The Washington State Pharmacist PerspectiveJenny Arnold, PharmD, BCPSDirector of Pharmacy Practice DevelopmentWashington State Pharmacy Association
ObjectivesDescribe Washington State’s Opiate DeathsDiscuss the Scope of Practice of PharmacyExplain Collaborative Practice AgreementsAnalyze the challenges of initiating a CPAExamine alternatives for pharmacy involvement
Methadone does not include methadone dispensed by narcotic treatment programs. Methadone data provided by DEA for 2007-2010 included narcotic treatment programs, estimates removing expected NTP use are shown with a dashed lineSource: Drug Enforcement Administration Automation of Reports and Consolidated Orders System, data include medications prescribed and dispensed.Data provided to and analyzed by Caleb Banta-Green Alcohol & Drug Abuse Institute, University of WashingtonDefined Daily Dose utilized from WHO http://www.whocc.no/atcddd/
Opioid Sales in WA State, Estimated # daily doses sold annually
• At the population level rx opiate abuse appears to precede heroin abuse• King county data show that 40% of heroin users were “hooked on” Rx opiates first
Outpatient, Inpatient, MMT,
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
0
100
200
300
400
500
600
Prescription Opioid + alcohol or illicit drug
Prescription Opioid +/- Other Prescriptions
Nu
mb
er o
f d
eath
s
23
505
Unintentional prescription opioid involved overdose deaths Washington 1995-2008
Source: Washington State Department of Health, Death Certificates, Jennifer Sabel, PhD
Surpassed traffic fatalities
Medic One Responses
45 serious opiate overdoses per month responded to by SFD in 2011*• Approximately 1:1
Heroin:Rx Opiate
32 cardiac arrest cases per month responded to by SFD in 2010**
*268 serious opiate overdoses per our chart abstraction for 6 months in 2011** “384 out of hospital cardiac arrest cases treated by SFD in 2010”
Drug Caused Deaths, King County WA
0
30
60
90
120
150
180
# of
Tim
es D
rug
Iden
tifie
d
Other Opiate 22 38 29 43 49 63 79 115 127 144 147 154 161 130
Benzo Barb Tricylic MuscRlx GHB 48 53 34 42 46 58 66 76 74 82 77 98 94 79
Alcohol 90 112 70 113 93 132 97 127 68 60 70 71 59 62
Heroin_mophine_opiate 111 144 117 102 61 87 62 76 74 71 65 59 50 50
Cocaine 66 69 76 89 49 79 52 92 80 111 86 71 60 46
Methamphetamine 3 3 13 10 5 13 18 18 24 19 18 13 19 15
Total 178 221 197 215 150 195 186 252 240 286 272 257 254 240
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Source: King County Medical Examiner Public Health- Seattle & King County
Drug Caused Deaths, Most Common Pharmaceuticals King County WA
0
10
20
30
40
50
60
70
80
90
100
Methadone 14 20 19 25 24 37 47 67 81 94 82 88 85 65
Antidepressant 30 52 40 42 50 50 78 77 85 76 80 75 80 58
Benzodiazepine 26 31 16 18 19 34 34 42 44 52 43 66 67 57
Oxycodone 1 5 4 12 18 20 14 32 31 44 51 44 58 33
Tri-cyclic anti-depressant 20 36 23 26 21 23 32 28 29 25 18 17 16 16
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Source: King County Medical Examiner Public Health- Seattle & King County
Opioid Overdose Risk by Average Daily Dose of Prescribed Opioids Received
Current average daily dose in morphine equivalents (MED) preceding event
Overdose events,Persons age 18+
(N=9,940)
Hazard Ratio(95% Confidence
Interval)
Rate per 100 person years (%)
(# of person years)
0 mg MED 1.0 0.047 % (16,980)
1-19 mg MED 2.4 (1.0, 5.5) 0.15 % (14,263)
20-49 mg MED 4.1 (1.5, 11.8) 0.29 % (2,401)
50-99 mg MED 6.1 (1.8, 20.9) 0.44 % (910)
100+ mg MED 22.1 (8.3, 58.5) 1.75 % (628)
Pharmacists• Doctor of Pharmacy Degree is now the minimum degree to
enter practice.• This entails normally 7 years minimum of education• Pharmacists are the medication experts in healthcare• Post graduate training opportunities include residencies and
fellowships.
Pharmacists as Mid-level Prescribers
o Dependent prescribing o Collaborative Prescriptive Agreementso Similar to PA’so The laws vary in in each state.
Collaborative Prescriptive Agreements
o A legal agreement between a prescriber and pharmacisto Agreement must list:o Where and whoo Which drugs or diseaseso Policies and procedureso Liability insurance
o RI Pharmacy Laws Section 25.0
Pharmacist Participating in CPA in RIo A pharmacist participating in CPA musto Have post graduate training/experienceo Access to patient information o 5 hours of CE in the area each year
Washington State
Washington Modelo Public Health- Seattle & King County began distributing in
February in 2012o Recruitment via needle exchangeo OD prevention and intervention training at Needle Exchangeo Narcan prescribing and dispensing by Public Health pharmacist o CPA facilitates this
o Police training video recently released based on survey findings
Expanded Washington ModeloPartnering with Community Pharmacieso Target those either at risk of having, or witnessing an
overdoseoUtilizing web based patient education and other
handouts to limit impact on pharmacist time
Opportunities to engage pharmacistso Show the pharmacists what their practices will look like if they
prescribe and dispense naloxone o Screening formso Example CPAo Physician Partners to sign CPAs and refer patients
o Education – make the pharmacists the experts in naloxoneo Resources and references for questions and further educationo Studentso Teach this material in schools, so that students come out
expecting to do thiso Partner with faculty members to include in curriculum
Challengeso Evolution of pharmacy practiceo Pharmacists can be black and whiteo Medicaid coverage
Other ways pharmacy can helpo Stock Naloxone injections or kitso Cash payment
o Overdose education, especially to patients on more than 100 morphine equivalents daily
o Other Public Health Opportunitieso Immunizationso Emergency Response
Questions?