SAJP 9( 12) 347 365

Scholars Academic Journal of Pharmacy

Abbreviated Key Title: Sch Acad J Pharm
ISSN 2347-9531 (Print) | ISSN 2320-4206 (Online)

Journal homepage: http://saspublishers.com

@ OPEN ACCESS

A Pharmacist Telephonic Intervention: Saving Lives, One Naloxone at

a Time

Tina M. Menedjian’’, Patricia L. Gray’, Ryan Chaput’, Jason Shan“

'Post-Graduate Year 1 Pharmacy Resident

*Pharm.D., FCSHP, Riverside Pharmacy Clinical Operations Manager, Post-Graduate Year 1 Pharmacy Residency Coordinator

*Pharm.D., Drug Education Coordinator
“Pharm.D., Pain Management Pharmacy

DOI: 10.36347/sajp.2020.v09112.006

*Corresponding author: Tina M. Menedjian

Abstract

| Received: 27.11.2020 | Accepted: 11.12.2020 | Published: 29.12.2020

Original Research Article |

Purpose: As of January 1* 2019, the California Assembly Bill (AB) 2760 (amended January 2020 to AB 714) requires
physicians to offer a naloxone prescription and education to high-risk patients about overdose prevention and naloxone
use [1, 2]. In 2019, Kaiser Permanente Riverside Service Area Local Controlled Substances Safety Committee
developed a plan for an ambulatory care pharmacist (ACP) second naloxone outreach for high-risk patients. Methods:
This is a single-center, retrospective, data-only study. Naloxone prescription pick-up rate was analyzed for patients
who received an ACP second naloxone offer call in March 2020. The primary outcome was to increase naloxone
prescription pick-up rates. Patients were included if they were > 18 years old, on concurrent opioid(s) plus a
benzodiazepine, had no history of naloxone sold at index date, and either previously declined a naloxone offer or
failed to pick up a naloxone prescription ordered by their primary care provider (PCP). Index date was the first
documented ACP outreach call. A secondary outcome was to identify patient reasons for declining naloxone. Results:
79 patients were included in the study. Nine (11.4%) patients successfully picked up their prescription. The top two
patient reported reasons for declining naloxone were “I don’t need it” 53% and “too expensive” 20%. Descriptive
Statistics were used. Conclusion: Nine patients picked up their prescription. The study had several limitations and
challenges, including the timing of outreach during the COVID-19 outbreak. Future studies using a larger sample size
and initiatives involving pharmacists to improve naloxone prescription pick-up rates should be considered.

Keywords: ambulatory care pharmacist (ACP), California Assembly Bill (AB), COVID-19 outbreak.

Copyright © 2020 The Author(s): This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International
License (CC BY-NC 4.0) which permits unrestricted use, distribution, and reproduction in any medium for non-commercial use provided the original

author and source are credited.

INTRODUCTION

According to the CDC report in 2018, every
day 41 people died from prescription opioid overdose
[3]. In 2019, the National Institute on Drug Abuse
(NIDA) added that 30% of opioid-related overdoses
involve benzodiazepines (BZDs) [4]. Use of naloxone is
one of the key recommended mitigation strategies to
reduce the incidence of death due to opioid-induced
respiratory depression [5].

As of January Ist, 2019, the new California
AB 2760 Naloxone law (which was amended and
updated in January of 2020 to AB 714) requires
physicians and other providers to offer a prescription of
naloxone for the complete/partial reversal of opioid
depression and to provide education to a patient and
his/her designee on overdose prevention and the use of
naloxone [1, 2].

Naloxone, a short-acting opioid antagonist, 1s
used to reverse the effects of opioid-induced overdose
and has proven to be widely successful in a population-
level reduction in overdose mortality [6]. Thus,
expanding naloxone availability through diverse
mechanisms is considered an important component of
opioid-induced overdose prevention. Despite the federal
endorsement through the Centers for Disease Control
and Prevention (CDC), in addition to the California AB
2760/714 naloxone law, naloxone prescribing and
naloxone prescription acceptance rates are still
relatively nascent [6]. It is crucial that gaps in care be
identified to increase naloxone provider and patient
education, prescribing, and _ patient prescription
acceptance.

