Jeffrey Bratberg, PharmD, BCPS Clinical Professor of Pharmacy Practice University of Rhode Island College of Pharmacy 25 June 2014 PARTNERING WITH PHARMACISTS: NALOXONE PRESCRIBING AND DISPENSING TO PREVENT OVERDOSE DEATHS (AOAAM) Funding for this initiative was made possible (in part) by Providers' Clinical Support System for Opioid Therapies (grant no. H79TI023439) from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.
71
Embed
PARTNERING WITH PHARMACISTS: NALOXONE PRESCRIBING …€¦ · Naloxone prescribing, dispensing and billing Public health model (no billing) Patients targeted High-dose opioids for
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
Jef frey Bratberg, PharmD, BCPS
Cl inical Professor of Pharmacy Pract ice
University of Rhode Is land Col lege of Pharmacy
25 June 2014
PARTNERING WITH
PHARMACISTS:
NALOXONE
PRESCRIBING AND
DISPENSING TO
PREVENT OVERDOSE
DEATHS (AOAAM)
Funding for this initiative was made possible (in part) by Providers' Clinical Support System for Opioid
Therapies (grant no. H79TI023439) from SAMHSA. The views expressed in written conference materials or
publications and by speakers and moderators do not necessarily reflect the official policies of the
Department of Health and Human Services; nor does mention of trade names, commercial practices, or
organizations imply endorsement by the U.S. Government.
TARGET AUDIENCE
The overarching goal of PCSS-O is to make available the most
effective substance abuse treatments to serve patients in a
variety of settings, including osteopathic physicians, family
practice physicians, pharmacists, and clinicians who practice
in rural communities.
Identify the role naloxone has in opioid
overdose prevention and treatment
List three ways to best educate patients and
caregivers on overdose management
Describe the implementation of a
collaborative practice agreement for naloxone
(CPAN) in community pharmacies
OBJECTIVES
Prescription Monitoring Program (PMP)
Opioid substitution therapies
Methadone
Buprenorphine
Harm Reduction
New needles
Condoms
Drug testing
Referrals
Dispense and counsel on prescription opioids
EXISTING PARTNERSHIPS PHARMACISTS
http://www.cnn.com/2011/HEALTH/06/03/drugstore.robberies/index.html Accessed on: 3 June 2014.
http://www.southcoasttoday.com/apps/pbcs.dll/article?AID=/20131216/NEWS/131219921. Accessed on 3 June 2014.
• Self-identified barriers to the provision of health-
promotion and preventive services in current
pharmacy practice
Laliberte MC, et al. Ideal and actual involvement of community pharmacists in health promotion and prevention: a cross-sectional study in Quebec, Canada. BMC
Public Health 2012;12:192. http:/www.biomedcentral.com/1471-2458/12/192
Teleflex/LMA America – lmaems.com; Cardinal Health
No NDC – durable medical equipment (DME)
INTRAMUSCULAR NALOXONE RESCUE KIT
www.prescribetoprevent.org
IM NALOXONE: PRESCRIBING
INTRANASAL NALOXONE RESCUE KIT
www.prescribetoprevent.org
IM NALOXONE: PRESCRIBING
Intra-Nasal
Rx: Naloxone 1mg/1mL
Quantity: 2-4 x 2 mL prefilled Luer-Jet™ Luer-Lock needleless syringe
Sig: For suspected opioid overdose, spray 1 mL (half of the syringe) into each nostril. Repeat after 3 minutes if no or minimal response.
Refills: prescriber preference
NALOXONE PRESCRIPTION
INSTRUCTIONS
Intramuscular
Rx: Naloxone 0.4 mg/mL
Quantity: 2-4 single-use 1 mL vials or 1 X 10 mL multi-use vial
Sig: For suspected opioid overdose, inject 1 mL in shoulder or thigh. Repeat after 3 minutes if no or minimal response.
Refills: prescriber preference
Auto-IM
Use as directed.
EVZIO AUTO-INJECTOR
EVZIO AUTO-INJECTOR
EVZIO is user actuated and may be administered through clothing [e.g. , pants, jeans, etc.] i f necessary.
Inject EVZIO while pressing into the anterolateral aspect of the thigh. In pediatric patients less than 1 year of age, pinch the thigh muscle while administering EVZIO.
Upon actuation, EVZIO automatically inser ts the needle intramuscularly or subcutaneously, del ivers the naloxone, and retracts the needle fully into its housing. The needle is not visible before, during, or af ter injection.
Each EVZIO can only be used one t ime.
I f the electronic voice instruction system on EVZIO does not work properly, EVZIO wil l st i l l del iver the intended dose of naloxone hydrochloride when used according to the printed instructions on its label.
The electronic voice instructions are independent of activating EVZIO and are not required to wait for the voice instructions to be completed prior to moving to the next step in the injection process.
Evzio package insert. 4/2014.
EVZIO ADMINISTRATION INSTRUCTIONS
Post-injection, the black base locks in place, a red indicator appears in the viewing window and electronic visual and audible instructions signal that EVZIO has delivered the intended dose of naloxone hydrochloride.
EVZIO’s red safety guard should not be replaced under any circumstances. However, the trainer is designed for re-use and its red safety guard can be removed and replaced.
It is recommended that patients and caregivers become familiar with the training device provided and read the Instructions for Use ; however, untrained caregivers or family members should sti l l attempt to use EVZIO during a suspected opioid overdose while awaiting definitive emergency medical care.
Periodically visually inspect the naloxone solution through the viewing window. If the solution is discolored, cloudy, or contains solid particles, replace it with a new EVZIO.
Replace EVZIO before its expiration date.
