Evaluation of a pharmacist-led naloxone coprescribing program in primary care

Influence of Implementing an Opioid Stewardship Team in the Primary Care Setting

Background: The Updated 2022 Centers for Disease Control (CDC) Clinical Practice Guideline for Prescribing Opioids for Pain highlights the importance of shared decision making and provider-patient relationships. Interprofessional teams may be helpful in supporting providers and patients. A large, multi-site primary care department created an interprofessional primary care opioid stewardship team to target high-risk opioid prescribing and improve practice alignment with CDC recommendations through dashboard reporting and education. Objective: The primary objective was to assess reduction in morphine milligram equivalents (MME) from baseline to 6 months in patients on opioid doses ≥90 MME daily. The secondary objective assessed change in number of naloxone prescriptions from baseline to 6 months after education. Methods: The study was conducted across 30 primary care sites of one health system within Michigan from 2021 to 2022. The opioid stewardship team included 2 physicians, 3 pharmacists, a project operations manager, and IT support. Interventions included creation of a dashboard, provider education, dissemination of policy, and chart audits. Using the electronic health record (EHR) dashboard, patients on chronic opioid doses ≥90 MME daily or missing an active naloxone prescription were identified. Primary care providers (PCP) were provided with an individual list of patients for whom to consider intervention. Support was provided for prescribers, but the team did not interact with patients directly. Results: Baseline analysis identified 290 patients on doses ≥ 90 MME daily. There was reduction in median daily MME from baseline to 6 months in the overall study population (140 [105 240] vs 120 [90 240], P < .001). At 6 months 181 (62.4%) of patients had been given a prescription for naloxone versus 108 (37.2%) who had one at baseline, P < .001. Conclusion: The initiatives implemented by the opioid stewardship team resulted in statistically significant reductions in MME and an increase in naloxone prescribing from baseline to 6 months post-education.

Naloxone access in perinatal substance use disorder

BACKGROUND

Risk of fatal drug overdose is higher in pregnant and postpartum people with substance use disorder (SUD) than for nonpregnant women of reproductive age. It is recommended that naloxone is prescribed for pregnancies complicated by opioid or stimulant use disorder.

OBJECTIVE

The purpose of this study was to assess the rates of naloxone coprescribing with buprenorphine in a perinatal SUD (PSUD) specialty clinic and identify opportunities for pharmacist-led interventions to improve communication and documentation surrounding naloxone access to achieve a rate of 100% coprescribing of naloxone with buprenorphine.

PRACTICE DESCRIPTION

A clinical pharmacist practitioner is embedded on the Project CARA (Care that Advocates Respect/Resilience/Recovery for All) team, which provides outpatient SUD care integrated with perinatal care in Western North Carolina.

PRACTICE INNOVATION

The clinical pharmacist practitioner assessed baseline rates of naloxone coprescribing with medications for opioid use disorder. Interventions to improve rates of coprescribing include provider education, electronic health record (EHR) documentation templates, and direct patient outreach.

EVALUATION METHODS

Baseline rates of naloxone coprescribing were assessed and then re-evaluated after different interventions to measure pharmacist impact.

RESULTS

Each intervention improved rates of naloxone coprescribing in a PSUD clinic. EHR documentation templates had the largest impact on baseline efforts, although the long-term benefits derived from these efforts have not yet been demonstrated. Substantial time investment from the pharmacist was required to address patients' barriers to obtaining naloxone after their visits.

CONCLUSION

Further process improvement should address barriers to naloxone access for both patients and providers. This may include proactive identification of patients in need of naloxone and a "meds-to-beds" pilot to assist patients in navigating logistical challenges.