In lieu of the new law and with concern for
patient safety, it was important to KP Riverside to study
the impact of a pharmacist telephonic intervention in
this high-risk patient population.

© 2020 Scholars Academic Journal of Pharmacy | Published by SAS Publishers, India 368

In 2019, the Kaiser Permanente Riverside
Service Area (SA) Local Controlled Substances Safety
Committee (LCSSC) identified 666 high-risk patients
on concurrent opioid(s) plus a BZD. Naloxone was
ordered for 81% of these patients and 38% of these
patients did not pick up their naloxone prescription up
to four months later, and thus remained at a high-risk
for opioid-induced respiratory depression (OIRD). In
November 2019, LCSSC developed a plan for an ACP
second naloxone outreach for these high-risk patients
that would be performed by an ambulatory care
pharmacist (ACP) to increase naloxone prescription
pick-up rates.

The ACP second naloxone outreach workflow
consisted of the ACP first obtaining primary care
provider (PCP) permission to contact their eligible
high-risk patients (who had either initially declined
their PCP first naloxone offer or failed to pick up their
first naloxone prescription ordered by their PCP). The
ACP then performed a pre-assessment electronic chart
review through accessing patient record via
HealthConnect®, and prescription pick-up history via
Permanente Online Interactive Network of Tools
(POINT). Next, the ACP called the patient to provide
the second naloxone outreach (Appendix 1). The ACP
educated the patient about the risks, prevention, and
detection of OIRD and naloxone use. The ACP also
addressed patient barriers they had in _ previously
picking up their first naloxone prescription ordered by
their PCP, in addition to assessing barriers to declining
ACP naloxone second offer at the end of telephone
encounter (if patient declined second offer). If the
patient agreed to pick up the naloxone prescription, the
patient was informed of their prescription cost based on
their pharmacy benefit and arranged for it to be filled at
their preferred KP pharmacy. The ACP then
documented the telephone encounter, patient reported
barriers, outcomes of the call, and “time spent”
(includes pre-assessment, ACP call, naloxone cost
retrieval via POINT, documentation, KP Electronic
Pharmacy Information Management System (ePIMS)
order entry, etc.) in the electronic chart and pharmacist-
managed Microsoft Excel® sheet.

The primary outcome of the study was to
evaluate the impact of ACP naloxone outreach in
increasing naloxone prescription pick-up rates. A
secondary outcome was_ to _ identify patient
barriers/reasons for declining naloxone prescription
offered by their PCP. If the ACP outreach could prove
to make a significant impact, the results could be used
to potentially define care gaps and areas for
improvement within KP and serve as a model for
pharmacists as a safety net filling gaps in opioid safety
at other KP Southern California facilities.

METHODS

This is a single-center, retrospective, data-only
study, where the subjects served as their own control.

© 2020 Scholars Academic Journal of Pharmacy | Published by SAS Publishers, India 369

Tina M. Menedjian et al., Sch Acad J Pharm, Dec, 2020; 9(12): 368-374

Data was collected from electronic medical records
(EMRs) for patients managed within the KP Riverside
SA. The study population included adult patients > 18
years, with active prescriptions for concurrent opioid(s)
plus a BZD, and with no history of naloxone sold prior
to ACP naloxone call. The primary outcome of the
study was to increase patient naloxone prescription
pick-up rates through ACP second naloxone outreach
calls. The index date was the first documented outreach
call from the ACP to the patient. Patients were included
in this study if they were > 18 years old, on concurrent
opioid(s) plus a BZD at index date, had no prior history
of naloxone sold on patient EMR prior to index date,
and received an ACP telephonic outreach call between
March 9, 2020 to March 20, 2020. Patients were
excluded if there was any loss of KP membership, if
they were enrolled in hospice/palliative care or on
active chemotherapy, within 1 month pre- and post-
ACP outreach.

