Cindy Powers Magrini , PharmD , BCPS

1. Cindy Powers Magrini, PharmD, BCPS Clinical Pharmacy Specialist Positive Health Clinic

2. Naloxone Prescribing at The Positive Health ClinicCindy Powers Magrini, PharmD, BCPSClinical Pharmacy Specialist, Positive Health Clinic (PHC) July 31, 2012

3. Introduction to the PHC • Clinic offers early HIV intervention and treatment using a harm reduction model • Funded through a federal grant under the Ryan White CARE Act of 1990 • ~750 HIV-positive patients • 5 physicians • 2 nurse practitioners • 3 nurses • 4 social workers • 2 medical assistants • 1 patient advocate • 1 data analyst • 1 grant coordinator • 1 administrative director • 1 pharmacist 3

4. Cristina Elgins’s Presentation for PHC Staff • Local trends in overdose • National trends in overdose • Strategies for preventing opioid fatalities • Prevention Point Pittsburgh • Other naloxone prescribers in Pittsburgh • Project Lazarus • Legality of prescribing naloxone—Temple University School of Law Memo • How to treat an overdose situation

5. Naloxone Prescribed When: 1. Patient release after emergency medical care involving opioid OD/intoxication 2. Suspected history of illicit or nonmedical opioid use 3. High-dose opioid prescription (> 50 mg of morphine equivalence/day) 4. Any methadone prescription to opioid naïve patient Any opioid prescription and … 5. smoking/COPD/emphysema/asthma or other respiratory illness 6. renal dysfunction, hepatic disease 7. known or suspected concurrent alcohol use 8. concurrent benzodiazepine prescription 9. concurrent SSRI or TCA anti-depressant prescription

6. Naloxone Prescribed When: 10. Prisoner released from custody 11. Release from opioid detoxification or mandatory abstinence program 12. Voluntary request from patient 13. Patients in methadone or buprenorphine detox/maintenance (for addiction or pain) 14. Patient may have difficulty accessing emergency medical services (distance, remoteness) 15. Other (specify): ____________________________________

7. Policy and Procedure Creation • Intranasal Naloxone Policy • Controlled Substances Policy • Any patient with an opioid prescription can be ordered intranasal naloxone by either a nurse or pharmacist per protocol • Any patient who has a known history of opioid misuse will be offered a prescription for intranasal naloxone after discussion with a prescribing practitioner

8. Patient Education • Patients and family members or friends will watch the intranasal naloxone training video (produced by PPP) • Staff will review the patient education checklist • Patients will be given the opportunity to ask questions

9. Naloxone Dispensing at PHC • After the patient has been educated, they will leave the clinic with naloxone in hand that has been dispensed from clinic stock • The clinic stock will be replaced by placing an order with the clinic’s contract pharmacy • The order will be adjudicated with the patient’s insurance, if applicable • The replacement stock will be received at the clinic next day

10. Naloxone Dispensing at PHC

11. Challenges and Obstacles • Mechanism for patient education that is sustainable • Naloxone shortage • EHR implementation • Prescribers • Raises uncomfortable issues for prescribers

12. Questions