IMPLEMENTATION OF A SHARED MEDICAL APPOINTMENT FOR OPIOID OVERDOSE EDUCATION AND NALOXONE KIT TRAINING FOR VETERANS Kristin A. Tallman, Pharm.D, BCPS Clinical Pharmacy Specialist Providence Medical Group April 28, 2017
DISCLOSURE Kristin A. Tallman, author of this presentation, has nothing to disclose concerning possible financial or personal relationships with commercial entities that may have a direct or indirect interest in the subject matter of this presentation This quality improvement project was performed to improve patient care at the VA Roseburg Healthcare System. It was approved by the Chief of Pharmacy and Pharmacy Therapeutics & Nutrition Committee. As a quality improvement project, this data is not generalizable. The contents of this presentation represent the views of the author; they do not represent the views of the Department of Veterans Affairs or the United States Government.
LEARNING OBJECTIVES Review rationale and key recommendations for the outpatient prescribing of naloxone Identify appropriate candidates for a naloxone prescription Discuss benefits of a shared medical appointment (SMA) for providing education to patients
PRE-TEST ASSESSMENT 1. Which education topics should be discussed with each patient prescribed a naloxone kit? a) How to determine if a second dose of naloxone is needed b) How to recognize signs and symptoms of an opioid overdose c) When and how to administer naloxone d) All of the above 2. Which of the following patients would benefit most from a naloxone prescription based on their risk factor(s)? a) 66 y.o. male with hypothyroidism prescribed hydrocodone as needed after a motor vehicle accident b) 52 y.o. female prescribed morphine ER with a history of sleep apnea and substance use disorder c) 31 y.o. male with generalized anxiety prescribed hydroxyzine and oxycodone as needed d) 42 y.o. female prescribed oxycodone with a history of diabetes and neuropathy 3. Which of the following is most likely to be observed after implementation of a shared medical appointment? a) Patients feel discouraged and ask fewer questions b) Patient education is provided less efficiently c) Patients report greater satisfaction with care provided d) Patient contact time with their healthcare team is decreased
BACKGROUND More than 1,000 people are seen in emergency departments daily for misuse of prescription opioids According to the Centers for Disease Control and Prevention (CDC), in 2015 91 Americans died from an overdose daily Majority of opioid overdose-related deaths occur outside of medical settings, primarily occurring in homes Deaths from prescription opioids has quadrupled since 1999 Centers for Disease Control and Prevention. 2015.
BACKGROUND The World Health Organization, CDC, Substance Abuse and Mental Health Services Administration recommend naloxone as an essential intervention to prevent overdose Naloxone s action is to reverse opioid-mediated effects, which include respiratory depression, CNS depression, and hypotension The VA developed an Opioid Education and Naloxone Distribution (OEND) Program as a harm reduction/risk mitigation strategy Centers for Disease Control and Prevention. 2015. Substance Abuse and Mental Health Services Administration. 2016. United States. Department of Veterans Affairs. 2014. World Health Organization. 2014.
MEDICATION USE EVALUATION Total of 46 prescriptions for naloxone over 12 months (Apr 2015 Mar 2016) Average 4 prescriptions per month Primary Indications For Use Prescription for an opioid, dose <50 mg MED 28% Prescription for an opioid with concomitant benzodiazepine 22% History of, or active, substance use disorder 15% Prescription for an opioid, dose 50 to <100 mg MED 15% Prescription for an opioid, dose 100 mg MED 6.5% No clear indication 6.5% MED = morphine equivalent dose Education of naloxone use and administration was clearly documented in 70% of patients
OBJECTIVES AND GOALS Increase access to naloxone kits for patients at risk of opioid overdose Enhance patient and caregiver knowledge about opioid safety and use of naloxone Improve clinic efficiency in providing education to patients about naloxone Develop standardized approach to providing and documenting education
SHARED MEDICAL APPOINTMENTS Often referred to as a group visit Includes one or more healthcare professionals Typical length of appointment can be 60-120 minutes Focused environment for a common condition Benefits include: Increased patient access to care Improved productivity Increased patient satisfaction Edelman D, McDuffie JR, Oddone E, et al. 2012. Jaber R, Braksmajer A, Trilling JS. J Am Board Fam Med. 2006. Scott JC, Conner DA, Venohr I, et al. J Am Geriatr Soc. 2004.
CLINIC DESCRIPTION Weekly 60 minute group visit Led by clinical pharmacist Optional 15-30 minute individual appointment Standardized template to guide education and documentation Patients identified proactively by pharmacy or by provider consult Education Topics Defining an opioid overdose Learning what can cause an overdose Recognizing signs and symptoms of an overdose Learning how to prevent an overdose Steps to take as a first responder Do s and don'ts of responding to an overdose Overview of naloxone and how it works When to use and how to administration naloxone When to give a second dose of naloxone Hands on naloxone kit training
EXAMPLES OF CANDIDATES Veterans with high risk medical history Opioid use disorder diagnosis Prescription opioid misuse or injection opioid use History of previous opioid overdose Chronic hepatitis, cirrhosis, alcohol use disorder or other substance use disorder and taking opioid Sleep apnea or pulmonary disease and taking opioid Veterans with high risk medication history An extended-release or longacting prescription opioid 50 mg morphine equivalents per day Prescription benzodiazepine with an opioid Veterans who receive VA or non-va care in these situations HIV education/prevention program (which may provide care to injection opioid users) Syringe access program Emergency departments (e.g. for opioid overdose or intoxication) Inpatient residential care or communitybased treatment for homeless Veterans taking an opioid Primary health care (e.g. follow-up of recent opioid overdose or intoxication) United States. Department of Veterans Affairs. 2014.
