Dylan Girardi, 2017 PharmD Candidate, the University of Connecticut

Providing education and naloxone to those at risk of witnessing or experiencing an overdose is associated with a 30%-45% decrease in overdose death rates, opioid consumption, and emergency visits. 

Pharmacies are uniquely positioned to educate on and distribute naloxone. However, little is known about attitudes and perceptions of the newest pharmacy-based harm reduction initiative. 

Journal of the American Pharmacists Association

 examines how to best implement naloxone dispensing and explore the attitudes of various stakeholders toward dispensing in community pharmacies. The research focused on pharmacies in Massachusetts and Rhode Island.

The researchers presented scenarios based on offering naloxone to 8 focus groups that represented:

People using illicit drugs or in recovery,

All cohorts identified stigmas. Patients, illicit drug users, and family members all reported feeling uncomfortable requesting naloxone for fear of being labeled or treated differently in the future. 

In the pharmacist groups, many practical issues surfaced. These included a lack of clarity on logistics, insufficient training and demonstration materials, and time and space constraints during patient education.

Pharmacists also worried that by offering naloxone, they might offend their chronic opioid patients, or undermine a patient’s care plan. Once patients requested naloxone, billing was often confusing and difficult. Many pharmacists were unaware of naloxone’s status as a rescue medication, which allows it to be dispensed and billed to someone other than the end user.  These concerns highlight the need for comprehensive pharmacist training programs.   

All cohorts agreed that offering naloxone to all patients according to clear evidence-based criteria would be the most comfortable for pharmacists and least stigmatizing for patients. This is in stark contrast to the “opt-in” method currently employed, where patients must initiate requests for naloxone. 

By adopting an opt-out method, pharmacists can reduce the stigma and increase access to naloxone. 

The next challenge will be to create clear criteria focused on risk factors that do not stigmatize patients, the researchers concluded. 

Green TC, Case P, Fiske H, et al. Perpetuating stigma or reducing risk? Perspectives from naloxone consumers and pharmacists on pharmacy-based naloxone in 2 states. 

 2017 Feb 14. pii: S1544-3191(17)30013-4. doi: 10.1016/j.japh.2017.01.013. [Epub ahead of print]

Articles

Providing education and naloxone to those at risk of witnessing or experiencing an overdose is associated with a 30%-45% decrease in overdose death rates, opioid consumption, and emergency visits. 
 

Changing the Conversation: Flip the Script on Naloxone

All over the world, drug shortages cause complex and risky adjustments to medical regimens.  While epidemiologic data tracking shortages has only been collected since the early 2000s, the trend shows a definite increase in incidence. Shortages stem from a variety of causes including:

The causes are well understood, but little research documents the consequences of drug shortages. Understanding how patients, providers, and health systems are affected by drug shortages can be complicated by:

Difficulties in determining inventories in real-time

Difficulties associating shortages with clinical outcomes in a population 

A research group from Montreal, Quebec, Canada has studied drug shortages since 2006. In Canada, more than 1000 drugs may be affected within a single year, and most shortages last 4-5 months. In the same year, the FDA reported just 210 shortages here in the United States—although comparisons are difficult due to variable definitions of the word 

In the United States and Canada, cardiovascular drugs account for 1 of the top 5 drug-class shortages. Resulting adjustments cause suboptimal drug selection, increased labor cost, errors, and poor outcomes including death.

Previous attempts to increase transparency have been unsuccessful due to voluntary reporting of data by manufacturers. New Canadian legislation requires manufacturers to give advanced notice of shortages—like in the United States&mdash;starting in 2017. 

But mandatory reporting alone is not expected to solve the drug shortage problem. Researchers are calling on clinicians and government organizations to make manufacturers more accountable for drug availability and adaptation during shortages. 

They recommend that hospitals create a multidisciplinary committee with a mandate to identify drug shortages and create action plans. They urge clinicians to collect and publish more data on incidents related to drug shortages so that we may understand their impact on patients better.

The researchers conclude that pharmacies must review their inventory management policies to ensure a safe buffer in case of shortages. 

This article appears in the February, 2017 issue of the 

Rinaldi F, de Denus S, Nguyen A, Nattel S, Bussières JF. Drug Shortages: Patients and Health Care Providers Are All Drawing the Short Straw. 

Fox ER. Drug Status Update. Available at: 

www.fda.gov/downloads/Drugs/NewsEvents/UCM274565.pdf

Ventola CL. The Drug Shortage Crisis in the United States: Causes, Impact, and Management Strategies. 

All over the world, drug shortages cause complex and risky adjustments to medical regimens. 

Drug Shortages: Manufacturer Accountability Increasing

Each year outpatient medication errors account for approximately 3.3 million outpatient visits, and cost an estimated $8 billion. Pharmacists are the final step in a system of checks and balances that should prevent medication errors, yet they often encounter problems while filling prescriptions. (

E- prescribing has been widely adopted over the past decade, accounting for 75% of all prescriptions written in 2015. Accordingly, we expect to see an improvement in information transmission between physicians and pharmacies, and a resulting decrease in the number of physician callbacks. However, the impact of e-prescribing on pharmacy communication patterns has not been well studied. 

Recently, 2 researchers in Connecticut examined a group of independent pharmacies to quantify e-prescribing's impact. They performed a convenience sample and cross sectional study in 5 locations over a 14-day period. Participants included pharmacists and technicians. 

During the study period, 141 prescriptions required clarification. Surprisingly, the prescribing method most often implicated was e-prescribing. Pharmacists had to clarify prescriptions transmitted by e-prescribing 4 times more often than faxed prescriptions and twice as often as hand-written prescriptions.

Most often, a pharmacist clarified the problem by telephone, and resolved the majority of incidents during the first contact. Phone communications had a resolution rate of 80%, versus fax communications with a 55% resolution rate. 

The researchers noted that the majority of office contacts involved communication with medical assistants or clerical staff (58%), followed by physicians (24%), and nurses (18%).  This challenges what many physicians believe &shy;— that nurses have the most contact with pharmacists.

The high volume of e-prescriptions requiring clarification are attributed to incomplete information, software incompatibility, and inability to discontinue old medications. 

The researchers recommend that interoperability standards be implemented to standardize e-prescribing data.

Finally, they encourage e-prescribing vendors to experiment with new features and interfaces to assess how changes may affect the need for prescription clarification. 

Smith M, Sprecher B. Pharmacy communication with physician offices to clarify prescriptions. 

Pharmacists are the final step in a system of checks and balances that should prevent medication errors, yet they often encounter problems while filling prescriptions. 