Naloxone co-prescriptions for surgery patients prescribed opioids: A retrospective cohort study

Background

Surgeon-prescribed opioids contribute to 11% of prescription drug overdoses in the United States (US). With prescription opioids involved in 24% of all opioid-related overdose deaths in 2020, the US Centers for Disease Control and Prevention (CDC) recommends naloxone co-prescribing to patients at high-risk of overdose and death as a harm reduction strategy. We sought to 1) examine naloxone co-prescribing rates to surgical patients (using common post-surgical prescribing amounts) and those with potential risk factors for opioid-related overdoses or adverse events, and 2) identify the factors associated with patients receiving naloxone co-prescriptions.

Methods

We conducted a single-institution, retrospective study using the electronic medical records of all patients undergoing surgery at an academic institution between August 2020 and May 2021. We included post-surgical adults prescribed opioids that were sent to a pharmacy in our health system. The primary outcome was the percentage of co-prescribed naloxone in patients prescribed opioids.

Results

The overall naloxone co-prescription rate was low (1.7%). Only 14.6% of patients prescribed ≥350 morphine milligram equivalents (MME, equivalent to 46.7 oxycodone 5 mg tablets) and 8.6% of patients using illicit drugs were co-prescribed naloxone. On multivariable analysis, patients who were prescribed >350 MME, used illicit drugs or tobacco, underwent an elective or emergent general surgery procedure, self-identified as Hispanic, or had ASA scores of 2-4 were more likely to receive a naloxone co-prescription.

Conclusions

Naloxone co-prescribing after surgery remains low, even for high-risk patients. Harm reduction strategies such as naloxone, safe storage, and disposal of leftover opioids could reduce surgeons' iatrogenic contributions to the worsening US opioid crisis.

Effects of pharmacist-driven protocol on naloxone prescribing rates in two primary care clinics

The Centers for Disease Control and Prevention (CDC) Guidelines for Prescribing Opioids for Chronic Pain recommend co-prescribing naloxone as a harm reduction strategy when there is an increased risk of opioid overdose. Although naloxone co-prescribing is an important harm reduction strategy, many at risk patients are not prescribed naloxone. The objective was to assess the effectiveness of a pharmacist-driven protocol at increasing the number of patients co-prescribed naloxone according to CDC recommendations. The study design was a multi-center retrospective cohort to evaluate the outcomes of a quality improvement intervention at two primary care clinics which aimed to increase naloxone co-prescribing. The intervention used a two-pronged approach consisting of telephonic outreach to eligible patients by pharmacists and pharmacy interns related to naloxone education and recommendations for naloxone co-prescribing. Additionally, recommendations were sent to the primary care provider in the electronic medical record (EMR) for consideration and implementation. After the 3 month intervention, 57 of the 86 patients contacted were co-prescribed naloxone (66.3%). Most naloxone initiation occurred at the time of telephonic outreach as a new medication order (n = 36), however an additional 12 patients were co-prescribed naloxone at a subsequent primary care provider visit. The proportion of patients at each clinic with MME ≥ 50 co-prescribed naloxone significantly increased after implementation of the intervention (pre 25/64 vs. post 43/76, p = 0.043). Overall, telephonic outreach to patients with recommendations to primary care providers in the EMR were effective methods to increase the rate of naloxone co-prescribing in primary care based on this study.

Organizational Readiness to Implement Community Pharmacy-Based Opioid Counseling and Naloxone Services: A Scoping Review of Current Practice Models and Opportunities

