The Emergency Department at University of Colorado Hospital is making a concerted effort to get a lifesaving drug that reverses the effects of opioid overdose into more hands.
The drug, naloxone, is available at all UCH pharmacies and a growing number of others around the state. That’s the result of a law passed last summer that gives the chief medical officer for the Colorado Department of Public Health and Environment (CDPHE) the authority to issue standing orders for pharmacies and “harm reduction agencies” to dispense the drug to those at risk of an overdose or those in a position to prevent injury or death from an overdose, such as a family member, friend, or first responder.
The legislation emerged from a growing awareness of the toll in lives and lost productivity exacted in Colorado and around the nation by misuse of opioid painkillers. The cost and tighter scrutiny of prescription drugs have also helped to fuel an increase in heroin use in both the state and the nation. Currently, pharmacies in nine communities in Colorado dispense naloxone; King Soopers plans to approve standing orders for its pharmacies on Nov. 11.
At UCH, the Center for Dependency, Addiction, and Rehabilitation (CeDAR) began dispensing naloxone kits last year to families and loved ones of patients in recovery from opioid addiction. Staff at CeDAR give instructions in administering naloxone intranasally to a patient whose respiratory system has shut down because of a drug overdose. Naloxone restores breathing and allows the individual to recover.
“It’s an avenue to save someone’s life,” said Dawn O’Keefe, RN, an ED nurse at UCH.
O’Keefe comes to her advocacy of naloxone through experience. Her son, now in recovery from addiction, overdosed on drugs in her family’s home two years ago. When she broke a door down to reach him, O’Keefe found her son unresponsive and used a naloxone injection to revive him. He’s been sober for about a year, she said. “I can’t imagine my life if I hadn’t had it.”
O’Keefe said she has heard stories from individuals “in all walks of life” who have been faced with similar life-and-death situations with loved ones. She actively encourages people to get and learn to use naloxone, if for no other reason than to save lives. Those who miss the opportunity “are facing a lifetime of what ifs and lost futures,” she said. “The dead addict cannot ever recover and the pain for families is forever. And as a society we will have to live with that.”
O’Keefe recently spearheaded a new initiative naloxone initiative with inpatient pharmacists and Jason Hoppe, DO, associate professor in the University of Colorado School of Medicine’s Department of Emergency Medicine.The ED at UCH now has inpatient pharmacists meet with patients who are addicted to opioids or those at risk of an overdose, such as individuals taking prescription medications for chronic pain. After completing a screening, pharmacists follow a protocol that includes discussing naloxone and demonstrating how to assemble and use the delivery system – either an intranasal or a voice-guided auto-injector kit.
The pharmacists also explain to patients and those accompanying them the risks of overdose and the science of addiction, said Gabrielle Jacknin, PharmD, supervisor of Inpatient Pharmacy Services at UCH.
“We talk extensively about how addiction forms,” Jacknin said. She noted that opioids target the same brain hormones that help people form memories. With excessive use, the drugs “deepen the memory grooves” in the brain of the pleasure the individual experienced or the stress that was relieved, she said.
“Even when there are negative outcomes, the body still tells the individual to use the drug,” Jacknin said.
The power of addiction helps to explain why opioid overdose is the number-one cause of unintentional death in Colorado, added Jennifer Spears, PharmD, a clinical pharmacist in the outpatient ED at UCH. Making naloxone readily available is one way to change that, said Spears, noting that the pharmacy will dispense naloxone to “anyone who walks to the counter,” regardless of age. Spears and her colleagues will discuss naloxone with the person requesting it and walk him or her through the administration process.
Hoppe said he hopes the ED program will boost the modest number of naloxone prescriptions written and dispensed the first half of 2015. Through June 15 of this year, ED providers wrote a total of 45 naloxone prescriptions, with just 13 dispensed. But from June 15 to Sept. 15, the ED wrote 41 more prescriptions for the drug, with 22 dispensed. Jamie Billotti, PharmD, an emergency medicine clinical pharmacist who demonstrates using the naloxone system in the ED, said she now talks with more patients and family members about the drug – perhaps three to five a week compared with three to five per month before the new approach.
“The numbers are going up as people get more comfortable screening patients,” Billotti said. She will also help to spread awareness of naloxone to the community in the near future with a trip to Arapahoe House, the largest substance abuse disorder treatment facility in Colorado.
Pharmacists in the ED at UCH help deliver education about the dangers of overdose and how to use the OD antidote, naloxone. Left to right: Jennifer Spears, Jamie Billotti, and Gabrielle Jacknin.
Seeking MD buy-in
While the number of pharmacies stocking naloxone is increasing rapidly, physician acceptance of the medication is spotty, Hoppe said, in part because the risk posed to patients taking prescription painkiller medications is not as obvious as it is for individuals exhibiting obvious signs of IV drug abuse. Discussing naloxone could be more uncomfortable for a physician who sees a patient regularly than for an ED provider who likely will have a single encounter with a patient, Hoppe said.
“Physicians may feel that offering patients the antidote may compromise a relationship or may not be necessary,” he said.
There are also “misconceptions” nationally about the safety of naloxone among providers who believe that it may give individuals “a false sense of security” when they take high-risk medications, Hoppe said. He noted discomfort providers may feel with the idea of simultaneously prescribing medications for pain together with a drug designed to reverse an overdose of those same medications.
A presentation by Ingrid Binswanger, MD, MPH, co-sponsored by CU’s Division of General Internal Medicine and Kaiser Permanente, looked at the barriers among providers to assessing patients’ overdose risk, offering counseling, and prescribing naloxone. In addition to practical questions about how to train people to administer Naloxone, some providers confirmed worries that prescribing naloxone gives the okay for risky behavior and that simply bringing up the question might be offensive to patients.
“The main concern that we try to demystify is safety,” Hoppe said. He said the belief that administering naloxone increases the likelihood of a person subsequently taking a higher drug dose has been “relatively debunked.” Some prescribers are also concerned about their liability if an individual goes into withdrawal after receiving naloxone. Hoppe noted, however, that Colorado law protects anyone who administers naloxone to another person in good faith.
“There isn’t really an alternative,” he said. “An individual with an opioid overdose revived with naloxone could go into drug withdrawal,” he conceded, but without the antidote, the likelihood of injury or death from respiratory depression is great.” Naloxone, Hoppe emphasized, is “by no means a silver bullet” for the problem of opioid addiction, but a stop-gap measure that “gives people a second chance.”
O’Keefe, who was a participant in the annual meeting of the Colorado Consortium for Prescription Drug Abuse Prevention at the CU Skaggs School of Pharmacy and Pharmaceutical Sciences Oct. 15, said overdoses too often are the result of social stigma that puts drug use in the shadows. She believes the ED’s initiative is one small step toward shining a light on a deadly epidemic.
“People feel isolated and wonder where they can go to talk about the problem,” O’Keefe said. “We’re saying, ‘You’re not alone in this.’”