Education

Pharmacists

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The Board of Pharmacy Newsletter explains legislative updates regarding naloxone (including the standing order), as well as detailed information on dispensing naloxone.

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What is naloxone?

Naloxone is a competitive antagonist at opioid receptor sites with a primary purpose of reversing respiratory depression and death associated with an overdose. It has been used by EM and emergency department clinicians for over 40 years to save patient lives. The antidote is highly effective at reversing an overdose of heroin as well as prescription opioids, but it must be administered within minutes of an overdose.

Naloxone for take home

Naloxone should not just be in hospitals and ambulances — it should be in homes and other settings where overdoses occur. It is essential that ALL patients who are at risk of experiencing or witnessing an opioid overdose have access to naloxone.

Naloxone for take home use is most commonly prescribed and/or dispensed as a nasal spray or intramuscular (IM) device. Missouri Medicaid currently provides coverage for the naloxone nasal spray as well as generic IM naloxone vials.

As of August 28th, 2017, all Missouri pharmacies can dispense naloxone under a statewide standing order to any patient without an outside prescription. Physician protocols are no longer needed.

Dispensing Naloxone in Missouri Using Statewide Protocol

  1. Review laws on Missouri Board of Pharmacy website regarding the naloxone standing order.
  2. Fill the prescription for the person requesting the naloxone and use the physician name from the statewide protocol (Dr. Randall Williams).
  3. Document all sales, including: transaction, date, product name/strength/dosage form, quantity and name of the person, if known. If unknown, document “John/Jane Doe”

**Note: If a prescription for naloxone is brought in, it should be filled per standard prescription regulations NOT according to the statewide protocol procedures. **

For additional information on how to implement the naloxone standing order at your pharmacy, see the regulations at:

www.pr.mo.gov/pharmacists-naloxone.asp.

  • Counseling Guide
    • Pharmacists should counsel recipients about overdose and naloxone. A summary document including a guide to naloxone administration should be provided.
    • Things to note when discussing naloxone:
      • According to Missouri’s standing order, anyone who requests naloxone at a pharmacy ca receive it.
      • Patients will vary in their knowledge about their risk, the medication, and overdose response protocols — be sure they feel prepared to use the naloxone device before leaving the pharmacy. It is very simple – a little instruction goes a long way.
      • Patients may be self-conscious when requesting or discussing naloxone. Choosing non offensive language will help (e.g., say person who uses opioids instead of “addict” or “junkie”).

To receive FREE expert pharmacy training on overdose education and naloxone dispensing for your staff through the Missouri State Targeted Response to the Opioid Crisis (Opioid STR) grant, contact:

Lauren Green

Overdose Prevention Coordinator

Missouri Institute of Mental Health

314-516-8479

Lauren.Green@mimh.edu

Additional Resources

Overdose Prevention Education:

Pharmacists

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The Board of Pharmacy Newsletter explains legislative updates regarding naloxone (including the standing order), as well as detailed information on dispensing naloxone.

What is naloxone?

Naloxone is a competitive antagonist at opioid receptor sites with a primary purpose of reversing respiratory depression and death associated with an overdose. It has been used by EMS and emergency department clinicians for over 40 years to save patient lives. The antidote is highly effective at reversing an overdose of heroin as well as prescription opioids, but it must be administered within minutes of an overdose.

Naloxone for take home

Naloxone should not just be in hospitals and ambulances — it should be in homes and other settings where overdoses occur. It is essential that ALL patients who are at risk of experiencing or witnessing an opioid overdose have access to naloxone.

Naloxone for take home use is most commonly prescribed and/or dispensed as a nasal spray or intramuscular (IM) device. Missouri Medicaid currently provides coverage for the naloxone nasal spray as well as generic IM naloxone vials.

As of August 28th, 2017, all Missouri pharmacies can dispense naloxone under a statewide standing order to any patient without an outside prescription. Physician protocols are no longer needed.

Dispensing Naloxone in Missouri Using Statewide Protocol

  1. Review laws on Missouri Board of Pharmacy website regarding the naloxone standing order.
  2. Fill the prescription for the person requesting the naloxone and use the physician name from the statewide protocol (Dr. Randall Williams).
  3. Document all sales, including: transaction, date, product name/strength/dosage form, quantity and name of the person, if known. If unknown, document “John/Jane Doe”

**Note: If a prescription for naloxone is brought in, it should be filled per standard prescription regulations NOT according to the statewide protocol procedures. **

For additional information on how to implement the naloxone standing order at your pharmacy, see the regulations at:
www.pr.mo.gov/pharmacists-naloxone.asp.