The principal investigator identified patients
through pharmacist-managed Microsoft Excel” sheets
that were used to document and track ACP outreach
calls and follow-up of prescription pick-up within 15-
days post-index date. A data analyst abstracted the data
for each identified patient using HealthConnect®,
POINT, Pharmacy Management Data System, and
International Classification of Diseases Codes (ICD-9
and ICD-10). The primary investigator performed
medical record reviews of _ patients through
HealthConnect® and POINT to confirm patient had not
picked up their naloxone prescription prior to ACP
second naloxone call. The number of risk factors for
medications and comorbidities that may increase the
risk of OIRD was collected for each patient, as defined
by AB2760/714 naloxone prescribing criteria.’ The
risk factors were identified through ICD-9 and ICD-10
codes and prescription history from their electronic
medical records (Table-1). The primary investigator
then analyzed data through Microsoft Excel®.

The primary outcome was the naloxone
prescription pick-up rate: the rate of prescriptions
successfully picked up after ACP outreach. With
authorization from qualified patients’ PCPs, the ACP
outreach calls targeted patients who declined their PCP
first offer for a naloxone prescription or did not pick up
their first naloxone prescription ordered by their PCP.
An “index date” was defined as the date and time of the
completion of the ACP first documented contact with
the patient. Patient prescription pick-up was tracked up
to 15 days post-index date. Naloxone prescription pick-
up was considered successful if the naloxone
prescription was picked up within 15 days post-index
date.

One of the secondary outcomes included was
to determine the patient reported barriers/reasons for
declining their naloxone prescription. This was
determined by ACP interviewing the patient at the

beginning of the telephone encounter about their
barriers to picking up their first naloxone prescription.
Additionally, if the patient declined the ACP second
naloxone offer, the ACP would assess the patient
reported reason(s) for declining the second naloxone
prescription offered.

Another secondary outcome was to determine
the average recorded time for the ACP telephonic
outreach process as a work-process measure.

Descriptive statistics were used to analyze the
prescription pick-up rate, patient — reported
barriers/reasons for declining first and second naloxone
prescription, and ACP telephonic outreach average
recorded time.

RESULTS

As shown in Figure-1, 516 patients were on
concurrent opioid(s) plus a BZD from October 2019
through December 2019. After applying inclusion
criteria, 84 patients remained in the study with no
history of naloxone sold. 5 patients were then excluded
from the study due to loss of KP membership (2),
enrollment in hospice/palliative care (2), and initiation
of active chemotherapy (1). After applying inclusion
and exclusion criteria, this study had a total sample size
of 79 patients. Of the 79 patients that met the inclusion
criteria, there were a total of 49 patients successfully
reached by ACP from March 9, 2020 to March 20,
2020.

Baseline characteristics of the 79 patients
included in the study were identified (Table-2). The
mean age was 60.6 years old, with 30 (37%) patients
greater than or equal to 65 years old. 55 (69%) patients
were female. Patients were prescribed an average
morphine equivalents (MME) of 33.5, combined with a
BZD. The number of risk factors (RFs) for OIRD was
abstracted (excluding concurrent use of BZD from RF
count as every patient had this RF from baseline).
(Table 1) RFs for OIRD included disease comorbidities
and concurrent medications. 31 (39%) patients had at
least five to six RFs for OIRD and 26 (33%) patients
had greater than or equal to seven RFs for OIRD. 34
(43%) patients were prescribed an opioid + BZD +
Non-Benzodiazepine Z Drug (NBZD) combination, 26
(33%) patients were prescribed an opioid + BZD +

Tina M. Menedjian et al., Sch Acad J Pharm, Dec, 2020; 9(12): 368-374

Skeletal Muscle Relaxant (SMR) drug combination, and
10 (12%) patients were prescribed an opioid + BZD +
NBZD + SMR drug combination.

