(92) Impact of a Pharmacist-Initiated Naloxone Dispensing Program in Community Pharmacies

Purpose: In the twelve-month period ending in June 2021, there were over 99,000 reported overdose deaths in the United States, 74,000 of which involved opioids.1 While there are many ways to prevent opioid overdose deaths, one of the simplest is to increase naloxone access for patients at risk of overdose. Despite the CDC’s 2016 guidance on the use of naloxone for overdose prevention2, less than 1% of patients meeting criteria are co-prescribed naloxone.3

Methods: To address naloxone under-prescribing, United Health Services Hospitals, Inc. (UHS) created a standing order naloxone program in its five retail pharmacies. Patients eligible for the program were at risk of an opioid overdose due to 1) ≥ 50 prescribed daily morphine milligram equivalents (MME)2 or 2) an opioid of any MME co-prescribed with either a benzodiazepine4, gabapentin5, or pregabalin6 and 3) no active naloxone prescription in the electronic medical record.

Prior to program launch, all retail pharmacists completed a 2-hour online accredited CEU naloxone course covering overdose prevention strategies, naloxone products and administration, and standing orders. Post-launch, weekly meetings between supervising pharmacists and pharmacy leadership focused on streamlining workflows and fostering a culture supportive of harm reduction at the pharmacy window.

Upon receipt of an opioid prescription, a flag in the electronic medical record identified, to the dispensing pharmacist, patients meeting criteria 1 or 2. If an eligible patient did not already have a naloxone prescription on file and had not yet been offered naloxone through this program, pharmacists offered overdose prevention education, naloxone, and an educational handout to the patient or the individual picking up the prescription on the patient’s behalf. Naloxone was dispensed under a standing order from either the New York State Department of Health or the medical director of our addiction medicine department, depending on whether the opioid prescription originated from a UHS or non-UHS prescriber. Naloxone cost was minimized through utilization of New York State’s Naloxone Co-payment Assistance Program (N-CAP) and/or our organization’s 340b reallocation funds. Pharmacy staff alerted providers, through the electronic medical record, when their patients received naloxone.

Results: From April 1, 2021 to January 31, 2022, 720 patients met criteria for naloxone dispensing; 490 patients (68%) accepted naloxone and were trained in its use by a pharmacist. 360 (50%) of the qualifying patients presented across all five sites in April of 2021, 130 (18.1%) presented in May of 2021, and 42 (5.8%) in June of 2021. Subsequent months through January of 2022 have seen a range of 16-36 qualifying patients each month. All 490 patients received naloxone with no out-of-pocket cost.

Conclusion: It is both feasible and practical for community pharmacists to offer overdose prevention education and naloxone to patients at risk of overdose from prescription opioids. More than two-thirds of eligible patients in the program accepted naloxone, suggesting that patients are willing to be counseled about overdose prevention by pharmacists and that standing orders can increase naloxone access for patients at risk of overdose. As the program was structured to offer naloxone to eligible patients once, it is not surprising that the highest percentage of eligible patients received naloxone in program’s initial phase. The stabilization in the number of patients qualifying for naloxone, 16-36 per month for the past seven months, suggest that the program has not significantly impacted workflow in our retail pharmacies.

Reference List:
1) Centers for Disease Control and Prevention. Provisional Drug Overdose Death Counts. https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm. Published February 16, 2022. Accessed February 17, 2022.
2) Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016. Morbidity and Mortality Weekly Report. https://dx.doi.org/10.15585/mmwr.rr6501e1. Published March 18, 2016. Accessed February 17, 2022.
3) U.S. Department of Health & Human Services. How to Respond to an Opioid Overdose. https://www.hhs.gov/opioids/treatment/overdose-response/index.html. Published September 25, 2020. Accessed February 17, 2022. The citation is from a document on the website, "How Healthcare Providers and Patients Can Better Utilize Naloxone, the Opioid Reversal Drug - PDF." https://www.hhs.gov/opioids/sites/default/files/2018-12/naloxone-coprescribing-guidance.pdf
4) U.S. Food & Drug Administration. FDA requiring Boxed Warning updated to improve safe use of benzodiazepine drug class. Drug Safety and Availability. https://www.fda.gov/drugs/drug-safety-and-availability/fda-requiring-boxed-warning-updated-improve-safe-use-benzodiazepine-drug-class. Published September 23, 2020. Accessed February 17, 2022.
5) Gomes T, Juurlink DN, Antoniou T, Mamdani MM, Paterson JM, van den Brink W. Gabapentin, opioids, and the risk of opioid-related death: A population-based nested case–Control Study. PLOS Medicine. 2017;14(10). doi:10.1371/journal.pmed.1002396
6) Gomes T, Greaves S, van den Brink W, et al. Pregabalin and the risk for opioid-related death: A nested case–Control Study. Annals of Internal Medicine. 2018;169(10):732. doi:10.7326/m18-1136