OUTCOMES Six month evaluation Total of 42 naloxone fills in 6 months (Apr 2016 Sept 2016) Average 7 prescriptions per month 33 of the 42 patients attended the SMA Improved documentation of education provided; 79% vs 70% All patients who attended the SMA had documentation completed Recent update Total of 41 naloxone fills in 4 months (Nov 2016 Feb 2017) Average 10 prescriptions per month Primary indications for use were opioid dose 100 mg MED (54%) and combination opioid and benzodiazepine (31%)
CONCLUSION Implementation of a SMA for opioid and naloxone education increased access to naloxone kits Higher risk patient population targeted ( 100 mg MED) Education was provided efficiently to patients by clinical pharmacists Utilization of a standardized template increased completed documentation Recommendations/Future Steps Utilizing pharmacy students to identify and contact patients categorized as high risk patients Patients prescribed buprenorphine/naloxone for opiate use disorder will be coprescribed a naloxone kit during the induction period
POST-TEST ASSESSMENT 1. Which education topics should be discussed with each patient prescribed a naloxone kit? a) How to determine if a second dose of naloxone is needed b) How to recognize signs and symptoms of an opioid overdose c) When and how to administer naloxone d) All of the above
POST-TEST ASSESSMENT 1. Which of the following patients would benefit most from a naloxone prescription based on their risk factor(s)? a) 66 y.o. male with hypothyroidism prescribed hydrocodone as needed after a motor vehicle accident b) 52 y.o. female prescribed morphine ER with a history of sleep apnea and substance use disorder c) 31 y.o. male with generalized anxiety prescribed hydroxyzine and oxycodone as needed d) 42 y.o. female prescribed oxycodone with a history of diabetes and neuropathy
POST-TEST ASSESSMENT 1. Which of the following is most likely to be observed after implementation of a shared medical appointment? a) Patients feel discouraged and ask fewer questions b) Patient education is provided less efficiently c) Patients report greater satisfaction with care provided d) Patient contact time with their healthcare team is decreased
REFERENCES Centers for Disease Control and Prevention. Prescription Drug Overdose in the United States: Fact Sheet. 2015. Retrieved from: http://www.cdc.gov/drugoverdose/index.html Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain United States, 2016. Centers for Disease Control and Prevention. March 18, 2016. Retrieved from: https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm. Edelman D, McDuffie JR, Oddone E, et al. Shared Medical Appointments for Chronic Medical Conditions: A Systematic Review. Department of Veterans Affairs Health Services Research & Development Service. VA-ESP Project #09-010; 2012. Jaber R, Braksmajer A, Trilling JS. Group Visits: A Qualitative Review of Current Research. J Am Board Fam Med. 2006;19(3):276-290. Oregon Health Authority. Opiate Overdose Treatment: Naloxone Training Protocol. September 22, 2016. Retrieved from: https://public.health.oregon.gov/preventionwellness/substanceuse/opioids/pages/naloxone.aspx. Scott JC, Conner DA, Venohr I, et al. Effectiveness of a Group Outpatient Visit Model for Chronically Ill Older Health Maintenance Organization Members: A 2-year Randomized Trial of the Cooperative Health Care Clinic. J Am Geriatr Soc. 2004;52:1463-1470. Substance Abuse and Mental Health Services Administration. SAMHSA Opioid Overdose Prevention Toolkit. January 15, 2016. Retrieved from: http://store.samhsa.gov/product/opioid-overdose-prevention-toolkit-updated-2016/sma16-4742. United States. Department of Veterans Affairs. Veterans Health Administration. Implementation of Opioid Overdose Education and Naloxone Distribution (OEND) to Reduce Risk of Opioid- Related Death (IL 10-2014-12). 2014. Washington DC: Petzel, R. United States. Department of Veterans Affairs. Veterans Health Administration. Recommendations for Issuing Naloxone Rescue for the VA Opioid Overdose Education and Naloxone Distribution (OEND) Program. 2016. Washington DC: Goodman, F. Wheeler, E., Burk, K., McQuie, H., & Stancliff, S. Guide To Developing and Managing Overdose Prevention and Take-Home Naloxone Projects: Harm Reduction Coalition. 2012. Retrieved from: http://harmreduction.org/wp-content/uploads/2012/11/od-manual-final-links.pdf. World Health Organization. Community Management of Opioid Overdose. 2014. Retrieved from: http://www.who.int/substance_abuse/publications/management_opioid_overdose/en/.