Figure-2. the primary outcome was_ the
prescription pick-up rate 15 days post-ACP outreach. 9
(11.4%) patients of the 79 patients that met the study
criteria successfully picked up _ their naloxone
prescription 15 days after the outreach call. However,
using a sub-analysis of the 49 out of 79 patients that
were reached by phone, the naloxone prescription pick-
up rate was 9 (18.4%). Although it was not a primary
outcome, of the 49 patients reached, 19 (38.8%)
patients accepted the ACP second offer for naloxone.
Of these 19 patients, the successful naloxone
prescription pick-up rate was 9 (47.4%).

Figure-3 one of the secondary outcomes was to
determine the patient reported barriers/reasons for
declining their naloxone prescription. The patient
reported barriers for not picking up their first naloxone
prescription offered by their PCP were the following: “I
don’t need it” 53%, “Too expensive” 20%, “What is
naloxone?” 18%, “I live alone” 4%, and “My
spouse/family member has it” 4%. The third column in
Figure 3 displays patient reported barriers/reasons for
declining second naloxone offered by ACP. 30 (61.2%)
out of 49 patients reached declined the naloxone second
offer and reported the top two reasons for decline: “T
don’t need it” 17%, and “Too expensive” 18%. The
percent of patients that reported they did not “need” the
naloxone and the percent of patients that reported “what
is naloxone” after the ACP naloxone outreach, both
decreased by 18% compared to when the PCP made the
first offer for naloxone.

Figure-4 another secondary outcome was to
determine the average recorded time for the ACP
telephonic outreach process as a work-process measure.
The average time for the ACP workflow was 28
minutes for patients reached and 11 minutes for those
not reached. The total time for the ACP outreach project
for the 79 patients was 38 hours. Additionally, after
analysis of this secondary outcome, tasks were
determined that could be performed by ancillary
support staff to assist the ACP in the telephone outreach
process, which could help to alleviate pharmacist time
spent and lower future expenses to provide this service.

Table-1: Comorbidities and Medication Risk Factors for OIRD*

Comorbidities

Concurrent Medications

Psychiatric: MDD, schizophrenia, schizoaffective disorder, BPD | Benzodiazepine class

Respiratory: Asthma, COPD, OSA

History of dependence or abuse: Opioid, alcohol, cannabis

Others: Advanced age, kidney or liver dysfunction

Non-Benzodiazepine Z Drug class

Skeletal muscle relaxant class

CNS depressant drugs

“OIRD = opioid-induced respiratory depression, MDD = major depressive disorder, BPD = bipolar disorder, COPD = chronic
obstructive pulmonary disorder, OSA = obstructive sleep apnea, CNS = central nervous system

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Tina M. Menedjian et al., Sch Acad J Pharm, Dec, 2020; 9(12): 368-374

Table-2: Demographic and Clinical Variables in Study Populations”
Variable Patients (n = 79)
Mean + S.D. age, yr 60.6 + 14.2
Female, no. (%) 55 (69%)

Age > 65 years, no. (%) 30 (37%)
Age > 60 years, no. (%) 50 (63%)
Avg MME, no. 33.5
OIRD risk factors (RF)
1-2 RF, no. (%) 18 (22%)
3-4 RF, no. (%) 27 (34%)
5-6 RF, no. (%) 31 (39%)
> 7 RF, no. (%) 3 (4%)
On concurrent BZD + NBZD drug, no. (%) 34 (43%)
On concurrent BZD+ SMR drug, no. (%) 26 (33%)
On concurrent BZD + NBZD + SMR, no. (%) 10 (12%)
"MME = morphine equivalents, OIRD = opioid-induced respiratory depression, BZD = benzodiazepine, NBZD = non-
benzodiazepine, SMR = skeletal muscle relaxant

Tolat! KP Riverside SA Patents
On Concurrent
Opioxiis) « BZD

(Get — Dac 2070)

Inclusion: Patients on Cpsoid(s) + BZD,
Oectined First Naloxone Offer or Did Not
‘Pick Up Their First Naloxone Rx Ordered,
No History Naloxone Sold

Fig-1: Study Population

Fig-2: Primary Outcome: Naloxone Prescription Pick-Up Rate

a 8 Circa @ed
Pick-Up (n = 79) Outreach (n = 49)
pick-up, no. (%)

Fig-3: Secondary Outcome: Patient Reported Barriers*

Naloxone PCP (n = 49), no. (%) ACP (n = 30), no. (%)

Fig-4: Secondary Outcome: Time for ACP Workflow

oe ee
(n=49) (n= 30)
ACP outreach Tasks Pre-assessment Rx review* | Pre-assessment Rx review*
ACP outreach call | ACP voicemail, if available
Documentation on electronic chart
Rx benefit cost* and Rx fill
Post-assessment Rx _ review*
PCP follow-up, if applicable*

ACP outreach, avg time, min.

