Description of a pharmacist-led clinical video telehealth group clinic for opioid overdose prevention and naloxone education

Abstract

To achieve the nationwide goal of reducing opioid-related deaths, a clinical pharmacy specialist–led clinical video telehealth (CVT) clinic was created at a Veterans Affairs medical center (VAMC) to deliver opioid overdose prevention and naloxone education to at-risk patients. The purpose of this innovative practice was to improve access to this potentially life-saving intervention to patients across urban and rural areas. This study is a single-center, descriptive analysis of adult patients across 2 VAMC campuses and 4 community-based outpatient clinics from July 11, 2016, through December 31, 2016. The purpose of this innovative practice was to increase access to overdose education and naloxone distribution (OEND) to at-risk patients across urban and rural areas. Patient-specific factors were also examined among those receiving naloxone through the CVT clinic compared to other prescribers. During the first 6 months from the initiation of the clinic, 1 pharmacist prescribed 21% of the health care system's naloxone. These patients identified by the pharmacist-led CVT clinic were more likely to be considered high-risk due to concomitant use of opioids and benzodiazepines. In conclusion, the pharmacist-led CVT group clinic has been an efficient strategy to extend OEND services to high-risk patients beyond central, urban areas.

Opioid medicines management in primary care settings: A scoping review of quantitative studies of pharmacist activities

“…In the 51 studies included in the scoping review, pharmacists developed, led [37][38][39][40][41][42][43][44][45][46][47][48][49][50] and were part of interdisciplinary teams 47,[51][52][53][54][55][56][57][58][59][60][61][62][63][64][65][66][67] and physician collaborative care models 45,48,[68][69][70][71][72][73][74] in the management of opioids. The pharmacists undertaking these roles were embedded in prescribers' location of practice [40][41][42][43][44]46,[55][56][57]…”

“…In the majority of studies, the outcome of interest for the patient cohorts was any change to opioid doses prescribed, in the context of reducing risk from high opioid doses in CNCP. 38,40,51,53,55,56,61,63,67,74,76,82 For comparative studies, the opioid load was most often estimated by converting it to the oral morphine equivalent daily dose, or oMED, a method to standardise the dose based on the knowledge that different opioids with varying potency may produce a similar analgesic effect. 88 Additional outcomes included the impact of any change to oMED or pharmacist involvement on symptom scores and functionality, 47,48,52,57,69 which were also outcomes for the four palliative care studies.…”

“…49,65,66,84 One study only investigated opioid specifically for acute pain and that was in a free dental clinic where the outcome was the change in rates of opioid prescribing. 73 Other quantitative outcomes were retention rates in pharmacist programs, 39,68,70 discontinuation of regular opioids, 77 initiation of pharmacist care plans, 40,51 procurement of take-home naloxone, 38,39,43,50,55,81 change of long-acting opioid formulation, 67 effect on overdose occurrence or premature deaths 39,62 and emergency department presentations. 55 For medical and nurse prescriber participants, the outcomes were any impact as assessed by acceptance rates of pharmacist or multidisciplinary committee recommendations 37,40,42,47,54,59,60,63,67,72,75,78,80,85 as well as measures of prescriber behaviour change, such as adherence to pain management protocols, initiation of nonopioids, prescriptions for take-home naloxone, referrals to external providers, reduced concomitant prescribing with benzodiazepines, engagement of patients in prescriber-patient opioid agreements, prescription monitoring, urine toxicology screening and other measures to assess patient aberrant behaviours, 37,38,40,41,…”

“…• THN targeted as one risk-mitigation measure, as member of integrated pain team, face-to-face or via telehealth 55 • Education of patients identified as at risk and their carers 39 and THN prescribing, 39 including via telephone and CTV outreach 38,50,81 and from community pharmacy practice 77 • Developed, implemented programs to identify at-risk patients; improved co-prescribing of naloxone 41,43,44,62,85 • Included as a key message of academic detailing to prescribers 86 Co-prescribing of opioid/ sedatives targeted…”

“…• Pharmacist-led medication review 42 • Pharmacist-led interprofessional nonmalignant pain management service 47 • Identification of risk via electronic records and communication to prescribers in team 37,53 or via fascimile 80 • Review by pharmacist-independent prescribers after identification by risk-assessment tool and GP referral 83 • Risk assessment in outpatient palliative care radiotherapy clinic 65 • Developed and implemented protocols and recommendations for cardiac monitoring of high-risk patients receiving methadone 37,46 • Managed patients under collaborative care models and drug therapy management protocols 45,69 • Developed and implemented programs to identify at-risk patients and to improve THN prescribing, 38,39,41,43,44,62 including calculation of overdose risk scores 39 • Interdisciplinary controlled substance committee recommendations 61 • Intensive intervention of outpatients identified with prescription opioid misuse 77 • Communicated to prescribers of risky combinations after review of electronic records 80 • Outreach education via telephone to patients identified as at risk by algorithm assessment of records 81 (Continues) 61,62,67,71,74,75,[77][78][79][80]85 Activities to reduce harm included targeting the opioid load and sedative combinations, increasing uptake of takehome naloxone supply, assessing potential risks of opioids, either of use disorder or for adverse effects, enabling opioid agreements, urine screening and prescription monitoring programs, and improving access to treatments. In many studies, pharmacists were actively involved in patient management and received direct referrals or prescribed independently.…”