The purpose of this study was to explore existing practice models and opportunities surrounding community pharmacist-delivered opioid counseling and naloxone (OCN) services in the U.S., with the goal of enhancing organizational readiness and improving patient access. A scoping literature review was conducted. English-language articles published in peer-reviewed journals from January 2012-July 2022 were sought via PubMed, CINAHL, IPA, and Google Scholar using permutations of terms such as "pharmacist/pharmacy", "opioid/opiate", "naloxone", "counseling", and "implement/implementation". Original articles reporting the resources/inputs (personnel; pharmacist full-time equivalents; facilities and expenses; in-house versus outsourced personnel), implementation processes (legal source of pharmacist authority; patient identification strategies; intervention procedures; workflow strategies; business operations), and programmatic outcomes (uptake and delivery; interventions made; economic impact; patient or provider satisfaction) of pharmacist-delivered OCN services in community (retail) settings were retained. Twelve articles describing ten unique studies were included. The studies primarily used quasi-experimental designs and were published from 2017 to 2021. The articles described seven broad program elements/themes: interprofessional collaboration (n = 2); patient education format including one-on-one patient education (n = 12) and group education sessions (n = 1); non-pharmacist provider education (n = 2); pharmacy staff education (n = 8); opioid misuse screening tools (n = 7); naloxone recommendation/dispensing (n = 12); and opioid therapy and pain management (n = 1). Pharmacists screened/counseled 11-2716 patients and provided 11-430 doses of naloxone. Limited implementation costs, patient/provider satisfaction, or economic impact measures were reported. This review may serve as a guide for community pharmacists in implementing OCN services in their own practices. Future studies should clarify OCN program implementation costs, patient/provider satisfaction, and the economic impact.

Pharmacists' naloxone services beyond community pharmacy settings: A systematic review

BACKGROUND

Pharmacists' provision of naloxone services in community pharmacy settings is well-recognized. Recently, studies describing pharmacists' naloxone services in settings other than community pharmacies have emerged in the literature. There is a need to synthesize evidence from these studies to evaluate the scope and impact of pharmacists' naloxone services beyond community pharmacy settings.

OBJECTIVES

The objectives of this systematic review were to a) identify pharmacists' naloxone services and their outcomes, and b) examine knowledge, attitudes, and barriers (KAB) related to naloxone service provision in non-community pharmacy settings.

METHODS

Eligible studies were identified using PubMed, Web of Science, and CINAHL. Inclusion criteria were as follows: peer-reviewed empirical research conducted in the U.S. from January 2010 through February 2022; published in English; and addressed a) pharmacists' naloxone services and/or b) KAB related to the implementation of naloxone services. PRISMA guidelines were used to report this study.

RESULTS

Seventy-six studies were identified. The majority were non-randomized and observational; only two used a randomized controlled (RCT) design. Most studies were conducted in veterans affairs (30%) and academic medical centers (21%). Sample sizes ranged from n = 10 to 217,469, and the majority reported sample sizes <100. Pharmacists' naloxone services involved clinical staff education, utilization of screening tools to identify at-risk patients, naloxone prescribing and overdose education and naloxone dispensing (OEND). Outcomes of implementing naloxone services included improved naloxone knowledge, positive attitudes, increased OEND, and overdose reversals. Pharmacists cited inadequate training, time constraints, reimbursement issues, and stigma as barriers that hindered naloxone service implementation.

CONCLUSION

This systematic review found robust evidence regarding pharmacist-based naloxone services beyond community pharmacy settings. Future programs should use targeted approaches to help pharmacists overcome barriers and enhance naloxone services. Additional research is needed to evaluate pharmacist naloxone services by using rigorous methodologies (e.g., larger sample sizes, RCT designs).

Outpatient Opioid and Naloxone Prescribing Practices at an Academic Medical Center during the COVID-19 Pandemic

While improving opioid safety has been a national priority, the coronavirus disease 2019 (COVID-19) pandemic has been associated with increased rates of opioid overdose. The present study characterized outpatient opioid and naloxone prescribing patterns during the COVID-19 pandemic. A retrospective chart review was conducted of adult patients receiving opioid therapy between August 2020 through October 2020 from outpatient clinics within a Texas health system. The primary outcome was naloxone co-prescription during the study period or within the year prior. During the study period, 1,368 patients received an opioid prescription, most of which were prescribed for chronic pain treatment (63.0%). Most opioid prescriptions (91.5%) were written for < 50 MME/day. For prescriptions written for acute pain, 78% were written for ≤ 10 days supply. While 31.1% of patients received gabapentinoid prescriptions, few (7.9%) received benzodiazepine or Z-hypnotic prescriptions. Twenty-two (1.6%) patients were co-prescribed naloxone. In this study, naloxone was rarely prescribed for outpatients receiving opioid prescriptions during the COVID-19 pandemic. Health systems should continue to prioritize adherence to evidence-based clinical guidelines and increase access to naloxone.