Evzio package insert. 4/2014.
EVZIO ADMINISTRATION INSTRUCTIONS
NALOXONE: BILLING
Most major public and private insurers cover naloxone formulations
Prior authorization may be required
Pharmacists perform real -time claim submission to determine coverage
Patients without insurance can buy prescribed naloxone
State vary in regard to over -the-counter IM syringe availability and quantity for purchase
Mucosal atomizer devices
Cost ~$5 each
Billed as DME only
Mechanism not usual practice
NALOXONE: BILLING
CPAN OVERVIEW
Also called Collaborative Drug Therapy Management (CDTM)
Not associated with reimbursement
Some agreements permit “initiation,” most permit “modify”
COLLABORATIVE PRACTICE AGREEMENTS
Definition: “A formal agreement in which a licensed
provider makes a diagnosis, supervises patient care,
and refers patients to a pharmacist under a protocol
that allows the pharmacist to perform specific patient
care functions.”
Patient care services
provided by
pharmacists can
reduce fragmentation
of care, lower health
care costs, and
improve health
outcomes
A 2010 study found
that patient health
improves significantly
when pharmacists
work with doctors and
other providers to
manage patient care
Centers for Disease Control and Prevention. Collaborative Practice Agreements and Pharmacists’ Patient Care Services: A Resource for
Pharmacists. Atlanta, GA: US Dept. of Health and Human Services, Centers for Disease Control and Prevention; 2013.
RI CPAN STEPS
“Epidemiologic
Trends in Rx Opioid
Abuse and
Unintentional Opioid
Poisoning:
Pharmacy - Based
Interventions for
Patient Safety”
Traci Green, Msc, PhD
~70 pharmacists
attended
CPAN IMPLEMENTATION STEPS
MAY 2012
“Rhode Island
Overdose Death
Prevention:
Naloxone Access
and Distribution
Strategy Day” Jenny
Arnold, PharmD,
BCPS
Washington State
Naloxone
Collaborative
Practice Agreement
CPAN IMPLEMENTATION STEPS
AUGUST 2012
University of Rhode Island College of Pharmacy Student Tara Thomas ’13 develops 1 -hour online Continuing Professional Education (CPE) Program with URI CPE Office
“Opioids: Addiction, Overdose Prevention (Naloxone) and Patient Education.”
Corporate pharmacy managers are approached, Walgreens agrees to participate
Four locations are selected as CPA pilot sites located near clusters of opioid overdose death reports
RI Pharmacy Foundation funds ten pharmacists at those stores to complete online CE for Naloxone CPA participationafter “initiation” waiver approved by Board of Pharmacy
CPAN IMPLEMENTATION STEPS
SEPT 2012
Rhode Island Board of Pharmacy unanimously approves
waiver to permit “initiation” of naloxone by pharmacists
trained using URI CE program, recognizing the epidemic of
overdose deaths as a public health emergency.
CPAN IMPLEMENTATION STEPS
OCT 2012
Walgreen’s corporate legal
department approves CPA
Nov 2013: Naloxone
shortage
Ten pharmacists complete
online training
IM and IN naloxone
formulations and mucosal
atomizer devices stocked
at pharmacies
CPA is signed by Jody Rich,
MD and all pharmacists
CPAN IMPLEMENTATION STEPS
NOV-FEB 2013
Michael Botticelli, Deputy Director
of the White House Office of
National Drug Control and
Prevention(ONDCP), holds
overdose prevention roundtable in
Woonsocket, RI in response to 14
acetyl fentanyl heroin overdose
deaths between Feb-May (MMWR
2013;62:703-4.)
CPA extended to fif th Walgreen’s
store in Woonsocket and then to
all 26 RI locations after Board of
Pharmacy approval.
CPAN IMPLEMENTATION STEPS
JUNE 2013
Aug 2013 SAMSHA Opioid
Overdose Prevention Toolkit
released, RI CPA solution
cited
79 Walgreens pharmacists
from 26 stores complete
online CE training
Nov 2013 ~100 Connecticut
pharmacists trained in Opioid
Overdose certification
program
CPAN IMPLEMENTATION STEPS
AUGUST-NOV 2013
Rhode Island Opioid overdose
death rate doubled
Media attention magnified
State health department
recommends patient and
caregivers go to Walgreens to
receive naloxone and overdose
education
February 2014 - Health
department emergency
regulations released requiring
behavioral health staff and
patients to be trained on and
dispensed naloxone
IMPLEMENTATION
JAN-FEB 2014
More emergency regulations released with Board consultation giving all pharmacists the ability to prescribe naloxone and prescribers to dispense naloxone
Front-page Sunday Providence Journal story on naloxone and pharmacy access
Insurers, pharmacists, prescribers meet to discuss naloxone reimbursement
CT stakeholder meeting
CPAN IMPLEMENTATION
MARCH 2014
Controlled Substances and Other Medications with the Potential
for Abuse and Use of Opioid Reversal Agents
1. APhA supports education for pharmacists and student
pharmacists to address issues of pain management, palliative
care, appropriate use of opioid reversal agents in overdose,
drug diversion, and substance ‐related and addictive disorders .
2. APhA supports recognition of pharmacists as the health
care providers who must exercise professional judgment in the
assessment of a patient’s conditions to fulfill corresponding
responsibility for the use of controlled substances and other
medications with the potential for misuse, abuse, and/or
diversion.
2014 AMERICAN PHARMACISTS
ASSOCIATION HOUSE OF DELEGATES
http://www.pharmacist.com/sites/default/files/files/2014 Report of the APhA House of Delegates--Public—Final.pdf