Transcript Take Home Naloxone Kits – October 27, 2016 Slides

“Reducing the risk of a
fatal opioid overdose:
The role of the pharmacist”
October 27, 2016
Rob Gillespie, Sergeant of the Street Crime Unit, Brantford Police Service
Shawna Wilson R.N., Brant County Health Unit
Anna Romano, RPh - BCPA
Lisa Reeder, RPh -BCPA and Brant Community Healthcare System
Andrew Shi, RPh – Brant Community Healthcare System
Please visit the BCPA website:
http://www.bcparx.ca
Agenda
1. Discuss the work being done by various community partners
participating in the “Fentanyl Roundtable” initiative initiated by the
Brantford Police Service
2. Gain a local perspective on opioid misuse and overdoses.
3. Receive training on the use of the “Take Home Naloxone Kits” by a
Public Health Nurse
4. Discuss Naloxone Kit billing codes and obtaining additional Naloxone
Kits
5. Network and share your experiences dispensing Naloxone Kits with
local colleagues
6. Discuss and provide input on managing the Patch-for-Patch Fentanyl
Program requirements when your patient is admitted and discharged
from the Brant Community Healthcare System.
7. Brant Community Healthcare System update regarding a NEW
standardized discharge process as of December 12th
Pharmacist CE Event:
November 23, 2016
Brant Community Healthcare
System
Formal invite to follow
Please complete survey!
Pharmacy Connection – OCP, Fall 2016, Volume 24:4
http://bcparx.ca
Ontario Naloxone Program
 As of October 7, 2013 organizations eligible to take part in the Ontario
Naloxone Program included:
 Public Health Units that manage a core Needle Syringe Program
 Community-base organizations that have been contracted by their
local Public Health Unit to manage a core Needle Syringe Program
 Ministry funded Hepatitis C Teams
 As of June 24th naloxone is Schedule II “when indicated for emergency
use for opioid overdose outside of hospital settings”
(remains Schedule I for any other indication)
Reference: http://www.health.gov.on.ca/en/pro/programs/drugs/opdp_eo/notices/not_exec_office_20160824.pdf
Ontario Naloxone Program
 Currently the Take Home Naloxone Kits are available from:
 Community Pharmacies – for an “eligible person”
 Public Health Units – for an “eligible person”
 Correctional Facilities – starting next week intranasal naloxone will
be available at 2/26 correctional facilities in Ontario, with a phased
roll-out
 In the coming months will be rolled out to shelters, community health
centres, outreach programs and other service organizations
Ontario Naloxone Program
Criteria for an “Eligible Person”:
 Currently using opioids (for both medical and non-medical reasons)
 Is a past opioid user who is at risk of returning to opioid use
 Family member, friend or other person in a position to assist a person at
risk of an overdose from opioids.
Reference: http://www.health.gov.on.ca/en/pro/programs/drugs/opdp_eo/notices/not_exec_office_20160824.pdf
Ontario Naloxone Program: WHY?
