Orienting patients to greater opioid safety: models of community pharmacy-based naloxone

Abstract

The leading cause of adult injury death in the USA is drug overdose, the majority of which involves prescription opioid medications. Outside of the USA, deaths by drug overdose are also on the rise, and overdose is a leading cause of death for drug users. Reducing overdose risk while maintaining access to prescription opioids when medically indicated requires careful consideration of how opioids are prescribed and dispensed, how patients use them, how they interact with other medications, and how they are safely stored. Pharmacists, highly trained professionals expert at detecting and managing medication errors and drug-drug interactions, safe dispensing, and patient counseling, are an under-utilized asset in addressing overdose in the US and globally. Pharmacies provide a high-yield setting where patient and caregiver customers can access naloxone—an opioid antagonist that reverses opioid overdose—and overdose prevention counseling. This case study briefly describes and provides two US state-specific examples of innovative policy models of pharmacy-based naloxone, implemented to reduce overdose events and improve opioid safety: Collaborative Pharmacy Practice Agreements and Pharmacy Standing Orders.

What is known about community pharmacy supply of naloxone? A scoping review

“…This editorial also highlighted the requirement to train bystanders, family members or caregivers as first initial witnesses of overdose and most likely to respond. Green et al (Green, et al, 2015) in their case study described comprehensive eligibility for patient participation in Collaborative Pharmacy Practice Agreements (CPAN) in Figure 3, which were consistent with patient groups described by Wermeling (2010).…”

“…The criteria for eligibility for naloxone described by Albert et al (2011) are similar to those described above by Green et al (2015).…”

“…There is great variation in different countries with the involvement of community pharmacy in different aspects of harm reduction (Hammett, et al, 2014). Levels of engagement with harm reduction more broadly vary between the US, Australia, Europe and the United Kingdom (UK), with supervised dosing of opioid substitution treatments for example not being common practice in the US, in contrast with being an accepted practice model in Australia (Green, Dauria, Bratberg, Davis, & Walley, 2015;Watson & Hughes, 2012). Analyses of changing attitudes over time demonstrate that in Scotland, pharmacists have demonstrated a willingness to receive further training, which in turn appears to increase their participation in harm reduction activities (Matheson, Thiruvothiyur, Robertson, & Bond, 2015).…”

Twenty years of take-home naloxone for the prevention of overdose deaths from heroin and other opioids—Conception and maturation

“…In pharmacy-based THN provision, pharmacists take on a dual role: a) monitoring patients' opioid prescriptions and assessing their risk of opioid use disorder as well as b) expansion of naloxone access (Green et al, 2015b;Penm et al, 2017). Since October 2015, UK pharmacies providing supervised opioid substitution treatment can supply THN without prescription to individuals likely to witness an opioid overdose provided "the [naloxone] supply is suitably recorded" (PHE, 2015).…”

“…As of August 2016, US pharmacists can prescribe naloxone in 5 states and dispense naloxone via standing orders in forty-two states (Davis and Carr, 2017). Pharmacy-based provision has been piloted as a strategy to promote naloxone access in rural areas (Green et al, 2015b) and increased dramatically in the US since 2013 (Jones et al, 2016). However, pharmacists' willingness to dispense THN varies (Freeman et al, 2017) and patients and carers report stigma of THN receipt .…”