3Objectives Describe Washington State’s Opiate Deaths Discuss the Scope of Practice of PharmacyExplain Collaborative Practice AgreementsAnalyze the challenges of initiating a CPAExamine alternatives for pharmacy involvement
4Opioid Sales in WA State, Estimated # daily doses sold annually In Washington we have been aggressive about treating pain. 6.8 million individuals. Enough for each Washington residents to have about 6 days worth of hydrocodone – which is about 20 vicodin tablets each year for every resident in our state.Methadone does not include methadone dispensed by narcotic treatment programs. Methadone data provided by DEA for included narcotic treatment programs, estimates removing expected NTP use are shown with a dashed line Source: Drug Enforcement Administration Automation of Reports and Consolidated Orders System, data include medications prescribed and dispensed. Data provided to and analyzed by Caleb Banta-Green Alcohol & Drug Abuse Institute, University of Washington Defined Daily Dose utilized from WHO
5Outpatient, Inpatient, MMT, Treatment admits are going up… this is good as people are accessing treatment, but does seem to parallel the increase in opiate prescribing.At the population level rx opiate abuse appears to precede heroin abuseKing county data show that 40% of heroin users were “hooked on” Rx opiates first
6Unintentional prescription opioid involved overdose deaths Washington 1995-2008 Surpassed traffic fatalitiesThis chart shows the unintentional opioid-related deaths in Washington from 1995 through As you can see these have increase dramatically over this period of time. In addition, there has been a shift from illicit and unspecified opioid-related deaths – shown in yellow to those that are definitely or possibly prescription opioid-related deaths.We went from 23 deaths in the definite and possible groups combined in 1995 to 505 in 2008.Morphine deaths are included in the unspecified because it was impossible to know if these were heroin or morphine deaths as the toxicology tests use to detect morphine – and this what would be listed on the death certificate.Besides the opiates, the most commonly listed drugs on the death certificates are antidepressants and benzodiazepines. And the majority of those in the possible category are there because they had also consumed alcohol.Source: Washington State Department of Health, Death Certificates, Jennifer Sabel, PhD666
7Medic One Responses45 serious opiate overdoses per month responded to by SFD in 2011*Approximately 1:1 Heroin:Rx Opiate32 cardiac arrest cases per month responded to by SFD in 2010**This one really hit for me. Our fire department was the first in the country to have medics that were trained basically as physician extenders to go to cardiac calls. Now this specially trained group is responding to more overdoses than cardiac arrests. This really drove home to me that we need to have just as drastic a response to control this issue as we had to reduce deaths from heart attacks.*268 serious opiate overdoses per our chart abstraction for 6 months in 2011** “384 out of hospital cardiac arrest cases treated by SFD in 2010”
8Source: King County Medical Examiner Public Health- Seattle & King County
9Source: King County Medical Examiner Public Health- Seattle & King County
10(95% Confidence Interval) Rate per 100 person years (%) Opioid Overdose Risk by Average Daily Dose of Prescribed Opioids ReceivedCurrent average daily dose in morphine equivalents (MED) preceding eventOverdose events, Persons age 18+ (N=9,940)Hazard Ratio(95% Confidence Interval)Rate per 100 person years (%)(# of person years)0 mg MED1.00.047 % (16,980)1-19 mg MED2.4 (1.0, 5.5)0.15 % (14,263)20-49 mg MED4.1 (1.5, 11.8)0.29 % (2,401)50-99 mg MED6.1 (1.8, 20.9)0.44 % (910)100+ mg MED22.1 (8.3, 58.5)1.75 % (628)
11PharmacistsDoctor of Pharmacy Degree is now the minimum degree to enter practice.This entails normally 7 years minimum of educationPharmacists are the medication experts in healthcarePost graduate training opportunities include residencies and fellowships.
12Pharmacists as Mid-level Prescribers Dependent prescribingCollaborative Prescriptive AgreementsSimilar to PA’sThe laws vary in in each state.
13Collaborative Prescriptive Agreements A legal agreement between a prescriber and pharmacistAgreement must list:Where and whoWhich drugs or diseasesPolicies and proceduresLiability insuranceRI Pharmacy Laws Section 25.0
14Pharmacist Participating in CPA in RI A pharmacist participating in CPA mustHave post graduate training/experienceAccess to patient information5 hours of CE in the area each year
16Washington ModelPublic Health- Seattle & King County began distributing in February in 2012Recruitment via needle exchangeOD prevention and intervention training at Needle ExchangeNarcan prescribing and dispensing by Public Health pharmacistCPA facilitates thisPolice training video recently released based on survey findings
17Expanded Washington Model Partnering with Community PharmaciesTarget those either at risk of having, or witnessing an overdoseUtilizing web based patient education and other handouts to limit impact on pharmacist time
18Opportunities to engage pharmacists Show the pharmacists what their practices will look like if they prescribe and dispense naloxoneScreening formsExample CPAPhysician Partners to sign CPAs and refer patientsEducation – make the pharmacists the experts in naloxoneResources and references for questions and further educationStudentsTeach this material in schools, so that students come out expecting to do thisPartner with faculty members to include in curriculum
19Challenges Evolution of pharmacy practice Pharmacists can be black and whiteMedicaid coverageWhat a pharmacist does is evolving and changing, back in the 1970s the APhA definition of the practice of pharmacy, did not include the pharmacist even telling the patient the name of the drug or what it was for. We have come a long way, but it is an evolving process.We need to get state medicaid plans to universally cover naloxone. This will help to reduce some of the risk of stocking a medication, and it not being dispensed, and expiring.With 5 hours of pharmacist education required each year in RI, we need to provide clear explanation of where and how pharmacists can to get this informationMost pharmacists like to know what they need to do and how to so it before they jump in. They are so heavily regulated and audited, that practicing in the grey area as far as prescribing and compensation leaves them exposed. Including the boards of pharmacy and associations in your planning to reinforce changes in practice can help with this a great deal.
20Other ways pharmacy can help Stock Naloxone injections or kitsCash paymentOverdose education, especially to patients on more than 100 morphine equivalents dailyOther Public Health OpportunitiesImmunizationsEmergency Response