FALLS CHURCH, VA—In June 2018, Defense Health Agency Director Raquel Bono, MD, directed all MHS pharmacies to dispense the opioid reversal agent naloxone to eligible beneficiaries and those who request it without requiring a prescription. Since then, MHS pharmacists have provided more than 6,200 kits.
That marks a significant change in the provision of naloxone. From the date of Bono’s procedural instruction “through May 2019, naloxone prescriptions for high risk patients increased by a factor of 10,” DHA spokesman Kevin Dwyer told U.S. Medicine.
The DoD’s Basic Core Formulary now includes nasal naloxone, which is stocked at all MTF pharmacies. Naloxone auto-injectors are on the Uniform Formulary and can be provided by MTF pharmacies to meet patient needs, he noted.
“The naloxone policy is one component of the Military Health System’s multipronged opioid safety and pain management strategy,” Dwyer said.
Every day, opioid-related overdoses lead to the deaths of 130 people in the U.S., principally as a result of respiratory arrest, according to the National Institutes of Health.
“Naloxone is a very effective opioid reversal agent when administered upon recognition of an overdose. Although naloxone has been most commonly utilized in hospitals and ambulances, there was realization of a need to provide first responders, prescribers and pharmacists with improved access to naloxone for the community to increase the population health benefit and reduce adverse outcomes associated with opioid use,” Dwyer said.
As a result, the U.S. Centers for Disease Control and Prevention, Substance Abuse and Mental Health Services Administration and others have urged greater patient access to naloxone. Available as both a nasal spray and an injection, naloxone binds opioid receptors to reverse or block the effect of opioids and restores breathing when given in time.
The DHA policy and state-level naloxone access laws aim to put naloxone in the hands of individuals at risk of opioid overdoses or their friends, families or caretakers, so that the potentially life-saving medication can be administered before it’s too late.
Policy Maximizes Access
Based on a recent study published in in JAMA Internal Medicine, the DHA policy provides the type of access shown to most effectively increase access to naloxone and reduce deaths from opioids. 1
The study looked at the effectiveness of state naloxone access laws enacted over the past several years. Nearly all states have adopted some type of NAL, but the specifics differ widely. Some still require a physician’s prescription for the drug, while others give pharmacists direct authority to dispense naloxone to patients in specific programs. Nine states grant pharmacists authority to dispense naloxone to anyone who requests it—just like the DHA policy.
“The evidence shows that states allowing pharmacists direct authority to dispense naloxone to anyone have seen large increases in the dispensing of the medication. In contrast, states granting pharmacists’ only indirect authority to dispense naloxone have experienced little change,” according to NIH director Francis Collins, MD.
More importantly, the study found that states that adopted direct authority naloxone access laws “experienced far greater reductions in opioid-related deaths than states with indirect authority NALs or no NALs. Specifically, the analysis showed that in the year after direct authority NALs were enacted, fatal opioid overdoses in those states fell an average of 27%, with even steeper declines in ensuing years,” Collins noted.
Identifying High-Risk Beneficiaries
While any beneficiary who requests naloxone can receive it, pharmacists received training and tools to better identify those most likely to need the opioid antagonist.
When a beneficiary presents an opioid prescription, “MTF pharmacists at the outpatient window use the Risk Index for Overdose or Serious Opioid-Induced Respiratory Depression, known as the RIOSORD, to determine whether or not a beneficiary is at risk for overdose,” Dwyer explained. “This is a nationally recognized, validated screening tool used to estimate the likelihood of overdose among users of prescription opioids. If the beneficiary’s RIOSORD score is over 32 (maximum score of 115), naloxone is recommended.”
RIOSORD is embedded in the MTF CarePoint Look-Up Tool, which has seen a dramatic increase in use since issuance of the DHA-procedural instruction. In the six months prior to the new policy, MTF pharmacists used the tool 8,708 times. In the 11 months after the expansion of naloxone access, pharmacists used the tool 48,514 times, Dwyer reported.
The new policy required all pharmacists to receive training on naloxone before they could prescribe it. DHA recommends several industry standard courses and developed and distributed educational materials to further explain the procedural instruction. Materials also were developed for patients and caregivers.
“The educational materials highlight the appropriate use and administration of naloxone, beneficiary counseling and provide links to resources from other government agencies, such as the U.S. Food and Drug Administration and the Substance Abuse and Mental Health Services Administration,” Dwyer said.
With the combination of materials, focused education and expanded access, he noted, “Naloxone education and training has become a core competency for clinical pharmacists.”
Abouk R, Pacula RL, Powell D. Association Between State laws Facilitating Pharmacy Distribution of Naloxone and Risk of Fatal Overdose. JAMA Intern Med. 2019 May 6;179(6):805-811.
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