The Pharmacist’s Role in Naloxone Dispensing to Combat the Opioid Epidemic

Prescription opioids are derived from the opium poppy plant and help to relieve pain by binding opioid receptors in the brain or spinal cord.After binding with the receptor, opioids block pain by preventing the release of neurotransmitters like dopamine. Opioids are effective in this mechanism but when they are misused, it can lead to addiction and possibly death.¹

The opioid epidemic has escalated as a result of increased opioid prescribing, forcing government officials and health care providers to take immediate action. To help combat the increasing instances of overdose, the opioid reversal agent naloxone was introduced into health care.

This product is available as a nasal spray, infusion, and injection, and works as a pure opioid antagonist by displacing opioids from their receptors. With its FDA approval in 2014, the product has made some headway in reaching the hands of patients. Physicians and pharmacists, alike can educate patients about its availability and usefulness.

Thoughtful use of opioids for pain management, continues to be important for optimal patient care. Research has shown that with training focused on prevention of overdose situations as well as utilization of naloxone, results in decreased deaths. The use of naloxone has proven beneficial, but there are still questions of how effective it is in all overdose situations.

How can pharmacists assist patients regarding its use? This article will review opioid use and the importance of naloxone education to achieve better health outcomes.

CDC Chronic Pain Guidelines 2016
Most commonly, opioids are given to help treat chronic pain. Prescribing opioids and managing this therapy for patients can be difficult. Public organizations, such as the Centers for Disease Control (CDC), assist providers in selecting therapy that may be most beneficial. Their guidelines are designed to further complement other drug therapies that are used for pain prevention.

Guidelines cover instances in which opioids should be prescribed for chronic pain, how to taper them, harms and risks of opioids, issuance of naloxone to prevent harm from opioids, and factors to consider when prescribing opioids.²

Opioid Use

According to the 2016 CDC Chronic Pain Guidelines, opioids are prescribed to treat chronic pain, but the risks and benefit of patient function and pain management need to be closely monitored. Nonpharmacological care such as physical therapy or weight loss to help with knee pain should be an adjunct to opioids.

Medication should be utilized at the lowest possible dose and patients should be weaned off the drug as soon as feasible. Opioids are effective in the short term, however there is less evidence for their use in long-term pain management.Patient-specific care should be utilized in all instances. Goals of therapy should be established for each patient to achieve better outcomes.²

Prescribing Considerations

When considering which opioid to initiate for a patient, extended-release formulations should be avoided in the opioid naïve. If patch formulations are prescribed, patient education is very important. It is essential that patients understand proper administration of the patch and dosing should be closely monitored by the physician.

Patient follow-up is also important. This is especially true when first starting opioid treatment. Patient follow-up appointments should occur at least every 3 months. Closer monitoring of patients should occur when doses greater than 50 mg equivalents of morphine are prescribed.Patients using this dosage are considered high risk for an opioid overdose.²

Opioid Overdose Guidance

CDC guidelines highlight the use of naloxone for patients at high risk of an opioid overdose. Administration of naloxone may cause symptoms of opioid withdrawal and patients should be educated on its use in overdose situations. All guidance is meant to correctly utilize opioid therapies in certain patients, so that benefits are achieved, while minimizing their risks.²

Pharmacists play a role in prevention of opioid overdose by providing information to patients about signs and symptoms.³ Signs and symptoms can include pale or clammy skin, blue fingertips or lips, inability to wake the person, or vomiting.³ Understanding the signs and symptoms of an opioid overdose is crucial to saving a life.^3,4

Preventing Opioid Overdose
The need for naloxone therapy and education should not be limited to chronic opioid users. One of the highest instances of overdose occurs in children. Instruction should be provided to patients regarding proper storage to avoid accidental ingestion. Opioids should be kept out of reach of children and pets, because even a small amount could be fatal.

They should be stored in a locked cabinet or other secure area. In addition, opioids should be kept out of plain sight. Prevention of diversion is also key. Encourage patients to record their daily use that includes description of when and how much medication was taken. Lastly, if theft activity is suspected, law enforcement should be notified.⁴

Opioids should be disposed of properly. Disposing in the trash or toilet is not recommended but mixing with cat litter and then throwing away, is a good option. Medications can also be turned in during community drug take back programs. These may be available at specific pharmacies or at police stations.⁴

Community Pharmacists and Barriers to Dispensing Naloxone
Pharmacists are being called upon to assist in the rising opioid crisis. They play a role in the health care field because of the ease the public has in obtaining their guidance. Pharmacists have the expertise to provide patients with an in-depth understanding of their medications and the ability to educate them on how to obtain the most benefit. Pharmacists can readily dispense naloxone; however, some difficulties have occurred.

In a survey of North Carolina community pharmacists, barriers were discussed regarding naloxone dispensing.Questions in the survey included willingness to dispense naloxone, knowledge of naloxone related to opioid overdose, barriers that were perceived in implementing a distribution program, demographics, and method of receiving educational training.