*Tasks that could be performed by ancillary support staff in the future

DISCUSSION

The study demonstrated the impact of an
ambulatory care pharmacist-led naloxone outreach for
patients that either previously refused their PCPs offer
for naloxone or failed to pick up their naloxone
prescription (Rx) prescribed by their PCP. Figure-2 for
the 79 patients included in the study, the overall
naloxone prescription pick-up rate was 11.4% and
18.4% if reached by phone. Moreover, of the 49
patients reached, 19 patients accepted the ACP second
offer for naloxone and of these 19 patients, the
successful naloxone prescription pick-up rate was
47.4%.

Figure-3 the three most common patient
reported barriers for picking up naloxone were “I don’t
need it,” “too expensive,” and “what is naloxone?” The
most concerning response was the 18% of patients that
replied, “what is naloxone?” as these patients were
outreached with the impression that they had declined
their PCP first offer for a naloxone prescription after the
PCP provided education to them on the risks of OIRD
and the use of naloxone to help prevent unpredictable
death due to OIRD. It appears either the patients did not
understand their PCP, or the physicians may not have
had time to do the required patient naloxone education
and prescribed it for the patient without adequate
education. The study revealed that while some
physicians are doing their best effort to provide this
education, there is room for improvement. The percent
of patients that reported they did not “need” the
naloxone and the percent of patients that reported “what
is naloxone” after the ACP naloxone outreach, both
decreased by 18 percent compared to when the PCP
made the first offer for naloxone. Both of the stated
reasons for declining naloxone may have improved as a
result of more thorough naloxone education provided
by the ACP.

During an ACP telephone encounter, one
patient shared, “I was unaware of the risks of the
combination of drugs. I was not familiar with naloxone.
I am very interested in learning more and thankful KP
cares about my safety.” PCP feedback for the ACP
outreach was unanimously positive. Every PCP that was
contacted by the ACP, authorized the ACP naloxone
outreach. PCP feedback included, “Thank you for this. I
really appreciate the great care being spent with this
patient” and “This was a tough patient. I am so happy to
hear they finally picked up their naloxone!”’.

The average time for the ACP telephone
outreach as a work-process measure was also evaluated.
The average time for the ACP workflow for patients
reached and not reached was 28 minutes and 11
minutes, respectively. For the 79 patients that met the
inclusion criteria and a telephone outreach attempt was
made, the total time for the ACP outreach project was
38 hours. After data analysis, outreach tasks that could
be performed by ancillary support staff to assist the

Tina M. Menedjian et al., Sch Acad J Pharm, Dec, 2020; 9(12): 368-374

ACP in the telephone outreach process, was
determined. Use of ancillary support staff could help to
decrease the pharmacist time spent and lower future
labor expenses to provide this service.

Limitations of the study included that it was
retrospective, had a small sample size, and patients
served as their own control. One of the main challenges
of this study was the timing of the ACP outreach during
the COVID-19 pandemic outbreak, that deterred
patients from visiting the pharmacy to pick up their
naloxone. Because a mandatory in-person patient
consultation was required, the naloxone prescription
could not be mailed to the patient, however, this is
under future consideration.

A next step for increasing naloxone
prescription pick-up rate, especially for high-risk
patients, would include expanding and emphasizing the
importance of the outpatient pharmacist role in
naloxone education when dispensing opioid
prescriptions. Additionally, further feasible and
effective initiatives should be considered to increase
naloxone education and naloxone prescription pick-up
using a more robust multidisciplinary approach,
involving pharmacists, ancillary staff support, and
PCPs.