Stigma by Association: To what Extent is the Attitude Toward Naloxone Affected by the Stigma of Opioid Use Disorder?

The United States opioid epidemic is fueled by illicit opioid abuse and prescription opioid misuse and abuse. Consequently, cases of opioid use disorder (OUD, opioid addiction), opioid overdose, and related deaths have increased since the year 2000. Naloxone is an opioid antagonist that rapidly reverses opioid intoxication to prevent death from overdose. It is one of the major risk mitigation strategies recommended in the 2016 Centers for Disease Control and Prevention Guideline for Prescribing Opioids for Chronic Pain. However, despite the exponential increase in dispensing and distribution of naloxone, opioid overdose and related deaths have continued to increase; suggesting that the increased naloxone supply still lags the need. This discordance is attributed at least in part to the negative attitude toward naloxone, which is based on the belief that naloxone is only meant for "addicts" and "abusers" (OUD patients). This negative attitude or so-called naloxone stigma is therefore considered a major barrier for naloxone distribution and consequently, overdose-death prevention efforts. This article presents evidence that challenges common assertions about OUD stigma being the sole and direct driving force behind naloxone stigma, and the purported magnitude of the barrier that naloxone stigma constitutes for naloxone distribution programs among the stakeholders (patients, pharmacists, and prescribers). The case was then made to operationalize and quantify the construct among the stakeholders to determine the extent to which OUD stigma drives naloxone stigma, and the relative impact of naloxone stigma as a barrier for naloxone distribution efforts.

Opioid medicines management in primary care settings: A scoping review of quantitative studies of pharmacist activities

To undertake a scoping review of pharmacist activities in opioid medicines management in primary care settings, including those developed or led by pharmacists, or in which pharmacists were members of broader multidisciplinary teams, and to collate the activities, models of care and settings, and reported outcomes. The bibliographic databases MEDLINE, EMBASE, International Pharmaceutical Abstracts, CINAHL, SCOPUS and Web of Science were searched. Studies with quantitative evaluation and published in English were eligible. Participants were patients with any pain category or an opioid use disorder, and healthcare providers. Studies originating in hospitals or involving supply functions were not included. Screening of literature and data charting of results were undertaken by two researchers. The 51 studies included in the scoping review occurred in primary care settings collated into four categories: general practice or primary care clinics, healthcare organisations, community pharmacies and outreach services. Studies were primarily of opioid use in chronic, noncancer pain. Other indications were opioid use disorder, cancer and dental pain. Pharmacist activities targeted risk mitigation, patient and provider education and broader, strategic approaches. Patient-related outcomes included reduced opioid load, improved functionality and symptom management, enhanced access to services and medication-assisted treatments, and engagement in risk-mitigation strategies. Behaviour change of providers was demonstrated. The review has identified the significant contribution that pharmacists working in primary care settings can make to minimise harm from opioids. Strategies implemented in isolation have the potential to further reduce adverse clinical outcomes with greater collaboration and coordination, such as opioid stewardship.

An initiative to increase opioid overdose education and naloxone distribution for homeless veterans residing in contracted housing facilities

BACKGROUND

Up to 35% of veterans with opioid use disorder (OUD) are homeless, and veterans with OUD are nearly 29 times higher risk for homelessness; however, few are prescribed naloxone, an evidence-based intervention to reverse life-threatening opioid overdose.

LOCAL PROBLEM

Many housing facilities for homeless veterans contracted with the San Francisco Veterans Affairs Health Care System are located in neighborhoods with high rates of opioid overdose. No systematic interventions have been implemented to provide opioid overdose education and naloxone kits to veterans and staff at these facilities. This quality improvement (QI) initiative aimed to increase provision of opioid overdose education and naloxone for veterans and staff at contracted housing facilities.

