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Shafer PO, Dean P, Brooks L, Gidal B, Misra SN, Carrazana E. Intranasal Delivery of Medications for the Treatment of Neurologic Conditions: A Pharmacology Update. J Neurosci Nurs 2024; 56:136-142. [PMID: 38976832 DOI: 10.1097/jnn.0000000000000769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
ABSTRACT INTRODUCTION: Nurses have a central role in educating patients and families about treatment options and how to integrate them into action plans for neurologic conditions. In recent years, a growing number of intranasal formulations have become available as rescue therapy for neurologic conditions or symptoms including migraine, opioid overdose, and seizures. Rescue therapies do not replace maintenance medications or emergency care but are designed to enable rapid treatment of urgent or disabling conditions in community settings. Yet, discussion of rescue therapies for neurologic conditions remains limited in nursing literature. CONTENT: Intranasal formulations are specifically formulated for delivery and absorption in the nose and have several characteristics that are well suited as rescue therapies for neurologic conditions. Intranasal formulations include triptans for migraine, naloxone and nalmefene for opioid overdose, and benzodiazepines for seizure clusters in patients with epilepsy. Therapeutic attributes discussed here include ease of use in community settings by nonmedical professionals, relatively rapid onset of action, and favorable safety profile and patient experience. This information is critical for nurses to make informed decisions about rescue therapy options, incorporate these into plans of care, and educate patients, care partners, and other healthcare providers. CONCLUSION: Rescue therapies are increasingly important in the care of people with neurologic conditions. Various formulations are available and continue to evolve, offering easy and quick ways for nurses, patients, and nonmedical care partners to administer critical rescue medications. For nurses overseeing medication management, the attributes of intranasal rescue therapies should be considered in the context of providing patients with the right care at the right time.
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Vascimini A, Dioses C, Certain T, Duane K, Allison C, Tolle T, Curtis S. A pilot study surveying the impact of pharmacist-led counseling on naloxone dispensing. J Opioid Manag 2024; 20:185-192. [PMID: 39017610 DOI: 10.5055/jom.0855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2024]
Abstract
OBJECTIVE The purpose of this study was to evaluate the impact of pharmacist counseling on patients purchasing naloxone and to highlight reasons for naloxone purchase refusal. DESIGN A multisite study that was conducted from September 15, 2022, to January 11, 2023. SETTING Independent community pharmacies. PATIENTS/PARTICIPANTS Fifty patients met inclusion criteria. Data collected included demographics, preintervention knowledge assessment, post-intervention naloxone purchase, and reasons for naloxone refusal. OUTCOME MEASURES The primary outcome was naloxone purchase after pharmacist education intervention. The secondary outcome was reasons for naloxone purchase refusal. RESULTS The primary outcome showed that 60 percent of patients purchased naloxone after pharmacist intervention. As a secondary outcome, the number of patients who refused to purchase naloxone was 20 percent, with the majority of patients expressing that naloxone was not necessary as a reason for refusal. CONCLUSION More studies are needed in order to conclude the impact of pharmacist education on the increasing purchase of naloxone.
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Affiliation(s)
- Angelina Vascimini
- Pharmacotherapy & Translational Research, College of Pharmacy, University of Florida, Gainesville, Florida. ORCID: https://orcid.org/0000-0003-0638-1214
| | - Calynn Dioses
- Community-Based Pharmacy Residency Program, College of Pharmacy, University of Florida, Jacksonville, Florida
| | - Taylor Certain
- Community-Based Pharmacy Residency Program, College of Pharmacy, University of Florida, Gainesville, Florida
| | | | | | | | - Stacey Curtis
- Community-Based Pharmacy PGY1 Residency Program; Clinical Associate Professor, Pharmacotherapy & Translational Research; Associate Dean, Experiential Education, University of Florida, Gainesville, Florida. ORCID: https://orcid.org/0000-0002-4335-1471
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Sandelich S, Hooley G, Hsu G, Rose E, Ruttan T, Schwarz ES, Simon E, Sulton C, Wall J, Dietrich AM. Acute opioid overdose in pediatric patients. J Am Coll Emerg Physicians Open 2024; 5:e13134. [PMID: 38464332 PMCID: PMC10920943 DOI: 10.1002/emp2.13134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 02/13/2024] [Indexed: 03/12/2024] Open
Abstract
Recent increases in pediatric and adolescent opioid fatalities mandate an urgent need for early consideration of possible opioid exposure and specific diagnostic and management strategies and interventions tailored to these unique populations. In contrast to adults, pediatric methods of exposure include accidental ingestions, prescription misuse, and household exposure. Early recognition, appropriate diagnostic evaluation, along with specialized treatment for opioid toxicity in this demographic are discussed. A key focus is on Naloxone, an essential medication for opioid intoxication, addressing its unique challenges in pediatric use. Unique pediatric considerations include recognition of accidental ingestions in our youngest population, critical social aspects including home safety and intentional exposure, and harm reduction strategies, mainly through Naloxone distribution and education on safe medication practices. It calls for a multifaceted approach, including creating pediatric-specific guidelines, to combat the opioid crisis among children and to work to lower morbidity and mortality from opioid overdoses.
