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The Washington State Pharmacist Perspective Jenny Arnold, PharmD, BCPS Director of Pharmacy Practice Development Washington State Pharmacy Association

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Page 1: The Washington State Pharmacist Perspective Jenny Arnold, PharmD, BCPS Director of Pharmacy Practice Development Washington State Pharmacy Association

The Washington State Pharmacist PerspectiveJenny Arnold, PharmD, BCPSDirector of Pharmacy Practice DevelopmentWashington State Pharmacy Association

Page 2: The Washington State Pharmacist Perspective Jenny Arnold, PharmD, BCPS Director of Pharmacy Practice Development Washington State Pharmacy Association
Page 3: The Washington State Pharmacist Perspective Jenny Arnold, PharmD, BCPS Director of Pharmacy Practice Development Washington 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

Page 4: The Washington State Pharmacist Perspective Jenny Arnold, PharmD, BCPS Director of Pharmacy Practice Development Washington State Pharmacy Association

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

Page 5: The Washington State Pharmacist Perspective Jenny Arnold, PharmD, BCPS Director of Pharmacy Practice Development Washington State Pharmacy Association

• 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,

Page 6: The Washington State Pharmacist Perspective Jenny Arnold, PharmD, BCPS Director of Pharmacy Practice Development Washington State Pharmacy Association

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

Page 7: The Washington State Pharmacist Perspective Jenny Arnold, PharmD, BCPS Director of Pharmacy Practice Development Washington State Pharmacy Association

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”

Page 8: The Washington State Pharmacist Perspective Jenny Arnold, PharmD, BCPS Director of Pharmacy Practice Development Washington State Pharmacy Association

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

Page 9: The Washington State Pharmacist Perspective Jenny Arnold, PharmD, BCPS Director of Pharmacy Practice Development Washington State Pharmacy Association

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

Page 10: The Washington State Pharmacist Perspective Jenny Arnold, PharmD, BCPS Director of Pharmacy Practice Development Washington State Pharmacy Association

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)

Page 11: The Washington State Pharmacist Perspective Jenny Arnold, PharmD, BCPS Director of Pharmacy Practice Development Washington State Pharmacy Association

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.

Page 12: The Washington State Pharmacist Perspective Jenny Arnold, PharmD, BCPS Director of Pharmacy Practice Development Washington State Pharmacy Association

Pharmacists as Mid-level Prescribers

o Dependent prescribing o Collaborative Prescriptive Agreementso Similar to PA’so The laws vary in in each state.

Page 13: The Washington State Pharmacist Perspective Jenny Arnold, PharmD, BCPS Director of Pharmacy Practice Development Washington State Pharmacy Association

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

Page 14: The Washington State Pharmacist Perspective Jenny Arnold, PharmD, BCPS Director of Pharmacy Practice Development Washington State Pharmacy Association

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

Page 15: The Washington State Pharmacist Perspective Jenny Arnold, PharmD, BCPS Director of Pharmacy Practice Development Washington State Pharmacy Association

Washington State

Page 16: The Washington State Pharmacist Perspective Jenny Arnold, PharmD, BCPS Director of Pharmacy Practice Development Washington State Pharmacy Association

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

Page 17: The Washington State Pharmacist Perspective Jenny Arnold, PharmD, BCPS Director of Pharmacy Practice Development Washington State Pharmacy Association

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

Page 18: The Washington State Pharmacist Perspective Jenny Arnold, PharmD, BCPS Director of Pharmacy Practice Development Washington State Pharmacy Association

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

Page 19: The Washington State Pharmacist Perspective Jenny Arnold, PharmD, BCPS Director of Pharmacy Practice Development Washington State Pharmacy Association

Challengeso Evolution of pharmacy practiceo Pharmacists can be black and whiteo Medicaid coverage

Page 20: The Washington State Pharmacist Perspective Jenny Arnold, PharmD, BCPS Director of Pharmacy Practice Development Washington State Pharmacy Association

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

Page 21: The Washington State Pharmacist Perspective Jenny Arnold, PharmD, BCPS Director of Pharmacy Practice Development Washington State Pharmacy Association

Questions?