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 In Washington we have been aggressive about treating pain. 6.8 million individuals. Enough for each Washington residents to have about 6 days worth of hydrocodone – which is about 20 vicodin tablets each year for every resident in our state. 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, Treatment admits are going up… this is good as people are accessing treatment, but does seem to parallel the increase in opiate prescribing. 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

Unintentional prescription opioid involved overdose deaths Washington 1995-2008 Surpassed traffic fatalities This chart shows the unintentional opioid-related deaths in Washington from 1995 through 2008. As you can see these have increase dramatically over this period of time. In addition, there has been a shift from illicit and unspecified opioid-related deaths – shown in yellow to those that are definitely or possibly prescription opioid-related deaths. We went from 23 deaths in the definite and possible groups combined in 1995 to 505 in 2008. Morphine deaths are included in the unspecified because it was impossible to know if these were heroin or morphine deaths as the toxicology tests use to detect morphine – and this what would be listed on the death certificate. Besides the opiates, the most commonly listed drugs on the death certificates are antidepressants and benzodiazepines. And the majority of those in the possible category are there because they had also consumed alcohol. Source: Washington State Department of Health, Death Certificates, Jennifer Sabel, PhD 6 6 6

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** This one really hit for me. Our fire department was the first in the country to have medics that were trained basically as physician extenders to go to cardiac calls. Now this specially trained group is responding to more overdoses than cardiac arrests. This really drove home to me that we need to have just as drastic a response to control this issue as we had to reduce deaths from heart attacks. *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”

Source: King County Medical Examiner Public Health- Seattle & King County

Source: King County Medical Examiner Public Health- Seattle & King County

(95% Confidence Interval) Rate per 100 person years (%) Opioid Overdose Risk by Average Daily Dose of Prescribed Opioids Received Current average daily dose in morphine equivalents (MED) preceding event Overdose events, Persons age 18+ (N=9,940) Hazard Ratio (95% Confidence Interval) Rate per 100 person years (%) (# of person years) 0 mg MED 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 Dependent prescribing Collaborative Prescriptive Agreements Similar to PA’s The laws vary in in each state.

Collaborative Prescriptive Agreements A legal agreement between a prescriber and pharmacist Agreement must list: Where and who Which drugs or diseases Policies and procedures Liability insurance RI Pharmacy Laws Section 25.0

Pharmacist Participating in CPA in RI A pharmacist participating in CPA must Have post graduate training/experience Access to patient information 5 hours of CE in the area each year

Washington State

Washington Model Public Health- Seattle & King County began distributing in February in 2012 Recruitment via needle exchange OD prevention and intervention training at Needle Exchange Narcan prescribing and dispensing by Public Health pharmacist CPA facilitates this Police training video recently released based on survey findings

Expanded Washington Model Partnering with Community Pharmacies Target those either at risk of having, or witnessing an overdose Utilizing web based patient education and other handouts to limit impact on pharmacist time

Opportunities to engage pharmacists Show the pharmacists what their practices will look like if they prescribe and dispense naloxone Screening forms Example CPA Physician Partners to sign CPAs and refer patients Education – make the pharmacists the experts in naloxone Resources and references for questions and further education Students Teach this material in schools, so that students come out expecting to do this Partner with faculty members to include in curriculum

Challenges Evolution of pharmacy practice Pharmacists can be black and white Medicaid coverage What a pharmacist does is evolving and changing, back in the 1970s the APhA definition of the practice of pharmacy, did not include the pharmacist even telling the patient the name of the drug or what it was for. We have come a long way, but it is an evolving process. We need to get state medicaid plans to universally cover naloxone. This will help to reduce some of the risk of stocking a medication, and it not being dispensed, and expiring. With 5 hours of pharmacist education required each year in RI, we need to provide clear explanation of where and how pharmacists can to get this information Most pharmacists like to know what they need to do and how to so it before they jump in. They are so heavily regulated and audited, that practicing in the grey area as far as prescribing and compensation leaves them exposed. Including the boards of pharmacy and associations in your planning to reinforce changes in practice can help with this a great deal.

Other ways pharmacy can help Stock Naloxone injections or kits Cash payment Overdose education, especially to patients on more than 100 morphine equivalents daily Other Public Health Opportunities Immunizations Emergency Response

Questions?