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Affiliation(s)
- Stephen Sandelich
- Department of Emergency MedicinePenn State College of MedicinePenn State Milton S. Hershey Medical CenterHersheyPennsylvaniaUSA
| | - Gwen Hooley
- Department of Emergency MedicineChildren's Hospital of Los AngelesLos AngelesCaliforniaUSA
| | - George Hsu
- Department of Emergency MedicineAugusta University‐Medical College of GeorgiaAugustaGeorgiaUSA
| | - Emily Rose
- Department of Emergency MedicineKeck School of Medicine of the University of Southern CaliforniaLos Angeles General Medical CenterLos AngelesCaliforniaUSA
| | - Tim Ruttan
- Department of PediatricsDell Medical SchoolThe University of Texas at AustinUS Acute Care SolutionsCantonOhioUSA
| | - Evan S. Schwarz
- Division of Medical ToxicologyDepartment of Emergency MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
| | - Erin Simon
- Department of Emergency MedicineCleveland ClinicAkronOhioUSA
| | - Carmen Sulton
- Departments of Pediatrics and Emergency MedicineEmory University School of MedicineChildren's Healthcare of Atlanta, EglestonAtlantaGeorgiaUSA
| | - Jessica Wall
- Departments of Pediatrics and Emergency MedicineSeattle Children's HospitalHarborview Medical CenterSeattleWashingtonUSA
| | - Ann M Dietrich
- Department of Emergency MedicinePrisma HealthGreenvilleSouth CarolinaUSA
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Freiermuth CE, Ancona RM, Brown JL, Punches BE, Ryan SA, Ingram T, Lyons MS. Evaluation of a large-scale health department naloxone distribution program: Per capita naloxone distribution and overdose morality. PLoS One 2023; 18:e0289959. [PMID: 37566565 PMCID: PMC10420337 DOI: 10.1371/journal.pone.0289959] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 07/30/2023] [Indexed: 08/13/2023] Open
Abstract
OBJECTIVES To report per-capita distribution of take-home naloxone to lay bystanders and evaluate changes in opioid overdose mortality in the county over time. METHODS Hamilton County Public Health in southwestern Ohio led the program from Oct 2017-Dec 2019. Analyses included all cartons distributed within Hamilton County or in surrounding counties to people who reported a home address within Hamilton County. Per capita distribution was estimated using publicly available census data. Opioid overdose mortality was compared between the period before (Oct 2015-Sep 2017) and during (Oct 2017-Sep 2019) the program. RESULTS A total of 10,416 cartons were included for analyses, with a total per capita distribution of 1,275 cartons per 100,000 county residents (average annual rate of 588/100,000). Median monthly opioid overdose mortality in the two years before (28 persons, 95% CI 25-31) and during (26, 95% CI 23-28) the program did not differ significantly. CONCLUSIONS Massive and rapid naloxone distribution to lay bystanders is feasible. Even large-scale take-home naloxone distribution may not substantially reduce opioid overdose mortality rates.