METHODS

This was a prospective single-arm cohort QI intervention. All contracted veteran housing programs were included. Descriptive statistics evaluated results.

INTERVENTIONS

A total of 18 contracted veteran housing programs were contacted from July 2019 through January 2020 to schedule training.

RESULTS

Of those, 13 programs responded to outreach and 10 visits were completed at 8 housing facilities. Training was provided by pharmacist and nurse practitioner trainers to 26 staff members and 59 veterans. Naloxone was prescribed to 37 veterans.

CONCLUSIONS

A pharmacist-led and nurse practitioner-led initiative was effective in increasing veteran and staff access to opioid overdose education and naloxone at >44% contracted veteran housing facilities. Challenges included lack of response from housing programs, low veteran turn out, and inability to provide naloxone to veterans not enrolled/ineligible for health care. Future initiatives should examine strategies to standardize access in homeless veterans' programs.

Patient acceptance of naloxone resulting from targeted intervention from community pharmacists to prevent opioid misuse and accidental overdose

Background: Community pharmacists are in a unique position to prevent opioid-related deaths through the provision of naloxone. However, for those identified as candidates for take-home naloxone, the acceptance rate remains low. Value would be gained from knowing what patient demographics and pharmacist actions are associated with increased patient acceptance of naloxone. Methods: Through a state-wide program, community pharmacists screened all patients receiving an opioid prescription for risk of opioid misuse and/or accidental overdose. Pharmacists prescribed and/or dispensed take-home naloxone to patients at elevated risk. Naloxone acceptance rates were stratified based on risk factors for misuse and overdose to determine which patients are most likely to accept naloxone. Patient acceptance of naloxone and risks were captured electronically. Results: Pharmacist-initiated naloxone recommendations based on risk screening resulted in a 5.81% take-home naloxone acceptance rate. Individuals that were taking multiple opioid medications were most likely to accept the naloxone (20.45%). Concurrent disease states or medications (COPD, concurrent anxiety/depression medication, concurrent sleep aid) were associated with a statistically significant increase in the rate of naloxone acceptance. Acceptance of take-home naloxone increased as a patient risk for opioid misuse and/or accidental overdose increased. Conclusion: Patient acceptance of naloxone at the community pharmacy level was notably higher compared to national naloxone dispensing rates when pharmacists implemented a patient screening and systematic risk-based approach to identify candidates in need of take-home naloxone.

Naloxone coprescription in U.S. ambulatory care centers and emergency departments

OBJECTIVES

The rise in both drug overdoses and deaths owing to opioids has been increasing for at least 2 decades in the United States. Naloxone-prescribing programs have been in use since the mid-2000s with a guideline to manage their use being published in 2012. This study seeks to determine the national prevalence of naloxone coprescribing within U.S. ambulatory care centers and emergency departments (EDs).

METHODS

This study was a retrospective, cross-sectional, observational analysis of data collected by the Centers for Disease Control and Prevention (CDC) in the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey: Emergency Department Summary during the years 2012-2016. All survey participants aged 18 years or older with documented opioid use-with the exception of codeine, dihydrocodeine, and opioid-containing cough syrups-were included. Variables of interest that were available in the data were summarized.

RESULTS

Naloxone was coprescribed with opioids in less than 0.1% of visits. Despite 5 years of data combined across 2 national surveys including 48,158 adults with documented opioid use, further analyses of naloxone coprescription could not be performed owing to the limited number of such coprescriptions. Among the factors previously documented to increase the risk of opioid overdose, concurrent benzodiazepine use (18.7%) was the most reported, followed by history of substance use disorder (1.6%) and history of overdose (< 0.1%).

CONCLUSION

Using nationally representative data collected by the CDC from ambulatory care centers and EDs, we found that naloxone was coprescribed with opioids in only less than 0.1% of visits. Future research is warranted to determine whether current practices have adapted to meet the standards set by the 2016 CDC guidelines.