  • Counseling Guide
    • Pharmacists should counsel recipients about overdose and naloxone. A summary document including a guide to naloxone administration should be provided.
    • Things to note when discussing naloxone:
      • According to Missouri’s standing order, anyone who requests naloxone at a pharmacy can receive it.
      • Patients will vary in their knowledge about their risk, the medication, and overdose response protocols — be sure they feel prepared to use the naloxone device before leaving the pharmacy. It is very simple – a little instruction goes a long way.
      • Patients may be self-conscious when requesting or discussing naloxone. Choosing non offensive language will help (e.g., say “person who uses opioids” instead of “addict” or “junkie”).

For printable patient education handouts created by the Missouri State Targeted Response to the Opioid Crisis (Opioid STR) grant, click here. To receive FREE expert pharmacy training on overdose education and naloxone dispensing for your staff through STR, contact:
                  Lauren Green
                  Overdose Prevention Coordinator
                  Missouri Institute of Mental Health
                  314-516-8479
                  Lauren.Green@mimh.edu

Additional Resources

Emergency Responders

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In an emergency, calling 911
is often the first reaction people have. In the instance where 911 is called in response to an opioid related overdose, it is critical that emergency responders be trained and equipped to administer naloxone. Simply put, when emergency responders have naloxone on hand, they are able to save lives.

 

What is naloxone?

Naloxone is a medication that quickly reverses the effects of an opioid overdose, usually within 1-3 minutes. It can be injected under the skin or into muscle or a vein. A nasal spray version of naloxone is also available. Naloxone does not have harmful side effects, get people “high,” or reverse overdoses caused by substances other than opioids.

Naloxone has been in use in the medical field for decades, but as of August 2014 it is available to all emergency responders in Missouri.

What to do when you report to the scene of an overdose:
(For complete information about respond at the scene of an overdose and administer naloxone, request a MO-HOPE Emergency Responder training *here*)

  • Assess the individual – look for signs and symptoms of an opioid/heroin overdose
  • Once you have identified that you are responding to an opioid/heroin overdose, begin rescue response (while waiting for EMS to arrive):
    1. Administer 1 dose of naloxone
    2. Administer rescue breathing (if pulse); Administer chest compressions (if no pulse)
    3. Place person in recovery position if you stop administering rescue breaths or leave the person’s side
    4. Give 2nd dose of naloxone if after 2-3 minutes the first dose was not successful* Prepare: In some cases, naloxone can precipitate withdrawals among those with physical dependence.

What to do after an overdose:

Resources
*Information provided on this site is not intended to cover everything–there are many places to find helpful information about naloxone and overdose prevention programs. To learn more, we suggest the following sites:

*For additional information see our Resources Page or access the following links for resources for Overdose Prevention and Harm Reduction, Opioid Use Disorder Treatment, Research and Data, and Legislation and Advocacy.

An officer describes his thoughts on naloxone

 

Missouri Law Enforcement and Public Safety Officers

Law Enforcement and Public Safety departments across Missouri received an email from the Missouri Department of Public Safety regarding the MO-HOPE opioid overdose reporting system (field reports). Many of the departments have expressed similar questions and concerns, which are addressed below:

Is the overdose reporting system mandatory?

  • Although field reports are not yet mandatory, their use has been requested by the Missouri Department of Public Safety. Tracking these incidents will inform state-wide prevention and intervention efforts and allow us to most effectively support our law enforcement and first responders. As such, each police department will have different protocols regarding filling out the MO-HOPE field report.

Why did the email state that these reports must be submitted within 12 hours of the overdose event?

  • We strongly recommend entering the field report as soon as possible to avoid forgetting and to ensure accurate information regarding the overdose event. Within 12 hours is ideal, but we understand that that may not always be possible/plausible to do so, therefore personnel can still fill out the field report after 12 hours has passed.

What is being done with the data collected through the field reports?

  • The data collected through the MO-HOPE field report will help us better understand overdoses are occurring, naloxone administration patterns, and success rates of overdose reversal attempts.
  • The data will be utilized in a few ways. Primarily, the MO-HOPE project will use these numbers to ensure we are training and equipping those most likely to respond to opioid overdose events to the best of our abilities. Additionally, this information will be used to help develop future programs and obtain funding for grants. Aggregated information is available to the public on our website (under ‘Results’) to help other programs and departments gain insight to how opioid overdoses have impacted communities across Missouri, and to use that information to implement or strengthen efforts to combat the opioid crisis.

