Barriers to Naloxone Prescribing, Dispensing, and Utilization

Theresa Mallick-Searle, MS, RN-BC, ANP-BC: There are 2 groups of individuals that we are looking at. There are our patients using the opiates appropriately, who need to be trained so they are in a safe environment, but then there is also the community. I would really like to see a bigger attempt made in getting naloxone—and I’m hearing this from Joshua and I’m also hearing this from Jeffrey—into the communities with the social workers and educating those folks on the streets who need it as well.

I’m taking a step back, but when you look at the whole 2016 CDC guidelines on the opiate crisis, where does this start? What is the reality of it? The reality of it, and why we started using it, is because people were dying. Patients were dying or people using opiates were dying. That is what has given a lot of fuel to this effort to make naloxone more accessible, and this is why the government has paid attention to it.

Now we have the widespread availability of an antidote, and to not use it or to not know about it is mind-boggling. It’s baffling that we would not take this and run with it.

Charles Argoff, MD: There is another big gorilla in the room—a lot of gorillas—and that is the payers or the insurance companies. They could play a huge role if every time they paid for CVS care—I don’t want to mention anyone specifically, but in all the pharmacy benefit programs, when they filled and paid for a prescription, there would be an automatic discussion. It could be along the lines of, “Have you prescribed naloxone? We would like you to prescribe naloxone. We suggest that you prescribe it.” They could say whatever is legal and legitimate—but they need to play an active role. The reality is that they are filling the prescription, and they could play a huge role in normalizing this as well.

Jeffrey Bratberg, PharmD, FAPhA: Chain pharmacies have done that. The same EMR [electronic medical record] alert that Dr Salgo mentioned exists at some major pharmacies to recommend naloxone. That is our state because we recommend coprescribing, something that can also be found in Vermont and Virginia. New York has a wonderful naloxone co-pay program, so we know that from data that people will not pay more than $10 or so for naloxone. They may be convinced by the pharmacists or their primary care physician that they need this, and they will go, and they pick it up and when they’re told, “It’s $20,” they’re like, “No, thank you.” They understood everything. New York says we’ll pay up to $40, but it is still 0, and it’s been very successful. I would go even farther than that.

Peter Salgo, MD: How about this: If you want to get really annoying—and why not? It’s in the EMR, which in my definition is annoying—why don’t you have an opt-out as opposed to an opt-in? That is, you’d say, “We are going to go prescribe naloxone unless you specifically uncheck this box. By doing so you’ve got to provide a reason.”

Jeffrey Bratberg, PharmD, FAPhA: That is coprescribing. For coprescribing in Rhode Island, you have to have a reason not to do it. The only downside is that sometimes people show up to their pharmacy postsurgery or postinpatient visit, and the pharmacist says, “I filled this naloxone,” and the patient responds, “My doctor never told me about it. Why didn’t he?” 

These same barriers are here. They do not want to talk about it; they are meeting the law. We are dispensing more naloxone per capita than anywhere in the nation, but we are still having those disconnects. If the pharmacist says, “Let me tell you about it; we do this all the time” like in the EMR and in surgery, what do we do in medicine? We practice, and then we keep practicing. Do we ever master anything? We always practice everything, but we have to do things over and over to make it normal for us, to normalize those conversations. As a pharmacist—you probably know—if you say something to the patient and then the pharmacist says something to the patient, they are more likely to do it, to stay adherent to their regimen, to monitor their blood sugar, to do those exercises, to maintain their appointments, to see their counselor. It is a 2-step process.

Charles Argoff, MD: Frankly, the EMR allows you to send messages to the pharmacist as you prescribe, and you can work together.

Peter Salgo, MD: In the community, if every time Mr or Mrs Jones hears about 1 of his or her friends who gets an opioid and every 1 of them got Narcan [naloxone], it’s a normal thing at that point. It is not something extraordinary; it is not about you or about the expectations that you are going to have a problem, it is the expectation that this drug requires Narcan [naloxone] to be prescribed with it.

Joshua Lynch, DO, EMT-P, FAAEM, FACEP: Just a quick note on the EMR—we noticed that we had a lot of naloxone from the Health Department sitting on the shelves of the pharmacy or sitting in the Pyxis system, and it was not being moved. It was just sitting there. We went into the order sets and rewrote the order set for painful condition discharges, the order set for overdose in the ED [emergency department], and the order set for altered mental status. We prechecked opiate overdose kits, which used to be kits in little bags that you had to assemble with the atomizers; now they just consist of the nasal spray. Having it prechecked pings the nurse to pull it out of the Pyxis system and put it in the patient’s room. Now the patient has it. They did not have to ask; there was not a long discussion about it, and they had the opportunity walk out of the hospital with it in their hand. We think this is 1 step easier. Although it’s not practical in all circumstances, it has worked fairly well.

Transcript Edited for Clarity