 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
Legal Barriers to Prescription Model
“Prescribing naloxone in the USA is fully consistent with state
1.
2.
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
• 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
Opportunities for
prescription naloxone
• 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 prescription model elements
Patient at risk
for OD
Prescriber gives
rx for naloxone
rescue kit +
education
Pt goes to
pharmacy of
choice to fill
Pt gets naloxone
rescue kit
Pharmacist bills
insurance (or
charges pt
directly)
Pharmacist
compounds
rescue kit, offers
education
Practical barriers to prescribing naloxone
Patient at risk for OD
Pt and/or prescriber must
recognize OD risk
Practical barriers to prescribing naloxone
Prescriber gives rx for naloxone
rescue kit + education
Prescriber comfort
Patient inclusion criteria
How to write prescription
Institutional approval(?)
Practical barriers to prescribing naloxone
Pt  pharmacy of choice to fill
Groundwork necessary inhibitivefocus on main pharmacy(ies)
patients use or internal (hospital)
pharmacy
Practical barriers to prescribing naloxone
Pharmacist “compounds” rescue
kit, offers education
Informed pharmacist
Naloxone & delivery devices (MAD
or syringes) in stock?
Literature for patient(?)
Barriers to Traditional Prescription
Pharmacist bills insurance (or pt)
Medicaids often pay, private ins
varies
Doesn’t cover MAD (~$4)
Some pharmacies absorb cost
Traditional Prescription
Pt gets naloxone rescue kit!
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Overdose Education in Medical Settings
• 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:
1. Have you ever overdosed?
1.
2.
What were you taking?
How did you survive?
2. What strategies do you use to protect yourself from overdose?
3. How many overdoses have you witnessed an overdose?
1.
2.
Were any fatal?
What did you do?
4. What is your plan if you witness an overdose in the future?
1.
2.
Have you received a narcan rescue kit?
Do you feel comfortable using it?
Overdose Education in Medical Settings
What patients need to know:
1.Prevention - the risks:
–
–
–
–
–
–
Mixing substances
Abstinence- low tolerance
Using alone
Unknown source
Chronic medical disease
Long acting opioids last longer
2.Recognition
– Unresponsive to sternal rub with slowed breathing
– Blue lips, pinpoint pupils
3.Response - What to do
•
•
•
•
•
Call for help
Rescue breathe
Deliver naloxone
Continue rescue breathing for 3-5 minutes
Stay until help arrives
Passed Massachusetts 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
•
•
•
•
•
•
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