Is the field report confidential?

  • The field reports are submitted through REDCap, which is a secure database that is only accessible to the MO-HOPE evaluation team. No personal information is collected and all reports will remain confidential.

Treatment Providers

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Incorporating  overdose education and naloxone
distribution (OEND) into clinical practice has been strongly recommended by the CDC , World Health Organization , and the American Society of Addiction Medicine. This page is designed to provide treatment providers with brief pieces of information and available resources to help them establish OEND within substance use, mental health, and medical settings.

After an overdose, use the first meeting as an opportunity to:
– Start the OEND conversation about use patterns and fluctuations in risk
– Acknowledge the patient’s struggle with substance use
– Discuss a harm reduction approach to drug use and recovery
– Highlight naloxone as a way to keep the patient alive to pursue treatment
– Emphasize this as standard practice; not a personal judgement
** Educate families & friends when possible – remember, if people are unresponsive due to an overdose, they will not be able to administer naloxone to themselves!

What to include in the OEND conversation:
(For complete information about how to conduct OEND with patients, request a MO-HOPE provider training *here*)

♦ Risk Factors:
Talk with the person about what makes them at risk of experiencing an overdose- both in general and on any given day

♦ Recognize Signs
Explain what an overdose looks like and provide specific signs/”what to look for” (e.g, unresponsiveness, shallow breathing)

♦ Reversal Myths
Discuss reversal myths (e.g., injecting cocaine, placing in a bath of ice
Emphasize that the only method to reverse an opioid overdose that has proven to be safe and effective is to administer naloxone.

♦ Introduce Naloxone:
Review the basics about naloxone

♦ Response
Outline a specific rescue response:

1. Administer 1 dose of naloxone
2. Call 911 (review 911 Good Samaritan laws)
3. Administer rescue breaths
4. Place person in recovery position if you stop administering rescue breaths or leave the person’s side
5. Give 2nddose of naloxone after 2-3 minutes if 1st dose is not successful
6. Stay with the person until medical help arrives (Naloxone has an effective time of 30 minutes to an hour, and after that time elapses, the individual can go back into an overdose state.)

♦ Accessibility
Explain how naloxone can be obtained
Discuss keeping naloxone readily available and how to store it appropriately

♦ Prevention Strategies
Use the harm reduction approach to discuss overdose prevention
Use phrases like “If you choose to use…” followed by prevention strategies
For example: “If you choose to use, always have naloxone nearby (and
someone who knows how to use it)”

Resources
*Information provided on this site is not meant to cover everything. There are many places to find helpful information about naloxone and overdose prevention programs.

  • For additional information on opioid overdose prevention and education:
    • Access the SAMHSA Opioid Overdose Toolkit
    • Access StopOverdose for additional information specific to treatment providers including talking about overdose, overdose prevention, naloxone, and treatment
    • Review the Opioid Overdose Basics including recognizing an opioid overdose, responding to an opioid overdose, and risks and prevention strategies
    • Access patient education and training materials here
    • Access the Healthcare Professional Toolbox for additional information on understanding overdose and addition, professional development, and patient education resources
  • For Buprenorphine Waiver- Medication-Assisted Treatment Trainings offered throughout the state of Missouri, visit here.
  • For clinical support (provided by the American Academy of Addiction Psychiatry in collaboration with others with support from SAMHSA) and training related to opioid use disorder, visit the Provider’s Clinical Support System
  • For free Continuing Medical Education courses funded by the Substance Abuse and Mental Health Services Administration (SAMHSA), visit here

*For additional information see our Resources Page or access the following links for resources for Overdose Prevention and Harm Reduction, Opioid Use Disorder Treatment, Research and Data, and Legislation and Advocacy.

 

Community Members

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Watching someone struggle with opioid use disorder can be hard to understand. Opioid use disorder is complicated but this 5 minute video below gives a simple but insightful explanation on pain, endorphins, opioid receptors, prescription medications, tolerance, withdrawal, risks of addiction, and recovery:

There are many ways we can help people who struggle with substance use disorders. The video below talks about one important way is to look at the way we think about people who use drugs and what biases we might have:

When someone is using heroin or prescription painkillers – or has a friend or family member using them – they are at risk of experiencing or witnessing an overdose. This can be scary, but doesn’t need to be deadly. It is important to know what makes someone at risk of an overdose, how to respond when one happens, and prevent one from happening again.