Through ACP telephonic outreach, this study
focused on a high-risk population who did not have
access to naloxone in the case of emergent, life-
threatening OIRD. This study also evaluated patient
reasons for refusing initial provider education/naloxone
prescription and barriers to picking up the medication
when prescribed. While there are several articles that
have discussed mitigation strategies to improve opioid
safety, reduce/taper patients off opioid medications or
opioid plus BZD combinations, and improve provider
prescribing education, many do not include or focus
specifically on improving patient naloxone acceptance
rates.”*” Moreover, they do not focus on a pharmacist-
directed role to improve patient naloxone acceptance
rates in a patient population at a higher risk for OIRD
that either refused the physician previous offer or did
not pick up their prescription of naloxone for various
reasons. Three studies focused on a_ patient
questionnaire or survey that identified experiences
and/or perceptions of patients that had either received a
naloxone prescription or were identified as high risk for
an opioid-induced overdose [7-9]. These — studies
characterized the patients’ prior education about the
risks of overdose from their medications or measured
naloxone prescriptions rates, however, none of these
studies included an explicit pharmacist role in the
intervention [7-9]. Moreover, one study excluded
patients who refused naloxone in their questionnaire
[7], whereas this study focused primarily on patients at
high risk for OIRD who refused a naloxone prescription
from their provider or failed to pick up their
prescription. Lastly, a 2017 study conducted in eighty

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Tina M. Menedjian et al., Sch Acad J Pharm, Dec, 2020; 9(12): 368-374

primary practices in three large facilities, (including patients who decline naloxone prescriptions [8], which
Kaiser Permanente Colorado), strongly recommended was a secondary outcome of this study.
future qualitative studies to explore the perceptions of

Appendix 1: ACP Naloxone Second Outreach Education

Hi is this ? My name is _lam a clinical pharmacist calling from Kaiser Permanente Riverside. I am calling on behalf
of Dr. to discuss with you your pain medication use and offer you some information about opioid safety. Do you have a about
10-15 minutes for this call?

l. Vertfy if taking meds:

a. Our records show you are currently taking (opioid). Is that correct? How do you take that medication?
Frequency?

b. Our records show you are currently taking (BZD). Is that correct? How do you take that medication?
Frequency?

ec. Ferifv iftaking other meds that increase risk for OIRD

d. Jf Problem List includes: Asthma/COPD/obstructive sleep apnea... verify w/ patient

2. Has your doctor explained to you the risks associated with the combination of your (opioid) and (BZD)
medications? (+ if they have skeletal muscle relaxant or # drug AND/OR other risk factors: age, psychiatric comorbidity,
COPD /asthma/sleep apnea)

Mainly, we are calling all of our patients on these medications because we know now more about the increased risk for
opioid overdose and want to provide another outreach call for your safety. All opioids can cause breathing to slow or even
stop. It can happen by accident at any dose at any time and can cause death within a few minutes. Some studies have reported
that the risk of overdose (including accidental overdose) can be 10 tumes higher with the combination of opioid + |
(BZD) than taking an opioid alone. Taking alcohol or benzodiazepines such as your (BZD) and other medicines that
can make you sleepy could change your ability to tolerate the dose of opioid medication.

3. Has your doctor previously offered you naloxone education (also known as Narcan)? | see they have written you a
prescription for the rescue medication, but it was never picked up...

Counsel points:

a. Itis an emergency rescue medication that, when given right away, temporarily works to reverse the effects of
opioids, including slowed or stopped breathing. It may prevent possible death.

b. Naloxone 1s given to you by someone else (a bystander, family member, or someone trained to use it) when your

breathing is slowed, or you cannot breathe, and you become unresponsive or unconscious

Naloxone only works if opioids are the cause of the overdose. It has no effect on alcohol or other drugs.

d. Takes 2-5 minutes to start working and may require more than one dose. The effects only last for 30-90 minutes, so
someone MUST call 911 before giving you naloxone. If only one other person is present, have them give naloxone
first and them immediately call 911.

e. Ifthey ask: May result in withdrawal symptoms (NV, agitation, cramps). If these symptoms occur, they will go
away as the naloxone wears off.

f Itis VERY important to share the info with family and friends and make a plan so others are prepared to respond to
an emergency

p

4 According to our records, you did NOT pick up the naloxone medication prescribed to you by your provider. May I ask what
barriers you had to picking up the medication?

