Understanding Naloxone Standing Orders Is Vital

Naloxone hydrochloride is becoming more accessible, but some pharmacists are unaware that prescriptions may not be required.

With opioid-related overdose deaths at an all-time high, doubling from 21,089 in 2010 to 42,249 in 2016,¹ the use of naloxone hydrochloride in incidences of overdose has become increasingly important.

US Surgeon General Jerome M. Adams, MD, MPH, recently recommended the life-saving drug and encouraged Americans to carry it and know how and when to use it. Pharmacists play an extremely important role in providing Narcan to patients and educating them about how to prevent opioid deaths.

Forty-two states and the District of Columbia have enacted standing orders to make naloxone hydrochloride available without a prescription, but many pharmacists are still unaware of these orders.

In Wisconsin, for example, a Milwaukee Journal Sentinel-USA Today Network-Wisconsin survey of 465 pharmacies across 15 counties in the state found that 27% said that a prescription is needed and did not know about the state’s standing order, in place since 2016.²

Another 2016 study in Indiana found that pharmacies had not dispensed naloxone hydrochloride to patients who needed it, implying that the life-saving drug is not being used.³

Pharmacists need to become aware of the laws related to Narcan in their states, as it has continually proven to save lives.

The drug is especially important for those who take high doses of opioid main medication, those taking benzodiazepines and opioid concurrently, and those misusing prescription of illicit opioid drugs.

“Working under authorization of standing orders can be a new ballgame for pharmacists. They are accustomed to working under a scope of practice defined by the legislature and refined by the board of pharmacy,” said Joseph L. Fink III, BSPharm, JD, DSc (Hon), FAPhA, a professor of pharmacy law and policy and the Kentucky Pharmacists Association Endowed Professor of Leadership at the University of Kentucky College of Pharmacy in Lexington.

“To have authorization come from another source can be new and the law surrounding that in their state may be less than crystal clear. Pharmacists prefer legal guidance that is indeed crystal clear,” Fink said.

Naloxone hydrochloride was used in an August mass overdose in New Haven, Connecticut, when more than 70 patients were treated. These patients had taken a synthetic cannabinoid, known as K2, that had been laced with fentanyl. Emergency responders used naloxone hydrochloride onsite, and patients were treated with higher doses once they arrived at the emergency department.

The first responders initially ran out of the drug, and the Connecticut State Department of Public Health had to deliver 50 additional doses to treat everyone, including homeless individuals who had been affected, according to a statement from Connecticut Gov. Dannel P. Malloy.⁴

Bringing awareness and accessibility to people who struggle with substance abuse and those surrounding them could potentially prevent opioid-related deaths in the future, according to an article speculating on opioid use in the hip-hop industry in Vibe.⁵

Additionally, high school and college campuses are beginning to stock naloxone hydrochloride, as are libraries and YMCA facilities, and emergency medical technicians, firefighters, and police officers, firefighters are carrying it with them, according to the resource page. ⁶

For a map of states with standing orders allowing pharmacists to distribute naloxone without a patient-specific prescription from another medical professional, please see the Figure.⁷

References

• Statement from FDA Commissioner Scott Gottlieb, M.D., on agency’s efforts to advance new ways to increase the availability of naloxone as one means for reducing opioid overdose deaths [news release]. Silver Spring, MD; October 23, 2018: FDA website. https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm624053.htm. Accessed November 7, 2018.
• Luthern A. Under Wisconsin law, it should be easy to buy the drug to reverse and opioid overdose. It’s not. Milwaukee Journal Sentinel. August, 23, 2018. jsonline.com/story/news/local/wisconsin/2018/08/23/wisconsin-pharmacies-unclear-narcan-laws-reduce-opioid-heroin-overdoses/1013650002/. Accessed November 7, 2018.
• Meyerson BE, Agley JD, Davis A, et al. Predicting pharmacy naloxone stocking and dispensing following a statewide standing order, Indiana 2016. Drug Alcohol Depend. 2018:18; 187-19 doi: 10.1016/j.drugalcdep.2018.03.032.
• Gov. Malloy statement on outbreak of overdose cases in New Haven [news release]. Hartford, CT: Office of Governor Dannel P. Malloy; August 15, 2018. portal.ct.gov/Office-of-the-Governor/Press-Room/Press-Releases/2018/08-2018/Gov-Malloy-Statement-on-Outbreak-of-Overdose-Cases-in-New-Haven. Accessed November 7, 2018.
• Grant J. Hip-hop has an opioid problem too, and it’s time people cared. Vibe.com website. September 11, 2018. vibe.com/2018/09/hip-hop-opioid-problem-mac-miller-asap-yams-lil-peep/. Accessed November 7, 2018.
• Community programs. Website. narcan.com/community/education-awareness-and-training-resources/. Accessed November 7, 2018.
• Naloxone overdose prevention laws. Prescription Drug Abuse Policy System website. pdaps.org/datasets/laws-regulating-administration-of-naloxone-1501695139. Updated July 1, 2017. Accessed November 8.