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Affiliation(s)
- Caroline E. Freiermuth
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
- Center for Addiction Research, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
| | - Rachel M. Ancona
- Department of Emergency Medicine, Washington University, St Louis, Missouri, United States of America
| | - Jennifer L. Brown
- Department of Psychological Sciences, Purdue University, West Lafayette, Indiana, United States of America
| | - Brittany E. Punches
- College of Nursing, The Ohio State University, Columbus, Ohio, United States of America
- Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, Ohio, United States of America
| | - Shawn A. Ryan
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
- Brightview Health LLC, Cincinnati, Ohio, United States of America
| | - Tim Ingram
- Hamilton County Public Health, Cincinnati, Ohio, United States of America
- Department of Environmental and Public Health Sciences, University of Cincinnati College of Medicine, Cincinnati, Ohio, United States of America
| | - Michael S. Lyons
- Department of Emergency Medicine, The Ohio State University College of Medicine, Columbus, Ohio, United States of America
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Madden S, Carrazana E, Rabinowicz AL. Optimizing Absorption for Intranasal Delivery of Drugs Targeting the Central Nervous System Using Alkylsaccharide Permeation Enhancers. Pharmaceutics 2023; 15:2119. [PMID: 37631332 PMCID: PMC10458890 DOI: 10.3390/pharmaceutics15082119] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 07/19/2023] [Accepted: 08/07/2023] [Indexed: 08/27/2023] Open
Abstract
Intranasal delivery of drugs offers several potential benefits related to ease of delivery, rapid onset, and patient experience, which may be of particular relevance to patients with central nervous system (CNS) conditions who experience acute events. Intranasal formulations must be adapted to address anatomical and physiological characteristics of the nasal cavity, including restricted dose volume, limited surface area, and barriers to mucosal absorption, in addition to constraints on the absorption window due to mucociliary clearance. Development of an effective formulation may utilize strategies including the addition of excipients to address the physicochemical properties of the drug within the constraints of nasal delivery. Dodecyl maltoside (DDM) and tetradecyl maltoside are alkylsaccharide permeation enhancers with well-established safety profiles, and studies have demonstrated transiently improved absorption and favorable bioavailability of several compounds in preclinical and clinical trials. Dodecyl maltoside is a component of three US Food and Drug Administration (FDA)-approved intranasal medications: diazepam for the treatment of seizure cluster in epilepsy, nalmefene for the treatment of acute opioid overdose, and sumatriptan for the treatment of migraine. Another drug product with DDM as an excipient is currently under FDA review, and numerous investigational drugs are in early-stage development. Here, we review factors related to the delivery of intranasal drugs and the role of alkylsaccharide permeation enhancers in the context of approved and future intranasal formulations of drugs for CNS conditions.
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Affiliation(s)
- Stuart Madden
- Neurelis, Inc., San Diego, CA 92121, USA; (E.C.); (A.L.R.)
| | - Enrique Carrazana
- Neurelis, Inc., San Diego, CA 92121, USA; (E.C.); (A.L.R.)
- John A. Burns School of Medicine, University of Hawaii, Honolulu, HI 96813, USA
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Argenyi MS, Evans JK, Gay Y, Epstein DH, Weiss ST. The Opioid Overdose Resuscitation Education for Addiction Counselors and Trainees (Opioid Overdose REACT) naloxone response education pilot project improved confidence and knowledge among addiction counselors and trainees. Clin Toxicol (Phila) 2023; 61:509-517. [PMID: 37427894 PMCID: PMC10528373 DOI: 10.1080/15563650.2023.2229508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 06/12/2023] [Accepted: 06/20/2023] [Indexed: 07/11/2023]
Abstract
INTRODUCTION Community programs to teach nonmedical laypeople how to recognize an opioid overdose and effectively resuscitate the victim using naloxone have proliferated recently as a significant component of harm-reduction efforts. Although many such programs target laypeople like first responders or friends and family members of people who use drugs, there are currently no programs that specifically target addiction counselors, despite their work with a client population at high risk of an opioid overdose. METHODS The four-hour curriculum designed by the authors covered opioid agonist and antagonist pharmacology; opioid toxidrome signs; legal implications and indications for using the naloxone kits; and hands-on training. Participants were two cohorts of addiction counselors and addiction counseling trainees at our institution and an affiliated Opioid Treatment Program methadone clinic. Surveys testing participant knowledge and confidence were conducted at baseline, immediately post-training, six months post-training, and 12 months post-training. RESULTS Overall, opioid and naloxone pharmacology knowledge, as well as the confidence to intervene in an overdose emergency, improved among participants in both cohorts. Knowledge scores at baseline (n = 36, median 5/10) improved significantly immediately post-training (n = 31, median 7/10, P < 0.0001, Wilcoxon signed-rank test) and were sustained six (n = 19) and 12 months (n = 11) later. Two participants reported using their naloxone kits to successfully reverse a client overdose in the 12 months after taking the course. DISCUSSION These results from our knowledge translation pilot project suggest that our educational program to train addiction counselors in opioid pharmacology and toxicology, allowing them to recognize and respond to an opioid overdose, is feasible and could be effective. Specific barriers to implementing such educational programs include cost, stigma, and unclear best practice for designing and conducting these programs. CONCLUSIONS Further study of providing opioid pharmacology education and overdose and naloxone training to addiction counselors and counseling trainees appears to be warranted.