Overall, there was a total of 40 close-ended questions. Knowledge-type questions focused on indication, counseling points, and what steps were taken in an overdose emergency. The comfort level for each pharmacist was assessed via a Likert-type scale with questions related to dispensing naloxone in various situations and perceived benefit.⁵

The survey was collected from all pharmacists that had an active license in the community setting and a functional email address. The survey was distributed to 5695 community pharmacists and it had a 7.4% response rate.

The results obtained were primarily female, (60.8%) practicing in a national chain setting (45.9%).Study results showed 49.2% of participants were comfortable in dispensing naloxone in various scenarios.Statistical significance was found, p<0.001, between knowledge score and comfort level dispensing naloxone, but not related to practice setting or number of dispensed opioids.⁵

The survey revealed 2 important barriers regarding naloxone: inadequate training (53.7%) and workflow concerns (35.5%).⁵ Several important conclusions resulted from the study, including that more research is needed to engage pharmacist’s participation in the dispensing of naloxone and improvements in pharmacists’ training increasing naloxone dispensing under prescription orders.⁵

Communication Training for Pharmacists and Naloxone Dispensing
A pharmacist’s responsibility in their provider role requires communication with patients regarding their medications. Another study detailed the impact of communication technique training (CTT) and how it related to naloxone dispensing for opioid prescriptions.Conducted in the state of Illinois, it was designed as a prospective pre- and post-intervention in Chicago from February to May 2019.

Altogether 25 pharmacists from 6 pharmacies were included in the study. Each pharmacist had to have participated in Accreditation Council for Pharmacy Education approved training, from the Illinois Department of Human Services. Each pharmacy had to have dispensed at least 1200 prescriptions per week and filled prescriptions for daily opioid equivalent dosages greater than 50 mg of morphine.These pharmacies also dispensed less than 2 doses of naloxone per year. Participants received the CTT, pocket card case, and patient scenario.⁶

Pocket cards included counseling points on opioid adverse effects, and important phrases to use during the naloxone discussion with patients. Case scenarios were performed in a teach-back method format.⁶ 

Results of the study showed a statistically significant increase between pre-and post-intervention dispensing units versus units per pharmacist, p=0.004. Fewer opioids were dispensed in this instance. Non-24-hour pharmacies were found to dispense more naloxone units, 17 versus 7, and half were dispensed between noon and 6 pm.

No statistical significance was found related to gender, hours of operation, number of years of work experience, or time of naloxone related dispensing. Use of a CTT training session was helpful in providing pharmacists the tools to determine eligible patients and caused a 4-fold increase in naloxone dispensing. This study showed that education tools could be implemented to help train pharmacists in better opioid medication management.⁶

Conclusion

Pharmacists should continue to find ways to increase education of naloxone dispensing and utilization. These studies and research highlighted difficulties in its distribution, regardless of practice setting or area location. Communication by pharmacists, in addition to their understanding of the medications dispensed, can improve patient care.

Pharmacists are responsible for staying current regarding changing therapies. They also need to have significant knowledge of those that should receive naloxone, when to administer it, and what to discuss with each patient. Patient education provided by pharmacists related to opioids needs to include signs and symptoms of an overdose, proper storage of the medication, safe usage guidelines, management of an overdose, and how to dispose of unused medications.

These efforts will continue to be helpful in fighting the opioid epidemic and improve health outcomes for patients across the United States. Pharmacists should aim to share their knowledge with other providers. This increases the awareness of opioid reversal agents and their use in the health care setting.

References

1. NIDA. Prescription Opioids DrugFacts. National Institute on Drug Abuse website. https://www.drugabuse.gov/publications/drugfacts/prescription-opioids. May 29, 2020 Accessed June 16, 2020.

2. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep 2016;65(No. RR-1):1–49. DOI: http://dx.doi.org/10.15585/mmwr.rr6501e1external icon.

3. Opioid Overdose. Psychiatric News. 2020;50(5):1-1. doi:10.1176/appi.pn.2015.2a10. Opioid Overdose. SAMHSA.gov. https://www.samhsa.gov/medication-assisted-treatment/treatment/opioid-overdose. Accessed May 29, 2020.

4. American Society of Regional Anesthesia. Safe opioid storage, tapering, and disposal. American Society of Regional Anesthesia and Pain Medicine. https://www.asra.com/page/2725/safe-opioid-storage-tapering-and-disposal. Published 2020. Accessed May 30, 2020.

5. Rudolph SE, Branham AR, Rhodes LA, Hayes, HH, Moose JS, Marciniak MW. Identifying barriers to dispensing naloxone. A survey of community pharmacists in North Carolina. Journal of the American Pharmacists Association: JAPhA. https://www.ncbi.nlm.nih.gov/pubmed/30006187.Published 2018. Accessed May 18, 2020.

6. Gandhi N, Hanes S, Candelario DM, Clough C, Highland J. Impact of a communication technique training on rates of naloxone dispensing. Journal of the American Pharmacists Association: JAPhA. https://www.ncbi.nlm.nih.gov/pubmed/?term=impact+of+a+communication+techniques+training+on+rates+of+naloxone+dispensing.Published on March 18, 2020. Accessed May 18, 2020.