"Naloxone should be the fire extinguisher in the home of everyone who is at risk."
This year, APhA’s Generation Rx Award of Excellence has gone to Jeffrey P. Bratberg, PharmD, BCPS, in recognition of his commitment to educate pharmacists and future pharmacists about prevention of prescription medication abuse and misuse.
Jeffrey BratbergIn 2012, Bratberg, a clinical professor of pharmacy practice, University of Rhode Island College of Pharmacy, Kingston, R.I., and his student pharmacist Tara Thomas, a 2013 PharmD candidate, developed a continuing education program to train pharmacists under the first statewide collaborative pharmacy practice agreement (CPA) for naloxone.
The pilot program started in a few Walgreens drugstores in Rhode Island. As the epidemic continued to rage, the program expanded throughout the state and has since been used by other chains nationwide.
DT: Can you describe the overdose education and training program that you co-developed in 2012?
Bratberg: It is a little complex in how it started.
The regulations governing CPAs in Rhode Island actually don’t allow initiation of therapy by pharmacists. CPAs also require that pharmacists have two years of experience or a residency.
In addition, when you are entering into these agreements to manage certain conditions like diabetes or hypertension, five credits in that specialty are needed.
We asked the state Board of Pharmacy to acknowledge that only one credit is needed due to a CPA to initiate naloxone.
Each company or group that went before the board received a waiver that stated pharmacists in training don’t need five credits, just one credit per year to be able to prescribe, counsel, and dispense naloxone.
Basically, we worked out an agreement with the board to say, “Look, here is an epidemic. We need to fight this, and this seems to be the best way to do this.”
Asking pharmacists to find five credits of overdose education in 2012 would be difficult. It is a lot easier now.
DT:Who were the major stakeholders who had to be persuaded?
Bratberg: That is what is great about the Rhode Island model. Everybody was on board from the start.
We have one department of health, one Board of Pharmacy, and everybody knows each other. The Board had already been working on solutions for naloxone from pharmacies for over a year when we came to them with this plan.
DT:How has Rhode Island been affected by the prescription opioid epidemic?
Bratberg: When the deputy director of the Office of National Drug Control Policy came to Rhode Island because we had a spike in deaths  in the first six weeks of 2014, it sort of said that we had an epidemic that was evolving. Of these deaths, 25 were caused by acetyl fentanyl.
In 2016 so far, 50% to 60% of all overdose deaths in Rhode Island were actually due entirely to fentanyl, according to data from the governor’s office. The deaths from nonprescription fentanyl between 2012 and 2016 increased 1,500%.
My clinical practice site is at a hospital with an addiction unit. A person came to our hospital following an overdose at his group home and had been revived with naloxone. He admitted that he did heroin, but none was detected in his urine. While our hospital routinely screens for heroin, it doesn’t routinely test urine for fentanyl or its metabolites. So he probably overdosed on fentanyl.
This epidemic is changing so quickly. That is why pharmacists have to be there.
I conducted a training program at the Utah Experience with the APhA Institute on Alcoholism and Drug Dependencies. It is probably one of the best conferences that I’ve been to. Students would be saying, “Why would fentanyl be killing the patients? Why is it out there?” We don’t know.
Research has shown that only about half of users don’t know the difference between heroin’s and fentanyl’s power for injection. Most users surveyed report preferring fentanyl-free heroin. Fentanyl is 50 times more powerful than heroin.
So we are trying to figure out ways to get naloxone into the hands of those at the highest risk. One potential intervention to get naloxone into the hands of high-risk opioid users is to dispense naloxone with nonprescription syringe purchases, which are typically used by people who inject opioids.
DT:Since the overdose education program has been in place, approximately how many pharmacists have been trained?
Bratberg: We just added up the number of physicians and pharmacists who completed evaluations for
prescribetoprevent.org, which has been out for about one and a half years. The total was almost 15,000.
It was sponsored by SAMHSA [Substance Abuse and Mental Health Services Administration], so it is available to physicians, nurses, and pharmacists.