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Affiliation(s)
- Michael S. Argenyi
- Wake Forest Addiction Research and Clinical Health Program, Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
- Department of Psychiatry, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Joni K. Evans
- Department of Biostatistics and Data Science, Wake Forest School of Medicine, Winston-Salem, NC
| | - Yasmin Gay
- Wake Forest Addiction Research and Clinical Health Program, Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | - David H. Epstein
- Translational Addiction Medicine Branch, Intramural Research Program, National Institute on Drug Abuse, National Institutes of Health, Baltimore, MD
| | - Stephanie T. Weiss
- Wake Forest Addiction Research and Clinical Health Program, Department of Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
- Translational Addiction Medicine Branch, Intramural Research Program, National Institute on Drug Abuse, National Institutes of Health, Baltimore, MD
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Herman ST, Detyniecki K, O'Hara K, Penovich P, Rao VR, Tatum W, Long L, Stern JM, Carrazana E, Rabinowicz AL. Written seizure action plans for adult patients with epilepsy: Distilling insights from emergency action plans for other chronic conditions. Epilepsy Behav 2023; 140:109002. [PMID: 36822041 DOI: 10.1016/j.yebeh.2022.109002] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 10/31/2022] [Accepted: 11/15/2022] [Indexed: 02/25/2023]
Abstract
Seizure emergencies and potential emergencies, ranging from seizure clusters to prolonged seizure and status epilepticus, may affect adults with epilepsy despite stable antiseizure therapy. Seizure action plans (SAPs) are designed for patients and their caregivers/care partners to provide guidance on the individualized treatment plan, including response to potential seizure emergencies and appropriate use of rescue therapy. The use of pediatric SAPs is common (typically required by schools), however, most adults with epilepsy do not have a plan. Patient-centered action plans are integral to care for other chronic conditions and may offer insights applicable to the care of adults with epilepsy. This review analyzes the potential benefits of action plans for medical conditions by exploring their utility in conditions such as asthma, diabetes, chronic obstructive pulmonary disease, heart disease, and opioid overdose. Evidence across these conditions substantiates the value of action plans for patients, and the benefits of adult SAPs in epilepsy are emerging. Because wide implementation of SAPs has faced barriers, other conditions may provide insights that are relevant to implementing SAPs in epilepsy. Based on these analyses, we propose concrete steps to improve the use of SAPs among adults. A recent consensus statement promoting the use of formal SAPs in epilepsy and advances in rescue therapy delivery methods provides support to engage patients around the value of SAPs. The precedent for use of SAPs for pediatric epilepsy patients serves as the foundation to support increased usage in adults. Seizure action plans in the context of improved clinical outcomes are expected to reduce healthcare utilization, improve patient quality of life, and optimize epilepsy management.
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Affiliation(s)
- Susan T Herman
- Barrow Neurological Institute, Phoenix, AZ, United States.
| | | | | | | | - Vikram R Rao
- University of California San Francisco, San Francisco, CA, United States
| | | | | | - John M Stern
- University of California Los Angeles, Los Angeles, CA, United States
| | - Enrique Carrazana
- University of Hawaii John A. Burns School of Medicine, Honolulu, HI, United States; Neurelis, Inc, San Diego, CA, United States
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Doughty B, Young S, Eggleston W. Assessment of a comprehensive naloxone education program's impact on community member knowledge and attitudes on a college campus. JOURNAL OF AMERICAN COLLEGE HEALTH : J OF ACH 2022; 70:1332-1335. [PMID: 32877623 DOI: 10.1080/07448481.2020.1807992] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 08/02/2020] [Accepted: 08/03/2020] [Indexed: 06/11/2023]
Abstract
Objective: Access to naloxone is a priority for reducing opioid overdose deaths. Although participants who receive naloxone training are able to successfully administer it, the impact of training on community member knowledge and attitudes has not been explored. Participants: A total of 105 participants 18 years and older at a medium-sized university completed assessments between August and December 2019. Methods: Participants were scheduled to complete a standardized 30-minute naloxone training as developed by the research team. Assessments were taken at baseline, immediately following, and three-months following education using the Opioid Overdose Knowledge Scale (OOKS) and Opioid Overdose Attitudes Scale (OOAS). Results: The primary endpoint of change from baseline to immediate post-education for total OOKS and OOAS median scores significantly improved (p < 0.001) by 31 and 34 points, respectively. Conclusions: Naloxone education provides an opportunity to improve community attitudes and reduce stigma over time.
