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Multi-disciplinary workflow increases naloxone access in rural America
Pharmacists, front office staff and physicians worked together to boost the number of naloxone prescriptions at a clinic in rural Oregon, according to a report in Annals of Family Medicine.
CDC data show that residents of the most rural counties in the U.S. were 87% more likely to receive an opioid prescription than those living in large metropolitan counties. Previous reports have indicated nonurban areas of the U.S. are among the hardest hit by the opioid epidemic.
Nicholas B. West, DMD, of Winding Waters Clinic at Oregon Health & Science University, explained the six multi-disciplinary steps that create the note in an interview with Healio Primary Care.
“A pharmacist scrubs the chart every 3 months for patients prescribed more than 50 morphine equivalent doses and writes them a Narcan prescription. Then, the front office staff schedules appointments for them. When the patient comes in, the attending physician judges if the patient can taper the opioid dose with the prescribed Narcan. If so, the patient discusses Narcan use with the pharmacist and picks up their prescription,” he said.
West and colleagues wrote in the Annals study that 6 months after implemented the initiative, the number of naloxone prescriptions increased.
West said the review, though only tested in a rural area, has universal applicability.
“I cannot think of specific modifications that would be necessary for an urban setting vs. rural setting. It can be used elsewhere, regardless of rurality,” he said in the interview.
“The largest burden is the EPIC Report for opioids. Depending on what EHR or EPIC upgrade PCPs have, they might have access to reports that automatically calculate the morphine equivalent dose,” he said. “Ours did not calculate for us and so I spent a considerable amount of time monotonously calculating the morphine equivalent doses for various patients,” West added. – by Janel Miller
Disclosures: The authors report no relevant financial disclosures.
Perspective
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Naloxone has been widely recognized as a potential life-saving tool in the battle against opioid overdose death. While best proven as a rescue for people who inject drugs, naloxone has a role for patients prescribed opioids, particularly those on higher doses (typically 50 morphine milligram equivalents per day) or those co-prescribed benzodiazepines. In addition, people who are prescribed opioids and who have a history of accidental overdose, hepatic or renal impairment, or pulmonary disease, are also at higher risk and should be considered for naloxone co-prescribing. Clinicians should ensure that family or those living with the person at risk receive training in recognizing opioid overdose and are able to administer the naloxone, position the individual safely, and call EMS.
Naloxone, used properly, will typically result in acute withdrawal symptoms in the opioid dependent patient; otherwise, it poses almost no serious risks. It can be administered intranasally and through intramuscular injection. Standing orders, now available in most states, allow an individual at risk for overdose to obtain naloxone without prescription, although patients would need to ensure a family member or housemate receives training. Perhaps more importantly, standing orders allow for community organizations to obtain and distribute naloxone to high-risk people. For example, in 2015, the North Carolina Harm Reduction Coalition was able to distribute 15,789 naloxone doses and recorded 1,547 overdose rescues, although this was primarily among people who inject drugs.
Despite its safety and ready availability, patients at risk for overdose often don’t receive a prescription for naloxone. In a recent study in Oregon, West et al, used electronic medical records to identify patients who were prescribed more than 50 morphine milligram equivalents and facilitated prescribing with pending orders and by providing a documentation template. They also provided naloxone and training to their local police department — a strategic move given the frequency that police are called to the scene of an overdose. This sort of problem solving, customized to the needs of the community, can facilitate naloxone distribution to individuals who most need it for their own protection and in the service of others in their community.
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