Fatal opioid overdoses have quadrupled in the U.S. from 1999 to 2013.1 In 2013, 43,982 deaths in the U.S. were attributable to drug overdoses, and 37% of them involved opioids.1 Data from 2005 suggested that veterans are at an increased risk with a 2-fold rise in overdose observed.2 In 2013, there were 17,124 encounters at VA facilities for the treatment of opioid overdose.3 In response to this opioid epidemic, individual VA facilities began implementing Overdose Education and Naloxone Distribution (OEND) programs in 2013.4 In May 2014, the Under Secretary for Health mandated the implementation of OEND programs across all VA facilities, and the VA became the only health care system in the U.S. with a national OEND program.4
Naloxone
Naloxone is a pure opioid antagonist that competes with and displaces opioids at opioid receptors. In an overdose, opioids occupying opioid receptor sites can lead to respiratory depression, which can lead to death. Patients can experience rapid reversal of respiratory depression and opioid overdose with the first dose of naloxone 0.4 mg. Naloxone has a short half-life relative to opioids, whereas opioids can bind to opioid receptors once again after naloxone is eliminated, risking the reemergence of overdose symptoms. For this reason, a second dose of naloxone is often given. When administered appropriately with close monitoring, naloxone can provide a safe and effective way to reverse a potentially life-threatening opioid overdose.
Availability
In April 2014, Evzio, an intramuscular/subcutaneous formulation of naloxone, was FDA approved as an emergency treatment for known or suspected opioid overdose. Shortly after, in November 2015, Narcan, a nasal spray formulation of naloxone, also was approved. Each formulation has been instrumental in fulfilling an unmet medical need in the U.S. Both Evzio and Narcan have been used in opioid-overdose prevention programs to train health care professionals and lay persons to respond in the event of suspected overdose and administer naloxone.
Maxwell and colleagues implemented a naloxone distribution program in Chicago, Illinois, in January 2001 after a 4-fold increase in heroin-related overdose deaths was observed.5 Within a year, Chicago experienced a 20% decrease in heroin-related overdose deaths, and this trend continued with additional 10% reductions in heroin-related overdoses in 2002 and 2003. Similarly, Piper and colleagues implemented a naloxone distribution program and found that 82% of injection drug users felt “comfortable” to “very comfortable” administering naloxone in the event of an overdose, and 86% of subjects reported they would want naloxone in the event of an overdose.6
Naloxone is available for over-the-counter purchase in Rhode Island, which is a bordering state to VA Connecticut Healthcare System (VACT). In 2015 new legislation permitted the training and certification of Connecticut community pharmacists to prescribe naloxone. Furthermore, in May 2016, Connecticut passed legislation to permit qualified individuals to carry naloxone and administer it to another person that he or she, believes is experiencing an opioid-related drug overdose. Given the increase in naloxone availability both nationally and locally, VACT sought to implement a naloxone distribution program to offer the same access to veterans. The primary objective of this article is to describe the development, implementation, and preliminary results of this OEND program.
Development
In accordance with VA guidance, the VACT OEND program development and implementation process included 4 steps that required program coordinators to identify target populations, garner support, train staff members, and implement the OEND program.
A multidisciplinary team of representatives from pharmacy, mental health (MH), and substance abuse (SA) departments was established to draft hospital policy. The hospital policy detailed job functions related to the OEND program for prescribing, educating, verifying, and dispensing naloxone. This policy also served as a document to identify the target population.
With resources from the National VA Pharmacy Benefits Manager, the target population for VACT listed veterans with an opioid use disorder, prescription opioid use disorder, and injection opioid use disorder. Also listed were veterans at risk of an opioid overdose, such as those encountered in medication-assisted treatment programs for opioid use disorder, recent inpatient withdrawal management for opioid use disorder, HIV education/prevention programs, syringe access programs, outpatient and residential opioid use disorder treatment programs, community meetings/support group programs for opioid use disorder, emergency departments for opioid overdose or intoxication, domiciliary care or community-based treatment for homeless veterans, and primary health care for follow-up of recent opioid overdose or intoxication. The aim of the broad description of veterans was to ensure that naloxone access remained inclusive.
The program overview and hospital policy were presented to the VACT medication management committee (MMC), which approved a small pilot project for veterans engaged in SA treatment from January 2015 to April 2015. Barriers to implementation were encountered at this time, which included a belief that only MH or SA providers should prescribe naloxone rescue kits. Reasons for this were largely related to the belief that MH and SA providers are more familiar with substance use disorders. These barriers were addressed by increasing education to providers by detailing previous success stories regarding naloxone programs to highlight that the benefits outweighed any associated risks.