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Affiliation(s)
- Bennett Doughty
- School of Pharmacy and Pharmaceutical Sciences, Binghamton University, Binghamton, New York, USA
- Internal Medicine, Guthrie Robert Packer Hostpial, Sayre, Pennsylvania, USA
| | - Sarah Young
- Department of Social Work, Binghamton University, Binghamton, New York, USA
| | - William Eggleston
- School of Pharmacy and Pharmaceutical Sciences, Binghamton University, Binghamton, New York, USA
- Department of Emergency Medicine, SUNY Upstate Medical University, Syracuse, New York, USA
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Brandt L, Yanagida T, Campbell ANC, Jones JD, Schultes MT, Martinez S, Comer SD. Multi-informant Implementation and Intervention Outcomes of Opioid Overdose Education and Naloxone Distribution in New York City. GLOBAL IMPLEMENTATION RESEARCH AND APPLICATIONS 2021; 1:209-222. [PMID: 34622215 PMCID: PMC8450721 DOI: 10.1007/s43477-021-00021-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 07/23/2021] [Indexed: 11/28/2022]
Abstract
Overdose Education and Naloxone Distribution (OEND) is an effective public health intervention to reduce opioid overdose fatalities (McDonald and Strang, Addiction 111:1177-1187, 2016). However, we know little about OEND implementation outcomes (i.e., indicators of implementation success), specifically the fidelity of training delivery, and how these may relate to intervention outcomes (i.e., indicators of the success or effectiveness of an intervention), such as overdose knowledge and attitudes. This study evaluated 16 OEND trainings conducted at different Opioid Overdose Prevention Programs in New York City. Trainees (N = 75) completed the Opioid Overdose Knowledge and Attitude Scales before and after training (intervention outcomes). Implementation outcomes were fidelity (competence and adherence of the trainer, N = 10; modified Fidelity Checklist) and acceptability of OEND (Acceptability of Intervention Measure), assessed from multiple perspectives (trainees, trainers, and an independent observer). Trainees' overdose knowledge, t(71) = - 8.12, p < 0.001, 95% CI [- 6.54, - 3.96], and attitudes, t(65) = - 6.85, p < 0.001, 95% CI [- 0.59, - 0.33], improved significantly from pre- to post-training. Stepwise multiple regression models indicated that adherence of the trainer rated from the observer perspective added significantly to the prediction of changes in overdose knowledge, F(1, 67) = 9.81, p = 0.003, and explained 13% of the variance in outcome. However, fidelity measures from the perspective of trainees or trainers and acceptability of OEND were not associated with changes in trainees' overdose knowledge or attitudes. OEND implementation outcomes and their relationship with intervention outcomes differed depending on the role of the fidelity rater in relation to the intervention. Specifically, our findings indicate that fidelity should be measured from an independent perspective (i.e., an individual who is experienced with fidelity rating but not directly involved in the intervention). SUPPLEMENTARY INFORMATION The online version contains supplementary material available at 10.1007/s43477-021-00021-4.