 Accidental overdoses can occur in individuals:
 Who use opioids for non-medical reasons
 Who use opioids as prescribed by their physician (i.e. chronic pain)
GOAL: increase public awareness and access to more
people in an effort to prevent opioid-related mortality
HARM-REDUCTION STRATEGY
Take-Home Naloxone Kit: Required Contents
Per Ministry of Health:
 Two 1 mL ampoules or vials of naloxone hydrochloride 0.4 mg/mL injection
 Two safety engineered syringes with 25 g one inch needles attached
 Two safe ampoules opening devices (only if supplying ampoules)
 One pair of non-latex gloves
 One rescue breathing barrier
 One naloxone identifier card
Carrying case not listed as “required” but contents need to be appropriately packaged
together
Reference: http://www.health.gov.on.ca/en/pro/programs/drugs/opdp_eo/notices/not_exec_office_20160824.pdf
Naloxone
 Pure opioid antagonist that has high affinity for the mu receptors in the
brain; displaces and prevents binding of opioids to the mu receptors
reversing the central and peripheral physiological effects of opioids
 Has no agonist effect and does not cause physical or psychological
dependence (no abuse potential)
 In the absence of an opioid, naloxone exhibits no effects and does not
cause respiratory depression
Reference: UptoDate, Naloxone Product Monograph
Naloxone
ONSET: 2-5 minutes (for both IM and intranasal administration)
DURATION:
 20-90 minutes and depends on the route of administration of naloxone and the type
and dose of opioid
 Highly lipophilic and it is quickly redistributed out of the brain, therefore the duration
of action does not reflect the elimination t ½
WARNINGS/PRECAUTIONS
 Can precipitate symptoms of acute opioid withdrawal syndrome including: pain,
hypertension, sweating, agitation, vomiting, seizure, delirium, irritability and acute
respiratory distress syndrome
 Does not reverse respiratory depression cause by non-opioid drugs (i.e alcohol)
PREGNANCY/LACTATION:
 Crosses the placenta
 Risk versus benefit – should be given to a pregnant women in a life-threatening
overdose situation
 May precipitate withdrawals symptoms in mother and fetus
–
immediate medical attention is required
Reference: UptoDate, Naloxone Product Monograph
RPh Role
 Ideal point of access
 56.1% of people who died of an overdose had a prescription filled for
an opioid in the previous month
 Dispense a kit
 Provide training
 Create awareness of kit availability
 Keep a kit on hand in pharmacy in the event that a person overdoses in
your store
Reference: Ontario Pharmacists Association ‘”Take-Home Naloxone in Community Pharmacies online module “
Dispensing Naloxone: RPh Responsibility
 Usual requirements as per Schedule 2 drugs
 Stored where patient self selection is restricted, provided under direct
supervision of a pharmacist and patient/agent must be counselled
 Pharmacist Training (per OCP):
 It is the responsibility of the RPh to ensure she/he has sufficient
knowledge, skills and abilities to competently deliver any pharmacy
service.
 RPh must ensure that he/she has the appropriate training and has the
required resources to ensure that the service is provided in a safe and
effective manner
Per the Ministry of Health: “The ministry strongly encourages that pharmacists
complete appropriate training prior to providing naloxone emergency kits. The
ministry is aware of naloxone online webinar training (recorded) and additional
resources available on the Ontario Pharmacists Association website.
There may be other resources available to pharmacists. “
Reference: http://www.ocpinfo.com/library/practice-related/download/Naloxone.pdf
Dispensing Naloxone: RPh Responsibility
 Patient assessment:
 ALLERGY: to naloxone or concomitant ingredients (methylparaben or propylparaben)
• RARE and the benefits are likely to outweigh the risks of an allergic reaction
 If ALLERGY identified person should be encouraged to seek medical attention from a
physician. Pharmacist can only dispense if he/she confirms with a physician that the kit
should be dispensed
 Patient/Agent Education – 10 components:
1) Harm reduction strategies when using opiods
2) How to identify an opioid overdose
3) Importance of immediately calling 911
4) Importance of CPR
5) Rescue breathing
6) When and how to administer naloxone
7) Aftercare and the importance of staying with the person until emergency first responders
arrive
8) Withdrawal symptoms
