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12/19/2018

UW Health, Madison, WI

University of Wisconsin Health

Submitted by:
Alaa Abd-Elsayed, M.D., M.P.H.; Christi Ann Albert Pharm.D. BCPS; Matt Fischer, M.D., M.H.A.; and Brooke Anderson, DNP, RN

Initiation of a Naloxone Academic Detailing Program

Overview

The UW Health Pharmacy in March 2017 initiated a Naloxone Academic Detailing program — a series of short 15-minute educational sessions conducted at provider staff meetings in the primary care, emergency department (ED), and in inpatient and outpatient pharmacies. The detailing provided a brief educational background on naloxone availability, indications, and product selection for ambulatory patients.  We built an electronic orderable for naloxone, obtained approval from Prescribe to Prevent to modify and reprint educational brochures, developed content for each educational session, and administered pre and post-education surveys. We educated 138 providers with a 38 percent post-education survey response rate.

Key Elements of Success

Prior to initiating the naloxone academic detailing sessions, an educational handout was acquired from Prescribe to Prevent. With assistance from a local non-profit group, Safer Communities, and permission of Prescribe to Prevent, we modified and reprinted the handouts. We used a slide show during the academic detailing that was developed, reviewed and endorsed by the medical director of the health system’s pain program. A pre-populated electronic orderable prescription was built in the electronic health record for varying naloxone products in the ambulatory setting for ease of prescribing. A content expert conducted eight sessions for providers. Two additional sessions were conducted by proxies trained by the content expert.

Educational sessions were provided to ambulatory clinic prescribers, emergency department prescribers, inpatient pharmacists, ambulatory pharmacists, and emergency department pharmacists at their respective staff meetings. Staff meetings were selected in this case to take advantage of providing education in a smaller mandatory setting and to build rapport with the attendees. A statewide delegation protocol for pharmacists to dispense naloxone had already been developed in advance of the project and adopted by the health-system. Education was provided to both the prescribers and dispensers to allow for multiple opportunities to identify and capture patients who qualify for naloxone and to increase patient knowledge of naloxone availability from both settings.

Impact on Patient Outcomes

Following the educational sessions, there was a 32 percent increase in naloxone prescribing by prescribers and a greater than threefold increase in naloxone dispensing by pharmacists under our delegation protocol for the quarter following the academic detailing. There was an increase from 90 percent to 98 percent and 70 percent to 90 percent of survey respondents agreeing that patients prescribed 90MME and 60MME, respectively, should be co-prescribed naloxone in the ambulatory setting. Of those respondents, 60 percent versus 40 percent preferred the small group format of 5-10 people over large seminar-like settings. No respondents preferred educational ratios of 1:1 or 1:2 and 84 percent of respondents were satisfied with the education.

Role of the Pharmacy and Pharmacists

The main content expert and proxies were pharmacists and the prescription electronic orderable was built by pharmacy informatics. The content expert and proxies completed education as required by the state delegation protocol prior to providing the academic detailing. As previously described, a delegation protocol for ambulatory pharmacists to dispense naloxone without a prescription had already been established prior to the project, which required one hour of continuing education for those carrying out the protocol. Medical assistants and nurses were invited to the academic detailing sessions to help identify patients on behalf of prescribers with a busy practice or to independently refer patients to the health-system’s pharmacies to obtain naloxone via the delegation protocol.

Lessons Learned

Lessons learned and winning elements included connecting with clinic managers to have time allocated on staff meeting agendas to communicate the information to frontline staff. The biggest champions included the ED personnel and inpatient and pharmacists for heroin or opioid overdose admissions.  Despite positive feedback after the education, access to naloxone after prescribing was a challenge. Prescribers desired direct access to naloxone kits/products for dispensing out of the emergency department particularly for those presenting after pharmacy operating hours. Prescriptions sent to local retail pharmacy chains outside of the health system did not routinely stock the desired naloxone product or did not have pharmacists trained in dispensing it per the voluntary state delegation protocol. The cost of the trademarked products and varying insurance coverage decreased patient willingness to pay for expensive products that would hopefully never need to be used. Due to the rise in demand for naloxone to match current prescribing guidelines, prices of generic products (for off-label use) also became cost prohibitive.

Building an electronic orderable for the off-label generic products that also specified necessary administration devices (nasal atomizer for intranasal use, syringes for vials for injection, CPR mask) did not fit within a 140 character limit to allow electronic prescribing for the off-label products the health-system’s pharmacy had put together as kits.

During the academic detailing sessions, the branded nasal spray, Narcan® 4mg/0.1mL, was indicated as the preferred product due to local insurance, Medicare, and Medicaid coverage as well as ease of use. The off-label products have several additional steps for assembly and administration. There had been several cases of overdose patients admitted to the health system’s ED that had previously been dispensed generic naloxone kits, however, necessary pieces to the kit were missing preventing bystanders from administering the naloxone by nasal atomizer or by injection with a vial and syringe. The Narcan® product, by contrast, does not have any additional pieces or devices needed for administration, nor requires the victim to be breathing as the drug is absorbed directly into nasal mucosa. Therefore, while the off-label generic products have better pricing, the benefit of the price gap did not seem worth the risk of nonadherence due to complicated assembly/administration that could potentially result in death.

Budget & Resource Allocation

The program was a pilot that was a part of a collaborative grant from the Centers for Disease Control and Prevention to health systems in Dane County via a local non-profit group, Safer Communities.

Future Goals

Future goals of the program include additional educational sessions in pain management topic(s) were desired to follow the initial naloxone pilot series, however dedicated resources to do so were lacking. A dedicated resource had been requested from hospital leadership, however, budget constraints did not allow for this position to be allocated. Around this same time, the state medical examining board developed required continuing education for all prescribers statewide. Publishing the work as a journal submission is underway.