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Affiliation(s)
- Laura Brandt
- Division on Substance Use Disorders, Department of Psychiatry & New York State Psychiatric Institute, Columbia University Irving Medical Center, 1051 Riverside Drive, Unit #120, New York, NY 10032 USA
| | - Takuya Yanagida
- Department of Developmental and Educational Psychology, University of Vienna, Universitaetsstrasse 7 (NIG), 1010 Vienna, Austria
| | - Aimee N. C. Campbell
- Division on Substance Use Disorders, Department of Psychiatry & New York State Psychiatric Institute, Columbia University Irving Medical Center, 1051 Riverside Drive, Unit #120, New York, NY 10032 USA
| | - Jermaine D. Jones
- Division on Substance Use Disorders, Department of Psychiatry & New York State Psychiatric Institute, Columbia University Irving Medical Center, 1051 Riverside Drive, Unit #120, New York, NY 10032 USA
| | - Marie-Therese Schultes
- Department of Developmental and Educational Psychology, University of Vienna, Universitaetsstrasse 7 (NIG), 1010 Vienna, Austria
- Institute for Implementation Science in Healthcare, University of Zurich, Universitaetstrasse 84, 8006 Zurich, Switzerland
| | - Suky Martinez
- Division on Substance Use Disorders, Department of Psychiatry & New York State Psychiatric Institute, Columbia University Irving Medical Center, 1051 Riverside Drive, Unit #120, New York, NY 10032 USA
| | - Sandra D. Comer
- Division on Substance Use Disorders, Department of Psychiatry & New York State Psychiatric Institute, Columbia University Irving Medical Center, 1051 Riverside Drive, Unit #120, New York, NY 10032 USA
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Evoy KE, Hill LG, Davis CS. Considering the Potential Benefits of Over-the-Counter Naloxone. INTEGRATED PHARMACY RESEARCH AND PRACTICE 2021; 10:13-21. [PMID: 33623754 PMCID: PMC7894851 DOI: 10.2147/iprp.s244709] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 01/27/2021] [Indexed: 01/30/2023] Open
Abstract
Since 1999, annual opioid-related overdose (ORO) mortality has increased more than six-fold. In response to this crisis, the US Department of Health and Human Services outlined a 5-point strategy to reduce ORO mortality which included the widespread distribution of naloxone, an opioid antagonist that can rapidly reverse an opioid overdose. Increased distribution has been facilitated by the implementation of naloxone access laws in each US state aimed at increasing community access to naloxone. While these laws differ from state-to-state, most contain mechanisms to enable pharmacists to dispense naloxone without a patient-specific prescription. These laws have enhanced community naloxone distribution, both from pharmacies and overdose education and naloxone distribution programs, and produced positive effects on ORO mortality. However, a growing body of evidence has revealed that significant barriers to naloxone access from pharmacies remain, and annual ORO deaths have continued to climb. Given these concerns, there has been a push among some clinicians and policymakers for the US Food and Drug Administration to re-classify naloxone as an over-the-counter (OTC) medication as a means to further increase its accessibility. If an OTC transition occurs, educational outreach and funding for clinical innovations will continue to be crucial given the important role of health professionals in recommending naloxone to people at risk for experiencing or witnessing an ORO. Recognizing the severity of the ORO public health crisis, we believe transitioning formulations of naloxone approved for layperson use to OTC status would result in a net benefit through increased access. However, such a change should be combined with measures to ensure affordability.
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Affiliation(s)
- Kirk E Evoy
- University Health, Department of Pharmacy, The University of Texas at Austin College of Pharmacy, San Antonio, TX, USA
| | - Lucas G Hill
- Pharmacy Practice, The University of Texas at Austin College of Pharmacy, Austin, TX, USA
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Abstract
The opioid crisis continues to exact a heavy toll on the United States, and overdose deaths have only increased during the current global pandemic. One effective intervention to reduce overdose deaths is to distribute the opioid antagonist naloxone directly to persons actively using opioids (ie, "take-home naloxone"), especially at touchpoints with the potential for significant impact such as emergency departments and jails. A number of hospital emergency departments have recently sought to implement individual take-home naloxone programs; however, programmatic success has been inconsistent due primarily to the inability to secure reliable funding for a naloxone supply. In this commentary, we establish the argument for a publicly funded naloxone supply to support take-home naloxone distribution in emergency department settings. We posit that the complex billing and reimbursement system for medication dispensing is impossibly burdensome during emergency care for an acute opioid overdose, and that the mounting death toll from this public health crisis demands a strong commitment to harm reduction. A publicly financed naloxone supply would demonstrate this commitment and make a measurable impact in saving lives. Ultimately, provision of naloxone should be coupled with other comprehensive treatment services and medications for opioid use disorder to meaningfully reduce harms associated with opioid use.