9) Effectiveness with various drugs (i.e. buprenorhphine)
10) Risk of secondary overdose if opioids used when patient regains consciousness
Reference: http://www.ocpinfo.com/library/practice-related/download/Naloxone.pdf
Submitting a claim to the Health Network System (HNS)
Table 1: PINs to support reimbursement of Naloxone emergency kits
PINs
PIN Description
Total Amount
Reimbursed
93877251
Initial naloxone emergency kits (reimbursed amount
includes naloxone kit at $35, plus a professional fee at
$10, plus professional training at $25)
$70.00
93877252
Replacement naloxone emergency kit (reimbursed
amount includes naloxone emergency kit at $35 plus a
professional fee at $10)
$45.00
93877253
Initial naloxone emergency kits supplied by MOHLTC
(reimbursed amount includes professional training at
$25)
$25.00
Reference: http://www.health.gov.on.ca/en/pro/programs/drugs/opdp_eo/notices/not_exec_office_20160824.pdf
Submitting a claim to the Health Network System (HNS)
 Submitting a claim to the HNS for an ODB eligible recipient
 Follows the normal process for submitting claims on the HNS plus
the following:





Intervention code ‘PS’: (Professional Care Services)
Product Identification Number (PIN) – See Table #1
Valid Pharmacist ID
Professional Fee - See Table #1
Eligible person’s name, date of birth, and Ontario health card
number
Reference: http://www.health.gov.on.ca/en/pro/programs/drugs/opdp_eo/notices/not_exec_office_20160824.pdf
Submitting a claim to the Health Network System (HNS)
 Submiting a claim to the HNS for an eligible person who does not have
ODB coverage:









Person’s Gender: ‘F’ = female; ‘M’ = male
Person’s Date of Birth: Valid YYYYMMDD
Person’s Ontario Health Card number
Intervention codes:
• PS: (Professional Care Services)
• ML: Established eligibility coverage (i.e., 1 day of the Plan ‘S’
coverage)
Carrier ID: ‘S’
Product Identification Number (PIN) – See Table #1
Valid Pharmacist ID
Professional Fee - See Table #1
Eligible person’s name, date of birth, and Ontario health card
number
 NOTE: A maximum of one (1) naloxone kit may be provided to any
eligible person at one time
Reference: http://www.health.gov.on.ca/en/pro/programs/drugs/opdp_eo/notices/not_exec_office_20160824.pdf
Reporting Requirements
 Pharmacists, where possible,
must ensure that a quarterly
report relating to outcomes
for individuals who were
provided a naloxone
emergency kit, be completed
and returned to the ministry
(available at:
http://www.health.gov.on.ca/en/pro/progra
ms/drugs/opdp_eo/eo_communiq.aspx)
Reference: http://www.health.gov.on.ca/en/pro/programs/drugs/opdp_eo/notices/not_exec_office_20160824.pdf
Reporting Requirements
 The reporting schedule is as follows:
Reference: http://www.health.gov.on.ca/en/pro/programs/drugs/opdp_eo/notices/not_exec_office_20160824.pdf
Documentation and Record Keeping
 Standard record keeping requirements under current standards of
practice apply. Pharmacists must keep a record when the naloxone kit is
provided to an eligible person
 Pharmacists must keep records consistent with their obligations under
the Pharmacy Act, 1991, the Drug and Pharmacies Regulation Act and
any instructions provided by the Ontario College of Pharmacists or the
ministry. These records must include, at a minimum:
 The name, address and phone number of the eligible person.
 Full instructions for use of drug.
 The drug’s material risks, including side-effects, contradictions or
precautions were discussed with the Eligible Person.
Reference: http://www.ocpinfo.com/library/practice-related/download/Naloxone.pdf
Procuring Take-Home Naloxone Kits
 19 Pharmacies in Brantford/Brant County received 5-10 kits from the Ministry of Health
 PIN 93877253 Naloxone Professional Fee (Training at $25)
 Per Ministry:
“Pharmacies will procure naloxone and the required supplies to assemble the
naloxone kit through usual suppliers (i.e., pharmacy-assembled naloxone kits). The
emergency kit shall be assembled by a pharmacist, or a person under the
supervision of a pharmacist.....”
 OPA has complied a list of the required kit components as well as some suppliers for
these items
Reference: http://www.health.gov.on.ca/en/pro/programs/drugs/opdp_eo/notices/not_exec_office_20160824.pdf
Available from:
https://www.opatoday.com/profe
ssional/naloxone_kit_tools
The Control Group
 Group of pharmacists in Calgary with a mandate to provide consistent, low-priced
naloxone take-home kits nationally.
