Pharmacists should get training in naloxone use now

Michael PhorthThe epidemic of abuse of prescription drugs and heroin made national news when President Obama brought it up in January’s State of the Union address, not long after signing a Presidential Memorandum addressing this issue in October 2015. Through my involvement with the Marin County Pharmacists Association and Pharmacists Planning Services Inc., I learned why pharmacists should be trained in naloxone use and educated about buprenorphine.

Key numbers

According to the CDC, in 2014 alone more than 14,000 deaths occurred from prescription opioids, and from 1999 to 2014, the total was 165,000.¹

Prescription opioids are so commonly prescribed that friends or family were cited as sources of 54.4% of opioids; by comparison, 19.7% were acquired from a physician’s prescription.^2,3

In response to these alarming statistics, the Presidential Memorandum mandated a change in policy, calling for federal prescribers to be trained on appropriate prescribing of opioids and naloxone, as well as for improved access to treatments.⁴

Naloxone and the law

Laws addressing naloxone dissemination are being implemented throughout the country. For example, California passed a law that allows pharmacists to furnish naloxone under the protocol of the Board of Pharmacy, upon completion of a one-hour continuing education training program.

Before naloxone can be dispensed, the patient must be trained in the use of the naloxone product and must understand symptoms of both opioid overdose and withdrawal from use of the antagonist.

This mandate enables pharmacists to initiate a conversation about accidental overdose, safe use of the medication, and safe storage.

Naloxone formulations

There are three different naloxone formulations: Naloxone HCl, Evzio Auto-injector, and Narcan Nasal Spray.

Generic naloxone HCl can be given intravenously (IV), intramuscularly (IM), or intranasally. The duration of onset takes two to five minutes for IV and IM, while intranasal onset takes eight to 13 minutes due to lower intranasal bioavailability.⁵  Consequently, the intranasal dose (2 mg) is much higher than the injection dose (0.4 mg –2 mg).⁵

The Evzio Auto-injector combines a vocal device that gives instructions with an injection of 0.4 mg IM.

Narcan is a nasal spray that contains a 4-mg intranasal dose.5

Because of the expense of the auto-injector, the other formulations are more commonly dispensed.

In California, Ralph’s pharmacies and limited CVS and Walgreens locations now dispense naloxone without a prescription.⁶

Buprenorphine

Buprenorphine is an opioid partial agonist that is prescribed in cases of opioid and heroin abuse.

Compared to methadone, the drug has a lower risk of abuse and addiction, as well as a better side-effect profile.

The most commonly prescribed formulation is Suboxone, a sublingual film that contains a 4:1 ratio of buprenorphine and naloxone.⁷ Taken sublingually, naloxone has low bioavailability; it is added to the formulation in case a patient decides to inject the Suboxone, in which case the naloxone will produce the full effect of opioid withdrawal on the patient.

Public health interventions

Another approach to curbing this epidemic is being conducted by Partnership HealthPlan of California (PHC), a nonprofit managed care organization serving Medi-Cal recipients.

PHC’s Managing Pain Safely program implements 20 different public health intervention initiatives designed to help reduce the high opioid use in the state. ⁸

PHC has mandated that prescriptions written for opioid doses greater than 120 mg MED (morphine equivalence per daily dose) are not safe. It requires a treatment authorization request, a medical justification, and a plan for tapering treatment when the prescribed dose is higher than recommended.

In addition, through its data collection and analysis, PHC is able to provide statistics on physicians’ patterns of opioid prescription in each county. Through the introduction of such measures, PHC has been able to decrease opioid prescribing rates between 9% and 66%, depending on the county.

When it comes to curbing this country’s epidemic of prescription drug abuse, in many communities pharmacists are the most accessible healthcare resource. Once trained in naloxone use, we can train our patients in all aspects of opioid use. This will make a difference. 

References

1. National Institute on Drug Abuse. Overdose death rates. https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates.

2. Jones CM, Paulozzi LJ, Mack K A. Sources of prescription opioid pain relievers by frequency of past-year nonmedical use: United States, 2008-2011. JAMA Intern Med. 2014 May; 174(5):802-803.

3. Centers for Disease Control and Prevention. Injury prevention and control: Opioid overdose prescribing data. http://www.cdc.gov/drugoverdose/data/prescribing.html.

4. Obama BH. Presidential memorandum: Addressing prescription drug abuse and heroin use. Oct. 21, 2015. https://www.whitehouse.gov/the-press-office/2015/10/21/presidential-memorandum-addressing-prescription-drug-abuse-and-heroin.

5. Naloxone. Lexi-Drugs Online. Hudson, OH: Lexi-Comp, Inc. http://0-online.lexi.com.library.touro.edu/lco/action/doc/retrieve/docid/patch_f/7338.

6. Drug Policy Alliance. Press release. Drug Policy Alliance applauds Ralphs for being first chain supermarket in California to make overdose antidote naloxone available without a prescription. Dec. 12, 2015. http://www.drugpolicy.org/news/2015/12/drug-policy-alliance-applauds-ralphs-being-first-chain-supermarket-california-make-over.

7. Suboxone [package insert]. 2015. Warren, NJ: MonoSol Rx, LLC.

8. Partnership HealthPlan of California. Forum: Managing pain safely. Jan. 15, 2015. www.partnershiphp.org/Providers/HealthServices/Documents/Managing%20Pain%20Safely/MPSFourmII/MPSForumIISlides_SR.pdf.

Michael Phorthis a 2016 MPH/PharmD candidate at Touro University, Vallejo, Calif. He acknowledges assistance provided by Aglaia Panos, PharmD, in the preparation of this article. To contact him, e-mail michael.phorth@tu.edu.