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Franklin Edwards G, Mierisch C, Mutcheson B, Horn K, Henrickson Parker S. A review of performance assessment tools for rescuer response in opioid overdose simulations and training programs. Prev Med Rep 2020; 20:101232. [PMID: 33163333 PMCID: PMC7610043 DOI: 10.1016/j.pmedr.2020.101232] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 10/11/2020] [Accepted: 10/13/2020] [Indexed: 12/18/2022] Open
Abstract
Since the 1990s, more than 600 overdose response training and education programs have been implemented to train participants to respond to an opioid overdose in the United States. Given this substantial investment in overdose response training, valid assessment of a potential rescuers' proficiency in responding to an opioid overdose is important. The aim of this article is to review the current state of the literature on outcome measures utilized in opioid overdose response training. Thirty-one articles published between 2014 and 2020 met inclusion criteria. The reviewed articles targeted laypersons, healthcare providers, and first responders. The assessment tools included five validated questionnaires, fifteen non-validated questionnaires, and nine non-validated simulation-based checklists (e.g., completion of critical tasks and time to completion). Validated multiple choice knowledge assessment tools were commonly used to assess the outcomes of training programs. It is unknown how scores on these assessment tools may correlate with actual rescuer performance responding to an overdose. Seven studies reported ceiling effects most likely attributed to participants' background medical knowledge or experience. The inclusion of simulation-based outcome measures of performance, including the commission of critical errors and the time to naloxone administration, provides better insight into rescuer skill proficiency.
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Affiliation(s)
- G. Franklin Edwards
- Translational Biology, Medicine and Health, Virginia Tech, Blacksburg, VA, USA
- Fralin Biomedical Research Institute at VTC, Roanoke, VA, USA
- Carilion Clinic Center for Simulation, Research and Patient Safety, Roanoke, VA, USA
| | - Cassandra Mierisch
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
- Carilion Clinic, Department of Orthopedics and Opioid Task Force, Roanoke, VA, USA
| | | | - Kimberly Horn
- Fralin Biomedical Research Institute at VTC, Roanoke, VA, USA
- Virginia-Maryland College of Veterinary Medicine, Department of Population Health Sciences Virginia Tech, Blacksburg, VA, USA
| | - Sarah Henrickson Parker
- Fralin Biomedical Research Institute at VTC, Roanoke, VA, USA
- Carilion Clinic Center for Simulation, Research and Patient Safety, Roanoke, VA, USA
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA
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Naloxone provision to emergency department patients recognized as high-risk for opioid use disorder. Am J Emerg Med 2020; 40:173-176. [PMID: 33243535 DOI: 10.1016/j.ajem.2020.10.061] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/19/2020] [Accepted: 10/29/2020] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Patients with opioid use disorder (OUD) are at increased risk for overdose and death. Clinical practice guidelines and professional organization policy statements recommend providing naloxone to patients at risk for overdose. We sought to characterize fidelity to naloxone practice recommendations in a cohort of Emergency Department (ED) patients in whom opioid use disorder was suspected by the treating physician. METHODS This single-center cross-sectional study evaluated electronic health records from an urban academic ED with 73,000 annual encounters in a region with a high prevalence of OUD. Patients ≥18 years old with encounters from January 1, 2018 to November 30, 2019 were included if discharged from the ED and either administered buprenorphine in the ED or referred to outpatient substance use treatment. The primary outcome measure was the percentage of included patients provided naloxone (take-home or prescription). We used random effects multivariable logistic regression (accounting for multiple patient encounters) to estimate the odds ratio (OR) for receiving naloxone. RESULTS Of 1036 eligible patient encounters, 320 resulted in naloxone provision (30.9%, 95% CI: 28.1-33.8). Naloxone provision occurred for 33.6% (95% CI 30.5-36.7) of 900 patients referred to outpatient substance use treatment without ED buprenorphine administration, 10.6% (95% CI 5.0-19.2) of 85 patients administered buprenorphine and not referred to outpatient substance use treatment, and 17.6% (95% CI 8.4-30.9) of 51 patients administered buprenorphine and referred to outpatient treatment. After controlling for age, sex, race, and prior provision of naloxone, the administration of buprenorphine was associated with a 94% lower odds (aOR = 0.06 [95% CI 0.011-0.33]) for naloxone provision compared to those only referred to outpatient treatment. CONCLUSION A majority of ED patients who received an intervention targeted at OUD, in an ED where take-home naloxone is freely available, did not receive either take-home naloxone or a prescription for naloxone at discharge. Patients receiving buprenorphine were less likely to receive naloxone than patients only referred to outpatient treatment. These data suggest barriers other than recognition of potential OUD and naloxone availability impact provision of naloxone and argue for a treatment "bundle" as a conceptual model for care of ED patients with suspected OUD.