Connecticut’s Governor Dannel Malloy has asked academic experts and others within his state to assemble a strategic plan modeled on ours in Rhode Island.
With supply-driven models like this one, we just can’t cut off prescription medication supply. We also have to have demand-driven models to address people using heroin and people misusing prescription drugs. Treatment on demand is necessary.
DT:What is your main role on the Rhode Island Governor’s Overdose Prevention and Intervention Task Force?
Bratberg: I represent both the university and our pharmacy association. [Bratberg is a former president.] I am a connector. If people want to duplicate my role - and I think they should - it is literally having a seat at the table where there are individuals from industry and policymakers and the department of health and the state Board of Pharmacy. We are essential to developing solutions for the epidemic, so pharmacy has to be there.
It is not just this public health issue, but it is fighting epidemics such as Zika virus, pandemic influenza, bioterrorism, and emergency preparedness. Those are all things that I have been involved with in our department of health.
There are other states that don’t think of pharmacy as essential to sit at the table, but because of our almost 15 years’ work with the health department, it is natural that they call us to say, “Let’s see what pharmacy can do.”
Once you get a seat at the table, as I did 15 years ago, doing emergency preparedness, it is sort of natural to have pharmacy as part of this task force.
I had two roles: I represented “pharmacy,” but I was also one of the four members of the naloxone work group, which is implementing the overdose rescue portion of the strategic plan. I have helped to figure out how we encourage pharmacists to proactively dispense naloxone, and I am involved in lots of efforts to track naloxone through all the outlets that we have.
DT:Are most pharmacists enthusiastic about counseling patients about naloxone and dispensing the drug?
Bratberg: Community pharmacists have had this very difficult role when Jeff the Professor says, “Here is how we do patient-centered care.”
Then, in the pharmacy, there are the realities of managing time, personnel, and logistics of just getting the prescriptions dispensed.
Then I throw a wrench in and say, “Here is something that you really haven’t done before. Now you have this CPA or a standing order that says anybody can walk up to the counter and ask for naloxone, and you now are the prescriber of one of four naloxone products that we have taught in our training.”
That is just not part of our culture, nor is it part of what we teach, such as “Is this the right drug for the right patient in the right disease?”
The other side of the issue is dangerous combination drugs, like a prescription for a benzodiazepine and an opioid. “How do I counsel individuals who are prescribed a dangerous combination to get naloxone?”
If you are in a state or a pharmacy that lacks a model that permits pharmacists to prescribe naloxone, you need to call the patient’s doctor and ask the doctor to prescribe naloxone.
Are you ready to have that conversation? Does the doctor even know that naloxone exists? Does the physician know about dangerous opioid-drug combinations?
DT: So is naloxone dispensing saving lives?
Bratberg: We have seen a 1,100% rise in naloxone dispensing, according to one report. But our overdose deaths in Rhode Island have continued, despite being one of the states with the greatest access and marketing of naloxone. Maybe we have shifted the curve.
Massachusetts saw a 18% rise in its overdose deaths reported from 2013-2014. New Hampshire saw a 73% rise in its overdose deaths, also during that time period.
But there is positive news, and naloxone is part of the positive news. New Mexico just showed a 9% decline in overdose deaths from 2014-2015, and it was among the top states per capita for overdose deaths for over 10 years.
DT:Any last thoughts to share?
Bratberg: It is important to think of substance-use disorder as a disease. Starting with that foundation, it is necessary to have insurance coverage for managing this chronic disease, including naloxone. We should make it standard of care with dangerous opioid combinations and opioid disease combinations.
In addition, we need to be the educators of our prescribers, so that co-prescribing becomes standard of care. That is recommended by several national bodies.
Three years from now, the goal of [our] task force is to reduce overdose deaths by one-third. I want people to wonder why they didn’t get naloxone with their opioid, because they know that there is a small chance of a very bad outcome with overdose or death.
Naloxone should be the fire extinguisher in the home of everyone who is at risk.