1 Please visit the BCPA website: http://www.bcparx.ca“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:
2 Agenda Discuss the work being done by various community partners participating in the “Fentanyl Roundtable” initiative initiated by the Brantford Police Service Gain a local perspective on opioid misuse and overdoses. Receive training on the use of the “Take Home Naloxone Kits” by a Public Health Nurse Discuss Naloxone Kit billing codes and obtaining additional Naloxone Kits Network and share your experiences dispensing Naloxone Kits with local colleagues 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. Brant Community Healthcare System update regarding a NEW standardized discharge process as of December 12th
3 Brant Community Healthcare System Formal invite to followPharmacist CE Event: November 23, 2016 Brant Community Healthcare System Formal invite to follow Please complete survey! Pharmacy Connection – OCP, Fall 2016, Volume 24:4
4
5
6 Ontario Naloxone ProgramAs 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:
7 Ontario Naloxone ProgramCurrently 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
8 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:
9 Ontario Naloxone Program: WHY? Harm-reduction strategyAccidental 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
10 Take-Home Naloxone Kit: Required ContentsPer 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:
11 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
12 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
13
14 RPh Role Ideal point of access56.1% 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 “
15 Dispensing Naloxone: RPh ResponsibilityUsual 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:
16 Dispensing Naloxone: RPh ResponsibilityPatient 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: Harm reduction strategies when using opiods How to identify an opioid overdose Importance of immediately calling 911 Importance of CPR Rescue breathing When and how to administer naloxone Aftercare and the importance of staying with the person until emergency first responders arrive Withdrawal symptoms Effectiveness with various drugs (i.e. buprenorhphine) Risk of secondary overdose if opioids used when patient regains consciousness Reference:
17 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 Initial naloxone emergency kits (reimbursed amount includes naloxone kit at $35, plus a professional fee at $10, plus professional training at $25) $70.00 Replacement naloxone emergency kit (reimbursed amount includes naloxone emergency kit at $35 plus a professional fee at $10) $45.00 Initial naloxone emergency kits supplied by MOHLTC (reimbursed amount includes professional training at $25) $25.00 Reference:
18 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:
19 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:
20 Reporting RequirementsPharmacists, 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: Reference:
21
22 Reporting RequirementsThe reporting schedule is as follows: Reference:
23 Documentation and Record KeepingStandard 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:
24 Procuring Take-Home Naloxone Kits19 Pharmacies in Brantford/Brant County received 5-10 kits from the Ministry of Health PIN 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:
25 Available from: https://www.opatoday.com/professional/naloxone_kit_tools
26 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 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: 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:
27 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
28 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: 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?
29 Pharmacy Connection - OCPFall 2016, Volume 24:4
30
31
32 Please visit the BCPA website: http://www.bcparx.caSummary 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:
33 Patch-For-Patch Fentanyl Program Requirements & BCHS Hospital AdmissionCommunity pharmacy will be notified of patient’s admission Patient’s home patch will be disposed of into the hospital’s approved waste container & is co- signed by two nurses Patients will be sent home on a hospital supplied fentanyl patch
34 Standardized Discharge Process from BCHSCOMING 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
35
36 Indicates total number of pagesReason 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
37 Will prompt when LU CODE is required
38
39
40 Brant Community Healthcare System Formal invite to followCE Event: November 23, 2016 Brant Community Healthcare System Formal invite to follow Please complete survey! Pharmacy Connection – OCP, Fall 2016, Volume 24:4
41 Questions?