 Currently working directly with 6 provincial governments, including the Ontario Ministry
of Health and Long Term Care and the BC Centre of Disease Control.
Can supply:
• Naloxone Cases (empty): $4.00 each
• Naloxone kit (case containing all contents but without drug) $17.00 each
o Includes: instructions on how and when to administer the drug (BC CDC’s Save
Me Insert), 2 x 3cc VanishPoint 25G 3cc 1.5" syringes, 2 alcohol swabs, 2 pairs of
nitrile gloves, and a one-way rescue breathing mask.
• 2 vials of naloxone 0.4mg/mL (DIN: 02455935 made by Omega Laboratories Ltd.):
$14.00 for 2 vials ($7 per vial vs. list price of $14 per vial). Omega vials expire 2 years
from date of production. Their current lot expires January of 2018 (approx. 18
months).
Contact information:
Kar Leung, RPh
Cell: 403-473-6998
Email: [email protected]
The Control Group
 Delivery is via overnight air or 3 days ground (standard) at their Purolator corporate rate
(40% discount on retail rates) or the courier of your choice.
Order form: https://docs.google.com/forms/d/e/1FAIpQLSdVBaFjk-gvjmRWO09XWNf47MLp7Uifm3dF8ZAV_iUC-CX9cQ/viewform?c=0&w=1
Naloxone Nasal Spray
 “Received approval and is expected to have
Canadian Product available in early Spring next
year”
 U.S. Narcan Nasal Spray available for
Canadians under the Federal Health Minister’s
Interim Order
 Manufacturer is Adapt Pharma
 Canadian Distributor:
GMD PharmaSolutions located in Oakville
Phone: 1-877-870-2726
Email: [email protected])
 Cost = $145/ unit. Sold in boxes of 12 units.
Each unit contains two (2) unit doses of 4mg
naloxone nasal spray.
 Expected to be available at Ontario Naloxone
Program sites as of January 1, 2017
 Community pharmacies – no date, later in
2017?
Pharmacy Connection - OCP
Fall 2016, Volume 24:4
Summary
• Opioid overdose a growing problem in Canada
• Naloxone now available OTC can be life-saving
• Pharmacies reimbursed for dispensing and
training
Please visit the BCPA website:
http://www.bcparx.ca
Patch-For-Patch
Fentanyl Program
Requirements & BCHS
Hospital Admission
• Community pharmacy will be
notified of patient’s admission
• Patient’s home patch will be
disposed of into the hospital’s
approved waste container & is cosigned by two nurses
• Patients will be sent home on a
hospital supplied fentanyl patch
COMING SOON:
Standardized Discharge Process from BCHS
 As of December 12th all physicians will be required to utilize computer generated
discharge prescription for every patients discharged from BCHS
 Discharge prescription will be FAXED to the community pharmacy & family
physician – original copy will remain on the patient’s chart
 Last Dose Medication Report will be FAXED to the community pharmacy along
with the Discharge Prescription
 Improvements to the discharge prescription:
 Name of Pharmacy that the prescription was faxed to on 1st page
 If no quantity specified by physician community pharmacy may supply a 14 day supply
if patient requires.
 Medications Discontinued, Other Medications now on the 1st page
 Reason for admission
 Prompt for drugs requiring LU codes
 Continue/Resume versus Continue
 If the physician prints their name will automatically print, along with their CPSO
number
 Contact information for Pharmacy Department
Indicates total number
of pages
Reason for visit
If quantity not
specified; authorized
to dispense 14-day
supply
Now on page #1 as
this is vital info
New
ONLY if physician
prints the prescription
Will prompt when LU
CODE is required
CE Event:
November 23, 2016
Brant Community Healthcare
System
Formal invite to follow
Please complete survey!
Pharmacy Connection – OCP, Fall 2016, Volume 24:4
Questions?
[email protected]