April 23, 2018
On April 17, 2018, the U.S. Surgeon General issued an advisory on naloxone and opioid overdose. The advisory explains the Surgeon General’s position that expanding awareness regarding naloxone’s overdose-reversing effects and expanding availability of naloxone are key components to responding to the worsening opioid epidemic. The advisory describes the healthcare provider’s role in achieving these goals and the overarching goal of ending the epidemic as follows:
LEARN HOW TO IDENTIFY PATIENTS AT HIGH RISK FOR OVERDOSE, AND PRESCRIBE OR DISPENSE NALOXONE TO THOSE INDIVIDUALS AND/OR THEIR FRIENDS AND FAMILY
The Advisory lists the following as indications that an individual is at an elevated risk for an opioid overdose:
- Misusing prescription opioids (like oxycodone) or using heroin or illicit synthetic opioids (like fentanyl or carfentanil).
- Having an opioid use disorder, especially those completing opioid detoxification or being discharged from treatment that does not include ongoing use of methadone, buprenorphine, or naltrexone.
- Being recently discharged from emergency medical care following an opioid overdose.
- Being recently released from incarceration with a history of opioid misuse or opioid use disorder.
FOLLOW THE CDC GUIDELINE FOR PRESCRIBING OPIOIDS FOR CHRONIC PAIN
Among the Guideline’s recommendations, the CDC advocates for nonpharmacological therapy and non-opioid pharmacological therapy whenever possible and advises clinicians to consider opioid therapy only if the expected benefits for both pain and function are anticipated to outweigh the risks to the patient. Before starting opioid therapy for chronic pain, clinicians should establish treatment goals and consider how opioid therapy will be discontinued if the benefits do not outweigh the risks. Clinicians should also initially prescribe immediate-release opioids rather than extended-release opioids and should always prescribe the lowest effective dosage. The CDC discourages concurrently prescribing narcotics and benzodiazepines and encourages the use of random urine drug testing, at least annually, to assess for prescribed medications, other controlled prescription drugs, and illicit drugs. Opioid prescribers also should be prepared to offer or arrange evidence-based treatment for patients with an opioid use disorder.
UTILIZE YOUR STATE’S PRESCRIPTION DRUG MONITORING PROGRAM (PMP)
Virginia requires all licensed prescribers to be registered with the PMP and, with some exceptions, to check the PMP when initiating a new course of opioid treatment expected to last more than seven days. Prescribers should check the PMP to determine what, if any, other covered substances are currently prescribed to the patient and to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. The CDC recommends that clinicians continue to review PMP data at least every three (3) months during opioid therapy for chronic pain.
FIND OUT IF YOUR STATE PERMITS PHARMACISTS TO PRESCRIBE NALOXONE INDEPENDENTLY, OR DISPENSE NALOXONE UNDER A STANDING ORDER OR COLLABORATIVE PRACTICE AGREEMENT
Virginia permits a pharmacist to dispense naloxone pursuant to a standing order issued by a prescriber or by the Commissioner of the Virginia Department of Health. The Commissioner issued a standing order for naloxone in November 2016, which authorizes Virginia pharmacists to dispense naloxone in accordance with the Virginia Board of Pharmacy-approved protocol. The Board-approved protocol requires pharmacists to provide counseling on opioid overdose prevention and the administration of naloxone, unless the pharmacist verifies the requestor’s successful completion of the REVIVE! program. REVIVE! is the opioid overdose and naloxone education program for the Commonwealth of Virginia providing free training to professionals and laypersons about how to recognize and respond to an opioid overdose emergency with the administration of naloxone.
If you have any questions about opioid or naloxone prescribing practices, or need assistance with developing opioid and/or naloxone related policies and procedures, please contact a member of Hancock Daniel’s Health Regulatory Boards or Compliance teams.
The information contained in this advisory is for general educational purposes only. It is presented with the understanding that neither the author nor Hancock, Daniel & Johnson PC is offering any legal or other professional services. Since the law in many areas is complex and can change rapidly, this information may not apply to a given factual situation and can become outdated. Individuals desiring legal advice should consult legal counsel for up-to-date and fact-specific advice. Under no circumstances will the author or Hancock, Daniel & Johnson PC be liable for any direct, indirect, or consequential damages resulting from the use of this material.
 A complete summary of the CDC’s recommendations is available at https://www.cdc.gov/drugoverdose/pdf/Guidelines_Factsheet-a.pdf.
 A prescriber is not required to check the PMP if:
- The opioid is prescribed to a patient currently receiving hospice or palliative care;
- The opioid is prescribed to a patient as part of treatment for a surgical or invasive procedure and such prescription is for no more than 14 consecutive days;
- The opioid is prescribed to a patient during an inpatient hospital admission or at discharge;
- The opioid is prescribed to a patient in a nursing home or a patient in an assisted living facility that uses a sole source pharmacy;
- The Prescription Monitoring Program is not operational or available due to temporary technological or electrical failure or a natural disaster; or
- The prescriber is unable to access the Prescription Monitoring Program due to an emergency or disaster and documents such circumstances in the patient’s medical record.
 More information regarding Virginia’s REVIVE! program is available at http://www.dbhds.virginia.gov/behavioral-health/substance-abuse-services/revive.