Your Next Steps with Naloxone
So the Texas Pharmacy Association has created a Standing Order for dispensing of naloxone
and CVS is offering it at every store.
Now it's your turn....
But it really comes down to, as a pharmacy owner or manager... What's YOUR incentive to start advertising this service??
Providing solutions and options for patients in the depths of the opioid epidemic. It is our duty to help our patient, especially when we see these patients come in like clock work and often getting stronger dosing by the month. We have an opportunity to change the conversation and even identify those at high-risk for an overdose, because it is not who you may think.
Think about how many prescriptions you fill per day for chronic pain management and how many of those would you recommend to fill a naloxone kit just one time. Most insurances will cover the cost of a generic naloxone, but even out of pocket the average cost is somewhere around $20-$40 depending of which formulation option you find works best for the patient. Narcan and Evzio will have different reimbursement rates since they are brand.
TEXAS SB 1462: Creates liability protection to providers and bystanders and allows for the creation of standing orders and third party prescribing.
Ok, so lets break down the "How-To"...
1. Know your Dispensing options...
Option: Request Opioid Antagonist through patient's PCP
- I would HIGHLY recommend going through the steps for the TPA Standing Order:
- The CE course alone is a wealth of information
- Very helpful for conversations with practitioners and patients
- Able to provide Naloxone to patient, caregiver, or any person asking for the product
- Decreases waiting time to get Rx from PCP
- But if you want to get started in requesting the product for a patient, as they may already be asking about it ... here is an Rx Request template to fax for a prescription request and use a the hard copy, if approved
- Be ready to get phone calls from the physicians
- I also recommend reading through Section 295.14 "Dispensing an Opioid Antagonist by a Pharmacist" (page 287 in the PDF) on the Texas State Board of Pharmacy website.
- The FDA also created a very informative publication in 2016.
Option: Get the Naloxone Standing Order through TPA
- Go to the Texas Pharmacy Association (TPA) website at www.texaspharmacy.org
- under the tab "Products and Services" ----> select "Naloxone Standing Order"
- Fill out the information fields to register for the course, its $30 for members, $95 for non-members
- You will receive an email link to gain access to the one-hour course
- Once you complete this course, you will feel comfortable:
- identifying and counseling patients on their options
- the formulations and administration
- laws pertaining to the standing order
- risk factors for overdose
- the power point is available to print, I recommend taking notes as well.
- After completing the course and survey, you will be able to retrieve the certificate from the same site as the course: Print and Keep for your records
- In the following days, you will receive another email with the printable Standing Order. Print and keep with your certificate
- The Standing Order is applicable to the PHARMACIST, not the Pharmacy.
- There is no expiration on it either and TPA will send you updated ones as needed.
2. Workflow Implementation:
- Step 1: Get educated on the subject so you are comfortable answering questions from the patient and physician
- Step 2: Design your workflow:
- Identify high risk patients
- Add a counseling tag
- Counsel patient on Naloxone and formulation options
- Fax Rx request to Dr or type up Rx under standing order
- Process Rx
- Demonstrate product to patient
- Step 3: Have all documents and forms organized
- Step 4: Train staff and document in-service
- Step 5: Notify Physicians by fax or in person, especially the ones you have a good rapport with.
- the more they know you can help, the more they will ask you to help.
3. Administrative Documents you will need:
- Standard Operating Procedure...... or just print our template and customize to your store(s)
- Staff In-service form to review the new policy
- TPA Naloxone Certificate of Completion
- TPA standing order
- Incorporate into current SOP book or maintain in a binder that is readily available in case of an inspection
4. Workflow Documents to incorporate:
- Rx Request Form
- RPh Cheat Sheet, here is an example of one, it includes:
- High Risk Identifiers
- Product comparison
- Counseling/ Talking Points
- Keep this close by as a helpful reminder of when to add counseling tags for when you want to discuss with a patient
- CDC Calculating MME Fact Sheet and CDC Opioid guidelines
- very helpful tools in deciphering who is at high risk. Bookmark in your favorites!
- RPh Counseling Tag
- You can make them non-descript to prevent patient embarrassment during a counseling opportunity
- These can be printed in a specific color that all staff knows refers to naloxone
- When the staff gives you the counseling tag, first review the patient's profile for risk factors you want to include in your discussion
- Questions to ask yourself are:
- How proactive do you want to be to identify and counsel patients?
- What materials will you use to have this discussion with them?
- Be ready to make an appointment to discuss later and follow up
- Patient Talking Sheet
- This can be something you provide as a take home for your patients or
- Use this to help outline your discussion with patients, especially the first few!
- Use our sample above or create your own
- Rx Request Form- can be used if you do not have a standing order or the patient prefers to get a prescription from their physician.
- Patient Education Handout
- Place a copy inside the Naloxone Kit you will make
- Circle the formulation you are dispensing
- Create a laminated version to use during counseling along with you demonstration kit.
- Here is an example of one from prescribetoprevent.org
- Another great resource is naloxonesaveslives.org that has pdf's for each formulation, linked below:
5. Stock and supplies:
- Create yourself an ordering list with item numbers from your vendors
- There are different product options, so you may want to familiarize yourself with costs, package sizes etc
- Here's an example list I started for you...
- Mucosal Automization Device (MAD) is available though a few sites if your distributor does not have them
- Evzio- though it is not on the TPA standing order, you may see orders for it.
- You can request and Evzio trainer on their website. and get it in a few days.
- Naloxone Supply Kits
- For work flow simplicity, create a "kit" for each route of administration to accompany the naloxone, assign it an NDC number if you want
- The TPA standing order allows you to dispense supplies as well
- You can charge separately for these kits if you chose, retail price based on your cost to create the kit
- Dispensing Kit Cheat Sheet - useful for techs creating these kits for you
- Create your own demonstration kit
- This will make it much easier to go over the instructions with the patient and the third party who is likely to be administering the naloxone
6. Additional Pharmacy Education Tools: (also useful for patients!)
(Bookmark these links if you are able to share videos with patients.)
- How to give a Naloxone Injection video
- Intra-nasal naloxone with MAD video
- Narcan: Pharmacist training video or pdf
- California has created a very informative guide for community pharmacist, linked here. Most recent update June 2018.
Prescribetoprevent.org has a section specifically for pharmacists.
- FDA Publication from Sept 2016
7. Now Market!
Notify Physicians by Fax
Go out and meet with local physicians, especially those you have a good rapport with
Make sure to emphasize this is a collaborative team effort where pharmacists can help fill in the gaps where physicians may not have enough time to have these discussions. It'll be worth your time, especially when it results in a prescription being filled.
Some may even like the review of naloxone if they don't regularly prescribe it
Bring along the materials you will use during discussion and counseling
Let's not forget about social media... while some patients may not be comfortable asking for themselves, you may just open that door to a conversation they never realized they needed to have.
So I've given you the tools and templates to start... but it's still a touchy subject, right? Maybe you are still hesitant to begin this process.
You may fear that you will insult the patient by placing them in the "addicted" category or physicians by placing them in a "questionable prescribing" category,
but the fact of the matter is this: you may save a life.
Isn't that the reason for every DUR and prescription verification? This is no different, in fact, it may be more important.
Start slow, like your first time counseling a patient.... gain confidence in the conversation, but don't shy away.
You've got this.
AND, if you STILL want help implementing this... Scroll down and Let's chat. We are here for you!
Need more help? Email us at Vanessa@pharmacyconsultantstx.com