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Coon SA, Hill LG, Hutchison RW, Arnold LM, Jarrett JB, Ottney AR, Oung AB, Painter NA, Smith MA, Stranges PM, Tran TH, McFee Winans AR, Bratberg JP. Mobilizing pharmacists to address the opioid crisis: A joint opinion of the ambulatory care and adult medicine practice and research networks of the American College of Clinical Pharmacy. JOURNAL OF THE AMERICAN COLLEGE OF CLINICAL PHARMACY 2020. [DOI: 10.1002/jac5.1331] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Scott A. Coon
- Department of Pharmacotherapeutics & Clinical Research University of South Florida, Taneja College of Pharmacy, Morsani College of Medicine Tampa Florida USA
| | - Lucas G. Hill
- Division of Pharmacy Practice The University of Texas at Austin College of Pharmacy Austin Texas USA
| | - Robert W. Hutchison
- Department of Pharmacy Practice Texas A&M Irma Lerma Rangel College of Pharmacy Round Rock Texas USA
| | - Lindsay M. Arnold
- Department of Pharmacy Services St. Elizabeth's Medical Center Brighton Massachusetts USA
| | - Jennie B. Jarrett
- Department of Pharmacy Practice University of Illinois at Chicago, College of Pharmacy Chicago Illinois USA
| | - Anne R. Ottney
- Department of Pharmacy Practice Ferris State University, College of Pharmacy Big Rapids Michigan USA
| | - Alvin B. Oung
- Department of Pharmacy Practice University of Wyoming School of Pharmacy Laramie Wyoming USA
| | - Nathan A. Painter
- Division of Clinical Pharmacy University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences San Diego California USA
| | - Michael A. Smith
- Department of Clinical Pharmacy University of Michigan College of Pharmacy Ann Arbor Michigan USA
| | - Paul M. Stranges
- Department of Pharmacy Practice University of Illinois at Chicago, College of Pharmacy Chicago Illinois USA
| | - Tran H. Tran
- Department of Pharmacy Practice Midwestern University Chicago College of Pharmacy Downers Grove Illinois USA
| | - Amanda R. McFee Winans
- Section of Clinical Pharmacy, Department of Pharmaceutical Care Services Bassett Medical Center Cooperstown New York USA
| | - Jeffrey P. Bratberg
- Department of Pharmacy Practice University of Rhode Island College of Pharmacy Kingston Rhode Island USA
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Opioid Prescribing with Take-Home Naloxone: Rationale and Recommendations. CURRENT ANESTHESIOLOGY REPORTS 2020. [DOI: 10.1007/s40140-020-00419-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
PURPOSE OF REVIEW Over the last 3 years and for the first time in 60 years, life expectancy in the United States has declined across all racial groups primarily because of drug overdoses, alcohol abuse, and suicide. A public health response to the opioid crisis must expand its focus to more broadly include children, adolescents, and young adults while increasing efforts toward preventing new cases of opioid addiction, early identification of individuals with opioid-abuse disorder, and ensuring access to effective opioid addiction treatment, while simultaneously continuing to safely meet the needs of patients experiencing pain. RECENT FINDINGS Although a multimodal approach to pain management is fundamental in current practice, opioids remain an essential building block in the management of acute and chronic pain and have been for over 5000 years as they work. Left over, unconsumed opioids that were appropriately prescribed for pain have become the gateway for the development of opioid use disorder, particularly in the vulnerable adolescents and young adult patient populations. How to reduce the amount of opioids dispensed, improve methods of disposal in an environmentally safe way, and proactively make naloxone, particularly nasal spray, readily available to patients (and their families) receiving prescription opioids or who are at risk of opioid use disorder are highlighted in this review. SUMMARY We describe the historical use of opioids and the scope of the current opioid crisis, review the differences between dependence and addiction, and the private and public sectors response to pain management and highlight the issue of adolescent vulnerability. We conclude with a proposal for future directions that address both public and patient health needs.
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