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 Modified Prescription Model Nlx not dispensed from pharmacy Records establish provider- pt 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 Varies: person who gets nlx can be potential overdose bystander or must be potential overdose victim?

Legal Barriers to Prescription Model “ Prescribing naloxone in the USA is fully consistent with state 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.” 1.Prescribe to a person who is at risk for overdose (except IL, MA, WA, CT) 2.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;

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 Pharmacist compounds rescue kit, offers education Pharmacist bills insurance (or charges pt directly) Pt gets naloxone rescue kit

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 inhibitive- focus 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.What were you taking? 2.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.Were any fatal? 2.What did you do? 4.What is your plan if you witness an overdose in the future? 1.Have you received a narcan rescue kit? 2.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