May offer them options: (1=financial, 2=forgot, 3= Denial of need 1-¢. tapering already or does not exceed quantity
prescribed, 4=Belief system 1¢. believe they are labeled as a drug abuser, 3=misunderstanding importance of drug or how to
use, 6=perception that provider will take med away, /= report they live alone, 8=was not familiar with drug/unknown they
were prescribed)

© 2020 Scholars Academic Journal of Pharmacy | Published by SAS Publishers, India

aA

Tina M. Menedjian et al., Sch Acad J Pharm, Dec, 2020; 9(12): 368-374

Are you familiar with how to detect an overdose? Teach your family, friends, and caregivers who may be around you

when using an opioid how to respond to respiratory depression due to opioid overdose and how to use naloxone. When you
pick up your medication, a pharmacist must go over these instructions with you in more detail.

* Recognize respiratory depression, slow or no breaths, due to opioid overdose. Signs:

o Heavy nodding, deep sleep
Snoring, gurgling, choking

OO oO 8 6

Blue or gray lips and fingernails
o Pale, sticky, or damp skin
* (Check for a response.

o Lightly shake the person and yell his or her name.

Unresponsive, unconscious (won't wake even if you shake the person or say his or her name loudly)
Slow breathing (less than one breath every five seconds)
When breathing stops, even for short periods

o Ifthe person does not respond, give naloxone first and then call 911.

* Give naloxone and call 911.
fa
‘a
fa
fan

* Check whether the airway is open.

If you have naloxone nasal spray, DO NOT PRIME OR TEST the spray device.

Gently insert the tip of the nozzle into one nostril and press the plunger firmly to give the entire dose.
When calling 911, give the address of your location and say that the person is not breathing.

Stay with the person until emergency personnel arrive.

o Give rescue breathing if you witness an overdose and the person is not breathing.
o Grve chest compressions if you did not see the person collapse and there is no pulse.
* Consider giving a second dose. Ifthe person is not responsive and breathing in three to five minutes give a second dose
of naloxone. If using naloxone nasal spray, spray the second dose in the other nostril when possible.

* Recovery position. If the person is breathing but unresponsive, put the person on his or her side to prevent choking with
vomiting. Stay with the person until emergency personnel arrive for transport to a hospital.
e Ifyou have questions about opioid medications or naloxone, speak with any pharmacist.

CONCLUSION

Through ACP outreach, nine patients picked
up their naloxone prescription which may possibly
prevent nine future OIRD-associated events and/or
possible deaths. Through ACP patient interviews during
telephone outreach, it was learned that 18% of patients,
(that were previously offered and declined a naloxone
prescription from their provider), reported they did not
know what naloxone was. It appears either they did not
understand their PCP, or the physicians may not have
had time to do the required patient naloxone education.
This helped to identify areas for improvement in
naloxone patient education. The study had several
limitations and challenges, including the timing of
outreach during the peak of the COVID-19 outbreak,
that deterred patients from visiting the pharmacy to pick
up their naloxone. In conclusion, working as a team
with pharmacist, ancillary staff support, and providers,
continuation of and consideration of new, feasible
initiatives to increase naloxone prescription pick-up
rates should be considered.

Disclosure: The authors have no conflicts of interests to
disclose.

Additional Information

Dr. Tina Menedjian’s data collection, analysis,
and research write-up were used to fulfill requirements
for the ASHP PGY1 residency at Kaiser Permanente
Riverside.

REFERENCES

1.

Z,

“Assembly Bill No. 2760.” California Legislative
Information. 2019.

“Assembly Bill No. 714.” California Legislative
Information. 2020.

Wide-ranging online data for epidemiologic
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