What makes someone at risk of an overdose?

While every person is different, there are some people who have a higher chance of experiencing an overdose than others. This can vary greatly over time and by circumstance.

You have a higher chance of overdosing if you have ever:

  • overdosed before
  • had a history of a substance use disorder
  • attempted suicide before
  • had problems with lung functioning (like sleep apnea or even the flu),
  • are on a high dose of opioid medications, and/or
  • have a history of major depressive disorder

Your immediate risk of overdose might be higher if you:

  • have been sober (abstinent) for a period of a few days or more (like coming out of rehab or jail),
  • you mix heroin or opioids with other “downers” like alcohol, benzos, or stronger opioids like fentanyl or carfentanil,
  • you’re using alone, or
  • you’re injecting drugs (as opposed to snorting or swallowing).

How do I know if someone is overdosing?

An overdose is different than being “really high.” Some signs and symptoms of an opioid overdose are:

  • unresponsive (won’t wake up),
  • shallow breathing or not breathing,
  • small “pinpoint” pupils,
  • grey or blue lips and fingernails, and/or
  • cold or clammy skin.

What reverses an overdose?

Many have said they’ve had success reversing an overdose through methods like packing someone in a bathtub full of ice, injecting them with milk, salt, or cocaine, or slapping and yelling at the person. In reality, none of these methods have been shown to be safe or effective. The only overdose reversal strategy that is safe and effective is using naloxone.

What is naloxone?

Naloxone is a medication that quickly reverses the effects of an opioid overdose, usually within 1-3 minutes. It can be injected under the skin or into muscle or a vein. A nasal spray version of naloxone is also available. Naloxone does not have harmful side effects, get people “high,” or reverse overdoses caused by substances other than opioids.

Naloxone has been in use in the medical field for decades, and has become increasingly available to emergency responders and “layperson” (as in, community members who use drugs or may witness an overdose outside of a medical setting). To learn more about naloxone, click here.

Who should have naloxone? 

Anyone at risk of witnessing or experiencing an overdose should have naloxone on hand – especially people who use drugs, their family members, and associates. Think of it like a fire extinguisher. We have them on hand, but hope that we never have to use them. To learn how and where to get naloxone, click here.

What to do if someone overdoses:

  1. Administer 1 dose of naloxone
  2. Call 911 (review 911 Good Samaritan laws)
  3. Administer rescue breaths
  4. Place person in recovery position if you stop administering rescue breaths or leave the person’s side
  5. Give 2nddose of naloxone after 2-3 minutes if 1st dose is not successful
  6. Stay with the person until medical help arrives
    ( Naloxone has an effective time of 30 minutes to an hour, and after that time elapses, the individual can go back into an overdose state.)

How long does it take for naloxone to take effect? 

Anywhere from 30 seconds to 5 minutes, depending on the route of administration and the amount of opioids in someone’s system.

Relapse, and possibly overdoses, are often a part of recovery for many people with substance use disorder. This video, from the Phoenix Recovery Home in Chicago, talks about how they teach their residents that is important to support and help each other and how to save someone who is having an overdose:

How can I prevent an overdose from happening in the future?

Just like with any behavior that carries risk, the only way to completely prevent an overdose is by not using any opioids. However, that is not always realistic. If you or your family member does choose to use, it’s best to practice harm reduction strategies like not using alone, not injecting, “tasting your shot” if you do inject (use just a small amount at first to see how strong it is), avoid really strong opioids like fentanyl and carfentanil, don’t combine opioids with other “downers” like alcohol or benzos, and, importantly, if you’ve gone a few days since you last used, always start at a smaller dose than what you’re used to.

Is naloxone all that’s needed to get over an opioid use disorder?

No. Naloxone is not treatment (and neither is detox). If you’re interested in learning more about treatment for opioid use, visit here.

Fentanyl

Recently, articles about fentanyl (a powerful, man-made opioid that can be used to “cut” heroin or in counterfeit prescription pills) have flooded social media sites and the news. Since fentanyl is stronger than heroin and hard to detect, death rates involving fentanyl have continued to increase. Fentanyl overdoses occur much faster than heroin overdoses and may require more naloxone to reverse. To learn more about fentanyl, visit our FAQ page here.

Resources

Interested in connecting with other people who use drugs and their families? Check out some of these resources:

For specific information on opioid overdose, including recognizing and opioid overdose, responding to an opioid overdose, and risks and prevention strategies, visit here.